10.5826/dpc.1304a197
Vitiligo is a chronic, acquired autoimmune pigmentary skin disease, most times it can be diagnosed clinically. Dermoscopy can confirm vitiligo in a non-invasive way. It is a   diagnostic technique that visualizes sub-macroscopic morphological structures which correspond with specific histological structures. It detects subtle changes in the pigment pattern, evaluates vitiligo’s activity, attempts of repigmentation, leucotrichia, and differentiates it from other hypo pigmentary disorders.  Most dermatoscopic clues used to assess vitiligo’s activity are found at the perifollicular level in the center and edge of the lesion. Perifollicular pigmentation is present in both active lesions and treated pigmented lesions with treatment. However, perifollicular depigmentation represents poor response, in treated lesions, and poor prognosis in untreated ones. The center of the lesion has reduced and/or absent pigment network, in active and stable lesions. If on dermoscopy the center of the lesion shows islands of pigment, erythema, or telagiectasias, repigmentation is suggested. At the periphery of the lesion, unstable vitiligo usually shows up as a diffuse border, trichrome pattern, micro-koebner/comet tail phenomenon, satellite lesions, or a tapioca sago pattern. In stable lesions it is more frequent to find clear borders and trichromes. Pigmented lesions commonly present sharp borders and marginal or perilesional hyperpigmentation.
text/xml
2160-9381
3120
en
Karen Férez
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dermatoscopic patterns
Dermatoscopic Patterns in Vitiligo
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Review
2023-10-31
2022-12-28
2023-10-31
2024-01-15
e2023197
Dermatol Pract Concept
Vitiligo is a chronic, acquired autoimmune pigmentary skin disease, most times it can be diagnosed clinically. Dermoscopy can confirm vitiligo in a non-invasive way. It is a   diagnostic technique that visualizes sub-macroscopic morphological structures which correspond with specific histological structures. It detects subtle changes in the pigment pattern, evaluates vitiligo’s activity, attempts of repigmentation, leucotrichia, and differentiates it from other hypo pigmentary disorders.  Most dermatoscopic clues used to assess vitiligo’s activity are found at the perifollicular level in the center and edge of the lesion. Perifollicular pigmentation is present in both active lesions and treated pigmented lesions with treatment. However, perifollicular depigmentation represents poor response, in treated lesions, and poor prognosis in untreated ones. The center of the lesion has reduced and/or absent pigment network, in active and stable lesions. If on dermoscopy the center of the lesion shows islands of pigment, erythema, or telagiectasias, repigmentation is suggested. At the periphery of the lesion, unstable vitiligo usually shows up as a diffuse border, trichrome pattern, micro-koebner/comet tail phenomenon, satellite lesions, or a tapioca sago pattern. In stable lesions it is more frequent to find clear borders and trichromes. Pigmented lesions commonly present sharp borders and marginal or perilesional hyperpigmentation.
Karen Férez
2023/10/31
10.5826/dpc.1304a197
e2023197
National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico’s Ministry of Health, Mexico City. Mexico
2160-9381
dermatoscopic patterns
en
e2023197
Kang HY, le Duff F, Passeron T, Lacour JP, Ortonne JP, Bahadoran P. A noninvasive technique, reflectance confocal microscopy, for the characterization of melanocyte loss in untreated and treated vitiligo lesions. J Am Acad Dermatol. 2010; 63(5): e97-100. DOI: 10.1016/j.jaad.2010.02.010. PMID: 20950736.
Dermatoscopic Patterns in Vitiligo
https://dpcj.org/index.php/dpc/article/download/3120/2337
                        Dermatoscopic Patterns in Vitiligo
  Juan Alberto Godínez-Chaparro1, 2, Rodrigo Roldán-Marín3, Helena Vidaurri-de la Cruz4,
                         Luis Adrián Soto-Mota5, Karen Férez5,6


