10.5826/dpc.1304a277
Background: Previously laid down criteria for lesional stability of vitiligo are inconsistent. Longitudinal data on correlation between dermoscopic features of vitiligo and disease activity is limited.
Objective: To sequentially determine the dermoscopic features of vitiligo and to assess their association with the dynamic nature of the vitiligo patch.
Methods: Sixty patients with 200 vitiligo patches fulfilling the inclusion criteria on medical therapy were subjected to sequential clinical and dermoscopic examination for 6 months. Baseline lesional photographs, dermoscopy and tracing of the patch was made and repeated at 6 months. The follow up tracing was superimposed onto the baseline tracing. Based on the increase or decrease in size, their outcomes were grouped as responsive, progressive and quiescent. Paired analysis of dermoscopic features was done between baseline, and their follow up after 6 months.
Results: Well defined border was associated with static nature of the vitiligo patch and ill-defined borders and trichrome pattern depicted its dynamic nature. Statistically significant increase in leukotrichia and satellite lesions amongst progressive patches and a decrease amongst responsive patches was observed. Pigment network changes were statistically significant for both responsive and progressive patches. Satellite lesions and micro-Koebner’s phenomena was suggestive of progressive disease, while perifollicular pigmentation and perilesional hyperpigmentation was suggestive of repigmenting disease and proved to be an early marker for response to therapy.
Conclusions: Repeated dermoscopic evaluation of lesions in a serial manner to assess disease activity helps understand their evolving nature and is a valuable tool in planning appropriate further treatment.
text/xml
2160-9381
3365
en
Sachin  Chamle
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
dynamic characteristic of vitiligo
Monitoring of Vitiligo Patches Over 6 Months to Validate Dermoscopic Findings of Lesional Stability
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-10-31
2023-03-23
2023-10-31
2024-01-16
e2023277
Dermatol Pract Concept
Background: Previously laid down criteria for lesional stability of vitiligo are inconsistent. Longitudinal data on correlation between dermoscopic features of vitiligo and disease activity is limited.
Objective: To sequentially determine the dermoscopic features of vitiligo and to assess their association with the dynamic nature of the vitiligo patch.
Methods: Sixty patients with 200 vitiligo patches fulfilling the inclusion criteria on medical therapy were subjected to sequential clinical and dermoscopic examination for 6 months. Baseline lesional photographs, dermoscopy and tracing of the patch was made and repeated at 6 months. The follow up tracing was superimposed onto the baseline tracing. Based on the increase or decrease in size, their outcomes were grouped as responsive, progressive and quiescent. Paired analysis of dermoscopic features was done between baseline, and their follow up after 6 months.
Results: Well defined border was associated with static nature of the vitiligo patch and ill-defined borders and trichrome pattern depicted its dynamic nature. Statistically significant increase in leukotrichia and satellite lesions amongst progressive patches and a decrease amongst responsive patches was observed. Pigment network changes were statistically significant for both responsive and progressive patches. Satellite lesions and micro-Koebner’s phenomena was suggestive of progressive disease, while perifollicular pigmentation and perilesional hyperpigmentation was suggestive of repigmenting disease and proved to be an early marker for response to therapy.
Conclusions: Repeated dermoscopic evaluation of lesions in a serial manner to assess disease activity helps understand their evolving nature and is a valuable tool in planning appropriate further treatment.
Sachin  Chamle
2023/10/31
10.5826/dpc.1304a277
e2023277
Department of Dermatology, Venerology and Leprosy, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
2160-9381
dynamic characteristic of vitiligo
en
e2023277
Jha AK, Sonthalia S, Lallas A. Dermoscopy as an evolving tool to assess vitiligo activity. J Am Acad Dermatol. 2018;78(5):1017-1019.
Monitoring of Vitiligo Patches Over 6 Months to Validate Dermoscopic Findings of Lesional Stability
https://dpcj.org/index.php/dpc/article/download/3365/2385
 Monitoring of Vitiligo Patches Over Six Months to
Validate Dermoscopic Findings of Lesional Stability
                     Chitra Kamath1, Rachita Dhurat1, Bhavika Shah1, Richa Sharma1,
                                 Priyanka Arun Kowe1, Sachin Chamle1


