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

Study	Success rate
Shah HB, Joshipura PS, Thakkar KJ	Approx 90%
YV Tawade, BB Gokhale, A Parakh, PR Bharatiya104	89.28%
Gupta and Kumar	82%
Njoo et al	87%
Present study	93.33%

 

 

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.

 

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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)