Minimally Invasive Removal of Leukotrichia and Hair Transplantation: A 2-Step Surgery in the Treatment of Stable Follicular Vitiligo

Abstract

Background:

Follicular vitiligo is a distinct subtype of vitiligo characterized by the selective destruction of the follicular melanocytic reservoir. Treatment of follicular vitiligo–associated leukotrichia has always been a clinical challenge.

Methods:

Twenty participants (mean age, 29 years) with stable follicular vitiligo were recruited between 2020 and 2021 for 2-stage surgery. In stage 1, an incision around the vitiligo lesion was performed to subcutaneously dissect and scrape the leukotrichia. In stage 2, healthy follicles obtained from the occipital donor site were transplanted into the vitiligo area. Follow-up examinations were conducted for 1 year postoperatively using a camera and dermatoscope to observe the growth rate, color, and surviving number of the transplanted hairs. Patient satisfaction was recorded to evaluate the potential surgical improvement.

Results:

The transplanted hair grew with natural texture, as expected. The average survival rate of the transplanted hair follicles was 93.8%. No recurrence of leukotrichia was observed in the recipient area. No complications were observed, and the postoperative scars in the recipient area were entirely covered by black hair. All patients were satisfied with their resulting appearance.

Conclusion:

Minimally invasive removal of leukotrichia combined with hair transplantation might be an appropriate surgical option for stable follicular vitiligo to create natural and stable pigmented hair.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.

Vitiligo is an autoimmune acquired skin hypopigmentation disease that progressively destroys skin melanocytes.^1,2 As a new subtype of vitiligo, follicular vitiligo is caused by the selective destruction of follicular melanocytes, resulting in melanin deficiency in the hair stem (leukotrichia) at the susceptible site, while hair follicle growth proceeds.^3–6 Just as with vitiligo, if the loss of pigmentation in the affected area does not progress for at least 1 year, it can be diagnosed as stable follicular vitiligo.^7–9 The active and inactive follicular melanocytes in stable follicular vitiligo no longer exist, replaced by well-defined skin depigmentation blocks.^10–12 Leukotrichia causes a cosmetically disfiguring appearance in individuals, bringing about chronic and even serious psychological burdens, including depression, anxiety, and agrypnia.^13,14 At present, the mainstream treatment for vitiligo is medication, such as glucocorticoids and immunomodulators.^15,16 However, the efficacy of topical drug-based or current conservative therapeutics is not satisfying with follicular vitiligo, and the treatment is accompanied by long-term adverse reactions.¹⁷ It was announced recently that hair follicle transplantation plays a part in stable vitiligo. Follicular unit transplantation (FUT) has the limitation of being a tedious, time-consuming procedure with a potential shortage of donor follicular units and inability to treat medium-sized or large achromic lesions.^18,19 Follicular unit extraction (FUE) alone may provide the vitiligo patch with pigmentation.²⁰ However, the poor aesthetic appeal caused by leukotrichia will remain unresolved. The classic surgery for axillary osmidrosis could dislodge the hair follicles and accessory glands, generating an aesthetically and functionally pleasing result with fewer complications and minimal axillary scarring.²¹ We performed a combination of surgical procedures in patients with stable follicular vitiligo, and obtained an overall good cosmetic outcome. To our knowledge, no study of the combined surgery has been reported as the therapy for stable follicular vitiligo.

PATIENTS AND METHODS

Patient Selection

This study was designed as an observational and retrospective study in accordance with the code of ethics of the Declaration of Helsinki. The recruitment was conducted from 2020 to 2021 in the Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, and was approved by the hospital’s ethics committee. Twenty patients who were diagnosed by the clinical physicians as having stable vitiligo (no progression of existing lesions and no new lesions for at least 1 year) were included. Exclusion criteria included age younger than 18 years or older than 60 years, a tendency toward keloid formation, a history of photosensitivity or malignant proliferative skin diseases, poor surgical tolerance, pregnancy, lactation, and major complications such as hepatitis and HIV infection. Written informed consent was obtained from all participants before enrollment. The privacy rights of the patients were well protected.

