INTRODUCTION

Vitiligo is an acquired skin disease, characterized by depigmented or hypopigmented macules, which results from absence or reduction in melanocytes in the skin and/or mucous membranes that affect 1% of the world’s population and it has immense sociopsychological ramifications in addition to its cosmetic disability. The highest incidence of the condition has been reported in India, followed by Mexico and Japan.[12] Although vitiligo does not cause direct physical impairment, it can produce an important psychosocial burden in the form of poor body image, low self-esteem, and experience a considerable level of disability.[3] Various therapeutic options for repigmentation of vitiligo are available, including medical therapy (topical and oral) and phototherapy. The vitiliginous areas may remain static without showing any repigmentation or depigmentation to medical therapy and phototherapy. Such type of patients with disease stability of 1-year duration are considered appropriate for surgical treatment with a wide variety of methods; these include mini punch grafting (MPG),[4] suction blister epidermal grafting (SBEG),[5] thin split-thickness grafting (TSTG),[6] transplantation of basal cell layer-enriched suspension (noncultured melanocyte transfer),[7] cultured epithelial/melanocytes transplantation,[89] single hair follicle transplant, and recently developed “modified dermabrasion” (MD) which uses dermabraded epidermal material (melanocytes and keratinocytes) entangled in an antibiotic paste.[10]

Cellular transplantation methods include cultured and noncultured mixed melanocyte–keratinocyte suspension with or without carrier, and cultured pure melanocyte suspension.[11] Problems such as scarring, cobblestoning, and milia formation in addition to issues regarding area of coverage per sitting and inadequate donor area in extensive cases exist in tissue grafting techniques; 100% repigmentation of vitiligo cannot be obtained with any of the existing surgical methods of treatment of vitiligo.[12]

There is no study from India comparing conventional technique suction blister grafting (SBG) and novel technique epidermal harvesting system (EHS) in the treatment of stable vitiligo. However, there is no consensus regarding which surgical technique is preferred in stable vitiligo lesions of equal size and also the effectiveness of the surgical technique at a particular site or the surgical technique that is going to produce early repigmentation. It is necessary to rigorously study these two modalities of vitiligo grafting in areas of depigmentation to compare the rate of repigmentation as well as the final extent of repigmentation to standardize and validate the protocols for the performance of these procedures in our population.

MATERIALS AND METHODS

This was a prospective, single-center, observational, open-labeled comparative study of the rate of pigmentation at specified intervals and the final extent of pigmentation achieved at the end of 1 year of EHS and SBG in the treatment of vitiligo. The patients in this study were drawn from the outpatient Department of Dermatology of a Tertiary Care Hospital of the Armed Forces from July 1, 2015 to December 31, 2016. Ethical clearance was obtained before starting the study.

A total of 40 patients with at least two unresponsive depigmented patches in each patient were enrolled (both procedures were performed on the same patient on the same day). All patients of age group 16–60 years and both sexes with stable vitiligo, which is defined as no new lesions or increase in the size of existing lesions in the past 6 months, were included in the study. Patients having active vitiligo, active infection, keloidal tendency, unrealistic expectations, patients having less than two patches, patch over lips, and glans penis were excluded from the study.

Informed consents were taken from all the patients. Each patient in the study had undergone a detailed clinical, general physical, systemic, and a thorough dermatological examination with a set of investigations consisting of hemoglobin, total leukocyte count, differential leukocyte count, blood sugar (fasting and postprandial), hepatitis B, hepatitis C, venereal disease research laboratory (VDRL), and human immunodeficiency virus (HIV). Clinical photographs had been taken before the surgical procedure and every month for the first 6 months, then every 2 months for the next 6 months using standard aperture and lighting for the assessment. The sites were sequentially distributed into two groups of 40 each. In total, 40 sites into Group A were subjected to SBG and 40 sites into Group B were subjected to EHS. To calculate the size of vitiligo lesions, margins of rectangular lesions and radius of circular lesions were measured with a centimeter scale. Irregular big lesions were first divided into the nearest geometrical shapes, and then the areas were calculated.

RESULTS

Of 40 patients, 35 completed the study period of 12 months. Therefore, data of 35 patients including two depigmented patches in the same patients were considered for the analysis [Figures 1–9].

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Figure 1

Comparison of degree of repigmentation (objective) in both groups at the end of the 12 months

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Figure 2

Comparison of complication at recipient site in both groups

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Figure 3

Comparison of complication at donor site in both groups

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Figure 4

Comparison of repigmentation in both groups after 6 months

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Figure 5

Comparison of repigmentation in both groups after 6 months

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Figure 6

Comparison of repigmentation in both groups after 6 months

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Figure 7

EHS and SBG in a vitiligo patient

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Figure 8

Stepwise SBG grafting in a vitiligo patient

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Figure 9

Stepwise EHS grafting in a vitiligo patient

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Demographic characteristics are shown in Table 1. Both procedures were performed in the same patient so both groups were comparable with regard to age, sex, and type of vitiligo. The majority (18/40) of the patients had vitiligo vulgaris. Distribution of vitiligo lesions was not comparable, but the period of stability was comparable in all patients.

