LETTERS AND COMMUNICATIONS
laser for the treatment of steatocystoma multiplex: a case report. Dermatol Surg 2012;38:1104–6. 5. Park EJ, Youn SH, Cho EB, Lee GS, et al. Xanthelasma palpebrarum treatment with a 1,450-nm-diode laser. Dermatol Surg 2011;37:791–6. 6. No D, McClaren M, Chotzen V, Kilmer SL. Sebaceous hyperplasia treated with a 1450-nm diode laser. Dermatol Surg 2004;30:382–4.
Max Cheng-Ming Hsu, MD Department of Dermatology Kaohsiung Medical University Hospital Department of Dermatology, College of Medicine Kaohsiung Medical University Kaohsiung, Taiwan
Chih-Hung Lee, MD, PhD Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan Gwo-Shing Chen, MD, PhD Ching-Ying Wu, MD Department of Dermatology Kaohsiung Medical University Hospital Department of Dermatology, College of Medicine Kaohsiung Medical University Kaohsiung, Taiwan
Repigmentation of Vitiligo Using the Follicular Unit Extraction Technique
Vitiligo is a common skin pigmentary disorder that causes depigmented skin, resulting from the loss of melanin. Vitiligo is not a life-threatening disease. It has a huge negative psychological and social impact on patients.1,2 A number of therapeutic options for repigmentation of the skin of patients with vitiligo are available, including administration of corticosteroids, phototherapy, and calcineurin inhibitors. The aim of vitiligo treatment is to, ideally, obtain complete and permanent repigmentation toward the color of the surrounding normal skin.2 There are various surgical treatments available for vitiligo. Surgical modalities are indicated in stable vitiligo that does not respond to medical treatment. These can be tissue grafting, such as suction blister epidermal grafting, thin and ultrathin spilt-thickness skin grafting, minigrafting (punch grafting), and follicular grafting (FG), or cellular transplantation such as transplantation of cultured epidermis or noncultured, basal cell layer– enriched epidermal cell suspension.1 Treatment of vitiligo on hairy skin through the tedious procedure of hair follicle grafting has been carried out by few investigators. Herein, we report 2 cases of vitiligo treated through the follicular unit extraction (FUE) method.
Patient 1 A healthy 12-year-old boy presented to our clinic with depigmented patches and leukotrichia of the occipital scalp. These lesions were diagnosed as vitiligo by
a private dermatologic hospital. The patient had not responded to topical corticosteroid, calcineurin derivatives, and phototherapy. We planned to treat the patient’s stable vitiligo through the hairy skin FUE method. Hair samples were taken from the occipital area of the scalp (Figure 1A). The patient underwent the FUE method for hair follicle tissue harvesting. Hairs were trimmed to 1- to 2-mm length. Field block anesthesia was given with 2% lidocaine that infiltrated the skin, encircling the area chosen for FUE. To obtain follicular units, a 0.8-mm punch with Folligraft (AMM Industries, Fort Lauderdale, FL) was rotated in the direction of the hair follicle until it reached the middermis. Then, the follicular unit was pulled out gently using hair follicle–holding forceps by holding the skin surrounding the hair shaft. The hair suspension was preserved in a sectioned Petri dish filled with normal saline. Transected hair follicles were discarded. The recipient vitiligo patch was anesthesized with topical anesthetic cream (EMLA; AstraZeneca AB, Södertälje, Sweden) followed by a small amount of injected local anesthesia (2% lidocaine). The prepared actual hair was inserted uniformly over the incision site with the use of a pipette. The dressing was removed on the eighth day. After 4 weeks, the patients received a second FUE treatment. The method was the same as in the first treatment. The clinical outcome was documented monthly through standardized photographs until 6 months. The repigmentation was assessed subjectively by
40:12:DECEMBER 2014
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A) A healthy 12-year-old boy who presented with diffuse, whitish depigmented patches with leukotrichia on occipital scalp, and hair sample was taken from the occipital area of the scalp. (B) After 1 month, the second FUE transplant achieved repigmentation.
Figure 2. (A) A healthy 11-year-old boy who presented with diffuse, whitish depigmented patches on the scrotal area. (B) After 6 months, the FUE transplant achieved partially improved.
comparing the pretreatment and posttreatment pictures. One month later, the vitiligo lesion demonstrated some repigmentation (Figure 1B). Patient 2 The second case was that of an 11-year-old male patient with diffuse, whitish depigmented patches on the periorbital and scrotal areas. He had been treated with excimer laser 16 months ago. The effectiveness of the excimer laser was good on the perioral but was poor on the scrotum (Figure 2A). The scrotal area was treated with surgical treatment through FUE. We performed the same treatment as in the first case. After only 1 repigmentation surgery, the skin lesion partially improved (Figure 2B).
