Sci. Med. J. ESCME, Vol. 16, No. 4, Oct. 2004 THERAPY - RESISTANT VITILIGO: TREATMENT WITH AUTOLOGOUS EPIDERMAL GRAFTING US- ING THE TOPS OF SUCTION BLISTERS - MODIFIED TECHNIQUE Nabil Abdul Majeed (MD)* and Medhat H.M. Hassan (MD – FRCS) ** Dermatology Department *, Surgery Department** National Hepatology and Tropical Medicine Research Institute (NHTMRI) ABSTRACT OBJECTIVE: Current treatment of vitiligo has been disappoint- ing. In this study, emphasis was placed on treating the most refractory types of vitiligo, namely the segmental and focal varieties, none of which had responded satisfactorily to topical corticosteroids and topi- cal or systemic psoralen and exposure to ultraviolet light (PUVA ther- apy). Autologous epidermal grafting using the tops of suction blisters was the offered treatment to those resistant cases. Suction blister epi- dermal grafting is a useful modality for treatment of resistant and stable vitiligo; however, the original apparatus is expensive one. This study at- tempts to develop a cheap and small apparatus, which can be assembled in the physician’s, own office. DESIGN: Prospective study. SETTING: National Hepatology and Tropical Medicine Re- search Institute (NHTMRI). PATIENTS AND METHODS: Twenty patients with therapy- resistant segmental or focal type of vitiligo were treated with autolo- gous epidermal grafting using the tops of suction blisters. The epi- dermis was separated from underlying dermis by vacuum suction on the donor area. On the recipient area, similar blisters were raised by freezing of the skin. The blister roof induced by suction was removed and transplanted to the blister bed prepared on the depigmented area. The ventose machine used in obstetric delivery was connected to alu- minum cups especially designed for that purpose and applied to ob- tain the suction blisters from the donor area. RESULTS: Ten patients exhibited almost complete repigmenta- tion (80% - 100% improvement) at the grafted site within 1 to 3 months. In two patients a 70% response was achieved, while another four patients did not respond to the treatment. Four patients lost fol- low up. Repigmentation that was noted in the recipient areas was re- tained at 1.5 years follow up. The donor areas healed well, with minimal hyperpigmentation in most of the cases. No unwanted effects were met with cases treated. CONCLUSION: Our results suggest that autologous epidermal grafting using the tops of suction blisters is a good treatment for the (therapy-resistant) segmental and/or focal type of vitiligo. Epidermal grafting leaves no scarring at all. The technique appears to be safe, simple, and effective. Introducing this simple suction device made the procedure also cheap and suitable to be applied on outpatient bases in our community in Egypt. INTRODUCTION Vitiligo is a common, acquired skin disorder characterized by well-demarcated, depigmented lesions with variable size and shape that have a tendency to expand over time (Gupta and Kumar, 2003). The prevalence of vitiligo is estimated to be about 1% of the world’s population (Kovacs, 