10.5826/dpc.1303a186
Introduction: There are diverse assessment tools for vitiligo, with no standardized approach that helps unify treatment outcome measures. Thus, comparing different treatment modalities and developing evidence-based recommendations for vitiligo management has been quite challenging.
Objectives: We compared the most commonly used tools assessing both vitiligo activity and extent, namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to their newly developed counterparts, namely, Vitiligo Extent Score Plus score (VES plus) and Vitiligo Signs of Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome assessment protocol for vitiligo patients.
Methods: Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom  completed 48 sessions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed for its reliability in comparison to VASI score.
Results: Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant improvement following treatment. Additionally, VES plus and VASI were positively correlating both before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.
Conclusions: VES plus and VASI scores have proven of comparable reliability. While examination-based VSAS score comes as an additive tool to the history-based VIDA score.
text/xml
2160-9381
3015
en
Rania M Mogawer
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
vitiligo assessment
Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and Extent Scores and Their Change With Treatment
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-07-31
2022-11-22
2023-07-31
2023-08-24
e2023186
Dermatol Pract Concept
Introduction: There are diverse assessment tools for vitiligo, with no standardized approach that helps unify treatment outcome measures. Thus, comparing different treatment modalities and developing evidence-based recommendations for vitiligo management has been quite challenging.
Objectives: We compared the most commonly used tools assessing both vitiligo activity and extent, namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to their newly developed counterparts, namely, Vitiligo Extent Score Plus score (VES plus) and Vitiligo Signs of Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome assessment protocol for vitiligo patients.
Methods: Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom  completed 48 sessions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed for its reliability in comparison to VASI score.
Results: Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant improvement following treatment. Additionally, VES plus and VASI were positively correlating both before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.
Conclusions: VES plus and VASI scores have proven of comparable reliability. While examination-based VSAS score comes as an additive tool to the history-based VIDA score.
Rania M Mogawer
2023/07/31
10.5826/dpc.1303a186
e2023186
Dermatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
2160-9381
vitiligo assessment
en
e2023186
van Geel N, Depaepe L, Vandaele V, et al. Assessing the dynamic changes in vitiligo: reliability and validity of the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS). J Eur Acad Dermatol Venereol. 2022;36(8):1334-1341. DOI :10.1111/jdv.18134. PMID: 35398942; PMCID: PMC9543188.
Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and Extent Scores and Their Change With Treatment
https://dpcj.org/index.php/dpc/article/download/3015/2193
  Comparative Analysis of the Most Used Versus
the Recently Developed Vitiligo Activity and Extent
     Scores and Their Change with Treatment
                             Randa Youssef1, Nourhan Emad1, Rania M Mogawer1


1 Dermatology Department, Faculty of Medicine, Cairo University, Cairo, Egypt



Key words: VES plus, VASI, VIDA, VSAS, vitiligo assessment
Citation: Youssef R, Emad N, Mogawer RM. Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and
Extent Scores and Their Change With Treatment. Dermatol Pract Concept. 2023;13(3):e2023186. DOI: https://doi.org/10.5826
/dpc.1303a186
Accepted: February 6, 2023; Published: July 2023
Copyright: ©2023 Youssef 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: Rania M Mogawer, Lecturer of Dermatology, Faculty of Medicine, Cairo University, 15 D4, Maadi Grand City,
Cairo, Egypt. Telephone: +201068165330 Postal code: 11427 Orchid ID: https://orcid.org/0000-0002-9929-5413
Email: Raniamogawer@kasralainy.edu.eg