Both Groups A and B had the maximum number of lesions over the extremities (82.5% and 80%, respectively), whereas only a few lesions were seen over trunk and acral parts with no lesions over flexures.

As shown in [Figure 1], total 70 patches operated on; excellent results were seen in 82.9% patches by using the EHS method and in 80% by using the SBG method. Similarly, very good results were seen in 2.9% patches and Good results in 5.7% patches by using both methods. 11.4% patches showed poor results by using the SBG method and 8.6% patches showed poor results by using the EHS method.

By using both the methods, patches over face, trunk, legs, and ankle showed good repigmentation, whereas patches over feet and elbow showed poor repigmentation.

There was a statistically significant difference in the rate of repigmentation in both procedures observed, that is, repigmentation rate was more in SBG graft during the second month.

Figure 2 shows the complications observed in the recipient site such as infections, graft stuck on appearance, perigraft halo, color mismatch, and milia, whereas Figure 3 shows the complications observed in the donor site such as hyperpigmentation, hypopigmentation, depigmentation, and scarring.

Small polka dot appearance was observed with EHS grafting on the recipient site.

DISCUSSION

There is an increasing trend toward the use of advanced technology in the surgical treatment of stable vitiligo. However, these technologies are not available at most of the treatment centers making them inaccessible to most patients. Replenishing melanocytes selectively in vitiliginous macules by grafting is a promising treatment. Both the EHS and SBG techniques are essentially based on the principle of seeding of melanocytes. Grafting is a state of the art procedure that requires expertise and is being practiced in a few centers only.

Among the study population, of total 40 patients, 16 were males (40%) and 24 were females (60%). Female preponderance was seen in the different studies as shown in Table 2. Our study also showed female preponderance sex distribution among the study population. The greater number of reports among females is probably due to the greater social consequences to women and girls affected by this condition.

In our study, the mean duration of vitiligo in all 40 patients was 5.59 ± 5.00 years. In both groups, the minimum duration of vitiligo was 3 years and the maximum duration was 10 years. Our groups were comparable to other studies as shown in Table 3.

In this study, among the study groups vitiligo vulgaris was present in 18 (45%) patients, focal vitiligo was present in 17 (42.5%) patients, segmental was present in 4 (10%) patients, and 1 (2.5%) patient had acrofacial vitiligo. Vulgaris type of vitiligo was present in most number of patients in our study and similarly in other studies as shown in Table 4.

Extent of the repigmentation was calculated by percentage of repigmentation. We divided percentage of repigmentation into four groups. Similar groups were formed in other studies; however, Ko and Chen divided percentage of repigmentation into >90%, 50%–90%, 20%–50%, and <20% groups.

After 12 months of procedure, percentage of repigmentation was calculated for both groups. In the SBG method, 28 (80%) patches showed excellent repigmentation, that is, more than 75% repigmentation, 1 (2.9%) patch showed very good repigmentation, that is, 50%–75% repigmentation, 2 (5.7%) patches showed good repigmentation, that is, 25%–50%, and 4 (11.4%) patches showed poor repigmentation, that is, less than 25%.

In the EHS method, 29 (82.9%) patches showed excellent repigmentation, that is, more than 75% repigmentation, 1 (2.9%) patch showed very good repigmentation, that is, 50%–75% repigmentation, 2 (5.7%) patches showed good repigmentation, that is, 25%–50%, and 3 (8.6%) patches showed poor repigmentation, that is, less than 25% repigmentation.

The percentage of repigmentation and final outcome was dependent on the site of the vitiligo lesions. As per the study by Pandya et al.,[25] the results were most favorable on the legs, feet, face, and forearms. Results were poor on the elbows and acral areas of the hand. Repigmentation was not observed in any of the control patches. As compared to the other studies in the literature, repigmentation was poor over bony prominences and nonhairy acral areas. Patches over face, trunk, and legs showed good repigmentation by using both the methods, whereas patches over elbow and feet had poor repigmentation. Both SBG and EHS were tried over bony prominences and acral areas. Our groups were not matched with respect to the site. This restricted us to compare the results according to sites.

CONCLUSION

In our study, both procedures were performed in the same patient so various confounding factors such as sex, age of patient, and duration of disease were comparable in both the groups. The most common type of vitiligo was of vitiligo vulgaris type. Both groups showed comparable final extent of repigmentation after 12 months, however patients in the EHS group more patches showed excellent results and SBG group more patches showed poor results. During the initial few months, the rate of repigmentation was higher in SBG graft, but the final extent of repigmentation was found to be higher in EHS graft comparatively.

EHS is a simple, painless, less time-consuming, expensive but effective technique to produce homogeneous repigmentation without any donor site anesthesia and complication. SBG is time-consuming, painful, and labor-intensive technique with more infection over donor as well as recipient site, color mismatch, depigmentation, and hyperpigmentation over donor site, so EHS grafting technique has an advantage over conventional SBG technique.