1998). Phototherapy (oral or local meth- oxypsoralen combined with UVA) and local corticosteroids are cur- rently the most widely used conventional therapies for vitiligo (Grimes, 1993), and (Löntz et al, 1994). Surgical techniques have re- cently been introduced for patients with stable vitiligo that is unre- sponsive to conventional therapies (Falabella et al, 1995), and (Suga et al, 1996). These techniques are based on the transplantation of skin grafts from donor sites, which serve as melanocyte reservoirs to de- nuded vitiliginous areas. They include suction blister roofs (Koga, 1988), (Hann et al, 1995), and (Suga et al, 1996), mini- or punch grafts (Falabella, 1988), (Boersma et al, 1995), (Falabella et al, 1995), split- thickness grafts (Kahn and Cohen, 1995), and (Olsson and Juhlin, 1997), cultured epidermal sheets (Falabella et al, 1992), and (Andre- assi et al, 1998) or cultured melanocyte suspensions (Löntz et al, 1994), and (Kaufmann et al, 1998). In a systematic review of the effectiveness, safety, and applicabil- ity of autologous transplantation methods in vitiligo, the highest mean success rates (87%) were achieved with split-skin grafting and epi- dermal blister grafting (Njoo et al, 1998) and (Özdemir et al, 2002). . Unlike other surgical procedures, epidermal grafting does not cause scarring at the donor or recipient sites (Hann et al 1995) and (Gupta et al, 1999). PATIENTS AND METHODS Twenty patients with therapy-resistant segmental and focal va- rieties of vitiligo (12 male, 8 female) whose duration of disease varied from one to twenty years (mean 11.5 years) were included in the study. The age of the patients ranged from two to thirty years (mean 8.9 years). Informed consent was obtained after the nature of the procedure had been explained. The achromic lesion is frozen with liquid nitrogen using a large cotton applicator. Within a few hours, the depigmented epidermis becomes separated from the dermis, and 48 hours after freezing (when the inflammatory changes induced by low temperatures subside), unroofing of the blistered epithelium with iris scissors is accomplished. The denuded area is then covered with compresses moistened with normal saline until grafting done. The modified suction blister device used was the ventose machine used in obstetric delivery. It was connected to aluminum cups especially de- signed for that purpose. These cups have a wide flattened and grooved edge to ensure good cooptation and adherence between the donor site and the cup for a long period (3-4 hours) (fig. 2). This modified vac- uum extractor device induces in vivo separation of the epidermis (blis- tering) from the underlying dermis (fig. 1). When 200 – 300 mm Hg negative pressure is used (0.26 0.4 kg/cm2) after 3 – 4 hours multiple blisters become available for grafting. When the donor blisters are ready, the pigmented epidermis is harvested by cutting the periphery of the blisters, and then the epidermis is immediately applied on the recipient areas, with the dermal side in direct contact with the de- nuded dermis. Tulle gras with antimicrobial