Journal of Dermatological Treatment.

2012; 23: 219–223

ORIGINAL ARTICLE

Small-sized lesions of childhood vitiligo treated by autologous epidermal

grafting

JING-JING HU, AI-E XU, XIN-GANG WU, XUE-CHENG SUN & XIAN-YAN LUO

Department of Dermatology, Third People’s Hospital of Hangzhou, Hangzhou Institute of Dermatology and Venereology,
Hangzhou, China

Abstract
Background: Currently many children and adolescents with vitiligo fail to respond to traditional medical treatment. However,
their parents want the lesion to be removed as soon as possible. Although surgical therapies are viable alternatives in refractory
and stabilized vitiligo, there are rare reports on surgical therapies for childhood vitiligo. Objective: To assess the effectiveness
and feasibility of using suction blister epidermal grafting for small-sized childhood vitiligo. Methods: Twenty children with
small-sized lesions of stable vitiligo were treated using epidermal grafts and followed-up for 6–12 months. Results: After
6–12 months of follow-up, treatment outcomes were excellent in 17 patients (85%), good in two patients (10%), and poor in
one patient (5%), out of a total of 20 patients. The mean repigmentation rate was 88.55%. The location of the lesions was
probably a factor in determining the outcomes of transplantation. No scar formation or other complications were observed in
any patients. Conclusion: Suction blister autologous epidermal grafting is a rapid, safe, and effective treatment for stable
childhood vitiligo, especially in refractory and stable children with small-sized lesions.

Key words: childhood, epidermal graft, vitiligo

Introduction lead to complete repigmentation. Besides, the period

Vitiligo is a common idiopathic skin pigmentation
disease that affects between 1% and 2% of the world’s
population. Approximately 50% of the individuals
affected develop the disease before the age of 20 years
and about 25% prior to the age of 8 years (1,2).
Various therapeutic options are available to treat
vitiligo and many articles about the efficacy and safety
of various repigmentation therapies are published
each year. Unfortunately, few studies including chil-
dren are found.
After reviewing the articles published in PubMed,
we found that currently available and accepted ther-
apies for childhood vitiligo are limited, mainly to
topical corticosteroids, calcineurin inhibitors, vitamin
D3 analogues, UV therapy and pseudocatalase (3).
The response of these medical therapies is poor in
lesions with leukotrichia, and these therapies rarely
required to achieve some degree of success may range
from months to years. Meanwhile, non-surgical treat-
ment modalities present side effects (4–10).
Having a chronic disease in childhood can impede a
child’s health-related quality of life, such as pro-
foundly influencing the patient’s self-esteem and
social relationships. Negative experiences may have
an impact on childhood development and adult life
(11,12). Therefore, we could attempt to use surgical
technology. Suction blister epidermal grafting has
been the most extensively used among vitiligo patients
and has been found to be acceptable to both patients
and treating physicians (13). For many patients with
small, stable vitiligo, suction blister epidermal grafts
may be a promising alternative. However, our review
of the literature shows that studies evaluating the
efficacy of epidermal grafts in children are currently
rare. The purpose of this article is to evaluate the

Correspondence: Ai-e Xu, Third People’s Hospital of Hangzhou, Hangzhou Institute of Dermatology and Venereology, Hangzhou, China.
E-mail: xuaiehz@msn.com

(Received 19 October 2010; accepted 1 November 2010)