1 Department of Dermatology, Venerology and Leprosy, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India



Key words: dermoscopy, lesional stability, active vitiligo, dynamic characteristic of vitiligo
Citation: Kamath C, Dhurat R, Shah B, Sharma R, Kowe PA, Chamle S. Monitoring Of Vitiligo Patches Over Six Months To Validate
Dermoscopic Findings Of Lesional 98. Dermatol Pract Concept. 2023;13(4):e2023277. DOI: https://doi.org/10.5826/dpc.1304a277
Accepted: June 19, 2023; Published: October 2023
Copyright: ©2023 Kamath 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: Dr Rachita Dhurat, Opd 16, New OPD building, Sion Hospital Mumbai, India 400022.
Phone no.- +91-9833394951 Email: rachitadhurat@yahoo.co.in




  ABSTRACT              Introduction: Previously laid down criteria for lesional stability of vitiligo are inconsistent. Longitudi-
                        nal data on correlation between dermoscopic features of vitiligo and disease activity is limited.
                        Objectives: To sequentially determine the dermoscopic features of vitiligo and to assess their associa-
                        tion with the dynamic nature of the vitiligo patch.
                        Methods: Sixty patients with 200 vitiligo patches fulfilling the inclusion criteria on medical therapy
                        were subjected to sequential clinical and dermoscopic examination for 6 months. Baseline lesional
                        photographs, dermoscopy and tracing of the patch was made and repeated at 6 months. The follow
                        up tracing was superimposed onto the baseline tracing. Based on the increase or decrease in size, their
                        outcomes were grouped as responsive, progressive and quiescent. Paired analysis of dermoscopic fea-
                        tures was done between baseline, and their follow up after 6 months.
                        Results: Well defined border was associated with static nature of the vitiligo patch and ill-defined
                        borders and trichrome pattern depicted its dynamic nature. Statistically significant increase in leukotri-
                        chia and satellite lesions amongst progressive patches and a decrease amongst responsive patches was
                        observed. Pigment network changes were statistically significant for both responsive and progressive
                        patches. Satellite lesions and micro-Koebner’s phenomena was suggestive of progressive disease, while
                        perifollicular pigmentation and perilesional hyperpigmentation was suggestive of re-pigmenting dis-
                        ease and proved to be an early marker for response to therapy.
                        Conclusions: Repeated dermoscopic evaluation of lesions in a serial manner to assess disease activity
                        helps understand their evolving nature and is a valuable tool in planning appropriate further t­ ­reatment.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023277                                                                        1
Introduction                                                       morphology of lesion like manual excoriation and patches
                                                                   less than 1 cm2 in size.
Lesional stability in vitiligo is of paramount importance to
provide guidance in selecting patients for surgical interven-      Study Data
tion. Various definitions have been stated to explain disease      Detailed patient history and lesional clinical photographs
stability, that are inconsistent and depict conflict amongst       were obtained. Change in size of patches over six months
one another [1–6]. However, Vitiligo European Taskforce            was monitored by tracing the lesion on graph paper with
Consensus conference have stated, relying on lesional sta-         the help of a transparent sheet. The area of the patch was
bility is far better than the overall stability of the disease,    calculated using the point counting method at baseline and
as the latter is difficult to define precisely and reliably [7].   at six months. The follow up tracing of the patch was su-
Various clinical and experimental studies have tried to assess     perimposed on the baseline record of the same patch on the
the lesional stability on the basis of objective biochemical       transparent sheet. The clinical outcomes of these patches
and immunological parameters [8–11]. However, these in-            were documented as follows:
