|Year : 1992 | Volume
| Issue : 5 | Page : 315-319
Punch grafting as a treatment for residual lesions of vitiligo
S Siddhartha Das, JS Pasricha
S Siddhartha Das
Source of Support: None, Conflict of Interest: None
Sixty patients having 70 residual lesions of vitiligo not responding to medical treatment for a period of at least 4 months were subjected to punch grafting. The donor skin was taken from the buttock, thigh or leg of the same patients with a 4 mm skin biopsy punch and placed on the recipient area prepared by excising the vitiliginous skin with a 3 mm skin biopsy punch. The recipient areas were placed at a distance of 1 cm from the margin of the lesion and 1-2 cm from each other. Out of total of 280 grafts applied in these lesions, 256 (91.1%) gfafts were successful, while 21 grafts were rejected, 2 grafts became depigmented and 1 graft developed into a keloid. The pigment spread centrifugally around each of the successful grafts and 76% of grafts showed a pigment-spread of more than 6 mm within 6 months. Pigment continued to spread even in the grafts applied 2 years ago and the maximum spread so far has been 22 mm. The pigment-spread was faster in the lesions situated on the trunk, neck, face and proximal parts of the extremities. Lesions on the dorsal aspects of hands, fingers, feet and maleoli were slow to repigment. Treatment of the lesion with topical psoralen followed by sun exposure led to a faster spread of pigmentation.
Keywords: Vitiligo Punch Grafting
|How to cite this article:|
Das S S, Pasricha J S. Punch grafting as a treatment for residual lesions of vitiligo. Indian J Dermatol Venereol Leprol 1992;58:315-9
|How to cite this URL:|
Das S S, Pasricha J S. Punch grafting as a treatment for residual lesions of vitiligo. Indian J Dermatol Venereol Leprol [serial online] 1992 [cited 2020 Jan 25];58:315-9. Available from: http://www.ijdvl.com/text.asp?1992/58/5/315/3835
| Introduction|| |
In spite of a large proportion of patients of vitiligo responding to one or the other medical therapeutic regimen,  several patients are left with some areas which do not regain pigment. Such residual lesions may be left alone if these are not located on a cosmetically important area, or camouflaged with tattoos or creams. During the last few years, several surgical techniques  such as split thickness skin grafting , suction blister grafting, ,, punch grafting and melanocyte grafting, , have been used with success. We are reporting our experience with punch grafting in 60 patients.
| Material and Methods|| |
Patients having vitiligo were treated with various combinations of psoralens followed by sun exposure (PUVASOL), oral or topical corticosteroids and levamisole. The treatment regimen was selected on the basis of the extent and the rate of progression of the disease. The response to treatment was evaluated at 24 month intervals by comparing photographic records of representative lesions taken at the start of treatment and during follow up. The therapeutic regimen was modified if one therapeutic regimen did not produce the desired result. The treatment was continued as long as the lesions were regaining their pigment. If there was no further repigmentation in any lesion over a period of at least 4 months, it was subjected to punch grafting.
With these criteria, we selected 60 patients (21 men, 39 women; age range 562 years, mean 23.5 years). All patients belonged to the north Indian ethnic group. Seven patients had segmental and 53 patients had non-segmental vitiligo. The duration of vitiligo ranged from 2-12 years. Each of these patients had taken medicinal treatment for 2-3 years. Fifty one patients had a single residual lesion, 8 patients had 2 residual lesions, while 1 patient had 3 residual lesions. There were a total of 70 lesions. The locations of these lesions were forehead (4 cases), eyebrows (2), jaw (2), cheek (4), chin (3), upper lip (1), neck (5), chest (2), abdomen (3), back (3), axilla (1), elbow (1), forearm (1), wrist (3), dorsum of hand (4), dorsum of fingers (5), buttock (1), leg (3) malleolus (14), and dorsum of foot (8). The sizes of the lesions varied between 1 cm in diameter to 10 x 8 cm.
