Treatment of perioral vitiligo with a combination of upper hair follicle transplantation and the application of a 308 nm excimer laser

Dear Editors,

While melanocyte or epidermal transplantation can be employed to treat stable vitiligo, the efficacy of this approach is limited for sites surrounding the mouth. Hair follicle transplantation is another effective approach. However, the hair growth in the transplanted areas may cause aesthetic concerns ¹ . In this report, we describe the case of a patient with perioral vitiligo who was successfully treated with upper hair follicle transplantation in combination with the application of a 308 nm excimer laser.

In January 2022, a 17‐year‐old male patient with a striped vitiliginous lesion on the left upper lip and left corner of the mouth presented to our clinic. Melanocyte transplantation had been performed 6 months previously, but the repigmentation effect was poor (Figure 1A). Hair follicles from the left retroauricular hairline were selected as grafts (Figure 2A), after which a 0.6 mm trephine was used to drill holes in the donor site to ensure that the upper portion of the follicle was separated from the surrounding tissue without detaching the follicle root. Hair follicles were cut at the middle part of the isthmus and the upper portion was harvested (Figure 3), with an equal number of intact hair follicles being extracted (Figure 2B). The recipient site was divided into three similarly sized regions (Figure 2C). Punches were generated individually in these three regions separated by 0.3 cm. Upper hair follicles were inserted into region A, while intact hair follicles were inserted into region B, and region C remained unprocessed (Figure 2D). The recipient sites were then exposed to a 308 nm excimer laser once per week for 6 months. At 6 months post‐surgery, the vitiliginous lesions in regions A and B both exhibited repigmentation, with hair growth being evident in region B but not region A. No significant improvement was observed in region C (Figure 1B). Upper hair follicle transplantation combined with 308 nm excimer laser treatment was then performed for region C, which exhibited repigmentation after 6 months (Figure 1C).

FIGURE 1.

Clinical improvement in perioral vitiligo with upper hair follicle transplantation in combination with the application of a 308 nm excimer laser. (A) Before treatment, a striped vitiliginous lesion on the left upper lip and left corner of the mouth (about 4.0 × 0.3 cm). (B) At 6 months post‐surgery, the vitiliginous lesions in regions A and B exhibited repigmentation, with hair growth being evident in region B but not region A. No significant improvement was observed in region C. (C) After another 6 months, all of the vitiliginous lesions exhibited repigmentation.

FIGURE 2.

Surgical procedure of upper hair follicle transplantation. (A) Hair follicles from the left retroauricular hairline were selected as grafts. (B) Upper hair follicles and intact hair follicles were harvested. (C) The recipient site was divided into three regions designated A, B, and C. (d) Punches were generated individually in these three regions separated by 0.3 cm. Upper hair follicles were inserted into region A, while intact hair follicles were inserted into region B, and region C remained unprocessed.

FIGURE 3.

Hair follicles were cut at the middle part of the isthmus.

Hair follicle transplantation provides an opportunity to transplant follicles containing inactive melanin precursor cells into target vitiliginous lesions. These precursor cells can be activated and differentiate to active melanocytes that produce melanin conducive to skin repigmentation. ² However, this approach can lead to hair growth in the transplanted area. ³ Hair follicle‐associated pluripotent stem cells located in the bulge of the upper hair follicles are capable of differentiating into various cell types, including melanocytes, ⁴ while the melanin precursor cells found in the outer root sheath of anagen scalp hair follicles can be employed for the treatment of depigmented skin. ⁵ Here, pronounced repigmentation was observed in the regions transplanted with upper hair follicles without a hairy appearance.

The melanin precursor cells can undergo rapid differentiation to active melanocytes following exposure to a 308 nm excimer laser, whereupon these cells migrate into the epidermis and produce melanin, leading to repigmentation. This combined treatment strategy may represent an effective means of treating non‐hairy vitiliginous lesions that are insensitive to epidermal or melanocyte transplantation.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.