vestigations are not practical, may be invasive and expensive.
Off late, dermoscopy has been utilized with respect to the         1. Responsive-Patch having a minimum of 10% reduction
lesional stability of vitiligo.                                       in size from baseline.
    Some cross-sectional studies have tried to correlate the       2. Progressive-Patch having a minimum of 10% increase in
dermoscopic features with disease activity [12–15]. Results           size from baseline.
are non-homogenous and even contradictory, as far as asso-         3. No change, ie quiescent -no variation in size of the patch
ciation with disease activity/stability is concerned. In these        at baseline and follow up period.
studies, stability was assessed based on patient’s history         4. Resolved- complete repigmentation achieved within
which can be unreliable, and carries a degree of recall bias.         the patch.
Ideally, serial clinical and dermoscopic analysis must be per-
formed to establish lesional stability and there have been            Dermoscopy was performed for each vitiligo patch
paucity of studies achieving the same. This unique study was       in a clockwise direction, using Dinolite video dermoscope
planned to prospectively document the changes in dermos-           (Model number AF4115ZT) with 20X magnification un-
copy in vitiligo patches over six months and correlate them        der polarized light. Pre-defined dermoscopic parameters
with lesional activity.                                            [16] of border, pigment network, perilesional hyperpig-
                                                                   mentation, perifollicular pigmentation, leukotrichia, micro-
Objectives                                                         koebnerisation, satellite lesions and trichrome pattern were
                                                                   recorded at baseline and follow-up (Table 1). All patches were
To determine the dermoscopic changes of vitiligo patches se-       treated with tailor-made topical/ systemic therapy based on
quentially and correlate with its clinical outcome and estab-      the patient’s subsequent response. The dermoscopic findings
lish dermoscopic criteria for prognosis of the disease.            and size were documented at baseline and at 6 months. Der-
                                                                   moscopic findings based on their clinical outcomes were an-
Methods                                                            alyzed and compared to previously established criteria laid
                                                                   down for the stability of vitiligo.
Two hundred vitiligo patches from 60 patients were selected.
Study was conducted as a monocenter observational longitu-
                                                                   Statistical Analysis
dinal study at a tertiary hospital over a period of 18 months
                                                                   Data analysis was done using online software of SPSS 23.0.
from April 2021 to October 2022. The study was approved
                                                                   The comparison of two groups was done using one-way
by the institutional ethics committee.
                                                                   Chi Square test. Comparison of mean between two inter-
                                                                   vals within the group was done using Fischer exact test.
Inclusion Criteria
                                                                   A P <0.05 was taken as statistically significant.
1. All patients of vitiligo of any age group.
2. Patients who are willing to give consent and take treat-
    ment for the disease.
                                                                   Results
                                                                   Two hundred vitiligo patches from 60 patients were ana-
Exclusion Criteria                                                 lyzed. Of these, there was a loss to follow-up of three pa-
Mucosal and scalp vitiligo lesions, close differentials of hypo-   tients (eight patches), and nine patches showed complete
depigmented lesions, patients on phototherapy, previ-              resolution; and these were not considered for final analy-
ously surgically treated patches, any changes to primary           sis. The average age of the patients was 24.21 ± 09.40 years



