Treatment of Patients with Vitiligo by Intradermal Pricking of Vitiligenous Skin Using Sharp and Blunt Needle

Background: Vitiligo is a well known autoimmune disease, both cell me-diated and humeral reaction are implicated in its etiopathogensis. Pricking of marginal pigmented of vitiligo skin to stimulate normal melanocytes to migrate into vitiligenous area and induce new melanogenesis and this is well known mechanism to induce repigmentation and supported by publications. Objective: To use needling technique by using blunt and sharp needle by doing pricking completely white vitiligo skin in order to stimulate residual melanocytes of basal layer and or the melanocytes of outer root sheath of hair follicles to proliferate and induce active melanogenesis. Patients and Methods: This is an interventional, therapeutic, comparative, study that was done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq from April 2014-March 2015. Thirty five patient with vitiligo were enrolled in this study, their ages ranged from 5 - 55 (22.28 ± 12.09) years; 15 patients treated with sharp needle, 2 males and 13 females and 20 patients treated with blunt needle, 4 males and 16 females. All clinical types of vitiligo including the generalized, localized and segmental were treated. The number of vitiligo patches varied between square paper and this was carried out every month till the end of the 4 th month period of the treatment. All patients in both groups were evaluated every 2 weeks for the 1 st month and then monthly for 3 months and the rate of reduction in surface area was measured. Also to record any side effects and complications. Results: After 2 week, 2 months, and 4 months of treatment, there was 0.5%, 4.31%, and 10% respectively reduction in the surface area of lesions in Group A, while in Group B, there was 7%, 18.42%,and 13.5% respectively reduction in the surface area. Conclusions: Pricking the vitiligo skin by needle, gauge 18 gave success rate 10% and 13.5% at four months after therapy and needling could be repeated once a week to accelerate melanogenesis and until get complete repigmentation.


Introduction
When medical therapy of vitiligo has failed, surgical treatment is indicated, treating sfigle localized and segmental vitiligo. The aim of all these procedures is to implant melanocytes from the normal skin into vitiligenous areas. These surgical procedures are organ-cultured fetal skin allografting, epidermal culture grafting, melanocyte culture grafting, autologous noncultured melanocyte-keratinocyte cell transplantation, epidermal grafting by the suction blister technique, thin thiersch split skin grafting, or miniature punch grafting. Most methods are time consuming, costly and need sophisticated lab and personnel [1]- [6]. Hence simpler technique non-costly could be suggested like needling technique. The treatment of vitiligo is based on the principles of stimulating the existing melanocytes in the affected area or repopulating it with functioning melanocytes [7].
There have been some reports showing complete repigmentation of vitiliginous patches after repeated needling on them, and by needling from pigmented margins or spots towards white area. Ahmed et al. used needling technique by using gauge 30 needle and subjected treated patches 3 times per week for at least 6 months and he prick the dark pigmented margins of vitiligenous patches in order to move the melanocytes to vitiligenous areas achieved 94% repigmintation [8]. While the aim of present work is to apply needling technique by using sharp and blunt needle gauge 18 and by pricking the completely white vitiligenous patches rather than the pigmented margin in order to stimulate residual melanocytes in basal layer and or outer root sheath melanocytes.

Patient and Methods
Thirty five patient with vitiligo were enrolled in this interventional, comparative, therapeutic study (those with sharp needle 15 patients; 2 males and 13 females) and (those with blunt needle 20 patients: 4 males and 16 females) their age K. E. Sharquie et al.
ranged from 5 -55 years with mean of 22.28 SD ± 12.09 years. All clinical types of vitiligo including the generalized, localized and segmental were treated. The number of vitiligo patches varied between patients. So the number of treated patches by sharp needle 22 and by blunted needle 20 patches.

Inclusion Criteria
Segmental and localized areas of vitiligo were included. In patients with generalized vitiligo some localized areas were selected and treated either because cosmetically unacceptable areas or as the patient requested. Activity of the disease was recorded for each patient to fix the duration of stability of the disease.

Exclusion Criteria
All patients with active vitiligo either increasing in size of vitiligo lesions or appearance of new lesions at the time of grafting were excluded apart from few patients. All patients stopped their treatment at least two month before intervention. Formal consent was taken from each patient before starting therapy after full explanation about the nature of the disease, the procedure of treatment, follow up, prognosis and the need for pre and post treatment photographs. Also, ethical approval was performed by the Scientific Committee of the Scientific Council of Dermatology and Venereology-Iraqi Board for Medical Specializations. All patients are photographed by Samsung Galaxy S4 combines 13 megapixel camera in the same place and illumination.

