Physicians point of view on the use of micropigmentation- mechanism behind frequent phenomenon- Available treatment options for vitiligo
So with the treatment, they can start to generate pigments, and these pigments are going to appear on the skin. But if you don't have this reservoir, we call it a reservoir of melanocytes, if this reservoir is absent, which means that you see white hair in the middle, then possibly clinically, this little ligo is not going to respond to the medical treatment or ultraviolet treatment. So that's a clinical sign.
Now, the second component to your question, like when can the patient get surgery like MKTP or medical tattooing? We, as for surgery, and I know for sure that for medical tattooing, you also guys have your guidelines, but for surgery specifically, we request that the patient be stable for at least one year before proceeding to surgery. And the reason why is there is something called Kebner phenomenon. So what's Kebner phenomenon? Kebner phenomenon means that if you get any trauma on the skin, if the patient is exposed to any trauma of the skin, what happens is on this particular area where you get the trauma, the skin is going to produce the exact same pathology that the patient already has on other body sites, like vitiligo.
So let's say you have an active vitiligo and then you do tattooing or surgery. Let's say the vitiligo is on the face and it's active, right? And then you do tattooing on the neck. On the tattoo area, the patient is going to develop vitiligo.
This is called Kebner phenomenon, and it happens when the vitiligo is still active. So it's going to be a waste of your time, of the patient's money and time, and then the vitiligo is going to get worse. It's going to occur in a new area where he had the tattoo.
And that's why stability is one of the key components for vitiligo before it can be treated. Because medical tattooing is a procedure, right? It's considered surgery, too, because you're introducing needles inside the skin. So that's almost the same as a surgical procedure.
And actually, when we divide the treatment modality for tattooing, I mean for vitiligo, the three components is either tissue grafting, cellular grafting, and the third modality is tattooing. So that's considered a surgical modality for treatment of vitiligo, too. And so the rules that apply to surgery should apply also to medical tattooing as well.
Okay. So another question for you, Dr. Mahmoud, is that you had mentioned that the vitiligo has to be stable for a year. So just for the education purpose for my audience, stable means that vitiligo hasn't been spreading for a year, right? Okay.
So by definition, the stability of vitiligo means that the patient does not develop any new lesions of vitiligo in any other body sites or enlarging a pre-existing vitiligo area. So let's say the patient already has a patch on his cheek, right cheek for us, right? Yes. And this patch becomes bigger.
That's activity. Although it's the same patch, it's the same area, right? Right. But it becomes bigger.
That means that the vitiligo is still active. Still active. Or if he develops another patch in a different area or next to it, again, that's instability.
And that's why one of the things that we always advise patients, and we do it as physicians, is whenever the patient comes in, we always take photos. Because if you see the patient after six months, they may not remember. Like they will say, oh, I had this patch.
I'm not sure if it's growing or not. I'm not sure if I had one next to it. So we always take photos of the patient of all the areas of vitiligo.
And we do it with the regular light and with woods light. Because sometimes if the patient has fair skin, like very fair skin, the contrast between the vitiligo and his skin may not be very obvious. So what we do, we use what we call woods light.
It's like a black light. And this, like you know the light that they use in nightclubs? Yeah. Exactly.
So this light can actually make the contrast between the vitiligo skin and normal skin more obvious. And then we take pictures with that as well. And then when we see the patient for the next visit, we can compare between the two pictures.
And then we can say for sure if this patient is stable or not. I just finished one study with a new device on vitiligo. And one of the key features of this study is to make sure that the patient is stable.
And the way to do it is looking at the medical record of the patient and looking at pictures and comparing them now and before to make sure that he's actually stable and not just subjectively stable. Because some patients, they come and they want to get the procedure done. So when you ask them, and they know that they need to be stable.
So when you ask them and you say, is the device stable? Because they want to get the procedure done. So they wish it's stable. So they just say.
But when you compare the photos, it's not. And if you do the procedure, again, you're going to actually harm the patient more than you're going to benefit the patient. Got you.
