Journal of Dermatological Treatment.

2014; 25: 200–204

ORIGINAL ARTICLE

Follow-up study of vitiligo patients treated with autologous epidermal

sheet transplants

NA LU, AIE XU & XINGANG WU

Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third Hospital of Hangzhou,
Hangzhou, China

Abstract
Background: Autologous epidermal transplantation is available for the treatment of stable vitiligo. However, the results of this
technique are affected by many factors. Objectives: It is important to investigate the long-term results and factors that might
influence the outcome of the autologous epidermal grafting technique to form a basis for guidance for patients with vitiligo.
Methods: We performed a follow-up study involving 173 patients (95 male, 78 female) with vitiligo vulgaris and 109 patients
(59 male, 50 female) with segmental vitiligo who underwent autologous epidermal grafting. We investigated the long-
term percentage of repigmentation and colour matching up to 13 years after treatment (mean 1.87 years). Results: The mean
percentage of repigmentation in the total of 1938 sheets was 80.65%. In patients with vitiligo vulgaris, 110 (63.6%) showed
excellent repigmentation, 18 (10.4%) showed good, 4 (5.8%) showed fair and 12 (20.2%) showed poor repigmentation. In
patients with segmental vitiligo, 83 (76%) showed excellent repigmentation, 10 (9%) showed good, 4 (4%) showed fair and
12 (11%) showed poor repigmentation. In segmental vitiligo, the degree of repigmentation was significantly higher than that in
vitiligo vulgaris lesions. Better outcomes were obtained in female patients and less than 20 years old patients, whereas results in
male patients and more than 20 years old were inferior in both vitiligo vulgaris and segmental vitiligo patients. The face and
neck had a higher completely matching ratio in the treated area with the surrounding skin compared to the non-exposed sites.
However, the face and neck had a lower repigmentation in vitiligo vulgaris. There was a higher ratio of Koebner phenomenon
on the donor site and new lesions on the other sites in 45 no repigmentation patients. Conclusions: Autologous epidermal
transplantation achieves a high percentage of repigmentation which is affected by sex, age, types, position, duration and the
stability time before transplantation in vitiligo patients. A more perfect colour matching was obtained in exposure sites. Disease
activity after transplantation was very important for repigmentation or not.

Key words: vitiligo, autologous epidermal transplantation, follow-up study

Introduction of stable vitiligo. In patients with vitiligo, it has proven

Vitiligo is a common acquired pigment disorder, char-
acterized by sharply demarcated depigmented lesions
of the skin. The disease can cause significant social and
psychological distress with different treatment modali-
ties. The treatment of vitiligo is challenging; although
medical therapies are the primary treatments, some
patients are refractory to medical treatment. In such
patients, autologous epidermal transplantation is a
simple and frequently used technique for the treatment
to be a successful treatment (1,2). However, the out-
come is influenced by many factors. In the present
study, we evaluate the long-term results of autologous
epidermal transplantation in vitiligo by measuring per-
centage of repigmentation and colour. Furthermore,
we analyse the influence of sex, age, type of vitiligo,
sites, duration of the disease, the steady time before
transplantation, the follow-up time and on the out-
come of grafting and assess the influence of disease
activity on no repigmentation patients.

Correspondence: Aie Xu, MD, Department of Dermatology, Hangzhou Institute of Dermatology and Venereology, The Third Hospital of Hangzhou, 38 Xi Hu
Da Dao, Hangzhou, Zhejiang 310009, China. E-mail: xuaiehz@msn.com.