1 Pediatric Dermatology Service, High Specialty Medical Unit of the Dr. Gaudencio González Garza General Hospital, La Raza National
  Medical Center, Mexican Social Security Institute, Mexico City, Mexico
2 Postgraduate Studies and Research Section, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City, Mexico
3 Onocodermatology Clinic in the Experimental Medicine Unit of the Faculty of Medicine, Universidad Nacional Autónoma de México,
  Mexico City, Mexico
4 Pediatric Dermatology Service, General Hospital of Mexico Dr. Eduardo Liceaga, Ministry of Health. Mexico City, Mexico
5 National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico’s Ministry of Health, Mexico City, Mexico
6 Mexican Foundation for Vitiligo and Skin Diseases, Mexico City, Mexico



Key words: vitiligo, dermatoscopy, dermoscopy, dermatoscopic patterns
Citation: Godínez-Chaparro JA, Roldán-Marín R,Vidaurri-de la Cruz H, Soto-Mota LA, Férez K. Dermatoscopic Patterns in Vitiligo.
Dermatol Pract Concept. 2023;13(4):e2023197. DOI: https://doi.org/10.5826/dpc.1304a197
Accepted: February 27, 2023; Published: October 2023
Copyright: ©2023 Godínez-Chaparro et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Juan Alberto Godínez-Chaparro, Tuxpan 28, 202-A Roma Sur, Cuauhtémoc, CP:06760 Mexico City, Mexico.
Phone: 55 52 65 28 00 ext.1541, 1503 E-mail: alberto.godinezch@gmail.com




  ABSTRACT             Vitiligo is a chronic, acquired autoimmune pigmentary skin disease, most times it can be diagnosed
                       clinically. Dermoscopy can confirm vitiligo in a non-invasive way. It is a diagnostic technique that
                       visualizes sub-macroscopic morphological structures which correspond with specific histological
                       structures. It detects subtle changes in the pigment pattern, evaluates vitiligo activity, attempts of
                       re-pigmentation, leucotrichia, and differentiates it from other hypo pigmentary disorders. Most der-
                       matoscopic clues used to assess vitiligo activity are found at the perifollicular level in the center and
                       edge of the lesion. Perifollicular pigmentation is present in both active lesions and treated pigmented
                       lesions with treatment. However, perifollicular depigmentation represents poor response, in treated
                       lesions, and poor prognosis in untreated ones. The center of the lesion has reduced and/or absent
                       pigment network, in active and stable lesions. If on dermoscopy the center of the lesion shows islands
                       of pigment, erythema, or telangiectasias, re-pigmentation is suggested. At the periphery of the lesion,
                       unstable vitiligo usually shows up as a diffuse border, trichrome pattern, micro-Koebner/comet tail
                       phenomenon, satellite lesions, or a tapioca sago pattern. In stable lesions it is more frequent to find
                       well defined or trichromic border. Pigmented lesions commonly present sharp borders and marginal
                       or perilesional hyperpigmentation.




