Vitiligo treatment in Delhi- Medical treatment, surgery, melanocyte cell suspension, diet in Vitiligo, Best Treatment options by Vitiligo expert in Delhi

“Some diseases do not take life,but they just ruin it.”

–         Stephen Rothman

Vitiligo is a common pigmentary disorder of great cosmetic concern, social embarrassment, psychological distress, and at times,  a cause of disruption of famililial and social relationship, especially among the dark skinned individuals like indians. The outcome of this disorder is often unpredictable and uncertain.

Many Patients who have been taking treatment fo vitiligo at our clinic have been given their skin color back in their lives after successful medical and surgical treatments.

Suction blister epidermal grafting, melanocyte cell suspension are few modalities that work wonders for vitiligo patients in Delhi.

It is characterized by well circumscribed, acquired, idiopathic, progressive, hypomelanosis of skin and hair, with no predlication for sex or ethinicity.

There are several theories related to the pathogenesis of vitiligo,such as autoimmunity¹, self-destructing mechanisms,² neurals, ³ biochemicals,⁴ an imbalance of epidermal cytokines,⁵ and genetic factority.⁶

Ideally, the aim of the vitiligo treatment is to obtain complete and permanent repigmentation towards the color of the surrounding normal skin. Treatment trends that focus on developing techniques for the repigmenting, refractory and stable vitiligo led to the development of surgical options like minipunch grafting (MPG),^9,10,11 epidermal grafting, ^12,13  epithelial sheet grafting,¹⁴ suction blister epidermal grafting(SBEG), transplantation of epidermal cell suspension, cultured melanocyte suspension ,and cultured epidermis. ¹⁵     

Unfortunately most of these procedures require a special expensive set up and/or surgical expertise, which is not readily available to those living in developing countries.

Exceptions among these difficult and sophisticated procedures are MPG and SBEG, which are simple to perform, inexpensive, and less time consuming.¹⁶

MECHANISM OF SURGICALLY INDUCED  REPIGMENTATION

The aim of surgical induction of repigmentation is to replenish melanocytes in the depigmented lesions of vitiligo . Most surgical procedures, like epidermal grafting and transplantation of non-cultured melanocytes, restore normal epidermal melanocytes. The usual repigmentation seen with such a procedure is of diffuse type. The ability of the melanocytes to migrate forms the basis of repigmentation in Suction blister epidermal grafting technique. The mealnocytes from the graft  readily migrate to the graft bed on remaining in contact with the denuded area resulting in repigmentation. Contact period of about one week is sufficient for this migration and hence the epidermal graft  merely act as a carrier for the melanocytes. Subsequently, the melanocytes migrate to the surrounding area leading to a diffuse repigmentation.

Aim: To demonstrate the safety and efficacy of Suction Blister Epidermal grafting in patients of stable vitiligo, resistant to medical treatment.

Method:

A total of 60 patients were enrolled with a history of stable vitiligo of duration more than one year. Patients wer educated about the procedure and written consent was taken. Depending upon the size of the lesions, blisters were created on thigh area with the help of 10cc and 5 cc syringes. A 50cc syringe was used to create negative pressure required for vacuum creation. Once ready, the blister tops was removed using a jewellars scissors.

The recepient area was prepared using a manual or a motorised dermabrader and an area in excess of approx 2 mm beyond the boundry of the lesion was dermabraded.

Once ready the blister tops were placed on the recepient area and tightly bandaged with the help of a sticking plaster.

The dressing was removed after a week and topical antibacterial cream was prescribed tiill the crust falls off. Once the new skin formation got complete, topical PUVA and steroidal cream was prescribed to hasten the pigmentation process.

Results:

The duration of vitiligo in the study groups ranged from 1 ½  to 23 years.  The mean duration of vitiligo was  23.15 years. The stability of vitiligo lesions varied between 1  and  21 years.  The mean stability 5.34 years. Majority of the patients were young, mostly  unmarried  females in the age group 21-30 years. More than 75% of the patients observed a repigmentation of more than 50% at the end of 4 weeks while it took approximately 8-10 weeks to show complete results in most of the cases in this group. Young patients with age less than 30 years showed better color match , faster repigmentation when compared to the older patients. No difference in degree and rapidity of repigmentation was seen in the two sexes. Though the number of female patients outnumbered the male subjects. No significant difference was seen in the outcome of the treatment in any of the group in concordance with the duration of the stability of the disease.