(Received 29 November 2011; accepted 20 February 2012)

ISSN 0954-6634 print/ISSN 1471-1753 online
2014 Informa Healthcare USA on behalf of Informa UK Ltd.
DOI: 10.3109/09546634.2012.671912

Methods
A follow-up of 282 patients, who had been treated by
autologous epidermal grafting between 1998 and
2010, was carried out by clinical examination between
2010 and 2011. Age range of patients varied from 8 to
56 years, with a mean age of 23.4 years. Vitiligo
patients were categorized into two types: vitiligo vul-
garis 173, segmental vitiligo 109. The steady time of
vitiligo before grafting ranged from 4 months to
10 years, with a mean steady time of 2.1 years. The
duration period of vitiligo ranged from 1 to 30 years,
with a mean duration time of 6.55 years. A mean
follow-up period was 1.87 years. The longest follow-
up period was 13 years.
The procedure
Seventy-five per cent alcohol was used to sterilize the
depigmented recipient areas and the donor areas.
Suction cups were applied on the shaved inner aspect
of the abdominal area over normal-looking skin as well
as the lesions. Enough negative pressure (–300 mmHg)
was allowed for approximately 1–2 h while the patient
was sitting in a comfortable position until blisters
evolved underneath the transparent cups. A small
pair of scissors was then used to deroof the blister
on a recipient glass slide and a nipper was used to grind
until punctate haemorrhage occurred. The harvested
layers consisted of only epithelium with no dermal
components. Good homeostasis was ensured on the
recipient dermabraded areas and the grafts were then
applied smoothly, affirming direct contact between the
graft and recipient site. Styptic plaster was applied
smoothly on the grafts and then removed after
1 week. The sheets were applied to the recipient areas
or abscission from the recipient areas.
In all patients, the percentage of repigmentation
was measured by the pictures that were taken before
grafting and at the last follow-up time. The total
percentage of repigmentation was the ratio of the
repigmented sheets and the grafted sheets.
Repigmentation was graded as excellent with
95–100% pigmentation, good with 65–94%, fair
with 25–64% and poor with 0–24% of the treated
area. The degree of colour mismatch was divided into
three levels: (1) mild, (2) moderate and (3) severe.
Table I. The degree of repigmentation in patients with segmental vitiligo and vitiligo vulgaris.
No. of patients Sheets of transplanted
Segmental 109 842
Vulgaris 173 1096
Vitiligo autologous epidermal transplantation 201
Statistical analysis
Statistical assessments were performed using SPSS
16.0 for Windows.
Results
Assessment of repigmentation
In this study, we analysed the long-term results of auto-
logous epidermal grafting in 173 patients (95 male,
78 female) with vitiligo vulgaris and 109 patients
(59 male, 50 female) with segmental vitiligo. The
patients’ characteristics are shown in Table I. A total
of 282 patients with 1938 sheets were observed in our
study; 1563 sheets had been repigmented at the
follow-up time. The mean percentage of repigmen-
tation in the total of 1938 sheets was 80.65%.
The results of repigmentation in patients with seg-
mental vitiligo were significantly better than those in
patients with vitiligo vulgaris (c2 = 28.383, p < 0.001)
(Table I).
Segmental vitiligo (Table II)
In patients with segmental vitiligo, 83 (76%) patients
showed excellent repigmentation, 10 (9%) patients
showed good, 4 (4%) patients showed fair and
12 (11%) patients showed poor repigmentation.
Results of the percentage of repigmentation are shown
in Table I.
Age and gender: The mean repigmentation of the
female patients was higher than that of the male
patients (c2 = 16.822, p < 0.001). Patients who
were younger at the time of grafting tended to have
a higher degree of repigmentation (p = 0.002).
Treatment location: Best treatment results were
obtained on the extremities area (its repigmentation
reaches up to 90%). Lesions on the neck and face, the
trunk also responded well (the mean repigmentation
was 84.9% and 83.9% respectively). However, this dif-
ference did not reach statistical significance (p = 0.121).
The follow-up time: A significant lower repigmen-
tation was observed in patients for more than 1
follow-up year than in patients for less than 1
follow-up year (the mean repigmentation was
89.2% and 81% respectively) (p = 0.001).
Sheets of repigmented The mean repigmentation (%)
725 86.1 c2 = 28.383,
p < 0.001
838 76.5
202 N. Lu et al.

