This action might not be possible to undo. Are you sure you want to continue?
Journal of Dermatology 2011; 38: 1140–1145
Efﬁcacy 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
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 efﬁcacy 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 signiﬁcantly 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.
Vitiligo vulgaris is a refractory skin disease. Topical treatment has only moderate efﬁcacy for the limited disease subtype. Narrowband ultraviolet (UV)-B is used most often as ﬁrst-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 efﬁcacy 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 difﬁcult near the eyelid and the hairline.6 Minigrafts using a 1.5–4-mm punch have been used.7–10 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 ﬁrst described the efﬁcacy 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 efﬁcacy of 1-mm minigraft therapy in relation to patient age, disease site, disease duration and vitiligo subtype.
Twenty patients with vitiligo (10 males, 10 females), ranging in age from 5–75 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: email@example.com Received 25 August 2010; accepted 13 November 2010.
Ó 2011 Japanese Dermatological Association
holes are made in vitiligo lesions with 3–5 mm between them. Seki. All bar graphs are presented as mean value + standard error of the mean. score 1. The grafts are placed deeper than the surrounding skin to prevent a cobblestone appearance. Disease duration was stratiﬁed into three groups: 3 years or less. Kanagawa. 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. UV. Statistical analysis All data were statistically analyzed using Student’s t-test. score 0. Figure 1. The donor grafts were kept on wet gauze prior to use. The repigmentation rate was also analyzed (mm ⁄ week). Full-thickness grafts are obtained using a 1-mm punch (Kai Industry. score 3. 1–5%. disease duration and vitiligo subtype. and more than 20 years. holes were made in the vitiligo lesions with 3–5 mm between them. and more than 10 years. Tokyo.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. Japan) and Duoactive ET (Convatec). The skin donor site was the abdomen and full-thickness grafts were obtained using a 1-mm punch (Kai Industry. Japan) and Duoactive ET (Convatec.30 ± 2. Japan). RESULTS Fifteen cases developed pigmentation at the recipient sites (one case with generalized. Using the 1-mm punch. 1). 51–75%. the grafts were implanted into the holes.1 2 1 2 6. Subcutaneous fat tissue was removed from the graft. The grafts are covered with surgical tape (3 mol ⁄ L. 26–50%.Efﬁcacy of 1-mm minigrafts for vitiligo Table 1. Japan) following the administration of local anesthesia from abdominal skin. including patient age. score 2. Patients’ proﬁles Case no.11 SD. After uncovering the grafts. followed by an occlusive dressing for 1 week (Fig. they were observed once a month and the repigmentation rate was monitored and scored as follows: 0%. 6–25%. were also analyzed. standard deviation. eight cases with segmental and six cases Ó 2011 Japanese Dermatological Association 1141 . Seki.8 ± 22. The grafts were placed deeper than the surrounding skin to prevent a cobblestone appearance. score 4. Disease site was classiﬁed as face. Tokyo. The patients all provided written informed consent. and 76– 100%. body or hairline. followed by an occlusive dressing for 1 week. Other parameters. 4–10 years. approved by the ethics committee of Nagoya City University. The grafts were covered with surgical tape (3M Health Care. ultraviolet. After hemostasis.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. disease site. Using the 1-mm punch. 15– 20 years.86 ± 6. Age was stratiﬁed into three groups: less than 15 years. After hemostasis. Japan) following the administration of local anesthesia. score 5. Subcutaneous fat tissue is removed from the graft. the grafts are implanted into the holes. The donor grafts are kept on wet gauze prior to use.
1142 Ó 2011 Japanese Dermatological Association . The repigmentation score was 0. (d) Case 17. The repigmentation score was 5. Representative cases that received minigraft therapy with 1-mm punch grafts. Kato et al. The score was 5. Repigmentation of 80% of the area was achieved. Although lesions on the forehead sometimes respond poorly. Repigmentation of 80% of the area was achieved. The repigmentation score was 5. Repigmentation of 100% of the area was achieved. a 15-year-old girl. (a) (b) (c) (d) Figure 2. No repigmentation was achieved. an excellent response was achieved in this case. a 7-year-old boy. (b) Case 13. (c) Case 11.H. a 27-year-old woman. (a) Case 3. a 27-year-old man (non-responder).
