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Surgical management of vitiligo
J AM ACAD DERMATOL
1105
VOLUME 57, NUMBER 6
Surgical management of vitiligo Gupta S, Olsson MJ, Kanwar AJ, Ortonne JP, editors. Oxford: Blackwell Scientific, 2006. $169.95, hardcover. 304 pages. ISBN: 978-1-40-514521-3. 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 blueegray 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
1106 Book reviews
J AM ACAD DERMATOL DECEMBER 2007
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. James J. Nordlund, MD Dayton, Ohio doi:10.1016/j.jaad.2007.06.019
Photodermatology Henry Lim, Herbert Ho¨nigsmann, and John L. M. Hawk, editors. New York, 2007, Informa Healthcare USA, Inc. 472 pages. Finally, a photomedicine textbook that not only has it all, but also does it all so very well. Photodermatology, edited by Drs Lim, Ho¨nigsmann, and Hawk, covers the entire array of photodermatologic topics in 29 well-written, thoroughly researched, and amply referenced chapters. It is a comprehensive and amazingly current review of cutaneous photomedicine divided among 5 main themes, namely (1) basic photobiological principles (including history, laws, definitions, and radiation sources), (2) cutaneous effects of biological radiation (including molecular, genetic, immunologic, acute, and chronic with special attention to photocarcinogenesis and photoaging), (3) photosensitivity (including chemical-induced photosensitivity and the porphyrias) and all the photodermatoses (including history, diagnosis, pathogenesis, and treatment for all major disorders), (4) photoprotection (including novel developments, clothing, and public education), and (5) phototherapy. The latter section covers narrowband and broadband ultraviolet (UV)-B, psoralen photochemotherapy, photopheresis, UVA-1 phototherapy, photodynamic therapy (PDT), laser surgery, and intense pulsed light therapy. There is also a generous appendix that describes the art of phototesting in exquisite detail and the use and
application of photopatch testing. Another section provides guidelines for setting up either a referral phototherapy treatment center or, more simply, an office-based unit. Finally, there is even a section with guidelines for setting up a laser treatment center. Each chapter begins with a concise pre´cis summarizing the key points to be gained from that section. The tables are well laid out and numerous. The clinical photographs are excellent, especially in the chapters on polymorphous light eruption, actinic prurigo, chronic actinic dermatitis, and the DNA repair deficient photodermatoses such as xeroderma pigmentosum. The greatest strength of this book comes from its impressive authorship. Three world-renowned editors, representing different schools in the United States, Austria, and the United Kingdom, have taken meticulous care to ensure that the materials covered in this book reflect a carefully balanced perspective on an ever-expanding dermatologic subspecialty. The editing from chapter to chapter is unusually excellent, helping the reader to proceed through the book with a uniform sense of style, breadth, and approach. The opinion-forming authors of the individual chapters themselves are from 15 different countries on 4 different continents. Each author reaches for and achieves an outstanding blend of both clinical and scientific detail, giving muchneeded background on the clinical parts for the researcher and much-needed scientific background for the clinician. If I were to find any criticism of this work, it would be minimal indeed. For example, all of psoralen plus UVA photochemotherapy, a huge field that easily could fill a textbook itself, is covered in only 8 to 9 pages. Given that psoralen plus UVA is being used less globally since the advent of narrowband UVB phototherapy and given that all the major points are so very well summarized concisely therein, I should not complain, but I do think many of the nuances of this great therapy are sacrificed for the much-needed succinctness. Similarly, in an effort to cover such a huge field as PDT, the author goes over the many possible combinations of drugs and light sources. A beginner might be left with the idea that PDT is simply applicable to all skin diseases, whereas in practice, in spite of a huge body of research, the only dermatologic Food and Drug Administratione approved indication in the United States remains that of using aminolevulinic acid PDT for actinic keratoses. Sometimes when huge disciplines are given brief chapters, the naı¨ve reader can be left with the idea that psoralen plus UVA is rather simple to execute, when on many levels it is not, or that PDT can do it all, when in many instances it cannot. This criticism
