COEUR D’ALENE, IDAHO – Autologous grafting is a treatment of unmatched effectiveness for pediatric patients with segmental vitiligo unresponsive to medical modalities, according to Dr. Pearl E. Grimes, director of the Vitiligo and Pigmentation Institute of Southern California and a dermatologist at the University of California, Los Angeles.
"Segmental vitiligo is really the only type of vitiligo I think I can cure, and that’s because we get our absolute best responses with autologous grafting in combination with phototherapy," she said at the annual meeting of the Society for Pediatric Dermatology.
Dr. Pearl E. Grimes
She favors the use of 1-mm punch grafts over more elaborate techniques such as split-thickness grafts, blister roof grafts, and cultured cell transplantation. Autologous grafting using 1-mm punch grafts is simple, and long-term follow-up studies have documented the persistence of repigmentation for more than 5 years in patients with segmental vitiligo.
"It’s so, so easy," Dr. Grimes said. "And the great thing about punch grafts is this technique doesn’t require a lot of special equipment, unlike sheet grafts and the other methods. All you need are iris scissors and jeweler’s forceps."
"I’ve harvested anywhere from 10 to 250 grafts at one setting. We anesthetize a donor area on the hip, harvest the 1-mm punch grafts, place them in saline in sterile petri dishes, remove 1-mm punch grafts from the anesthetized recipient site, and then with jeweler’s forceps you place those harvested 1-mm grafts in those 1-mm recipient holes. You cover the areas with Steri-Strips, which stay in place for 7 days. Then you remove them and start phototherapy, either narrow-band UVB, PUVA [psoralen and UVA], or with an excimer laser," she explained.
In her experience, aggressive topical therapy using high-potency corticosteroids and tacrolimus (Protopic) often provides good results in treating segmental vitiligo on the face.
"If you have segmental vitiligo on the trunk and extremity areas, it’s much more difficult to get good results with topical therapies. Those are the patients who ultimately will need to be grafted," according to the dermatologist.
She stressed that when using autologous grafting to treat patients with generalized vitiligo, it’s imperative to stabilize them beforehand. This is accomplished using systemic steroids: for example, 5-10 mg/day of prednisone for 2 weeks, or mini-pulse dosing of betamethasone at 5 mg twice weekly.
"When I see kids with segmental vitiligo in my initial consultation, I always tell them and their parents that if I were going to get vitiligo, I’d choose segmental versus the generalized variety. That’s because of all the types of vitiligo that we see, the segmental variety is the most predictable. It burns itself out in about 95% of patients in that first year, so we know that in the overwhelming majority of patients it’s not going to spread beyond that dermatome," Dr. Grimes said.
She made a plea for physicians to be more aggressive in treating childhood vitiligo. Often they are reluctant to treat. Yet it has been shown across the board, for all treatment modalities, that efficacy is significantly greater in children than adults.
"Children are the ones who are more likely to give you that greater than 75% repigmentation. It’s a great reason to treat children early," Dr. Grimes said.
She reported having performed clinical research and/or serving as a consultant to a dozen pharmaceutical and cosmetics companies.