 Noe of the patients with white hair over the lesion showed any betterment in the color of the  hair over the lesion area even after the whole lesion got fairly repigmented. The donor site of all the patients healed completely without leaving an unsightedly mark. Some difficult to treat areas like genital areas, neck and lips were also treated and results wer equally good.

We were able to give satisfactory results in 93.33% patients . In the remaining patients pigmentation was achieved but was patchy and though there was some relief from the total depigmentation but other methods or a repeat sitting was required. The best pigmentation was achieved in 6 months duration. None of the patients complained of any side effects like – no pigmentation, scarring, keloid formation, hypertrophic scar etc.

Discussion:

SBEG was first performed by Kiistala and Mustakillo 75 in 1964 by using angiosterrometer. Its use in achromic lesions was reported and pioneered by Falabella in 1971. We used a modified suction blister harvesting technique deviced by Gupta et al, which is simple to use and doesn’t require any expensive machine. The unique advantage of SBEG is its ability to heal the RA and DA without much scarring. The limitations of the procedure are its inability to treat vast areas and the substantial time taken for the blisters to develop13. The pain associated with the blister formation is also a major drawback of the procedure. Blisters can be raised by using Liquid nitrogen but such a procedure has been shown to end up in hypertrophic scarring and  keloid formation84 and hence was not tried. Blisters have also been raised by using PUVA but it takes 2-3 days for blisters to develop in such cases and hence makes the procedure quite cumbersome.

Thickening of grafts and hyperpigmentation was found to be a problem in SBEG by Arvind Babu et al in their study. We found that though slight hyperpigmentation was a problem found in a small number of patients. No case of thickening of grafts was noticed. Rather one of the most important and commonly found complication in our study was the perilesional hypopigmeted halo which has been documented by Hann et al  in their study. It was resistant to the topical application of Clobetasol propionate cream for as many as 24 weeks post operatively and reminded the patient as well as the dermatologist of the erstwhile vitiligo lesion. It could be compared to the fossil remnant of the lesion, while the characteristic annular shape could be compared to a wrath, distressing everytime you come across

Table 1. Comparison of success rate in SBEG

Conclusion:

Though a bit cumbersome and time consuming, SBEG is an affordable and result oriented procedure in cases of stable vitiligo. Though the procedure cannot be caried out in patients with large lesions but periodic repettitions can cover large areas too. The only disadvantage is that the process of  graft harvesting and at times blister creation can be painful but given the results and short time span for which it lasts , it’s a pain worth the result. Its an easy, safe and simple, OPD procedure. A dedicated dermatologist with an inclinaton towards dermatosurgery is all that goes in performing this novel procedure which can help change the way vitiligo patients live there lives. A major advantage of   the procedure is that they are a suture less surgery which plays a major determinable role in patient’s consent and fearlessness for the procedure.

The popular notion of pining for a fair  skin is not always applicable and few people also prey to get rid of it. As already mentioned – Colors can be fun and symbolize happiness, joy and contentment but only if they fill a right place, in a right shade; then be it your life or body surface.

Ongenae K, van Geel K, Naeyart J-M. Evidence for autoimmune pathogenesis of vitiligo. Pigment Cell Res 2003;16:1-2.

1. Yee C, Thompson JA, Roche P, et al. Melanocyte destruction after antigen-spesific  immunotherapy of melanoma: direct evidence of T cell-mediated vitiligo. J Exp Med 2000; 192:1637-1643.
2. Taneja A. Treatment of vitiligo. J Dermatol Treatment 2002;13:19-25.
3. Schallreuter KU, Wood JM, Pittelkow MR, et al. Regulation of melanin biosythesis in human epidermis by tetrahydrobiopterin. Science 1994;263:1444-1446.
4. Morreti S, Spallanzani A, Amato L, et al. New insight into pathogenesis of vitiligo: imbalance of epidermal cytokines at sites of lesions. Pigment Cell Res 2002;15:87-82.
5. Kim SM, Chung HS, Hann SK. The genetics of vitiligo in Korean patients. Int J

Dermatol 1998;38:908-910.

