Utility of Dermoscopy and Interpretation of Dermoscopic Findings in Stable and Progressing Lesions of Vitiligo

By Sara Shafqat, Atiya Rahman, Zarin Manzoor, Shakila Junaid, Sidra Anwer, Janta Kumari

Affiliations

1. Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan

doi: 10.29271/jcpsp.2025.06.693

ABSTRACT
Objective: To identify the various dermoscopic patterns present in vitiligo and its predictive value in determining the stability of the disease.
Study Design: Cross-sectional study.
Place and Duration of the Study: Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan, from October 2023 to July 2024.
Methodology: A total of 80 clinically diagnosed patients of vitiligo, of either gender, with stable and progressing vitiligo, having age ≥18 years, were included. Dermoscopic examination of vitiligo lesions was done to evaluate the clinical stability of the lesions. SPSS version 26 was used to analyse the data. The dermoscopic findings of stable and progressing vitiligo were compared using the Chi-square test and Fisher’s exact test.
Results: Out of the 80 patients who were clinically diagnosed with vitiligo, 56 (70%) were women and 24 (30%) were men. The patients' average age was 31.94 ± 8.185 years. Approximately 38 (47.5%) patients had stable vitiligo, while 42 (52.5%) had progressing vitiligo. The dermoscopic patterns included perifollicular depigmentation in 15%, perifollicular hyperpigmentation in 33%, perilesional/marginal hyperpigmentation in 8%, intra/perilesional erythema with telangiectasia in 19%, trichrome pattern in 26%, leucotrichia in 14%, starburst appearance in 24%, comet tail appearance in 26%, and minor Koebner’s phenomenon in 33.75% cases. Comparison of findings between stable versus progressing vitiligo showed significant difference with a p-value of <0.05.
Conclusion: Specific dermoscopic patterns can be utilised to ascertain disease activity and accordingly decide on the management protocol.

Key Words: Dermoscopy, Dermatoscopy, Dermoscopic patterns, Dermatoscopic patterns, Stable vitiligo, Progressing vitiligo.

INTRODUCTION

Vitiligo is a chronic cutaneous disorder characterised by asymptomatic white macules and patches that can appear on any site on the body, including the mucosae. It affects 0.5 to 2% of the population globally and is most prevalent around the age of 20 years.¹ The aetiology of the disease is not fully understood, but an autoimmune mechanism is the most plausible. No ethnic or racial predisposition has been defined, and it affects both genders equally. The progression of vitiligo can be unpredictable and progressive, leading to significant psychological stress, such as discrimination and mental distress.²

Stability in vitiligo is an important concept guiding the direction of patient management.

A lesion with lack of progression or no new lesions for 2 years, absence of recent Koebner phenomenon, and evidence of repigmentation of existing patches, either spontaneously or with medical therapy, is considered stable vitiligo.³ Progressing vitiligo is defined as when pre-existing lesions exhibit increase in size, number, or both in the last 12 months.³ Patients with progressing vitiligo have a guarded prognosis and should be counselled accordingly. Such patients should be offered more proactive therapeutic options, such as phototherapy or photochemotherapy.⁴

In order to distinguish early emerging lesions of vitiligo from other hypopigmented lesions, specific examinations such as Wood’s lamp, dermoscopy, and histopathology may be required. Noninvasive methods can be extremely convenient and beneficial to assess the cases, helping in devising suitable management plans of every vitiligo patient.^5,6

Dermoscopy is a relatively simple technique, being employed for an increasing number of indications in dermatology. It is a portable device and can be easily carried out in a doctor’s clinic.⁷ In 1971, an Austrian Dr. Friedrich Wolff first employed dermoscopy for skin cancer diagnosis, especially melanomas. However, it was in the 1980s and 1990s, that significant advancement in the field of dermoscopy and its regular use in skin cancer diagnosis were made.⁸ Dermoscopic application for other cutaneous disorders followed later. It is relatively recent that it has been employed to diagnose and differentiate hypopigmented lesions. Different dermoscopic patterns identified in vitiligo include perilesional hyperpigmentation, perifollicular hyperpigmentation, minor Koebner’s phenomenon, starburst appearance, trichrome pattern, perilesional erythema with telangiectasia, comet tail appearance, leucotrichia, perifollicular depigmentation, etc.^5-7

To date, there are few studies published on this topic and none was from Pakistan. The purpose of this study was to evaluate the various dermoscopic patterns present in vitiligo and its comparison with the stability of the disease.