Table II. The degree of repigmentation and its relation to disease parameters in patients with segmental vitiligo.
No. of Sheets of Sheets of The mean
patients transplanted repigmented repigmentation (%)

Gender c2 = 16.822, p < 0.001

Male 50 487 399 81.9
Female 59 355 326 91.8
Age of onset c2 = 9.327, p = 0.002
Younger than 20 years 57 398 358 89.95
Older than 20 years 52 444 367 82.7
Position c2 = 4.224, p = 0.121
Extremities 20 231 208 90
Trunk 18 155 130 83.9
Neck and face 71 456 387 83.9
Stability time before grafting c2 = 14.504, p < 0.001
Less than 2 years 56 340 274 80.6
More than 2 years 53 502 451 89.8
Duration c2 = 7.625, p = 0.006
Less than 5 years 67 397 328 82.6
More than 5 years 42 445 397 89.2
Follow-up time c2 = 11.166, p =0.001
Less than 1 year 53 527 470 89.2
More than 1 year 56 315 255 81

The stability time before transplantation: Patients with
the stability time for less than 2 years had a signifi-
cantly lower degree of repigmentation at the acceptor
site than patients for more than 2 years (the mean
repigmentation was 80.6% and 89.8% respectively).
The duration of vitiligo: There was a trend for
patients for more than 5 years duration to have a
higher degree of repigmentation than patients for less
than 5 years duration (c2 = 14.298, p < 0.001).
Vitiligo vulgaris(Table III)
Of 173 vitiligo vulgaris patients, an excellent response
was seen in 110 (63.6%) patients, a good response
was noted in 18 patients (10.4%) and the response to
treatment was fair in 10 patients (5.8%), while
35 patients (20.2%) had poor repigmentation at the
end of the follow-up period.
Age and gender: The mean repigmentation of the
female patients was higher than that of the male
patients (c2 = 23.97, p < 0.001). We also found
that younger patients responded better to the treat-
ment in vitiligo vulgaris, but it was not significant
(c2 = 2.008, p = 0.156).
Treatment location: Best treatment results were
obtained on extremities and on the back of the feet
and hands (not including the joints), which may be
attributed to the total number of sheets, which were
far less on the back of the feet and hands than other
sites [it concerned only 18 patients (139 sheets) and
13 patients (69 sheets)]. The neck and face group was
generally the most difficult area to repigment.
The follow-up time: A significant lower repigmenta-
tion was observed in patients for more than 1 follow-
up year than patients for less than 1 follow-up year
(the mean repigmentation 81.7% and 73.1%
respectively).
The stability time before transplantation: Patients with
the stability time for less than 2 years had a signifi-
cantly lower degree of repigmentation at the acceptor
site than patients for more than 2 years (the mean
repigmentation was 65.3% and 89% respectively).
The duration: There was a trend for patients for
more than 5 years duration to have a higher degree of
repigmentation than patients for less than 5 years
duration (c2 = 12.19, p < 0.001).
Assessment of colour mismatch
A total of 615 sheets on the treated area were mod-
erate compared to the surrounding skin; only 89 sheets
were mild; 860 sheets were severe. The degree of
colour mismatch was mainly severe. In 297 sheets, no
colour differences could be observed between the
 Vitiligo autologous epidermal transplantation 203

Table III. The degree of repigmentation and its relation to disease parameters in patients with vitiligo vulgaris.
No. of Sheets of Sheets of The mean
patients transplanted repigmented repigmentation (%)

