30 Oct

Vitiligo - Thoughts on Pigmentation in Strip Scars

Background:

Vitiligo of the palm can be resistant to conventional treatments, and grafting is not attempted because of some difficulties. Objectives. To do a autologues minigrafts test on a vitiligo patch on the palm using skin of the instep as the donor. Methods. Under local anesthesia, two 2mn minigrafts were transplanted onto vitiliginous skin of the palm of a 28-year-old female. Psolaren with ultraviolet A therapy followed the surgery for 12 weeks Results. Excellent regimentation was seen around the grafts at the end of 12 weeks. There were no complications. Conclusion. The skin of instep is an ideal donor site for palmar vitiligo.

VITILIGO AFFECTS approximately 1% of the population and a host of treatment options are available, including psoralen with ultraviolet A (PUVA), local corticosteroids, and khellin. Surgical methods, such as suction blister grafting and minigrafting, are also used in stable local types of vitiligo. Stable vitiligo usually responds well to grafting; however, a minigrafts test helps before the actual procedure. Autologus minigrafting is a widely used surgical treatment for stable vitiligo. Failure to respond to medical or conventional lines of treatment indicates that the melanocytes. Of all of the surgical treatment options available, mini-punch grafting is probably the least aggressive and reportedly evokes the best response. Orentreich and Selmanwitz observed that when 1 or 2 mm grafts increased. He also noticed that 2 and 3 mm grafts were more likely to be visible and leave scars compared with 1 mm grafts. Appropriate selection of the patient for grafting becomes mandatory, and specific criteria have been laid down. It has been more than a decade since several studies for in vitro culture of epidermis and melanocyte suspension culture in vitro were reported, but punch grafting probably still remains popular. Palmar vitiligo can be resistant to conventional treatment owing to a lack of hair, which usually acts as a reservoir of melanocytes in vitiligo of other hair-bearing areas. The palm is considered a difficult site to graft because of its thick skin and lack of suitable donor as a donor site grafting on to the palm.

Case Report and Method

A 28-year-old unmarried female presented with stable vitiligo of the right palm that was resistant to PUVA treatment. Social stigma toward vitiligo patients, which is strong in some communities of southern India, brought her to the hospital for surgical cure. A minigraft test using the skin of instep of the right sole as the donor was planned. Written informed consent was received. An area of 1 x 1cm over the instep of the right sole was infiltrated with 2% lidocaine, and the vitiligo patch on the palm was similarly anesthetized. Two minigrafts were taken from the donor skin using a 2 mm disposable punch, ring forceps, and a double-curved scissor. Grafts were placed in the chambers, and there was no protrusion of the grafts prevented shrinking and curling of the tissue, and the recipient chambers did not gape, as in other sites. The grafts fitted perfectly, and no sutures or glue was used to secure the grafts in their chambers. The grafted with the four layers of 2 x 2cm paraffin gauze. Further pressure dressing was using gauze pads, which were bound down with Dyanaplast (Johnson & Johnson Ltd, Mumbai, India). The hand was immobilized in a ball-clutching position using a ball bandage, which was left in place for 10 days. The donor site was cleaned and dressed on alternate days until it healed. Asepsis was maintained throughout the procedure. Oral antibiotic, which started 2 days prior to the surgery, was continued. The dressing was later cleaned was removed on the tenth day. There was no evidence of infection or displacement of grafts. The area was later cleaned on alternate day using iodine solution and normal saline and was dressed with gauze pads postgrafting. The patient received 0.3 mg/kg body weight of psoralan orally 2 hours prior to exposure to ultraviolet A in a phototherapy unit. Starting with 4 J/cm² twice weekly, the dosage was increased every week by 0.5 J/cm² for 12 weeks. The last dose was 10 J/cm². The treatment was stopped after 25 exposures, and the patient was followed up for a period of 24 weeks after completion of treatment.

Results

The graft found to be in place on opening the dressing on the tenth day. Repigmentation was seen at the periphery of the grafts 6 weeks after biweekly PUVA therapy. At the end of 12 weeks of treatment, the pigment had spread to 3 mm around the minigrafts (Figure 1). The repigmentation persisted even 24 weeks after stopping PUVA. The minigrafts test was considered successful. The donor skin had healed without scarring, and there was no significant pebbling effect on the recipient skin.

Comment

The skin of the instep is an ideal donor site for minigrafting on palmar vitiligo because of similarity in thickness. The palm is a difficult site to graft because there is always a risk of fat herniation if the punch is driven too deep into the palmar spaces; hence, there is limitation to the depth of the chambers and thickness of the grafts. It is easier to trim the thick Keratin layer to avoid protrusion of the grafts on the surface; this keeps the viable tissue intact for better results. A comparative study of punch grafting followed by topical corticosteroid versus PUVA therapy showed no statistical significance. Photochemotherapy following grafting helps in faster spread of pigment from the donor skin to the recipient area. In this case as well, PUVA was used to stimulate the spread of pigment from the donor skin (see figure 1). It also shows that repigmentation around the grafts is excellent compared with the periphery of the vitiligo patch, where pigment-producing capacity is compromised. Satellite regimentation, as reported by Agrawal, was not evident. Laser-assisted punch grafting, which has been tried in vitiligo, could be tried on palms as well because there could be better control of the depth and bleeding. This procedure, although not done routinely, is very useful in exceptional cases.

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