Review | Dermatol Pract Concept. 2023;13(4):e2023197                                                                                  1
Introduction                                                          explained by the arrangement of the melanophages in the
                                                                      dermis are appreciated [7,8].
Vitiligo is the most frequent pigmentation disorder, it affects
0.38 to 1% of the world population [1]. It prevails in both        The evolution of vitiligo can be:
sexes equally and in 37% of cases, it begins before 12 years
of age [1,2]. It is caused by the targeted destruction or loss     a. Stable or inactive: there is no progression of the previous
of function of melanocytes. Its clinical features are a­ chromic      spots and no new spots in the last 12 months.
spots and poliosis, for it affects skin, hair, and mucosae.        b. Unstable or active or progressive: the number, size,
­Vitiligo is diagnosed by clinical examination, no laboratory         or both of existing vitiligo lesions increase in the last
tests are required, however, skin biopsies may be useful to           12 months.
distinguish it from other pigmentary disorders [3].                c. Repigmentation or regressive: the spots pigmented spon-
    Dermoscopy (or epiluminescence microscopy) is a                   taneously or with treatment [2,5].
diagnostic technique, which allows the visualization of
­
sub-macroscopic morphological structures which correlate              Decisions about the initiation, modification, and discon-
with specific histological structures [4]. Initially it was used   tinuation of vitiligo treatment depend on its topography and
for the study and screening of neoplastic pigmentary le-           evolution. The same patient may have stable, progressive,
sions, however, its use has gradually been extended to other       and regressive spots in separate locations at the same time.
­dermatoses, including vitiligo. This diagnostic tool allows the   Clinical activity is the result of cellular and inflammatory
detection of subtle changes in the pigmentary pattern that         mechanisms. Performing a skin biopsy to assess vitiligo ac-
aid the non-invasive confirmation of vitiligo. Additionally, it    tivity histologically is impractical and increases the proba-
assesses the disease activity and differentiates it from other     bility of complications such as the Koebner phenomenon,
hypo pigmentary disorders (piebaldism, tuberous sclerosis,         scarring, or infections.
pigment mosaicism, Waardenburg syndrome, etc).                        Therefore, it is desirable to use a non-invasive diagnostic
                                                                   method to evaluate all macules. Dermoscopy is exempt from

Clinical Nomenclature of Vitiligo                                  complications and allows the examination of all lesions. Ad-
                                                                   ditionally, the cellular dynamics of the disease can be ob-
According to its distribution, vitiligo can be classified in       served. Despite dermoscopy has gained popularity in the
the following clinical forms: 1) Segmental: It has a rapid         study of vitiligo, clinical studies in this area are still scarce
onset and can affect one, two, or multiple segments.               [9]. We will review the dermatoscopic patterns of vitiligo
2) Non-segmental which is subdivided into six subtypes:            evolutionary stage.
a) Acrofacial, b) Generalized, c) Universal, d) Mucosal,
e) Mixed and f) Less frequent variants. 3) Undetermined or
                                                                   Vitiligo and Dermoscopy
unclassifiable: it does not meet the criteria of any of the pre-
viously mentioned types after 2 years of follow-up [2,5].          In the dermoscopic evaluation of normal skin, the pigment
    Some rare clinical presentations of vitiligo include two       network corresponds to the pigmentation distributed along
main types:                                                        the epidermal ridges (homogeneous pigmented lines) inter-
                                                                   spersed with pale areas belonging to the papillary dermis
a. Follicular: primary depigmentation of the hair f­ollicle        [10,11]. Melanocytes are present in greater numbers on the
    and does not initially compromise the surrounding              slope of the ridges of the network compared to the tips of
    skin. D
          ­ ermoscopy shows white hair, and depigmenta-            the ridges which emphasizes the reticular pattern. The net
    tion affects the cortex and follicular medulla, yet the        corresponds to the slope and the pale areas to the tips of the
    surrounding skin is not affected. Leukotrichia precedes        ridges of the network [9]. In contrast, in vitiligo the loss of
    perifollicular depigmentation and eventually, achromic         melanocytes clears the pigment network beyond the pallor
    macules or leukoderma may appear [6].                          of the ridges, which produces a negative pigment network
b. Blue: the spots are bluish and asymptomatic; their              and creates different dermatoscopic patterns (Table 1 and
    ­coloration corresponds to the absence of epidermal me-        Figure 1) [9-11].
    lanocytes and the presence of dermal melanophages. In             Vitiligo lesions in their different evolutionary stages
    dermoscopy, it is possible to observe white spots with         (stable, progression, or regression) can be difficult to distin-
    linear areas and multiple blue dots, reticular telangiec-      guish clinically from other causes of hypopigmentation or
    tasias or homogeneous white areas without structure            depigmentation disorders. In 2004, Chuh and Zawar used
    with multiple black-bluish and gray-bluish points in the       dermatoscopy to study vitiligo and reported a pattern that
    form of an arch, linear, semicircular, and mottled that are    was not present in other hypopigmentation diseases. In this



