Target-like Pigmentation After Minipunch Grafting in Stable Vitiligo.

Surgical treatment for vitiligo has been ever evolving. Each surgical modality has its own benefits and limitations. Miniature punch grafting is the most extensively performed surgery, which gives good results in stable vitiligo. Herein we report an unusual type of repigmentation observed after minipunch grafting in a patient of stable vitiligo, which resembled target-like lesions with a "perigraft halo" surrounding individual grafts. Such pigment spread occurred despite the use of 0.5 mm larger graft from the donor site.

What was known?

Miniature punch grafting is one of the easiest and cheapest office procedure for vitiligo with excellent repigmentation and minimal complications.

Introduction

In spite of the rapid ongoing advancement in its treatment, vitiligo remains one of the most common difficult to handle pigmentary disorders for a dermatologist, with a high degree of psychosocial impact on the patients. A large proportion of vitiligo patients do not respond to the conventional medical modalities probably because of the total absence of melanocytic reservoir in their lesional skin.[1] In such cases, replacement of the achromic skin with newer source of melanocytes by surgical means, holds a good promise. Among the various surgical modalities, miniature punch grafting is still regarded as the easiest and cheapest office procedure. With proper procurement and placement of grafts and good postoperative care, repigmentation is excellent and complications are minimal. Here we report a case of stable vitiligo where target-like pigmentation occurred after miniature punch grafting, which is a rare and unique observation.

Case Report

A 14-year-old girl presented to us with asymptomatic depigmented macules in a segmental distribution over upper back of 5 years duration. The lesions had not shown any progression for the past 3 years and there was no evidence of Koebner's phenomenon. Patient did not suffer from any other autoimmune disorders and her routine investigations and thyroid function tests were normal. She was previously treated with topical steroids, tacrolimus, and topical psoralen and sunlight (PUVAsol) without much improvement. As her lesions were stable and unresponsive, we performed miniature punch grafting after taking informed consent from the patient. Punch grafts of 2.5 mm were taken from the gluteal skin while 2 mm punches were used to make the recipient chambers. A total of 27 grafts were put on the vitiliginous area. After achieving hemostasis, pressure bandaging was done and patient discharged with oral antibiotics. Dressing was changed after 8 days, all grafts had taken up well and she was started on topical PUVASol after 3 weeks. Patient came for second follow up only after 4 months when perigraft pigment spread was seen around majority excepting few grafts. Most of these sites showed a target-like pigmentation [Figure 1a and b]. At the center there was the pigmented graft in place, surrounding this was a circular hypopigmented zone (perigraft halo) and then the zone of pigmented annulus indicating the spread of pigment from the donor graft.

Figure 1 (a and b)

Target-like pigmentation seen after 4 months of punch grafting

Discussion

The successful repigmentation of achromic skin through punch grafting in vitiligo patients has been demonstrated by many authors.[123456] Various reported complications include cobble stoning, sinking pits, polka dot appearance, variegated appearance, color mismatch, static graft (no pigment spread), depigmentation of graft, perigraft halo, graft dislodgement/rejection, hypertrophic scar, and keloid formation.[14]

Most authors have described “perigraft halo” as the peripheral rim of hypo/depigmentation, which persists after skin grafting in a vitiliginous patch.[178] Two factors could be responsible for this perigraft halo in punch grafting. First, improper placement of donor grafts, that is, far from the margin of the patch so that the repigmentation does not extend till the margin. Second reason could be grafting in cases of unstable/active vitiligo.[9] As postulated by Badri et al. in active vitiligo, the autoimmune process consisting of activated T cells is maximum at the margin of the lesion.[10] These activated CD3+, CD4+, and CD8+ T cells express the cutaneous lymphocyte-associated antigen (HECA-452+) typical of infiltrating T cells. Hence the periphery of the vitiligenous patch fails to repigment. Perigraft halo is more commonly reported after split thickness skin grafting. This occurs due to the contracture of the graft when it is harvested because of the contraction of the elastin fibers. Overlapping of graft edges at the recipient site can prevent this complication.[78] In contrast to the above mentioned “perigraft halo,” the halo, which we found in our patient, was around the individual grafts. A possible reason for this could be circular scarring that occurred between the graft and the normal skin. Savant mentions use of donor grafts 0.5 mm larger than the recipient bed to compensate for any graft contraction and prevent perigraft circular scarring.[4] However, Malakar and Rajagopal et al. reported the use of same size punches with good results.[56] In our patient, in spite of using 0.5 mm larger graft from the donor site, a thin rim of hypopigmentation appeared around many of the grafts, which was then surrounded by a zone of pigment spread. Thus we could observe a “target-like pigmentation” consisting of three zones, that is, central pigmentation surrounded by a rim of hypopigmentation and a peripheral zone of hyperpigmentation. This has been depicted pictorially in the diagram [Figure 2]. The central zone (A) represented the graft in situ, whereas the rim of hypopigmentation (B) represented the junction of donor and the recipient skin. The subsequent pigment spread was represented by the peripheral most zone (C). We can consider the remaining area as the fourth zone also, which actually represents the presurgical vitiligenous skin (D). Thus we can assume that the melanocytes travelled from the graft to the periphery through the rim of hypopigmented zone. This rim of hypopigmentation can be considered as a thin scar between the graft and the vitiliginous skin. The above pattern of pigmentation was observed despite the use of 0.5 mm larger graft from the donor site thus debating the use of larger donor grafts for vitiligo punch grafting.

Figure 2

Pictorial depiction of the various zones of repigmentation. A- Central pigmented zone, B- Rim of hypopigmentation, C- Peripheral pigmented zone, D- Background vitiligenous skin

What is new?

We observed an unusual pattern of repigmentation following minipunch grafting, which resembled target-like lesions with a “perigraft halo” surrounding individual grafts despite the use of larger donor grafts.