  ABSTRACT             Introduction: There are diverse assessment tools for vitiligo, with no standardized approach that
                       helps unify treatment outcome measures. Thus, comparing different treatment modalities and develop-
                       ing evidence-based recommendations for vitiligo management has been quite challenging.
                       Objectives: We compared the most commonly used tools assessing both vitiligo activity and extent,
                       namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to
                       their newly developed counterparts, namely, Vitiligo Extent Score Plus (VES plus) and Vitiligo Signs of
                       Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome
                       assessment protocol for vitiligo patients.
                       Methods: Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom completed 48 ses-
                       sions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both
                       before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed
                       for its reliability in comparison to VASI score.
                       Results: Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant
                       improvement following treatment. Additionally, VES plus and VASI were positively correlating both
                       before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable
                       as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA
                       following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.
                       Conclusions: VES plus and VASI scores have proven of comparable reliability. While examination-based
                       VSAS score comes as an additive tool to the history-based VIDA score.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023186                                                                       1
Introduction                                                        (NSV) patients aging ≥ 18 years old were recruited. A VIDA
                                                                    score ≥2 was set as an inclusion criterion to ensure recent
Vitiligo is a chronic depigmenting skin disorder that can be        vitiligo activity and monitor its change following treatment.
cosmetically disfiguring with high psychological burden [1].        Of the 36 patients, only 30 patients completed the study.
Treatment is quite challenging [2] with no standardized as-            Thorough history was taken for different vitiligo character-
sessment tools for its evaluation and follow-up of treatment        istics including duration and age of onset. Baseline assessments
response as well as for comparing different treatment modal-        for vitiligo activity and extent as well as pigmentation were
ities. This, in turn, hinders comparison of different clinical      carried out. Vitiligo activity was evaluated using total VSAS,
trials and the development of evidence-based recommenda-            Koebner VSAS, confetti VSAS and hypochromic VSAS [14],
tions [3-7].                                                        together with the history-based VIDA score [13]. Vitiligo ex-
    Various tools are currently available for assessing vitiligo    tent and pigmentation were evaluated using both VES plus [8]
extent and response to treatment. Since re-pigmentation is          and VASI scores [9].
the most important reported treatment outcome [4], limita-             Both VSAS and VES plus, available through online vit-
tion to the previously developed Vitiligo Extent Score (VES         iligo calculator https://www.vitiligo-calculator.com, depend
score) was disregarding pigmentation [7]. Thus, Vitiligo Ex-        upon diagrammatic representation of different body sites.
tent Score Plus (VES plus score) was developed that consid-         In VES plus, diagrams representing different extents of vitil-
ered both extent and follicular pigmentation [8]. Accordingly,      igo with option of adding extent of follicular pigmentation
VES plus score stands as an alternative tool to Vitiligo Area       within each site are available. Final VES plus score is de-
and Severity Index (VASI), which is the most cited and used         veloped by automatically summing the extent in different
vitiligo extent assessment tool [9,10]. Both VES plus and VASI      affected sites after deducting extent of follicular pigmenta-
scores consider extent as well as follicular pigmentation.          tion [8]. In VSAS, the three main signs of vitiligo activity;
However, VASI score, despite being widely used [3], is more         koebnerization type IIB, confetti-like depigmentation and
time-consuming [9,10] since it is manually calculated [9],          hypochromic/ ill-defined edges, are recorded for different
in comparison to VES plus score, which is calculated online [7].    body sites giving a total activity score out of 15, for all signs
Additionally, VES plus has been pointed out to detect               as total VSAS, where one or more signs of activity within
small changes in the extent of vitiligo, which adds to its          one site scores 1 out of 15, and for each sign separately as
privilege [11,12].                                                  Koebner, hypochromic and confetti VSAS [14].
    Regarding vitiligo activity, history-based Vitiligo Disease        Regarding VIDA score, it is mainly based on the duration
Activity Score (VIDA) has been the most used tool [13]. It          since the date of last activity, which is essentially given by
was only in 2020, when examination-based Vitiligo Signs             history, in the form of expansion of old lesions, koebneriza-
Activity Score (VSAS) was introduced taking into account            tion or development of new lesions [13]. As for VASI, extent
different signs of vitiligo activity [14].                          of vitiligo as per hand units is multiplied by extent of depig-
                                                                    mentation in different body sites, which are added together
Objectives                                                          to get total VASI score [9].
                                                                       Total body narrow band ultraviolet B (NBUVB) was
The aim of this work is to provide some insights in the most        chosen as a unified treatment protocol that achieves both
recently introduced vitiligo extent score; namely, VES plus         re-pigmentation and stabilization [15]; thus, offering change
[8] in comparison to the most used one; namely, VASI score          in both extent and activity scores. Sessions were delivered
[9]. Additionally, we aimed at evaluating examination based         by a UV 100 L; Waldmann GmbH cabinet with 40 narrow
VSAS, which is the first vitiligo assessment tool that consid-      band UVB fluorescent tubes (Philips TL 01, 100 W, Philips
ers solely clinical signs of vitiligo activity [14] in compari-     company), an emission spectrum of 310-315 nm was used.
son to the most used and validated tool; VIDA score [13].           Patients received 3 sessions per week on non-consecutive
This study provides a cohort of vitiligo patients to evalu-         days for a total of 48 sessions.
ate change in the aforementioned extent and activity scores            Following 48 sessions of NB-UVB, patients were reas-
to allow for a deeper understanding and interpretability of         sessed for both activity using VIDA and VSAS scores and
change in these scores and their utility in follow up of vitiligo   extent using VES plus and VASI scores.
patients.
                                                                    Statistical Methods
Methods                                                             Data were coded and entered using the statistical package
                                                                    for the Social Sciences (SPSS) version 28 (IBM Corp.). Data
The study was conducted at the Vitiligo Clinic, Cairo Uni-          was summarized using mean, standard deviation, median,
versity Hospitals. Thirty-six active Non segmental vitiligo         minimum, and maximum in quantitative data and using