2                                                                              Review | Dermatol Pract Concept. 2023;13(4):e2023197
                         Table 1. Description of dermatoscopic structures with vitiligo.
           Pattern/signs                                                    Description
 Unstable or progressive vitiligo
 Perifollicular pigmentation         Achromic spots at the pilosebaceous orifice present a homogeneous surrounding
                                     pigment with a tone like that of normal skin.
 Reduced or absent pigment           Whitening or loss of the pigment network that causes an absent pigment network.
 network
 Inverted pigment network            The white or depigmented pattern is in the form of a network with intermediate
                                     pigmentation.
 Trichromic                          Depigmented middle area of pseudo-scarring appearance, surrounding the main area is
                                     a faint yellowish-brown pigmentation and in the periphery the characteristic phototype
                                     of the patient (3 different shades).
 Starburst                           Extension or peripheral whitish linear projections in various directions.
 Comet tail                          Unidirectional linear extension or projection to an area adjacent to the initial vitiligo
                                     lesion.
 micro-Koebner phenomenon            The appearance of isomorphic depigmented linear stretch marks distributed along the
                                     trauma line or around the main patch of vitiligo.
 Tapioca sago or satellite lesions   Small white spots with no structure less than 1 mm in diameter are located around the
                                     main patch of vitiligo right on the perilesional skin that looks clinically normal.
 Leukotrichia                        White hairy hairs
 Stable and pigmentary vitiligo
 Perifollicular depigmentation       Absence of surrounding pigment in the pilosebaceous orifice.
 Perilesional/marginal               Darker pigmentation around achromic lesions.
 hyperpigmentation
 Intra/perilesional erythema         Redness of the skin depigmented or on its margins.
 Telangiectasias                     Bright red dilated capillaries 1 to 4 mm in diameter; resemble spider veins.
 Atrophy                             The achromic spot that presents a decrease of one or several layers of the skin and its skin
                                     annexes causing thinned skin, folded and accompanied by telangiectasias.
 Perifollicular pigmentation         The pilosebaceous orifice in the depigmented areas has homogeneous surrounding pig-
                                     ment and is darker than that of normal skin.

pattern, depigmentation with reservoirs of perifollicular pig-     the dermo-epidermal junction were observed in half of
ment suggested that vitiligo was focally active or in repig-       the cases [14]. However, this publication does not describe
mentation [12].                                                    whether the determination of the number of melanocytes
   In a study of 176 patients with depigmentation, Meng            was made by immunohistochemistry. On the other hand, a
et al found that residual perifollicular pigmentation (Figure 2)   normal or decreased number of melanocytes does not al-
was more frequent in the progressive vitiligo group than in        ways reflect their proper functionality. In the initial stages of
the stable vitiligo group (91.94% versus 62.86%, P < 0. 05).       vitiligo, despite their misfunctions, the destruction of mela-
Residual perifollicular pigmentation was absent in patients        nocytes does not always occur but, this is not observable in
with depigmentation diseases other than vitiligo [13].             histopathology with hematoxylin and eosin.
   With dermoscopy, subtle changes in the pigment pat-                 In a study with one hundred cases, Wali et al found dif-
tern can be detected, allowing an early and more accu-             ferent dermatoscopic patterns corresponding with different
rate diagnosis [11]. In 30 patients with progressive vitiligo      evolutionary moments of the disease. In stable vitiligo, the
with less than one month of evolution, Thatte et al found          most frequent were reticular, perifollicular, and marginal pig-
that the most frequent dermatoscopic patterns were re-             mentation while in progressive vitiligo trichromic patterns
duced or absent pigment network (Figure 2) and the in-             were found (Figure 2), in salt and pepper, starbursts, and
verted pigment network. Perifollicular and perilesional            comet tails. Patients already receiving treatment showed ar-
hyperpigmentation was uncommon. In the same study,                 eas with erythema, telangiectasia, or atrophy, as well as pat-
a histopathological-dermatoscopic correlation was per-             terns of perifollicular pigmentation and marginal reticular
formed and the number of melanocytes was normal in                 hyperpigmentation [11]. In addition to the patterns already
60% of patients, lower in 23.5%, and absent in 16.5%.              indicated, progressive lesions may present perifollicular re-
Additionally, ­
              perivascular lymphocytic infiltrate and at           pigmentation points [15].



