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Vitiligo (सफेद दाग) / White Spots

When melanocytes, the skin cells which provide the unique colour to skin, have either been destroyed by a medical condition or through physical trauma, skin becomes white in colour.

Medical conditions such as vitiligo disease / leucoderma, piebaldism, or halo nevus for example, cause destruction of melanocytes. Burn scars often have white patches where there are no melanocytes, and laser tattoo removal often results in a loss of melanocytes as well as tattoo pigment.

Melanocyte Transplantation

Melanocyte transplantation is the latest surgical method for the treatment of stable Vitiligo/leukoderma and loss of pigmentation.

Melanocytes are the skin cells which produce melanin. A complete absence of skin colour usually means that the melanocytes have been destroyed. Thanks to an innovative treatment, it is now possible to take melanocytes from a healthy area of skin and transfer them as cellular suspension onto the de-pigmented patches of skin. This process can be performed in a clinic in one to three hours.

Who is suitable for Melanocyte Transplantation?
1. Clinically stable patient - Patients who have had stable vitiligo patches for a period of at least 1 year are good candidates to undergo melanocyte transplantation. Vitiligo patients should fulfill the following criteria to be eligible for surgery:
1. Existing patches should not have increased in size.
2. No new patches should have appeared on other areas.
3. Any injury should heal with normal skin color.
There are three main categories of patients that are suited to melanocyte transplantation.
Segmental vitiligo
Generalized vitiligo – Affected area < 20%
Leukoderma- Piebaldism, post-burn leukoderma
Selection of individual patient will depend upon assessment by a physician.

Who is not sutiable for Melanocyte Transplantation?
Patients with fingertip/lips involvement are not suitable for melanocyte transplantation.

Response according to type of vilitigo:
Segmental – most suitable. Success rate 90-94% (See below)
Focal – Success rate approximately 80%
Vulgaris - Success rate approximately 65%
Acral - Poor response in all areas. Success rate-data not available
Success rate of treatment is 94% i.e 94% of the treated patient who have pigmentation over 65% to 100% of the treated area. A statistical figure of success rate applies to a group of people and not to an individual.

Recurrence of vitiligo after treatment:
Segmental – Rarely it can recur.
Focal – Low chance of recurrence. It can develop in vulgaris type.
Vulgaris - can recur.
Acral - Very high rate of recurrence.

How much area can be treated?
In one operative session up to 100 sq. c.m. white patches can be treated depending upon the sites involved. It can be up to 250 sq. c.m. in selected patients. Multiple operative sessions are required for large areas.

Anaesthesia
Local - Injection. Lidocaine 2% or Lidocaine cream or combination.
General - used for multiple patches or if pain tolerance of the patient is low.
Is one operative session enough for complete recovery?
All patients do not achieve complete re-pigmentation in one session. Approximately 30% patients require repeat surgery to improve the results.

Most Advanced Method
Melanocyte transplantation is the latest modification in the surgical management of vitiligo/leukoderma. Large areas can be treated. Cosmetic results are superior to other surgical methods such as skin grafting and punch grafting. Difficult areas like bony surface, areola, genitals and knuckles can be treated with excellent results.

The operation step by step
In a clean procedure room, a thin shave biopsy is taken. The most common site is anterior, upper third of thigh.
The biopsy is processed using an enzyme to separate the layers of skin and to make a skin cell suspension. This suspension contains melanocytes-keratinocytes (epidermal cells).
The area to be treated is abraded with diamond fraize wheel and the cell suspension is applied. It is covered with dry collagen sheet, which helps to keep cells in place and promotes healing.
The final dressing consists of a micro pore or tegaderm depending on sites involved.

What happens post-treatment?
The treated site is protected by a dressing for one week. Verbal and written post treatment instructions are provided. Upon removal of dressing treated area appears bright red. Re-pigmentation begins in 4 to 8 weeks and continues to progress up to 4 to 6 months post-surgery. Post-operative pain depends upon the site and areas treated; feet being the most painful, and face the least.

Complications & Side Effects – are rare in expert hands.

Scarring and Koebner's phenomenon - Trauma of surgery may cause new lesions (Koebner's phenomenon) and is seen in approximately 2% of our patients.
Hypo pigmented ring - at the borders of treated and re-pigmented patches in some patients. Usually this ring disappears automatically or with application of local steroids, or by repeat surgery. Rarely does it persist in spite of treatment.
Bacterial infection. All patients are given oral antibiotics to prevent infection.
Colour mismatch.