2                                                                       Original Article | Dermatol Pract Concept. 2023;13(3):e2023186
frequency (count) and relative frequency (percentage) for                Baseline assessment for vitiligo extent revealed a VES plus
categorical data. For comparison of serial measurements              score area of 3.39 ± 3.66 and a VASI score of 4.38 ± 4.11.
within each patient, the non-parametric Wilcoxon signed              Regarding vitiligo activity, twenty-four patients (80%) had a
rank test was used. Correlations between quantitative vari-          VIDA score of +4 and mean VIDA score was 3.77±0.5. Re-
ables were done using Spearman correlation coefficient.              garding VSAS score, patients had a mean total VSAS, confetti
Testing for across items reliability (internal consistency) was      VSAS, Koebner VSAS and hypochromic VSAS of 6.63 ± 2.9,
done using the Intra Class Coefficient (ICC) and Cronbach’s          1.47 ± 1.46, 1.67 ± 1.77 and 6.1 ± 3.03 respectively.
alpha reliability coefficient with their 95% confidence inter-           After completing 48 sessions of NB-UVB, significant
val (95%CI). P values less than 0.05 were considered as sta-         improvement was evident in both activity and extent scores
tistically significant.                                              (P = 0.01). Patients had a mean VES plus score of 1.86 ± 2.15
                                                                     and a mean VASI score of 2.81 ± 2.58; while mean VIDA
                                                                     score was 2.5 ± 0.82 and mean total VSAS, Koebner VSAS,
Results                                                              hypochromic VSAS and confetti-VSAS were 0.83 ± 1.34,
Thirty-six patients were recruited, of whom 30 patients com-         0.23 ± 0.57, 0.63 ± 1.22 and 0.13 ± 0.35 respectively. The
pleted the 48 sessions of NB-UVB. Of those who completed             clinical data of the patients are summarized in Table 1.
the NB-UVB sessions, nine were males and twenty-one were                 On correlating both extent scores, namely, VES plus and
females. Patients had mean age of 29.6 ± 13.7 and an aver-           VASI, they were strongly positively correlating both before
age disease duration of 92.17 ± 83.08 months. The demo-              and after NB-UVB as well as their percent change (r = 0.936,
graphic data of the patients are summarized in Table 1               0.97 and 0.723, respectively, P < 0.001) (Figure 1).




      Table 1. Clinical and Demographic Data of the Patients Who Completed the Study (N = 30).
                                                            Characteristics
 Sex (%)                                       Females                                                21 (70%)
                                               Males                                                  9 (30%)
 Age (years)                                   Mean ± SD (Range)                                      29.6 ± 13.7 (18–61)
 Age of onset (years)                          Mean ± SD (Range)                                      22 ±13.01 (6–56)
 Duration of disease (months)                  Mean ± SD (Range)                                      92.17 ± 83.08 (3–360)
 Skin phototype (%)                            III                                                    14 (46.7%)
                                               IV                                                     16 (53.3%)
 Associated with stress or trauma (%)                                                                 24 (80%)
 Family history of vitiligo (%)                                                                       10 (33.3%)
 Family history of autoimmune disease (%)                                                             4 (13.30%)
                                                     Clinical assessment scores
 Cases                                         Before NB-UVB                      After NB-UVB                           P-value
                                               Mean ± SD (Range)                  Mean ± SD (Range)
 VIDA score                                    3.77±0.5 (2-4)                     2.5 ± 0.82 (2–4)                       < 0.001
 VIDA score (%)
 2                                             1(3.33%)                           20(66.66%)
 3                                             5(16.66%)                          3(10%)
 4                                             24(80%)                            6(20%)
 VASI score                                    4.38 ± 4.11(0.33–15.85)            2.81 ± 2.58 (0.17–10.62)               < 0.001
 VES plus score                                3.39 ± 3.66 (0.33 –13.33)          1.86 ± 2.15 (0.07–9.31)                < 0.001
 Total VSAS score                              6.63 ± 2.9 (2–14)                  0.83 ± 1.34 (0–5)                      < 0.001
 Confetti VSAS score                           1.47 ± 1.46 (0–6)                  0.13 ± 0.35 (0–1)                      < 0.001
 Koebner VSAS score                            1.67 ± 1.77 (0–6)                  0.23 ± 0.57 (0–2)                      < 0.001
 Hypochromic VSAS                              6.1±3.03 (2-14)                    0.63±1.22 (0-5)                        < 0.001