1. Kovacs SO. Vitiligo. J Am Acad Dermatol 1998;38:647-660.
2. Stephen O, Kovacs CME. Vitiligo. J Am Acad Dermatol 1998;38:647-666.
3. Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch      Dermatol 1988;124:1649-1655.
4. Falabella R. Repigmentation of segmental vitiligo by autologous minigrafting. J Am  Acad Dermatol 1983;9:514-521.
5. Boersma BR, Westerhot W, Bos JD. Repigmentation in vitiligo vulgaris by      autologous minigrafting. Results in nineteen patients. J Am Acad Dermatol        1995;33:990-995.
6. Suvanprakorn P, Dee-Ananlap S, Pongsomboon C, et al. Melanocyte autologous       grafting for treatment of leukoderma. J Am Acad Dermatol 1985;13:968-974.
7.  Koga N. Epidermal grafting using the top of suction blister in the treatment of       vitiligo. Arch Dermatol 1988;124:1656-1658.
8. Kahn AM , Cohen MJ. Vitiligo: Treatment by dermabrasion and epithelial sheet       grafting J Am Acad. Dermatol 1995;33:646-648.
9. Falabella R. Grafting and transplantation for repigmenting vitiligo and other types of  leukoderma. Int J Dermatol 1989;28:363-369.
10. Gupta S, Jain VK, Saraswat PK, Gupta S. Suction blister epidermal grafting versus  punch skin grafting in recalcitrant and stable vitiligo. Dermatol Surg 1999;25:955- 958.
11. Kandil E. Vitiligo: response to 0.2% betamethasone 17-valerate in flexible collodion. Dermatologica 1970;141:277-81.
12. Kandil E. Treatment of vitiligo with 0.1% betamethasone 17-valerate in isopropyl       alcohol: a double-blind trial. Br J Dermatol 1974;91:457-60.
13. Clayton R. A double-blind trial of 0.05% clobatosol proprionate in treatment of       vitiligo. Br J Dermatol 1977;96:71-3.

1. A.K.Dutta, P.K.Dutta, Sandipan Dhar. Pigmentary Disorders, IADVL Text book and Atlas of Dermatology, Edition 2 reprinted 2003 volume I, 596
2. Whitney MD, Atharva  Veda Samhita (translation and notes). Cambridge Haward University, Press; 1905
3. Rook textbook of dermatology, edition 7^th volume II, 39.53-39.57
4. Fitzpatrick : Mosher D.B., Disorder of Melanocytes. Dermatol in general medicine ; Int. Edn. Vol 1,4^th  edition , 1993; 923-933
5. Vitiligo A Monograph Gokhale BB, Tawade VV, Dambre GM Vitiligo.
6. McKee P, Calonje E, Granter S, eds. Disorders of Pigmentation. In: Pathology of the Skin with Clinical Correlations. Vol 2. 3^rd ed. China: Elsevier Mosby; 2005:993-7.
7. Moellmann G, Klein-Angerer S, Scollay DA, Nordlund JJ, Lerner AB. Extracellular granular material and degeneration of keratinocytes in the normally pigmented epidermis of patients with vitiligo. J Invest Dermatol. Nov 1982;79(5):321-30.
8.  Pawlere J, Leena AB 5-6 dihydroxyindole in a melanin precursor showing potent cytotoxicity. Nature 1978, 276, 627-228.
9. Wilson D. Etiology of vitiligo. Lancet 1971 : 11 : 1298-1299.
10. Schallreuta Ku, Hordinsky MK, Wood JM. Thioreductase  role in free radical reduction in different hypopig. Disorder. Arch Derm. 1987;123; 615-619.
11. Morrone A er al. Catecholamninne and Vitiligo. Pigment cell respiration 1992 : 5 : 65-69.
12. Verma K.K : Etiopathogenesis of vitiligo. Workshop on vitiligo 1997
13. Hara M, Toyoda M, Yaar M, et al. Innervation of melanocytes in human skin. J Exp Med 1996;184:1385-95
14. Nordlund JJ. The pigmentary system,2006.
15. Schallreuter KU, Moore J, Wood JM, et al. In vivo and in vitro evidence for hydrogen peroxide(H₂O₂) accumulation in the epidermis of patients with vitiligo and its successful removal by a UVB- activated pseuocatalase. J  Investig Dermatol Symp Proc 1999;4:91-6.
16. Gauthier Y, Cario- Andre M, Lepreux S, et al. Melanocyte detachment after skin friction in non lesionsal skin of patients with generalized vitiligo. Br J Dermatol 2003:148:95-101.
17. Gauthier Y, Cario Andre M, Taieb A. A critical appraisal of vitiligo etiologic theories. Is melanocyte loss a melanocytorrhagy? Pigment Cell Res 2003;16:322-32.
18. El mofty A.M. vitiligo and psoralen. Oxford.(eng) Pregnan press 1968.
19. Punshi S. K. et al. Vitiligo: probe (1969) 1-18.
20. Khaitan B.K. Clinical aspects and natural history of the disease, workshop of vitiligo 1997
21. Virendra N. Sehgal, Govind Shrivastava.Vitiligo: Compendium of clinico-epidemiological features.IJDVL 2007:Vol 3:149-153.
22.  Koga M, Tango T. Clinical features and courses of type A and type B vitiligo. Br. J Dermatol 1988;118:223-8.

