Surgical Treatment of Stable Vitiligo

When to Use What

Dalia Bassiouny, MD
Professor of Dermatology
Cairo University, Egypt
 Introduction
• Vitiligo is a major psychological problem
especially in dark-skinned individuals.
• Medical treatment especially PUVA is effective
but total re-pigmentation is rarely achieved
• In stable vitiligo several techniques of
autologous melanocyte transplantation are
used to achieve complete repigmentastion in
resistant areas.
 When to Use Surgical Therapy
Choice of Patient
• No signs of activity= stable vitiligo
– Stationary size of lesion for 1-3 years
– No recent development of new lesions
• Lesions refractory to medical treatment such
as:
– Stable segmental vitiligo ± leukotrichia
– Lesions with leukotricia
– Lesions over hands, feet, elbows or knees
 Contraindications for Surgical ttt
• Active vitiligo
– Lesions are increasing in size
– New lesions are developing
• Keloidal tendency
• Lichenified Skin over lesions
What if the patient is not sure about stability
 1. Minigrafting test
5-10 autologus minigrafts are implanted
into a vitiligo lesion and examined in 3-4 months

Grafts re-pigment and Grafts depigment or no

spread of pigment sign of pigment spread=
occurs= stable vitiligo active vitiligo

2. Koebnerization
Positive koebnerization is a sign of activity
Study of Clinical, biochemical & immunological
factors determining stability of disease in patients
with generalized vitiligo undergoing melanocyte
transplantation, Rao eta al., Br J Dermatol 2012;166:1230-36.
• 33 cases divided into 3 groups according to stability:
– Group 1: >3 months but < 1 year
– Group 2: ≥ 1 year but < 2 years
– Group 3 : ≥ 2 years
• 25 cases completed the follow-up. Success rate of SBEG
(significantly different, P=0.005):
– Group 1: 0% (< 1 year stability)
– Group 2: 37.5%
– Group 3: 77.8%
• Period of stability was significantly higher in responders.
Clinical features and histological findings are
potential indicators of activity in lesions of common
vitiligo. Benzekri et al, Br J Dermatol. 2013 Feb;168(2):265-
71.

• A standardized evaluation at start of study & 1

year later was done for 50 cases of vitiligo
including:
• Both the clinical changes and the histological
features of the lesions in actively spreading
vitiligo were compared with those in stable
vitiligo.
 Clinical features and histological findings are potential
indicators of activity in lesions of common vitiligo.
Benzekri et al, Br J Dermatol. 2013 Feb;168(2):265-71.
• The lesions were classified as hypomelanotic with poorly
defined borders (HPDB, 29 cases) correlated with activity or
amelanotic with sharply demarcated borders (ASDB, 21 cases).
correlated stable status (P < 0·001).
 When to Use Surgical Therapy
Choice of Patient
Minimum duration of Stability
1 Year

The longer the duration of stability the better

3 better than 2 years better than 1
Choose Lesions with sharply
demarcated borders
Which type of Surgical Therapy to use
Different Transplantation Methods

Tissue grafts Cellular grafts

Suction blister Cultured &
grafting Non-cultured
Split-thickness Autologous
grafting Melanocyte-
Full-thickness Keratinocyte
(Mini-Punch) Suspension
grafting Transplantation
 Tissue grafts
Suction blister grafting: Technique:

Usually, the grafts fall off in 1 to 2

weeks; so essentially this is a
Khunger et al, Ind J Dermatol, 2009)
technique of melanocyte transfer.
 Tissue Grafts
Suction blister grafting
Advantages: Disadvantages:
• It is a safe, easy, and • Time consuming & raising of
inexpensive method, blisters is painful.
with very good • Ratio of donor to recepient
success rates. 1:1 so larger areas require
multiple sittings.
• Repigmentation is
• Improper handling may lead
faster and the color to tearing of the graft or the
match is very good, epidermal side being
especially over the grafted, causing failure of
lips, eyelids and repigmentation.
areola
 Tissue Grafts
Split thickness grafting: Technique:

Khunger et al, Ind J Dermatol, 2009

 Tissue Grafts
Split thickness grafting:
Advantages: Disadvantages:
• Pigmentation can • Hyperpigmentation common
instantly cover larger esp on exposed areas in dark-
skinned patients.
areas over a short period
• Ratio 1:1 so large areas require
of time
multiple sittings due to
• Uniform pigmentation & limitation of the donor site.
no cobblestoning • Surgical skill is required to take
• No reagents, laboratory thin even grafts free-hand. (new
facilities or expensive electric dermatomes much
elaborate equipment are easier)
required
 Tissue Grafts
Mini Punch Grafting: (1 or 1.5 mm punches)
 Tissue Grafts
Mini Punch Grafting: (1 or 1.5 mm punches)
Advantages: Disadvantages:
• The easiest & least • Time-consuming
expensive • Cobblestoning may
• No special equipment or occur
laboratory set-up • Not suitable for body
• Very good results, larger folds
number of melanocytes • Donor site, superficial
transplanted compared to scar
epidermal or split thickness
grafts (Ratio 1:2)
 Cellular Grafting Techniques
• Donor skin sample: shave biopsy, suction blister
roof ,elliptical excision or Hair follicle units
• Sample preparation :
- Non-cultured Suspension : using Trypsin EDTA
0.25% of epidermal sample or HFU on the
same day to create a cell suspension.
- Pure melanocyte culture: 28 days in culture,
melanocytes number increased by 25 folds
• Recipient area: can be prepared using a manual
or motorized dermabrader, CO 2 or ErYAG laser
resurfacing or liquid nitrogen freezing
 Methods: Recipient Site Preparation:
Cryo-Cautery CO2 Laser Resurfacing
(5 to 8 sec 24 h before Power 12-20 Watts,
transplantation creating dwell time 600-1000 ms
10 mm cryoblebs spaced (according to site)
1-2 cm apart)
(Czajkowski et al.,2007)