So I was kind of running in my mind. So in my studio when vitiligo clients come, I refer them back to their dermatologist to make sure that doctors can determine that if they are eligible to come and get the camouflage tattooing done. If the clients, and just to kind of summarize treatment plan for camouflage tattoo artists who are in life today, so they can kind of have a plan set for the future clients.
If there's a new client coming, you're recommending to send them to do other treatments first. And then when the vitiligos are stable, at least for a year, then they can come and do the camouflage tattoo. And then in this process, their dermatologist can decide if it hasn't been spreading, it's been stable.
Correct? Correct. So it's more like a consult. So you send the patient, they have a consult with the dermatologist.
They discuss all previous treatment and all ongoing treatment. They assess how the vitiligo is progressing or not. And also we have to take into consideration that vitiligo can be associated with other diseases too.
And the patient needs to understand that. So because vitiligo is an autoimmune disease, some of the associated diseases that can happen with vitiligo is diabetes mellitus, autoimmune thyroid disease. So there are alopecia areata, which is loss of hair.
So we have to take all that into consideration. So the medical consult is important first to rule out any, because sometimes we order some thyroid tests, for instance. So it's very important to know what the extent of the disease is.
If there is any other medical association with the disease, make sure that the patient is active or not, that he tried other treatment. Because if the patient is active, if you actually treat the patient very early with medication that suppress the immune system, you can clear the patient completely. But if the patient waits until it becomes stable and was not treated at the beginning, then it's very hard to treat at that time.
And then you have to do surgery or medical support. I understand. Another question from some patients I have is about the sun exposure on vitiligo spots.
What does it happen when vitiligo patients are exposed to the sun? So there are two components to that. So there is the component that you have loss of pigment. And the reason why people have pigment is to protect them from sunburn.
That's the main thing. The pigment of the skin acts as a sunblock. Correct? Yes.
So someone who has done, and we divide in dermatology, we divide patient into skin types. So skin type one to six. So one is the very first, doesn't burn.
And then six, I mean, burn easily. And then six is the one that doesn't burn at all. Right? Like very hard skin.
So if someone has vitiligo, it's considered type one, even if his type six. Because the vitiligo patch is a milky white patch. Right? So if he's exposed to the sun, he can easily burn because he doesn't have any protection.
So people with vitiligo, we always advise them to use sunblock and protect the vitiligo area from the sun. Now, there is another component to the question is skin cancer. Because, I mean, people know that people who have fair skin are more liable to develop skin cancer.
Yeah. But in vitiligo, on the other hand, there is some kind of immune system for vitiligo patients that protect them from skin cancer. So actually, skin cancer, melanoma and non-melanoma skin cancer in vitiligo areas are less common than in normal skin.
Oh, wow. But, yep. It's amazing.
But they can sunburn. So they have to be careful with the sunburn, especially if it's on the face. It becomes really red.
And going back, remember when we talked about Kepner phenomena, which when you have a physical trauma, actually a trauma like sunburn can induce vitiligo. So this is one of the Kepner phenomena, too. If a patient has active vitiligo, right, and then he goes in the sun and then he gets a sunburn, an area that's normal may develop vitiligo because of the sunburn.
Because it's considered as a trauma to the skin. Because trauma can be anything. It can be like a physical trauma, a direct trauma from a knife, a trauma from a chemical burn, any of that.
Like even if he has like a burn in the kitchen, like the patient is cooking, right, and then he has a burn in the kitchen. This is considered a trauma. And then he can get the—she or he can develop vitiligo over the sun.
So sun exposure specifically can cause death in patients with active vitiligo, too. Got it. Oh, wow, so many amazing information and education you are giving us today.
Thank you so much. Thank you. Some of the answers that hasn't been a little bit unclear for me was definitely answered from this question.
Thank you. So we briefly discussed about available treatment for vitiligo patients. So I am aware that you are a specialist, one of the few specialists in MKTP surgery.
Could you tell us a little bit about what it is? So MKTP stands for melanocyte keratinocyte transplantation procedure. So melanocytes and keratinocytes are the cells that are in the epidermis. Because the skin is formed of epidermis, dermis, and then subcutaneous fat or tissue, right? So the epidermis is the layer that has all the cells that produce the pigment, which are the melanocyte and the keratinocyte, which is just next to it, right? So this is an advanced surgical technique.
