Optimizing suction blister epidermal graft technique in the surgical treatment of vitiligo

Abstract: Surgical management of vitiligo is considered an excellent terapeutic option for recalcitrant cases, provided the disease is stable and there is absence of Koebner phenomenom. Among surgical modalities, Suction Blister Epidermal Graft is a low cost and effective option (65 to 100% repigmentation can be achieved in up to 80% of patients). We describe how it can be optimized by using an alternative suction equipment, by customization of graft format and by application of an anesthetic technique that substantially reduces procedure time.

Evaluation of treatment response to autologous transplantation of noncultured melanocyte/keratinocyte cell suspension in patients with stable vitiligo

Abstract Background: Vitiligo is a chronic disease characterized by the appearance of achromic macules caused by melanocyte destruction. Surgical treatments with melanocyte transplantation can be used for stable vitiligo cases. Objectives: To evaluate treatment response to the autologous transplantation of noncultured epidermal cell suspension in patients with stable vitiligo. Methods: Case series study in patients with stable vitiligo submitted to noncultured epidermal cell suspension transplantation and evaluated at least once, between 3 and 6 months after the procedure, to observe repigmentation and possible adverse effects. The maximum follow-up period for some patients was 24 months. Results: Of the 20 patients who underwent 24 procedures, 25% showed an excellent rate of repigmentation, 50% good repigmentation, 15% regular, and 10% poor response. The best results were observed in face and neck lesions, while the worst in extremity lesions (88% and 33% of satisfactory responses, respectively). Patients with segmental vitiligo had a better response (84%) compared to non-segmental ones (63%). As side effects were observed hyperpigmentation of the treated area and the appearance of Koebner phenomenon in the donor area. Study limitations: Some limitations of the study included the small number of patients, a subjective evaluation, and the lack of long-term follow-up on the results. CONCLUSION: Noncultured epidermal cell suspension transplantation is efficient and well tolerated for stable vitiligo treatment, especially for segmental vitiligo on the face and neck.

Recipient site preparation for epidermal graft in stable vitiligo by a special fraise

BACKGROUND: The only approach used in the refractory lesions of stable vitiligo is the surgical supply of melanocytes. Suction Blistering Epidermal Graft is one of the most common and effective techniques. There are multiple modalities, including the motor-driven diamond fraise, for the preparation of recipient sites in suction blistering epidermal graft with different repigmentation rates and complications. OBJECTIVES: To evaluate preparation of recipient site by a motor-driven dental lab finishing carbide bur. METHODS: Sixty-one stable, depigmented lesions were selected in 14 patients (9 women and 5men), aged 16-29 years, of which 9, 3 and 2 had localized, generalized and segmental vitiligo, respectively. Recipient site was prepared by a motor-driven dental lab finishing carbide bur. RESULT: Excellent repigmentation at the recipient site was observed in 53 out of 61 (86.9%) grafted lesions. Postinflammatory hyperpigmentation and perigraft halo were seen in 11 (18%) and 17 (27.9%) patients at the recipient site, respectively. CONCLUSION: Using a motor-driven dental lab finishing carbide bur to prepare the recipient site of suction blistering epidermal graft technique is reliable and effective, removing only the depigmented epidermis in a simple and safe manner, even on complex-shaped lesions and scar-prone sites. .

Epidermal curettage technique (ECT) for tissue harvest from the donor area for melanocyte autologous grafting in cases of vitiligo

Vitiligo is a dermatosis requiring complex treatment. In clinically stable cases, melanocyte autologous grafting has shown good results, using different methodologies for obtaining the donor area: dermatomes, punches, blisters. However, these techniques are complex and require specific instruments. This study presents a simple technique for melanocyte harvest that has been performed in our service for more than ten years and includes epidermal curettage of the donor area, grafting of the obtained material, which was homogenized with saline or hyaluronic acid, on the achromic area, and the application of a semipermeable dressing that is removed 1 week later.

Non-cultured melanocyte/keratinocyte transplantation for the treatment of stable vitiligo on the face: report of two cases / Transplante de suspensao celular de melanocitos/queratinocitos para o tratamento de vitiligo estavel na face: relato de dois casos

There are many alternatives to treat vitiligo, including surgical procedures, which are recommended for patients resistant to other therapies. The melanocyte/keratinocyte transplantation consists in the separation of epidermal cells obtained from a donor site and spreading these cells on the depigmented and dermabraded recipient area. Two patients were submitted to transplantation, showing more than 70% repigmentation in the treated areas after four months, both with excellent degree of satisfaction. The method requires some laboratory skills, but represents a simple and safe procedure.

Existem várias alternativas para o tratamento do vitiligo, incluindo procedimentos cirúrgicos, que são indicados para pacientes refratários aos outros tipos de tratamento. O transplante de suspensão celular de melanócitos/queratinócitos consiste na separação de células da epiderme obtidas de área doadora, e aplicação destas células na área receptora despigmentada, após dermoabrasão. Dois pacientes com vitiligo estável foram submetidos ao transplante de suspensão de melanócitos/queratinócitos, apresentando repigmentação acima de 70% nas áreas tratadas após quatro meses, ambos com excelente grau de satisfação. O método requer alguma habilidade laboratorial, mas representa um procedimento simples e seguro.

