Iltefat Hamzavi, MD, Reviews Surgical Treatment Advances for Vitiligo

The 2023 Pigmentary Disorders Exchange Symposium held in Chicago, Illinois, from May 5th to May 6th, covered numerous hot topics in managing pigmentary disorders. Hosted by conference co-chairs Pearl Grimes, MD, and Jill Waibel, MD, faculty members met for the 2-day conference to discuss the pathogenesis of vitiligo, hyperpigmentation, medical and surgical treatments for vitiligo, cosmeceuticals for photodamage, and more.

Iltefat Hamzavi, MD, spoke with Dermatology Times® to review key highlights of his session, “Vitiligo Surgical Treatment Advances,” including punch graft techniques and non-cultured epidermis suspension.

Transcript

Hamzavi: I’m Iltefat Hamzavi from Henry Ford Hospital, Hamzavi Dermatology, and Dermatology Specialists, and a dermatologist in the Detroit area. And we'll get jump into some of the points of the talk today. So, I had the good fortune of joining as inaugural faculty with Pearl Grimes and the rest of the group to look at vitiligo surgery. So, we had a session on hypo and depigmentation, and I was charged with the responsibility of talking about vitiligo surgery. So, at the meeting, we talked about the role of the immune system on causing vitiligo. But the melanocytes also are an area of destruction and dysfunction. And so in order to really repigment individuals, you have to manage the immune system, but then you have to create the milieu for the melanocytes to come back into the skin. Sometimes melanocytes just don't want to come back in there.So there's a role for vitiligo surgery. Vitiligo surgery can provide rates of repigmentation you can almost never get with phototherapy, topical agents or systemic agents. But if you don't manage the immune system, the transplant procedure will not work. And we covered a variety of different transplant options. There is the traditional punch grafting where you take a larger punch, then you take another punch of the recipient site that's smaller, and you place a larger punch in that area. That can give you good results for smaller areas. Talked about blister grafting where you create a blister and transplant the blister on the recipient side. We talked about split-thickness skin grafting, which is basically what sounds like, when you take a split-thickness graft, you dermabrade the vitiligo area and place it on top.

We spent most of our time talking about non cultured epidermal suspension technique also known as MKTP, melanocyte keratinocyte transplant procedure. These non-cultured epidermal suspension techniques have become the preferred technique for many of us. It allows you to treat a larger area with a smaller donor area. And so if you've managed the immune system, or you have segmental vitiligo, you can often use that. So as many of the attendees knew, we categorized the ideal surgical patient as somebody whose immune system is stable, their vitiligo is not progressing. And within that group, there's 2 subgroups. There's the segmental vitiligo where it only covers one segment of their body, and there's nonsegmental, vitiligo. Nonsegmental vitiligo often has an immune activity, it's active, but it goes through active and quiescent phases, versus segmental often is burnt out. Segmental patients tend to have a better response than nonsegmental, partly because the immunomodulation that's occurring in the skin. And so with both of these types of subgroups, if you pick the right patient and location, you can have some dramatic results. And we talked about the rates of the repigmentation, they approached anywhere from 71% to 92% repigmentation in segmental vitiligo, and around 54% to 60% for nonsegmental. And that pigmentation tends to hold over 2 years based on some studies that have been presented, and again in this systematic reviews, it showed that split-thickness skin grafts and non-cultured epidermis suspensions were the most successful techniques. But our data is still generating, it doesn't have the same robust nature as the pharmaceutical trials.

The ideal treatment also involves an awareness of where you can treat. So generally we want to treat 40 to 100 square centimeter locations, we would like to use an appropriate dressing process. And then you also have to have a nursing team. The nursing team's role is to help you obtain the graft where you often from the hip, you process that tissue with the non-cultured epidermis suspension technique and the MKTP technique by heating it in an incubator and stripping off the collagen and dermal cells. And then you will continue to process that until the point where you are able to scrape the dermal components from the epidermal cells and you end up with a mix of keratinocytes and melanocytes. You spin those cells down and we suspend them in a solution and you convert that solid graft into a liquid solution. And then you dermabrade or laser abrade the recipient site, let's say in the face, and you spray that solution over there and then place a collagen dressing or a gauze dressing and over 6 to 7 days, we leave that dressing in place. And we showed pictures of the face, the legs, and arms, having significant degrees of repigmentation.

And then we talked a little bit about adjunct techniques to preserve the level of pigmentation. But there is nothing that we have today for vitiligo that repigments to the degree and the speed that the vitiligo surgery can offer. We finished up by talking about some new commercial options, which are going to FDA review, using kits that will allow this technique to be much more accessible. And we presented an FDA-approved trial, where I believe it's around 56% of patients had greater than 75% pigment. They're not able to use a VASI score yet for these areas. But we're working on that. But the VASI is the primary outcome measure for many of the topical systemic trials. But this measure of degree of repigmentation, more than 56% of people achieved that more than 75% pigmentation rate versus 0% in one arm, and about 12% was given to the other arm. So a great degree of improvement that was sustained with very few side effects ever noted. And we showed pictures of that. The patients served as their own control in these trials. And so this was comparing the area that did not receive treatment compared to treatment area that did receive treatment. So we finished the lecture summarizing the appropriate candidates, we talked about the appropriate expectations of the degree response. We talked about what patients to avoid, we talked about the upcoming new research. And we talked about how to continue to maintain the immunostability of the patient so that you don't get a recurrence of vitiligo after you do the surgery. And hopefully at the end of it, the audience was able to at least have an understanding of vitiligo surgery. And then hopefully, over time, develop the techniques we can apply that to that patient whose immune systems is managed, they just cannot repigment them.

Dermatology Times: What are a few highlights from the 2023 Pigmentary Disorders Exchange Symposium?

Hamzavi: I'm just so excited that we are able to actually have a conference on pigmentation. So there are some excellent talks on dermal pigmentation done by Dr. Heather Woolery Lloyd, and she talked about the different classifications and different agents that we can use. She talked about oral agents that might trigger pigmentation. This is very disfiguring pigmentation that can occur. We had some great talks on melasma options and treatment of hyperpigmentation with Dr. Andrew Alexis. And he gave us an extensive summary of treatment options and other from the therapeutic ladder of photoprotection, topical intervention, systemic interventions and procedural based interventions. And then we also had some great lectures by Dr. Berson, and she spoke about the numerous agents that help manage hyperpigmentation and where they might be useful. And Pearl Grimes also gave a very, very strong overview of these pigmentary options across the different disease states. And those are the portions that I was able to attend. But really an in-depth conference. If you really want to improve your ability to treat hyperpigmentation and depigmentation, I haven't seen a conference like this.

[Transcript edited for clarity]