(d) Relationship between disease duration and repigmentation rate. The repigmentation scores in cases with the segmental type were signiﬁcantly higher than those in cases with the generalized type (P < 0. probably due to the limited number of patients. which was higher than that of the hairline (n = 5. P < 0. No pigmentation was observed at the recipient site in the other ﬁve cases. (c) Relationship between the disease site and repigmentation rate. and disease duration and repigmentation rate. disease site. Ó 2011 Japanese Dermatological Association 1143 . The repigmentation score was analyzed in relation to the other parameters (patient age.05). 3). slight pigmentation began to develop but disappeared within a few weeks. Patients under 15 years of age (n = 7) had signiﬁcantly higher repigmentation scores than those over 20 years of age (n = 9.05). There was no statistically signiﬁcant relationship between the lesion site and the repigmentation score. disease type. (b) Relationship between patient age and repigmentation rate. disease duration. (a) (b) (c) (d) Figure 4. (a) Relationship between vitiligo subtype and repigmentation rate. Patient age and disease type were signiﬁcantly related to the repigmentation score. Patients with the segmental type had higher scores than patients with the generalized type. indicating that the efﬁcacy of minigraft therapy was not affected by the disease duration. with limited type vitiligo). vitiligo subtype and repigmentation score. Disease duration was not related to the repigmentation score. (c) Disease site was not signiﬁcantly related to the repigmentation score. P < 0. In some of the ﬁve negative cases. The mean repigmentation rate of the face was 4. (d) Disease duration was not signiﬁcantly related to the repigmentation score. (a) Disease type was signiﬁcantly related with the repigmentation score. disease site. Fig. Cases in which facial sites were affected (n = 8) showed better responses than those with other affected sites. Representative cases of responders and non-responders are shown in Figure 2.05). disease duration and vitiligo subtype. Relationship between patient age. Relationship between patient age.Efﬁcacy of 1-mm minigrafts for vitiligo Figure 3. Patients under 15 years of age had signiﬁcantly higher scores than those over 20 years of age. (b) Patient age was signiﬁcantly related to the repigmentation score. disease site.
1144 Ó 2011 Japanese Dermatological Association . Graft protruding caused by bleeding might cause the milia formation. Based on the repigmentation score and percent area of repigmentation. using 1-mm minigraft therapy.12 the procedure results in a cobblestone appearance and scar formation. we report the efﬁcacy of 1-mm minigraft therapy and propose this as a new and useful modality for the treatment of vitiligo vulgaris. The technique is now greatly improved compared to that of minigraft therapy using 3. 5 Gawkrodger DJ. however. the application of a topical steroid. disease site. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. 3 and 7 months after the minigrafting procedure. If epidermal grafts are performed and depigmented areas remain. There was no expansion from the donor site. In contrast to phototherapy.10 In particular. during which the vessels of the graft combine with the vessels in the recipient sites. Lesion site was not signiﬁcantly related to the rate of repigmentation.5 We propose the following criteria for vitiligo treatment.16. Guideline for the diagnosis and management of vitiligo. the phenomenon was improved in a few months. inosculatory and revascularization. vitamin D3 derivative. 2 Kishan Kumar YH. The repigmentation rate (mm ⁄ week) was analyzed in relation to the other parameters (patient age. Gopal KV et al. the efﬁcacy of 1-mm punch grafting technique might be better in the segmental than in the generalized type. Yasuda Y. (iii) proliferative. Therapy Guidelines and Audit Subcommittee. during which the vessels proliferate in both the graft and recipient sites. Elmets CA et al. the age of the patient and the site of involvement must be considered. The 1-mm minigraft is less invasive as compared to other surgical treatments such as a suction blister roof graft. 4 Kobayashi K. Update on skin repigmentation therapies in vitiligo. targeted phototherapy including an excimer light should be selected. 62: 114–135. and (iii) patients with facial involvement.13 The ﬁrst phase occurs during the ﬁrst 24 h. increasing evidence indicates that mast cells might play a pivotal role in wound repair. 25: 30–36. 159: 1051–1076. including stem cell factor (c-kit ligand).or 4-mm punches. inducing various cytokines such as bﬁbroblast growth factor. minigrafts are not recommended due to a high incidence of side-effects and poor cosmetic outcomes. Therefore. Pigment Cell Melanoma Res 2009. 75: 162–166. tissue growth factor-a and tissue growth factor-b.17 Consistent with the timing of these healing phases. The repigmentation rate was statistically analyzed at 1. or tacrolimus and pimecrolimus can be selected. Photodermatol Photoimmunol Photomed 2009. whole- body phototherapy including narrow-band UV-B should be selected. the repigmentation rate was not related to disease duration. Intensive sun exposure or unnecessary phototherapy.H. 1-mm minigrafts may be considered as an additional option. no cobblestone appearance or scar formation was observed. wound healing is divided into four phases: (i) hemostasis. Alternatively. 