autologous punch grafting techniques for vitiligo...
TRANSCRIPT
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Autologous punch grafting techniques for vitiligo and piebaldism patients:
The effects of punch depth and punch size
Student: L. Komen
Student number: 1490362
Faculty supervisor: Dr. I.M. Nijholt, Isala klinieken Zwolle
Direct supervisor: Dr. A. Wolkerstorfer, dermatologist AMC
Location: Academic Medical Centre (AMC), Amsterdam
Department: Netherlands Institute for Pigment Disorders (SNIP)
Period: 01-07-2011 – 02-01-2012
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Abstract
Background: Vitiligo and piebaldism are skin disorder that cause depigmented patches in
patients that can alter their appearances dramatically, thereby impairing patients’ quality of
life. These depigmented lesions are caused by localized loss of melanocytes (pigment cells).
In stable forms, such as stable non-segmental vitiligo, segmental vitiligo, and piebaldism,
autologous melanocyte transplantation results in repigmentation. Autologous punch grafting,
one of the methods for melanocyte transplantation, achieves more than 70 % repigmentation
in 68%–82% of the patients. Punch grafting appears to be the easiest and least expensive
surgical treatment method for stable vitiligo and piebaldism. It is a safe, simple and widely
used technique. Generally, superficial grafts with a size ranging from 1- 1.5 mm are used.
Hitherto, no reliable data on the effect of punch depth and punch size used during the
transplantation are available.
Objective: Assess the efficacy and safety of two different punch depths and punch sizes in
punch grafting.
Methods: A prospective, observer blinded, randomised controlled study was performed on 15
vitiligo or piebaldism patients. Four depigmented regions on the trunk or upper extremities
were randomly allocated to either four superficial 1.5 mm punch grafts, four superficial 1 mm
punch grafts, four deep 1.5 mm punch grafts, or four deep 1 mm punch grafts. After grafting,
all regions received UV-therapy twice a week for 3 months. The main outcome measure was
the pigmented surface area three months after grafting. Secondary objectives were the general
outcome assessed by the patient and side effects assessed by a blinded physician. Results: The median and (25
th and 75
th percentile) of the pigmented surface areas for the deep
1.5 mm grafts, the superficial 1.5 mm grafts, the deep 1 mm grafts, and the superficial 1 mm
grafts were 24.3 mm2
(12.6 - 33.8 mm2), 12.6 mm
2 (8.4 - 28.3 mm
2), 9.4 mm
2 (3.1 - 15.7
mm2), 7.1 mm
2 (4.1 - 22.4 mm
2), respectively. A significant better result was found in the
deep 1.5 mm grafts compared to the 1 mm grafts. There was no significant difference in side
effects between the treatment regimens, and patients’ satisfaction was comparable in all the
treatment regimens.
Conclusion: Preliminary results after three months indicated that 1.5 mm grafts are more
effective in inducing repigmentation than 1 mm grafts. There seemed to be a correlated effect
of depth and size that in the deep 1.5 mm grafts increased the pigment outgrowth.
Furthermore, the 1.5 mm deep grafts did not cause more side effects. Therefore, the deep 1.5
mm grafts seem to be a promising and easy to carry out grafting method for lesions on the
trunk and extremities in vitiligo and piebaldism patients
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Samenvatting
Achtergrond: Vitiligo en piebaldisme zijn huidaandoeningen die witte maculae op de huid en
slijmvliezen van patiënten veroorzaken. Piebaldisme is een congenitale huidaandoening en
vitiligo ontstaat in de loop van het leven door het plaatselijk verloren gaan van melanocyten
(pigmentcellen). Deze huidaandoeningen hebben een negatieve invloed op de kwaliteit van
leven van patiënten. Autologe transplantatie van melanocyten is een effectieve behandeling
die kan zorgen voor repigmentatie bij stabiele vitiligo en piebaldisme. Eén van die
transplantatie methoden is de biopt transplantatie techniek (punch grafting), die bij 68%-82%
van de patiënten meer dan 70% repigmentatie induceert. In de praktijk worden oppervlakkige
biopten van 1 - 1,5 mm gebruikt. Tot nu toe is er echter geen literatuur beschikbaar over het
effect van oppervlakte en diepte van de biopten op de uiteindelijke repigmentatie die bereikt
kan worden en over de bijwerkingen na transplantatie.
Doel: Het beoordelen van de effectiviteit en de veiligheid van twee verschillende diepten en
twee verschillende oppervlakten van de biopten tijdens biopt transplantatie.
Methoden: Een gerandomiseerde, prospectieve, geblindeerde studie werd uitgevoerd met 15
vitiligo en piebaldisme patiënten. Bij elke patiënt werden vier gedepigmenteerde laesies op de
extremiteiten of het bovenlichaam behandeld met één van de volgende regimes: vier
oppervlakkige 1,5 mm (millimeter) biopten, vier diepe 1,5 mm biopten, vier oppervlakkige 1
mm biopten of vier diepe 1 mm biopten. De belangrijkste uitkomstmaat was de pigment
uitgroei, gemeten na 3 maanden. Een onafhankelijke arts beoordeelde de bijwerkingen en
patienten beoordeelden ook zelf het resultaat op een categorische schaal.
Resultaten: De mediaan en (25ste
en 75ste
percentiel) van de gepigmenteerde oppervlakten
van de diepe 1,5 mm biopten, de oppervlakkige 1,5 mm biopten, de diepe 1 mm biopten en de
oppervlakkige 1 mm biopten waren respectievelijk: 24,3 mm2(12,6 – 33,8 mm
2), 12,6 mm
2 (
8.4 – 28,3 mm2), 9,4 mm
2(3,1 – 15,7 mm
2) en 7,1 mm
2 (4,1 – 22,4 mm
2). Er werd een
significant grotere gepigmenteerde oppervlakte gemeten bij de 1,5 mm diepe biopten
vergeleken met de beide 1 mm biopten. Er werd geen significant verschil gevonden in
bijwerkingen tussen de verschillende gebieden en de beoordeling van patiënten was gelijk in
de vier behandelde gebieden.
Conclusie: De voorlopige resultaten laten zien dat na transplantatie met 1,5 mm biopten een
groter gepigmenteerd gebied bereikt kan worden dan na behandeling met de 1 mm biopten,
zonder daarbij meer bijwerkingen te geven. Er lijkt een gecorreleerd effect te zijn in diepte en
grootte, waarbij grote diepe biopten het beste resultaat geven na transplantatie. De 1,5 mm
diepe biopten bewijzen een veelbelovende en gemakkelijk uit te voeren methode te zijn om
repigmentatie te verkrijgen bij stabiele vitiligo en piebaldisme patiënten met laesies op de
extremiteiten en het bovenlichaam.
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Table of Contents
1. Introduction ...................................................................................................................... 5
Vitiligo ............................................................................................................................... 5
Piebaldism .......................................................................................................................... 5
Quality of life ..................................................................................................................... 5
Treatment modalities ......................................................................................................... 6
2. Problem definition ........................................................................................................... 7
Primary objectives ............................................................................................................. 8
Secondary objectives ......................................................................................................... 8
3. Materials and methods .................................................................................................... 8
Study population ................................................................................................................ 9
Sample size calculation .................................................................................................... 10
Study period ..................................................................................................................... 10
Punch grafting procedure ................................................................................................. 10
Follow up ......................................................................................................................... 11
Measurements .................................................................................................................. 12
Statistical analysis ............................................................................................................ 12
4. Results ............................................................................................................................. 13
Pigmented surface area .................................................................................................... 14
Number of grafts with repigmentation ............................................................................ 15
Side effects ....................................................................................................................... 16
The general outcome assessed by the patient .................................................................. 17
5. Discussion ....................................................................................................................... 18
Pigmented surface areas .................................................................................................. 18
Side effects ....................................................................................................................... 19
Patient satisfaction ........................................................................................................... 19
Practical aspects ............................................................................................................... 19
Strengths and limitations of this study ............................................................................. 20
Conclusion ....................................................................................................................... 21
6. Reference List ................................................................................................................. 22
7. Appendix ......................................................................................................................... 24
Appendix 1. Patient information (Dutch) ........................................................................ 24
Appendix 2. Informed consent form (Dutch) .................................................................. 28
Appendix 3. Letter to the general practitioner (Dutch) ................................................... 29
Appendix 4. Questionnaire form 3 months after grafting (Dutch) .................................. 30
Appendix 5. Word of thanks (Dutch) .............................................................................. 34
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1. Introduction
Vitiligo and piebaldism are cutaneous conditions that can alter a patient’s appearance
dramatically, thereby impairing a patient’s quality of life. In a stable vitiligo that does not
respond to medical treatment and in piebaldism, punch grafting is a successful treatment
option. This study was performed to assess the efficacy and safety of two different punch
depths and punch sizes in punch grafting.
Vitiligo
Vitiligo is an acquired cutaneous condition, caused by destruction of melanocytes, which
induces white lesions in the skin and mucous membranes.1 Of the world’s population 0.5% to
2% is affected by vitiligo with no differences in prevalence regarding age, sex or skin color. 1
Several theories have been used to explain the pathogenesis of vitiligo. Nonetheless, until
now none of these theories completely explains the disorder. It seems that several factors
including autoimmune, biochemical, neuronal and environmental may contribute to its
development.2;3
Several subtypes of vitiligo can be defined. Non-segmental vitiligo (generalized vitiligo or
vitiligo vulgaris) is the most common subtype and is characterized by widespread white
macules that mostly appear symmetrically on both body halves. This subtype frequently
affects acral areas, the face, orifices and genital parts. Non-segmental vitiligo is usually
slowly progressive with flares interchanged by stable periods, and 10% to 20% of the patients
experience spontaneous repigmentation.1;2;4
Segmental vitiligo causes unilateral depigmented macules that occur in a (semi) dermatomal
distribution.4 This subtype appears at an earlier age than non-segmental vitiligo and spreads
quickly, after which a stable period commences.5 Contributing factors to the pathogenesis
seem to be neurogenic sympathetic abnormalities or a disorder of cutaneous mosaicism.4
Segmental vitiligo is less commonly associated with other autoimmune diseases than vitiligo
vulgaris.5;6
Other subtypes of vitiligo include focal, mucosal, and universal vitiligo.6 Focal vitiligo is
characterized by depigmented macules located in an isolated area. Patients with universal
vitiligo experience more than 90% depigmentation of the cutaneous surface. Acrofacial
vitiligo is the term for patients with vitiligo limited to the acra and the facial region.