ISSN 0954-6634 print/ISSN 1471-1753 online
2012 Informa Healthcare USA on behalf of Informa UK Ltd.
DOI: 10.3109/09546634.2010.543122
220 J.-J. Hu et al.
effectiveness and feasibility of autologous epidermal
grafting for small-sized stable lesions of childhood
vitiligo.
Materials and methods
Patients
From June 2009 to December 2009, 20 children
(9 boys and 11 girls), ranging in age from 6 to 14 years
(median, 11.3 years), with different types of stable
vitiligo were recruited into the study (Figure 1).
Informed consent was obtained from each patient
and their parents. The study protocol complied
with the provisions of the Declaration of Helsinki
and was reviewed and approved by the Ethics Com-
mittee of the Third People’s Hospital of Hangzhou.
Skin phototype was established for all of the patients
according to Fitzpatrick’s classification. The duration
of vitiligo varied from 1 to 12 years.
Inclusion criteria
Patients with stable vitiligo without further spreading
for at least 6 months were selected for surgical treat-
ment (VIDA score < +2) (14); the treated lesions were
smaller than 20 cm2, including generalized vitiligo
lesions in the exposed site.
Exclusion criteria
Patients younger than 5 years or with keloidal ten-
dencies; lesions larger than 20 cm2; or lesions over the
fingers, toes, knees, or elbows, where suction cups
could not be easily placed, were excluded.
Figure 1. A 14-year-old boy with focal vitiligo on the mandible
before grafting.
Methods
The normally pigmented area of the abdomen was
selected as donor skin and then 75% alcohol was used
to sterilize the depigmented recipient areas and the
donor areas. To reduce pain, 5% compound lidocaine
cream was applied to the donor and recipient areas 1 h
before the procedure and then the areas were covered
(occlusive dressing) to enhance the penetration of the
cream. The suction cups were applied onto the shaved
inner aspect of the abdominal area over normal-
looking skin and onto the recipient areas. Enough
negative pressure (400–500 mmHg) was allowed for
about 1–2 hours, depending on the speed of blister
formation, while the patient was sitting in a comfort-
able position until blisters evolved underneath the
transparent cups (skin separating instruments,
Model BFYIIA, Shaoxing, China). Then a small
pair of scissors was used to de-roof the blister on a
recipient glass slide. The harvested layers consisted of
only epithelium with no dermal components. Good
homeostasis was ensured on the recipient dermab-
raded areas, and then the grafts were applied
smoothly, affirming direct contact between the graft
and recipient site. Styptic plaster was applied
smoothly, affirming direct contact between the graft
and recipient site. Styptic plasters were removed after
1 week. Patients were advised not to perform vigorous
activities. Where the sheets of skin were applied to the
recipient areas or abscission occurred from the recip-
ient areas, the colour would be a little red. For
patients with larger vitiliginous lesions who required
repeated sessions to cover the entire depigmented
area, a second treatment was performed several
months later.
Repigmentation was graded as excellent with 90%
to 100% pigmentation, good with 50% to 89%, fair
with 25% to 49% and poor with 0% to 24% pigmen-
tation of the treated area. Evaluation of repigmenta-
tion was carried out based on the comparison of
before and after photographs of the vitiligo lesions,
which was performed at every follow-up.
Results
A total of 20 childhood patients were followed-up for
6–12 months: 17 (85%) patients had an excellent
response, two (10%) had a good response, and one
(5%) received poor repigmentation. Some patients
received repeated surgical sessions to achieve nearly
complement repigmentation; the mean repigmenta-
tion rate was 88.55% (Table I). The face and neck
achieved excellent and good results of 50%, with the
mean repigmentation rate of 96.2%. The trunk
achieved excellent and good results, with mean
 Childhood vitiligo treated by autologous epidermal grafting 221

Table I. Characteristics of and effective treatment for childhood vitiligo patients.

Clinical Treated Repigmented Last

No./age/sex/ type of Stability of areas (cm2)/ areas (%)/ Koebner Donor follow-up
phototype vitiligo vitiligo (years) Site sessions gradea phenomenon site (months)

1/14/M/III Segmental 5 Neck 10/2 95%/E No hyper 11

2/12/M/IV Segmental 2 Right waist 6/1 50%/G No good 6
3/14/M/IV Segmental 1 Right arm 10/2 90%/E No hyper 8
4/8/M/III Segmental 0.8 Forehead 2/1 90%/E No hyper 10
5/11/F/III Segmental 1.5 Left thigh 20/4 95%/E No hyper 12
6/10/F/IV Segmental 3 Neck 6/1 95%/E No hyper 6
7/8/M/III Focal 1 Labial angle 2/1 100%/E No good 6
8/13/M/III Focal 3 Left arm 1/1 95%/E No hyper 10
9/13/F/III Focal 0.6 Back 4/1 98%/E No hyper 12
10/7/F/III Focal 0.6 Labial angle 2/1 100%/E No hyper 10
11/14/M/III Focal 4 Mandible 10/1 100%/E No hyper 8
12/14/M/IV Focal 5 Back 8/1 75%/G Yes hyper 6
13/12/F/IV Generalized 3 Back 8/1 98%/E No hyper 10
14/6/M/III Generalized 1 Neck 16/4 95%/E No hyper 12
15/10/F/IV Generalized 0.6 Chest 11/2 20%/P Yes hypo 6
16/11/F/IV Generalized 1 Neck 10/1 96%/E No hyper 6
17/12/F/IV Generalized 0.8 Forearm 6/1 98%/E No hyper 6
18/12/F/IV Generalized 2 Face 6/1 95%/E Yes hypo 8
19/13/F/IV Generalized 0.6 Right leg 8/1 90%/E No hyper 12
20/14/F/III Generalized 0.6 Neck 4/1 96%/E No hyper 10
Total Mean
repigmentation
Rate = 88.55%