1426
Discussion Vitiligo is a common depigmenting disorder with amelanotic macules that result from the loss of melanocytes. The exact pathogenesis remains unknown, although several mechanisms have been implicated. Many treatment modalities have been used for vitiligo, but an obvious cure remains unknown. The current main pharmacologic treatments of vitiligo are topical corticosteroids, calcineurin inhibitors, vitamin D analogs, depigmenting agents, and systemic medications. Other possible treatment options include phototherapy, photochemotherapy, and surgery. If there is no response to topical steroids, phototherapy, or calcineurin derivatives, then surgical treatment is considered. An appropriate selection of patients is
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
mandatory to have success with surgical techniques for vitiligo.2 Stable vitiligo is a condition where depigmentation, enlargement, new lesions, or Koebner phenomena are not identified during a certain time period.3 Currently, the modality of vitiligo treatment, especially in dermatosurgery, includes various replenishment methods of melanocyte transplantation, such as suction blister grafting, split-thickness skin grafting, minigrafting (punch grafting), FG, cultured melanocyte transplantation, and noncultured melanocyte transplantation.2 These techniques are based on the ideas of restoring melanocytes on recipient sites. The FUE grafting technique is based on an understanding that the hair follicle is one of the important reservoirs of melanocytes. In FUE, the extraction of an intact follicular unit is dependent on the principle that the area of attachment of arrector muscle to the follicular unit is the tightest zone.4 The inferior segment can be extracted easily once it is made loose and separated from the surrounding dermis.4 Because the follicular unit is narrowest at the surface, one needs to use small micropunches, and therefore the resulting scar will be too small to be recognized.4
from many hair follicles also improves the results. This method offers the advantage of minimal postinflammatory hyperpigmentation and scarring in most patients. The challenges of these cases were that sometimes the hair did not grow and how to remove the grown hair when it was unwanted. Although there were limitations, the use of FUE for repigmentation in cases with stable vitiligo may increase. In conclusion, FUE is an interesting advancement that propels the field of minimally invasive vitiligo surgical treatment. It assures scarless surgery that is attractive to both the patient and the surgeon. More studies are needed to explore how to make the procedure faster and decrease the transection rates of follicles so that the treatment can be performed on a greater number of patients. References 1. Mohanty S, Kumar A, Dhawan J, Sreenivas V, et al. Noncultured extracted hair follicle outer root sheath cell suspension for transplantation in vitiligo. Br J Dermatol 2011;164:1241–6. 2. Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006;45:411–7. 3. Kim HY, Kang KY. Epidermal grafting for treatment of stable and progressive vitiligo. J Am Acad Dermatol 1999;41:412–7. 4. Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthet Surg 2010;3:76–81.
Significant repigmentation in our patients indicates that the procedure can be used to cover stable vitiligo. Furthermore, there was no significant difference between the 2 cases. Hair melanocytes have a remarkable synthetic capacity, and a relatively small number of melanocytes can potentially produce sufficient melanin for pigmentation.5 The ideal candidate for hair follicular unit grafting is the one with a narrow and stable depigmented patch. In terms of technique, using a hair follicle suspension created
5. Slominski A, Wortsman J, Plonka PM, Schallreuter KU, et al. Hair follicle pigmentation. J Invest Dermatol 2005;124:13–21.
Seok Rim Kim, MD Ki Deuk Han, MD Chi Yeon Kim, MD, PhD Department of Dermatology Gyeongsang Institute of Health Science Gyeongsang National University and Hospital Jinju, Korea
A Reference (All-in-One) Image Demonstrating the Outcome of Suction Blister Formation in Vitiligo Surgery Suction blister epidermal grafting (SBEG) is a timetested method for surgical correction of stable and segmental vitiligo.1 The authors present an image taken when they encountered all the outcomes (positive and negative) of blister formation in the
same patient in 1 sitting, which they believe would be difficult to reproduce, even in a controlled setting. Suction blisters were first raised by Kiistala and Mustakallio1 in 1964 by using an angiosterrometer.