2                                                                      Original Article | Dermatol Pract Concept. 2023;13(4):e2023277
                                     Table 1. Definition of dermoscopic parameters.
     SrNo       Dermoscopic feature                                               Definition
 1           Margins                          Ill defined- at least 25% of the margins are ill-defined.
                                              Well-defined or ill- defined margins are mutually exclusive.
 2           Perilesional                     Accentuated pigment network in at least 25% of the perilesional/marginal
             Hyperpigmentation                uninvolved skin of a vitiligo patch
 3           Satellite lesions                White structureless areas of size >1mm in diameter in the perilesional skin which
                                              may not be apparent on clinical examination
 4           Micro-Koebner                    Linearly arranged areas of depigmentation, which are not easily perceived by
             phenomenon                       naked eye examination
 5           Leukotrichia                     It is defined as the presence of depigmented hair in at least 25% of total hair
                                              follicles.
 6           Pigment network changes          At baseline
             (interfollicular regions)        • Absent pigment network refers to no pigment in interfollicular regions.
                                              • Reduced pigment network refers to pigment dilution or decreased pigment as
                                                compared to the normal skin
                                              At follow-up
                                              • Initiation of Pigment network refers to onset of new pigmentation on a
                                                previously absent pigment network
                                              • Well-formed pigment Network -Formation of a reticular pigment network on
                                                follow up period.
                                              • Status Quo- A patch with absent pigment network at baseline shows the same
                                                pigment network on follow up and similarly a patch with reduced pigment
                                                network at baseline depicts same findings of pigment network on follow up
                                                period as well.
 7           Perifollicular Pigmentation      Pigment network around hair follicles, in at least 25% of the hair follicles.
                                              Perifollicular re-pigmentation: refers to reappearance of pigment network
                                              around hair follicles, which previously had a complete loss of pigment network
                                              in at least 25% of the hair follicles.



(range of 05 – 70 years). Of the 183 patches studied, 102               Findings of leukotrichia and satellite lesions decreased
patches (55.73%) were observed in females and the remain-           from baseline to follow-up in responsive patches, and in-
ing 81 (44.27%) in males. The descending order of involve-          creased in progressive patches, and the differences seen
ment of these patches were lower limbs (36.97%), upper              for both of these parameters were statistically significant
limb (33.86%), trunk (15.10%) and 4.69% each for the                ­(Tables 3 and 4).
face, neck and back. At the end of 6 months, 124 (64.58%)               There was also a statistically significant increase of per-
patches were responsive, 37 (19.28%) were progressive, and          ifollicular pigmentation and perilesional hyperpigmentation
22 (11.45%) had no change in size from the baseline to the          amongst responsive patches at follow up, and a decrease in
follow-up period.                                                   the same for progressive patches, when compared to their
                                                                    respective baselines (Table 3). A statistically significant
Dermoscopic Analysis                                                difference in the perifollicular pigmentation were noted in
The changes in border (P = 0.0001) and trichome pattern             those that had terminal hair versus those that had vellus hair
(P = 0.02) in responsive vitiligo patches from baseline to six-     within responsive patches.
month follow-up were statistically significant. A significant           Pigment network changes were seen in both responsive
number of patches had ill-defined borders among both re-            and progressive patches, whose differences from baseline to
sponsive and progressive groups. Ill-defined borders were           follow up period were statistically significant (Table 5).
present in 82.2% of responsive patches at their baseline. Of
these patches, 98.04% continued to show ill-defined borders
                                                                    Conclusions
at the follow up period. Among progressive patches, 78.38%
had ill-defined borders at baseline, of which 100% remained         In the present study, dermoscopic parameters were studied
ill-defined at follow up. Well defined borders of quies-            by observing dynamic changes in a vitiligo patch over a pe-
cent patches (81.82%) showed no change over 6 months                riod of 6 months while receiving therapy, to verify the le-
(Table 2).                                                          sional stability.



