Surgical therapy of vitiligo: Current status

Vitiligo is an acquired condition that presents as sharply demarcated white macules.[1],[2] It affects 1%-2% people of all races regardless of sex and age. Although the disease does not have any systemic complications, it is of great cosmetic concern, particularly in darker skinned individuals, as in Indians, where it creates psychological problems due to the stigma attached to it. In vitiligo, there is a partial or total destruction of melanocytes, initially only of the epidermis, and later even of the hair follicle, which acts as a reservoir for providing melanocytes during repigmentation.[3] Hence, in patients with vitiligo, the existing melanocytes need to be activated. While medical therapies are the primary treatment, there are some patients refractory to medical treatment. In such patients, surgical therapies can be used either alone or in conjunction with medical therapy to achieve repigmentation provided the disease is stable. Stability has been defined by different authors as a period varying from 6 months to 2 years during which the existing lesions should not have enlarged, no new lesions should have developed, and there should be no koebnerization. [4],[5],[6],[7] It is best to confirm the stability of the disease by doing trial test grafting in a small vitiliginous area 1½-2 months before undertaking surgery of the entire lesion.[8],[9]

Various surgical procedures have been designed with the following aims:[10]

1) Introduction of artificial pigments into the lesions for permanent camouflage, e.g. tattooing.

2) Removal of the depigmented areas forever, e.g. excision with primary closure, and covering with thin Thiersch′s graft.

3) Repopulation of the depleted melanocytes by various grafts, e.g. ultra-thin grafts, suction blister and miniature punch grafts, non-cultured epidermal cell suspension or transplantation, and epidermal and melanocyte cultures.

4) Therapeutically wounding the lesion to stimulate the melanocytes from the periphery and the black hair follicles to proliferate, migrate and re-pigment the lesion, e.g. therapeutic dermabrasion, laser ablation, cryosurgery (liquid nitrogen spraying), needling, and local application of phenol or trichloroacetic acid.

Since 1964, various surgical techniques and modifications have been used to treat recalcitrant but stable vitiligo with permanent and almost complete repigmentation.[11] Behl was the first to report the use of thin Thiersch′s skin graft to treat vitiligo.[12] In 1971, Falabella described the suction blister technique for repigmentation through melanocyte transplantation.[13] Falabella also introduced the autologous miniature punch graft technique in 1978.[14] Suji and Hamada in 1983 used therapeutic spot dermabrasion for stable vitiligo.[15] The technique of spot therapeutic wounding was further extended by using needling, phenol, trichloroacetic acid, cryosurgery, carbon dioxide laser, etc. [16],[17],[18] Halder et al reported the use of ferrous oxide pigment for tattooing for the treatment of vitiligo in a large series in 1989.[19] Cultured autologous melanocytes were first introduced by Lerner et al in 1987.[20] Gaunthier and Surleve-Bazeille used a non-cultured autologous melanocyte rich epidermal cell suspension in 1989 and this technique was further refined by Olsson and Juhlin.[21]-[22] In 1993, Kahn et al successfully re-pigmented vitiligo lesions by a melanocytic transplant using ultra-thin epidermal sheets.[23] Since then, various techniques of vitiligo surgery have been improvised and modified to achieve better results. [24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],

The result of all surgical methods should be uniform pigmentation throughout the lesion with the surface texture and color matching that of the surrounding skin as much as possible to be cosmetically acceptable to the patient. The different methods have their own advantages and disadvantages. The choice of method in a particular patient depends on the site, size, shape, etc. of the lesions as well as the experience of the surgeon and the available technical support.

The following methods have been found to be useful at certain locations. For vitiligo areas with at least 25%-50% of black hair, any of the therapeutic wounding methods (phenolization is the simplest and cost effective) will accelerate the process of repigmentation. For the tips of the fingers and toes, and palms and soles, miniature punch grafting (MPG) is the best method. For the angles of the mouth and genitalia, tattooing is the best choice because the chance of graft rejection at these sites is high. The suction blister technique (SBT) works very well over the lips and eyelids, especially after the introduction of surgical glue and the multiple syringe technique.

Large patches can be covered either with thin Thiersch′s split thickness skin grafts (TT-STSG), ultra-thin skin grafts (UTSG), non-cultured epidermal cell suspension or cellular cultures. The pattern of the lesion also dictates the method to be used. Small gaps or partially healed lesions can be needled, phenolized or tattooed. For geographical amoeboid lesions, MPG is suitable. Round or oval lesions are best treated with TT-STSG, UTSG, suspensions or culture.

While the availability of technical support (e.g. tissue culture laboratory equipment, technical help, and hospital set-up) is also a deciding factor in the selection of the technique, the most important criterion is the expertise of the dermatosurgeon in various techniques. One must select the method with which one is most conversant and comfortable. The technique should be individualized and tailored with respect to each patient. Some patients may require a combination of two techniques. [36],[37],[38],

Vitiligo surgeries are not without complications [Table - 1]. Most authors have claimed good-to-excellent results (60% to 95% repigmentation) with the surgical method that they had adopted depending upon the type, size, site and stability of vitiligo lesions, age and color complexion of patient, and whether PUVA/PUVASOL was used post-operatively. [6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41], Overall, better results are reported in focal and segmental vitiligo (75%-95%) than in generalized vitiligo. Younger (20-30 years) and darker complexioned patients have better results. Comparatively, acral areas, malleoli, knees, and elbows are less responsive to surgery. Smaller patches respond better. Addition of PUVA/PUVASOL therapy enhances repigmentation and increases the success rate (90%-95%).

On an average, TT-STSG, UTSG, and SBT yield 1:1 coverage of the affected area. [6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],In MPG the perigraft spread of pigment is 2-4 folds.[3] However, the limitation of MPG is that cosmetic acceptability is not very good. Non-cultured epidermal cell suspension gives coverage of 3-4 times the biopsy specimen size but requires tedious perioperative steps.[42] The best expansion obtained is with pure cultures (mixed or pure melanocytes). But, facilities for culture are expensive, available at few centers, and need technical support. This technique has now been simplified by the commercial availability of an autologous harvesting device (Recell), which reduces the tedious perioperative steps. To cover wider areas, a similar system, called single cell suspension spray (cell spray), is available. [42] It contains expanded autologous cultured epidermal cells. Both these systems are expensive and are not available in India.

In India, miniature punch grafting and SBT will remain the mainstay of vitiligo surgical treatment by virtue of their simplicity, cost effectiveness and efficacy. In future, the method that gives a wider coverage with a smaller amount of donor tissue will succeed if it is economical and easily available.