doi: 10.1111/j.1346-8138.2010.01184.

Journal of Dermatology 2011; 38: 11401145

ORIGINAL ARTICLE

Efcacy of 1-mm minigrafts in treating vitiligo depends on patient age, disease site and vitiligo subtype
Hiroshi KATO, Takuya FURUHASHI, Erika ITO, Natsumi KANEKO, Motoki NAKAMURA, Shoichi WATANABE, Yoichi SHINTANI, Akira MAEDA, Yuji YAMAGUCHI, Akimichi MORITA
Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan

ABSTRACT
Vitiligo vulgaris is a refractory skin disease. Treatment modalities include topical steroids, phototherapy, suction blister roof grafts and cellular grafting techniques. Adverse effects may occur, however, and some cases remain unresponsive to treatment. To evaluate the efcacy of small (1-mm) punch minigraft therapy in relation to patient age, disease site, disease duration and vitiligo subtype. We used a recently developed disposable 1.0-mm punch apparatus to perform minigraft therapy in 20 patients with either generalized (n = 4), segmental (n = 9) or limited (n = 7) vitiligo, and evaluated the area and rate of repigmentation in relation to patient age, disease site, disease duration and vitiligo subtype. The area of repigmentation was signicantly greater in patients with segmental vitiligo (n = 9) than in those with generalized vitiligo (n = 4). Repigmentation covered a broader area and occurred more quickly in patients under 15 years of age than in those over 20 years of age (n = 9). Disease duration did not affect the repigmentation rate. The results of the present study suggest that 1-mm minigrafts are effective for treating patients with vitiligo. Better results occurred in patients under 15 years of age, patients with facial grafts, and patients with segmental and limited subtypes.

Key words: 1-mm minigraft, narrow-band ultraviolet B, suction blister roof graft, surgical treatment, vitiligo vulgaris.

INTRODUCTION
Vitiligo vulgaris is a refractory skin disease. Topical treatment has only moderate efcacy for the limited disease subtype. Narrowband ultraviolet (UV)-B is used most often as rst-line therapy for generalized cases.1 The clinical responses are satisfactory in many cases, but narrow-band UV-B therapy requires a large number of irradiations, usually more than 100.2 Recently, shorter wavelength, 308-nm excimer light was developed to treat psoriasis.3 The excimer light requires fewer sessions and smaller doses to achieve clinical efcacy for both psoriasis and vitiligo. Although the wavelength is only 3 nm shorter than narrow-band UV-B, the excimer light produces a six-fold greater cyclobutane pyrimidine dimer formation,4 suggesting that long-term phototherapy using excimer light may be carcinogenic. Moreover, treatment modalities for children are limited, especially for the segmental type. The repigmentation rate with narrow-band UV-B or 308-nm excimer light is relatively low in cases with segmental vitiligo. Based on the guidelines for the diagnosis and management of vitiligo, narrow-band UV-B therapy for vitiligo received a D grade of recommendation, indicating that narrow-band UV-B for vitiligo is not strongly recommended.5

Suction blister roof graft therapy is used for segmental vitiligo, but this can be difcult near the eyelid and the hairline.6 Minigrafts using a 1.54-mm punch have been used.710 This procedure using a large-sized punch, however, causes a cobblestone appearance, polka-dot appearance and scar formation.1,5 In a recent study, these adverse effects were not observed with the use of a smaller punch (1.2 mm).1 Orentreich and Selmanowitz11 rst described the efcacy of 1-mm punch minigrafting for treating leukoderma in 1972, but a disposable 1-mm punch has recently been developed. In the present study, we evaluated the safety and efcacy of 1-mm minigraft therapy in relation to patient age, disease site, disease duration and vitiligo subtype.

METHODS
Twenty patients with vitiligo (10 males, 10 females), ranging in age from 575 years (mean, 27.8 years), were enrolled in the study (Table 1). The 20 patients comprised four with generalized, nine with segmental and seven with limited types of vitiligo. Disease duration ranged from 1 month to 25 years (mean, 6.9 years). The study was

Correspondence: Hiroshi Kato, M.D., Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya 467-8601, Japan. Email: h-kato@med.nagoya-cu.ac.jp Received 25 August 2010; accepted 13 November 2010.