1.  Hann SK, Lee HJ. Segmental vitiligo: clinical findings in 208 patients. J Am Acad Dermatol 1996;35:671-4.

1. Njoo MD, Spuls PI, Bos JD, et al. Nonsurgical repigmentation therapies in vitiligo. Meta-analysis of the literature. Arch Dermatol 1998;134:1532-40.

1. Passeron T. UVB therapy for pigmentary disorders. In: Nordlund JJ, Boissy RE, Hearing VJ, King RA, and Ortonne JP (eds.) The Pigmentary System. 2^nd ed. New York: Oxford University Press,2006;1183-7.

Koster W, Wiskemann A. [ Phototherapy with UV-B in vitiligo]. Z Hautkr 1990;65:1022-4,1029

Lotti TM, Menchini G, Andreassi L. UV-B radiation microphototherapy. An elective treatment for segmental vitiligo. J Eur Acad Dermatol Venereol 1999;13:102-8

Menchini G, Tsoureli-Nikita E, Hercogova J. Narrow band UV-B micro-phototherapy: a new treatment for vitiligo. J Eur Acad Dermatol Venereol 2003;17:171-7.

Grimes PE, Soriano T, Dytoc MT. Topical tacrolimus for repigmentation of vitiligo. J Am Acad Dermatol 2002; 47:789-91.

Parsad D, Pandhi R, Dogra S, Kumar B. Topical prostaglandin analog (PGE2) in vitiligo – a preliminary study. Int J Dermatol 2002:41:942-5

arman KD, Khaitan BK, Verma KK. A comparative study of punch grafting followed by topical corticosteroid versus punch grafting followed by PUVA therapy in stable vitiligo. Dermatol surg 2004:30:49-53.

Van Geel N, Ongene K, Naeyaert J-M. Surgical techniques for vitiligo: a review. Dermatology 2001;202:162-6.

Gupta S, Olsson Mats J, Kanwar Amrinder J, Ortonne Jean-Paul. Surgical Management of Vitiligo.2007:59-65.

1. alabella R, Escobar C, Borrero I. Tretment of refractory and stable vitiligo by   transplantation of in-vitro cultured epidermal autografts bearing melanocytes. J Am Acad  Dermatol 1992;26(2 Pt 1):230-6.

1. Das SS, Pasricha JS.Punch grafting as a treatment for residual lesions in vitiligo. Ind J  Dermatol Venereol Leprol 1992;58:315-19.

1. Boersma BR, Westerhof W. Repigmentation in vitiligo vulgaris by autologous minigrafting: results in 19 patients. J Am Acad Dermatol 1995;33:990-5.

1. Jha AK, Pandey SS, Shukla VK. Punch grafting in vitiligo. Ind J Dermatol Venereol Leprol  1992;58:328-30.

1. Falabella R. Grafting and transplantation of melanocytes for repigmenting vitiligo and other types of leukodermas. Int J Dermatol 1989;28:363-9.

1. Falabella R. Reply. J Am Acad Dermatol 1995;33:1061.

1. Van Geel N, Ongenae K, Vander Haeghen Y, Naeyaert JM. Autologous transplantation techniques for vitiligo: how to evaluate treatment outcome? Eur J Dermatol 2004;14:46-51.

1. Falabella R, Arrunategui A, Darona MI, Alzate A. The minigrafting test for vitiligo: detection of stable lesions for melanocyte transplantation. J Am Acad Dermatol 1995;32:228- 32.

1. Van Geel N, Ongenae K, De Mil M, et al. Double blind placebo controlled study of autologous transplanted epidermal cell suspensions for repigmenting vitiligo. Arch Dermatol 2004;140:1203-8.

1. Olsson M, Juhlin L. Long term follow-up of leukoderma patients treated with transplants of autologous cultured melanocytes, ultrathins epidermal sheets and basal cell layer suspensions. Brit J Dermatol 2002;147:893-904.