It's present in very few centers in the United States. And the idea, it's a cell transplant, which means that we transplant cells and not actual tissue. And the reason why we're doing that, because previously, many years ago, people used to do tissue grafting.
And tissue grafting is a very easy procedure, and I can explain to you in a minute how easy it is. And any dermatologist can actually do it. So an example of tissue grafting is punch grafting.
For instance, a punch is like a pen that has a hollow end. It's like if you go to a dermatologist and he does like a skin biopsy, usually use a punch, right? So this punch is like exactly like a pen with a hollow end at the end, and then you puncture the skin. So you take a small piece of skin, like one to two millimeters.
So this is a punch. We call it punch grafting. So the idea is you take punches, one to two millimeters from normal skin, and then you put them in a dish.
And then at the same time, you take the same size or a little bit smaller punches from vitiligo area, right? So you have the same number of holes in the vitiligo and from normal skin. And then you take the punches and then you put them in the holes that you created in the vitiligo skin, right? And then up on like with regular interval between each punch, right? So after a few weeks, these punches start to spread the pigment, and then the color comes back in the skin. So it's a very easy technique, right? Wow.
It's an easy, but it is fascinating. So it's called tissue grafting or punch grafting. Now, the pros that it's easy, but the cons is that when this heals, because you took punch grafting, it leaves what we call cobblestone on the skin.
You know the cobblestone? You know like when you walk in the streets of Paris and then you see these cobblestones in the old streets? So it looks like that. So the skin, instead of being nice and flat, yes, it's pigmented, but it's cobblestone. It's bumpy.
Got it. Which is cosmetically unacceptable. Like imagine you have this on your face, on the cheek, or on the nose.
And then you have all this bumpiness that you create. Actually, it's much easier to hide vitiligo with cover-up makeup than to hide the cobblestone, because the cobblestone is like a bump. That's true.
So if you try to hide it, it may even look a little bit abnormal, right? So that's the tissue graft. The second tissue grafting, which is again an easy technique, is to take a graft from the skin, like a piece of skin, and then you suture it on the vitiligo area. So again, that's tissue grafting.
Now, tissue grafting, it's better than punch grafting because it doesn't leave the cobblestone. But the disadvantage is that you can only do one-to-one ratio from donor to recipient. So let's say you have a 10-square centimeter of vitiligo, and then you do a tissue grafting from normal skin.
You have to take a 10-square centimeter normal skin to apply it on 10-square centimeter of vitiligo. So because the ratio is one-to-one, it limits the procedure to a very small surface area. Now let's go to the cell transplant, the technique that I'm doing now, which is the new technique.
So the idea of the cell transplant is that you take the tissue graft, but the size that you take is up to 1 to 20, the size of the vitiligo. So let's say you have 100-square centimeter of vitiligo. You take 20 times less the size of a graft from the skin.
So it makes you treat a huge surface area instead of doing one-to-one. So that's the main advantage of the cellular graft. So basically what you do is you take a very tiny piece of skin, again, 1 to 20, from the donor to recipient side.
I usually take it from a hidden area, like the upper thigh or the bottom. So it's a very hidden area in the body. And then I send it to the lab, which is the same whole way.
What the lab done is that it separates the epidermis from the dermis. Remember when we talked that the melanocytes are in the epidermis? So what we need is the cells, right? So we separate the epidermis from the dermis with certain enzymes. And then we take these cells and then we suspend it in a solution.
So the cells, the melanocytes itself that produce the pigment, are suspended in a solution. And while doing that, I do a laser resurfacing for the patient. And the reason why I do that is to make the vitiligo area able to uptake the cells.
Because if we apply those cells on normal skin of vitiligo, these cells are going to leak. It's like a solution, right? It's a liquid water in your skin. So it's not going to leak.
So in order for these cells to be uptaken by the vitiligo area, we have to sand the skin. You know, like sandpaper? Yeah. Instead of using a sandpaper, we use like a little bit of high-tech technique, which is the laser resurfacing.
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