Punch Minigraft Versus Transverse Needling or Combination of Both in Treatment of Non-Segmental Vitiligo
Phase: NA
Conditions: Vitiligo
Sponsor: Alexandria University

 
 
 
 
Punch Minigrafts versus Transverse Needling or Combination of 
Both in Treatment of Non-Segmental Vitiligo 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
 
 
 
 
 
 
INTRODUCTION 
 
     Vitiligo is a common pigmentary cutaneous disorder occurring with an 
incidence of 1-2% worldwide, without predilection for sex or race. (1, 2) 
   The disease is characterized by gradual loss of the normal color of the skin 
resulting from melanin pigment loss due to the underlying destruction of 
the melanocyte. (3) 
    Vitiligo is a multifactorial disorder with many theories explaining its 
pathogenesis  
such as autoimmunity,(4) self-destructing mechanisms,(5) neural mediators,(6)  
biochemicals,(7) an imbalance of epidermal cytokines(8) and genetic factors.(9)  
 
Vitiligo is not a life-threatening disease,but it may cause a major social and  
emotional distress with significant impairment in the quality of life. (10) 
 

         Clinically; vitiligo is classified into segmental, non-segmental and  
unclassified 
vitiligo 
.Non-segmental 
includes 
generalized, 
acrofacial,universal,  
mucosal (more than one mucosal site) , mixed (associated with segmental 
vitiligo)  
and other rare variants. Segmental vitiligo includes uni- ,bi- or pleuri-
segmental 
 subtypes. Unclassified includes focal or mucosal (one site) subtypes. (11) 
 
Treatment options for vitiligo include attempting repigmentation of affected 
areas, 
 
      depigmentation of non-involving skin or camouflage if neither is  
effective.Repigmentation could be attempted using medical therapy, 
surgical  
modalities.(12)  
 
Topical 
medications 
include 
corticosteroids 
or 
calcineurin 
inhibitors.Ultraviolet  
radiation therapy, such as narrow-band ultraviolet B light (NB-UVB), is also 
widely  
used. It is minimally invasive, has few adverse effects and provides a good 
response  
rate. Excimer laser or light has become available for use recently, and 
favorable  

treatment results have been reported. (13) 
 
 When medical treatments are ineffective, surgical treatment is indicated. (14) 
The basic principle of all surgical methods is transfer of melanocytes from  
uninvolved skin into a stable vitiliginous lesion not responding to other lines 
of 
 treatment, where they function as effective epidermal melanin units. (15) 
 
Surgical modalites are divided into two groups, tissue grafting and cellular 
grafting. 
 Tissue grafting includes dermoepidermal grafts,split thickness skin grafts, 
punch  
grafts/minigrafts, and epidermal grafts/blister roof grafts While cellular 
grafting  
includes cultured or non-cultured epidermal suspensions.(16) 
 
Transverse needling is a recently described technique in the treatment of 
stable  
vitiligo. It is believed to induce pigmentation in treated areas by physically 
moving  
melanocytes from pigmented edges of the lesions into depigmented 
marginal areas  
using a horizontal needle moving within the skin tangentially between the 
two zones. (17, 18) 
 

AIM OF THE WORK
 
 
The aim of this study is to evaluate the effectiveness and tolerability of 
autologous punch minigrafting, transverse needling technique or combination of 
both followed by narrow band ultraviolet B phototherapy (311 nm) in the 
treatment of patients with stable non-segmental vitiligo lesions. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PATIENTS 
 
This study will be carried out on twenty patients having non segmental 
vitiligo recruited from the attendants of the dermatology and phototherapy 
outpatient clinics of the dermatology, venereology and andrology department, 
faculty of medicine, Alexandria University. 
 
Approval of the medical ethics committee of Alexandria Faculty of 
Medicine will be obtained. An informed written consent for participation in the 
study and photography will be taken from every participant included in the study 
after full explanation of the study protocol. 
 
❖ Inclusion criteria: 
• Adult patients (>16 years old) of either gender having stable non segmental  
vitiligo, that is resistant to other lines of repigmentation therapy. 
• Stability will be defined in terms of ;(14,19,20) 
➢ Lack of progression of old lesions with the past 6 months. 
➢ No development of new lesions within the same period. 
➢ Absence of history of koebner phenomenon. 
➢ Absence of confetti lesions or hypopigmented lesions within 
the past 6 months. 
➢ Presence of repigmentation of depigmented areas by 
medications or spontaneously in the past 6 months. 
 