1. Thompson CJS. The evolution and development of surgical instruments. IV. The trepan. Br J Surg 1937;25:726.

1. Watson BA. Gunpowder disfigurements. St. Louis Med Surg J 1878;35:145.

1. Keyes EL. The cutaneous punch. J Cutan Genitourin Dis 1887;5:98.

1. Falabella R. Repigmentation of stable  leukoderma by autologous minigrafting. J Dermatol Surg Oncol 1986;12:172-179.

1. Malakar S, Dhar S. Rejection of punch grafts in three cases of herpes labialis induced lip leucoderma, causation and precaution. Dermatology 1997;195:414.

1.  Malakar S, Dhar S. Acyclovir can abort rejection of punch grafts in herpes-simplex induced  lip leucoderma. Dermatology 1999;199:75.

1. Malakar S, Lahiri K. Successful repigmentation of six cases of herpes labialis induced lip leucoderma by micropigmentation. Dermatology 2001;203:194.

1. Lahiri K, Malakar S. Herpes simplex induced lip leucoderma: revisited. Dermatology 2004;208:182.

1.  Unna P. Zur anatomic der blasenbildung an der manschlichen haut. Vjschr Derm Syph  1878;5:1-4.

1.  Blank H,  Miller OG. A method for separating the epidermis from dermis. J Invest Dermatol 1950;15:9-12.

1. Slowey C, Leider M. Abstract of a preliminary report.: the production of bulla by quantitated suction. Arch Dermatol 1961;83:1029-30.

1. Falabella R. Epidermal grafting: an original technique and its application in achromic and granulating areas. Arch Dermatol 1971;104:592-600.

1.  Kiistala U, Mustakallio KK. In-vivo separation of epidermis by production of suction  blisters. Lancet 1964;1:1444-5.

1. Kiistala U. Suction blister device for separation of viable epidermis from dermis. J Invest Dermatol 1968;50:129-37.

1. Mukhtar M, Singh S, Shukla VK, Pandey SS. Surgical pearl: suction syringe for epidermal grafting in vitiligo. J Am Acad Dermatol 1997;37:638-9.

1. Lewis EJ. Mechanism of “suction”. J Am Acad Dermatol 1998;39:664.

1. Gupta S, Shroff S, Gupta S. Modified technique of suction blistering for epidermal grafting. Int J Dermatol 1999;38:306-9.

1. Gupta S, Ajith C, Kanwar AJ, Kumar B. Surgical pearl: standardized suction syringe for epidermal grafting. J Am Acad Dermatol 2005;52:348-50.

1. Gupta S, Kumar B. Suction blister induction time: 15 minutes or 150 minutes? Dermatol Surg2000;26:754-6

1. Yaar M, Gilchrist BA. Aging of skin. In: Freedberg IM, Eisen AZ, wolff K, Austen KF,  Goldsmith LA, and Katz SI(eds.) Fitzpatrick’s Dermatology in General Medicine, 6^th edn. New York: McGraw Hill, 2003;1386-98

1. Van der Leun JC, Beerens ED, Lowe LB. Repair of dermal-epidermal adherence: a rapid process observed in experiments on blistering with interrupted suction. JInvest Dermatil 1974;63:397-401.

1. Hann SK, Im S, Bong HW, park YK. Treatment of stable vitiligo with autologus epidermal grafting and PUVA. Jam Acad Dermatol 1995;32:943-8.

1. Suga Y, ButtKI,Takimato R, Fujioka, N , Yamada H, Ogawa H, Successful treatment of vitiligo with PUVA-pigmented autologus epidermal grafting. Int J Dermatol1996;35:518-22

1. Oh C-K, Cha J-H, Lim J-Y, et al. Treatment of  vitiligo with suction epidermal grafting by the use of an ultrapulse CO2 laser with a computerized pattern generator. Dermatol Surg 2001;27:565-8

1. Albert S, Srinivas CR, Shenoi SD, et al. Phototoxic blister induction in vitiligo surgery. Br J Dermatol Surg 1999;141:30-31

1. Kim C-Y, Yoon T-J, Kim T-H. Epidermal grafting after chemical epilation in the treatment of vitiligo. Dermatol Surg 2001;27:855-6.

1. Gupta S. Sandhu K, Kanwar AJ, Kumar B. Melanocyte transfer via epidermal grafts for vitiligo of labial mucosa. Dermatol Surg 2004;30:45-8

1. Gupta S. Commentary on: epidermal grafting over the eyelid-special considerations. Dermatol Surg 2006;32:391-2

1. Tang WYM, Chan LY, Lo KK. Treatment of vitiligo with autologus epidermal transplantation using the roofs of suction blisters. Hong Kong Med J 1998;4:219-24.

