To the Editor: Vitiligo, a common pigmentary disorder, is often difficult to treat. Phototherapy, including narrowband ultraviolet (UV) B (NBUVB) radiation, psoralen and UVA radiation, and the 308-nm excimer laser, is often successful; however, acral lesions are usually resistant to treatment.1Njoo M.D. Spuls P.I. Bos J.D. Westerhof W. Bossuyt P.M. Nonsurgical repigmentation therapies in vitiligo: meta-analysis of the literature.Arch Dermatol. 1998; 134: 1532-1540Crossref PubMed Scopus (236) Google Scholar, 2Passeron T. Ortonne J.-P. Use of the 308-nm excimer laser for psoriasis and vitiligo.Clin Dermatol. 2006; 24: 33-42Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar A new 308-nm monochromatic excimer light (MEL) device (Excilite, National Biological Corp, Beachwood, OH) has been developed for the treatment of vitiligo that may be more effective in achieving repigmentation compared with older modalities.3Casacci M. Thomas P. Pacifico A. Bonnevalle A. Paro Vidolin A. Leone G. Comparison between 308-nm monochromatic excimer light and narrowband UVB phototherapy (311–313 nm) in the treatment of vitiligo–a multicenter controlled study.J Eur Acad Dermatol Venereol. 2007; 21: 956-963Crossref PubMed Scopus (93) Google Scholar We performed a pilot study to determine the efficacy of this device for acral vitiligo and its effect on punch grafts compared with standard phototherapy. Thirteen patients gave written informed consent for this study, which was approved by a local institutional review board. Patients had stable vitiligo on the forearms and hands, defined as no more than 10% reported change in lesion size over the previous 6 months, lack of improvement with topical immunomodulators or corticosteroids for 6 months, and not receiving more than 12 previous phototherapy treatments. Five 1.5-mm minigrafts were harvested from hip skin and placed in each of two target lesions per patient. One week after transplantation, the MEL device was used on one target lesion, while the other was treated with a hand-foot NBUVB device (Hand/Foot II NBUVB system, National Biological Corp) 3 times weekly for 12 weeks. Treatment assignments were based on a computer-generated randomization code. Initial dose was 200 mJ on both sides with an increase of 15% per treatment on the NBUVB side and 50 mJ on the MEL device side. The primary outcome measure was improvement in target lesion size performed by a blinded investigator using Scion Image J measurement software (National Institutes of Health, Bethesda, MD) on baseline and week-12 images. These images were taken under standardized conditions. The majority of the patients were Hispanic (61%) and had skin type III (46%) or IV (31%), mean age of 47 years (range 21-74 years), and mean duration of vitiligo of 15 years (range 4-44 years). Ten patients completed the trial. The remaining 3 did not have any adverse effects before dropping out. NBUVB gave a significant improvement (median = 13%, Wilcoxon P = .037) at week 12 (Fig 1) whereas the MEL device did not show significant improvement (median improvement 9%, Wilcoxon P = .169). There was no significant difference between standard NBUVB and the MEL device over time (baseline to 12 weeks) using multivariate repeated measures analysis of variance. Of the 37% of grafts surviving at week 12, maximum pigment spread was a mean 4.5 times the original graft size with NBUVB versus 2 times original graft size with the MEL device. This difference was not significant (Fig 2). There were no adverse events.Fig 2Vitiligo in patient 7 at 1 week after grafting (A) and showing improvement at week 12 after standard narrowband ultraviolet B therapy (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT) This study confirms the difficulty of treating vitiligo in acral locations. Even after 12 weeks and 36 treatment sessions, target lesions improved only 9% to 13% with the MEL device, which was not better than standard NBUVB therapy. Maximum pigment spread from grafts did not show a significant difference either. Although this new device shows promise in other locations, acral vitiligo was relatively unresponsive.