Gender c2 = 23.97, p < 0.001

Male 95 642 457 71.2
Female 78 454 381 83.9
Age of onset c2 = 2.008, p = 0.156
Younger than 20 years 63 367 290 89.95
Older than 20 years 110 729 548 82.7
Position c2 = 53.933, p < 0.001
Extremities 18 139 127 91.4
Trunk 57 364 295 81
Acral 13 69 63 91.3
Neck and face 85 524 353 67.4
Stability time before grafting c2 = 85.161, p < 0.001
Less than 2 years 108 579 378 65.3
More than 2 years 65 517 460 89
Duration c2 = 12.19, p < 0.001
Less than 5 years 88 458 326 71.2
More than 5 years 85 638 512 80.3
Follow-up time c2 = 10.807, p = 0.001
Less than 1 year 70 427 349 81.7
More than 1 year 103 669 489 73.1

treated area and the surrounding skin. The mean time
of the treated area completely accord with the sur-
rounding skin was 2.791 months. The longest time
was 1 year. No found need longer time.
Lesions on the acra demonstrated hyperpigmenta-
tion more frequently compared to other sites, while
those on the face and neck presented more often
moderate compared to other sites. So colour mis-
match was significant linked to treatment sites.
A significant higher hyperpigmentation was obser-
ved within 1-year follow-up period (60.86%) com-
pared to the follow-up period over 1 years (51.35%)
(c2 = 12.912, p < 0.001). There was a repigmentation
of 222 sheets over 5 years, all the same 148 sheets
were severe.
difference was noticed between them (c2 = 12.912,
p < 0.001).
Among 45 patients of no repigmentation,
24 (53.33%) had new lesions on other sites, while
only 54 (22.78%) had the same phenomenon among
237 patients of repigmentation (c2 = 17.639,
p < 0.001).
New lesions were noticed in a nontransplanted area
in 23 segmental vitiligo patients while the transplanted
area stayed pigmented. In those 13 patients who had
recurrence at treatment area after repigmentation,
8 patients were generalized vitiligo and 5 patients
were focal vitiligo. However, we found 23 segmental
vitiligo, 10 focal vitiligo, 36 generalized vitiligo and
9 acral vitiligo had new lesions on the other sites.

