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DERMATOSURGERY ROUND
Year : 2012  |  Volume : 57  |  Issue : 4  |  Page : 282-284
Efficacy of suction blister epidermal graft without phototherapy for locally stable and resistant vitiligo


1 Research Center for Skin Disease and Cutaneous Leishmaniasis, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2 Resident of Dermatology, Mashhad University of Medical Sciences, Mashhad, Iran

Date of Web Publication29-Jun-2012

Correspondence Address:
Mahnaz Banihashemi
Department of Dermatology, Research Center for Skin Disease and Cutaneous Leishmaniasis, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad
Iran
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Source of Support: Research Council of Mashhad University of Medical Sciences, Mashhad, Iran.,, Conflict of Interest: None


DOI: 10.4103/0019-5154.97669

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   Abstract 

Introduction: Surgical methods for treatment of vitiligo include punch grafts, blister grafts, follicular grafts and cultured melanocyte grafts. The aim of this study was to determine the efficacy of suction blister grafts for treatment of vitiligo, without the use of phototherapy. Materials and Methods: This clinical trial study was conducted on 10 patients with vitiligo that was resistant to usual treatments and with limited involvement in the affected sites. We used cryotherapy and a manual suction device for blistering at the recipient and donor sites, respectively. The blister was separated and fixed with sutures and a dressing to the recipient site. Repigmentation of lesions was evaluated monthly for 6 months after treatment. Repigmentation rates higher than 90%, between 71%-90%, from 51%-70%, and less than 50% were graded as complete, good, moderate, and poor, respectively. Results: Ten patients (five females with a mean age of 23.2±3.96 years and five males with a mean age of 30.60±4.15 years) were enrolled in the study. Reponses to treatment after a 6-month follow-up were 'complete,' 'good,' and 'moderate' in 7 (70%), 1 (10%), and 2 (20%) patients, respectively. Conclusion: With this technique, patients with restricted sites of involvement, that did not respond to the usual treatments showed very good repigmentation without any additional phototherapy over a 6-month follow-up; moreover, there were no side effects such as scarring.


Keywords: Blister graft, PUVA, repigmentation, vitiligo


How to cite this article:
Maleki M, Banihashemi M, Sanjari V. Efficacy of suction blister epidermal graft without phototherapy for locally stable and resistant vitiligo. Indian J Dermatol 2012;57:282-4

How to cite this URL:
Maleki M, Banihashemi M, Sanjari V. Efficacy of suction blister epidermal graft without phototherapy for locally stable and resistant vitiligo. Indian J Dermatol [serial online] 2012 [cited 2019 Jul 19];57:282-4. Available from: http://www.e-ijd.org/text.asp?2012/57/4/282/97669

What was known? Suction Blister graft without PUVA Therapy is an effective treatment for stable Vitiligo.



   Introduction Top


Vitiligo is an acquired pigmentary disorder that is caused by loss of melanin, resulting in depigmented skin, mucous membrane, eyes, and sometimes hair bulbs. It occurs worldwide, with a prevalence of 0.1%-2% in various populations. [1],[2] A number of therapeutic options for regimentation are available. Narrow-band UVB is effective and considered by many to be the first choice for most patients. [3],[4],[5],[6] Psoralens and UVA treatment is the most important treatment for generalized vitiligo that affects more than 10%-20% of the cutaneous surface. For localized vitiligo, topical corticosteroids or calcineurin inhibitors are the most valuable treatments. [4]

Surgical techniques have also been introduced for stable, segmental and unresponsive vitiligo. A number of dermatosurgery techniques are available to promote repigmentation of vitiligo in adults and children, such as mini- or punch grafts, split-thickness skin grafts, cultured epidermal sheets, cultured melanocyte suspensions, follicular grafts and suction blister grafts. [7],[8],[9],[10],[11],[12],[13],[14],[15],[17],[18] Among these methods, the highest success rates have been achieved with split-thickness skin grafts and epidermal blister grafts. For better results, phototherapy or photochemotherapy of donor sites can also be performed after or before grafting. [19],[20],[ 21] Because phototherapy is not without limitations and side effects, the aim of the present study was to evaluate treatment of stable vitiligo in Iranian patients using suction blister grafting, without phototherapy either before or after grafting.


