Vitiligo Diagnosis

Nonsegmental (bilateral) vitiligo (NSV)

• Also known as vitiligo vulgaris, generalized vitiligo
• Chronic symmetrical depigmentation w/ an on-off cycle
• Depigmentation starts then stops for some time, w/ progressive expansion of affected area
• Usually starts on hands, feet or mouth

Segmental (unilateral) vitiligo

• Asymmetrical depigmentation w/c usually begins in childhood
• Remains stable after 1 yr of onset
• Lesion follows a dermatomal pattern; may also have leaf-like or checkerboard pattern

Mixed vitiligo

• NSV w/ segmental vitiligo

Unclassified vitiligo

• Focal at onset, then progresses as multifocal w/ segmental & nonsegmental features
• Serves as a diagnostic point until disease can be classified as NSV, segmental, or mixed

• Onset of the lesion: 50% of patients first present before the age of 20
• Course of the disease: Usually progressive
  • Spontaneous repigmentation may occur in 25-40% of patients w/in 6 mth

• Precipitating factors: Eg emotional stress, sunburn, chemical exposure, skin trauma, inflammation, irritation or rash may precede lesions by 2-3 mth
• Family history of vitiligo or premature graying of the hair
• History of associated conditions (patient & patient’s family)
  • Eg thyroid disorders, alopecia areata, DM, pernicious anemia, collagen vascular diseases, Addison’s disease, melanoma, etc

• History of ocular (eg loss of visual acuity, poor night vision, or photophobia) or auditory (eg deafness) disorders

Morphology of the Lesions

• Asymptomatic white colored macules or patches, w/ well-defined borders & otherwise normal skin surface
  • Occasionally, patients present w/ patches that have inflamed or hyperpigmented borders

Site of Distribution

• Hypopigmented areas usually appear on exposed areas eg the dorsal surface of the hands & feet, the arms, face (lips & around mouth, nose & eyes), hyperpigmented areas (eg axilla, genital, around nipples), umbilicus, anus & at sites of trauma (Koebner’s phenomenon) & bony prominences (eg knee & elbow)

Other Important Physical Findings:

• Depigmented hairs w/in vitiliginous areas & on the head (including eyelashes, beard, etc)
• Changes in the choroid & retinal pigment epithelium
• Uveitis

Scoring Systems

Vitiligo Area Scoring Index (VASI)

• Quantifies total extent of depigmentation based on 5 sites: upper extremities, hands, trunk, lower extremities, feet
• Uses a percentage scale to visually assess involvement & degree of skin pigmentation

Vitiligo European Task Force (VETF) System

• Analyzes disease extent, stage, & disease progression
  • Extent - uses rule of nines
  • Stage - based on pigmentation of skin & hair

  Stage	Pigmentation
  0	normal (no depigmentation)
  1	incomplete depigmentation (includes spotty depigmentation, trichrome, light homogenous pigmentation)
  2	complete (hair whitening included <30%)
  3	complete w/ significant hair whitening (>30%)

  • Disease progression - assesses degree of spreading based on Wood’s lamp & electric light exams

Vitiligo Extent Tensity Index (VETI)

• A recently formulated scoring system that produces a constant number based on the extent & severity of vitiligo
• Uses the rule of nines; disease tensity is stages according to the affected area (head, upper extremities, trunk, lower extremities, genital area)
• Further studies are needed to prove its potential in accurately diagnosing vitiligo

Diagnostic Examinations

Wood’s Lamp Examination

• In patients w/ fair skin, it is used to detect vitiliginous lesions & in patients w/ darker skin, it is used to assess the degree of vitiligo lesions
• May also be used to detect vitiligo lesions on the axillae, anus & genitalia which are often clinically inapparent

Other Exams

• Additional laboratory exams may be needed for patients w/ history of autoimmune disorders
  • Anti-thyroid peroxidase, antithyroglobulin antibodies, thyroid function tests
• Punch biopsy is suggested to differentiate vitiligo from other dermatoses