Progress in the treatment of special parts of vitiligo

Type:Uv phototherapy   Time:2018-11-20 14:18:33 on: initial; background-size: initial; background-repeat: initial; background-attachment: initial; background-origin: initial; background-clip: initial;"> After continuous observation for more than 1 year, most of the patients had normal skin color, a small part was slightly hyperpigmented, and the new long hair was also black. Hair Transplantation: Hair transplantation is an effective treatment for localized/segmental vitiligo, especially for hair parts such as eyelids, eyebrows, and scalp. Some scholars carried out single hair follicle transplantation for vitiligo patients, 11 cases were eyebrows, 8 cases had good complex coloring effect, 3 cases had no response; 1 case had excellent curative effect after scalp transplantation.

Kumaresan performed a single hair follicle transplantation on a 30-year-old man with stable vitiligo. The lesion was located on the right lip and the scalp on the occipital scalp. The pigment was visible after 4 weeks, and the white spot was completely recolored after 8 weeks. Cell transplantation: Mohanty et al applied a new surgical method to extract hair follicle outer root sheath cells from scalp hair follicles and transplanted cell suspension. The average color recombination rate was (65.7��36.7)% in 14 patients with vitiligo.

 

 Some scholars have applied 13 non-cultured cells to treat vitiligo in the whitening area of ​​the hair and evaluated the effect of whitening complexion. After 6 months of transplantation, 1 case was lost to follow-up, and 8 of the remaining 12 cases (67%) reached Good color-recovery effect, continued follow-up until 9 to 12 months, and one case was lost to follow-up, and 10 of the remaining 11 cases (91%) achieved satisfactory color-recovering effects. Among the 9 cases of eyebrows, 8 were white hair complex colors. It can be seen that non-cultured cell transplantation therapy has a good effect on white hair complexion.

3. Joints and extremities vitiligo

 

  3.1 Drugs and phototherapy

 

 Hofer et al used 308nm cesium chloride laser to treat 85 lesions in 25 patients, 3 times a week for 6 to 10 weeks. A total of 24 patients completed the study, of which 16 (67%) patients had complex Color, "ultraviolet sensitive area" (face, trunk, limbs) began to appear pigment after 13 treatments on average, while "ultraviolet-insensitive areas" (elbow, wrist, knee joint and back of the hand and foot) began to color after 22 treatments.

 

Passeron compared the effect of using a 308nm excimer laser and a 308nm excimer laser in combination with tacrolimus ointment. It has been found that in the UV-insensitive areas (such as bony prominences and extremities), the combined use of 0.1% tacrolimus ointment is more pronounced than the 308 nm excimer laser alone.

3.2 surgical treatment

 

  Micro-drilling transplantation: Sa-vant reviewed the treatment of vitiligo, and it is considered that the mini-punch grafting (MPG) is a relatively good method for the lesions of the digits of the toe and the palmar. Autologous non-cultured cell suspension transplantation: Mulekar et al reported that autologous non-cultured cell suspension was used to treat patients with symmetric appendage vitiligo, and 10 cases of symmetrical elbow vitiligo were effective (4 cases reached 95%-100% complex color). 6 cases reached 65% to 94% complex color). In 11 cases of symmetrical knee vitiligo, 11 cases had excellent color-recovery effect, and 6 cases had good complex color effect. One patient with asymmetrical extremities had a good complexing effect.

4. Large area of ​​vitiligo

 

  For patients with stable vitiligo (such as topical glucocorticoids, immunomodulators, etc. or phototherapy), patients with stable vitiligo (including the leukoplakia in the above-mentioned refractory sites), if the area is larger, autologous melanocyte transplantation can be used. Method of treatment. In 1987, Lerner et al. successfully used the autologous melanocyte transplantation in vitro to treat mottled disease.

 

  With the increasing maturity of melanocyte culture technology, the use of cultured autologous melanocyte transplantation has become a development direction of vitiligo treatment research. In recent years, there has been a large amount of literature reported in foreign countries that improved in vitro cultured cells can provide more melanocytes for transplantation. Domestic scholars have also conducted research on the application of autologous melanocytes in the treatment of vitiligo, confirming that this method is effective in treating stable vitiligo, and can treat large-area skin lesions with a small amount of donor site. The study found that 2.0cm2 was used for skin feeding. The melanocytes cultured in the region can successfully treat white spots with a maximum area of 250 cm2, and have clinical application value.

In addition, the transplantation of autologous cultured melanocytes using a bioengineered membrane as a carrier can improve the stability and efficacy of melanocyte transplantation. Re-dondo applied amniotic membrane as a cell carrier and scaffold in 5 patients with melanocyte transplantation. After 6 months of follow-up, the skin color loss rate of the patients was 90%-95%. Although there have been many studies on melanocyte culture transplantation methods at home and abroad, in vitro cell culture requires the addition of some substances that promote cell mitosis, and such additives have potential carcinogenic potential.