Assessment of no repigmentation patients Discussion

Forty-five patients were no repigmentation at follow-
up time. Thirty-two patients were no repigmentation
at all, while 13 patients were recurrent at treatment
area after repigmentation.
In 45 patients of no repigmentation, 14 (31.11%)
patients had a Koebner phenomenon on the donor site,
while only 30 (12.66%) had the same phenomenon
among 237 patients of repigmentation. A significant
In this study, the percentage of repigmentation in the
total of 282 patients was 80.65%. After a mean follow-
up of 1.87 years, we found mean repigmentation in
76.5% of the patients with vitiligo vulgaris and 86.1%
of the patients with segmental vitiligo. The differences
in transplantation results between the two types of
leucoderma can probably be explained by aetiological
differences. The pathogenesis of vitiligo vulgaris is
204 N. Lu et al.
presumed to involve mainly immunological factors,
while segmental vitiligo is considered to be caused by
a neurogenic sympathetic disturbance and possibly
also a genetic anomaly restricted to the segment. We
hypothesize that the different pathogenetic back-
ground and particularly the lack of progression in
segmental vitiligo causes the good prognosis in the
long term. In patients with segmental vitiligo there are
no pigment cells in the hair follicles and no autoim-
mune component is involved in the aetiology, explain-
ing why UV light and corticosteroid treatments are
ineffective. Here, autologous epidermal transplanta-
tion is the method of choice. This had previously
been reported in other types of epidermal grafting
as well (3,4).
Olsson and Juhlin (1) proved no statistically signifi-
cant difference between the sex (but there was a slight
better outcome in women), and that the variation of
our outcome can be due to patient selection variations.
Gupta and Kumar (5) also reported that the transplant
effect was better in patients younger than 20 years,
which was the same with our result in segmental
vitiligo. But there was no statistical significance
between younger than 20 years and older than 20 years
in vitiligo vulgaris, which was also proved by Jin (6).
We found the result was better in patients with
stability of more than 2 years before grafting in two
types of vitiligo. Most investigators recommend 1 year
of clinical stability to select patients for surgical treat-
ment. It pointed to the need for careful selection of
patients in the groups with vitiligo. Patients with exten-
sive vitiligo vulgaris and those who have not had
completely stable, non-progressive vitiligo for at least
2 years should not be chosen for transplantation (7).
In tropical countries, the initial lesions of vitiligo are
often seen on sun-exposed areas. UV radiation may be
acting as a trauma (8). This may be a cofactor in
some patients for the poor response on the face and
the neck in vitiligo vulgaris in our study.
The result of patients with follow-up time for more
than 1 year was worse, which can be explained by that
the acceptor site could have lesions again in some time.
We also found the outcome was better in patients
with more than 5 years duration. It may be that the
patients with shorter duration had the shorter stability
time before grafting.
In this study, the degree of colour matching was
mainly severe. Juhlin (1) has also previously statistically
shown the high incidence of hyperpigmentation in
epidermal sheet grafting method when they show
that epidermal sheets are more likely to give hyperpig-
mentation compared to cultured melanocytes and
basal layer suspension respectively. We found colour
matching was significantly linked to treatment sites.
This may be explained by sun exposure.
Koebner phenomenon at donor sites and new
lesions on the other sites are both objective para-
meters for disease activity. Patients with a Koebner
phenomenon at the donor site had a significantly
lower degree of repigmentation at the acceptor site
than patients without a Koebner phenomenon. We
found a significantly higher rate of Koebner phenom-
enon at donor sites and new lesions on the other sites
in 45 patients who fail to repigment. The results of
grafting had a great relationship with disease activity.
Lee (9) found new lesions on non-transplanted area
presented in segmental vitiligo while the transplanted
area remained good. We also found new lesions were
noticed in a non-transplanted area in 23 patients with
segmental vitiligo and 9 patients with areal vitiligo
while the transplanted area stayed pigmented. It
deserved us to study further.
Conclusion
The technique of autologous epidermal transplanta-
tion is a simple, safe and effective surgical treatment
for the management of vitiligo.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
References
1. Olsson MJ, Juhlin L. Long-term follow-up of leucoderma
patients treated with transplants of autologous cultured mela-
nocytes, ultrathin epidermal sheets and basal cell layer suspen-
sion. Br J Dermatol. 2002;147:893–904.
2. Olsson MJ, Juhlin L. Epidermal sheet grafts for repigmentation
of vitiligo and piebaldism, with a review of surgical techniques.
Acta Derm Venereol. 1997;77:463–466.
3. Gupta S, Kumar B. Epidermal grafting in vitiligo: influence of
age, site of lesion and type of disease on outcome. J Am Acad
Dermatol. 2003;49:99–104.
4. Falabella R, Arrunategui A, Barona MI, Alzate A. The mini-
grafting test for vitiligo: detection of stable lesions for melano-
cyte transplantation. J Am Acad Dermatol. 1995;32:228–232.
5. Gupta S, Kumar B. Epidermal grafting in vitiligo: influence of
age, site of lesion, and type of disease on outcome. J Am Acad
Dermatol. 2003;49:99–104.
6. Jin Y, Xu A, Wang P, Song X, Liu X. Long-term follow-up and
correlated factors of vitiligo following autologous epidermal
transplantation. Cutis. 2011;87:137–141.
7. Olsson MJ, Juhlin L. Long-term follow-up of leucoderma
patients treated with transplants of autologous cultured mela-
nocytes, ultrathin epidermal sheets and basal cell layer suspen-
sion. Br J Dermatol. 2002;147:893–904.
8. Mulekar SV. Long-term follow-up study of 142 patients
with vitiligo vulgaris treated by autologous, non-cultured mela-
nocyte–keratinocyte cell transplantation. Int J Dermatol. 2005;
44:841–845.
9. Lee DY, Park JH, Lee JH, et al. Recurrence of segmental
vitiligo after epidermal grafting does not involve epidermal
grafting area. Clin Exp Dermatol. 2010;35:205–206.
Copyright of Journal of Dermatological Treatment is the property of Taylor & Francis Ltd
and its content may not be copied or emailed to multiple sites or posted to a listserv without
the copyright holder's express written permission. However, users may print, download, or
email articles for individual use.