Dr. Iltefat Hamzavi discusses surgical options in vitiligo treatment, including skin grafting approaches and the melanocyte keratinocyte transplant procedure.
Iltefat Hamzavi, MD, Senior Staff Physician at Henry Ford Health System’s Department of Dermatology, and dermatologist at Hamzavi Dermatology and Dermatology Specialists in Detroit, Michigan
“The key pillars [of medical vitiligo treatment] are addressing triggers, managing immunology, and then replacing and regenerating melanocytes. There are oral and topical options to manage immunology. There are phototherapeutic options to bring in melanocytes,” said Iltefat Hamzavi, MD, who presented “Vitiligo Surgical Treatment Advances” at the Pigmentary Disorders Exchange meeting in Chicago.
But very few of these treatments will rapidly re-pigment, said Dr. Hamzavi.
“Once you manage immunology, it takes a long time for the pigment to come back spontaneously. You add phototherapy and it still takes months. Surgery can move melanocytes from areas that do not have vitiligo… to areas that do have vitiligo and re-pigment within weeks to months.”
Punch grafting, blister grafting, and split thickness skin grafting are among the surgical options, he said.
“Punch grafting can be done for smaller areas—from 2 to 4 cm in diameter. [Donor tissue] can be taken from the retroauricular sulcus behind the ears and placed on the recipient areas. It doesn’t cover large areas and can leave a little bit of a halo but gives good results.”
Clinicians can treat larger areas with blister grafting, split thickness skin grafting, or non-cultured epidermal cell suspension, also known as melanocyte keratinocyte transplant procedure (MKTP), said Dr. Hamzavi.
“In suction blister epidermal grafting, blisters are raised, harvested, and transferred from a [donor site] to [recipient site]. Suction blister epidermal grafting is useful for difficult-to-treat areas such as the eyelids. Complications such as peripheral ‘halo’ depigmentation, milia, hypertrophy, and hyperpigmentation (especially in darker skin phototypes) may occur, including infection rarely,” according to a review by Dr. Hamzavi and colleagues.1
According to Dr. Hamzavi, in his experience split thickness skin grafting offers a better result.
“But you have to take the recipient skin equivalent, so you’re taking a lot of skin and creating trauma and a scar on the recipient site and the donor site,” said Dr. Hamzavi.
The MKTP technique has the advantage that the donor site can be one-fifth to one-tenth that of the recipient site, said Dr. Hamzavi.
“MKTP involves numbing a donor site. …you take a split thickness skin graft and process it by heating it. You add some trypsin to the heating components and solution. The trypsin solution with the heat breaks the dermal cells away from the epidermal cells of keratinocytes and melanocytes. And then you are able to spin that down and place it inside the solution.”
Essentially, you take a solid structure and make it into a solution, he said.
“You then derm abrade or laser abrade the recipient area [before applying the cellular suspension solution], place a collagen dressing on top of the donor site, and then over 5 to 7 days remove it. In a few weeks to a few months, you have significant re-pigmentation.”
While few U.S. centers offer MKTP (Dr. Hamzavi’s among them), clinicians in India, Saudi Arabia, China, and other countries commonly perform it, said Dr. Hamzavi.
“It requires a specialized team to be able to do it.”
But that could soon change, he said. Commercial prep kits have been developed that eliminate the need for an in-office solution processing team. In FDA trials these performed similarly to traditional processing techniques for MKTP. These kits are not yet approved in the U.S. for use in vitiligo but are approved to reepithlialize skin after burns, said Dr. Hamzavi.
“In general, about 92% of patients with segmental vitiligo and about 54% patients with generalized vitiligo have complete re-pigmentation. The kit is getting similar results but with smaller numbers in studies. So, we’ll see how it does in future FDA trials.”
Patient selection is important, according to Dr. Hamzavi.
“You cannot do [MKTP] in unstable vitiligo patients. You cannot do this for the tips of the fingertips. Perioral does not do as well. But if you have a stable patient that does not have any signs of unstable vitiligo, whose disease is stable for 6 months, this is a very good option for areas that just don’t respond or are responding very slowly to other treatments.”
Reference:
1. Nahhas AF, Braunberger TL, Hamzavi IH. Update on the Management of Vitiligo. Skin Therapy Lett. 2019;24(3):1-6.
Disclosure: Dr. Hamzavi is an investigator and consultant for Avita Medical.