40:12:DECEMBER 2014
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
laser for the treatment of steatocystoma multiplex: a case report. Dermatol Surg 2012;38:1104–6. 5. Park EJ, Youn SH, Cho EB, Lee GS, et al. Xanthelasma palpebrarum treatment with a 1,450-nm-diode laser. Dermatol Surg 2011;37:791–6. 6. No D, McClaren M, Chotzen V, Kilmer SL. Sebaceous hyperplasia treated with a 1450-nm diode laser. Dermatol Surg 2004;30:382–4.
Max Cheng-Ming Hsu, MD Department of Dermatology Kaohsiung Medical University Hospital Department of Dermatology, College of Medicine Kaohsiung Medical University Kaohsiung, Taiwan
Chih-Hung Lee, MD, PhD Department of Dermatology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan Gwo-Shing Chen, MD, PhD Ching-Ying Wu, MD Department of Dermatology Kaohsiung Medical University Hospital Department of Dermatology, College of Medicine Kaohsiung Medical University Kaohsiung, Taiwan
Repigmentation of Vitiligo Using the Follicular Unit Extraction Technique
Vitiligo is a common skin pigmentary disorder that causes depigmented skin, resulting from the loss of melanin. Vitiligo is not a life-threatening disease. It has a huge negative psychological and social impact on patients.1,2 A number of therapeutic options for repigmentation of the skin of patients with vitiligo are available, including administration of corticosteroids, phototherapy, and calcineurin inhibitors. The aim of vitiligo treatment is to, ideally, obtain complete and permanent repigmentation toward the color of the surrounding normal skin.2 There are various surgical treatments available for vitiligo. Surgical modalities are indicated in stable vitiligo that does not respond to medical treatment. These can be tissue grafting, such as suction blister epidermal grafting, thin and ultrathin spilt-thickness skin grafting, minigrafting (punch grafting), and follicular grafting (FG), or cellular transplantation such as transplantation of cultured epidermis or noncultured, basal cell layer– enriched epidermal cell suspension.1 Treatment of vitiligo on hairy skin through the tedious procedure of hair follicle grafting has been carried out by few investigators. Herein, we report 2 cases of vitiligo treated through the follicular unit extraction (FUE) method.
Patient 1 A healthy 12-year-old boy presented to our clinic with depigmented patches and leukotrichia of the occipital scalp. These lesions were diagnosed as vitiligo by
a private dermatologic hospital. The patient had not responded to topical corticosteroid, calcineurin derivatives, and phototherapy. We planned to treat the patient’s stable vitiligo through the hairy skin FUE method. Hair samples were taken from the occipital area of the scalp (Figure 1A). The patient underwent the FUE method for hair follicle tissue harvesting. Hairs were trimmed to 1- to 2-mm length. Field block anesthesia was given with 2% lidocaine that infiltrated the skin, encircling the area chosen for FUE. To obtain follicular units, a 0.8-mm punch with Folligraft (AMM Industries, Fort Lauderdale, FL) was rotated in the direction of the hair follicle until it reached the middermis. Then, the follicular unit was pulled out gently using hair follicle–holding forceps by holding the skin surrounding the hair shaft. The hair suspension was preserved in a sectioned Petri dish filled with normal saline. Transected hair follicles were discarded. The recipient vitiligo patch was anesthesized with topical anesthetic cream (EMLA; AstraZeneca AB, Södertälje, Sweden) followed by a small amount of injected local anesthesia (2% lidocaine). The prepared actual hair was inserted uniformly over the incision site with the use of a pipette. The dressing was removed on the eighth day. After 4 weeks, the patients received a second FUE treatment. The method was the same as in the first treatment. The clinical outcome was documented monthly through standardized photographs until 6 months. The repigmentation was assessed subjectively by
40:12:DECEMBER 2014
1425
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Figure 1. (A) A healthy 12-year-old boy who presented with diffuse, whitish depigmented patches with leukotrichia on occipital scalp, and hair sample was taken from the occipital area of the scalp. (B) After 1 month, the second FUE transplant achieved repigmentation.
Figure 2. (A) A healthy 11-year-old boy who presented with diffuse, whitish depigmented patches on the scrotal area. (B) After 6 months, the FUE transplant achieved partially improved.
comparing the pretreatment and posttreatment pictures. One month later, the vitiligo lesion demonstrated some repigmentation (Figure 1B). Patient 2 The second case was that of an 11-year-old male patient with diffuse, whitish depigmented patches on the periorbital and scrotal areas. He had been treated with excimer laser 16 months ago. The effectiveness of the excimer laser was good on the perioral but was poor on the scrotum (Figure 2A). The scrotal area was treated with surgical treatment through FUE. We performed the same treatment as in the first case. After only 1 repigmentation surgery, the skin lesion partially improved (Figure 2B).