NB-UVB = narrow band ultraviolet B; SD = standard deviation; VIDA = Vitiligo Disease Activity Score; VES = Vitiligo Extent Score;
VSAS = Vitiligo Signs of Activity score.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023186                                                                     3
Figure 1. Strong Positive correlation between Vitiligo Extent Score plus (VES plus) and Vitiligo Area and Severity Index (VASI) scores both
before and after narrow band Ultraviolet B (NB-UVB) treatment as well as percent change in the scores following treatment (r = 0.936, 0.97,
0.723).




    On correlating both history-based VIDA score and exam-             treatment outcome [11], comparing the different available
ination based total VSAS, Koebner VSAS, hypochromic VSAS               scores would help provide insights in their application. This,
and confetti VSAS, none of the VSAS scores correlated with             in turn, will aid in the process of unifying vitiligo assess-
the VIDA score before NB-UVB treatment (r = - 0.007, -0.132,           ment, which would help give way for a better analysis of
-0.106 and -0.015, respectively) (P = 0.97, 0.488, 0.576 and           different treatment modalities as well as comparing different
0.938, respectively). Similarly, percent change in both scores         clinical trials, which has currently been an urging need for
did not correlate with one another (r = 0.03, -0.103, -0.005           the development of evidence -based recommendations for
and -0.140, respectively) (P = 0.876, 0.589, 0.98 and 0.462,           vitiligo [3-7].
respectively). After NB-UVB treatment, total, hypochromic                  When assessing vitiligo, both vitiligo activity and ex-
and Koebner VSAS positively correlated with history-based              tent, together with lesional pigmentation are to be consid-
VIDA score (r = 0.846, 0.873 and 0.427, respectively)                  ered, where both pigmentation and cessation of spread of
(P < 0.001, < 0.001 and 0.018, respectively) (Figure 2). On            vitiligo are main treatment outcomes, from both patients’
the other hand, confetti VSAS did not correlate with VIDA              and physicians’ perspectives [16]. Both VES plus [8] and
score after NB-UVB treatment (r = 0.211, P = 0.263).                   VASI [9] scores consider extent and follicular pigmenta-
    For assessing reliability of VES plus score in comparison to       tion; thus, they stand as alternative tools, but the first is
VASI, which is the most commonly used and cited extent score,          less time consuming, while the latter is most used. Regard-
reliability score was done for all readings of VES plus in com-        ing activity, VIDA [13], which is essentially history based,
parison to VASI (both before and after treatment with NB-UVB)          is the most used prior to the introduction of the VSAS [14],
including the readings of the six patients who were dropped out        which is examination based. Thus, this work aimed at
making a total of 66 readings. It revealed an Intraclass Correla-      comparing the most recently developed vitiligo assessment
tion Coefficient of 0.962 and Cronbach Alpha score of 0.981,           tools for extent and activity in comparison to the most
P < 0.001 denoting high reliability of both scores (Table 2).          commonly used ones, at baseline, following treatment as
                                                                       well as their change with treatment.

Conclusions                                                                In the current study, all scores have proven to change sig-
                                                                       nificantly with disease regression, which in turn points out to
In the light of the challenging nature of vitiligo treatment [2],      their utility as outcome measures for vitiligo follow up and
together with the diversity of the available tools for assessing       comparison of different treatment modalities.