First-Stage Surgery

The first stage consists of a minimally invasive procedure for axillary osmidrosis.²¹ Hairs of the vitiligo lesion are shaved to 2 to 4 mm. After the area is disinfected with chlorhexidine lotion, a tumescent fluid containing 0.2% lidocaine and 1:100,000 epinephrine is injected into the subcutaneous layer of the operating field, with or without 2% lidocaine for the local anesthetic. A 1- to 3-cm incision is made around or in the center of the vitiligo lesion with a no. 11 scalpel. The length of the incision should not exceed half of the diameter of the lesion, and the depth of the incision should reach the subcutaneous layer. Separation, both blunt and sharp, of the subcutaneous tissue of the scalp is performed about 1 cm beyond the range of the leukotrichia, and the residual tissue attaching to the dermis is resected using ophthalmic scissors. A 497-mm fenestrated cup curette is then used to scrape back and forth along the undermined flap for subcutaneous trimming, until the white hairs are easily pulled out. After sufficient hemostasis and washing, the incision is sutured and bandaged with moderate pressure. The wound is rinsed with an iodine-containing disinfectant for 3 days after the surgery, and sutures are removed 7 to 9 days after the operation. Hair transplantation is performed in the vitiligo area when the incision has healed, 1 to 3 months later (Fig. 1).

Fig. 1.

General schematic diagram of the 2-step surgical procedure.

Second-Stage Surgery

Hair transplantation is performed using the FUE technique.²² Before being disinfected with chlorhexidine lotion, the hairs of the occipital donor site are shaved to a length of 1 mm. Anesthesia is administered in both the donor and recipient sites via a tumescent fluid containing 0.2% lidocaine with 1:100,000 epinephrine. The hair grafts are obtained using a 1-mm hollow punch. The grafts are transferred by microforceps to iced Ringer solution (compound sodium chloride injection). The recipient sites are drilled with a 1.2-mm needle and implanted with grafts at a presupposed density of 35 to 45 follicular units/cm². Based on the orientation of the residual hairs, the drilling direction, angle, and depth are adjusted properly. The recipient sites are covered with a topical antibiotic cream for 2 to 3 days, and the sterile gauze dressing is removed on postoperative day 3. The patients are advised not to wash the transplanted hair until 5 days after the procedure (Fig. 1).

Assessment of Curative Effect

Data on complications, patient satisfaction, and amounts and pigmentation of transplanted hair were obtained at the follow-up examinations, using photography (Canon EOS 850D) and a dermatoscope (Medical Electronic Dermatoscope Imaging System, CH-DSIS-2000; Chuanghong Medical Technology Co., LTD, Guangzhou, China), at 12 months after the transplantation (Table 1). Patient satisfaction was documented on a questionnaire based on the original FACE-Q and a visual analogue scale ranging from high dissatisfaction to high satisfaction with the outcome²³ (Table 2).

Table 1.

Patient Demographic and Clinical Characteristics^a

Patient	Sex	Age (yr)	Affected Site	Area Transplanted (cm2)	Survival Rate at Postoperative Month 12 (%)	Family History	Reappearance of Leukotrichia
1	Male	23	Right forehead	6	92.3 (180/195)	Yes	No
2	Female	24	Median forehead	4.5	95.8 (161/168)	Yes	No
3	Female	26	Right temple	3	97 (131/135)	No	No
4	Male	32	Left forehead	8	93 (279/300)	Yes	No
5	Female	36	Median forehead	12	91.9 (386/420)	Yes	No
6	Male	19	Median forehead	5	95.7 (181/189)	No	No
7	Female	20	Left vertex	6.2	92.1 (177/192)	No	No
8	Male	22	Median forehead	4	94.1 (127/135)	No	No
9	Male	26	Right temple	6.6	93.6 (206/220)	No	No
10	Female	40	Right forehead	5	94.8 (182/192)	Yes	No
11	Male	38	Right vertex	6	92.5 (183/198)	Yes	No
12	Female	34	Left forehead	4.2	91.4 (171/187)	No	No
13	Female	26	Left forehead	13.5	91.1 (467/513)	No	No
14	Male	29	Median forehead	10	90.3 (325/360)	No	No
15	Female	33	Right forehead	2	97.5 (78/80)	Yes	No
16	Male	35	Median vertex	4.5	93.3 (168/180)	Yes	No
17	Female	33	Median forehead	3	98.2 (121/123)	No	No
18	Female	23	Right temple	5.4	92.2 (224/243)	Yes	No
19	Female	25	Left vertex	4	95 (152/200)	No	No
20	Female	27	Median forehead	12	93.8 (347/370)	No	No
21	Male	40	Median vertex	12	94.3 (396/420)	No	Yes
22	Male	42	Left forehead	6	91.7 (176/192)	Yes	Yes
23	Male	44	Median forehead	7.7	92.1 (258/280)	Yes	Yes
24	Female	39	Median vertex	9.3	92.4 (176/357)	No	Yes
25	Male	42	Median forehead	6.6	93.3 (196/210)	Yes	Yes
Mean ± SD		31 ± 7.5			93.6 ±2.01

^aThe follow-up period for all patients was 12 months.

