Silicone gel sheet dressings for prevention of post-minigraft cobblestoning in vitiligo

Value of silicone gel in prevention of cobblestoning following punch minigrafting in vitiligo

Background: Cobblestoning is the most common complication of minipunch grafting.Objective: To assess the value of silicone gel application following minipunch grafting and the histopathological and immunohistochemical changes in cases with cobblestoning.Methods: Minipunch grafting was performed in two similar vitiligo lesions in 27 cases with stable vitiligo. After healing, silicone gel was applied twice daily on one lesion while zinc oxide ointment was applied to the other lesion serving as a control. Four biopsies were taken from each case; normal, vitiliginous skin before treatment and the two treated lesions 3 months after therapy, for histopathology and immunohistochemical staining for MMP9 & tenascin-C.Results: Repigmentation occurred in 19 cases (70.7%). The number of lesions showing excellent and good response was significantly higher on the silicone gel side (p < .001). In 20 cases, cobblestoning either occurred or was absent on both sides. Histopathologically, cobblestoning was similar to hypertrophic scarring. Both markers were elevated after therapy on both sides with no significant difference in percentage change between lesions showing positive and negative cobblestoning.Conclusion: Silicone gel application after minigrating improved the final response with no significant effect on the occurrence of cobblestoning. Cobblestoning resembled hypertrophic scarring histopathologically.

Grafting in vitiligo: how to get better results and how to avoid complications

Grafting procedures in vitiligo have become quite popular over the last one or two decades especially in India. Starting with the simplest punch grafting we have now a multitude of different grafting techniques available in vitiligo. All of these grafting procedures are associated with certain complications. In addition there are certain factors and surgical pearls that can go a long way in improving the cosmetic results achieved with any of these grafting techniques. This paper will try to address these specific factors and complications associated with these grafting techniques and the ways and means to avoid them.

A useful method to overcome the difficulties of applying silicone gel sheet on irregular surfaces

To date, silicone gel and silicone occlusive plates are the most useful and effective treatment options for hypertrophic scars (surgical and traumatic). Use of silicone sheeting has also been demonstrated to be effective in the treatment of minor keloids in association with corticosteroid intralesional infiltration. In our practice, we encountered four problems: maceration, rashes, pruritus and infection. Not all patients are able to tolerate the cushion, especially children, and certain anatomical regions as the face and the upper chest are not easy to dress for obvious social, psychological and aesthetic reasons. In other anatomical regions, it is also difficult to obtain adequate compression and occlusion of the scar. To overcome such problems of applying silicone gel sheeting, we tested the use of liquid silicone gel (LSG) in the treatment of 18 linear hypertrophic scars (HS group) and 12 minor keloids (KS group) as an alternative to silicone gel sheeting or cushion. Objective parameters (volume, thickness and colour) and subjective symptoms such as pain and pruritus were examined. Evaluations were made when the therapy started and after 30, 90 and 180 days of follow-up. After 90 days of treatment with silicone gel alone (two applications daily), HS group showed a significant improvement in terms of volume decrease, reduced inflammation and redness and improved elasticity. In conclusion, on the basis of our clinical data, we find LSG to be a useful method to overcome the difficulties of applying silicone gel sheeting on irregular surface.

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.

Reoperative soft tissue trauma

Trauma remains the leading cause of death in the first 4 decades of life and is surpassed only by cancer and atherosclerotic disease as the overall leading causes of death in the United States. Many of the injuries involve the facial region, including soft tissue trauma. This article highlights the current available modalities used in the management of unsightly scars or those scars whose location and appearance compromise function.

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.

Punch grafting versus suction blister epidermal grafting in the treatment of stable lip vitiligo

BACKGROUND

Among surgical methods, punch skin grafting (PSG) and suction blister epidermal grafting (SBEG) are simple, inexpensive, and effective treatment methods for resistant lip vitiligo cases, but there is a lack of comparison between these procedures for lip vitiligo.

OBJECTIVE

The objective was to compare the outcome following PSG and SBEG in stable lip vitiligo.

METHODS

Eighteen patients with stable lip vitiligo were randomly selected. Eight patients were included in PSG group and 10 patients in SBEG. All patients were kept on PUVA-SOL (psoralen+ultraviolet A therapy of solar origin) treatment after grafting. The results were evaluated after a follow-up period of 6 months.

RESULTS

At the end of 6 months of grafting in PSG group, two patients had a repigmentation of 50% to 75%, one had 75% to 90%, and three had 90% to 100% in the recipient site in lip. In SBEG group, one patient had repigmentation of 50% to 75%, three had 75% to 90%, and two had 90% to 100%. The color match was statistically significant in PSG when compared to SBEG. In the recipient site, cobblestone appearance was the predominant complication in PSG whereas hyperpigmentation and thickening of grafts were common in SBEG. In the donor site, superficial scarring and hypopigmentation were the common findings in PSG group whereas hyperpigmentation was the main problem in SBEG group.

CONCLUSIONS

Although both the procedures are effective in lip vitiligo, PSG gives a better color match than SBEG.

Satellite repigmentation after punch grafting

Punch grafting is an established treatment modality for management of localized, nonprogressive vitiligo resistant to conventional therapies.(1) In our set up, punch grafting is routinely carried out in focal vitiligo, segmental vitiligo and even in few cases of generalized vitiligo, especially when it is a serious cosmetic problem.(2) However, the procedure is adopted only when the disease is stable for a sufficient period. All patients are routinely kept on psoralen tablets and ultraviolet light exposure from sunlight (PUVA sol therapy) after 2-3 weeks of punch grafting. Interestingly, follow up of such patients revealed conspicuous repigmentation in surrounding ungrafted patches in four of the patients (out of 55 follow-up cases). Herein, this phenomenon has been aptly termed satellite repigmentation (SR). To the best of our knowledge, no other report documenting SR after punch grafting exists in the medical literature. We report the observations of these four patients.

International clinical recommendations on scar management

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.