3 Menter A. Royal College of Physicians of London. Rao GR. might cause unwanted darker pigmentation compared with the surrounding normally pigmented area. The second phase occurs in the ﬁrst 3 days after the operation. (ii) inﬂammatory. The 1-mm minigraft therapy should be selected for facial lesions. Cochrane Skin Group. For patients who wish to avoid surgical treatment. Repigmentation rate reached a maximum at 2 months in those under 20 years of age. Barona MI. Shintani Y et al. Based on the guidelines put forth for the diagnosis and management of vitiligo in the British Journal of Dermatology in 2008. surgical treatment should be applied for the stable lesion. Evaluation of narrow-band UVB phototherapy in 150 patients with vitiligo. the maximum repigmentation rate was observed in the face. For patients with either the limited or segmental type. especially for children with segmental or limited type lesions of the face. The repigmentation rate peaked at 2–3 months after the minigrafting procedure. 124: 1656–1658. British Association of Dermatologists. Arch Dermatol 1988. Rapid repigmentation was observed in those with facial lesions and in those with a short disease duration (£3 years). Guidelines of care for the treatment of psoriasis with phototherapy and photochemotherapy. 6 Koga M.14 The series of phases occurs within 2 months after grafting. For cases with the generalized type and a small disease area. At 3 months after the minigrafting. in which a greater response is obtained in those with a shorter disease duration. One patient who had only 1-month duration was treated with this method because of the strong request. 2. Korman NJ. The third phase occurs over the ﬁrst 2 weeks.5–4-mm punches. REFERENCES 1 Falabella R. the 1-mm punch minigrafting technique was effective for the following cases: (i) children under 15 years of age. Graft healing is divided into three phases: plasmatic inhibition. Guidelines of care for the management of psoriasis and psoriatic arthritis Section 5. The development of a ﬁlter to enhance the efﬁcacy and safety of excimer light (308 nm) therapy. Kato et al. but maximal repigmentation rate was observed at 3 months in the face and at 2 months in the other sites. Ormerod AD. during which the graft absorbs the wound ﬂuid. and at 3 months in those over 20 years of age. the maximum repigmentation rate was observed between 2 and 3 months after the minigrafting procedure. For patients with the generalized type and large disease area. Clinical Standards Department. and (iv) remodeling.7 In the present study. 4). However. Indian J Dermatol Venereol Leprol 2009. Disease duration was not signiﬁcantly related to the repigmentation rate. including a cobblestone and polka dot appearance. super-thin split-thickness skin grafts. Fig. The repigmentation rate was signiﬁcantly greater in patients under 20 years of age compared to patients over 20 years of age at 1 month (P < 0. Shaw L et al. Br J Dermatol 2008. 1-mm minigrafts and epidermal grafts should be equally considered on a case-by-case basis. in the generalized type. stimulate melanocyte proliferation and effectively induce pigmentation. 22: 42–65. DISCUSSION The efﬁcacy of minigraft therapy using a newly developed 1-mm punch grafting technique was evaluated in patients with vitiligo. the vitiligo lesion is sometimes easily developed. Vitiligo Society.05). J Am Acad Dermatol 2010. Generally. (ii) patients with limited and segmental types of vitiligo.15 These cytokines. disease duration and vitiligo subtype. If the lesion is large and patients strongly request surgical options. Although repigmentation can be easily achieved with minigraft therapy using 1. However. In conclusion.
Pigment Cell Melanoma Res 2009. Repigmentation after autologous miniature punch grafting in segmental vitiligo in North Indian patients. Arch Dermatol 1972. Kim NH. 145: 895–903. Kawashima M et al. Westerhof W. Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm) – a prospective study. 16 Jeon S. Mast cells in tumor growth: angiogenesis. 13 Yamaguchi Y. Mehta SD. Autograft repigmentation of leukoderma. 134: 1543–1549.Efﬁcacy of 1-mm minigrafts for vitiligo 7 Sarkar R. Int J Dermatol 2000. Stem cell factor induces ERM proteins phosphorylation through PI3K activation to mediate melanocyte proliferation and migration. 39: 868–871. 9 Lahiri K. Br J Dermatol 2001. 28: 540–546. 16: 287–296. 17 Wehrle-Haller B. Ó 2011 Japanese Dermatological Association 1145 . Kanwar AJ. Int J Dermatol 2006. Hosokawa K. Kadono S. Pigment Cell Res 2003. Dermatologic surgery: pulsed erbium: YAG laser-assisted autologous epidermal punch grafting in vitiligo. Malakar S. 8 Boersma BR. 26: 463–469. 14 Manaka L. tissue remodeling and immune-modulation. 1796: 19–26. A systematic review of autologous transplantation methods in vitiligo. J Am Acad Dermatol 1995. Bos JD et al. Arch Dermatol 1998. 15 Maltby S. Shankar DS. Involvement of keratinocyte activation phase in cutaneous graft healing: comparison of full-thickness and split-thickness skin grafts. 12 Njoo MD. 45: 649–655. McNagny KM. J Dermatol 2001. Kawai K et al. The mechanism of hyperpigmentation in Seborrhoeic keratosis involves the high expression of endothelin-covering enzyme-1alpha and TNF-alpha. Biochim Biophys Acta 2009. 10 Sachdev M. Kim JY et al. Bos JD. Selmanowitz VJ. 11 Orentreich N. which stimulate secretion of endothelin 1. Sarma N et al. Khazaie K. 105: 734–736. 22: 77–85. Dermatol Surg 2000. The role of kit-ligand in melanocyte development and epidermal homeostasis. Westerhof W. 33: 990–995. Repigmentation in vitiligo vulgaris by autologous minigrafting: results in nineteen patients.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue listening from where you left off, or restart the preview.