Recommendations
Standard guidelines of care for vitiligo surgery
Davinder Parsad, Somesh Gupta #
Members, IADVL Dermatosurgery Task Force*, Department of Dermatology, Postgraduate Institute of Medical Education & Rearch, Chandigarh, India, #Department of Dermatology & Venereology, All India Institute of Medical Sciences, New Delhi, India
Address for correspondence:Address for correspondence: Dr Davinder Parsad, Department of Dermatology, Postgraduate Institute of Medical Education & Rearch, Chandigarh. Email: dprs@satyam.in
ABSTRACT
Vitiligo surgery is an effective method of treatment for lected, resistant vitiligo patches in patients with vitiligo. Physician’s quali fi cations: The physician performing vitiligo surgery should have completed postgraduate training in dermatology which included training in vitiligo surgery. If the center for postgraduation does not provide education and training in cutaneous surgery, the training may be o
btained at the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatosurgeon at a center that routinely performs the procedure. Training may also be obtained in dedicated workshops. In addition to the surgical techniques, training should include local anesthesia and emergency resuscitation and care. Facility: Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place, with which all nursing staff should be familiar. Vitiligo grafting for extensive areas may need general anesthesia and full operation theater facility in a hospital tting and the prence of an anesthetist is recommended in such cas. Indications for vitiligo surgery : Surgery is indicated for stable vitiligo that does not respond to medical treatment. While there is no connsus on de fi nitive parameters for stability, the Task Force suggests the abnce of progression of dia for the past one year as a de fi nition of stability. Test grafting may be performed in doubtful cas to detect stability. Preoperative counling and Informed connt: A detailed connt form elaborating the procedure and possible complications should be signed by the patient. The patient should be informed of the nature of the dia and that the determination of stability is only a vague guide. The connt form should speci fi cally state the limitations of the procedure, about the possible future progression of dia and whether more procedures will be needed for proper results. The p
atient should be provided with adequate opportunity to ek information through brochures and one-to-one discussions. The need for concomitant medical therapy should be emphasized and the patient should understand that proper results take time (a few months to a year). Preoperative laboratory studies include hemogram including platelet counts, bleeding and clotting time (or prothrombin and activated partial thromboplastin time), and blood chemistry pro fi le. Screening for antibodies for hepatitis B surface antigen and HIV is recommended depending on individual requirements. Anesthesia: Lignocaine (2%) with or without adrenaline is generally ud for anesthesia; in fi ltration and nerve block anesthesia are adequate in most cas. General anesthesia may be needed in patients with extensive lesions. Postoperative care: Proper postoperative immobilization and care are very important to obtain satisfactory results.Key Words: Vitiligo, Skin grafting, Punch grafting, Suction blister grafting
How to cite this article: Prasad D, Gupta S. Standard guidelines of care for vitiligo surgery. Indian J Dermatol Venereol Leprol 2008;74:S37-S45.
Received: August, 2007. Accepted: May, 2008. Source of Support: Nil. Con fl ict of Interest: Nil.The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) Dermatosurgery Task Force consisted of the following members: Dr. Venkataram Mysore (co-ordinator), Dr. Satish Savant,
Dr. Niti Khunger, Dr. Narendra Patwardhan, Dr. Davinder Prasad, Dr. Rajesh Buddhadev, Lt. Col. Dr. Manas Chatterjee, Dr. Somesh Gupta, Dr. MK Shetty, Dr. Krupashankar DS, Dr. KHS Rao, Dr. Maya Vedamurthy, Ex of fi -cio members: Dr. Chetan Oberai, President IADVL (2007-2008), Dr. Koushik Lahiri, Secretary IADVL, Dr. Sachidanand S, President IADVL (2008-2009), and Dr. Suresh Joshipura, Immediate Past president IADVL (2007-2008).Evidence - Level A- Strong rearch-bad evidence- Multiple relevant, high-quality scienti fi c studies with homogeneous results, Level B- Moderate rearch-bad evidence- At least one relevant, high-quality study or multiple adequate studies, Level C- Limited rearch-bad evidence- At least one adequate scienti fi c study, Level D- No rearch-bad evidence- Bad on expert panel evaluation of other information
For Disclaimers and Disclosures, plea refer to the table of contents page (page 1) of this supplement. The printing of this document was funded by the IADVL.