Piebaldism
Piebaldism is a congenital autosomal dominant stable pigment disorder characterized by
widespread symmetrical depigmented macules often near the midline on the front. Lesions
mostly appear on the anterior thorax, the abdomen, the arms, and legs.7 Hyperpigmented
macules within the lesions and at the periphery of the depigmented lesions are often seen in
piebaldism.
The pathogenesis of piebaldism seems to be a mutation of the c-kit proto-oncogene. This
mutation can cause failure of proliferation of melanocytes and melanoblasts, or failure of
melanoblasts to migrate to the dermo-epidermal junction in embryonic life.7;8
Quality of life
Vitiligo and piebaldism can alter a patient’s appearance dramatically and impair the patient’s
quality of life.3;9
Patients become psychosocially distressed and worry about the course of the
disease; which is unpredictable in a lot of cases.3;9
The cosmetic disfigurement of the white
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patches can make patients feel depressed and embarrassed. Moreover, the depigmented skin
of patients is more sensitive to sunburn than the normal skin.3;9
In consequence, successful
treatment of the vitiligo and piebaldism lesions can improve the quality of life of the patient.10
Treatment modalities
The standard treatment of vitiligo consists of local topical treatment with corticosteroids
(cream, ointment) or other immunomodulators, and/or phototherapy. However, these
therapies are not satisfying in every patient and usually induce incomplete
repigmentation.1;10;11
In stable unresponsive depigmented lesions, autologous melanocyte
transplantation is the treatment option of choice.10;12;13
Various methods of autologous
melanocyte transplantation have been developed to treat stable unresponsive depigmented
lesions.14-16
The basic principle of all these surgical techniques is to transplant (autologous)
melanocytes from the normal pigmented skin to the depigmented macules where melanocytes
are absent.8
Stability of vitiligo, i.e. no enlargement of existing lesions and absence of new lesions for at
least one year, is crucial for the outcome of transplantation methods.17
When vitiligo is still
active there is a higher risk of treatment failure and development of the Koebner phenomenon
(induction of new lesions) at the donor site.18;8
Therefore, patients with active vitiligo should
be excluded for surgical techniques.10
The Vitiligo Disease Activity (VIDA) score can be
used to assess the vitiligo activity (see table 1). NB- UVB- treatment before epidermal
grafting may mask possible disease activity and may lead to an incorrect selection of patients
with unstable disease.10
A more powerful tool for detecting stable vitiligo is the minigrafting
test.17
This test identifies patients with stable vitiligo who will establish repigmentation after
melanocyte transplantation. A minigrafting test consists of the assessment of pigment spread
after implanting 4 punch grafts of 1.5 mm within depigmented vitiligo lesions. When the 4
punch grafts show pigment outgrowth a test is positive, when these grafts do not show
pigment outgrowth surgical treatment is not recommended. In one study, a minigrafting test
was performed on 47 patients to evaluate pigment outgrowth around the minigrafts in order to
anticipate on the results of surgical repair. 95% of the patients with unilateral
(segmental/focal) vitiligo tested positive, indicating high possibilities of repigmentation
success in these stable forms of vitiligo. 52% of patients with an apparent stable non-
segmental vitiligo had a negative test. The negative tests predicts a lower success rate when
grafting techniques will be used.17
In summary, a minigrafting test is advisable in a likely
stable vitiligo vulgaris because a more appropriate selection of patients can be done using this
test, allowing higher repigmentation rates after grafting. In this way, sparing negative patients
an unsuccessful treatment is prevented for patients with a negative test.17
Disease activity VIDA score
Active in the past 6 weeks +4
Active in the past 3 months +3
Active in the past 6 months +2
Active in the past year +1
Stable for at least 1 year 0
Stable for at least 1 year and spontaneous repigmentation -1
Table 1 - VIDA Score; indicating Vitiligo activity.
The punch grafting technique, also known as the minigrafting technique, is one of the
common transplantation methods. This technique involves 1- to 2-mm full-thickness
epidermal punch grafts punched out from normally pigmented donor sites. These grafts are
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transplanted into depigmented acceptor sites from which similar punch grafts have been
removed.10;13
Autologous melanocytes can also be obtained by one of the following
techniques: shave biopsy (split-thickness grafting), suction pressure or liquid nitrogen
(epidermal blister grafting), non-cultured or cultured melanocytes, or melanocytes and
keratinocytes cell suspensions (epidermal suspension grafting). In these cases, dermabrasion
of the recipient area can be done with a laser, a dermabrader, or by a suction pump or liquid
nitrogen to induce blisters in order to prepare the acceptor site for transplantation.8
Currently, the selection of a particular transplantation method is based on technical
possibilities, personal experience, and on data from a limited number of studies.8;18
Splitskin
grafting and punch grafting showed to be effective and relatively simple compared to other
surgical modalities especially in patients with stable vitiligo.7;19
Punch grafting seems to be
the easiest and most inexpensive procedure, which takes 45 minutes for 50 cm² and does not
require special equipment.8 Punch grafting shows good (more than 70%) repigmentation in
68%- 82% of the patients treated.8;12;13
Systematic reviews of autologous transplantation
methods on vitiligo patients reported the highest success rates with split-thickness grafting
and epidermal blister grafting (87% achieving more than 75% repigmentation).8;18
In a
randomized controlled trial of 64 patients, punch grafting was compared with split-skin
grafting. In the punch grafting group, 44% showed excellent repigmentation compared to 83%
in the split-skin grafting group. Cosmetic results were better in the split-skin grafting group.
However, in this study 2.5 mm grafts were used for the mini-grafting and the results were
only evaluated after 3 months. Grafts can continue to spread repigmentation till at least six
months after the transplantation.20;21
Punch grafting is a technique known to cause adverse
events, consisting of cobblestone appearance at the acceptor site and scars at the donor site.
Cobblestone effects are tiny thickened hypopigmented lesion at the site of the grafts. These
effects seem to occur more often when punches larger than 1.25 mm are used.10
If smaller
punches are used cobblestone appearance are reported less frequently.20
In piebaldism, the depigmented lesions are unresponsive to any form of topical or systemic
medical treatment. Although little literature is available on patients with piebaldism who have
been treated with transplantation methods, these surgical techniques seem to be
effective.7;15;16;19;22
In the Netherlands Institute for Pigment Disorders (NIPD), the most used transplantation
method is a combined treatment consisting of epidermal punch grafting with a subsequent
Ultraviolet (UV)-treatment. Both UVA and Narrow-Band Ultraviolet B (NB UVB) are potent
melanocyte stimulants for repigmentation.20;21;23
In several studies punch grafting was
followed by PUVA(SOL) which results in a faster rate of repigmentation with better cosmetic
results. Unfortunately, PUVA is known to increase the risk of developing skin
malignancies.12;13
UVA during a short period and NB-UVB at an equivalent erythema/oedema
are believed to be safer than PUVA.21;24
There is one study published on punch grafting
followed by therapy NB-UVB in Indian patients showing pigment spread of 50 times the graft
size.21
The only study comparing UVA, NB UVB, or no phototherapy after punch grafting did
not show significant differences, mainly because the number of patients included was too
small.25
2. Problem definition
Autologous punch grafting appears to be the easiest and least expensive surgical treatment
method for stable vitiligo and piebaldism. It is a safe, simple and widely used technique.
Hitherto, no reliable data on the effect of punch depth and punch size on the outcome of this
technique is available.
8
Currently superficial grafts are the method of choice, because it is suggested that the thinner
the graft, the denser the capillary network in the superficial network, allowing an earlier
process of vascularisation that prevents side effects and the loss of grafts.20
However, the
hypothesis in this study is that a larger and deeper (dermal) punch graft could induce a larger
pigmented surface area, by stimulating repigmentation due the following reasons; deeper
grafts contain hair follicles that are surrounded by vital melanocytes which will be
transplanted along. Moreover, active and functional melanocytes spread centrifugally from
the infundibulum to the basal cell layer and recolonise the epidermis. The use of deeper stem
cells could stimulate repigmentation and have a positive effect on the survival of the grafts.23
Repigmentation could be influenced by deep vascular components as well. A recently
formulated hypothesis is that larger grafts are able to induce a larger pigmented surface,
although they seem to cause more side effects as well. Previous studies showed that grafts of
1 mm could repigment an area 25 times larger than the graft itself.11;13
Another study showed
that grafts of 1.5 mm this value was increased until 56 times.21
To validate these hypotheses a
randomized controlled trail with the following objectives was performed.
Primary objectives:
1) Assess the efficacy and safety of autologous superficial (epidermal) punch grafting
compared to autologous deep (dermal) punch grafting.
2) Assess the efficacy and safety of autologous 1.5 mm punch grafting compared to
autologous 1 mm punch grafting.
Secondary objectives:
1) Assess the patient’s satisfaction on the different punch graft techniques.
2) Asses the practical aspects of the different punch graft techniques.
3. Materials and methods
This study was a prospective, observer blinded, randomised, controlled study with four arms
conducted at the Netherlands Institute for Pigment Disorders (NIPD), Department of
Dermatology, Academic Medical Centre, University of Amsterdam, the Netherlands. The
study was approved by the Medical Ethical Committee of the Academic Medical Centre,
Amsterdam.