 

 Czajkowski et al. confirmed by genetic analysis that some of the additives that promote melanocyte proliferation have no risk of damage to the RAS/RAF/MEK/ERK signaling pathway and the CDKN2A gene, but more research is needed to confirm autologous melanocyte culture therapy. Security.

5. Summary

 

 These refractory parts such as lips, genitals, scalp, eyelids, elbows, knees, limbs, and palmars are relatively difficult to treat due to internal and external causes. However, according to the characteristics of each part, rational use of drugs and phototherapy , a variety of transplantation and combination therapy to improve efficacy.

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Vitiligo is a common pigmentation degenerative disease. The clinical manifestations are leukoplakia of the skin, often involving the exposed parts of the head and hands. All kinds of families can be affected, no obvious gender differences, easy to diagnose and difficult to treat, often affecting the patient's beauty and Mental health. The incidence of vitiligo is about 1%, and the higher the skin tone, the higher the incidence of people.

According to the patient's disease period, type, lesion area, disease course and other factors, develop a safe, effective and reasonable program. There are still many problems in the treatment of vitiligo, such as mucosa, limbs, and vitiligo involving hair. It is difficult to treat with conventional treatments. The treatment of vitiligo in special parts is reviewed in this paper. Doctors offer more options for treating refractory parts of vitiligo.

1 mucous membrane parts and thin and tender parts of the skin

 

       1.1 Lips

 

       1.1.1 drug treatment

 

       Studies have shown that prostaglandins can induce melanocyte proliferation, Kapoor et al used prostaglandin gel in the treatment of 7 patients with lip vitiligo, 2 times / d, a total of 6 months, of which 2 patients with complex color effect of 75% ~ 100 %. The incidence of adverse reactions was 18%, mainly due to the short burning sensation of the lips.

 

     1.1.2 Surgical treatment

 

 Surgical treatment is available for patients with stable vitiligo. There are many surgical procedures for the treatment of labial vitiligo, including autologous epidermal grafting and autologous melanocyte transplantation. Simple epidermal grafting or combined phototherapy: Malakar et al reported that 108 cases of lip vitiligo were treated with drilling grafts. The results showed that 78 cases (72%) achieved complete coloration; 32 cases (30%) showed paving stone appearance. Gupta et al treated 31 leukoplakia in 26 patients with vitiligo with blister epidermal grafting. Twenty-seven (87%) of the 31 lesions were completely recolored, but 12 of them had long-term hyperpigmentation.

   Babu conducted a comparative study of borehole grafting and negative pressure blister epidermal grafting. Eighteen patients with stable vitiligo of the lip, 8 patients were treated with drilling and transplantation, and 10 patients were treated with blister epidermal grafting. After 6 months, the effect was observed. . In the borehole transplantation group, 2 cases achieved 50% to 75% re-coloring effect, 1 case achieved 75%-90% re-coloring effect, and 3 cases achieved 90%-100% re-coloring effect. In the blister epidermal graft group, 1 case achieved 50% to 75% re-coloring effect, 3 cases achieved 75% to 90% re-coloring effect, and 2 cases achieved 90% to 100% re-coloring effect.

 

  Compared with vesicle epidermal grafting, the chromatic aberration after drilling is small, but the borehole graft has irregularities. The author suggests that a small area of ​​the vitiligo can be treated with micro-drilling transplantation, and a large-area lip vitiligo is selected for negative pressure blister epidermal grafting. After the lip epidermis transplantation, the attachment and fixation of the skin is a common factor affecting the late treatment. Ghorpade uses tissue glue to assist in the fixation of the micro-drilled skin graft, which achieves good results and is firmly fixed. The patient can speak or drink immediately after surgery. Stable period lip lesions and bone grafting generally have a good effect. If no obvious effect is obtained after transplantation, re-transplantation and 311nm phototherapy can be performed.

Lahiri et al. performed re-transplantation and combined 311 nm phototherapy in 5 patients who did not see color after bone grafting. After 16 weeks, 3 patients achieved satisfactory results. Local excision and suture: Sacchidanand performed a local leukoplak resection and in situ suture in a patient with stable vitiligo in a small area of ​​the vitiligo. The curative effect was determined. There was no adverse reaction of blister epidermal or drilling graft, no late hyperpigmentation, but It is only suitable for small-area patients, otherwise it may affect the lip shape due to local resection. Tattoo: Singh et al. applied electric tattoo instruments and medical dyes to 15 cases of lip vitiligo under local anesthesia. After 2 to 3 courses, the patients achieved satisfactory results. This method is simple, less painful and less expensive, but some patients may have a shallow pigmentation after a long time.

1.2 vitiligo in the eyelid area

 

 1.2.1 drug treatment

 

 His carbamazeol ointment: Ama-no et al reported that an 11-year-old vitiligo girl with skin lesions at the periocular, posterior, and lumbar regions was treated with 0.0002% tacrolimus ointment in combination with sun exposure (30 min after morning medication). After 1 month, the skin lesions were completely recolored. Pimecrolimus cream: Souza and other 1% pimecrolimus cream was used to treat a patient with vitiligo in the orbital area of ​​the child. After 4 months, the skin lesions were completely recolored. After 1 year of follow-up, no recurrence was found.