INTRODUCTION
Vitiligo is a common acquired depigmentation disorder of great cosmetic importance. The basic pathogenesis of vitiligo or for any of the putative subts of vitiligo, still remains unknown. The medical treatment of vitiligo is dependent upon the prence of a melanocyte rervoir and is effecti
ve in only 60-70% of the patients. Certain types of vitiligo do not respond well to medical treatment and resistant lesions do persist even in tho who respond. In light of the limitations of medical treatment, surgical treatment of vitiligo was first propod in the 1960s. Over the years, the concept of surgical treatment has been expanded to include surgical “biotherapies” such as autologous, cultured melanocyte transplantation. The dia has a major impact on the quality of life of patients, particularly the Indian population, in which there is a vere stigma attached to the dia, affecting the social and psychological aspects of the patients. Due to the effects, there is a considerable need for active treatment of this dia, in contrast to fair-skinned patients in whom the dia is less apparent.
RATIONALE AND SCOPE
As such, there are no uniformly acceptable measurement tools and indices for measurement of the efficacy of outcomes of the surgical modalities of vitiligo treatment. Asssment of quality of life and global asssment should be performed becau the percentage of regimentation may not always be a good indicator of patient satisfaction. There is an urgent need for universally acceptable, objective, reproducible and easy-to-u measurements to evaluate the efficacy of surgical vitiligo studies. The guidelines provide minimal standards of care for various surgical methods of treatme
nt of vitiligo, with a brief description of the procedures as well as their advantages and disadvantages.
PHYSICIAN’S QUALIFICATIONS
The physician performing vitiligo surgery should have completed postgraduate training in dermatology; he/she should also have had adequate training in vitiligo surgery during postgraduation. Alternatively, training in vitiligo surgery may be obtained on the surgical table (hands-on) under the supervision of an appropriately trained and experienced dermatological surgeon. The training may also be obtained in dedicated workshops. In addition to the surgical technique, training should include techniques in local anesthesia and emergency resuscitation and care.FACILITY
Vitiligo surgery can be performed safely in an outpatient day care dermatosurgical facility under local anesthesia. The day care theater should be equipped with facilities for monitoring and handling emergencies. A plan for handling emergencies should be in place with which all nursing staff should be familiar. Transplantation for extensive areas of vitiligo may need general anesthesia and in such cas, an operation theater facility in a hospital tting and the prence of an anesthetist are recommended. INDICATIONS FOR SURGERY AND PATIENT SELECTION
Surgery is indicated for all types of stable vitiligo including gmental, generalized and acrofacial types that do not respond to medical treatment. While there is no connsus on definitive parameters for stability, various recommendations suggest a period of dia inactivity ranging from six months to two years. The task force agrees on a year of dia inactivity as the cut-off period for defining stability (Level D). Test grafting may be performed in doubtful cas to detect stability. The choice of surgical intervention should be individualized according to the type of vitiligo, stability, localization of lesions and cost-effectiveness of the procedure. Patient counling about the nature of the dia and about the fact that the determination of stability is only a rough guide is esntial.
EXPLANATION FOR STABILITY
The outcome of surgery is good in stable lesions whereas unstable lesions respond poorly. Thus, the stability status of vitiligo is the single, most important prerequisite in ca lection. However, despite many studies, there is no connsus regarding the minimum required period of stability. The recommended period of stability in different studies has varied from four months to three years. Most authors have suggested that vitiligo can be classified as being stable when there is no progression of old lesions and/or development of new lesions during the past one year. A t of objective criteria-t
he Vitiligo dia activity score (VIDA), was suggested by Njoo et al.[7] in 1999 to follow the progress of the patient. It is a 6-point scale on which the activity of the dia is evaluated by the appearance of new vitiligo lesions or the enlargement of preexisting lesions gauged during a period ranging from < 6 weeks to one year [Table 1]. The task force recommends that surgery
Parsad and Gupta: Guidelines of care for vitiligo surgery
for vitiligo should be performed only in patients with VIDA scores of -1 or 0 (Level D).
EVIDENCE
Das SS, Pasricha JS. Punch grafting as a treatment of 1.
residual lesions of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.
Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo 2.
vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.
Falabella R. Repigmentation of gmental vitiligo by 3.
autologous minigrafting. J Am Acad Dermatol 1983;9:514-21.
Falabella R. Grafting and transplantation of melanocytes for 4.
repigmenting vitiligo and other types of leukoderma. Int J Dermatol 1989;28:363-9.
Falabella R. Surgical treatment of vitiligo: Why, when and 5.
how. J Eur Acad Dermatol Venereol 2003;17:518-20.
Savant SS. Autologous miniature punch grafting in vitiligo.
6.
Indian J Dermatol Venereol Leprol 1992;58:310-4.
Njoo MD, Das PK, Bos JD, Westerhof W. Association of the 7.
Kobner phenomenon with dia activity and therapeutic responsiveness in vitiligo vulgaris. Arch Dermatol 1999;
135:407-13.
Falabella R. Surgical therapies for vitiligo and other 8.
leukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.
In contrast, other authors have questioned the concept of stability and stated that existing parameters are arbitrary. EVIDENCE
1. Malakar S, Dhar S. Treatment of stable and recalcitrant vitiligo
eam
by autologous miniature punch grafting: A prospective study of 1,000 patients. Dermatology 1999;198:133-9.
vcr是什么意思
2. Malakar S, Lahiri K. How unstable is the concept of stability
in surgical repigmentation of vitiligo? Dermatology 2000;
201:182-3.
Considering the variety of opinions, it is preferable to take multiple factors during patient lection for vitiligo surgery into account.PARAMETERS FOR ESTABLISHING STABILITY
OF VITILIGO
1. History of progression: Abnce of new lesions
mitsake
艺术设计考研考什么2. Extension of old lesions: No extension of old lesions
3. Koebner phenomenon: Abnce of Koebner
phenomenon either bad on history or by checking
for experimentally induced vitiligo
weight什么意思4. Mini-grafting test or test-grafting: The original test
was propod by Falabella et al.[1] to lect patients
with stable vitiligo who may respond to melanocyte
transplantation. The test was considered positive if
unequivocal repigmentation took place beyond 1
mm from the border of the implanted graft over a
period of three months. Although this test has been
considered as a gold standard for establishing the
stability and success of repigmentation, doubts have
been expresd over its utility. It has been en that
even when the minigraft test is positive, the dia
itlf may be unstable.
EVIDENCE
1. Falabella R, Arrunategui A, Barona MI, Alzate A. The
minigrafting test for vitiligo: Detection of stable lesions for
melanocyte transplantation. J Am Acad Dermatol 1995;32:228-
32.
CONSENSUS RECOMMENDATION OF THE TASKFORCE ON STABILITY
The available evidence is insufficient to recommend a single cut-off period to asss stability. To facilitate connsus on this issue, the task force attempts to provide a clear definition of stability-a patient reporting no new lesions, no progression of existing lesions, and abnce of Koebner phenomenon during the past one year. Spontaneous repigmentation should be considered as a favorable sign for the transplantation procedure. A test graft may be considered whenever there is a doubt about the stability, or the patient is unable to give a clear history on stability. It needs to be stresd here that the treating physician should always consider each patient individually and exerci his/ her judgment (LEVEL D).
2. The age of the patient for vitiligo surgery: As such, no uniformly accepted opinion exists concerning the minimum age for surgery. Vitiligo surgery is generally performed under local anesthesia, which would be difficult
in children. General anesthesia for vitiligo surgery in a
Table 1: VIDA 6-point score
Dia activity VIDA score
Active in past 6 weeks +4
Active in past 3 months +3
Active in past 6 months +2
Active in past 1 year +1
Stable for at least 1 year 0
Stable for at least 1 year and
spontaneous repigmentation -1
Parsad and Gupta: Guidelines of care for vitiligo surgery
young child pos unacceptable risks and the progress of the dia is difficult to predict in children. Hence, many dermatologists feel that surgical procedures should not be performed in children. However, studies have suggested that results of transplantation procedures were better in y
ounger individuals than in older ones. Thus, no connsus exists in this aspect and physicians should exerci their judgment after taking all aspects of the individual patient into consideration. (LEVEL C)
EVIDENCE
1. Gupta S, Kumar B. Epidermal grafting in vitiligo: Influence of
age, site of lesion, and type of dia on outcome. J Am Acad Dermatol 2003;49:99-104.