In each patient, four parts of a depigmented lesion, called A, B, C and D (see figure 1), were
randomly allocated to receive one of the following treatments:
1) 4 times a deep 1.5 mm punch graft + UV-therapy
2) 4 times a superficial 1.5 mm punch graft + UV-therapy
3) 4 times a deep 1 mm punch graft + UV-therapy
4) 4 times a superficial 1 mm punch graft + UV-therapy
A digitally random list generated by an independent person using a software package,
(Graphpad Software Inc.) determined the randomisation and allocation of the treatments to
the patients. Sealed envelopes contained cards that indicated the treatment allocation. The
sealed envelopes were numbered and opened in ascending order. The treating physician and
the patients were not blinded because this was hardly possible in practice.
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Figure 1 - Acceptor site on the calf; before (left) Figure 2 - Donor site on the hip; before (left) and
and three months after punch grafting (right). directly after punch grafting (right).
Study population
The population in this study consisted of outpatient clinic patients of the NIPD with
segmental and non-segmental stable vitiligo or piebaldism who have been treated by punch
grafting or started this treatment during the period of this study. There was a selection of
consecutive subjects who met the following inclusion and exclusion criteria.
Inclusion criteria:
Patients with piebaldism, non-segmental and segmental stable vitiligo lesions on the
trunk or upper extremities larger than 5x5cm;
patients under medical treatment at the Netherlands Institute for Pigment Disorders
aged between 18 and 60 years;
patient who were willing and able to give written informed consent;
patients with a stable vitiligo since 12 months without systemic therapy or 6 months
without topical therapy as defined by the absence of new lesions and/or enlargement
of existing lesions (VIDA score 0 and -1, see table 1), confirmed by a positive punch
grafting test on non-segmental vitiligo;
patients with skin type II – VI (see table 2).
Exclusion criteria:
Patients who received UV -therapy or systemic immunosuppressive treatment during
the last 12 months or topical treatment during the last 6 months;
patient with vitiligo lesions with folliculair or non-folliculair repigmentations in the
treatment area;
patient with skin photo type I (see table 2);
patients with a VIDA score of +1, +2, +3,+4 (see table 1);
non-segmental vitiligo patients with a negative punch grafting test
patients with hypertrophic scars and/or keloid;
patients with a history of hypersensitivity to (UVB) light and allergy to local
anaesthesia;
patients who are pregnant or breast-feeding;
patients not competent to understand the procedures involved;
patients with a personal history of cardial insufficiency, melanoma or non-melanoma
skin cancer;
patients with a first degree relative with melanoma skin cancer;
patients with atypical naevi.
The patients’ skin photo types were classified according the Fitzpatrick Classification Scale
(table 2).
Skin Photo type Reaction to sun exposure Skin Color
I Burn and no tan Pale white
10
Skin Photo type Reaction to sun exposure Skin Color
II Burn and minimal tan Pale white
III Burn and tan well White
IV Tan, no burn Light brown
V Tan, no burn Brown
VI Tan, no burn Dark brown
Table 2 - Fitzpatrick Classification Scale, indicating the patients’ skin photo type
Sample size calculation
The standard deviation was estimated because a similar study has not been performed. The
estimated standard deviation used was 0.4 (40% differences of repigmentation) with an
estimated true difference in the mean response of 0.4 (40%) for punch depth and 0.2 (20%)
for punch size. With probability (power) 0.8, a type I error probability of 0.05 and a normal
distribution, it was calculated that 10 pairs of subjects will be needed to be able to reject the
null hypothesis if the estimated true difference in the mean response of matched pairs for
punch depth is normally distributed. 33 pairs of subjects will be needed if the estimated true
difference in the mean response of matched pairs is 0.2 for punch size. Taken into account
possible drop outs, inclusion of 35 patients was planned. PS-power and sample size
calculation software was used to perform the calculation.
Study period
The inclusion of patients started in June 2011 and will continue until the 35 patients needed to
be able to reject the null hypotheses, are included. The expected end date is March 2012.
Therefore, it was unfortunately not possible to include the results of all these patients within
the time frame of this study.
Punch grafting procedure
All patients visited the NIPD three times during the study (table 3). During the first visit
screening was completed, intake took place, written informed consent was obtained, and the
punch grafting procedure was performed.
Before the punch grafting procedure could take place, the acceptor sites and donor sites were
cleaned with Chlorhexidine solution and infiltrated with Lidocaine 2% with adrenaline. The
acceptor site consisted of a depigmented lesion of at least 5 by 5 centimetres (cm) which was
arranged in four equal areas of 2.5 by 2.5 cm. In all the four areas, a randomly selected regime
of the four punch graft techniques was punched out to prepare the acceptor site for
transplantation. Using the same regime as with the acceptor site, the punch grafts were
punched from the donor site and directly placed into the prepared acceptor site. In all the
patients, treatment was done by the same two physicians. To allow measurements after six
months the distance from the graft to the border at the acceptor site was at least 5 mm, and the
distance between the grafts was 10 mm, because the maximum pigment spread of one graft is
5 mm.11;13
The punch grafts at the donor site were taken as close to each other as possible in
order to make the donor site small. The hip was used as donor site because in this area the
skin is consistent in structure to the skin of the acceptor site, it contains many melanocytes,
and it is an inconspicuous area, mostly covered by clothes.
After the punch grafting, silver sulfadiazine cream was applied to the donor site covered with
a sterile gaze and Tegaderm dressing. For the recipient site a standardized wound regimen of
steri-strips and Tegaderm dressing was applied, which could be taken off after five days. Five
11
days after the transplantation, UV-treatment (UVA facial tanner Eurosolar 924 T, the
Netherlands) was started at home, two times a week, and continued until 3 months after the
procedure. The exposure-time increased from 4 to 8 to 12 minutes in the first three sessions.
From the fourth session onwards, exposure-time remained 14 minutes.25
If patients possessed
another facial tanner or a NB-UVB device these were used because of practical and financial
reasons.
Visit Time Procedure
First visit Grafting procedure Intake
Written informed consent
Photo documentation
Punch grafting
Wound care 5 days after grafting Dressing removal
Start UV-therapy
Follow up by phone 1 week after grafting Assessment on side effects and
wound healing
First follow up visit
3 months after grafting Inspection of donor and acceptor
sites
Assessments
Photo documentation
Second follow up visit 6 months after grafting Inspection of donor and acceptor
sites
Final Assessments
Photo documentation Table 3 - Summary of procedures employed at each visit in the study protocol
Follow up
Within the complete study period three follow up moments took place (see table 3). The
follow up was done by a blinded investigator and recorded on questionnaire forms. During all
the follow up visits in the NIPD, the treated areas were photo documented.
One week after treatment follow up was done by phone. Assessments were made on the side
effects and on the time points where wound healing had taken place. The patient assessed
pain, redness, itch and burning sensation on a categorical scale from zero to three (0 = absent,
1 = mild, 2 = moderate and 3 = severe). The patient was asked if there were signs of infection,
if wound healing had taken place, and if differences were observed between the test regions of
the four different punch graft techniques. During this first follow up moment it was
practically not possible for patients to make a difference between the treatment regions.
Assessments were used to get an overall conception of the side effects of the grafting and
wound healing after treatment.
After three months, the first follow up visit took place at the NIPD. Objective assessment by a
blinded physician was conducted per test region, consisting of measuring the pigmented
surface area, counting the number of grafts that showed pigment outgrowth, and scoring the
visual side effects. The general outcome was assessed by the patient (see appendix 4).
The final, second, follow up visit will take place six months after treatment. This visit will
consist of the same assessments done during the first follow up visit. The final results of
pigmented surface area, number of grafts with pigment outgrowth, the general outcome
assessed by the patient, and the visual side effects will be assessed at this follow up moment.
During the period of this study only the results of the first follow up moment were available
and these data were used for the analyses.
12
Measurements
Measurement of the diameter of pigment outgrowth was done using a dermatoscope with a
ruler. The pigmented surface area of one punch grafts was calculated using the following
formula:
Pigmented surface area = π x 0.5 diameter X x 0.5 diameter Y, where:
X = horizontal diameter, Y = vertical diameter
The total pigmented surface area of one treatment region was calculated by the sum of the
pigmented surface areas of the four punch grafts in that treatment region. The grafts that had
not shown pigment outgrowth were included in the calculation and taken into account as zero.
To calculate the relationship between the donor graft and the pigmented surface area after
three months, the mean pigmented surface area of one graft was divided by the original
(starting) area of that graft. The mean pigmented surface area of one graft per treatment
region was calculated by summing up all the pigmented surface areas per test region and
dividing this by the number of grafts that showed pigment outgrowth per test region. The
grafts that did not show pigment outgrowth were excluded from this calculation.
The original pigmented surface area was calculated as follows:
The 1.5 mm grafts have an r of 0.75; π x 0.752
= 1.77 mm2
Four 1.5 mm grafts have a starting surface area of (π x 0.752) x 4 = 7.069 mm
2
The 1 mm grafts have r of 0.5; π x 0.52
= 0.785 mm2
Four 1 mm grafts have a starting surface of (π x 0.52) x4; 3.14 mm
2
The visual side effects were scored on a categorical scale from zero to three (0 = absent, 1 =
mild, 2 = moderate and 3 = severe) per test region at the donor and acceptor site. The side
effects assessed were; hyperpigmentation, hypopigmentation, scar, and cobblestone effect for
the acceptor site, and hyperpigmentation, hypopigmentation, scars, relief and erythema for the
donor site. The patients assessed the general outcome of the procedure on a 5 point
categorical scale, as very poor, poor, neutral, good, or very good.
Statistical analysis
All data received were handled anonymously and confidentially. The data were recorded on
questionnaire forms and transferred to a computer database (Microsoft Excel). Statistical
analyses were performed by PASW statistics 18 (SPSS 18) software. On the contrary of what
was expected, and what was assumed in the power analyse, the data did not fit a normal
distribution, not even after transforming the data. Therefore, nonparametric tests were used.
