24. Permanent de-pigmentation with timedsurgical mixed peeling of normal facial skin in vitiligo universalis
KEYWORDS: Vitiligo, de-pigmentation of the skin, mixed peeling
This patient has generalized vitiligo. There are some areas of pigmented skin on the cheeks, which require de-pigmentation. For this purpose, we use timedsurgical mixed peeling with de-epithelialization, one of the standardized techniques made possible by the Timed apparatus (Patent US).
De-pigmentation is necessary because, when exposed to the sun, these areas darken and are difficult to cover with masking creams. In generalized vitiligo, the normal color of the patient's complexion appears as a hyperpigmented patch.
Once local anesthesia has been carried out, de-epithelialization begins. The epidermis of the pigmented areas is raised by the specific pulsed current of the Timed apparatus. The edge of the angle of the EM 10 Yellow electromaniple brushes the skin in small circular movements.
The Timed apparatus is programmed with the following data: Direct Pulsed 4/9 hundredths of a second, Coag, 2 Watt, EM 10 Yellow electromaniple (edge of the angle).
Timedsurgical de-epithelialization enables us not only to de-pigment the skin, but also to re-pigment it. Achromic scar areas, stable vitiligo or piebaldism can be re-pigmented by applying to the de-epithelialized area grafts of autologous keratinocytes and melanocytes cultivated from a square centimeter of intact skin that has been removed 20 days earlier.
The success of these techniques stems from the fact that de-epithelialization leaves the dermal papillae and the capillary-papillary plexus perfectly intact.
In mixed peeling with de-epithelialization, the resorcin that is subsequently applied is perfectly absorbed and acts on all the geometric points of the surface. De-epithelialization can be carried out accurately only by means of the specific current of the Timed apparatus, the power system of which has been expressly designed for this purpose. It is impossible to achieve the same result by means of a light ray that travels in a straight line at a speed of over 300,000 km/s. Indeed, the widespread use of laser technology in dermatology never ceases to amaze us, as laser beams lack precision and cause in-depth trophic damage. Our diathermic current also travels at over 300,000 km/s, but not in a straight line; it returns to the generator across the surface, without damaging the deep tissues.
Once the EM10 Yellow electrode has been brushed over the pigmented skin, the raised epidermis is removed with the same electrode, while inactivated. If any fragments of epidermis do not detach, they are again brushed with the edge of the angle of the activated electrode. The epidermis must be raised by the current, not by the mechanical action of the electrode. No bleeding occurs, as we are working above the capillary-papillary plexus. The operator uses magnifying lenses in order to identify the adjacent area of achromic skin precisely. Having removed the epidermis that has been detached by the timedsurgical current, the operator washes the area with physiological solution and then dries it.
At the beginning of treatment, a saturated solution of resorcin is prepared. A small amount of resorcin powder is placed in a small container and partially dissolved in a tiny quantity of water. A little resorcin must remain on the bottom of the container, as this indicates that the solution is saturated and that no further resorcin can be dissolved. The resorcin solution is applied to the de-epithelialized area, where it is left for 60 seconds. As soon as the solution touches the dermis, it generates a frost. This frosting enables us to identify any areas that have not been de-epithelialized. Using the activated electrode, the operator detaches any portions of epidermis that are still attached to the dermis, and then removes them. The resorcin solution is again applied to these points and then washed off.
After a few minutes, a thin crust forms; this thickens over time. No other products must be applied to the area.
If any exudation occurs, the patient simply dries the de-pigmented area with a paper tissue.
The crust that forms must be left to drop off spontaneously. If the edges begin to detach, they can be trimmed with scissors. Resorcin exerts a selective action on the melanocytes; for this reason, we use it to treat hyperpigmentation and to lighten the skin.
One day after the crust has dropped off, the patient can apply a colored cream to mask the slight reddening that occurs after treatment.
Two treatment sessions, six months apart, are normally needed in order to lighten the skin. Application of the resorcin solution always lasts 60 seconds.
In this patient, only a small pigmented area on the right cheek remains after treatment; this will be de-pigmented during the second session of mixed peeling. The result is permanent.
Capurro S. (2022): Permanent de-pigmentation with timedsurgical mixed peeling of normal facial skin in vitiligo universalis. Timedsurgery section. https://www.crpub.org
Mixed peeling solves the problems of normo-pigmented facial skin in patients with generalized vitiligo. What advantages does it have over other methods?
• No other methods can be compared with this extraordinary technique.
• No standardized methods are able to de-pigment the skin in one or two sessions, as timedsurgical mixed peeling does.
• No existing methods act specifically on the melanocytes, as timedsurgical mixed peeling does.
• No existing methods act on all the geometric points of the pigmented surface, as timedsurgical mixed peeling does.
• No other methods utilize a chemical substance that, when applied to intact skin, has no effect, as timedsurgical mixed peeling does.
• No other methods exist in which medications are not required, as in timedsurgical mixed peeling.
• No other methods have such little toxic effect, as timedsurgical mixed peeling does.
• No existing techniques or treatments are as safe and efficacious as timedsurgical mixed peeling.
What can you say about re-pigmentation?
De-epithelialized achromic areas are re-pigmented by grafting cultivated autologous keratinocytes and melanocytes. Only patients with stable vitiligo, piebaldism and areas of scarring can be treated. However, we no longer perform this procedure, as we no longer have a cell-culture laboratory available.
What happens if the areas treated with mixed peeling are medicated with ointments or creams?
Healing takes place underneath the crust. If we hinder the formation of the crust by applying creams, ointments or disinfectants, we will delay the healing process and probably cause problems of scarring. The crust forms within a few hours, facilitates healing and prevents infections and other complications.
No comments yet