2. Gupta S, Kumar B. Epidermal grafting for vitiligo in adolescents.
Pediatr Dermatol 2002;19:159-62. PREOPERATIVE COUNSELING AND INFORMED CONSENT
Proper counling is esntial; the nature of the dia, procedure, expected outcome and possible complications should be clearly explained to the patient. The need for concomitant medical therapy should be emphasized. Patients should understand that proper results may take time to appear (few months to one year). The patient should be provided with adequate opportunity to ek information through brochures, computer prentations, and one-to-one discussions.
A detailed connt form (e appendix 1) describing the procedure and possible complications should be signed by the patient. The connt form should specifically state the limitations of the procedure, possible future dia progression and whether more procedures will be needed for optimal outcome.
ANESTHESIA
The recipient site is locally anesthetized by infiltration of 2% xylocaine, the pain of which can be reduced by prior application of EMLA® cream applied under occlusion for 1-2 hours. Adrenaline should not be ud on the recipient site as it makes the judgment of adequacy of the denudation to the required depth difficult. Tumescent anesthesia and nerve blocks may be ud in larger areas. If grafting is planned for extensive areas, general anesthesia may be needed in a hospital tting. (LEVEL D)METHODS OF SURGICAL MODALITIES
Methods of surgical modalities for vitiligo include both tissue grafts and cellular grafts.
TISSUE GRAFTS
1. Punch grafting: In this procedure, punch grafts (of
1.2-
2.0 mm diameter) are taken from donor areas
over the thighs, buttocks, postauricular areas/
posterior earlobe or the medial aspect of the upper
arm. The are grafted into recipient sites in stablemul
vitiligo lesions, which are created by using punches
1-2 mm in diameter. To ensure a better fit, recipient
punches are generally smaller by 0.5 mm than donor
punches. Smaller sized grafts may be ud to yield
better cosmetic results.
Sockets are created in the recipient area at a distance of
5-10 mm and the harvested grafts are placed in the
sockets. This allows the perigraft spread of pigment to
cover the surrounding depigmented skin, the extent of
which varies according to the skin color and site of the
treated patch (more on expod sites). (LEVEL B)
EVIDENCE
1. Savant SS. Miniature punch grafting. In: Savant SS, editor.
Association of scientific cosmetologists and dermatosurgeons textbook of dermatosurgery and cosmetology. 2nd ed.
Mumbai: ASCAD; 2005. p. 359-69.
2. Babu A, Thappa DM, Jaisankar TJ. Punch grafting versus
suction blister epidermal grafting in the treatment of stable lip vitiligo. Dermatol Surg 2008;34:166-78.
3. Das SS, Pasricha JS. Punch grafting as a treatment of residual lesions
美女与野兽 美剧
of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9.
4. Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo
vulgaris by autologous minigrafting: Results in nineteen patients. J Am Acad Dermatol 1995;33:990-5.
5. Falabella R. Repigmentation of gmental vitiligo by
autologous minigrafting. J Am Acad Dermatol 1983;9:514-21.
Dressings are postoperatively placed to ensure immobili- zation, and may be removed in 24 hours to check for the displacement of the grafts. Grafts are taken up in 7-10 days after which phototherapy or treatment with topical steroid is started to ensure even spread of perigraft pigment.
EVIDENCE
1. Barman KD, Khaitan BK, Verma KK. A comparative study of
punch grafting followed by topical corticosteroid versus
Parsad and Gupta: Guidelines of care for vitiligo surgery
punch grafting followed by PUVA therapy in stable vitiligo.
Dermatol Surg 2004;30:49-53.
2. Lahiri K, Malakar S, Sarma N, Banerjee U. Inducing
repigmentation by regrafting and phototherapy (311 nm) in punch grafting failure cas of lip vitiligo: a pilot study. Indian J Dermatol Venereol Leprol 2004;70:156-8.
Advantages: This is the easiest and least expensive method and may be ud satisfactorily in all areas other than the nipples and the angle of the mouth, where involuntary muscle contraction may interfere with graft uptake. It is even suitable for ‘difficult-to-treat’ locations such as the fingers, toes, palms and soles, etc.