Advantages of Melanocyte Transplantation

It is a day care procedure. Patient can go home immediately if local anaesthesia is used.
A large area can be treated in one operative session.
A very small piece of normal skin is sufficient to treat large affected area, e.g. 10cm2 of donor skin is enough to treat 100cm2 of vitligo/leukoderma patches.
Very good cosmetic results.
Very minimal or no side effects.
Postoperative treatment depends upon the response
It is important to note that since no cause is known there is no permanent cure for the vitiligo/leukoderma. The disease can be treated to achieve re-pigmentation of vitiligo patches, but it cannot be cured from the roots.

Non-Vitiligo Indications

There are several disorders, other than Vitiligo, which lead to loss of pigment. Some of these disorders are listed below and can be treated with Melanocyte Keratinocyte Transplantation (MKTP).

Post-burn Leukoderma

A burn is a common accidental injury seen in medical practice. It results in scarring and fairly frequently, hypo or de-pigmentation. Normal pigmentation returns in many patients without any treatment, within about 6 months after complete healing. Some patients however, experience permanent hypo/depigmented patches similar to that of vitiligo. This is mainly due to mechanical destruction of melanocytes. Post-burn Leukoderma can be successfully treated by surgical transplantation methods. Any other medical treatment including photo therapy is likely to be unsuccessful. 

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Piebaldism

This is a hereditary disorder characterized by milky white patches of variable size and shape. These patches are present since birth and remain unchanged throughout life and are located on the front portion of the body (ventral part of the body).

This is a genetic disorder with complete absence of melanocytes. This disease does not respond to any kind of medical therapy.

Transplantation of melanocytes almost always gives excellent outcomes with very good re-pigmentation. Any surgical method will produce good results. Non-cultured epidermal cell transplantation may be the best option to treat large patches of piebaldism. 

Nevus depigmentosus

This is a localized hypo pigmented non-progressive lesion, which remains unchanged throughout life. It appears at birth or within a few months after birth. The exact cause of nevus is not known. Medical treatment including photo therapy, is not effective. Transplantation methods have been tried to treat this disease with variable results. 

Discoid lupus erythematosus

This disease can lead to scarred and depigmented patches on the face and upper chest. Usually these lesions fail to respond to medical treatments. There are only 2 reports in the literature which show very good results with surgical treatment. However, more studies with long term follow up will be helpful to assess/prove the efficacy of surgical therapies.

Leukoderma caused by laser

Lasers have been increasingly used in dermatology to treat vascular disorders, hair removal, hyper pigmented disorders, tattoo removal etc. These treatments sometimes lead to white spots. Melanocyte Keratinocyte Transplantation (MKTP) may be used to treat these white patches with good results.

Chemical Leukoderma (contact Leukoderma)

Certain chemicals like quinon and hydroquinone cause pigment cell destruction leading to white spots. These chemicals are present in industry and cosmetics. Occasionally phenol or tricholracetic peeling may also lead to white patches. MKTP can be considered to treat such lesions.

Halo Nevus

Halo nevus consists of a pigmented mole surrounded by sharply outlined area of depigmentation. Although it is often associated with vitiligo, in most cases it is a separate entity. Sometimes the pigmented mole disappears spontaneously and the depigmeted area pigments spontaneously. These nevi have been successfully treated by transplantation methods when they become stable.

Phototherapy/Light Therapy for Vitiligo

Nero band UVB Phototherapy has been getting increasingly popular as a treatment option for Vitiligo.  After careful evaluation of the patient’s skin condition and his other medical history, Phototherapy may be prescribed for the patient. Unprotected and unregulated exposure must be avoided in order to avoid any complications. Ultraviolet A (UVA) and Ultraviolet B (UVB) are the two types of ultraviolet light that are used for the treatment. It can be used alone or in combination with other medications applied directly to the skin or taken internally. Patients typically receive a series of exposures to the light about 2 -3 times per week for a period of 4- 8 months to get the improvement/repigmentation spots. The exact duration of treatment varies from case to case and can be decided after initial evaluation. They may also receive periodic maintenance treatments to prevent recurrence of their condition.

Targeted Phototherapy is a safe mode of treatment. Excessive exposure to Ultraviolet light is associated with skin ageing and hence it should be avoided. Targeted phototherapy may be compared to a reaction that occurs after excess exposure to sunlight but the major difference here is that sun tanning would affect the entire body but in targeted phototherapy, only the affected parts of the body are exposed to the Ultraviolet light. The normal skin remains unaffected whatsoever.

Advantages of targeted phototherapy:

  • It is a safe procedure
  • Absolutely painless
  • No downtime required: Patient can get to his work immediately after the treatment and does not require taking rest on account of the procedure
  • Treatment takes only a few seconds of exposure and the entire sitting takes about 10- 15 minutes only.
  • Prevents from the side-effects of conventional phototherapy (tanning of the rest of the body)
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