The recipient sites in the vitiligo lesion were prepared by excising circular areas of skin upto the depth of superficial dermis by a 3 mm skin biopsy punch. Each site was approximately 1 cm from the margin of the lesion and 1-2 cm from each other. The number of recipient sites varied from 1 to 15 per lesion depending upon the size of the lesion, but all grafts were not necessarily applied at the same time, more so when the vitiligo lesion was large. The total number of grafts applied in these lesions was 280. A corresponding number of donor punch biopsies were taken from the normally pigmented skin on the buttock, thigh or leg of the same patient using a 4 mm skin biopsy punch. The donor biopsies were taken with a larger punch than the recipient sites because the excised skin tends to contract, while the excised wound tends to expand. The donor skin pieces were placed on the recipient sites and pressed in place to remove the blood/ serum excluding from the recipient site, and then covered with micropore adhesive tape applied directly over the grafts. Stitches were not used. The adhesive tape was removed after 7 days, and the number of grafts rejected, if any, were recorded. The patients were followed up at 3-month intervals to measure the diameter of the pigmented area around each graft.
| Results|| |
Of the 280 grafts, 21 grafts were rejected, 2 grafts became depigmented during follow up and 1 graft developed a keloid, The success rate was 91.1%. The keloid was controlled with an intralesional injection of 40 mg/ml of triamcinolone acetonide. At 3 months, the pigment in the remaining grafts was noticed to be spreading centrifugally from the graft into the adjoining depigmented skin [Figure - 1]. At the time of analysis, 97 grafts had been followed up for at least 6 months. The maximum duration of follow up was 2 years, and the maximum pigment-spread 22 mm. The pigment was continuing to spread in all the grafts, but none of the lesions had yet attained complete pigmentation [Figure - 2]. The extent of pigment-spread with the duration of follow up is shown in [Table - 1].
The rate of pigment-spread varied in different lesions even if the lesions were present in the same patient. To study the effect of various factors on the rate of pigment-spread, we have calculated the percentage of patients (P%) and grafts (G%) which attained a pigment-spread of more than 6 mm within 6 months. A high P% and G% thus indicates a faster rate of pigment-spread. The P% was 100 for lesions on the neck and trunk, 92.3 for face, 83.3 for lower extremity, and 50 for upper extremity. The G% also followed a similar pattern, 100, 97.2, 90, 82.9 and 26.6 for lesions on the neck, trunk, face, lower and upper extremities respectively. The lesions on the dorsal aspects of hands, fingers, feet and malleoli were particularly slow to repigment.
Similarly, the P% and G% were 77.2 and 80 respectively for patients less than 20 years in age and 78.5 and 87.7 for patients between 20 and 40 years, compared to 66.6 and 50 for patients more than 40 years in age, though there were only 7 grafts applied in 5 patients in the last category.
For men the P% and G% were 90 and 84.6 compared to 82.1 and 83.3 for women.
The P% and G% for patients having no treatment were 87.5 and 85.3 compared to 57.1 and 59.1 for patients who were still receiving oral corticosteroids in the form of weekly pulses. Forty eight grafts applied in the lesions of 10 patients were given topical psoralens with sun exposure on the lesions after the grafts had taken. All the lesions showed a faster rate of pigment-spread, the P% and G% being 100.
The P% and G% for patients having segmental vitiligo were 87.5 and 92.9 compared to 81.4 and 75.5 for patients having non-segmental vitiligo.
| Comments|| |
Punch grafting was first used by Orentreich and Selmanowitz in 1972  for a patient having post-burn leukoderma, and then by Bonafe et al in 1983  for 2 patients having vitiligo. Subsequently, Falabella has used this technique extensively for a variety of depigmented lesions including vitiligo.  The success rates in all the reports including our own have been high. The ultimate extent to which the pigment would spread from each graft cannot be determined as yet in this study, because the pigment was continuing to spread further from most of the grafts. The maximum spread so far has been 22 mm. We had therefore preferred to apply a few grafts at a time and added more grafts subsequently to cover the areas which seemed to be left out.
One of the major limitations with punch grafting is that the spread of pigmentation into the adjoining skin is slow. Falabella  recorded complete pigmentation of the skin in 3-6 months by placing the mini punch grafts at a distance of 3-4 mm. In our cases, a fairly high percentage of patients showed a pigment spread of at least 6 mm within 6 months. The pigment-spread was faster in younger individuals and if the lesions were located on the trunk, neck, face and proximal parts of the extremities. The major reasons for a slower rate of pigment-spread in some of our cases were, location of the lesions on the fingers, hands, feet or malleoli and possibly when the patient was older. The lower P% recorded in patient having corticosteroids and those having non-segmental vitiligo was found to be due to a larger proportion of the lesions being located on the fingers, hands or malleoli in these groups rather than the effect of corticosteroids or the type of psoralen and sun exposure after the grafting, resulted in a faster pigment-spread in a few cases studied so far. If corroborated by further experience, this can be used to achieve quicker repigmentation. Even then, compared with the results of suction blister grafting or split thickness grafting, the results with punch grafting are slow.
