Portal de Periódicos da CAPES

Surgical management of vitiligo

2007; Elsevier BV; Volume: 57; Issue: 6 Linguagem: Inglês

10.1016/j.jaad.2007.06.019

1097-6787

James J. Nordlund,

Biochemical Analysis and Sensing Techniques

A book on the “surgical management of vitiligo” is a welcome surprise. In the 1970s, even the medical treatments of vitiligo were considered unimportant, and too many dermatologists unfortunately still hold that same view today. Clearly, the value of treating vitiligo has come into its own, when the more complex surgical approaches are sufficiently popular to earn a book dedicated to their description. This is a comprehensive monograph on all the current and some possible new ways to transplant autologous melanocytes from areas of pigmented skin to areas of leukoderma in patients with vitiligo and several other forms of leukoderma. The latter disorders include piebaldism, thermal burn scars, and discoid lupus erythematosus. The first section of the book reviews general topics about vitiligo, such as pathogenesis, medical therapies, and the importance of the melanocyte reservoir within the hair follicle. The reservoir is essential for success of medical treatments, and surgical treatments are a way to replace a missing reservoir in areas such as glabrous skin or that with white hair. Surgery also is a way to repigment individuals in whom the reservoir does not respond the medical treatments. The introductory chapters are important as a basis for understanding the indications for surgical treatment of depigmentation. It is a bit annoying that these concepts are briefly repeated in the introductory paragraphs to many of the later chapters. The second section provides other important concepts about properly choosing patients who are good candidates for surgical repigmentation. Several sections are devoted to description of stable vitiligo and its differentiation from active, progressive vitiligo. Throughout the book, there is agreement that surgical success depends on vitiligo being stable and not progressive. Rafael Falabella proposed that implantation of 3 or 4 minigraphs that successfully repigment white skin could be a reasonably reliable indicator of vitiligo activity or stability. The Falabella minigraft test is discussed in some detail. The authors herein down rate the Falabella test as not being perfectly predictable for disease activitiy, a claim he never made. The authors caution about the use of arbitrary criteria about stability and “…not to refrain from the surgical option.” However, their suggestion that “…parameters [of cellular stabililty] should…be taken into consideration” is vague and not helpful for the individual embarking into the surgical approaches to vitiligo. The list of authors contributing to this book includes many of those actively involved in vitiligo surgery. It would have been a service to other vitiligo surgeons had they agreed on a common set of standards, albeit arbitrary at this time, for assessing the stability of vitiligo. The surgical procedures are divided into two types: transplantation of tissues and transplantation of cell or cell suspensions. The various techniques and procedures for transplantation of tissues are described in detail and are well done. Similarly, the techniques for the preparation of cell suspensions or expansion of pure melanocyte in cultures are presented in detail and will be helpful for those interested in setting up culture facilities. One very well done aspect of these sections is the description of preparation of the recipient sites to be grafted. There are many techniques for removing the epidermis of the depigmented skin before applying a tissue or cellular graft. The techniques are described in sufficient detail that those undertaking these procedures should have sufficient information to do this successfully. The transplantation of pure melanocytes that have been grown and multiplied in culture in many ways is an ideal methodology. As pointed out it is much more expensive and time consuming. A future technique presented in the chapter “Simplifying the delivery of cultured melanocytes and keratinocytes” is hardly simple, and might be prohibitively expensive for treating vitiligo. However, it was developed in the UK for the treatment of individuals with severe burns. This culture system is excellent in its science and exciting for its potential uses. Although it is not likely to be applicable immediately for treatment of vitiligo, the methodology might be a future treatment for a variety of skin disorders including vitiligo. The final sections cover a assortment of topics such as surgical approaches to the eyelids, genitalia, hands, and leukotrichia. These are brief chapters for which there is a paucity of data, but they are useful summaries of extant information for those wishing to attempt surgical repigmentation of these areas. Micropigmentation (ie, tattooing of the skin and lips) is illustrated. It has been used effectively for lips for those with dark skin color. Its use on depigmented skin has been complicated by the Tyndall effect, in which tattooing of brown or brown black color produces a blue–gray discoloration. This problem is not mentioned by the authors but is a real issue observed by this reviewer. One of the last chapters presents “surgical” approaches to depigmentation of the skin for those whose vitiligo is too extensive for repigmentation. This is an interesting chapter for those who treat many patients with vitiligo. Depigmentation is indicated at times. Medical depigmentation (ie, applications of monobenzone) is not always effective. This review provides useful alternatives. The book is not a monograph that will be purchased by all dermatologists and surely was not intended to be so. It is for those who have an interest in vitiligo and its treatment and who find medical therapies at times frustrating or useless. It will be a book that probably will be of more interest in the Middle East where vitiligo has severe social and personal consequences and where successful repigmentation is most important even at great cost and effort. Although the book has minor flaws that can be easily corrected during a second edition, it should be in the library of all those involved in this type therapy. It will expand the surgical armamentarium of those with interests in the surgical management of vitiligo.