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Table 1. Patients proles Case no. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Mean SD Age (years) 52 75 7 17 14 40 61 60 63 10 15 23 27 17 9 11 27 5 16 6 27.8 22.3 Sex F F M F M M M M F M F M F F F M M F M F Parts Hairline Hairline Face Face Body Face Body Hairline Body Body Hairline Body Face Body Hairline Body Face Face Face Face Disease duration (years) 4 3 3 12 9 7 15 25 7 3 2 20 3 5 7 7 0.1 2 1 2 6.86 6.57 Type Localized Generalized Segmental Localized Segmental Localized Generalized Segmental Generalized Localized Segmental Segmental Generalized Localized Segmental Segmental Segmental Localized Localized Segmental Pretreatment Narrow-band UV-B Narrow-band UV-B Narrow-band UV-B Topical steroid Narrow-band UV-B Topical steroid Narrow-band UV-B Narrow-band UV-B Full-thickness skin graft No treatment Topical steroid Topical steroid Topical steroid Topical steroid Topical steroid Narrow band UV-B Topical vitamin D Topical steroid Topical vitamin D Topical steroid Score after operation 0 0 5 5 4 5 5 0 0 3 5 3 5 3 5 5 0 5 3 5 3.30 2.11

SD, standard deviation; UV, ultraviolet.

approved by the ethics committee of Nagoya City University. The patients all provided written informed consent. The skin donor site was the abdomen and full-thickness grafts were obtained using a 1-mm punch (Kai Industry, Seki, Japan) following the administration of local anesthesia. Subcutaneous fat tissue was removed from the graft. The donor grafts were kept on wet gauze prior to use. Using the 1-mm punch, holes were made in the vitiligo lesions with 35 mm between them. After hemostasis, the grafts were implanted into the holes. The grafts were placed deeper than the surrounding skin to prevent a cobblestone appearance. The grafts were covered with surgical tape (3M Health Care; Tokyo, Japan) and Duoactive ET (Convatec, Tokyo, Japan), followed by an occlusive dressing for 1 week (Fig. 1). After uncovering the grafts, they were observed once a month and the repigmentation rate was monitored and scored as follows: 0%, score 0; 15%, score 1; 625%, score 2; 2650%, score 3; 5175%, score 4; and 76 100%, score 5. The repigmentation rate was also analyzed (mm week). Other parameters, including patient age, disease site, disease duration and vitiligo subtype, were also analyzed. Age was stratied into three groups: less than 15 years, 15 20 years; and more than 20 years. Disease site was classied as face, body or hairline. Disease duration was stratied into three groups: 3 years or less; 410 years; and more than 10 years.

Figure 1. Full-thickness grafts are obtained using a 1-mm punch (Kai Industry, Seki, Japan) following the administration of local anesthesia from abdominal skin. Subcutaneous fat tissue is removed from the graft. The donor grafts are kept on wet gauze prior to use. Using the 1-mm punch, holes are made in vitiligo lesions with 35 mm between them. After hemostasis, the grafts are implanted into the holes. The grafts are placed deeper than the surrounding skin to prevent a cobblestone appearance. The grafts are covered with surgical tape (3 mol L; Kanagawa, Japan) and Duoactive ET (Convatec), followed by an occlusive dressing for 1 week.

Statistical analysis
All data were statistically analyzed using Students t-test. All bar graphs are presented as mean value + standard error of the mean.

RESULTS
Fifteen cases developed pigmentation at the recipient sites (one case with generalized, eight cases with segmental and six cases

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(a)

(b)

(c)

(d)

Figure 2. Representative cases that received minigraft therapy with 1-mm punch grafts. (a) Case 3, a 7-year-old boy. Repigmentation of 80% of the area was achieved. The repigmentation score was 5. (b) Case 13, a 27-year-old woman. Repigmentation of 100% of the area was achieved. The repigmentation score was 5. (c) Case 11, a 15-year-old girl. Repigmentation of 80% of the area was achieved. The score was 5. Although lesions on the forehead sometimes respond poorly, an excellent response was achieved in this case. (d) Case 17, a 27-year-old man (non-responder). No repigmentation was achieved. The repigmentation score was 0.

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Figure 3. Relationship between patient age, disease site, disease duration, vitiligo subtype and repigmentation score. Patient age and disease type were signicantly related to the repigmentation score. (a) Disease type was signicantly related with the repigmentation score. Patients with the segmental type had higher scores than patients with the generalized type. (b) Patient age was signicantly related to the repigmentation score. Patients under 15 years of age had signicantly higher scores than those over 20 years of age. (c) Disease site was not signicantly related to the repigmentation score. (d) Disease duration was not signicantly related to the repigmentation score.