Because of matched observations, a Friedman test and Wilcoxon signed-ranks tests (Post-hoc)
were used to compare the pigmented surface areas of the different treatment regions. For the
Post-hoc analyses the Bonferroni method was used to adjust the significance level for
multiple testing, calculated as p x K x (K−1)/2, with p as the uncorrected significance level
and K as the number of comparisons. The significance level was set at p < 0.05. Side effects
and time of healing were described per item. To test the significant difference of the side
effects, these were transformed to binary data and analysed by a McNemar test to compare
test regions in pairs. When the median and IQR range were 0 (absent), the mean is presented
as well.
13
4. Results
Between June 2011 and November 2011, 32 consecutive patients with stable non- segmental
and segmental vitiligo, or piebaldism were included in this study. Because the study is still
ongoing, only preliminary results of 15 patients and their first follow up visit were available
for analysis (table 4).
The characteristics of the 15 included patients are shown in table 4. The grafting was
performed in patients with non-segmental vitiligo (n = 3, all female), segmental vitiligo (n =
4, 1 females), and piebaldism (n = 8, 4 females). In total 53% of the patients were female (n =
8). In all 15 patients, the disease duration was longer than 10 years. The mean age of the
patients at the time of grafting was 27 years old with a range from 18-56 years old. 73% of the
patients had Fitzpatrick photo type III (n = 11), 13% (n = 2) had photo type II and another
13% had photo type IV. The treatment location was the leg in 8 patients (53%), the upper arm
in 3 patients (20%), and in 5 patients (33%) the trunk. Seven patients (47%) scored 0 on the
VIDA score and for 8 patients (53%) the score was 0 and -1.
Sex, n (%)
Male 7 (47)
Female 8 (53)
Age (years), mean (median; min-max) 27 (22;18-56)
Fitzpatrick skin photo type, n (%)
II 2 (13)
III 11 (73)
IV 2 (13)
Treatment indication, n (%)
Vitiligo non-segmentalis 3 (20)
Vitiligo segmentalis 4 (27)
Piebaldism 8 (53)
Duration of disease, n (%)
Longer than 10 years 15 (100)
VIDA score, n (%)
0 7 (47)
-1 8 (53)
Treatment location, n (%)
Trunk 5 (33)
Extremities leg 8 (53)
Arm 3 (13)
Type of UV treatment, n (%)
UVA 13 (87)
NB-UVB 2 (13) Table 4 - Characteristics of patients in study population, N = 15.
The results of two patients were excluded from the study analysis. One of these excluded
patients was a piebaldism patient who was lost to follow up after the grafting procedure. The
other excluded patient was a non-segmental vitiligo patient who was excluded because
perifollicular repigmentation after NB-UVB therapy appeared in the test region. This patient
was treated with NB-UVB instead of UVA therapy because she already possessed a UVB
device. During the first follow up visit it was impossible to distinguish the repigmentation in
the treatment regions from this perifollicular repigmentation. Therefore, no measurement of
repigmentation could be done and these results were regarded as missing values. The side
effects of this patient were assessed and taken into account in the analysis.
14
Pigmented surface area
The pigmented surface areas
were dependent on the person
treated and on size and depth
of the treatment (figure 3).
The 1.5 mm grafts generally
resulted in larger pigmented
surface areas than the 1 mm
grafts. In general, a downward
trend can be seen from
treatment with the deep 1.5
mm grafts towards treatment
with the superficial 1.5 mm
grafts, the deep 1 mm grafts
and the superficial 1 mm
grafts (treatment 1 to 4, figure
3). Patient 2, 12, and 13 differ
from this trend. In patient 2,
the overall pigment outgrowth
in the treatment with the deep
1.5 mm grafts and the
superficial 1 mm grafts was
larger than in other patients, were in treatment with the superficial 1.5 mm and the deep 1 mm
grafts the pigmented surface areas were small. Patient 12 and 13 showed larger pigmented
surface areas in treatment with the deep 1 mm grafts compared to the other treatments.
The median (in mm2) and 25
th and 75
th percentile (IQR) of the pigmented surface areas for the
deep 1.5 mm grafts, the superficial 1.5 mm grafts, the deep 1 mm grafts, and the superficial 1
mm grafts were 24.3 (12.6 - 33.8), 12.6 (8.4 – 28.3), 9.4 (3.1 - 15.7), and 7.1 (4.1 - 22.4),
respectively (see Figure 4 and table 5). Overall, a significant difference (p = 0.001) between
the pigmented surface areas of the different treatment regimens could be observed.
Table 5 – The total pigmented surface area per test region. Data represent; Mean; median; IQR. N = 13
Deep grafts Superficial grafts p value; adjusted p
value
1.5 mm 3.46 2.92 0.288; 1.00
1.0 mm 1.81 1.81 1.000; 1.000
P value; adjusted P
value
0.001; 0.007 0.028; 0.166
Table 6 – The pigmented surface area per test region. Data represent the rank per test region. P value calculated
by post-hoc analyses, p adjusted by the Bonferroni method. N = 13
Repigmentation
(in mm2)
1.5 mm
deep grafts
1.5 mm
superficial
grafts
1 mm deep
grafts
1 mm
superficial
grafts
P value
Mean; median;
IQR
26.8; 24.3;
12.6-33.8
18.1; 12.6;
8.4-28.3
12.6; 9.4;
3.1-15.7
12.4; 7.1;
4.1- 22.4
0.001
Figure 3 – Pigmented surface area per treatment region per patient; the
line connects the different treatment regions per patient
15
Figure 4 - The pigmented surface area of four grafts per test region in mm
2.
o and
* are outliners.
The one by one comparison of the treated areas that differ only in depth or size showed a
significant difference between the deep 1.5 mm and the deep 1 mm grafts (adjusted p = 0.007,
table 6). The difference between the superficial 1.5 mm grafts compared to the superficial 1
mm grafts was not significant (adjusted p = 0.166) although the median and IQR are higher in
the superficial 1.5 mm grafts; 12.6 (8.4 - 28.3) compared to 7.1 (4.1 - 22.4). The pigmented
surface areas in deep grafts compared to superficial grafts are not significantly different in the
1.5 mm grafts (p = 0.288 and adjusted p = 1.00) or the 1 mm grafts (p and adjusted p = 1.00).
There was also a significant difference between the 1.5 mm deep and the 1 mm superficial
grafts (p = 0.001, adjusted p = 0.007). The 1.5 mm superficial grafts did not show a
significant difference when compared to the 1 mm deep grafts (p = 0.028, adjusted p = 0.166).
The mean pigmented surface area of one 1.5 mm deep graft after three months was 6.16 mm2,
which was an area 3.5 times larger than its starting area. The mean pigmented surface area of
one 1.5 mm superficial graft was 4.9 mm2, which was an area 2.8 times larger than its own
starting area. The mean pigment outgrowth in the 1 mm deep grafts was 3.90 mm2
and in the
1 mm superficial grafts the pigment outgrowth was 3.75 mm2, which were areas of 5.0 and of
4.8 times larger than their starting areas.
Number of grafts with repigmentation
1.5 mm
deep grafts
1.5 mm
superficial
grafts
1 mm deep
grafts
1 mm
superficial
grafts
Number of
grafts with
repigmentation
4 (4;4-4) 3.69 (4;2-4) 3.23 (4;1;4) 3.23 (3;0-4)
Table 7 – Number of grafts with pigment outgrowth per patient per test region. Data represent mean (median;
minimum-maximum).
All the 52 deep 1.5 mm grafts transplanted in 13 patients showed pigment outgrowth (table
7). From the 52 transplanted superficial 1.5 mm grafts, 48 grafts showed pigment outgrowth,
with a range from 2 to 4 grafts per patient. 42 of the 52 placed deep and superficial 1 mm
16
grafts showed pigment outgrowth with a mean number of grafts with pigment outgrowth of
3.23 and a range of 1 to 4 grafts and 0 to 4 grafts per patient for the deep and superficial
grafts, respectively.
Side effects
During the follow up one week after grafting 5 patients (33.3%) reported 2 types of side
effects, 4 patients (26.7%) reported 1 side effect, and 6 patients (40%) did not report any side
effects at the donor site. The side effect pain was most often reported. Four patients
experienced mild pain, 1 patient moderate pain, and 1 patient reported severe pain (table 8).
Generally, the reported pain, included the severe pain, improved after 2 days and did not
continue for more than 5 days. Mild and moderate erythema occurred in 3 patients and in 1
patient respectively. 10 patients reported that the donor site was healed within a week, 5
patients reported that the donor side healed within two weeks.
Absent Mild Moderate Severe
Pain 9 4 1 1
Erythema 11 3 1 0
Itch 12 3 0 0
Burning sensation 14 1 0 0 Table 8 - Side effects in the donor site. Data represent the number of patients that had the side effect in the donor
site within the first week after grafting. N = 15
At the acceptor site, 4 patients (26.7%) reported none of the side effects, 5 patients (33.3%)
reported 1 side effect, 3 patients (20 %) 2, and 2 patients (13.3%) reported 3 of the side
effects. Itch was the most reported side effect at the acceptor site. Mild itch occurred in 7
patients, moderate in 3 patients, and as severe itch in 1 patient (table 9). The itch did not occur
longer than 5 days and improved when the wound dressing was removed. Mild and moderate
pain and burning sensation were also reported by a few patients. None of the patients reported
infection at the donor or acceptor site during the follow up one week after grafting.
Absent Mild Moderate Severe
Pain 11 3 1 0
Erythema 13 1 0 1
Itch 4 7 3 1
Burning sensation 12 2 1 0 Table 9 - Side effects in the acceptor site. N = 15 Data represent the number of patients that had the side effect
after within the first week after grafting.