Review | Dermatol Pract Concept. 2023;13(4):e2023197                                                                              3
Figure 1. (A) Normal pigmentary pattern. (B) Perifollicular hyperpigmentation. (C) Perifollicular pigmentation. (D) Perifollicular
­depigmentation. (E) Reduced/absent network. (F) Reversed network. (G) Leukotrichia. (H) Tapioca sago appearance. (I) Micro-Koebner
 phenomenon. (J) Comet tail pattern. (K) Perilesional/marginal hyperpigmentation (L) Starburst pattern. (M) Trichrome pattern. (N) erythema
 with telangiectasia.


    Jha et al also studied the association of dermatoscopic            dermatoscopic examination. Other dermatoscopic patterns
patterns with different evolutionary stages of the disease.            observed in active vitiligo are named pattern in tapioca sago
They found that perifollicular pigment is an important                 (Figure 2) which comprehends small white spots without a
­dermatoscopic marker of vitiligo activity. Perifollicular pig-        structure and less than 1 mm in diameter localized around
mentation patterns and pigment network alteration (­reduced,           the main vitiligo patch or on the perilesional skin that looks
absent, or inverted) were more frequent in progressive                 clinically normal [16].
­vitiligo while perifollicular depigmentation and leukotrichia             In an additional study, Jha et al evaluated the dermato-
predominated in stable vitiligo. Leukotrichia (Figure 2) was           scopic patterns that correlated with vitiligo activity. In pro-
found in both stable and regressive vitiligo. Treated vitiligo le-     gressive vitiligo, perifollicular pigmentation and alteration of
sions presented perilesional hyperpigmentation and intra- or           the pigment network were most frequent, in stable vitiligo,
perilesional erythema with telangiectasias (Figure 2). In this         perifollicular depigmentation predominated. Dermatoscopic
study, a micro-Koebner microphenomenon was described for               patterns observed exclusively in progressive vitiligo lesions
the first time that is characterized by forming i­ somorphic de-       included: the starburst pattern, comet tail, and small pearly
pigmented linear striations distributed along the trauma line          white globules, which were also observed in clinically nor-
or around the main patch of vitiligo. ­Morphologically it is           mal perilesional skin of patients with progressive vitiligo.
different from that of a white comet tail composed of a uni-           ­Leukotrichia was associated with refractoriness to treatment.
directional linear extension or projection to an area adjacent         Perilesional hyperpigmentation, intralesional or perilesional
to the initial vitiligo lesion which appears in patients with          erythema, and telangiectasias were observed exclusively in
progressive vitiligo. Both evoke koebnerization that is not            patients responding to treatment. Their first publication also
detected by the naked eye highlighting the clinical value of           suggests that the loss or retention of perifollicular pigment is

4                                                                                   Review | Dermatol Pract Concept. 2023;13(4):e2023197
Figure 2. Representative dermoscopic images of vitiligo lesions (20x). (A) Normal skin reticulate pigmentary pattern. (B) Perifollicular
pigmentation (black arrow). (C) Trichromic pattern, black arrow: intermediate pigmentation more faint yellowish brown, blue arrow: de-
pigmented central area. (D) Absent network (black arrow). (E) Reduced network. (F) Leukotrichia (black arrow). (G) Tapioca sago (black
arrow). (H) Erythema with telangiectasia (black arrow) accompanied by repigmentation isles (blue arrow).