(a)

(b)

(c)

(d)

Figure 4. Relationship between patient age, disease site, disease type, and disease duration and repigmentation rate. (a) Relationship between vitiligo subtype and repigmentation rate. (b) Relationship between patient age and repigmentation rate. (c) Relationship between the disease site and repigmentation rate. (d) Relationship between disease duration and repigmentation rate.

with limited type vitiligo). No pigmentation was observed at the recipient site in the other ve cases. In some of the ve negative cases, slight pigmentation began to develop but disappeared within a few weeks. Representative cases of responders and non-responders are shown in Figure 2. The repigmentation score was analyzed in relation to the other parameters (patient age, disease site, disease duration and vitiligo subtype; Fig. 3). The repigmentation scores in cases with the segmental type were signicantly higher than those in cases with the generalized type (P < 0.05). Patients under 15 years of age (n = 7)

had signicantly higher repigmentation scores than those over 20 years of age (n = 9, P < 0.05). There was no statistically signicant relationship between the lesion site and the repigmentation score, probably due to the limited number of patients. Cases in which facial sites were affected (n = 8) showed better responses than those with other affected sites. The mean repigmentation rate of the face was 4, which was higher than that of the hairline (n = 5, P < 0.05). Disease duration was not related to the repigmentation score, indicating that the efcacy of minigraft therapy was not affected by the disease duration.

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The repigmentation rate (mm week) was analyzed in relation to the other parameters (patient age, disease site, disease duration and vitiligo subtype; Fig. 4). The repigmentation rate peaked at 23 months after the minigrafting procedure. Rapid repigmentation was observed in those with facial lesions and in those with a short disease duration (3 years). The repigmentation rate was statistically analyzed at 1, 2, 3 and 7 months after the minigrafting procedure. The repigmentation rate was signicantly greater in patients under 20 years of age compared to patients over 20 years of age at 1 month (P < 0.05). Repigmentation rate reached a maximum at 2 months in those under 20 years of age, and at 3 months in those over 20 years of age. Lesion site was not signicantly related to the rate of repigmentation, but maximal repigmentation rate was observed at 3 months in the face and at 2 months in the other sites. Disease duration was not signicantly related to the repigmentation rate. At 3 months after the minigrafting, the maximum repigmentation rate was observed in the face.

DISCUSSION
The efcacy of minigraft therapy using a newly developed 1-mm punch grafting technique was evaluated in patients with vitiligo. Based on the repigmentation score and percent area of repigmentation, the 1-mm punch minigrafting technique was effective for the following cases: (i) children under 15 years of age; (ii) patients with limited and segmental types of vitiligo; and (iii) patients with facial involvement. In contrast to phototherapy, in which a greater response is obtained in those with a shorter disease duration, the repigmentation rate was not related to disease duration. Generally, surgical treatment should be applied for the stable lesion. One patient who had only 1-month duration was treated with this method because of the strong request. There was no expansion from the donor site. The 1-mm minigraft is less invasive as compared to other surgical treatments such as a suction blister roof graft. However, in the generalized type, the vitiligo lesion is sometimes easily developed. Therefore, the efcacy of 1-mm punch grafting technique might be better in the segmental than in the generalized type. Although repigmentation can be easily achieved with minigraft therapy using 1.54-mm punches,12 the procedure results in a cobblestone appearance and scar formation.7 In the present study, using 1-mm minigraft therapy, no cobblestone appearance or scar formation was observed. Graft protruding caused by bleeding might cause the milia formation. However, the phenomenon was improved in a few months. The technique is now greatly improved compared to that of minigraft therapy using 3- or 4-mm punches. Intensive sun exposure or unnecessary phototherapy, however, might cause unwanted darker pigmentation compared with the surrounding normally pigmented area. Based on the guidelines put forth for the diagnosis and management of vitiligo in the British Journal of Dermatology in 2008, minigrafts are not recommended due to a high incidence of side-effects and poor cosmetic outcomes, including a cobblestone and polka dot appearance.5 We propose the following criteria for vitiligo treatment. For patients with the generalized type and large disease area, whole-