1. Falabella R. Pigmentation of leucoderma by minigrafts of normal pigmented autologus skin. J Dermatol Surg Oncol 1978;4:916-9.

1. Gupta S, Jain VK, Saraswat PK, et al. Suction blister epidermal grafting versus punch skin grafting in recalcitrant and stable vitiligo . Dermatol surg 1999; 25: 855-856.

1. Singh KG, Bajaj AK. Autologous miniature skin punch grafting in vitiligo. Indian J Dermatol Venereol Leprol 1995;61:77-80

1. Babu Aravind, Thappa Devinder Mohan, Jaisankar Telanseri J. Punch grafting versus suction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol  Surg 2008; 34: 166-78.

1. Suvanprakoran P, Dee-Analap S, Pongsomboon C, Klaus SN. Melanocyte autologus grafting for treatment of leukoderma. J Am Acad Dermatol 1985;13:968-74.

1. Hatchome N, Kato T, Hachiro T. Therapeutic success of epidermal grafting in generalized vitiligo is limited by Kobners phenomenon. J Am Acad Dermatol 1990;22:87-91.

1. Tawade YV, Gokhala BB, Parakh A, Bhartiya PR. Autologus grafts by suction blister technique in management of vitiligo. Indian J Dermatol Venereol Leprol 1991:57;91-3.

1. Skouge JW, Morison WL, Diwan RV, Rotter S. Autografting and PUVA combination therapy for vitiligo. J Dermatol Surg Oncol 1992;18:357-60.

1. Mutalik S. Transplantation of melanocytes by epidermal grafting. J Dermatol Surg Oncol.1993;19:231-4.

1. Shah BH, Joshipura SP, Thakkar JK. Surgical treatment in acrofacial vitiligo. Indian J Dermatol Venereol Leprol 1994;60:26-7.

1. Lee A-Y, Jang J-H. Autologus epidermal grafting with PUVA- irradiated donor skin for treatment of vitiligo. Int J Dermatol 1998;37:551-4.

1. Yang JS, Kye YC. Treatment of vitiliho with autologus epidermal grafting by means of pulsed erbium: YAG laser. J Am Acad Dermatol 1998;38:280-2.

1. Kim HY, Kang KY. Epidermal grafts for treatment of stable and progressive vitiligo. J Am Acad Dermatol 1999;40:412-7.

1. Kim HY,Yun SK.Suction devise for epidermal grafting in vitiligo:employing a syringe and a manometer to provide an adequatel negative pressure.Dermatol Surg 2000;26:702-4.

1. Kumar P. Autologus punch grafting for vitiligo of the palm.. Dermatol Surg. 2005;31:3:368-70.
2. Barman KD, Khaitan BK, Verma KK. A comparative study of punch grafting followed by topical corticosteroid versus punch grafting followed by PUVA therapy in stable vitiligo. Dermatol Surg 2004;30:49-53.

1. Orentreich N, Selmanowitz VJ. Autograft repigmentation of leukoderma. Arch Dermatol 1972;105:734-6.
2.  Savant SS. Miniature punch grafting. In: Savant SS, editor. Textbook of dermatosurgery and cosmetology. 2^nd ed. Mumbai: ASCAD;2005.p.359-69.
3. Malakar S, Laheri K. Punch grafting for lip leukoderma. Dermatology 2004;208:125-8.
4. Sachdev M,  Shankar DS. Pulsed erbium:YAG laser- assisted autologous epidermal punch grafting in vitiligo. Int J Dermatol 2000;39:868-71.
5. Njoo MD, Westerhof  W, Bos  JD, Bossuit  PMM. A systematic review of autologous transplantation methods in vitiligo. Arch Dermatol 1998;134:1543-9.
6.   Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo vulgaris by autologous mini-grafting: results in nineteen patients. J Am Acad Dermatol 1995;33:990-95.
7. Singh KG, Bajaj AK. Autologous miniature skin punch grafting in vitiligo. Ind J Dermatol Venereol Leprol 1995;61:77-80.
8. Das SS, Pasricha JS. Punch grafting as a treatment for residual lesions of vitiligo. Ind J Dermatol Venereol Leprol 1992;58:315-19.

Case 1: A depigmented patch in a ring form on neck (before treatment)

Case 1:Fully Pigmented neck after treatment

Case 2: A depigmented patch on neck before  treatment and pigmented patch after treatment.

Case 3: A depigmented patch on genital area (before treatment)

Case 3: A treated patch on genital area (after  treatment)