METHODOLOGY

This cross-sectional study was held from October 2023 to July 2024 in the Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan, after permission from the Ethical Review Committee [ERC/2023/DERM/44]. Clinically diagnosed 80 patients of either gender with stable and progressing vitiligo, aged ≥18 years, were included via non-probability consecutive sampling technique, after taking written informed consent. Each case was confirmed through Wood’s lamp examination. Patients with other causes of depigmentation and hypopigmentation, for example naevus anaemicus, neavus depigmentosis, pityriasis alba, pityriasis versicolor, ash leaf hypopigmentation, and occupational leucoderma, were excluded. Given a 2% prevalence of vitiligo,¹ and a 5% margin of error with a 95% CI, the OpenEpi calculator indicated that a sample size of at least 80 individuals was sufficient. The criteria used to confirm the stability of vitiligo included the absence of progression of old lesions for the past two years, no new lesions during the same period, no history of recent Koebner’s phenomenon, and repigmentation of the affected areas by medical treatment.³

Detailed history was inquired. Clinical and dermoscopic examination were performed, maintaining the confidentiality of the patients. Patients’ relevant information, e.g. age, gender, duration and progression of lesions, and dermoscopic findings were recorded on a pre-designed patients’ proforma. The clinical stability of the lesions was evaluated. Heine Delta T20 dermoscope was used, and pictures of the clinical lesions and dermoscopic images were captured using Apple iPhone 15 Pro Max.

The Statistical Package for the Social Sciences (SPSS) version 26 was used to analyse the data. For quantitative data, mean ± standard deviation (SD) was computed, whereas frequencies and percentages were used to show qualitative data. The dermoscopic findings were statistically analysed for any significant variations between stable and progressing vitiligo. The data were compared using Chi-square test and Fisher’s exact test. A p-value of less than 0.05 was deemed as significant.

RESULTS

Among the 80 clinically diagnosed adult patients of vitiligo, 56 (70%) of the patients were female and 24 (30%) were male. The duration of the disease varied from 1 to 10 years. The mean age of the patients was 31.94 ± 8.185 years, with a range of 18 to 50 years. Around 38 (47.5%) of the patients had a stable form of vitiligo, as shown in Table I.

Table I: Baseline data of the patients (n = 80).

Baseline data	(mean ± SD) / (n, %)
Age (years)	31.94 ± 8.185
Duration of disease (years)	5.16 ± 2.457
Gender       Male       Female	24 (30%) 56 (70%)
History of vitiligo       Progressing       Stable	42 (52.5%) 38 (47.5%)

Table II: Comparison of dermoscopic findings in stable and progressing vitiligo.

Dermoscopic findings	History of vitiligo		p-value
	Stable (n = 38)	Progressing (n = 42)
Perilesional hyperpigmentation       Present       Absent	21 17	09 33	0.001*
Perifollicular hyperpigmentation       Present       Absent	19 19	7 35	0.001*
Minor Koebners phenomenon       Present       Absent	08 30	19 23	0.02*
Starburst appearance       Present       Absent	5 33	14 28	0.03**
Trichrome pattern        Present       Absent	4 34	17 25	0.002**
Perilesional erythema with telangiectasia      Present      Absent	3 35	12 30	0.017**
Comet tail appearance      Present       Absent	4 34	17 25	0.02**
Leucotrichia       Present       Absent	2 36	9 33	0.03**
Perifollicular depigmentation       Present       Absent	2 36	10 32	0.02**
p* Chi-square.   p** Fisher’s exact test.

Patterns identified via dermoscopy included perifollicular depigmentation (15%), perifollicular hyperpigmentation (33%), and perilesional/marginal hyperpigmentation (38%). Other observations included intra / perilesional erythema with telangiectasia (19%), trichrome pattern (26%), leucotrichia (14%), starburst appearance (24%), comet tail appearance (26%), and minor Koebner phenomenon (33.75%), as shown in Figure 1.