Original Article | Dermatol Pract Concept. 2023;13(4):e2023277                                                                   3
4
                                                                                   Table 2. Dermoscopic features – Border and Trichrome pattern according to outcome patients at Baseline and Follow-up of the
                                                                                                                                  lesion in the study population.
                                                                  Dermoscopic                           Responsive(124)                                          Progressive(37)                                          No change(22)
                                                                    features                                 N(%)                                                     N(%)                                                    N(%)
                                                                  1. Border            Well Defined (Baseline)              Ill defined         Well Defined (Baseline)             Ill defined         Well Defined (Baseline)             Ill defined
                                                                                             22 (17.74)                      (Baseline)               08 (21.62)                    (Baseline)                18 (81.82)                    (Baseline)
                                                                                                                            102 (82.2)                                              29 (78.38)                                              04 (18.18)
                                                                                      Well defined   Ill defined   Well defined      Ill        Well defined   Ill defined   Well defined   Ill defined Well defined   Ill defined   Well defined   Ill defined
                                                                                         (FU)            (FU)         (FU)      defined (FU)       (FU)            (FU)         (FU)            (FU)       (FU)            (FU)         (FU)            (FU)
                                                                                      06 (27.27)     16 (72.73)     02 (1.96)   100 (98.04)      01 (12.5)     07 (87.5)        0 (0)       29 (100)     18 (100)          0 (0)        0 (0)         4 (100)
                                                                                                        p value = 0.0001                                            p value = 1                                              p value =1
                                                                  2. Trichrome           Present (Baseline)              Absent (Baseline)         Present (Baseline)           Absent (Baseline)          Present (Baseline)           Absent (Baseline)
                                                                                            52 (41.94)                     72 (58.06)                 17 (45.95)                  20 (54.05)                   02 (9.09)                  20 (90.91)
                                                                                      Present (FU)   Absent (FU) Present (FU)     Absent (FU)   Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                       24 (46.14)    28 (53.85)   07 (9.72)       65 (90.28)     12 (70.59) 05 (29.41)     07 (35)     13 (65)      01 (50)     01 (50)        0 (0)     20 (100)
                                                                                                              P = 0.02                                               P = 0.7004                                                 P=1
                                                                 FU = follow-up.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023277
                                                                  Table 3. Dermoscopic features of leukotrichia, perifollicular pigmentation and perilesional pigmentation according to outcome of patients at baseline
                                                                                                                  and follow-up of the lesion in the study population.
                                                                  Dermoscopic                           Responsive                                          Progressive                                         No change
                                                                    features                             (N=124)                                              (N=37)                                             (N=22)
                                                                  Leukotrichia         Present-Baseline                Absent - Baseline   Present - Baseline              Absent - Baseline   Present - Baseline              Absent - Baseline
                                                                                          38 (30.65)                     86 (69.35)           15 (40.54)                     22 (59.46)            9 (40.91)                     13 (59.09)
                                                                                   Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                        18          20            3          83           11          04           08          14           08          01           01          12
                                                                                     (47.37)      (52.63)      (3.49)      (96.51)     (73.33)      (26.67)     (36.36)      (63.64)     (88.89)      (11.11)      (7.69)      (92.31)




Original Article | Dermatol Pract Concept. 2023;13(4):e2023277
                                                                                                          P = 0.0001                                            P = 0.03                                            P = 0.96
                                                                  Perifollicular       Present - Baseline              Absent - Baseline   Present - Baseline              Absent - Baseline   Present - Baseline              Absent - Baseline
                                                                  pigmentation            65 (52.42)                     59 (47.58)           13 (35.14)                     24 (64.86)           05 (22.73)                      17(77.27)
                                                                                   Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                        64           1           41          18           08          05           02          22           02          03           01          16
                                                                                     (98.46)      (1.54)      (69.49)      (30.51)     (61.54)      (38.46)      (8.33)      (91.67)       (40)        (60)        (5.88)      (94.12)
                                                                                                        P = 0.00001                                         P = 0.0005                                              P = 0.67
                                                                  Perilesional         Present - Baseline              Absent - Baseline   Present - Baseline              Absent - Baseline   Present - Baseline              Absent - Baseline
                                                                  Hyper-                  60 (48.39)                     64 (51.61)           13 (35.14)                     24 (64.86)           04 (18.18)                     18 (81.82)
                                                                  pigmentaion      Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                        57          03           33          31           05          08           02          22           01          03          0 (0)        18
                                                                                       (95)         (5)       (51.56)      (48.44)     (38.46)      (61.54)      (8.33)      (91.67)       (25)        (75)                    (100)
                                                                                                          P = 0.0001                                            P = 0.02                                             P=1
                                                                 FU = follow-up.