   Materials and Methods Top


The patients enrolled in this study had limited vitiligo that was stable but resistant to common treatments. They were admitted to the dermatology ward of the Imam Reza Hospital, Mashhad, Iran. Patients excluded from the study included those with unstable disease and those under 18 years (because of the pain associated with surgical procedures). All patients were advised to discontinue previous treatments at least 1 month before the grafting procedure to minimize any possible drug effects.

The day before surgery, relatively intense cryotherapy was done at the vitiligo-affected recipient site. Cryotherapy was performed with liquid nitrogen and a cotton swab through two cycles of 15-20 seconds, with 20 seconds intervals. On the day of surgery, a donor site was selected on the medial aspect of the thigh (with normal skin) and the area was cleaned first with povidone iodine and then with normal saline. After local anesthesia, the site was attached to the vacuum device and the device piston was pulled steadily to produce a high negative pressure. For blister induction at the donor site, we used a YUEXIAO™ vacuum device (made in China) that is originally intended for relieving muscle and joint pain [Figure 1]. After about 3-4 hours of application of suction, the blister was ready and was removed by scalpel or scissors and placed in a dish containing normal saline. The donor site was dressed with antibiotic ointment and Vaseline gauze. After removing the roof of the donor and recipient site blister, donor graftable epidermis was placed on the recipient site, sutured with 6-0 nylon and then covered with antibiotic ointment and Vaseline gauze. To prevent shifting of the graft, wet sterile cotton was applied over the area and covered with sterile gauze, with the dressing firmly bound in place with a compression bandage. After surgery, a 7-day course of antibiotic (cephalexin 500 mg qid orally) was given and the patient was advised to keep the site immobilized for a week. The dressing was changed after a week and sutures were removed after 2 weeks. Finally, repigmentation rates were evaluated by comparing images of the lesions every month for 6 months after surgery. Repigmentation rates >90%, 71%-90%, 51%-70%, and <50% were graded as 'complete,' 'good,' 'moderate,' and 'poor,' respectively.
Figure 1: The vacuum device that was used for this study

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   Results Top


In this study, 10 patients (5 female and 5 male) with stable vitiligo were evaluated for response following suction blister grafting, without pre- or post-graft phototherapy. The mean ages of our male patients and female patients were 30.60±4.15 and 23.20±3.96, respectively. Responses to treatment at different follow-up evaluations are presented in [Table 1]. No gender differences were noted in the response to treatment, although 'complete' responses were more common in men and 'moderate' responses were more common in women. Responses to treatment were mild, moderate, good, and complete in 20%, 20%, 40%, and 20% of patients, respectively, after 1 month of follow- up. After 5 and 6 months of follow-up, moderate, good, and complete responses were found in 20%, 10%, and 70% of patients, respectively [Figure 2].
Figure 2: (a) before the blister graft, (b) 1 month after graft surgery, and (c) 6 months after graft surgery

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Table 1: Responses to blister graft surgery at different follow-up evaluations in female (F) and male (M) patients.