The dermoscopic findings, with a p-value of less than 0.05, employing the Chi-square and Fisher’s exact test, revealed significant differences between the vitiligo subtypes, as shown in Table II.

Therefore, the study has demonstrated that perilesional/ marginal hyperpigmentation and perifollicular hyperpigmentation are seen, in a statistically significant manner, in stable form of vitiligo. However, minor Koebner’s phenomenon, starburst appearance, trichrome pattern, perilesional erythema with telangiectasia, comet tail appearance, leucotrichia, and perifollicular depigmentation are seen more in the progressing form of vitiligo. The most frequent observation in stable vitiligo is peri- lesional/marginal hyperpigmentation (55.26%), while in pro- gressing illness, there is minor Koebner phenomenon (45.2%).

Figure  1:  Dermoscopic findings in stable and progressing vitiligo.

Figure 2:  Dermoscopic findings: (A) Normal pigmentary network. (B) Tri-chrome pattern with areas of depigmented, hypopigmented, and normal pigment network. (C) Perilesional hyperpigmentation is shown with black arrow and absent reticulate pattern with a blue arrow. (D) Intralesional erythema with telangiectasia. (E) Starburst pattern is shown with red arrow. (F) Leucotrichia.

DISCUSSION

For a long time, the main methods for diagnosing vitiligo have been clinical diagnosis and Wood's lamp examination. However, Wood's lamp has limitations when it comes to making an accurate diagnosis. It may not detect early or mild cases of vitiligo, especially if the lesions are not significantly depigmented. Other conditions, such as naevus anaemicus, neavus depigmentosis, pityriasis alba, pityriasis versicolor, ash leaf hypopigmentation, and chemical leucoderma, may also show considerable accentuation under Wood's lamp, leading to false positive results. Hence, at times, there is difficulty in differentiating between vitiligo and other hypopigmented disorders. Similarly, Wood's lamp examination is not appropriate for all skin types and relies on the operator's experience and skill level. Noninvasive techniques such as dermoscopic examination are especially helpful when diagnosis is unclear, such as in cases of progressing disease and for objectively assessing the response to treatment.⁹

 A typical reticulate pigmentary pattern is seen in healthy skin, which is correlated with pigmentation over the rete ridges and light patches that represent the papillary dermis.^10,11 The vitiligo lesions alter the reticulate pigmentary pattern present in healthy skin.¹² In dermoscopy of vitiligo, there is perilesional / marginal hyperpigmentation (more intense pigmentation in the areas surrounding the achromic lesions), perifollicular pigmentation (a pilosebaceous orifice in the depigmented areas surrounded by homogeneous pigment darker than that of the skin), trichrome pattern (the middle of pseudo-scarring appearance, around the main area faintly yellowish brown pigmentation and on the edge characteristic phototype of the patient depicted in three different shadings), starbursts (extension or peripheral whitish linear protrusions in different directions), and comet's tail (unidirectional linear extension to the area adjacent to the initial vitiligo lesion), leucotrichia (depigmented hairs), micro-Koebner phenomenon (the appearance of isomorphic scars in the form of linear depigmented striae distributed remotely from the trauma line or along the outline of the main patch of vitiligo), and telangiectasia (bright red dilated capillaries of 1 to 4 mm in diameter similar to spider veins, as shown in Figure 2.¹³

In agreement with this study’s results, Purnima et al. found peri-lesional and marginal hyperpigmentation dermoscopic features associated with stable forms of vitiligo. They indicated the presence of marginal hyperpigmentation in all stable cases of vitiligo and noted perifollicular pigmentation in 87.5% of stable vitiligo patients.¹⁴ In the current study, 55.26% of patients with stable vitiligo showed perilesional/marginal hyperpigmentation, and in the same group, 50% of patients demonstrated perifollicular hyperpigmentation in a stable disease state.