• While resistance to therapy will be judged after receiving standard 
protocol of NB-UVB together with oral mini pulse dexamethasone at a 
dose of 2.5 mg on two consecutive weekly days for 3 months.(21) 
 
• Patients having lesions showing absence (0%) or poor (<25% 
according to VASI score) repigmentation after this regiment will be 
considered resistant to medical repigmentation and indicated to 
surgery. (22,23) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Exclusion criteria:- 
• Cases of active, progressive disease lacking criteria of stability 
previously mentioned. 
•  Patients with segmental or universal vitiligo covering more than 70% 
body surface area. 
• Patients with known associated autoimmune diseases, bleeding 
tendency, current or history of skin neoplasia, photosensitive disorders 
or any contraindications to corticosteroids therapy. 
• Patients with tendency towards hypertrophic scars or keloid formation. 
• Pregnant female and lactating mothers. 
• Patients with emotional and psychological instability. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
METHODS 
 
 All included patients will be subjected to:  
• History taking focusing on duration of the disease, age at onset , 
progression, site of lesions, number ,date and site of last activity of the 
affected lesions. 
• Family history , previous medications and response to them and general 
medical history 
• General clinical examination and determination of skin phototype. 
• Dermatological examination for confirmation of the diagnosis. 
• Base line VASI scoring. 
• VETF scoring using wood’s light examination. 
• Base line standardized photography for the lesions. 
  
For each included patient in the study, three main lines of surgical treatment will 
be used in different areas and compared to a non-surgically treated areas as 
control. 
 
LINE 1; Autologous punch mini grafts:(24) 
Under local anesthesia, multiple 1mm holes will be made in the depigmented 
treatment area using 1mm punch graft instrument inserted to a depth of 2-4 mm to 
remove a small column of depigmented skin that is to be discarded. The punches 
will be situated at or very close to the border of the lesion to avoid leaving an 
achromic fissure and will be separated by 5-8 mm distance from each other. 

On the donor area mostly is the gluteal area, punches will be harvested using the 
same sized punches very close to each other so that maximum number of grafts 
can be taken from a small area.  
Then the harvested-punch minigrafts will be inserted into the recipient chambers, 
pressed firmly by saline soaked gauge for hemostasis and secured by sterile strips 
or a compression bandage if applicable. 
 
 
 
LINE 2; Transverse needling technique: (17, 18) 
 
 Needling will be done for selected treatment patch using a 30 G disposable insulin 
syringe, going from the pigmented margins of the lesion into the vitiliginous patch, 
Position of the needle will be kept close to the dermoepidermal junction and 
movement will be from normal skin towards the lesion. Needle pricks may lead to 
oozing of a small drop of blood which will be managed by physical pressure. No 
dressings will be needed. The procedure will be repeated for selected lesions 
weekly for a duration of 3 months. 
 
LINE 3;Punch minigrafts followed by transverse needling: 
 
In a third lesion, punch minigrafts will be done as mentioned in line 1 and will be 
left to stabilize for 3 months then transverse needling will be done weekly for the 
margins of the lesion as well as the areas of the punch grafts toward the 
vitiliginous area. 
 
 

 
• A fourth lesion will be chosen as a control lesion, to which no surgical 
treatment will ba attempted. 
• All lesions will receive NB-UVB therapy according to standard protocol 
twice weekly and the patients will continue on the oral mini pulse 
dexamethasone at 2.5 mg dose for two consecutive days weekly all through 
the study period. 
• All included patients will be followed up for a duration of 6 months 
following intervenions.(25) 
• Follow up will be done by clinical examination, wood’s light and serial 
photography at each follow up visit. 
• Clinical assessment of disease severity initially , after 3 months and at end 
of 6 months using Vitiligo Area Scoring Index (VASI);(26) 
For each body region, the VASI will determined by the product of the 
area of vitiligo in hand units (which was set at 1% per unit) and the 
extent of depigmentation within each hand unit–measured patch 
(possible values of 0, 10%, 25%, 50%, 75%, 90%, or 100%). 
 The total body VASI will be calculated using the following formula by 
considering the contributions of all body regions (possible range, 0-100): 
 
 
 