Table 2.

Modified FACE-Q Questionnaire for the Outcome Satisfaction Evaluation

	Answers (Score Based on VAS)
Patient questionnaire
Satisfaction with appearance (natural, covers the scar)	0 (very dissatisfied) to 10 (very satisfied)
Satisfaction with density	0 (very dissatisfied) to 10 (very satisfied)
Satisfaction with shape	0 (very dissatisfied) to 10 (very satisfied)
Satisfaction with symmetry	0 (very dissatisfied) to 10 (very satisfied)
Satisfaction with decision	0 (very dissatisfied) to 10 (very satisfied)
Social function	0 (very dissatisfied) to 10 (very satisfied)
Psychological well-being	0 (very dissatisfied) to 10 (very satisfied)
Early life impact	0 (very dissatisfied) to 10 (very satisfied)
Observer assessments
Satisfaction with all the appearance (overall evaluation based on preoperative and 6-mo postoperative photographs)
Observer 1	0 (very dissatisfied) to 10 (very satisfied)
Observer 2	0 (very dissatisfied) to 10 (very satisfied)
Observer 3	0 (very dissatisfied) to 10 (very satisfied)

VAS, visual analogue scale.

Statistical Analysis

The grafting hairs were transplanted at an average diameter of 75 μm and a density of 35 to 45 follicular units/cm². Quantifiable data were analyzed using a statistical computer package (SPSS version 22.0; IBM Corp, Armonk, NY) and expressed as the mean ± SD. Enumerate data were expressed as a rate.

RESULT

Subject Characteristics

Twenty patients (12 women and 8 men) with stable follicular vitiligo underwent 2-stage surgery. Their mean age was 29 ± 6.2 years (range, 19 to 40 years). Their demographic characteristics are given in Table 1.

Efficacy

With the day of the second-stage surgery as the baseline, the reappearance of leukotrichia at 12 months was compared with the preoperative value. The color of the transplanted hairs in all lesions stayed black, with no change over the course of the treatment. The average survival rate of the transplanted hair follicles was 93.8%. At the end of month 12, no reappearance of leukotrichia was observed. The postoperative scar in the recipient area was entirely covered by black hair (Figs. 2 through 4).

Fig. 2.

Clinical images of patient 1, a 35-year-old woman. (Above, left) Follicular vitiligo lesion on the forehead showing leukotrichia and hypopigmentation before treatment. (Above, right) Hair follicle transplantation immediately after stage 2 surgery. (Below) Result at 1 year after the stage 2 surgery.

Fig. 4.

Clinical images of patient 2, a 38-year-old man. (Left) Well-defined leukotrichia with hypopigmentation covering the vertex areas before treatment. (Right) Repigmentation of the hair on the vertex lesion 3 months after the combined surgery.

Fig. 3.

Clinical dermoscopic images of patient 1, a 35-year-old woman. (Left) Lesion before the surgery. (Right) Lesion at 1 year after the stage 2 surgery.

Safety and Satisfaction

No complications, such as swelling, erythema, or infection, were observed after the 2-step surgery. All patients were satisfied with their surgical experience and their cosmetic results at 12 months after the surgery (Table 3).

Table 3.

Patient Standard Operating Procedure Measurement

Measurements	Value (N = 20)
Survival rate (%)	93.8 ± 2.2
Patient satisfaction, no. of patients
Very satisfied	16
Satisfied	4
Neither satisfied nor dissatisfied	0
Dissatisfied	0
Very dissatisfied	0
Complications
Hematoma	0
Infection	0
Hemorrhage	0
Folliculitis	0
Erythema	0
Koebner phenomenon	0