5
6
                                                                            Table 4. Dermoscopic features of satellite lesions and microkoebnerisation according to outcome of patients at baseline and follow-up
                                                                                                                              of the lesion in the study population.
                                                                      Dermoscopic                          Responsive                                           Progressive                                         No change
                                                                        features                            (N=124)                                               (N=37)                                             (N=22)
                                                                  Satellite Lesions        Present - Baseline               Absent - Baseline   Present - Baseline              Absent - Baseline   Present - Baseline         Absent - Baseline
                                                                                              36 (29.03)                      88 (70.97)           13 (35.14)                     24 (64.86)           03 (13.64)                19 (86.36)
                                                                                        Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                             13          23           04          84           10          03           09          15           03           0            0          19
                                                                                          (36.11)     (63.89)       (4.55)     (95.45)      (76.92)     (23.08)       (37.5)      (62.5)       (100)         (0)          (0)       (100)
                                                                                                                P = 0.001                                            P = 0.02                                            P=1
                                                                  Microkoebnerisation      Present - Baseline               Absent - Baseline   Present - Baseline              Absent - Baseline   Present - Baseline         Absent - Baseline
                                                                                              16 (12.90)                      108 (87.10)          08 (21.62)                     29 (78.38)             1 (4.55)                21 (95.45)
                                                                                        Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU) Present (FU) Absent (FU)
                                                                                             06          10           04         104           07          01           06          23           1            0            0          21
                                                                                           (37.5)      (62.5)        (3.7)      (96.3)       (87.5)      (12.5)      (20.69)     (79.31)       (100)         (0)          (0)       (100)
                                                                                                                P = 0.32                                         P = 0.0004                                              P=1
                                                                 FU = follow-up.




Original Article | Dermatol Pract Concept. 2023;13(4):e2023277
Table 5. Dermoscopic features of pigment network according to outcome of patients at Baseline and
                         Follow-up of the lesion in the study population.
                                                   Baseline                                     Follow-up
             Pigment Network                        N (%)                Change             (6 months), N(%)          P - Value
 Responsive (124)               Absent                88            Absent (SQ)                58(65.91)               0.0001
                                                    (70.97)               IPN                  25(28.41)
                                                                         WFPN                   05(5.68)
                                Reduced               36           Reduced (SQ)                15(41.67)
                                                    (29.03)              WFPN                  20(55.56)
                                                                         Absent                 01(2.78)
 Progressive (37)               Absent                29            Absent (SQ)                24(82.76)               0.0001
                                                    (78.38)              WFPN                     0(0)
                                                                          IPN                  05(17.24)
                                Reduced               08                 WFPN                     0(0)
                                                    (21.62)        Reduced (SQ)                 01(12.5)
                                                                         Absent                 07(87.5)
 No Change (22)                 Absent                20            Absent (SQ)                  18(90)                   1
                                                    (90.91)               IPN                    02(10)
                                                                         WFPN                     0(0)
                                Reduced                02                Absent                   0(0)
                                                     (9.09)              WFPN                     0(0)
                                                                   Reduced (SQ)                 02(100)
IPN = initiation of pigment network; SQ = status quo; WFPN = well-formed pigment network.