 
• Serial photography will be done to evaluate type, pattern and extent of 
repigmentation. 
•  Assessments of repigmentation will be performed by two blinded 
dermatologists using a 5-point scale; grade 0 (no repigmentation), grade 1 

(1%-5%), grade 2 (6%-25%), grade 3 (26%-50%), grade 4 (51%-75%) and 
grade 5 (76%-100%).(27) 
• Extent of peri punch repigmentation in mm using a ruler. 
• Digital assessment of the size of the lesion and of the depigmented versus 
repigmented area using Adobe photoshop software. 
• Patient satisfaction assessment using visual analogue scale (VAS) after 
treatment period grading as (VAS, 0-10; 0 grade will be defined as “Not 
satisfied at all” while grade 10 will be defined as “completely satisfied”).(27) 
• Time till appearance of repigmentation will be calculated for each 
procedure. 
• Possible side effects of the NB-UVB ( erythema , itching and burning) , of 
the systemic steroids ( weight gain, increase in blood  pressure, insomnia 
,acne ,agitation or menstrual disturbances) or of surgery ( ecchymosis , 
scaring , cobble stoning or color mismatching ) will be reported.(28) 
 
 
 
 
 
 
 
 
 
 
 
 

ETHICS OF RESEARCH 
Research on human or human products:  
Prospective study: Informed consent will be taken from patients. In case of 
incompetent patients, the informed consent will be taken from the guardians. 
 
Retrospective study: Confidentiality of records will be considered   
 
DNA / genomic material: Informed consent for DNA / genomic test and for research 
will be taken from patients. No further tests will be carried out except with further 
approval of committee and patients. If the samples will travel outside Egypt the 
researcher will be responsible for transportation and security approval.  
All drugs used in the research are approved by the Egyptian Ministry of Health  
 
Research on animal: 
The animal species are appropriate for the test.  
After test, if the animal will suffer, it will be euthanized and properly disposed.  
After operation, it will have a proper postoperative care. 
 
 
 
√ 

RESULTS 
 
The results of the study will be tabulated and analyzed with the use of 
appropriate statistical methods and appropriate figures and diagrams in order to 
fulfill the aim of the work. 
 
 
 
 

DISCUSSION 
 
The results will be discussed in view of achievement of the aim, their 
significance and their comparison with previous related studies in literature. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
REFERENCES 
 
1. 
Boisseau-Garsaud AM, Garsaud P, Calès-Quist D, Hélénon R, Quénéhervé C, 
Claire RC. Epidemiology of vitiligo in the French West Indies (Isle of 
Martinique). Int J Dermatol 2000; 39:18–20. 
2. 
Felsten LM, Alikhan A, Petronic-Rosic V. Vitiligo: a comprehensive overview 
Part II: treatment options and approach to treatment. J Am Acad Dermatol 
2011; 65(3):493-514. 
3. 
Drake LA, Dinehart SM, Farmer ER, Graham GF, Hordinsky MK, Webster 
SB.Guidelines of care for vitiligo. J Am Acad Dermatol 1996; 35(4):620. 
4. 
Ongenae K, Van Geel K, Naeyert JM. Evidence for autoimmune pathogenesis 
of vitiligo. Pigment Cell Res 2003; 16: 1-11. 
5. 
Cassian Y, Thompson JA, Roche P, Byrd DR, Lee PP, Piepkorn, M, et 
al.Melanocyte destruction after antigen-spesific immunotherapy of melanoma: 
direct evidence of T cell-mediated vitiligo. J Exp Med 2000; 192: 1637–1644. 
6. 
Taneja A. Treatment of vitiligo. J Dermatol Treatment 2002; 13: 19–25. 
7. 
Schallreuter KU, Wood JM, Pittelkow MR, Gutlich M, Lemke KR, Rodl W,et 
al.Regulation of melanin biosynthesis in the human epidermis by 
tetrahydrobiopterin. Science 1994; 263:1444–1446. 