Manejo del vitiligo / Handling of the vitiligo

El vitiligo, caracterizado por máculas acrómicas de distribución localizada o generalizada, tiene una prevalencia de 0,1-2%. Su etiología es desconocida y el diagnóstico es generalmente clínico. Se asocia a enfermedades autoinmunes (como tiroiditis de Hashimoto y enfermedad de Graves) y a la afección de órganos que contienen melanocitos (uveitis e hipoacusia neurosensorial). La enfermedad afecta la calidad de vida. El objetivo del tratamiento es estabilizar el proceso de despigmentación y recuperar el pigmento de las lesiones (repigmentacion promedio del 70-75%). El tratamiento puede ser médico o quirúrgico y despigmentación en casos refractarios.Aunque no hay una opción terapéutica efectiva para todos los pacientes existe una variedad de terapias establecida, y recientemente desarrolladas, que podrían beneficiar a muchos de los que lo padecen. Un corto tiempo de evolución de la enfermedad parecería ser un factor que aumenta la posibilidad de éxito con cualquier modalidad terapéutica.

A study of autologous melanocyte transfer in treatment of stable vitiligo.

BACKGROUND: Replenishing melanocytes selectively in vitiliginous macules by autologous melanocytes is a promising treatment. With expertise in culturing melanocytes, it has now become possible to treat larger recipient areas with smaller skin samples. AIM: To study the extent of repigmentation after autologous melanocyte transplantation in patients with stable vitiligo. METHODS: The melanocytes were harvested as an autologous melanocyte rich cell suspension from a donor split thickness graft. Melanocyte culture was performed in selected cases where the melanocyte cell count was insufficient to meet the requirement of the recipient area. These cells were then transplanted to the recipient area that had been superficially dermabraded. RESULTS: An excellent response was seen in 52.17% cases with the autologous melanocyte rich cell suspension (AMRCS) technique and in 50% with the melanocyte culture (MC) technique. CONCLUSION: Autologous melanocyte transplantation can be an effective form of surgical treatment in stable but recalcitrant lesions of vitiligo.

Reliable site for suction blister induction and harvesting.

BACKGROUND: Suction blister grafting is a useful modality of treatment of patients with resistant and stable vitiligo. However, there have been no detailed studies to find out the best donor site for blister formation. METHODS: The study was conducted between the period of October 2004 and February 2005 in the dermatology department at a tertiary care center. Nine patients with vitiligo (focal vitiligo, 3; mucosal vitiligo, 2; acrofacial vitiligo, 2; vitiligo vulgaris, 1; and segmental vitiligo, 1) were selected for blister harvesting and grafting. The blisters were raised using the method described by Gupta et al. RESULTS: Suction blisters were attempted to be raised at 52 sites, but only 38 blisters could be raised, 24 complete and 14 incomplete. Blisters were raised in all the three cases on the flexor aspect of the arm (100%), 15 of 17 cases (88.2%) on the flexor aspect of the forearm, 4 of 5 cases (80%) on the abdomen, 11 of 16 cases (68.7%) on the anterolateral thigh, and less frequently over leg or foot. Complete blisters were formed in 13/15 cases (86.6%) on the flexor aspect of the forearm, 6/11 cases (54.5%) on the anterolateral thigh, and in all cases over leg. CONCLUSION: The flexor aspect of the forearm is a good site for suction blister harvesting.

Vitiligo: analysis of grafting versus curettage alone, using melanocyte morphology and reverse transcriptase polymerase chain reaction for tyrosinase mRNA

CONTEXTO E OBJETIVO: Estudos recentes têm indicado que áreas de vitiligo contêm melanócitos inativos ou dormentes. A síntese de melanina está relacionada com a presença de tirosinase é indicadora de estado metabólico ativo. O escopo deste artigo é comparar repigmentação, distribuição epidérmica de melanócitos e detecção do RNAm de tirosinase através da reação de polimerase em cadeia por transcriptase reversa, em amostras de tecido de vitiligo, antes e após curetagem, seguido ou não por uma nova técnica de enxerto autólogo de pele. TIPO DE ESTUDO E LOCAL: Prospectivo, na Disciplina de Dermatologia da Faculdade de Medicina do ABC, Santo André. MÉTODOS: Duas áreas de vitiligo foram curetadas. Uma foi subseqüentemente enxertada com pele autóloga sacral normal, enquanto a outra não recebeu nenhum enxerto. As áreas curetadas foram examinadas após 30 dias, para avaliar o grau de repigmentação. A porcentagem de melanócitos e a presença de RNAm de tirosinase de pele normal e de pele de vitiligo (antes e após curetagem apenas e antes e após curetagem seguida de enxertia) foram comparadas. RESULTADOS: Repigmentação completa foi observada em todas as áreas enxertadas, enquanto as áreas de vitiligo apenas curetadas apresentaram repigmentação parcial. A porcentagem de melanócitos nas áreas enxertadas excederam as áreas de vitiligo não tratados (p = 0.01) e as áreas tratadas com curetagem simples (p = 0,015). RNAm de tirosinase foi negativo em 93.75 por cento das áreas não tratadas de vitiligo. Após tratamento (somente curetagem ou curetagem seguida de enxerto), todas as lesões tornaram-se positivas para RNAm de tirosinase. CONCLUSÃO: Melanócitos metabolicamente inativos ou dormentes estão provavelmente presentes dentro das áreas de vitiligo, e podem ser ativados por estímulos endógenos ou exógenos.

