Suction blister grafting for stable vitiligo using pulsed erbium:YAG laser ablation for recipient site

Plasma & urinary catecholamines & urinary vanillylmandelic acid levels in patients with generalized vitiligo

Background & objectives

Vitiligo is an acquired skin disease characterized by depigmented areas of the skin. Increased release of catecholamines from autonomic nerve endings in microenvironment of melanocytes in affected skin might be involved in the aetiopathogenesis of vitiligo. Levels of catecholamines are considered as being related to onset or worsening of the disease. Therefore, in this study, the role of catecholamines was evaluated in mapping disease stability and outcome of vitiligo patients undergoing melanocyte transfer.

Methods

In this study, circulatory and urinary levels of catecholamine (CA) and vanillylmandelic acid (VMA) were determined in 45 individuals (30 vitiligo patients and 15 healthy controls) using ELISA.

Results

A significant increase for plasma and urinary catecholamines along with VMA was observed as compared to healthy controls. When the pre- and post-intervention levels were analyzed in responders and non-responders, respectively, only dopamine showed significant decline in urine, rest of the molecules in plasma as well as urine showed non-significant decline except VMA which showed insignificant increase.

Interpretation & conclusions

Levels of plasma/urinary epinephrine, and plasma dopamine, could not be established as biomarkers for disease stability or successful outcome of autologous melanocyte transfer in generalized vitiligo patients. However, dopamine (urine) might be of help in determining the stability in patients with generalized vitiligo undergoing melanocyte transfer. Further studies need to be done on a large sample of patients to confirm our findings.

Vitiligo: a comprehensive overview Part II: treatment options and approach to treatment

Vitiligo is a common skin disorder that results in depigmentation. With the appropriate management, many patients can minimize disease progression, attain repigmentation, and achieve cosmetically pleasing results. There are numerous medical and surgical treatments aimed at repigmentation; therapies for depigmentation are available for patients with recalcitrant or advanced disease. The use of cosmetics at all stages of treatment may be vital to the patient's quality of life. Understanding all the available options helps choose the appropriate treatment plan and tailor it to your patient. Part II of this two-part series on vitiligo discusses the indications for, evidence behind, and adverse effects associated with many of the therapies used for vitiligo. Both conventional medical and surgical options are discussed in addition to several alternative and promising new therapies.

Vitiligo treatment options: An evolving scenario

Sequential displays of several treatment options for vitiligo have been scanned from the literature, and are presented here. A few of the medical modalities have been resigned to history, whereas others have become customary in clinical practice. There has also been a recent surge of interest in the surgical treatment of this disease. Accordingly, this has been appraised and summarized. Special attention has been given to prevalent medical modalities so that they may be effectively utilized by those currently in practice.

Treatment of periungual vitiligo with Erbium-YAG-laser plus 5-flurouracil: a left to right comparative study

Despite the multiple treatment modalities available for vitiligo, none of them gives satisfactory results in the periungual type. In this study we tried to explore and evaluate the effects of the combination treatment of erbium:YAG laser resurfacing and topical 5-flurouracil in periungual vitiligo. Nine adult patients presenting with periungual vitiligo lesions were included in this prospective left-right comparative study. The desirable inflammation was achieved after a mean of 4.7 days of 5-flurouracil application. The mean re-epithelization time in the treatment sessions was 11.3 days. The patients received a mean of 3.4 sessions in a mean duration of 7.6 months. The mean overall response to therapy in the treated group was 47.8% while in the control group it was 1.1% (P < 0.0001). No side effects necessitated the stoppage of treatment. This study points to the efficacy and safety of this combination in the treatment of periungual vitiligo.

Dermatosurgical techniques for repigmentation of vitiligo

There are a number of dermatosurgery techniques available to achieve repigmentation of vitiligo, such as suction blister grafting, split-thickness skin grafting, punch grafting, follicular grafting, cultured-melanocytes transplantation, and noncultured-melanocytes transplantation. Each method has advantages and disadvantages. As there are no specific data available from the prospective studies in this field it is uneasy to recommend which surgical approach to vitiligo offers the best result. According to a systematic review by Njoo et al.,(17) suction blister and split-thickness skin grafting have the highest rates of success (87%), while the average success rates for other methods varied from 13% to 53%. Punch grafting has the highest rate of adverse effects, including cobblestoning appearance (27%) and scar formation (40%) in the donor site. Accordingly, it is also mandatory to appropriately select vitiligo patients in order to achieve a complete and permanent repigmentation.