Grade: E = excellent; G = good; F = fair; P = poor.

a

Hyper = hyperpigmentation; hypo = hyperpigmentation.

repigmentation rates of 20% and 80.25%, respec-
tively. The limbs achieved excellent and good results,
with mean repigmentation rates of 25% and 93.6%,
respectively. No scars or other complications were
observed in either donor sites or recipient sites at each
follow-up after the operation. Koebner phenomenon
was observed at donor sites in two of the generalized
vitiligo patients. Meanwhile, one generalized vitiligo
patient and one focal vitiligo patient had new lesions.
We also found a segmental vitiligo located on the right
waist with only 50% repigmentation after the last
follow-up.
Discussion
Currently, the treatment of vitiligo is challenging.
Widely accepted non-surgical treatment modalities
for children are limited, and many children with
vitiligo fail to respond to traditional medical treat-
ment. Moreover, non-surgical treatment modalities
may interfere with childhood activities such as school
attendance because of side effects, being time-
consuming and generally inconvenient (4–10). It is
difficult for children to adhere to the treatment.
However, the chronic cosmetic disfigurement will
impose profound psychological effects on the chil-
dren, including depression, low self-esteem, social
rejection, and even job discrimination in the future.
Therefore, surgical options may be an alternative
method, depending on the patient’s specific condi-
tion, especially for better compliance in children with
stable vitiligo, though most authors do not consider
surgical therapies in children (15). Epidermal grafting
using suction blisters has the advantages of easy
operability and, most importantly, it is less painful,
with no scar formation. Especially, it has good effects
in small vitiligo lesions (16). Recently, skin grafting
has been recommended for selective use in the pae-
diatric population (17). Lee et al. (18) successfully
treated a 6-year-old vitiligo child by topical
222 J.-J. Hu et al.
anaesthesia and epidermal grafting. This illustrates
that epidermal grafting using topical anaesthesia can
be considered for stable, localized, childhood vitiligo.
Based on the effective and positive results of this
method, we propose the use autologous epidermal
grafting for small-sized childhood vitiligo in children
ranging in age from 6 to 14 years.
In this study, we used autologous epidermal graft-
ing to treat 20 patients, and found that 17 (85%)
patients had an excellent response, two (10%) had a
good response, and one (5%) achieved only poor
repigmentation. In our patients, repigmentation
occurred in a diffused and not in a follicular pattern,
showing that it is originated from the transplanted
grafts (Figure 2). No scar formation or other com-
plications were observed in any of the patients. After
6–12 months of follow-up, most of the transplantation
areas showed a good to excellent colour match with
the surrounding skin. We observed that one general-
ized vitiligo patient and one focal vitiligo patient had
new lesions; both donor sites in two generalized
patients became hypopigmented, indicating the dis-
ease was in progression. The low repigmention in one
segmental patient may be due to the poor contact of
the graft with the recipient location (right waist),
which is vulnerable to friction. Hyperpigmentation
was noted on the donor areas of most patients, except
for hypopigmentation in two patients; only two
patients are similar to the normal skin, which may
be related to personal fitness.
Figure 2. Complete repigmentation 8 months after grafting.
We found that the face and neck location obtained
excellent and good results of 50%, with the mean
repigmentation rate of 96.2%. The trunk location
obtained excellent and good results, with mean repig-
mentation rates of 20% and 80.25%, respectively.
The limbs obtained excellent and good results, with
mean repigmentation rates of 25% and 93.6%,
respectively. We believe that the location of the lesions
is probably a factor in determining the outcomes of
transplantation.
Our study has some advantages. First, we were able
to treat stable and small-sized childhood vitiligo
successfully and quickly with less pain. It is not
necessary for the children to be in hospital and they
will grow up without anxiety, with an improved qual-
ity of life after the operation. Second, for stabilized
childhood patients with large vitiligo lesions and
generalized vitiligo, we could only treat exposed
small-sized sites to improve the cosmetic effect. For
small-sized depigmented lesions, in comparison with
transplantation of autologous cultured melanocytes,
epidermal grafting could reduce any unnecessary
waste of time, money and materials. However, it
has several limitations. First, it is not practical to
apply autologous epidermal grafting for large-
sized vitiligo lesions because the ratio of donor site
to recipient skin size is 1:1. Second, it is unsuited to
the poor compliance of children.
In summary, the results of our study indicate that
autologous epidermal grafting is a rapid, safe and
effective treatment for small, stable vitiligo. It can
be considered in refractory and stable vitiligo in
children, especially in patients requesting urgent
treatment with small-sized, stable vitiliginous lesions.
Acknowledgement
The authors declare that they have no conflicts of
interest.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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