Needling Technique by Sharp and Blunt Needle
In good illuminated room and patient lie semi-supine position where the upper body is tilted at 45˚ and not horizontal where the medical gauze, disposable needle gauge 18 sharp one and blunted one, scissor, xylocaine 2% with adrenalin 1:100,000, alcohol and sterile gloves.
In the Group A: 15 patients, 3 males and 12 females with 21 patches were involved (Table 1). Photograph has been taken then taken surface area of leukodermic patches using transparent paper and graph square papers. Sterilizing area of vitiligenous skin with alcohol and intradermal needling was started geometrically, softly and rapidly in systemic horizontal rows away from pigmented margin and pigmented spot inside the patches. Needle gauge 18 hold at 45˚ to skin surface was used and the distance between each pricking was ranged from 5 -10 mm. When pricking was completed the area is again sterilized by alcohol. Each patient was advised to have daily sun light exposure for at least 15 min a day. The Group B included 20 patches in 20 patients, 4 males and 16 females were treated in similar way to group A but using blunt needle (tip cut by a scissor) gauge 18 (Table 2).

Follow up and Evaluation of Response
All patients in both groups were evaluated every 2 weeks for the 1 st month and K. E. Sharquie et al.

Mean of Surface Reduction
The mean ± SD of surface area of lesions in Group A was decreased from 4.55 ± 3.55 cm 2 at baseline visit to 4.48 ± 3.42 cm 2 at second visit (after 2 weeks) which was statistically non-significant (p value = 0.317). The mean surface area continued to be reduced till reaching 4.26 ± 3.30 non-significant (p value = 0.068 at 4 th visit), 3.85 ± 3.31 at 5 th visit (p value = 0.068) ( Table 3, Figure 1).
The mean ± SD of surface area of lesions in Group B was decreased from 4.96 ± 4.33 cm 2 at baseline visit to 4.45 ± 4.07 cm 2 at second visit (after two weeks) which was statistically significant (p value = 0.01). The mean surface area continued to be reduced till reaching 4.00 ± 3.93 at 4 th visit, 4.22 ± 4.36 at 5 th visit.
All were statistically significant when compared to baseline visit (Table 4

Percent of Reduction
After 2 week, 2 months, and 4 months of treatment there was 0.5%, 4.31% and 10% respectively reduction in the surface area of lesions in Group A, while in Group B there was 7%, 18.42%, and 13.5% reduction in the surface area.

Pattern of Repigmentation
In Group A, the pattern of repigmentation was peripheral and perifollicular in all patients who response to needling. While in Group B, the pattern of repig-K. E. Sharquie et al.
mentation was halo pigmentation.
No side effects or any complications were noticed during treatment and follow up periods.

Discussion
Each disease might have many alternative therapies that could be used singly or in combination like vitiligo where there are many therapeutic options like medical treatment. But when this fails, surgical implantation of melanocytes could be applied especially in stable localized vitiligo and these techniques are usually non-easy and need experience and costly procedures [1]- [6]. Needling technique has been used as very simple non-costly and could be repeated frequently. The objective of this procedure is to stimulate the marginal melanocytes, by needle pricking, to divide and proliferate and induce new melanogenesis [7].
In present work, needle gauge 18 was used both sharp and blunt in order to induce more damage to the skin but only pricking the vitiligenous skin rather than marginal pigmented area and gave 10% reduction rate for sharp one and 13.5% for blunt one after four months and these results very comparable whether use sharp or blunted needle. This pigmentation was considered high because only one pricking was done. While Ahmed et al. used needling technique by using gauge 30 needle and pricking the pigmented margin was carried out 3 times per week for at least 6 months in order to move the melanocytes to vitiligenous areas and gave excellent pigmentation in 94% of treated patches [8]. While in present work pricking was done once to completely vitiligenous areas and if pricking was repeated 3 time per week, it will get much higher rate of repigmentation.
The aim of inducing trauma by pricking is to stimulate both keratinocytes and fibroblast to release inflammatory cytokines and growth factors and these cytokines will stimulate residual melanocytes in vitiligenous area and hair follicles' to multiply, proliferate and migrate into different directions in vitiligenous area and will this induce new melanogenesis [9].

Conclusion
In conclusion, pricking the vitiligo skin using needle gauge 18 gave reduction rate 10%, 13.5% after one prick and this procedure could be repeated once a week until get complete repigmentation and this needling could be combined with other therapies like sunlight exposure tacrolimus use. Also even patients could be advised to do this procedure by himself using a sharp needle and topical xylocain cream.

Disclosure
This study was an independent study and not funded by any drug companies.