The Use of the 308-nm Excimer Laser for the Treatment of Vitiligo

BACKGROUND

Recent reports show that 308-nm excimer laser may be an effective and safe method for the treatment of vitiligo, which is usually resistant to other available treatment methods.

OBJECTIVE

The objective was to study the effectiveness of the new 308-nm excimer laser for the treatment of vitiligo.

METHODS

A retrospective chart review of thirty-two patients with 55 spots of vitiligo were enrolled; a population-based sample was studied that included men and women, adults and children, with different ethnic backgrounds. The treatment was started with the lowest dose, which is 100 mJ/cm(2) (comparable to one minimal erythema dose value and one multiplier). Depending on Fitzpatrick skin type, the dose was raised gradually in a stepwise fashion. In skin types I to II, the same does was repeated twice before going up to avoid burns. Patients were treated for 30 sessions, or 75% repigmentation, whichever comes first.

RESULTS

Overall 55 spots were treated: 29 (52.8%) had 75% pigmentation or greater, and 35 (63.7%) had 50% pigmentation or greater. The best results were on the face: of the 21 spots treated 15 (71.5%) had 75% pigmentation, and 16 (76.2%) had 50% pigmentation or greater. Other areas (neck, extremities, trunk, and genitals) had moderate response in comparison to the face. The least response was on the hands and feet; of the 5 spots treated only 20% showed 50% pigmentation or more.

CONCLUSION

Slightly more than 50% of the patients tested showed 75% or more pigmentation of their lesions, after 30 treatments or less; most of the responders had Fitzpatrick skin type III and above. All the untreated patches (controls) remained unchanged. This demonstrates that the 308-nm excimer laser is an effective method of treatment for vitiligo.

Efficacy of erbium YAG laser-assisted autologous epidermal grafting in vitiligo

BACKGROUND

Of the various modalities of therapy available for the treatment of vitiligo, a combination of psoralen + ultraviolet A (PUVA) with autologous epidermal grafting appears to offer the best results. The erbium YAG laser can be used to prepare the recipient site in both punch grafting and suction blister grafting.

METHODS

In this study 29 subjects, 26 with localized and three with generalized stable vitiligo, had received pregrafting PUVA and underwent further PUVA starting 2 weeks after surgery until maximal pigmentation was achieved. The erbium YAG laser was used on 16 subjects; the recipient site for punch grafting was prepared with laser and minigrafts harvested by manual punch were placed into the prepared sites. For suction blister grafting, the site was dermabraded with a laser and the harvested blister roof (created using suction apparatus) was transplanted on to the site.

RESULTS

More than two-thirds (68.75%) of the subjects who were punch grafted using a laser showed repigmentation of more than 75%, but only one-half of those who underwent conventional punch grafting showed a similar response. All subjects with laser-assisted suction blister grafting showed a good response, compared with only 60% of those who underwent conventional suction blister grafting.

CONCLUSIONS

The results obtained with laser-assisted grafting are more satisfactory than those achieved with conventional grafting techniques. We found that the repigmentation zones are larger (up to 9 mm in the former vs. 3 mm in the latter) and cobblestoning does not occur with laser-assisted grafting. Also, the procedure is precise, relatively atraumatic and can be performed rapidly even when covering vast areas.

Laser surgery for traumatic incomplete earlobe clefts

BACKGROUND

Various scalpel surgeries have been described to correct earlobe clefts secondary to wearing earrings. Limitations include notching, scarring, and technical difficulty operating on a small surface.

OBJECTIVE

To report the development of a more rapid and less complicated method of using a laser to partially close an incomplete earlobe cleft.

METHODS

An Er:YAG laser was used to deepithelialize the anterior and posterior lower border of an incomplete earlobe cleft followed by suturing the anterior and posterior defect.

RESULTS

An excellent result was obtained which left the pierced hole in its original location.

CONCLUSION

This technique is simple to perform and has definite advantages over other methods currently in use.

Treatment of vitiligo with suction epidermal grafting by the use of an ultrapulse CO2 laser with a computerized pattern generator

BACKGROUND

Laser ablation is used to remove the recipient epidermis in the suction epidermal grafting in vitiligo surgery.

OBJECTIVE

To evaluate the effectiveness and safety of a suction epidermal grafting method after the removal of the epidermis by the use of the Ultrapulse CO2 laser with a computerized pattern generator.

METHODS

Eleven patients with 34 lesions of refractory stable vitiligo were studied.

RESULTS

Of the 34 lesion sites, excellent repigmentation was seen in 30 and the other 4 had good repigmentation. No complications occurred.

CONCLUSION

The Ultrapulse CO2 laser is particularly well suited for deepithelialization in vitiligo surgery.