After 3 months the side effects were assessed at the donor en acceptor site per test region. At
the donor site, hyperpigmentation occurred mostly in the deep 1.5 mm grafts, were it
appeared mildly in 4 patients (28.6%). In the superficial 1.5 mm and the deep 1 mm grafts
mild hyperpigmentation appeared in 1 patient (7.1%), in the superficial 1 mm grafts
hyperpigmentation occurred in none of the patients. Mild hypopigmentation appeared in 3
patients (21.4%) in the deep 1 mm grafts, in 2 patients (14.3%) in the superficial 1.5 mm, the
deep 1.5 mm grafts, and in the superficial 1 mm grafts. Erythema occurred mostly, although
not significantly more, in the deep 1.5 mm grafts, were it appeared mildly in 4 patients and 3
patients (21.4%) showed moderate erythema. Mild erythema was seen in 3 patients (21.4%) in
the superficial 1.5 mm grafts, in 4 patients (28.6%) in the deep 1 mm grafts and mild and
moderate erythema occurred in 1 patient (7.1%) in the 1 mm superficial grafts. Mild relief
occurred in 3 patients (21.4%) in the deep 1.5 mm grafts, and in 1 patient (7.1%) in the
17
superficial 1.5 mm and the 1 mm grafts (table 10). No significant differences were found
between the side effects of the test regions at the donor site in inter-patient comparisons.
Table 11 shows the side effects assessed at the acceptor site. At the acceptor site, mild
cobblestone effect was seen in 3 patients (21.4%). One of these patients (7.1%) showed a
cobblestone effect at the deep and superficial 1.5 mm grafts, 1 (7.1%) patient showed
cobblestone effects at the superficial 1.5 mm and the superficial 1 mm grafts. Two patients
(14.3%) showed cobblestone effects only at the superficial 1 mm grafting region or the deep
1.5 mm grafting region. Mild hyperpigmentation was seen in 5 (35.7%), 2 (14.3%) or 1
(7.1%) patient in respectively the deep 1.5 mm, the superficial 1.5 mm and the deep 1 mm,
and the superficial 1 mm grafts. Hyperpigmentation did not appear significantly more in the
deep 1.5 mm grafts compared to the superficial 1 mm grafts.
Side effect 1.5 mm
Deep
1.5 mm
Superficial
1 mm Deep 1 mm
Superficial
Hyperpigmentation 0.36 (0;0-1)*
0.14 (0;0-0) 0.14(0;0-0) 0.07(0;0-0)*
Hypopigmentation 0(0;0-0) 0(0;0-0) 0(0;0-0) 0(0;0-0)
Scar 0(0;0-0) 0(0;0-0) 0(0;0-0) 0(0;0-0)
Cobblestone effect 0.14 (0;0-0) 0.14 (0;0-0) 0(0;0-0) 0.07(0;0-0) Table 11- Side effect in the acceptor site assessed by a blinded physician on a scale from 0 - 3 (were 0 = absent,
1 = mild, 2 = moderate and 3 = severe, N = 14) Data represent mean (median; IQR). *Difference not significant
tested with the McNemar test.
The general outcome assessed by the patient
There were only minor differences between the test regions in the general outcome assessed
by the patient. Most patients assessed the outcome of the donor sites as good or very good
(table 12). The 1 mm superficial grafts had a slightly better general outcome than the other
regions. The acceptor sites were mostly assessed as good with slightly better results in the 1.5
mm deep grafts, which most patients assessed as very good. The patient that assessed the
acceptor sites as poor and very poor is patient number 2 whose grafts, in these regions got
lost, probably caused by the pressure of trousers.
Donor 1.5 mm Deep
Donor 1.5 mm
Superficial Donor 1 mm Deep
Donor 1 mm Superficial
Outcome
3;3-4 (Neutral 7.7 % Good 46.2%
Very good 46.2%)
3;3-4 (Neutral 7.7 % Good 46.2%
Very good 46.2%)
3;3-4 (Neutral 7.7 % Good 46.2%
Very good 46.2%)
4; 3-4 (Neutral 7.7 % Good 38.5%
Very good 53.8%)
Side effect 1.5 mm
Deep
1.5 mm
Superficial
1 mm
Deep
1 mm
Superficial
Hyperpigmentation 0.29(0; 0-1)#
0.07(0 ;0-0)
0.07(0;0-0) 0(0;0-0)#
Hypopigmentation 0.14(0;0-0)
0.14(0;0-0)
0.21(0;0-
0.25)
0.14(0;0-0)
Scar 0.07(0;0-0)
0.07(0;0-0) 0(0;0-0) 0(0;0-0)
Erythema 0.71(0.5;
0-1.25)*
0.21(0;
0-0.25)
0.29(0;
0-1)
0.14(0;
0-0)*
Relief 0.21(0;0-0)!
0.07(0;0-0) 0(0;0-0)!
0.07(0;0-0)
Table 10- Side effects in the donor site assessed by a blinded physician on a categorical scale from 0-3 (were 0 =
absent, 1 = mild, 2 = moderate and 3 = severe, N = 13). Data represent mean (median; IQR).N = 14.
#*
! Differences not significant, tested with the McNemar test.
18
Acceptor 1.5 mm
Deep Acceptor 1.5 mm
Superficial Acceptor 1 mm Deep
Acceptor 1 mm
Superficial
Outcome 4;3-4 (Neutral 7.7 % Good 38.5%
Very good 53.8%)
3;3-4 (Poor 7.7% Neutral 7.7 % Good 38.5% Very good 46.2%)
3;3-4 (Very poor 7.7% Neutral 7.7 % Good 38.5% Very good 46.2%)
3:2-4 (Neutral 7.7 % Good 46.2%
Very good 46.2%)
Table 12 - General outcome assessed by the patient on a categorical scale from 0-4 (were 0 = very poor, 1 =
poor, 2 = neutral, 3 = good, and 4 = very good). Data represent median; IQR (percentage of patients with
categorical outcome). N = 13
5. Discussion
This study shows that autologous deep 1.5 mm punch grafting has the highest efficacy of the
four treatments. No differences with regard to safety and patient’s satisfaction were found
between the four treatment regions during this study.
Pigmented surface areas
Present study shows a significant difference between the pigmented surface areas of the four
treatments. The deep 1.5 mm grafts (median: 24.3 mm2) show significantly more
repigmentation compared to both the deep 1 mm (median: 7.1mm2) and the superficial 1 mm
grafts (median: 9.4 mm2). The superficial 1.5 mm grafts showed a higher median pigmented
surface area (median: 12.6 mm2) compared to the superficial 1 mm and the deep 1 mm grafts,
although not significantly higher. The deep grafts did not cause significant larger pigmented
surface areas than the superficial grafts. Overall, it can be concluded that the 1.5 mm grafts
showed larger pigmented surface areas than the 1 mm grafts, and size seems to have more
effect on pigment spread than depth. Although there seems to be a correlated effect of depth
and size, since the deep 1.5 mm grafts showed the largest pigmented surface areas after
grafting. The effect of size could partly be explained by the larger pigmented starting area,
and thereby more melanocytes that are expected to be grafted along. The larger, deeper grafts
are expected to contain hair follicles that are surrounded by vital melanocytes.23
These active
and functional melanocytes can spread centrifugally from the deep infundibulum to the basal
cell layer and recolonise the epidermis and could therefore cause repigmentation.23
Another
explanation could be that deeper grafts contain deeper laying stem cells which could stimulate
the repigmentation and could have a positive effect on the survival of the grafts. The deeper
vascular components could as well influence the repigmentation.23
The inferior results of the
deep 1 mm grafts could be explained by the smaller dermal part were these stem cells, hair
follicles and vascular components are expected to be less present than in the deep 1.5 mm
grafts. Histological analyses are recommended to confirm these hypotheses.
The better results after grafting with the deep 1.5 mm grafts compared to the other treatments
may also be explained by the larger number of grafts that showed pigment outgrowth in these
treatment regions; 52 of the 52 grafts transplanted in 13 patients compared to 48, 42 and 42
grafts with pigment outgrowth in 13 patients in the other treatments. The loss of the deep 1
mm grafts could be explained by desecration and the loss of the deep and superficial 1 mm
grafts could be explained by the small adherent surface of these grafts enabling these grafts to
grow onto the acceptor site.
In this study, the deep 1.5 mm deep grafts were able to become 3.5 times larger than its
starting area, which is more than the 1.5 mm superficial grafts that reached a mean surface
area of 2.8 times larger than their starting surface. This supports the statement that there is a
correlated effect of depth and size. Unexpectedly, the 1 mm grafts seemed to have the ability
19
to become 5 times larger than their own starting area, which is more than the 1.5 mm grafts
were able to. Previous studies showed that 1 mm grafts induced a pigmented surface area 25
times larger and the 1.5 mm grafts induced a pigmented surface area 56 times larger than the
starting area of the donor grafts.11;13;21
The inferior results compared to the results in literature
could be explained by the follow up time of three months after grafting, while pigment
outgrowth occurs until six months after grafting.8;20
The light skin photo types of the patients
and the UVA therapy in this study, in contrast to NB-UVB therapy could also account for the
inferior results. 8;20
Side effects
Preliminary results in this study showed that although side effects were slightly more often
seen in the 1.5 mm deep grafts, these grafts did not induce significantly more side effects than
the other treatments. In daily practice superficial grafts of 1.5 mm are advised for the trunk
and extremities and 1 mm grafts for the face.8;13
Superficial grafts are recommended because
it is suggested that the thinner the graft the denser the capillary superficial network, which
stimulates an earlier process of vascularisation and thereby prevents side effects and the loss
of grafts.20
Smaller punches are recommended because these are known to cause less adverse
events.10;21
Hyperpigmentation, cobblestone appearance and scar formation at the donor site
are the most prevalent side effects in punchgrafting.8 In studies were 2 mm punch grafts are
used, cobblestone appearance and cobble-stone like effects were reported in 27 - 44% of the
treated patients.10;12
If 1.5 mm grafts are used cobblestone appearance was seen in 30% of the
patients, which is in accordance with the results of the present study (28.6%). It has
furthermore been hypothesized that most complications, and especially cobblestone effects,
results from the dermal part of larger and thicker grafts.10
Results in this study indicate, in
contrary to the literature, that there are no differences in side effects including cobblestone
effects between 1 mm and 1.5 mm grafts, or the deep or superficial grafts. Therefore it is
suspected that it is not the dermal part that causes a cobble stone effect; most important is that
the grafts at the acceptor site should be taken at least as deep as the donor grafts, in order that
the grafts do not protrude and have good contact with the underlying tissue.