8. 
Moretti S, Spallanzani A, Amato L, Hautmann, G, Gallerani I, Fabiani, M, et 
al. New insight into pathogenesis of vitiligo: imbalance of epidermal cytokines 
at sites of lesions. Pigment Cell Res 2002; 15: 87–92. 
9. 
Kim SM, Chung HS, Hann SK. The genetics of vitiligo in Korean patients. Int 
J Dermatol 1998; 38: 908–910. 
10. Kovacs SO. Vitiligo. J Am Acad Dermatol 1998; 38: 647–660. 
11. Ezzedine K, Lim HW, Suzuki T, Katayama I, Hamzavi I, Lan CE ,et 
al.Revised classification/nomenclature of vitiligo and related issues: the 
Vitiligo Global Issues Consensus Conference. Pigment cell Res 2012; 25(3): 
E1-E13. 
12. Daniel BS, Wittal R. Vitiligo treatment update. Australasian Journal of 
Dermatology. 2015 May 1;56(2):85-92. 
13. Passeron T, Ortonne JP: Use of the 308-nm excimer laser for psoriasis and 
vitiligo. ClinDermatol 2006;24:33–42. 
14. Falabella R. Surgical approaches for stable vitiligo. Dermatologic surgery. 
2005 Oct 1;31(10):1277-84. 
 
15. Rajaram M, Alagarsamy S, Sundarapandiyan S. Post Punch Graft Appearance 
of Repigmentation Time in Stable Vitiligo: A Retrospective Study. 
International Journal Of Scientific Study. 2017;5(5):81-4. 
 
16. Mulekar SV, Isedeh P. Surgical interventions for vitiligo: an evidence‐based 
review. British Journal of Dermatology. 2013 Oct 1;169(s3):57-66. 
 

17. Mohaghegh F, Asilian A, Faghihi G, Adibi N. A comparison between the 
efficacy of narrow band ultra violet B phototherapy with and without needling 
of the lesion in the treatment of vitiligo. Journal of Research in Medical 
Sciences. 2012 Mar 16;17. 
 
18. Ahmad TJ, Rashid T, Rani Z. Needling: an adjunct to narrowband ultraviolet 
B therapy in localized fixed vitiligo. Journal of Pakistan Association of 
Dermatology. 2016 Dec 24;18(3):149-53. 
 
 
19. Mulekar SV. Melanocyte–keratinocyte cell transplantation for stable vitiligo. 
International journal of dermatology. 2003 Feb 1;42(2):132-6. 
 
20. Mutalik S, Ginzburg A. Surgical management of stable vitiligo: a review with 
personal experience. Dermatologic surgery. 2000 Mar 1;26(3):248-54. 
 
21. Kanwar AJ, Mahajan R, Parsad D. Low-dose oral mini-pulse dexamethasone 
therapy in progressive unstable vitiligo. Journal of cutaneous medicine and 
surgery. 2013 Jul;17(4):259-68. 
 
22. Dayal S, Sahu P, Gupta N. Treatment of Childhood Vitiligo Using Tacrolimus 
Ointment 
with 
Narrowband 
Ultraviolet 
B 
Phototherapy. 
Pediatric 
dermatology. 2016 Nov 1;33(6):646-51. 
 
23. Barman KD, Khaitan BK, Verma KK. A comparative study of punch grafting 
followed by topical corticosteroid versus punch grafting followed by PUVA 
therapy in stable vitiligo. Dermatologic surgery. 2004 Jan 1;30(1):49-53. 
 

24. Mulekar SV, Isedeh P. Surgical interventions for vitiligo: an evidence‐based 
review. British Journal of Dermatology. 2013 Oct 1;169(s3):57-66. 
 
25. Lahiri K. Evolution and evaluation of autologous mini punch grafting in 
vitiligo. Indian journal of dermatology. 2009 Apr;54(2):159. 
 
26. Njoo MD, Spuls PI, Bos JT, Westerhof W, Bossuyt PM. Nonsurgical 
repigmentation therapies in vitiligo: meta-analysis of the literature. Archives 
of dermatology. 1998 Dec 1;134(12):1532-40. 
 
27. Abdelghani R, Ahmed NA, Darwish HM. Combined treatment with fractional 
carbon dioxide laser, autologous platelet‐rich plasma, and narrow band 
ultraviolet B for vitiligo in different body sites: A prospective, randomized 
comparative trial. Journal of cosmetic dermatology. 2017. 
 
28. Taieb A, Alomar A, Bohm M, Dell'anna ML, De Pase A, Eleftheriadou V, 
Ezzedine K, et al. Guidelines for the Management of Vitiligo: the EDF 
consensus by the Vitiligo European Task Force (VETF) in cooperation with 
the European Academy of Dermatology and Venereology (EADV) and the 
Union Europeenne des Medecins Specialistes (UEMS). BJ Dermatol. 
2013;168(1):5-19.