1105
VOLUME 57, NUMBER 6
Surgical management of vitiligo Gupta S, Olsson MJ, Kanwar AJ, Ortonne JP, editors. Oxford: Blackwell Scientific, 2006. $169.95, hardcover. 304 pages. ISBN: 978-1-40-514521-3. 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 blueegray 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
1106 Book reviews
J AM ACAD DERMATOL DECEMBER 2007
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. James J. Nordlund, MD Dayton, Ohio doi:10.1016/j.jaad.2007.06.019
Photodermatology Henry Lim, Herbert Ho¨nigsmann, and John L. M. Hawk, editors. New York, 2007, Informa Healthcare USA, Inc. 472 pages. Finally, a photomedicine textbook that not only has it all, but also does it all so very well. Photodermatology, edited by Drs Lim, Ho¨nigsmann, and Hawk, covers the entire array of photodermatologic topics in 29 well-written, thoroughly researched, and amply referenced chapters. It is a comprehensive and amazingly current review of cutaneous photomedicine divided among 5 main themes, namely (1) basic photobiological principles (including history, laws, definitions, and radiation sources), (2) cutaneous effects of biological radiation (including molecular, genetic, immunologic, acute, and chronic with special attention to photocarcinogenesis and photoaging), (3) photosensitivity (including chemical-induced photosensitivity and the porphyrias) and all the photodermatoses (including history, diagnosis, pathogenesis, and treatment for all major disorders), (4) photoprotection (including novel developments, clothing, and public education), and (5) phototherapy. The latter section covers narrowband and broadband ultraviolet (UV)-B, psoralen photochemotherapy, photopheresis, UVA-1 phototherapy, photodynamic therapy (PDT), laser surgery, and intense pulsed light therapy. There is also a generous appendix that describes the art of phototesting in exquisite detail and the use and
application of photopatch testing. Another section provides guidelines for setting up either a referral phototherapy treatment center or, more simply, an office-based unit. Finally, there is even a section with guidelines for setting up a laser treatment center. Each chapter begins with a concise pre´cis summarizing the key points to be gained from that section. The tables are well laid out and numerous. The clinical photographs are excellent, especially in the chapters on polymorphous light eruption, actinic prurigo, chronic actinic dermatitis, and the DNA repair deficient photodermatoses such as xeroderma pigmentosum. The greatest strength of this book comes from its impressive authorship. Three world-renowned editors, representing different schools in the United States, Austria, and the United Kingdom, have taken meticulous care to ensure that the materials covered in this book reflect a carefully balanced perspective on an ever-expanding dermatologic subspecialty. The editing from chapter to chapter is unusually excellent, helping the reader to proceed through the book with a uniform sense of style, breadth, and approach. The opinion-forming authors of the individual chapters themselves are from 15 different countries on 4 different continents. Each author reaches for and achieves an outstanding blend of both clinical and scientific detail, giving muchneeded background on the clinical parts for the researcher and much-needed scientific background for the clinician. If I were to find any criticism of this work, it would be minimal indeed. For example, all of psoralen plus UVA photochemotherapy, a huge field that easily could fill a textbook itself, is covered in only 8 to 9 pages. Given that psoralen plus UVA is being used less globally since the advent of narrowband UVB phototherapy and given that all the major points are so very well summarized concisely therein, I should not complain, but I do think many of the nuances of this great therapy are sacrificed for the much-needed succinctness. Similarly, in an effort to cover such a huge field as PDT, the author goes over the many possible combinations of drugs and light sources. A beginner might be left with the idea that PDT is simply applicable to all skin diseases, whereas in practice, in spite of a huge body of research, the only dermatologic Food and Drug Administratione approved indication in the United States remains that of using aminolevulinic acid PDT for actinic keratoses. Sometimes when huge disciplines are given brief chapters, the naı¨ve reader can be left with the idea that psoralen plus UVA is rather simple to execute, when on many levels it is not, or that PDT can do it all, when in many instances it cannot. This criticism