4                                                                           Original Article | Dermatol Pract Concept. 2023;13(3):e2023186
Figure 2. Positive correlation between Vitiligo Disease Activity Score (VIDA) and total, Koebner and hypochromic Vitiligo Signs Activity
Score (VSAS) after narrow band Ultraviolet B (NB-UVB) treatment (r = 0.846, 0.427 and 0.873 respectively) (P < 0.001, 0.018 and < 0.001,
respectively).




  Table 2. Reliability of Vitiligo Extent Score Plus score in Comparison to Vitiligo Area and Severity
                                           Index score (N = 66).
                                                                              95% Confidence Interval
                                                        Value           Lower Bound                 Upper Bound             P value
 Intraclass Correlation Coefficient                     0.962                0.939                       0.977              <0.001
 Cronbach alpha                                         0.981                0.968                       0.988              <0.001




    A significant positive correlation was detected between           previously compared to VASI score, which have simulated
VES plus score and VASI before and after NB-UVB as well as            patient reported activity to flipping a coin, due to lack of cor-
their percent change following treatment. Additionally, both          relation to physician reported VASI score [17]. Since VIDA
VES plus and VASI scores were found equally reliable. Thus,           score is essentially history based [13], patients can easily miss
VES plus score stands as an easy, less time-consuming tool,           activity especially prior to starting treatment when he is not
to assess vitiligo extent taking into account perifollicular pig-     much concerned about change in his disease. While on treat-
mentation which was one of the drawbacks of the original              ment, patients are more likely to be concerned about their
VES score [7,10].                                                     disease and its progression which could explain why scores
    Regarding activity scores, a significant positive correla-        correlated only after treatment but not prior to treatment.
tion was detected between VIDA score and total VSAS score,                Regarding confetti VSAS, it did not correlate with VIDA
Koebner VSAS and hypochromic VSAS after NB-UVB. How-                  neither before nor after treatment being a difficult clinical
ever, VIDA score did not correlate with either VSAS scores            sign that patients are very likely to miss until the small mac-
before treatment with NB-UVB or with confetti VSAS after              ules coalesce in a well-recognized lesion. This highlights the
treatment.                                                            fact that an examination-based assessment tool for vitiligo
    To the best of our knowledge, no studies have yet                 activity is indispensable to accurately identify vitiligo activity
compared VSAS to VIDA score. However, VIDA has been                   status and to meticulously follow up vitiligo activity.



Original Article | Dermatol Pract Concept. 2023;13(3):e2023186                                                                        5
    In the context of vitiligo follow up and assessment of its            6. Wolkerstorfer A. The long road to valid outcomes in vitiligo.
dynamic change in terms of both pigmentation and activ-                      Br J Dermatol. 2019;180(3):454-455. DOI:10.1111/bjd.17409.
                                                                             PMID: 30821367. PMCID: PMC6850450.
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                                                                          7. van Geel N, Lommerts J, Bekkenk M, et al. Development and Val-
ity Score (VDAS) and Vitiligo Disease Improvement Score
                                                                             idation of the Vitiligo Extent Score (VES): an International Col-
(VDIS) have been recently introduced. Vitiligo Sings of Ac-                  laborative Initiative. J Invest Dermatol. 2016;136(5):978-984.
tivity Score is suggested for a single point static assessment,              DOI: 10.1016/j.jid.2015.12.040. PMID: 26827762.
while VDAS and VDIS scores for dynamic assessments on                     8. van Geel N, Wolkerstorfer A, Lommerts JE, et al. Validation
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                                                                             PMID: 29180094.
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                                                                          9. Hamzavi I, Jain H, McLean D, et al. Parametric modeling of
score is not readily available for implementation, but worth                 narrowband UV-B phototherapy for vitiligo using a novel quan-
assessment and comparison to utilizing separate scores for                   titative tool: the Vitiligo Area Scoring Index. Arch Dermatol.
assessing vitiligo extent and activity in the follow up.                     2004; 140:677-683. DOI: 10.1001/archderm.140.6.677. PMID:
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                                                                         10. Mogawer RM, Mostafa WZ, Elmasry MF. Comparative anal-
newly developed semi-subjective scores; VES plus and VSAS
                                                                             ysis of the body surface area calculation method used in vitil-
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                                                                             igo extent score vs the hand unit method used in vitiligo area
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                                                                         12. Uitentuis SE, Wolkerstorfer A, Bae JM, et al. Assessing the
    Both VES plus and VSAS are effective tools for assessing
                                                                             minimal important change in the vitiligo extent score and the
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