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Patient selection
Patient selection
Vitiligo surgery is typically considered after patients have failed conservative measures such as medical and light-based therapy. History and physical examination are used to determine a patientโs vitiligo subtype. Vitiligo patterns are classified as segmental and nonsegmental, with generalized vitiligo being the most common variant of nonsegmental vitiligo. Segmental vitiligo is typically unilateral, in a localized region, and is considered stable, whereas generalized vitiligo is bilateral, symmetric, and follows a relapsing and remitting course.1 Patients with focal or segmental vitiligo have an excellent response to surgery, which is considered a first-line treatment option in this patients.2 In contrast, patients with generalized vitiligo and other subtypes have a less favorable response to surgical intervention, though surgery remains an option in the setting of stable disease and a history of failed response to medical therapy.
Prior to attempting surgery, disease stability must be evaluated. The main criterion marking stable disease is the lack of new or enlarging lesions for a minimum of 6
months and up to 2 years. Koebnerization is a marker of unstable disease. Several methods are available to assess disease stability, including patient report, serial photography, and validated scoring systems. These include the Vitiligo Area Scoring Index (VASI), Vitiligo European Task Force Assessment (VETF), and Vitiligo Disease Activity Score (VIDA), the latter of which is appropriate in patients who have discontinued vitiligo treatment for at least 6 months.3
In patients with unclear disease stability, a single punch graft (typically 1โ1.5 mm) can be performed in the center of a stable, depigmented lesion as a test spot to assess repigmentation, responsiveness to treatment, and healing tendency.4 A test is considered positive when repigmentation occurs beyond 1 mm and up to 2 to 3 mm from the minigraft border; a test is considered negative when less than 1 mm or no repigmentation occurs.4
Emerging methods to evaluate disease stability include reflectance confocal microscopy,5 total antioxidant status,6 antimelanocyte antibody levels, and measurement of serum catecholamines and their metabolites.7 Similarly, cellular markers such as IL- 17,8 CXCL 9 and 10,9 and microRNA10 may also play a role in evaluating stability.
Lesion location also plays a role in determining likely response to vitiligo surgery. Areas with a greater vascular supply and follicular density, such as the face and neck, have better repigmentation rates compared to the extremities.11โ13 The acrofacial variant of vitiligo, characterized by perioral and/or distal fingertip involvement around the nailbeds, responds poorly to surgery. Areas over joints also respond poorly, likely secondary to increased susceptibility to repeated friction and injury.12 Patients with a strong tendency toward keloid formation, significant bleeding diatheses, or other relative contraindications to surgery should probably not undergo vitiligo surgery.