DISCUSSION

Vitiligo is classified as a complex disease associated with genetic and environmental factors, such as oxidative stress and cell abnormalities.² Vitiligo is the most frequent cause of depigmentation worldwide, with an estimated prevalence of 1%.⁸ Follicular vitiligo is a subtype of vitiligo that is characterized clinically by white patches resulting from the selective loss of melanocytes.^3,5,6,24 Leukotrichia of follicular vitiligo is derived from the extinction of the melanocyte reservoir.²⁵ The follicular melanocytes in the follicular vitiligo lesion are easily attacked by specific antigens, which is unusual compared with the priority invasion of epidermal melanocytes in common vitiligo.^19,26–28 Stable vitiligo is a phase of vitiligo defined as no progression of old lesions and no new lesions in 1 year.⁹ In stable follicular vitiligo, the progression of leukotrichia basically ceases, while active and inactive melanocytes vanish.²⁴ For the time being, the melanocytes in the lesions are overwhelmingly destroyed, which may induce resistance to medical treatments and phototherapy.²⁵ Nevertheless, the emergence of black hairs within the vitiliginous lesion is a good prognostic sign.¹² Therefore, surgical treatment in the stable stage of follicular vitiligo may be the most appropriate choice,²⁹ as normal and healthy hairs are needed for transplantation to previously vitiliginous lesions to resemble the unaffected area, which is of great significance in inducing repigmentation.²⁷ The surgical solutions reported for repigmenting the stable vitiligo lesion are tissue grafting^30,31 and cellular grafting.³² For tissue grafting, although electrolysis is considered to be a permanent hair removal surgery, it requires that hairs be removed individually. Consequently, it is inefficient, difficult, and tedious. Possible complications of electrolysis include perifollicular inflammation, permanent cutaneous burning, and scarring, which can hinder hair transplantation. In addition, some patients report discomfort and pain, while approximately 20% to 40% of the treated leukotrichia will regrow.³⁰ Fongers et al.³³ demonstrated that stimulation of the inactive melanocytes occurred in the outer sheath of hair follicles increased the repigmentation of vitiligo by FUT. Meanwhile, some active melanocytes appeared in the outer root sheaths, hair follicle orifices, and around the perifollicular epidermis. Mapar et al.⁷ proposed that, compared with FUT, the mini-punch graft might achieve better repigmentation in patients with drug-resistant vitiligo. Complications, such as Koebner phenomenon or a cobblestone-like appearance, were prevented by using a smaller drill size and selecting patients with stable vitiligo.³³ The postoperative cicatrix is so tiny that it can be covered completely by growing hair, thus providing a more natural appearance, while the reason why the depigmented macules still exist after surgery remains ambiguous. We have used FUE autologous hair transplantation to treat cicatricial alopecia and androgen alopecia, with a considerable graft survival rate.³⁴ Compared with FUT, FUE has the advantages of a simpler process, less trauma, a lower incidence of postoperative complications, and less conspicuous postoperative scars .³⁵ In addition, FUE is considered a safe and affordable method of surgical repigmentation when dealing with vitiligo, and FUE has the advantage of a high survival rate for grafted hairs.²⁹ Using cellular grafting, Pangti et al.²⁰ reported 1 case in which a dermabraded vitiligo lesion coated with noncultured epidermal cell suspension was partially repigmented. Nevertheless, hair color in the vitiligo lesion remained white, giving the appearance of ragged pigmentation.³⁶ Whether combining multiple kinds of active hair follicle cells with FUE followed by transplantation could be a treatment for follicular vitiligo requires further study. In contrast to the other surgical treatments for follicular vitiligo, microscopic removal of leukotrichia retains the local blood supply of the recipient area, which is necessary for survival of the grafts. Meanwhile, subcutaneously dislodging all the leukotrichia avoids the drilling and harvesting process, which is vital but was ignored by the previous study. In our study, the leukotrichia was removed as much as possible during the stage 1 surgery. After the wound healed well, the surrounding tissue provided a stable perifollicular environment. During the stage 2 operation, normal hairs were supplemented to fill the vacancy. Either the removal of leukotrichia or the hair repigmentation of vitiligo patches causes a better normal appearance. All patients demonstrated positive responses and obtained an overall good cosmetic effect, and the treatment was well tolerated. Limitations of our research include the small sample size, the short amount of time evaluated, and the lack of a control group. Nevertheless, the 2-stage combination surgery can be considered as a treatment for stable follicular vitiligo.

DISCLOSURE

The authors have no conflicts of interest to disclose.

ACKNOWLEDGMENTS

This work was funded by the Guangdong Province Medical Research Foundation (no. C2019112) and the Natural Science Foundation of Guangdong Province (nos. 2019A1515012170, 2020A1515110037, and 2021A1515012150).