body phototherapy including narrow-band UV-B should be selected. For cases with the generalized type and a small disease area, targeted phototherapy including an excimer light should be selected. For patients with either the limited or segmental type, the age of the patient and the site of involvement must be considered. The 1-mm minigraft therapy should be selected for facial lesions. If the lesion is large and patients strongly request surgical options, super-thin split-thickness skin grafts, 1-mm minigrafts and epidermal grafts should be equally considered on a case-by-case basis. If epidermal grafts are performed and depigmented areas remain, 1-mm minigrafts may be considered as an additional option. For patients who wish to avoid surgical treatment, the application of a topical steroid, vitamin D3 derivative, or tacrolimus and pimecrolimus can be selected. Graft healing is divided into three phases: plasmatic inhibition, inosculatory and revascularization.13 The rst phase occurs during the rst 24 h, during which the graft absorbs the wound uid. The second phase occurs in the rst 3 days after the operation, during which the vessels of the graft combine with the vessels in the recipient sites. The third phase occurs over the rst 2 weeks, during which the vessels proliferate in both the graft and recipient sites. Alternatively, wound healing is divided into four phases: (i) hemostasis; (ii) inammatory; (iii) proliferative; and (iv) remodeling.14 The series of phases occurs within 2 months after grafting, inducing various cytokines such as bbroblast growth factor, tissue growth factor-a and tissue growth factor-b.10 In particular, increasing evidence indicates that mast cells might play a pivotal role in wound repair.15 These cytokines, including stem cell factor (c-kit ligand), stimulate melanocyte proliferation and effectively induce pigmentation.16,17 Consistent with the timing of these healing phases, the maximum repigmentation rate was observed between 2 and 3 months after the minigrafting procedure. In conclusion, we report the efcacy of 1-mm minigraft therapy and propose this as a new and useful modality for the treatment of vitiligo vulgaris, especially for children with segmental or limited type lesions of the face.

REFERENCES
1 Falabella R, Barona MI. Update on skin repigmentation therapies in vitiligo. Pigment Cell Melanoma Res 2009; 22: 4265. 2 Kishan Kumar YH, Rao GR, Gopal KV et al. Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo. Indian J Dermatol Venereol Leprol 2009; 75: 162166. 3 Menter A, Korman NJ, Elmets CA et al. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 5. Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. J Am Acad Dermatol 2010; 62: 114135. 4 Kobayashi K, Yasuda Y, Shintani Y et al. The development of a lter to enhance the efcacy and safety of excimer light (308 nm) therapy. Photodermatol Photoimmunol Photomed 2009; 25: 3036. 5 Gawkrodger DJ, Ormerod AD, Shaw L et al. Therapy Guidelines and Audit Subcommittee, British Association of Dermatologists; Clinical Standards Department, Royal College of Physicians of London; Cochrane Skin Group; Vitiligo Society. Guideline for the diagnosis and management of vitiligo. Br J Dermatol 2008; 159: 10511076. 6 Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988; 124: 16561658.

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7 Sarkar R, Mehta SD, Kanwar AJ. Repigmentation after autologous miniature punch grafting in segmental vitiligo in North Indian patients. J Dermatol 2001; 28: 540546. 8 Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo vulgaris by autologous minigrafting: results in nineteen patients. J Am Acad Dermatol 1995; 33: 990995. 9 Lahiri K, Malakar S, Sarma N et al. Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm) a prospective study. Int J Dermatol 2006; 45: 649655. 10 Sachdev M, Shankar DS. Dermatologic surgery: pulsed erbium: YAG laser-assisted autologous epidermal punch grafting in vitiligo. Int J Dermatol 2000; 39: 868871. 11 Orentreich N, Selmanowitz VJ. Autograft repigmentation of leukoderma. Arch Dermatol 1972; 105: 734736. 12 Njoo MD, Westerhof W, Bos JD et al. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998; 134: 15431549.

13 Yamaguchi Y, Hosokawa K, Kawai K et al. Involvement of keratinocyte activation phase in cutaneous graft healing: comparison of full-thickness and split-thickness skin grafts. Dermatol Surg 2000; 26: 463469. 14 Manaka L, Kadono S, Kawashima M et al. The mechanism of hyperpigmentation in Seborrhoeic keratosis involves the high expression of endothelin-covering enzyme-1alpha and TNF-alpha, which stimulate secretion of endothelin 1. Br J Dermatol 2001; 145: 895903. 15 Maltby S, Khazaie K, McNagny KM. Mast cells in tumor growth: angiogenesis, tissue remodeling and immune-modulation. Biochim Biophys Acta 2009; 1796: 1926. 16 Jeon S, Kim NH, Kim JY et al. Stem cell factor induces ERM proteins phosphorylation through PI3K activation to mediate melanocyte proliferation and migration. Pigment Cell Melanoma Res 2009; 22: 7785. 17 Wehrle-Haller B. The role of kit-ligand in melanocyte development and epidermal homeostasis. Pigment Cell Res 2003; 16: 287296.

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