Patient satisfaction
In this study, no differences were found in the general outcomes assessed by the patient
between the test regions. Most patients (84.6%-92.3%) assessed the test regions as good or
very good, indicating that the patients were satisfied with the grafting procedure. However,
this conclusion should be taken with caution because it was hard for patients in this study to
criticize the test regions. Only four grafts have been placed in each test region, 10 mm from
each other to allow measurements after six months. Normally, grafts are placed closer
together, i.e. 5 mm, during the punch grafting procedure, enabling the pigment to grow
together to achieve uniform repigmentation. Furthermore, even in studies using
repigmentation rate as primary end-point, there is a high discrepancy between the objective
repigmentation and the patients’ own assessments.10
Indicating that a high percentage of
repigmentation does not mean an excellent result for the patient. This is explained by
researchers by hyper- or hypopigmentation and side effects like cobblestone- like effects.10
Based on this study, it can be stated that the use of 1 mm, 1.5 mm, deep or superficial grafts
did not influence the patients’ satisfaction of the treatment.
Practical aspects
All the treatments were carried out by the same two physicians. Transplantation of the 1 mm
grafts was more difficult and time consuming than transplantation of the other grafts,
especially the deep 1 mm grafts were harder to punch out and to place than the other grafts.
20
These grafts tend to get stuck in the grafting device, causing manipulations of the grafts and
thereby probably desecration. Which could be an explanation for the large number of grafts
that did not showed pigment outgrowth in the 1 mm deep grafts.
Strengths and limitations of this study
To date, only preliminary results from the follow up after three months were available.
Therefore, conclusions and recommendations should be formulated with caution. Since grafts
can continue to spread pigment outgrowth until six months after punch grafting, the results
will underestimate the repigmentation effects.8;11
Furthermore, it is expected that the side
effects at the donor and acceptor sites will decrease during the last three months of follow up.
Therefore, no definite conclusions can be drawn on the side effects as well.
The grafts were placed in the same patients, using the same lesions and thus making the
different treatments highly suitable for comparisons, by partly excluding the risk of
confounders. This study once again confirms that the success of the transplantation method
and thereby on pigmented surface area varies from patient to patient (see e.g. figure 3). The
selection of patients plays a significant role in achieving successful repigmentation, and was
therefore very strict in this study.8 The punch grafting test was performed in non-segmental
vitiligo patients and had to be positive before inclusion could take place. In previous studies
results showed to be less on non-segmental vitiligo patients, where the vitiligo may still
remain or become active and depigment treated sites and therefore these studies had to
exclude many patients.25
In this study, until now, only 1 vitiligo vulgaris patient had to be
excluded because perifolliculair pigmentations appeared. The last year before treatment, this
patient has not used the NB-UVB device on the treatment area which raises the suspicion that
the repigmentation observed was UVB induced. Because of these strict inclusion criteria none
of the patients had to be excluded because all the grafts depigmentated. In patient 2 treatment
regions 2 and 3 were compromised by the pressure of trousers, which could be the reason that
many off the grafts in these regions did not show pigment outgrow at all. In patient 12 and 13,
the 1 mm deep grafts were more effective than the other grafts. A possible explanation why
the deep 1 mm grafts were more effective better than the 1.5 mm grafts could not be found.
All test regions in these two patients were placed on the same location on the trunk, and
treated with UVA equally.
In this study the four treatments were compared one by one in the analyses. Size and depth
could not be analysed separately, because of their correlated effect. To draw conclusions on
the effect of size and depth and the interactions of these effects a linear regression model
should be used, this was not possible since the data were not normally distributed and the
number of patients was too small. The possibilities of statistical analyses will be larger when
the results of more patients are available.
Not all the measurements done during this study were objective, which is a limitation.
Although, the primary end-point pigmented surface area is an objective measure, the other
assessments were mainly subjective measures done by indicating side effects on a categorical
scale by a blinded investigator and by the patients. There is no uniformity in assessment
systems for treatment outcome in vitiligo studies concerning autologous transplantation
methods. The objective measurement tools that were available, like the VASI and Quality of
life scores, were not suitable for this study.27
Therefore, it was difficult to make comparisons
between this study and other studies. The punch grafting in this study was performed on the
trunk and proximal and distal extremities. Therefore, based on the results of this study
recommendations for grafting on the face cannot be made. In daily practice, 1 mm grafts are
21
advised for grafting on the face, to prevent cobblestone effects.26
Based on present results
advisements can be made against the use of 1 mm deep grafts, mainly for practical reasons.
Conclusion
Repigmentation and side effects will change until six months after grafting, therefore definite
conclusions cannot be drawn. Preliminary results show that punch grafting, in all the
treatment regimens, is a safe and effective method for the treatment of depigmented lesion in
stable vitiligo and piebaldism patients. The pigmented surface area after three months is
largest when 1.5 mm deep grafts are used, in part because there was no loss of grafts when
this treatment was carried out. Furthermore, the 1.5 mm deep grafts did not induce significant
more side effects, although the scars on the donor and acceptor site are slightly more prone to
show hyperpigmentation, relief and erythema. This grafting technique was easy to perform
and patients’ satisfaction on both donor and acceptor sites was equal in all the test regions.
Hence, 1.5 mm deep punch grafting proved to be a promising grafting method for lesions on
the trunk and extremities in vitiligo and piebaldism patients.
Figure 5 - Acceptor site on the trunk; before (left). And three months
after punch grafting (right).
Figure 6 - Donor site on the hip;
before (left) and three months after
punch grafting (right).
22
6. Reference List
1. Drake LA, Dinehart SM, Farmer ER et al. Guidelines of care for vitiligo. American
Academy of Dermatology. J Am Acad Dermatol 1996; 35: 620-6.
2. Njoo MD, Westerhof W. Vitiligo. Pathogenesis and treatment. Am J Clin Dermatol
2001; 2: 167-81.
3. Alikhan A, Felsten LM, Daly M et al. Vitiligo: A comprehensive overview Part I.
Introduction, epidemiology, quality of life, diagnosis, differential diagnosis,
associations, histopathology, etiology, and work-up. J Am Acad Dermatol 2011; 65:
473-91.
4. Taieb A, Picardo M. Clinical practice. Vitiligo. N Engl J Med 2009; 360: 160-9.
5. Hann SK, Lee HJ. Segmental vitiligo: clinical findings in 208 patients. J Am Acad
Dermatol 1996; 35: 671-4.
6. Ortonne J. Vitiligo and other disorders of hypopigmentation. JL, Jorizzo JL Rapini
RP. 2008. Elsevier Limited 2008. Dermatology, 2nd ed, Bolognia, (Eds).
Ref Type: Serial (Book,Monograph)
7. Richards KA, Fukai K, Oiso N et al. A novel KIT mutation results in piebaldism with
progressive depigmentation. J Am Acad Dermatol 2001; 44: 288-92.
8. van GN, Ongenae K, Naeyaert JM. Surgical techniques for vitiligo: a review.
Dermatology 2001; 202: 162-6.
9. Ongenae K, van GN, De SS et al. Effect of vitiligo on self-reported health-related
quality of life. Br J Dermatol 2005; 152: 1165-72.
10. Fongers A, Wolkerstorfer A, Nieuweboer-Krobotova L et al. Long-term results of 2-
mm punch grafting in patients with vitiligo vulgaris and segmental vitiligo: effect of
disease activity. Br J Dermatol 2009; 161: 1105-11.
11. Falabella R. Grafting and transplantation of melanocytes for repigmenting vitiligo and
other types of leukoderma. Int J Dermatol 1989; 28: 363-9.
12. Malakar S, Dhar S. Treatment of stable and recalcitrant vitiligo by autologous
miniature punch grafting: a prospective study of 1,000 patients. Dermatology 1999;
198: 133-9.
13. Boersma BR, Westerhof W, Bos JD. Repigmentation in vitiligo vulgaris by
autologous minigrafting: results in nineteen patients. J Am Acad Dermatol 1995; 33:
990-5.
14. Olsson MJ, Juhlin L. Long-term follow-up of leucoderma patients treated with
transplants of autologous cultured melanocytes, ultrathin epidermal sheets and basal
cell layer suspension. Br J Dermatol 2002; 147: 893-904.
23
15. Njoo MD, Nieuweboer-Krobotova L, Westerhof W. Repigmentation of leucodermic
defects in piebaldism by dermabrasion and thin split-thickness skin grafting in
combination with minigrafting. Br J Dermatol 1998; 139: 829-33.
16. van GN, Wallaeys E, Goh BK et al. Long-term results of noncultured epidermal
cellular grafting in vitiligo, halo naevi, piebaldism and naevus depigmentosus. Br J
Dermatol 2010; 163: 1186-93.
17. Falabella R, Arrunategui A, Barona MI et al. The minigrafting test for vitiligo:
detection of stable lesions for melanocyte transplantation. J Am Acad Dermatol 1995;
32: 228-32.
18. Njoo MD, Westerhof W, Bos JD et al. A systematic review of autologous
transplantation methods in vitiligo. Arch Dermatol 1998; 134: 1543-9.
19. Murakami T, Fukai K, Oiso N et al. New KIT mutations in patients with piebaldism. J
Dermatol Sci 2004; 35: 29-33.
20. Lahiri K. Evolution and evaluation of autologous mini punch grafting in vitiligo.
Indian J Dermatol 2009; 54: 159-67.
21. Lahiri K, Malakar S, Sarma N et al. Repigmentation of vitiligo with punch grafting
and narrow-band UV-B (311 nm)--a prospective study. Int J Dermatol 2006; 45: 649-
55.
22. Neves DR, Regis Junior JR, Oliveira PJ et al. Melanocyte transplant in piebaldism:
case report. An Bras Dermatol 2010; 85: 384-8.