Czajkowski R, Placek W, Drewa T, et al. Dermatol Surg 2007; 33: 1027–1036.

 Cellular Grafting Techniques
Non-Cultured Suspension
Advantages: Disadvantages:
• Less expensive than • Requires some
cultured Mel reagents (trypsin, Ham
transplantation medium)
• Less complicated • Special laboratory
procedure setup and trained
• Good donor to recipient personnel.
ratio ranging from 1:5
up to 1:10
 Cellular Grafting Techniques
Cultured Autologous Melanocyte Suspension
Advantages: Disadvantages:
• Very large donor to • Requires expensive
recipient ratio ( may growth factors and
reach 1:100) mutagens (? Safety
concerns)
• Advanced tissue culture
laboratory setup and
expert personnel.
• Lag period of weeks
 Tattooing
Advantages : Disadvantages:
• Relatively easy to • Poor colour matching esp
perform on sun exposed areas
where skin colour varies
• Minimal side effects
with tanning
• Loss of pigment with time
• Allergic or lichenoid
reaction to exogenous
pigment.
Different Transplantation Methods
Tissue grafts Cellular grafts
Suction blister Cultured &
grafting Non-cultured
Split-thickness Autologous
grafting Melanocyte-
Full-thickness Keratinocyte
(Mini-Punch) Suspension
grafting Transplantation

Which type of Surgical Therapy to use

 Site & Size
of lesion
Minipunch

Technical Skills
& Facilities
Small lesions Large lesions
Suction Blister Non-Cultured Mel-KC
Non-Cultured Mel-KC Split thickness grafts
(consider HFU)

Economical
Ability
Cultured Mel-Kc
suspension
 Which type of Surgical Therapy to use

Small Lesion

Dorsum hands Face

Fingers or Foot, (all except eyelids
Elbows, Knees

Mini Punch grafting

Mini punch grafting Non-Cultured Mel-KC
Non-cultured Mel-Kc
Suction blister
(using cryoblebs for Non-cultured Mel-Kc
Minipunch grafting
recipient) Suction blister
Suction blister

Eyelids: Non-cultured Mel-Kc Suspension

 Which type of Surgical Therapy to use

Large Lesion

Trunk Legs, Arms Face

Non-cultured Mel-Kc Non-Cultured Mel-KC

Non-cultured Mel-Kc Split thickness graft
Split thickness graft
(skilled surgeon) Split thickness graft (skilled surgeon)
(skilled surgeon)

Minipunch grafting or suction blister techniques may be used in sessions

Phototherapy after surgical grafting
• With the exception of split thickness grafting
all other techniques must be followed by
phototherapy to stimulate pigment spread
• PUVA-Sol is an economic alternative in our
sunny climate
The additive effect of excimer laser on NCES
transplantation for ttt of vitiligo: a clinical trial
in an Iranian population. Ebadi et al,J Eur Acad
Dermatol Venereol. 2014 Oct 28.
• 39 patches divided into 4 groups : 10 by combined
NCES & excimer, 10 suspension only, 10 by excimer
laser only and 10 untreated as control.
• Patches treated with combination therapy of excimer
and NCES responded best.
• However the % repigmentation was around 40%
which is lower than previous reports.
 A randomized controlled study of the effects of
different modalities of narrow-band ultraviolet B
therapy on the outcome of cultured autologous
melanocytes transplantation in treating vitiligo.
Zhang et al., Dermatol Surg 2014 Apr;40(4):420-6.
• 437 cases were divided into 4 groups:
– Group 1: 20 sessions before ttt,
– Group 2: 30 sessions after ttt,
– Group 3 underwent 20 sessions before & 30 after ttt
– Group 4 underwent only transplantation.
• Best response in group 3 cases >90% repigmentation was
achieved in 81.3% of patients, (significantly better than
the rest of the groups)
 Conclusion
• Stability >1 year is essential for good response,
the longer the stability the better the outcome
• Choice of technique depends on site & size of
the lesions, skills & facilities of the surgeon &
economic status of the patient
• Phototherapy combined with grafting improves
the results.
Dermatology Department
Cairo University, Egypt
Tha
nk
you