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   Discussion Top


Vitiligo should initially be treated with medical therapy. When the therapy fails in spite of all appropriate interventions, surgical treatment may be indicated. [3] Autologous skin grafts can be obtained from uninvolved skin using several techniques, including a number of dermatosurgery techniques. [1] Each method has its advantages and disadvantages. The mini-graft is the simplest, least expensive, and most commonly used, but it has the highest rate of adverse effects, with 35% risk of cobblestone appearance at the recipient site and hypopigmentation and keloid formation at the donor site. [22],[23] Thin split-thickness grafting has the highest mean success rate (87%) according to a systematic review by Njoo et al. [19] Transplantation of cells cultured in vitro from a small piece of donor skin is also used for treatment of large areas by expanding the melanocyte population; however, this method is very expensive and requires special and advanced laboratory facilities that is now available only at a few academic centers. [3] Suction blister grafting is accomplished by suction of viable epidermis from dermis and pigmented epidermis is used for coverage of achromic areas. In most studies in the literature, when epithelization was completed (usually after 1 week) phototherapy was used to induce proliferation and migration of melanocytes in the recipient sites. [24],[25],[26] The repigmentation rate in these studies, according to the review by Njoo et al., was 87%, whereas Ozdemi et al. reported rates between 25%-65%. [19],[27] In a similar study in our region, Maleki et al. evaluated ten patients with refractory vitiligo who were treated by suction blister graft and subsequent PUVA therapy and reported over 90% repigmentation in seven patients. [28] Nanda et al. evaluated six patients with resistant eyelid vitiligo who underwent suction blister grafting without phototherapy (as performed in the present study) and reported repigmentation in all cases. [29]

In our study, blister grafting without phototherapy showed excellent results in 70% of our patients. The advantages of this technique include low cost, absence of scarring and the possibility of reusing the donor site. The disadvantages are that it is time consuming, painful and not suitable for large areas, uneven surfaces and the palm. Our study shows that this technique is effective and safe for treating stable and limited vitiligo especially when phototherapy is not available.


   Acknowledgment Top


The authors greatly appreciate the financial support provided by the Research Council of Mashhad University of Medical Sciences, Mashhad, Iran for this student thesis (2160). We thank Dr Musa Mirshekar and all the dermatology residents of Imam Reza Hospital for their assistance in this evaluation. We also thank Hadis Yousefzadeh for her assistance in preparing this paper.

 
   References Top

1.Halder RM, Taliaferro SJ. Vitiligo. In: Fitzpatrick's Dermatology in General Medicine. Wolff K, Goldsmith LA, Katz SI,Gilchrest BA, Paller AS, Leffell DJ, editors. New York: McGraw Hill; 2008. p. 611-22.  Back to cited text no. 1
    
2.Majumder MP. Genetic and prevalence of vitiligo vulgaris. In: Vitiligo. Hann BK, Nordlund JJ, editors. Hoboken, New Jersey: Blackwell Sience; 2000. p. 18-20.  Back to cited text no. 2
    
3.Anstey AV. Disorders of Skin Colour. In: Rook's Textbook of Dermatology. Burns T, Breathnach S, Cox N, Griffiths CEM, editors. Vol 58. Hoboken, New Jersey: Wiley Blackwell; 2010. p. 47-50.  Back to cited text no. 3
    
4.Ortonne JP. Pigmentary disorders. In: Dermatology. Bolognia JL, Jorrizo JL, Rapini RP, editors. 2 nd ed. Philadelphia: Mosby Elsevier; 2008. p. 913-20.  Back to cited text no. 4
    
5.Westerhof W, Nieuweboer-Krobotova L. Treatment of vitiligo withUV-B radiation vs topical psoralen plus UV-A. Arch Dermatol 1997;133:1525-8.  Back to cited text no. 5
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6.Scherschum L, Kim JI, Lim HW. Narrow-band ultraviolet B is a useful and well tolerated treatment for vitiligo. J Am Acad Dermatol 2001;44:999-1003.  Back to cited text no. 6
    
7.Falabella R, Barona MI. Update on skin repigmentation therapies in vitiligo. Pigment Cell Melanoma Res 2009;22:42-65.  Back to cited text no. 7
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8.Agrawal K, Agrawal A. Vitiligo: Repigmentation with dermabrasion and thin split thickness skin graft. Dermatol Surg 1995;21:295-300.  Back to cited text no. 8
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9.Falabella R. Repigmentation of segmental vitiligo by autologous minigrafting. J Am Acad Dermatol 1983;9:514-21.  Back to cited text no. 9
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10.Khunger N, Kathuria SD, Ramesh V. Tissue grafts in vitiligo surgery - past, present, and future. Indian J Dermatol 2009;54:150-8.  Back to cited text no. 10
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11.Lahiri K. Evolution and evaluation of autologous mini punch grafting in vitiligo. Indian J Dermatol 2009;54:159-67.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.Lahiri K, Malakar S, Sarma N, Banerjee U. Repigmentation of vitiligo with punch grafting and narrow-band UV-B (311 nm) a prospective study. Int J Dermatol 2005;45:649-55.  Back to cited text no. 12
    