 

 Tacrolimus Ointment: Lepe et al. A randomized, double-blind trial of 20 patients with vitiligo to study the efficacy and safety of 0.1% tacrolimus ointment and 0.05% clobetasol propionate, clobetasol in the right eyelid The left eyelid is treated with tacrolimus. It has good curative effect for 2 months. Because of its small side effects, it can be used for young patients and sensitive parts. It is an effective and safe choice for patients with vitiligo at the orbit.

1.2.2 surgical treatment

 

 The eyelid dermis has less fat, thin and slack skin, special anatomical parts, difficult treatment, but rich blood supply. Therefore, a reasonable transplantation method can achieve better results. Epidermal transplantation: Nanda et al. performed stable hypotonic vitiligo in 6 patients with stable orthotopic vitiligo. After 3 to 6 months, the patients achieved satisfactory color-recovery and no complications. Kahn used a holmium laser (Er-biumYAGlaser) to remove the epidermis of the leukoplakia area under local anesthesia, and then transplanted the epidermis. Partial dressing was carried out for 2 days. After 1 week, the pigment was visible and there was no scar on the part.

 

 Non-cultured epidermal cell suspension: Mulekar and other autologous non-cultured epidermal cell suspensions were used to treat 9 cases of orbital vitiligo. Among them, 4 cases of symmetrical eyelid vitiligo achieved 95%-100% re-coloring effect, while 5 cases were asymmetric. 3 cases of eyelid vitiligo achieved more than 65% of the complex color effect.

1.3 genital area vitiligo

 

  1.3.1 Drug treatment

 

  Pimecrolimus cream: Souza et al applied 0.1% pimecrolimus cream in the treatment of 1 case of genital vitiligo, 2 times / d, 4 months after the lesion completely re-color. Prostaglandin gel: Kapoor and other prostaglandin gel treatment of 3 cases of genital vitiligo, 2 times / d, a total of 6 months, 1 case achieved 75% ~ 100% complex color effect.

 

  1.3.2 Surgical treatment

 

 Melanocyte transplantation: Mulekar et al reported that 3 cases of genital vitiligo were treated with non-cultured autologous epidermal cell suspension, and the complex color effect was better. In 2009, Mulekar and other cell suspensions were used to treat 4 cases of genital vitiligo, and all of them achieved good results. One case of vitiligo in symmetrical genital area achieved 95%-100% color-recovery rate, and 3 cases of asymmetric genital vitiligo also obtained. Good efficacy. Tattoos: Savant summarizes the surgical treatment of vitiligo and believes that spurs are also a good choice for the genital area.

2. Vitiligo in the hair area

 

  2.1 drug treatment

 

 Prostaglandin gel: Kapoor and other prostaglandin gel treatment of a case of scalp vitiligo, 2 times / d, a total of 6 months, achieved 50% complex color effect. Melanogenin: Xu et al. used 22 cases of scalp vitiligo in the treatment of topical melanin liquid combined with infrared radiation, 2 times / d, 18.2% of patients completely re-color, 27.3% of patients were markedly effective, 36.3% of patients improved, suggesting black Cytokinin may be a safe and effective method.

 

 5% minoxidil combined with tacrolimus ointment: Wu Yifei and other 5% minoxidil combined with tacrolimus ointment for the treatment of scalp vitiligo patients, a total of 120 cases, divided into 5% minoxidil combined with him Kemus cream group, 5% minoxidil group and tacrolimus ointment group. After 3 months of treatment, the effective rate was 69.05% in the combination treatment group, 47.37% in the minoxidil group and 52.50% in the tacrolimus group.

2.2 surgical treatment

 

 Simple epidermal grafting: In 1995, Agrawal et al. underwent localized anesthesia for 8 patients with vitiligo in the hair area. The skin graft was combined with thick-skinned epidermis. After 3 months, the eyebrows (70%-90%) showed complex color, while the scalp The color of the beard is later (6 to 9 months), and about 50% to 60% of the complex color appears. Epidermal transplantation after chemical hair removal: Kim et al. performed chemical depilation in 2 cases of scalp vitiligo, followed by local vesicle epidermal transplantation, and treated with PUVA 2 weeks later. Both cases were successfully recolored with skin lesions.

 

 It is indicated that epidermal grafting combined with chemical hair removal is one of the effective and safe methods for the treatment of vitiligo in the hair. Autologous epidermal grafting after plucking: Lin Hui et al. performed exfoliation of 35 cases of vitiligo in the hairy area, and grafted 190 pieces of skin, and survived 173 pieces. After 3 months, the curative effect was observed, the effective rate was 91.05%, and the supplementary treatment was 1 time. After that, the cure rate was 100%.

    

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