Disadvantages and complications: This method is not suitable for large lesions as uniform pigmentation may not always be achieved. Other important complications include cobblestoning and a polka dot appearance.
2. Suction blister epidermal grafting: This procedure
consists of obtaining very thin skin grafts consisting
of only the epidermis. A physiological split is made
at the dermoepidermal junction by the application
of prolonged suction at a negative pressure of -200
to -500 mm of Hg to the donor site. The recipient
site is dermabraded by using either a manual or a
motorized dermabrader, depending on the size and site of the lesion. Thin grafts are applied to the dermabraded recipient site. Alternatively, the recipient site may be denuded by an Erbium:YAG
or carbon dioxide (CO
2) Lar. Equipment needed
includes specially altered disposable syringes, suction
cups or glass funnels, suction apparatus and manual/
motorized dermabraders. The graft may fall off in a
period of a week to ten days. (LEVEL B)
Advantages: It yields excellent cosmetic results as the graft is very thin. One of the major advantages of this procedure is that chances of scarring at the donor or recipient sites are minimal as the graft is purely epidermal.
Disadvantages: The major disadvantage of this procedure is that it is time-consuming as donor site blistering requires a few hours. Large areas can not be treated by this method. EVIDENCE
bubbletea
affable1. Falabella R. Surgical therapies for vitiligo and other
leukodermas, part 1: Minigrafting and suction epidermal grafting. Dermatol Ther 2001;14:7-14.
2. Hagawa T, Suga Y, Ikejima A, Muramatsu S, Mizuno Y,
Tsuchihashi H, et al. Suction blister grafting with CO(2) Lar
resurfacing of the graft recipient site for vitiligo. J Dermatol 2007;34:490-2.
appreciate的用法
3. Pai GS, Vinod V, Joshi A. Efficacy of erbium: YAG Lar-assisted
autologous epidermal grafting in vitiligo. J Eur Acad Dermatol Venereol 2002;16:604-6.
3. Split-thickness grafting: Split-thickness skin grafting
involves the free transfer of the epidermis along with
a portion of the dermis from one site to another.
The procedure is carried out under local anesthesia
(for localized lesions) or general anesthesia (for extensive lesions). It consists of obtaining very thin, split thickness skin grafts, consisting of the epidermis and a part of the upper papillary dermis,
and grafting them on the denuded (dermabraded or Lar-abraded) recipient site. The grafts are further cured with pressure and immobilization.
Motorized dermatomes such as Padgett’s or Zimmer’s
dermatomes, may be ud to obtain ultra-thin, split-thickness grafts, which may give cosmetically superior results compared to tho with manual dermatomes (Level B).
Instruments include dermabraders, skin-grafting knives such as the Humby’s knife or any of its modifications, as well as other surgical instruments. Large areas can be grafted in a single sitting.
Advantages: This method has the advantage of treating a relatively large area in a short period of time.
Disadvantages: Taking split-thickness grafts of uniform thickness requires skill and experience. Other disadvantages include ‘stuck-on’ or ‘tire patch’ appearance, curling of the border with beaded appearance, color mismatch, milia, perigraft halo of depigmentation, and donor site scarring.
EVIDENCE
1. Achauer BM, Le Y, Vander Kam VM. Treatment of vitiligo with
melanocytic grafting.Ann Plast Surg 1994;33:644-6.
2. Kahn AM, Cohen MJ. Repigmentation in vitiligo patients.
Melanocyte transfer via ultra-thin grafts.Dermatol Surg 1998;24:365-7.
3. Oz d emir M, Cetinkale O, Wolf R, Kotoğyan A, Mat C, Tüzün B,
Tüzün Y. Comparison of two surgical approaches for treating vitiligo: a preliminary study. Int J Dermatol. 2002;41:135-8. 4. Agrawal K, Agrawal A. Vitiligo: repigmentation with
dermabrasion and thin split-thickness skin graft. Dermatol Surg 1995;21:295-300.
4. Other tissue grafting procedures: Several other
methods of tissue grafting have been performed Parsad and Gupta: Guidelines of care for vitiligo surgery