13.Gauthier Y, Surleve-Bazeille JE. Autologous grafting with noncultured melanocytes: A simplified method for treatment of depigmented lesions. J Am Acad Dermatol 1992;26:191-4.  Back to cited text no. 13
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14.Guerra L, Capurro S, Melchi F, Primsvera G, Bondanza S, Cancedda R, et al. Treatment of 'stable' vitiligo by Timedsurgery and transplantation of cultured epidermal autografts. Arch Dermatol 2000;136:1380-9.  Back to cited text no. 14
    
15.Kim CY, Yoon TJ, Kim TH. Epidermal grafting after chemical epilation in the treatment of vitiligo. Dermatol Surg 2001;27:855-6.  Back to cited text no. 15
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16.Falabella R. Grafting and transplantation of melanocytes for repigmenting vitiligo and other types of leukoderma. Int J Dermatol 1989;28:363-9.  Back to cited text no. 16
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17.Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988;124:1656-8.  Back to cited text no. 17
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18.Hong W, Hu DN, Qian GP, McCormick SA, Xu AE. Treatment of vitiligo in children and adolescents by autologous cultured pure melanocytes transplantation with comparison of efficacy to results in adults. J Eur Acad Dermatol Venereol 2011;25:538-43.  Back to cited text no. 18
    
19.Njoo MD, Westerhof W, Bos JD, Bossuyt PM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998;34:1543-9.  Back to cited text no. 19
    
20.Hann SK, Im S, Bong HW, Park YK. Treatment of stable vitiligo with autologous epidermal grafting and PUVA. J Am Acad Dermatol 1995;32:943-8.  Back to cited text no. 20
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21.Suga Y, Butt KI, Takimoto R, Fujioka N, Yamada H, Ogawa H, et al. Successful treatment of vitiligo with PUVA-pigmented autologous epidermal grafting. Int J Dermatol 1996;35:518-22.  Back to cited text no. 21
    
22.Babu A, Thappa DM, Jaisankar TJ. Punch grafting versus suction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol Surg 2008;34:166-78.  Back to cited text no. 22
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23.Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006;45:411-7.  Back to cited text no. 23
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24.Lee AY, Jang JH. Autologous epidermal grafting with PUVA-irradiated donor skin for the treatment of vitiligo. Int J Dermatol 1998;37:551-4.  Back to cited text no. 24
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25.Ortonne JP, MacDonald DM, Micoud A, Thivolet J. PUVA-induced repigmentation of vitiligo: A histochemical (split-DOPA) and ultrastructural study. Br J Dermatol 1979;101:1-12.  Back to cited text no. 25
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26.Awad SS, Abdel-Raof H, El-Din WH, El-Domyati M. Epithelial grafting for vitiligo requires ultraviolet A phototherapy to increase success rate. J Cosmet Dermatol 2007;6:119-24.  Back to cited text no. 26
    
27.Ozdemir M, Cetinkale O, Wolf R, Kotogyan A, Mat C, Tüzün B, et al. Comparison of two surgical approaches for treating vitiligo: A preliminary study. Int J Dermatol 2002;41:135-8.  Back to cited text no. 27
    
28.Maleki M, Javidi Z, Ebrahimi_rad M. Treatment of Vitiligo with Blister Grafting Technique. Iranian J Dermatol 2008;11:55-9.  Back to cited text no. 28
    
29.Nanda S, Relhan V, Grover C, Reddy BS. Suction blister epidermal grafting for management of eyelid vitiligo. Dermatol Surg 2006;32:391-2.  Back to cited text no. 29
    

What is new? This study shows our technique is a simple, low cost and effective treatment especially when phototherapy is not available.


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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    Materials and Me...
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