                              Table 6. Summary of dermoscopic findings of our study.
       Dermoscopic finding               Findings of previous studies                    Conclusions of our study
 Well defined border                    Marker of stability [15,19,20]       Marker of static nature of disease which has poor
                                                                             tendency for marginal re-pigmentation
 Ill-defined border                     Marker of instability [15,17],       Marker of dynamic nature of the patch which has
                                        activity of the disease, poor        a potential to re-pigment (upgrade) with treatment.
                                        prognosis [18]                       Hence, not necessarily a poor prognostic factor.
 Trichrome pattern                      Marker of activity/ progressive      Marker of both re-pigmentating and progressive
                                        nature of the disease/ poor          vitiligo and not a reliable marker to define
                                        prognostic factor [20,23-26]         prognosis and instability of the condition.
 Leukotrichia                           Poor prognosis [15,27]               Leukotrichia may reverse after therapy. Patches
                                        Marker of instability                with leukotrichia may still show re-pigmentation,
                                                                             hence it is not necessarily a poor prognostic factor
 Perifollicular pigmentation and        Marker of stability                  Aids in re-pigmentation of patch
 perilesional hyperpigmentation         Marker for re-pigmentation           Marker of response to therapy
                                        [16,21]
 Satellite lesion and                   Marker of activity /unstable         Marker of activity/ progressive nature of vitiligo
 microkoebnerisation                    nature of the disease                patch
                                        [15,16,29,30]




    Lesional stability and the disease stability of vitiligo do      a common consensus. Previous studies have laid down der-
not go hand in hand. A patient with unstable vitiligo can            moscopic characteristics of “unstable” and “stable” vitiligo
have several stable vitiligo patches. Various studies have           with inconsistent conclusions. Dermoscopic parameters
aimed to define the stability of vitiligo but failed to reach        of ill-­
                                                                            defined borders, trichrome pattern, satellite lesions,



Original Article | Dermatol Pract Concept. 2023;13(4):e2023277                                                                      7
                  Figure 1. (A) Well-defined border; (B) Ill-defined border; (C) Trichrome pattern; (D) Satellite lesions.




                  Figure 2. (A) Perifollicular pigmentation; (B) Perilesional Hyperpigmentation (black arrows);
                  (C) Micro-koebnerisation; (D) Leukotrichia.



leukotrichia and micro-koebnerisation were largely linked               synonymous with progressive disease. Dermoscopic fea-
with unstable vitiligo, and well-defined borders, perilesional          tures of unstable vitiligo described by previous authors were
hyperpigmentation and an absent/reduced pigment network                 seen even in the responsive patches. These studies failed to
as positive predictive markers for stability [15,17-19]. They           document the dynamic changes of the disease, due to their
linked the stability of a vitiligo patch to its static nature           cross-sectional nature and the results derived were not
or a good prognostic factor, and the term “unstable” was                corroborative.

8                                                                            Original Article | Dermatol Pract Concept. 2023;13(4):e2023277
                    Figure 3. (A) Absent pigment network; (B) Reduced pigment network.