cream covered with a sterile gauze was applied to each area with some pressure following the procedure; then the grafted area was secured with elastic bandage to obtain a better graft attachment and assist survival. Since the grafts are not sutured, proper bandages and restricted activity are necessary after the operation. The dressings were first uncovered 10 days later. Postoperatively, patients were followed up for a period of 1.5 years. The clinical evaluation was made regularly once monthly. RESULTS As shown in table 1, ten patients exhibited complete repigmenta- tion (80% - 100% improvement) at the grafted site within 1 to 3 months. In two patients a 70% response was achieved, while another four patients did not respond to the treatment. Four patients were lost in their follow–up. The donor areas healed well, with minimal hyper- pigmentation in most of the cases. The rate of pigmentation in the re- cipient area varied from site to site, being faster on legs and arms than head and neck areas. No unwanted effects were met with cases treated. It is noteworthy that pigment retention in the successfully treated individuals was persistent during 1.5 years follow up in all- successful cases. The donor areas from which suction blisters were taken healed well, but mild hyperpigmentation was noted in half of the cases. No scarring was observed. DISCUSSION Vitiligo is a major psychosocial problem. The prevalence of vitiligo has varied in studies of different populations from 0.14 to 2% (Majumder, 2000), and (Gupta, and Kumar 2003). Although the treatment of vitiligo has improved in recent times, many fail to re- spond to medical treatment and require melanocyte replenishment with one of the various surgical methods. Vitiligo can be categorized into: type B vitiligo in which depigmented patches are confined to a definite dermatome in the same manner as herpes zoster (segmental vitiligo), and type A, which include all cases of vitiligo not classified as type B. Koga and tango, 1988 proposed that type A vitiligo is caused by autoimmune mechanisms and type B results from dysfunction of sympathetic nerves in the affected area. Segmental vitiligo is a local- ized therapy-resistant type, which occurs at early age and not associ- ated with Kobner’s phenomenon. Once it occurs, segmental vitiligo spreads rapidly over the affected dermatomal area and then the activ- ity usually ceases after a short period. The depigmented patches then persist unchanged for the rest of the patient’s life. Patients with vitiligo are treated mainly with PUVA and topical corticosteroids alone or in combination. These therapies, however, are not always successful and certain areas, such as the lips, nipples, genitals, eyelids, and distal extremities, usually respond poorly; thus, there is a need for additional treatment modalities. Several methods of autologous transplantation of melanocytes have been developed to repigment le- sions that are stable and those that are refractory to medical therapies (Grimes, 1993), (Jimbow, 1998), and (Özdemir et al, 202). Refractory vitiligo can be