However, Jha et al.’s findings oppose the results of the current study.¹⁵ They identified perifollicular pigmentation dermatoscopic patterns in 34 out of 40 cases (85%) of unstable vitiligo and only 2 out of 20 (10%) cases of stable disease. These patterns were, however, noted in 14 out of 20 (70%) cases of stable vitiligo and only 6 out of 40 (15%) cases of unstable vitiligo. In this study, it was noted that 31% of the patients with progressing vitiligo had perifollicular depigmentation. Jha et al. suggested that the presence or absence of perifollicular pigmentation seems to be an important dermoscopic attribute of vitiligo activity; perifollicular pigmentation denotes instability and its absence with stable vitiligo.¹⁵

Nonetheless, in the present research, perifollicular depigmentation, although associated with some cases of stable vitiligo, was strongly linked to disease advancement. In Jha et al.’s study, altered pigment network was noted in 36 out of 40 (90%) cases of unstable and 3 out of 20 (15%) cases of stable vitiligo. In their study, violet starburst and comet tail patterns, as well as small white pearls, were dermoscopic features pertaining to the active phase of the disease. Globules were also noted in apparently normal perilesional skin of patients with active vitiligo. In stable cases of vitiligo, leucotrichia was recorded in 11 out of 20 (55%) patients which in their study was associated with treatment refractoriness. Leucotrichia was seen in both stable and progressing vitiligo in the present study and dermoscopy helped in visualising leucotrichia in 11 (14%) of patients, in which, it was not so evident on clinical examination; thus, enabling to counsel patients about the disease prognosis, as leucotrichia is associated with recalcitrant disease.

According to Nirmal et al., the most sensitive indicators of stable vitiligo are the lack of satellite lesions and minor Koebner phenomena.^16,17 However, compared to 45.2% of patients with progressing lesions, 21.1% of individuals with stable vitiligo in this study showed micro-Koebner lesions. This raises the possibility that the patient’s history may not always be accurate in differentiating the subtypes of vitiligo. It is difficult for patients to maintain an objective account of the lesions, and their assessment may be biased depending on how bothered they are by the disease, psychosocial impact of the condition, and how much time they find to observe the lesions and apply the medicament.

Meng et al. observed 176 patients with different types of depigmentation, out of which 97 (55.1%) had vitiligo.¹⁸ They observed residual perifollicular pigmentation in 91.9% of patients with unstable vitiligo and 62.8% in those with stable vitiligo. The findings of the above-mentioned study varied from this research. In the present study, 50% of the stable vitiligo patients had perifollicular pigmentation, but only 16.7% of the progressing vitiligo group exhibited this finding.

The disparity amongst various studies underscores the importance of gathering more data on the topic.^18-20 Additionally, the patients’ accounts of the disease course may not be accurate in all cases. This further necessitates dermoscopic examination of vitiligo lesions not only for disease diagnosis but also as an aid in further classification into stable and progressing types. Based on history and clinical and dermoscopic examinations, treating physicians would be better able to counsel the patients about their disease and formulate effective management plans. Hence, all patients with vitiligo should undergo dermoscopic examination at the time of diagnosis and repeated assessment of the lesions throughout the disease course, enabling treating physicians to assess the clinical response of the treatment for stability of the disease.

Patients were diagnosed clinically on the basis of clinical, Wood’s lamp, and dermoscopic examination. There was no microscopic examination of skin confirming changes on the histopathology, such as the absence of melanocytes or total loss of pigmentation in the epidermis.

CONCLUSION

Dermoscopy is a noninvasive diagnostic procedure useful in diagnosing and subclassification of vitiligo into stable and progressing types. Specific dermoscopic patterns can be used to determine disease activity and tailor management strategies accordingly.

ETHICAL  APPROVAL:
Approval was obtained from the Ethical Review Committee of the PNS Shifa Hospital, Karachi, Pakistan [ERC/2023/DERM/ 44].

PATIENTS’  CONSENT:
Written informed consent was provided by the patients.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
SS: Design of the work, acquisition, analysis, and interpretation of the data.
AR: Drafting of the work and revision of the manuscript.
SJ: Contributed to the abstract writing and references.
SA: Provided resources for research work.
JK: Provided data of the patients where follow-up was done.
ZM: Interpreted data and results.
All authors approved the final version of the manuscript to be published.

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