    Few prospective studies have tried to assess dermoscopic        possibility of re-pigmentation is minimal. In contrast, our
parameters of vitiligo patches to monitor their therapeutic         study revealed reversal of leukotrichia amongst responsive
response [21,22]. However, these studies lacked data on             patches. Hence it is not necessarily a poor prognostic factor.
lesional stability. Erichetti et al, checked perifollicular pig-    Our study found that responsive patches with leukotrichia
mentation, non-follicular pigmentation, leukotrichia and            at baseline exhibited evidence of re-pigmentation, which
follicular red dots. They found perifollicular pigmentation to      contributes to the development of pigmentation within the
be associated with response to NB-UVB phototherapy [21].            patch. Additionally, it was seen in progressive patches, that
Gupta et al analyzed 60 active vitiligo lesions over 12 weeks,      the color of pigmented hair disappeared over time (increase
on treatment [16]. They found perifollicular re-pigmentation        in incidence of leukotrichia) along with depigmentation of
to be a marker for response, and perifollicular depigmenta-         the skin, which was attributed to the natural progression of
tion, satellite lesions micro-koebnerisation to be a marker         the disease.
for activity of the disease and did not draw any conclusion             Overall incidence of perifollicular pigmentation in-
with respect to perilesional hyperpigmentation and disease          creased in responsive patches from 52.4% at baseline (65
activity. However, there is paucity of data evaluating lesions      out of 124) to 84.67% (105 out of 124).
over a longer duration with a larger sample size to validate            Perifollicular pigmentation can be due to two reasons:
findings of lesional stability.
    In various studies, well-defined borders have been re-          1. perifollicular pigment retention in a vitiliginous patch re-
ported as a marker of stability or good prognosis of the                fers to the pigment around hair follicle retained;
disease [15,19,20]. The present study confirmed that well           2. perifollicular re-pigmentation, refers to appearance of
defined borders is associated with a static nature of vitiligo          new pigmentation from follicular melanocytes in a vit-
patch with low chances of marginal re-pigmentation. Hence,              iligo patch.
the term “stable” cannot always be used to represent a good
prognosis for the disease Ill-defined borders were seen in              These findings can be assessed only when a patch is mon-
both responsive and progressive patches and hence it is re-         itored over a period of time.
lated to the dynamic characteristic of the patch. Such bor-             Of 65 responsive patches, 64 showed perifollicular pig-
ders have potential to re-pigment with optimum treatment,           mentation at baseline and follow up period, ie perifollicular
and hence it is not necessarily a poor prognostic factor.           pigment retention. The perifollicular pigmentation of such
    Trichrome pattern also reflects the dynamic character of        patches was enhanced and notably darker than at baseline.
the patch and not a reliable marker to define prognosis and         Of responsive patches that had no perifollicular pigmenta-
instability of the condition, contrary to the findings of previ-    tion at baseline, 69.5% developed perifollicular pigmenta-
ous studies [20,23–26]. The present study found statistically       tion at follow up period, ie perifollicular re-pigmentation.
significant change in trichrome pattern during follow up pe-        Increase in findings of perifollicular pigmentation in respon-
riod amongst responsive patches.                                    sive patches and its decrease amongst progressive patches
    Incidence of leukotrichia from baseline decreased in            were both statistically significant. This is consistent with
responsive patches, and increased in progressive patches,           findings from previous studies where perifollicular re-­
with these changes being statistically significant. It has          pigmentation was found to be associated with re-pigment-
been considered as a poor prognostic factor [15,27] prob-           ing disease [16,21] but in contrast to few other studies that
ably because it indicates that the melanocyte reservoir             have claimed perifollicular pigmentation to be a marker of
within the hair bulb has been destroyed indicating that the         active disease [28,29]. It is merely impossible to comment

Original Article | Dermatol Pract Concept. 2023;13(4):e2023277                                                                   9
on whether perifollicular pigmentation is a marker of active                             cell transplantation. Arch Dermatol. 2004;140(10):1211-1215.
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     Our study shows that perilesional hyperpigmentation is a
                                                                                         nomenclature of vitiligo and related issues: the Vitiligo Global
marker of re-pigmenting vitiligo in concurrence with a study
                                                                                         Issues Consensus Conference. Pigment Cell Melanoma Res.
by Gupta et al [16]. Many cross-sectional studies have stated                            2012;25(3):E1-E13. DOI: 10.1111/j.1755-148X.2012.00997.x.
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Hence, more such studies with larger sample size will help to                            M. Preliminary evaluation of vitiligo using in vivo reflectance con-
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     Satellite lesion and micro-Koebner phenomenon reflect
                                                                                         17958840.
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significant increase of these findings at follow-up visits for                           ical and immunological factors determining stability of disease
progressive patches supporting the fact that these findings                              in patients with generalized vitiligo undergoing melanocyte
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                                                                                         More Important Than Disease Stability for Performing Surgical
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ger to appear as compared to perifollicular or perilesional                              PMID: 27081244. PMCID: PMC4812882.
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                                                                                         Catecholamines and vitiligo. Pigment Cell Res. 1992;5(2):65-69.
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                                                                                   12.   Purnima G, Tejaswitha Gudivada NA, Narasimharao T V.
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Original Article | Dermatol Pract Concept. 2023;13(4):e2023277                                                                                11