treated with surgical replenishment of melanocytes utilizing various methods including total skin grafts (Spencer, 1951), minipunch grafts (MPG) (Falabella, 1978 and 1983 and Bonafé et al, 1983), suction blister epidermal grafts (SBEG) (Hann et al, 1992), thin Thiersch grafts (Behl, 1985), transplantation of epidermal cell suspension, cultured melanocyte suspension, and cultured epidermis (Falabella, 1989). Unfortunately most of these procedures require a special setup and/or surgical expertise, which are not readily available to those liv- ing in developing countries (Gupta and Kumar, 2002). Cultured melanocyte transplantation techniques are expensive and time-consuming, requiring 6 to 8 weeks for preparation. These techniques require special laboratory setup and trained personnel, and the safety of these procedures is yet to be proven as the growth promoters used may have tumorogenic potential (Njoo et al, 1998). Dermoepidermal grafts (miniature punch, thin Thiersch's, and pinch) retain characteristics of their site of origin, and this may lead to mismatch in the texture and thickness with the surrounding skin (Gupta and Kumar, 2003). Also the usefulness of the Dermoepidermal grafts is limited be- cause it caused depigmented areas at the donor site via the Koebner phenomenon (Özdemir et al, 2002). In vivo separation of viable epidermis by the production of suc- tion blisters using an angiosterrometer was first reported by Kiistala and Mustakillo in 1964. Falabella first described epidermal grafting using the tops of suction blisters for the first time in 1971. This tech- nique has the advantage of achieving considerable repigmentation without scarring. A 200 – 300 mm Hg negative pressure is used. After 3 – 4 hours, a dermo-epidermal separation occurs, and multiple blis- ters become available for grafting. Pure epidermal grafts (in the absence of donor dermal tissue) adopt most of the characteristics of the recipient area. Obviously, among all nonculture transplantation techniques, the most satisfac- tory aesthetic results are likely to be obtained with pure epidermal grafts and melanocyte resuspension procedures (Gupta et al, 1999) and (Gupta et al, 2003). Epidermal grafting using the tops of suction blisters has been found to be the most effective surgical procedure (Gupta and Kumar 2002). However, epidermal-grafting using the tops of suction blisters requires expensive and heavy suction apparatus (Gupta et al, 1999). The present modification of the technique is an attempt to simplify the procedure and to reduce the cost by using the already available ven- tose machine with the especially designed aluminum cups. Gupta et al 1999 also made a modification in the suction apparatus to make it simple and cheap. This apparatus consisted of a cylindrical funnel connected with a three-way tap, and suction was given by a 50-mL syringe. The pressure inside the suction cup was retained by changing the position of lock of the three-way tap. The pressure was measured by connecting the three-way tap to a vacuum gauge. Our results are in consistent with that