23. Falabella R. Vitiligo and the melanocyte reservoir. Indian J Dermatol 2009; 54: 313-
8.
24. Hearn RM, Kerr AC, Rahim KF et al. Incidence of skin cancers in 3867 patients
treated with narrow-band ultraviolet B phototherapy. Br J Dermatol 2008; 159: 931-5.
25. Wind BS, Meesters AA, Kroon MW et al. Punchgraft testing in vitiligo; effects of
UVA, NB-UVB and 632.8 nm Helium-Neon laser on the outcome. J Eur Acad
Dermatol Venereol 2011; 25: 1236-7.
26. Falabella R. Surgical treatment of vitiligo: why, when and how. J Eur Acad Dermatol
Venereol 2003; 17: 518-20.
27. Van Geel NA, Ongenae K, Vander Haeghen YM et al. Autologous transplantation
techniques for vitiligo: how to evaluate treatment outcome. Eur J Dermatol 2004; 14:
46-51.
24
7. Appendix
Appendix 1. Patient information
Patiëntinformatie
Studie Titel: Minigrafting technieken bij vitiligo en piebaldisme.
Onderzoekers: drs. C.Vrijman, L.Komen, dr. A. Wolkerstorfer
Geachte heer/mevrouw,
U bent gevraagd deel te nemen aan een onderzoek. Voordat u besluit om deel te nemen, is het
belangrijk dat u begrijpt waarom dit onderzoek wordt gedaan en wat het voor u inhoudt.
Wilt u de volgende informatie zorgvuldig doorlezen. Bespreekt u eventuele deelname aan het
onderzoek met uw behandelend arts, vrienden en/of familie. U krijgt hier voldoende tijd voor.
Als iets niet duidelijk is, of als u vragen heeft, wendt u zich dan tot de ondergenoemde
onderzoeksartsen.
Achtergrond en doel van het onderzoek
Vitiligo en piebaldisme zijn onschuldige huidaandoeningen waarbij spierwitte plekken
ontstaan of vanaf de geboorte aanwezig zijn. Het kan zeer ontsierend zijn waardoor het
cosmetisch storend is voor veel patiënten. Minigrafting is een van de mogelijke
behandelingen wanneer de witte plekken niet meer uitbreiden en dus stabiel zijn.
Minigrafting is een huidtransplantatie waarbij kleine stukjes normaal gepigmenteerde huid
van de patiënt zelf, in de witte plekken worden geplaatst. Om deze behandeling optimaal te
laten zijn is onderzoek nodig naar verschillende technieken van deze huidtransplantatie. In de
SNIP willen wij patiënten met piebaldisme of stabiele vitiligo oproepen om mee te werken
aan het onderzoek met minigrafting. Momenteel wordt de transplantatie met heel
oppervlakkige stukjes huid uitgevoerd. We willen onderzoeken of het gebruik van diepere
stukjes huid zorgt voor een beter resultaat. Daarnaast willen we onderzoeken of de grootte van
de huidstukjes invloed heeft op het resultaat van de minigrafting.
Wat houdt het onderzoek voor u in?
Naast de standaard minigrafting voor uw vitiligo of piebaldisme zullen er 16 extra huidstukjes
getransplanteerd worden. Er zullen 4 proefgebieden worden afgetekend. Elk proefgebied
krijgt 4 huidstukjes getransplanteerd. Met behulp van een computer programma zal
willekeurig bepaald worden welk proefgebied oppervlakkige en welk proefgebied diepere
huidstukjes krijgt en welk proefgebied grote (1,5 mm) en welk proefgebied kleine (1 mm)
huidstukjes krijgt. Alle proefgebieden zullen net als het gebied van de standaard minigrafting
2x per week met licht behandeld worden. Dit kan bij u thuis, of bij de polikliniek van de
SNIP. Omdat de behandelde proefplekken eerst met een prikje verdoofd worden, zal de
behandeling niet pijnlijk zijn. De behandeling zelf duurt ongeveer 30 minuten. Het eerste
bezoek duurt in totaal ongeveer 60 minuten. Drie maanden en zes maanden na de behandeling
verzoeken we u terug te komen voor een beoordeling, foto’s en om een vragenlijst in te
vullen. In totaal kost het onderzoek u 40 minuten extra tijd naast de standaard behandeling. U
zult net als de standaard behandeling met minigrafting drie keer op de SNIP komen, dit
25
betekent dat u niet voor extra bezoeken naar de SNIP hoeft komen. In de onderstaande tabel
staat schematisch weergegeven voor u wat het onderzoek voor u gaat inhouden.
Inhoud
1e bezoek SNIP (week 1)
(60 minuten)
Intake
Vragenlijst invullen
Foto’s proefplek
Minigrafting (+16 extra huidstukjes)
5 dagen na 1e bezoek SNIP Thuis zelf pleisters verwijderen
Start lichtbehandeling 2x per week
2e bezoek (week 12)
(20 minuten)
Vragenlijst invullen
Foto’s proefplek
3e bezoek (week 24)
(20 minuten)
Vragenlijst invullen
Foto’s proefplek
Wat wordt verder van u verwacht?
U wordt verzocht de instructies van de behandelend dermatoloog te volgen.
Direct voor behandeling met de minigrafting dient u geen cosmetica (crèmes, parfum, make-
up, zonnebrandcrème) op de huid te gebruiken.
Verder wordt u verzocht om de behandelend dermatoloog op de hoogte te houden over
bestaande en eventueel nieuwe medicatie die tijdens de behandeling met de gebruikt worden.
Mag u weigeren om deel te nemen aan de studie?
Uw deelname in dit onderzoek is geheel vrijwillig. U kunt weigeren mee te doen en u kunt
zich te allen tijde terugtrekken uit het onderzoek zonder u daarvoor te hoeven verantwoorden.
Uw beslissing zich terug te trekken zal geen gevolgen hebben voor uw verdere medische
behandeling. U moet dit wel melden aan uw behandelend arts.
Mogelijk risico en ongemakken
Tijdens dit onderzoek zal u eenmalig 16 extra huidstukjes getransplanteerd krijgen. Ten
gevolge van de behandeling kunnen er de volgende bijwerkingen optreden: roodheid, pijn,
branderigheid van de huid. Regelmatig wordt direct na de behandeling een tijdelijke zwelling
van de huid gezien. Er is een zeer geringe kans dat er een litteken ontstaat na de behandeling.
De minigrafting behandeling is matig pijnlijk. Daarom zal de te behandelen huid met een
injectie verdoofd worden. Voorafgaand aan de behandeling mag u geen cosmetica op de huid
gebruiken (crèmes, parfum, make-up, zonnebrandcrème).
Mogelijke voordelen
Wij hopen met dit onderzoek kennis te verwerven over de beste behandeltechniek voor uw
aandoening. Tegelijkertijd kunt u hiervan voordeel hebben omdat er meer huidstukjes
getransplanteerd worden dan als u niet mee doet aan de studie. U zult geen behandeling
26
mislopen door deelname aan het onderzoek. De behandeltechniek die het meest effectief blijkt
te zijn is voor u als u dat wenst in ons instituut beschikbaar na afloop van de studie.
Vertrouwelijke behandeling van uw medische gegevens
Uw gegevens zullen vertrouwelijk worden behandeld. Hiervoor zullen de
onderzoeksgegevens onder code worden geregistreerd. Dit gebeurt onder
verantwoordelijkheid van de onderzoeksarts. De resultaten van de studie kunnen worden
gepresenteerd op bijeenkomsten en in publicaties, maar uw identiteit zal hierbij niet bekend
worden gemaakt. Uw naam zal op geen enkele wijze worden gebruikt in publicaties. Uw
deelname aan deze studie is vertrouwelijk en zal aan geen enkel niet-geautoriseerd persoon
worden meegedeeld.
Bescherming gegevens
De onderzoeksgegevens zullen worden opgeslagen in een computer bestand, met beperkte
toegang zoals bepaald in de wet. Het onderzoeksdossier zal 20 jaar na de de afloop van de
studie bewaard blijven. De resultaten van het onderzoek zullen vertrouwelijk worden
behandeld. De onderzoeksgegevens zullen alleen worden voorzien van een unieke
identificatie die niet herleidbaar is tot uw persoon, maar alleen tot gegevens als geslacht,
lengte en leeftijd. Alleen de onderzoeksartsen kunnen via de codesleutel uw identiteit
achterhalen. Ter controle van het onderzoek kan het echter noodzakelijk zijn dat aan de leden
van de Medisch Ethische Commissie of aan een vertegenwoordiger van de Inspectie voor de
Gezondheidszorg inzage wordt gegeven in uw medisch dossier. De opdrachtgever van het
onderzoek (het AMC) kan personen aanwijzen die ter controle van de studie toegang zullen
krijgen tot uw medisch dossier. Deelname aan deze studie betekent dat voor deze inzage
toestemming wordt gegeven.
Uw huisarts zal op de hoogte gesteld worden van uw deelname aan het onderzoek. Als u hier
geen toestemming voor wilt geven, kunt u niet meedoen aan de studie.
Verzekering
Overeenkomstig de Wet medisch-wetenschappelijk onderzoek met mensen heeft de AMC
Medical Research B.V. voor medisch-wetenschappelijk onderzoek een verzekering afgesloten
die door het onderzoek veroorzaakte schade door dood of letsel van de proefpersoon dekt.
* Dit betreft schade die zich tijdens of binnen vier jaar na de deelname aan onderzoek
openbaart en gemeld is binnen 4 jaar na beëindiging van de deelname aan het onderzoek.
* Het bedrag waarvoor de verzekering is afgesloten bedraagt € 450.000 per proefpersoon, met
een maximum van €3.500.000 voor het gehele onderzoek en € 5.000.000 voor schade ten
gevolge van medisch-wetenschappelijk onderzoek die per verzekeringsjaar wordt gemeld.