Another limitation with punch grafting can be that the grafted skin may not merge with the adjoining skin. Indeed, in a majority of our cases, the grafted skin still looked different from the adjoining skin, though in some cases, it had already merged with the surrounding skin. Similarly, it is also possible that the pigment spreading from the adjoining grafts may not be of uniform intensity and thus produce a cobble-stone appearance. We expect that with the passage of time, the grafted skin will become indistinct and the cobble-stone appearance will also disappear. Larger sized grafts as used by us are likely to take longer to merge with the recipient skin, but larger grafts have a better chance of survival, and fewer grafts are needed to cover the lesion. The fewer the grafts, the lesser the cobble-stone appearance. A long follow up will decide whether to prefer a larger number of smaller grafts or a smaller number of larger grafts. In any case, vitiligo being a socio-psychological problem, most of our patients would prefer an uneven pigmentation rather than a vitiliginous patch, though a uniform pigmentation would be ideal.
The rate of graft rejection in our cases was rather high. The reasons for rejection could be an excessive exudation of serum under the grafts, a mild infection or an inadvertent crushing of the grafts during handling. This rate, therefore, can be reduced by improving the technique. In 2 instances where the initial grafts got rejected, a repeat graft at the same site was successful.
The success of punch grafting depends upon the clinical status of vitiligo. In case the disease is active, the grafted skin is likely to get depigmented. We resorted to punch grafting when a lesion had shown no change for a period of at least 4 months, though several of our patients were still on medical treatment. The depigmentation in 2 of our grafts could be attributed to this cause.
The skin at the donor sites healed with an inconspicuous scar. In case there is any tendency for formation of a keloid, an intralesional injection of a corticosteroid should suffice.
The main question which still needs to be answered is, whether the pigment will stay permanently, or there is a chance of losing this pigment again. We believe surgical procedures are useful only after the disease has been rendered inactive. In case surgery is undertaken when the disease is active, or if it becomes active again, the pigment even in these areas can be lost.
The major advantage of this procedure is that the technique is very simple and easy to perform. Any person who has taken a punch biopsy can undertake this procedure.
| References|| |
|1.||Pasricha JS, Seetharan ;;-,A, Dashore A. Evaluation of five different regimes for the treatment of vitiligo, Ind J Dermatol Venereol Leprol 1989 ; 55 : 18-21. |
|2.||Falabella R. Grafting and transplantation of melanocytes for repigmenting vitiligo and other types of leucoderma, Int J Dermatol 1989; 28: 263-9. [PUBMED] |
|3.||Behl PN. Treatment of vitiligo with homologous thin Thiersch's skin graft. Curr Med Pract 1964; 8:218-21. |
|4.||Behl PN, Bhatia RK. Treatment of vitiligo with autologous thin Thiersch's grafts. IntJ Dermatol 1973; 12:329-31. [PUBMED] |
|5.||Suvanprakorn P, Dee-Ananlap S, Pongsomboon C, et al. Melanocyte autologous grafting for treatment of leukoderma. J Am Acad Dermatol 1985; 13:968-74. [PUBMED] |
|6.||Koga M. Epidermal grafting using the tops of suction blisters in the treatment of vitiligo. Arch Dermatol 1988; 124:1656-8. [PUBMED] |
|7.||Tawade YV, Gokhale BB, Parakh A, et al. Autologous graft by suction blister technique in managementof vitiligo. Ind J Dermatol Venereol Leprol 1991; 57:91-3. |
|8.||Falabella R. Treatment of localized vitiligo by autologous minigrafting. Arch Dermatol 1988; 124: 1649-55. [PUBMED] |
|9.||Lerner AB, Halaban R, Klaus SN, et al. Transplantation of human melanocytes. J Invest Dermatol 1987; 89: 219-24. [PUBMED] |
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|11.||Bonafe JL, Lassere J, Chavoin JP, et al. Pigmentation induced in vitiligo by normal skin grafts and PUVA stimulation. Dermatologica 1983; 166: 113-6. [PUBMED] |
[Figure - 1], [Figure - 2]
[Table - 1]
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