obtained by Suvanproken et al, (1985) who took 42 patients with leukoderma, 35 of whom had vitiligo, and performed grafting using blisters induced on the donor and re- cipient areas. The blisters were made with either vacuum or with liq- uid nitrogen. Five patients were lost to follow – up and 93% of the remaining 30 patients had partial or complete repigmentation. Suc- tion blisters were more effective than liquid nitrogen blisters in pro- ducing repigmentation (Suvanproken et al, 1985). The same effective and reliable results were also achieved by Hann (1995), Suga, (1996), and Gupta and Kumar (2003). Meta-analysis of the literature has shown that the procedure of suction blister epidermal grafting is safe and has no serious adverse event. Although donor-site Koebnerization did not occur in any of our patients, in the literature 8 of 462 (1.7%) patients had Koebner phe- nomenon develop at the donor site (Gupta and Kumar 2003). CONCLUSION Our results, as well as those of many investigators, clearly demon- strate the usefulness of epidermal grafting using the tops of suction blisters for repigmentation of localized, therapy – resistant type of vitiligo. The technique appears to be safe, simple, and effective. Intro- ducing this simple suction device made the procedure also cheap and suitable to be applied on outpatient bases in our community in Egypt. The technique is inexpensive and easy and obviates the need of cum- bersome and heavy equipment. The method described herein resulted in early repigmentation with a good color match. RECOMMENDATIONS 1-Medical therapy for repigmentation should be tried first, and surgi- cal correction is only indicated after medical treatment has failed. 2-To increase the percentage of success; it would be advisable to per- form a test area to check the responsiveness of the vitiliginous skin to the melanocytes transplanted. 3-Patients with non-progressive vitiligo (focal and segmental) are the candidates known to respond to surgical modalities. 4- Surgical correction (grafting) can be tried for other forms of stable leukoderm e.g. leukoderma following thermal burns and post inflammatory leukoderma. SUMMARY Vitiligo is a relatively common acquired disease affecting 1% to 2% of the population. At present, there are a number of medical therapies that may restore, improve, or at least decrease the depig- mentation of vitiligo (Grimes, 1993), and (Löntz et al 1994). When these trials fail, surgical methods for repigmenting leukoderma should be considered. The idea of the different surgical modalities is to intro- duce a new source of pigment cells to reinitiate melanogenesis within the affected areas. Surgical therapies include: autologous punch grafts, autologous pinch grafts, autologous suction blister grafts, Thiersch grafts, pure autologous melanocyte transplants, micropig- mentation (tattooing) and dermabrasion. Twenty patients with ther- apy- resistant segmental or focal type of vitiligo were treated with autologous epidermal grafting using the tops of suction blisters. In brief, the epidermis was separated from