De verzekering biedt dekking :
* voor schade ten gevolge van de verwezenlijking van de aan deelname aan het
wetenschappelijk onderzoek verbonden risico's waarover men niet schriftelijk is ingelicht;
* voor schade ten gevolge van de verwezenlijking van de risico's waarover de deelnemer wél
is ingelicht, maar die zich in ernstiger mate voordoet dan is voorzien;
* voor schade ten gevolge van de verwezenlijking van de risico's waarover de deelnemer wél
is ingelicht, maar die zeer onwaarschijnlijk werd geacht.
27
De verzekering biedt geen dekking :
* voor schade die het gevolg is van het uitblijven van een vermindering van de
gezondheidsproblemen van de proefpersoon, dan wel het gevolg is van de verdere
verslechtering van de gezondheidsproblemen, indien de deelname aan het wetenschappelijk
onderzoek plaatsvindt in het kader van de behandeling van die gezondheidsproblemen;
* voor schade door aantasting van de gezondheid van de proefpersoon waarvan aannemelijk
is dat deze zich ook zou hebben geopenbaard wanneer de proefpersoon niet aan het onderzoek
had deelgenomen;
* voor schade ten gevolge van deelname aan medisch-wetenschappelijk onderzoek waarbij in
de kring van beroepsgenoten gebruikelijke handelingen op het gebied van de geneeskunst met
elkaar worden vergeleken en aannemelijk is dat de schade het gevolg is van de toegepaste
handelingen;
* voor schade die zich bij een nakomeling van de proefpersoon openbaart als gevolg van een
nadelige inwerking van het onderzoek op de proefpersoon of de nakomeling;
* voor schade die het gevolg is van het niet of niet volledig opvolgen van aanwijzingen en
instructies door de proefpersoon, indien de proefpersoon daartoe althans in staat is.
De verzekering dekt uitsluitend de schade van natuurlijke personen.
De dekking van specifieke schades en kosten is tot bepaalde bedragen beperkt.
Om aanspraak te kunnen maken op schadevergoeding dient de proefpersoon in geval van
vermeende schade als gevolg van het onderzoek dit te melden aan:
naam verzekeraar: Centramed B.A.
adres verzekeraar: Postbus 191, 2270 AD Voorburg.
polisnummer: 620.872.806
Voorts wordt de proefpersoon verzocht dienaangaande contact op te nemen met dr. A.
Wolkerstorfer (tel. 020-566 6955).
Wat te doen wanneer u vragen heeft?
Wanneer u vragen heeft omtrent uw deelname aan dit onderzoek of op elk willekeurig
moment tijdens het onderzoek, dient u contact op te nemen met:
Arts: dr. A. Wolkerstorfer, (tel: 020 566 3623)
Of onafhankelijk arts (niet verbonden aan het onderzoek): drs. L. Nieuweboer Krobotova
(tel: 020 5666955)
De onafhankelijke arts kunt u ook benaderen met vragen of voor advies over deelname aan de
studie.
28
Appendix 2. Informed consent form
Toestemmingsverklaring
Studie Titel: Minigrafting technieken bij vitiligo Ik heb de schriftelijke informatie over dit onderzoek gelezen en de gelegenheid gehad vragen te stellen. Ik heb gelegenheid gehad om een en ander te overdenken. De aard en het doel van het onderzoek zijn mij voldoende duidelijk. Ik begrijp dat bij de minigrafting de kans bestaat, hetzij gering, op littekens. Ik begrijp dat deelname aan het onderzoek vrijwillig is en dat ik mij op elk moment en zonder opgave van redenen uit het onderzoek kan terugtrekken. Dit zal geen invloed hebben op de voor mijn ziekte gebruikelijke behandeling en zorg van mijn behandelende artsen. Ik weet dat voor dit onderzoek relevante medische gegevens over mij gebruikt zullen worden voor wetenschappelijk onderzoek en eventueel gepubliceerd zullen worden. Hiermee stem ik in mits mijn privacy gewaarborgd wordt. Ik geef goedkeuring dat mijn huisarts op de hoogte gesteld wordt van mijn deelname aan dit onderzoek. Ik ben ingelicht over de meest voorkomende risico’s en de consequenties van behandeling met minigrafting. Met in achtneming van deze informatie kies ik ervoor de behandeling met de minigrafting te ondergaan. Ik geef hierbij vrijwillig toestemming om deel te nemen aan dit onderzoek. …………………………….. (Naam patiënt) ………….. ………. ………………………. (Plaats) (Datum) (Handtekening patiënt) VERKLARING ARTS Ik heb mondelinge en schriftelijke toelichting verstrekt over het onderzoek. Naar mijn mening heeft de patiënt mijn uitleg begrepen. ………….. ………. ………………………………. (Plaats) (Datum) (Handtekening arts)
29
Appendix 3. Letter to the general practitioner
Huisartsenbrief
Geachte collega,
Graag stel ik u op de hoogte van het feit dat bovengenoemde patiënt(e) zal deelnemen aan het
onderzoek naar de effectiviteit van de behandeling met minigrafting bij vitiligo of
piebaldisme. Deze studie is goedgekeurd door de METC van het AMC. Patiënt(e) is conform
informed consent geïncludeerd in de studie.
Achtergrond van de studie:
Vitiligo en piebaldisme zijn onschuldige huidaandoeningen waarbij spierwitte plekken
ontstaan of vanaf de geboorte aanwezig zijn. Het kan zeer ontsierend zijn waardoor het
cosmetisch storend is voor veel patiënten. Wanneer de witte plekken niet meer uitbreiden en
dus stabiel zijn is minigrafting een van de behandelingen voor vitiligo en piebaldisme.
Minigrafting is een huidtransplantatie waarbij kleine stukjes normaal gepigmenteerde huid in
de witte plekken worden geplaatst. Om deze behandeling optimaal te laten zijn is onderzoek
nodig naar verschillende technieken van deze huidtransplantatie. In de SNIP roepen wij
patiënten met stabiele vitiligo of piebaldisme op om mee te werken aan het onderzoek met
minigrafting. Momenteel wordt de transplantatie met oppervlakkig afgenomen huidbiopten
uitgevoerd. We willen onderzoeken of het gebruik van diepere huidbiopten zorgt voor een
beter resultaat. Daarnaast willen we onderzoeken of de grootte van de oppervlakte van de
huidbiopten invloed heeft op het resultaat van de minigrafting.
Vertrouwende u hiermede voldoende te hebben geïnformeerd,
met collegiale hoogachting, mede namens,
Drs. C.Vrijman, Dr. J.P.W van der Veen,
arts-onderzoeker SNIP dermatoloog/directeur SNIP
30
Appendix 4. Questionnaire form 3 months after grafting
Score formulier 3 maanden na punch grafting
Patient code: Datum afname:
Afgenomen door:
Number of grafts with repigmentation
Lokatie Number of grafts
A
B
C
D
Objective assessment of the repigmentation
(Diameter horizontaal en vertikaal in mm gemeten met dermatoscoop)
A 1 A 2
A 3 A 4
B 1 B 2
B 3 B 4
31
C 1 C 2
C 3 C 4
D 1 D 2
D 3 D 4
Visual assessment of side effects acceptor site A :
Geen licht matig ernstig
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
cobble stone effect 0 1 2 3
Visual assessment of side effects acceptor site B :
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
cobble stone effect 0 1 2 3
Visual assessment of side effects acceptor site C :
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
32
cobble stone effect 0 1 2 3
Visual assessment of side effects acceptor site D :
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
cobble stone effect 0 1 2 3
Visual assessment of side effects donor site A :
Geen licht matig ernstig
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
Erytheem 0 1 2 3
Reliëf 0 1 2 3
Visual assessment of side effects donor site B:
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
Erytheem 0 1 2 3
Reliëf 0 1 2 3
Visual assessment of side effects donor site C:
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
Erytheem 0 1 2 3
Reliëf 0 1 2 3
Visual assessment of side effects donor site D :
hyperpigmentation 0 1 2 3
hypopigmentation 0 1 2 3
scar 0 1 2 3
Erytheem 0 1 2 3
Reliëf 0 1 2 3
Time to heal after grafting:
Donor site:
o A:___________________________
o B:___________________________
33
o C:___________________________
o D:___________________________
Acceptor site:
o A:___________________________
o B:___________________________
o C:___________________________
o D:___________________________
General outcome assessed by patient
Beoordeling van de patiënt (gevraagd aan de patiënt)
Donor site
A: zeer slecht slecht neutraal goed zeer goed
B: zeer slecht slecht neutraal goed zeer goed
C: zeer slecht slecht neutraal goed zeer goed
D: zeer slecht slecht neutraal goed zeer goed
Acceptor site
A: zeer slecht slecht neutraal goed zeer goed
B: zeer slecht slecht neutraal goed zeer goed
C: zeer slecht slecht neutraal goed zeer goed
D: zeer slecht slecht neutraal goed zeer goed
Foto’s (met en zonder strijklicht) □
Licht therapie type
UVA / UVB
Merk:
Lampen:
Watt:
34
Appendix 5. Word of thanks
Vanaf juli tot december heb ik mijn stage wetenschap gelopen in de SNIP (stichting
Nederlands instituut pigmentstoornissen). Bij deze zou ik graag alle medewerkers van de
SNIP willen bedanken voor hun betrokkenheid en hulp bij mijn onderzoek. Door het
uitvoeren van deze studie heb ik ontdekt dat het erg leuk en leerzaam is om onderzoek te
doen. Daarom heb ik de kans om te gaan promoveren bij het SNIP met beide handen
aangegrepen. Tijdens mijn stage was ik bij alle facetten van het onderzoek betrokken, van de
aanvraag bij de METC en het includeren van patienten tot het verwerken en analyseren van de
resultaten. Daarnaast heb ik de procedures van het graften mede uit kunnen voeren. Ik wil met
name Charlotte Vrijman en Albert Wolkerstorfer bedanken voor hun begeleiding en dat zij
mij overal bij betrokken hebben tijdens het onderzoek. Ik kijk dan ook erg uit naar onze
toekomstige samenwerking bij de SNIP.