Actualización en terapia de vitíligo / Current status of vitiligo therapy

El vitíligo es una enfermedad frecuente, de etiología desconocida y caracterizada por máculas acrómicas debido a pérdida de melanocitos. Según su localización puede ser altamente desfigurante, impactando negativamente en la calidad de vida de los afectados. En la actualidad no existe una terapia ciento por ciento efectiva en repigmentación. El vitíligo activo y de reciente comienzo responde bien con terapia médica; en conformidad con los principios de medicina basada en la evidencia, lo más efectivo son los corticoides tópicos en vitíligo localizado y PUVA o UVB en generalizado. La enfermedad estable o resistente puede tratarse quirúrgicamente, se describen técnicas efectivas y seguras, pero aún falta evidencia para hacer recomendaciones definitivas. Numerosas alternativas se encuentran actualmente en desarrollo: l-fenilalanina, pseudocatalasa y calcipotriol como medidas médicas y cultivos celulares en trasplantes.

Vitiligo is a frequent disease of unknown etiology characterized by depigmented patches due to loss of melanocytes. Depending on its location, it may cause important disfiguration, producing negative aesthetic impact. There is currently no 100 percent effective therapy. An active vitiligo of recent onset responds properly to medical therapy. In accordance with medical principles based on existing evidence, the most effective treatments are topical application of corticosteroids for localized vitiligo and PUVA or UVB for generalized vitiligo. The stable of resistant disease may be surgically treated. Effective and safe techniques are described, but there is still some evidence missing in order to make final recommendations. Numerous alternatives such as l-phenylalanine, pseudocatalase and calcipotriol - as well as cellular grafting with cells from cultures - are currently being developed.

Vitiligo: áreas tratadas por enxertia com raspados cutâneo e estudo da reaçäo de polimerase em cadeia de RNA mensageiro de tirosinase por transcritase reversa / Vitiligo: grafting areas with skin curettage and study of mRNA chair polymerase reaction by transcriptase

Quarenta pacientes com vitiligo - 22 com vitiligo generalizado 16 com vitiligo segmentar e dois com vitiligo peri-névico submeteram-se a enxertos de pele com uma nova técnica de implante (por raspagem cutânea) de execução simples. Estudou-se o comportamento da RTPCR de RNAM em áreas de vitiligo antes e após curetagem ou enxertia de pele. Para análise quantitativa de melanócitos empregou-se a contagem de células claras. Observou-se na evolução que as áreas tratadas com enxertia apresentaram 1OO por cento de repigmentação a partir do 30º dia, enquanto as áreas controle apresentaram pigmentação discreta a partir do 4º mês sem significância clínica. Observou-se o aumento estatisticamente significante do número de melanócitos nas áreas enxertadas e aumento sem significância estatística nas áreas controles. A RT-PCR de RNAM de tirosinase mostrou-se negativa em 93,75 por cento das 32 áreas de vitilígo examinadas previamente. Não se observaram diferenças estatisticamente significantes entre a positividade da RTPCR nas áreas enxertadas (1OO por cento) e nas áreas controle curetadas (82,4 por cento).Conclui-se da análise dos resultados que a técnica de enxertos Proposta se mostra eficaz na indução da repigmentação através da adição de melanócitos e que mesmo em indivíduos portadores de vitiligo de longa duração, permanecem células inativas capazes de produzir RNAM de tirosinase após estimulo adequado

Topical application of a melanotropin analogue to vulgar vitiligo dermo-epidermal minigrafts

Human subjects with active vulgar vitiligo do not respond well to autologous dermo-epidermal minigrafting. Eighteen subjects were treated with the a-melanocyte-stimulating hormone (a-MSH) synthetic analogue [Nle4, D-Phe7]-a-MSH. The hormone (50 µl, 0.4 mM) was applied topically to 30-cm2 lesions in which 29-48 minigrafts had been made. The hormone did not improve the success of the minigrafting and no differences were observed in local or distant repigmentation in treated subjects as compared to the placebo group. Aliquots of 24-h urine concentrated by lyophilization irreversibly darkened toad skins, demonstrating the presence of the analogue. This is the first report of the transdermal delivery of a topically applied melanotropin in living human subjects