underlying dermis by vac- uum suction on the donor area. A modified suction blister device was used by connecting the ventose machine to aluminum cups especially designed for that purpose on the recipient area; similar blisters were raised by freezing of the skin. The blister roof induced by suction was removed and transplanted to the blister bed prepared on the depig- mented area. Ten patients exhibited almost complete regimentation (80% - 100% improvement) at the grafted site within 1 to 3 months. In two patients a 70% response was achieved, while another four pa- tients did not respond to the treatment. Four patients lost to follow– up. Repigmentation that was noted in the recipient areas was retained at 1.5 years follow up. The donor areas healed well, with minimal hy- perpigmentation in half of the cases. No unwanted effects were met with cases treated. Our results clearly demonstrate the usefulness of epidermal grafting using this modified suction blisters device for repigmentation of localized, therapy – resistant type of vitiligo. Duration of Case No. Age/Sex Grafted site Regimentation disease (yr) 1 22/M 3 Thigh 100% 2 33/F 30 leg 0% 3 68/M 10 Abdomen 100% 4 25/M 8 Forearm Missed 5 22/F 19 Leg 100% 6 49/F 6 Thigh 100% 7 60/F 12 Neck 0% 8 57/M 14 Buttock 100% 9 59/F 9 Abdomen 100% 10 69/M 7 Back, abdomen 0% 11 48/M 17 Leg 70% 12 15/M 9 Face/neck 100% 13 18/M 6 Arm 100% 14 16/M 2 Thigh 100% 15 11/M 6 Back Missed 16 19/F 7 Face Missed 17 53/M 4 Nape of neck 70% 18 20/F 3 Wrist 100% 19 19/M 4 Face 0% 20 18/F 2 Arm Missed Table I: Data of patients studied. Fg.1: Suction blisters Fig.2: the suction blister device on the donor site. Notice the edges of the suction cup. Fig. 3: (case 5) multilocular suction Fig.4: (case 5) treated area shows blister on the anterior aspect of the almost 100% repigmentation. thigh (donor area) and a large unilocular cryo-induced bulla on the front of the leg (recipient area). 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Derm ﻋﻼﺝ ﻣﺮﺽ ﺍﻟﺒﻬﺎﻕ ﺍﳌﺴﺘﻌﺼﻲ ﺑﻮﺍﺳﻄﺔ ﺗﺮﻗﻴﻊ ﺍﳉﻠﺪ ﺑﺎﺳﺘﺨﺪﺍﻡ ﺟﻬﺎﺯ ﺷﻔﻂ ﻹﺣﺪﺍﺙ ﻓﻘﺎﻋﺔ ﻣﺎﺋﻴﺔ ﺑﲔ ﻃﺒﻘﱵ ﺍﳉﻠﺪ ﻧﺒﻴﻞ ﻋﺒﺪ ﺍﺠﻤﻟﻴﺪ – ﻣﺪﺣﺖ ﺣﺴﻦ ﺍﳌﻌﻬﺪ ﺍﻟﻘﻮﻣﻲ ﻟﻸﻣﺮﺍﺽ ﺍﳌﺘﻮﻃﻨﺔ ﻭﺍﻟﻜﺒﺪ ﺍﳌﻠﺨﺺ ﺍﻟﻌﺮﰊ ﻣﺮﺽ ﺍﻟﺒﻬﺎﻕ ﻣﻦ ﺍﻷﻣﺮﺍﺽ ﺍﻟﺸﺎﺋﻌﺔ ﻭﻳﺘﻤﻴﺰ ﲞﺼﻮﺻﻴﺔ ﺗﺪﻣﲑ ﺍﳋﻼﻳﺎ ﺍﻟﺼﺒﻐﻴﺔ ﺍﳌﻮﺟﻮﺩﺓ ﰲ ﺍﳉﻠﺪ. ﻭﳝﻜﻦ ﺗﻘﺴﻴﻢ ﺍﻟﻄﺮﻕ ﺍﳌﺨﺘﻠﻔﺔ ﻟﻌﻼﺝ ﺍﳌﺮﺽ ﺇﱃ ﺍﻟﻌﻼﺝ ﺑﻮﺍﺳﻄﺔ ﺍﻷﺩﻭﻳﺔ، ﺍﻟﻌﻼﺝ ﺍﳉﺮﺍﺣﻲ ﻭﺍﻟﻌـﻼﺝ ﺍﳌﺴﺎﻋﺪ. ﻭﺍﻟﻌﻼﺝ ﺍﳉﺮﺍﺣﻲ ﳌﺮﺽ ﺍﻟﺒﻬﺎﻕ ﺑﺪﺃ ﺍﺳﺘﺨﺪﺍﻣﻪ ﻣﻨﺬ ﺑﺪﺍﻳﺔ ﺍﻷﺭﺑﻌﻴﻨﺎﺕ ﻣﻦ ﻫﺬﺍ ﺍﻟﻘﺮﻥ ﻭﺍﺛﺒـﺖ ﻓﺎﻋﻠﻴﺔ ﻛﺒﲑﺓ ﰲ ﻋﻼﺝ ﺑﻌﺾ ﺍﳊﺎﻻﺕ ﺧﺎﺻﺔ ﺍﻟﱵ ﻓﺸﻠﺖ ﺍﻷﺩﻭﻳﺔ ﰲ ﻋﻼﺟﻬﺎ. ﻭﻟﻘﺪ ﻋﲎ ﻫﺬﺍ ﺍﻟﺒﺤـﺚ ﺑﺘﻘﻴﻴﻢ ﺇﺣﺪﻯ ﻃﺮﻕ ﺍﻟﻌﻼﺝ ﺍﳉﺮﺍﺣﻲ ﳍﺬﺍ ﺍﳌﺮﺽ ﻭﺫﻟﻚ ﺑﺘﺮﻗﻴﻊ ﺍﳉﻠﺪ ﺑﻮﺍﺳﻄﺔ ﺍﺳﺘﺨﺪﺍﻡ ﺟﻬﺎﺯ ﺷـﻔﻂ ﻹﺣﺪﺍﺙ ﻓﻘﺎﻋﺔ ﻣﺎﺋﻴﺔ ﺑﲔ ﻃﺒﻘﱵ ﺍﳉﻠﺪ ﰒ ﺗﻨﻘﻞ ﺍﻟﻄﺒﻘﺔ ﺍﳋﺎﺭﺟﻴﺔ ﻣﻦ ﺍﻟﻔﻘﺎﻋﺔ ﻭﺍﻟﱵ ﲢﺘﻮﻯ ﻋﻠﻰ ﺧﻼﻳـﺎ ﺍﳌﻴﻼﻧﻮﺳﻴﺖ ﺇﱃ ﺍﳌﻨﻄﻘﺔ ﺍﳌﺼﺎﺑﺔ ﺑﻌﺪ ﲡﻬﻴﺰﻫﺎ ﺑﱰﻉ ﺍﻟﻄﺒﻘﺔ ﺍﳋﺎﺭﺟﻴﺔ ﻣﻨﻬﺎ ﺑﻮﺍﺳﻄﺔ ﺍﻟﺘﱪﻳﺪ ﻣﺴـﺘﺨﺪﻣﲔ ﻏﺎﺯ ﺍﻟﻨﻴﺘﺮﻭﺟﲔ ﺍﻟﺴﺎﺋﻞ. ﻭﺗﻀﻤﻦ ﻫﺬﺍ ﺍﻟﺒﺤﺚ ﻋﺸﺮﻭﻥ ﻣﺮﻳﻀﺎ ) ٢١ ﺫﻛﺮ ﻭ ٨ ﺇﻧﺎﺙ( ﻭﻗﺪ ﰎ ﻋـﻼﺝ ﻋﺸﺮﺓ ﺣﺎﻻﺕ ﺑﻨﺠﺎﺡ ﺑﻨﺴﺒﺔ ﺗﺘﺮﺍﻭﺡ ﺑﲔ ٠٨% ﺇﱃ ٠٠١% ﻭﲢﺴﻨﺖ ﺣﺎﻟﺔ ﻣﺮﻳﻀﲔ ﺑﻨﺴـﺒﺔ ٠٧% ﺑﻴﻨﻤﺎ ﻓﻘﺪ ﺃﺭﺑﻌﺔ ﻣﺮﺿﻰ ﺑﻌﺪ ﻋﻼﺟﻬﻢ ﻭﱂ ﻳﺴﺘﺠﻴﺐ ﻟﻠﻌﻼﺝ ﺃﺭﺑﻌﺔ ﻣﺮﺿﻰ. ﻭﻧﺘﺎﺋﺞ ﻫﺬﻩ ﺍﻟﺪﺭﺍﺳﺔ ﻣﻘﺎﺭﺑﺔ ﻟﻜﺜﲑ ﻣﻦ ﺍﻟﻨﺘﺎﺋﺞ ﺍﻟﱵ ﰎ ﻓﻴﻬﺎ ﺍﺳـﺘﺨﺪﺍﻡ ﻧﻔـﺲ ﺍﻟﻄﺮﻳﻘـﺔ ﰲ ﺍﻷﻣـﺎﻛﻦ ﺍﳌﺘﻔﺮﻗـﺔ ﻣـﻦ ﺍﻟﻌـﺎﱂ.
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