Characterization Of Vitiligo-associated Leukotrichia:Clinical,Trichoscopic,Ultrastructural Observation And Pilot Study Of Treatment

BackgroundVitiligo is an acquired depigmenting disorder manifested as white patches of skin,mucosa.It can be cosmetically disfiguring and lead to serious psychological problems.The insufficient cognition of leukotrichia often lead to the ignoration of the examination and treatment.It is necessary to study the clinical features of vitiligo-associated leukotrichia(VAL).Dermatoscopy is important in the diagnosis and differential diagnosis of vitiligo.However,there has been no study about the trichoscopic feathers of VAL.Treatment of VAL is still a challenge.The current medical treatment and phototherapy have limited efficacy.Surgical treatment also showed poor result.The difficulty lies in the VAL removal and incomplete repigmentation of leukotrichia.Laser hair removal technology can only be used for black hair.Trichiasis electrolyzer is used to remove trichiasis by ophthalmologists.This technology is mature,safe and effective.Electrolysis combines with surgical transplantation has not been studied.ObjectivesThe aim of this study included the following:(1)To study the clinical features and treatment of VAL.(2)To study the trichoscopic,ultrastructural features of VAL and to explore the early changes of progressive VAL.(3)To explore the use of electrolysis in VAL removal.(4)To explore the use of electrolysis,follicular unit extraction(FUE),and the combination therapy in treating stable VAL.MethodsPatients with vitiligo and healthy volunteers were enrolled.Informed consents were obtained from all subjects.Patients were asked to complete questionnaires and received dermatological examination.The clinical features and treatments were analyzed.The VAL-related trichoscopic signs and its relationship with stage and hair whitening time were analyzed.Leukotrichia less than 3 months and black hair 2cm away from white patch of progressive nonsegmental vitiligo were collected,and observed by light microscopy and electron microscopy.The telogen hair were calculated.White hair,black hair and eyebrows were removed under different current,the depilation time and success rate were analyzed to obtain the optimal current.Trichoscopic and histopathological changes of electrolysis were observed.Stable VAL were treated with electrolysis,FUE or combined therapy(electrolysis combined with epidermal grafting or FUE).The patients were followed up for 3 months to evaluate the efficacy and side effects.The statistical analysis was performed by GraphPad prism 8 and SPSS26.0.ResultsA total of 337 patients with vitiligo were enrolled.VAL was found in 142 patients(42.1%),with terminal hairs involvements in 127 patients(169 lesions)mainly on the scalp and eyebrows(139 lesions).Multiple terminal hairs involvements were found in 23.6%(30/127)patients.Four patients had white nasal hairs,three of whom had white patches on the noses.Leukotrichia on peri-nevus rim was found in 20.83%(5/24)patients with halo nevus.Among 139 lesions of leukotrichia on the head and face,37(26.6%)sites with leukotrichia as the first manifestation,and 81 were less than one year,of which 76(93.8%)were in the progressive stage.Fifty-eight patients had the history of over 1 year and 27(46.6%)were in the progressive stage.Eight invisible white patches under VAL were identified by Wood lamp examination.No fluorescence enhancement was found in 10 lesions of VAL under Wood lamp.The proportion of hair whitening in complete depigmented group was much higher than that in incomplete depigmented group.The hair whitening time of sharp margin group was much longer than that in fuzzy margin group(P<0.05).Segmental vitiligo were independent risk factors for VAL.Ninety-one patients received treatment.Only 9 had partial repigmentation,2 of whom had over 76%repigmentation after topical corticosteroids treatment.The repigmentation were found in 63.6%(14/22)patients with body hair leukotrichia and the repigmentation were all less than 25%.A total of 140 trichoscopic images of 100 vitiligo patients were collected,including 109 terminal hair and 31 vellus hair images.Among 75 leukotrichia on the head,the most common trichoscopic sign was perifollicular hypopigmentation,followed by clustered leukotrichia,white area,telangiectasia,leukotrichia diameter diversity,red area,residual perifollicular pigmentation,white hair root,Pohl-Pinkus constrictions,hair repimentation,scale,and yellow dots.The incidence of leukotrichia diameter diversity,perifollicular pigmentation,Pohl-Pinkus constrictions and white hair root was much higher in progressive stage than those in stable stage,the incidence of clustered leukotrichia in stable stage was higher than that in progressive stage(P<0.05).The median time of hair whitening in patients with Pohl-Pinkus constrictions,white hair root and leukotrichia diameter diversity was shorter than that in patients without the above-mentioned trichoscopic signs(P<0.05).The median hair whitening time was 60 months in patients with clustered hair,which was longer than that in patients without clustered hair(P<0.05).Light microscopic examination showed that 87.8±10.7%white root hairs were in telogen stage,higher than other groups(P<0.5).Pohl-Pinkus constriction is associated with white hair root.Scanning electron microscopy(SEM)showed that the leukotrichia was thinner than black hair.Transmission electron microscopy(TEM)showed that the melanosomes in leukotrichia were smaller with vesicles formation,less in number,incomplete in shape.All hair was removed by electrolysis in volunteers.The average epilation time of black and white hair under 550mA was longer than that of 600mA and 650mA groups.The success rate was lower than that of 600mA and 650mA groups(P<0.05).There is no significance in the epilation time and success rate of eyebrows under different currents.The optimal current for hair removal and eyebrows removal was 600mA and 550mA,respectively.The trichoscopic examination showed that hair was completely peeled off from hair follicle.The histopathologic examination showed destroyed follicle,longitudinal cracks,cell necrosis.There is no collagen degeneration around follicle.Ten vitiligo patients were treated with electrolysis.Almost all leukotrichia was successfully removed.Three-month follow-up showed that only 9.1±6.3%leukotrichia relapsed.Four patients were treated with FUE and 67.2±23.31%leukotrichia were removed.The 1-year follow-up showed that 74.4±19.9%black hair remained.Three-month follow-up showed that 9.1±6.3%leukotrichia relapsed.The recovery time of FUE was from 2 weeks to 2 months.One patient had postoperative mild atrophic scar,reduced hair density and local sensory abnormalities.One patient was treated by electrolysis with epidermal grafting.All hair was removed,and 3-month follow-up showed that extent of repigmentation was over 75%,and 13.3%(32/240)leukotrichia relapsed.Four patients were treated by electrolysis with FUE and 98.33±3.35%leukotrichia was removed.Three-month follow-up showed that 90.7±4.73%black hair remained and 10.57±2.45%leukotrichia relapsed.No scar or hair density reduction were found in patients with combined therapy.ConclusionVitiligo-associated leukotrichia was found in 42.1%patients with vitiligo,mostly seen in segmental vitiligo.Leukotrichia occurs mainly on the scalp and eyebrows.The hair whitening time less than one year indicates the activity of the disease.Early detection and treatment are of great importance for repigmentation.The trichoscopic signs of leukotrichia diameter diversity,Pohl-Pinkus constrictions and white hair root were related to the progressive stage.Hair cycle turned into telogen stage,and the hair morphologic and chromic abnormalities suggested the process of hair growth and melanin synthesis were affected at the early stage.Trichiasis electrolyzer was successfully used to remove VAL,it precisely destroys the hair follicle tissue with less adverse effect.Electrolysis combined with surgical transplantation can improve the efficacy of stable VAL.