Vitiligo Treatment Toolkit Offers Novel Surgical Therapies

Sep 02, 2023

Sep 6, 2022

A wide range of therapies, such as microneedling and ablative laser therapy added to phototherapy, plus novel surgical therapies offer patients with vitiligo repigmentation options.

Multiple surgical treatments for vitiligo that can be readily performed by dermatologists and dermatologic surgeons in a clinical setting are often underutilized but can be beneficial in treating recalcitrant vitiligo, according to Loren D. Krueger, MD.

"We are grateful that treatment options for vitiligo are expanding," she says. "We now have topical and oral Janus kinase inhibitors that are being used widely. The world of procedural treatments is also expanding for vitiligo, especially for segmental vitiligo and vitiligo patches that are less responsive to treatment. However, we need to optimize our treatment options for these patients as vitiligo can certainly be devastating." Vitiligo, Dr. Krueger adds, can have a significant impact on patients’ psychological well-being and overall QOL.

For a systematic review and meta-analysis published in Dermatologic Surgery, Dr. Krueger and colleagues assessed 73 studies that included 2,911 participants receiving non-phototherapy surgical treatments for vitiligo, including less invasive procedures such as platelet-rich plasma, microneedling, and ablation therapies, and more invasive procedures, such as punch grafting (PG), suction blister epidermal grafting (SBEG), and non-cultured and cultured cellular transplantations (Table).

Microneedling & Ablative Laser Therapy Showed Minimal Adverse Effects

The study team observed that "dermatologists may be able to employ many of these surgical therapies using existing in-office tools," thereby greatly expanding the treatment options for patients with vitiligo resistant to conventional treatments, such as narrowband UVB (NB-UVB) phototherapy modalities.

Treatment success was defined as more than 75% repigmentation and treatment failure as less than 25% repigmentation of vitiliginous skin. Overall, the addition of microneedling or ablative laser therapy to NB-UVB phototherapy was linked with improvement in treatment success with minimal adverse effects (AEs). In contrast, more invasive techniques such as SBEG and PG were associated with the highest likelihood of treatment success but increased the risk for severe AEs, including hyperpigmentation and scarring.

Microneedling involves micropuncturing the vitiligo patch with fine needles to stimulate the wound healing cascade via release of regenerative factors, which may also assist in seeding of melanocytes. Overall, studies on microneedling reported improvement in repigmentation when it was added to NB-UVB and laser therapy. In the studies that compared NB-UVB with or without microneedling, the addition of microneedling was linked with lower odds of treatment failure. Microneedling was well tolerated, with the most common AEs including transient pain, pruritus, minor bleeding, and discomfort during or shortly after treatment.

Ablative therapies include laser therapy and manual dermabrasion, which are thought to facilitate repigmentation through the release of inflammatory mediators and metalloproteinases that spur melanocytes to migrate to and proliferate at the vitiligo patch, or to create channels that enable topical medications to penetrate more deeply into vitiliginous skin.

Both Types of Laser Therapy Improved Odds of Repigmentation

Laser therapy may include use of a CO2 laser or an erbium-doped yttrium aluminum garnet (Er:YAG) laser, which emit light at 10,600 nm and 2,940 nm and target water and melanin, respectively. Both forms of laser therapy were found to greatly improve the odds of repigmentation when added to NB-UVB, with an almost three-fold increase in treatment success with the addition of CO2 laser therapy and 14-fold increase in treatment success with the addition of Er:YAG laser therapy versus NB-UVB alone. Common AEs with laser therapy included pain, burning, erythema, and transient hyperpigmentation.

Dermabrasion was found to significantly improve the odds of treatment success when added to pimecrolimus versus pimecrolimus alone (43% vs 22%, respectively). Similar treatment success rates were reported for the combination of manual dermabrasion plus non-cultured epidermal suspensions (NECS) and electrofulguration-assisted dermabrasion plus NECS (60% vs 67%, respectively). Common AEs with dermabrasion included transient pain, erythema, and persistent hyperpigmentation.

SBEG Linked With Greater Repigmentation Rates Compared to PG

SBEG creates blisters on the patient's pigmented skin and then uses negative pressure to remove the tops of the blisters, which are then transferred to the vitiliginous skin, whereas PG replaces 1-2 mm full-thickness punch grafts in vitiliginous skin with similarly sized grafts from donors’ pigmented skin. Repigmentation success as high as 80% after 6 months of treatment was reported with PG; however, several studies found SBEG to be associated with greater repigmentation rates than PG.

The most common AE after SBEG was hyperpigmentation, whereas the most common AE after PG was cobblestone appearance, which affected up to 90% of patients. Dyspigmentation, which could include hyperpigmentation, hypopigmentation, and depigmentation, were reported with both modalities, though less frequently.

"We often do not think of vitiligo as a disease that would respond to procedural interventions," Dr. Krueger notes. "Hopefully, the expanded treatment repertoire will help many patients as well as clinicians looking for alternative therapies. Kudos to the many dermatologists who are exploring these options for their patients with vitiligo."