1426
Discussion Vitiligo is a common depigmenting disorder with amelanotic macules that result from the loss of melanocytes. The exact pathogenesis remains unknown, although several mechanisms have been implicated. Many treatment modalities have been used for vitiligo, but an obvious cure remains unknown. The current main pharmacologic treatments of vitiligo are topical corticosteroids, calcineurin inhibitors, vitamin D analogs, depigmenting agents, and systemic medications. Other possible treatment options include phototherapy, photochemotherapy, and surgery. If there is no response to topical steroids, phototherapy, or calcineurin derivatives, then surgical treatment is considered. An appropriate selection of patients is
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
mandatory to have success with surgical techniques for vitiligo.2 Stable vitiligo is a condition where depigmentation, enlargement, new lesions, or Koebner phenomena are not identified during a certain time period.3 Currently, the modality of vitiligo treatment, especially in dermatosurgery, includes various replenishment methods of melanocyte transplantation, such as suction blister grafting, split-thickness skin grafting, minigrafting (punch grafting), FG, cultured melanocyte transplantation, and noncultured melanocyte transplantation.2 These techniques are based on the ideas of restoring melanocytes on recipient sites. The FUE grafting technique is based on an understanding that the hair follicle is one of the important reservoirs of melanocytes. In FUE, the extraction of an intact follicular unit is dependent on the principle that the area of attachment of arrector muscle to the follicular unit is the tightest zone.4 The inferior segment can be extracted easily once it is made loose and separated from the surrounding dermis.4 Because the follicular unit is narrowest at the surface, one needs to use small micropunches, and therefore the resulting scar will be too small to be recognized.4
from many hair follicles also improves the results. This method offers the advantage of minimal postinflammatory hyperpigmentation and scarring in most patients. The challenges of these cases were that sometimes the hair did not grow and how to remove the grown hair when it was unwanted. Although there were limitations, the use of FUE for repigmentation in cases with stable vitiligo may increase. In conclusion, FUE is an interesting advancement that propels the field of minimally invasive vitiligo surgical treatment. It assures scarless surgery that is attractive to both the patient and the surgeon. More studies are needed to explore how to make the procedure faster and decrease the transection rates of follicles so that the treatment can be performed on a greater number of patients. References 1. Mohanty S, Kumar A, Dhawan J, Sreenivas V, et al. Noncultured extracted hair follicle outer root sheath cell suspension for transplantation in vitiligo. Br J Dermatol 2011;164:1241–6. 2. Rusfianti M, Wirohadidjodjo YW. Dermatosurgical techniques for repigmentation of vitiligo. Int J Dermatol 2006;45:411–7. 3. Kim HY, Kang KY. Epidermal grafting for treatment of stable and progressive vitiligo. J Am Acad Dermatol 1999;41:412–7. 4. Dua A, Dua K. Follicular unit extraction hair transplant. J Cutan Aesthet Surg 2010;3:76–81.
Significant repigmentation in our patients indicates that the procedure can be used to cover stable vitiligo. Furthermore, there was no significant difference between the 2 cases. Hair melanocytes have a remarkable synthetic capacity, and a relatively small number of melanocytes can potentially produce sufficient melanin for pigmentation.5 The ideal candidate for hair follicular unit grafting is the one with a narrow and stable depigmented patch. In terms of technique, using a hair follicle suspension created
5. Slominski A, Wortsman J, Plonka PM, Schallreuter KU, et al. Hair follicle pigmentation. J Invest Dermatol 2005;124:13–21.
Seok Rim Kim, MD Ki Deuk Han, MD Chi Yeon Kim, MD, PhD Department of Dermatology Gyeongsang Institute of Health Science Gyeongsang National University and Hospital Jinju, Korea
A Reference (All-in-One) Image Demonstrating the Outcome of Suction Blister Formation in Vitiligo Surgery Suction blister epidermal grafting (SBEG) is a timetested method for surgical correction of stable and segmental vitiligo.1 The authors present an image taken when they encountered all the outcomes (positive and negative) of blister formation in the
same patient in 1 sitting, which they believe would be difficult to reproduce, even in a controlled setting. Suction blisters were first raised by Kiistala and Mustakallio1 in 1964 by using an angiosterrometer.
40:12:DECEMBER 2014
1427
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