an important dermatoscopic marker of vitiligo activity, peri-         considered characteristic of stable vitiligo was less sensitive
follicular pigmentation suggests instability and perifollicular       (66.5%) and was not significantly correlated with clinical
depigmentation is characteristic of stable disease [17].              stability in this study (P = 0.251). However, the specificity
   In 2019, Nirmal et al evaluated the differences in derma-          of perifollicular pigmentation was higher (81.4%) indicating
toscopic patterns between inactive and progressive vitiligo.          that its absence is associated with unstable vitiligo [9].
The authors studied, in a cross-sectional and observational               So far, studies have described the different dermoscopic
model, 131 lesions from eighty-five patients between 16 and           patterns at the edges of the lesions. The tapioca sago pattern,
64 years of age using Wood light and dermatoscopy. Vitil-             the satellite lesions and the “micro-confetti-like depigmen-
igo activity was established using the vitiligo disease activity      tation” pattern mean depigmentation [9,16]. These perile-
score (VIDA); lesions with a score of 0 to -1 were classified         sional macules are too small to be recognized with the naked
as stable (at least for 1 year or with spontaneous repigmen-          eye. In addition, a poorly defined border also reflects lesion
tation) and those with a score of 1+ to 4+ as progressive             activity [9].
(activity from 6 weeks or less) [18]. With Wood light, it                 In vitiligo, melanocytes in hair follicles are one of the
was determined that the achromic lesions with well-defined            main sources of repigmentation. During dermatological ex-
boundaries were stable and that the progressive ones pre-             amination with the naked eye, it is possible to observe the
sented hypopigmentation, poorly defined boundaries, and               coloration of the hair shaft, whether it retains its pigment
trichromacy [9]. Dermatoscopically, stable vitiligo was char-         or becomes whitish (leukotrichia); segmental vitiligo is more
acterized by the absence of satellite lesions and Koebner             associated with this sign than non-segmental vitiligo. For
micro phenomena (sensitivity of 99.6% and 100% respec-                small hairs, dermoscopy is more useful than the naked eye to
tively). The presence of well-defined borders and cross-              detect pigmentation. Additionally, dermoscopy differentiates
linked or absent pigment networks within the vitiligo spots           white terminal hair (with greater length and thickness) from
were markers of stability (specificity of 100% and 96.8%).            vellous hair vitiligo spots and other locations. Dong-Young
The retention of perifollicular pigment that Chuh and Zawar           et al observed that leukotrichia in segmental vitiligo may

Review | Dermatol Pract Concept. 2023;13(4):e2023197                                                                                  5
insinuate a lack of response to medical treatment. Leukotri-       Conclusions
chia translates to the loss of melanocytes in the hair follicle,
that is, the patient lacks a reservoir of melanocytes to repig-    Dermoscopy is a non-invasive diagnostic tool that facilitates
ment the achromic spots. It is advisable to institute initial      the clinical approach to vitiligo and allows the clinician
treatment before most of the hairs located on the affected         to treat it according to its stage. The dermoscopic clues to
skin turn white [19].                                              assess vitiligo activity are found mainly at the perifollicu-
                                                                   lar level, as depigmentation or pigmentation. In active and

Repigmentation-guiding                                             ­stable lesions, an absent pigment network is commonly seen
                                                                   in the center. Repigmentation presents as islands of pigment,
Dermatoscopic Findings
                                                                   erythema, or telangiectasias. Finally, at the periphery of the
Another useful aspect of dermatoscopy in vitiligo is the           lesion, unstable vitiligo presents a diffuse or trichrome bor-
evaluation of the effectiveness of therapeutic interventions.      der, micro-Koebner/comet tail phenomenon, satellite lesions,
ElGhareeb et al evaluated the dermatoscopic characteris-           or a tapioca sago pattern. Pigmented lesions have a sharp
tics of vitiligo under systemic treatment. Patients who had        border and/or perilesional hyperpigmentation.
repigmentation presented increased perifollicular, intrale-
sional, and perilesional pigmentation, as well as a decrease       References
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