VITILIGO - CLINICAL CLASSIFICATION - George-Sorin Ţiplica Colentina Clinical Hospital Bucharest, Romania
Dec 05, 2014
VITILIGO
- CLINICAL CLASSIFICATION -
George-Sorin Ţiplica
Colentina Clinical Hospital
Bucharest, Romania
Gregor Johann Mendel
1822 – 1884
Czech-German Augustinian
monk and scientist
Studied the inheritance of
certain traits in pea plants
Founder of genetics
Why classifications are useful?
Prognosis evaluation
Treatment options
Clinical studies, meta-analysis
Reimbursment, DRG system
Classification: general considerations Classification system A
Classification system B
Classification system C
Classification system D
Validation by
Patho-mechanism
Treatment
Evolution / prognosis
Classification system B
Clinical classification
What can be observed? Objective criteria
Disease distribution
Speed of spreading
Lesion aspect (shape, dimension, color)
Subjective criteria Symptoms
Quality of life
Who can observe? General practitioner / dermatologist
Patient
Computer
Clinical classification: vitiligo
There is a current lack of consensus in definition and assessment methods which makes difficult any classification
Initial site involvement does not predict future evolution, localisation and activity of the disease
Many attempts to classify the disease
Several subtypes of vitiligo
Based on the distribution of lesions
Vitiligo - classification
Non-segmental vitiligo (type A) most common subtype
widespread macules often symmetrically placed
frequently involves acral areas, skin surrounding body orifices and extensor surfaces
Segmental vitiligo (type B)
dermatomal or blaschkolinear distribution
Koga M. Vitiligo: a new classification and therapy. Br J Dermatol. 1977 Sep;97(3):255-61.
Non-segmental vitiligo
Universal vitiligo (almost complete depigmentation of the cutaneous surface)
Generalized vitiligo (most frequent form) Acrofacial vitiligo (limited to acral and areas
surrounding the orifices) Mucosal vitiligo (limited to mucosa) Focal (depigmented macules located in an
isolated area without a dermatomal distribution) Koebner phenomenon present
Characteristics
usually slowly progressive spontaneous repigmentation in 10-20% of patients
Handa S, Kaur I. Vitiligo: clinical findings in 1436 patients. J Dermatol 1999; 26:653.
Clinical classification
FOCAL Most common distribution: -trigemminal nerve -neck -trunck
GENERALIZED - most common pattern - symmetrical distribution
Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
Associated diseases
Autoimmune origin: Thyroid disease (hyperthyroidism, hypothyroidism)
Addison’s disease
Pernicious anemia
Alopecia aerata
Diabetes mellitus
Myasthenia gravis
Halo nevus
Malignant melanoma
Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621 Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology, 8th Ed, 2010, vol 3, p 58.46-58.49
Segmental vitiligo
A less common subtype
Unilateral depigmented macules and patches that completely or partially occur in a dermatomal or blaschkolinear distribution
Characteristics
earlier age of onset
spreads rapidly after initial appearance
less commonly associated with other autoimmune diseases
pathogenesis: a neurogenic sympathetic abnormality or a disorder of cutaneous mosaicism
Taïeb A, Picardo M. Clinical practice. Vitiligo. N Engl J Med 2009; 360:160. Hann SK, Lee HJ. Segmental vitiligo: clinical findings in 208 patients. J Am Acad Dermatol 1996; 35:671. Mazereeuw-Hautier J, Bezio S, Mahe E, et al. Segmental… J Am Acad Dermatol 2010; 62:945. Halder, RM, Taliaferro, SJ. Vitiligo. In: Fitzpatrick's Dermatology in General Medicine, 7th ed, Wolff, K, Goldsmith LA, Katz, SI, et al (Eds), McGraw Hill 2008.
Clinical classification
SEGMENTAL
- does not cross the middle line -usually in children
Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
MIXED FORM
– combines segmental,
acrofacial and/or
generalized distribution
Facial segmental vitiligo
Not always correspond to dermatomal distribution
Facial SV classification (based on morphological similarities in numerous clinical observations) Type I-a:mid-level face from the forehead to the lower
cheek (28,8%) Type I-b: forehead and scalp hair Type II: lower face and the neck area (16%) Type III: lower face and the neck area (14,4%) Type IV: mid-level face from the forehead to the lower
cheek, but selectively appeared on the right side of the face and did not cross the midline
Type V: lesions were distributed mostly around the right orbital area
Kim, D.-Y., Oh, S. H., Hann, S.-K. Classification of segmental vitiligo on the face: clues for prognosis. British Journal of Dermatology; May2011, Vol. 164 Issue 5, p1004-1009.
Clinical variants of vitiligo Trichrome vitiligo
Both depigmented and hypopigmented macules
Hypopigmented macules become depigmented over time
Qvadrichrome vitiligo
Also associates marginal and perifollicular hyperpigmentation
Darker skin types
More often in areas of repigmentation
Pentachrome vitiligo (vary rare)
Blue-gray hyperpigmentation (dermal melanine incontinence, areas affected by postinflammatory hyperpigmentation in which vitiligo develops)
Confetti type (vitiligo ponctue)
Very numerous small, discrete hypopigmented macules
Inflammatory vitiligo
Erythema of the margins
Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
Rare syndromes
Vogt-Koyanagi-Harada Syndrome
Vitiligo and uveitis, aseptic meningitis, dysacusis, tinnitus, poliosis, alopecia
T-cell mediated autoimmune disease
Associated with other autoimmune disorders
Alezzandrini Syndrome
Facial vitiligo and poliosis, deafness, unilateral retinal degeneration
Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
Vitiligo in children
very rarely at birth
descending order of frequency:
generalized
focal
segmental
acrofacial
mucosal
universal
Halo nevus present – search for vitiligo
Paller A, Mancini A. Hurwitz Clinical Pediatric dermatology, 3rd Ed, 2006, p 226-229
Differential Diagnosis
According to site
Face: tinea, pityriasis versicolor, pityriasis alba, post-inflammatory hypopigmentation, chemical leucoderma, sarcoidosis, piebaldism, hypopigmentation after cosmetic procedures
Hands: chemical leucoderma, scleroderma
Trunk: scleroderma, pityriasis versicolor, tuberous sclerosis
Anogenital: lichen sclerosus, lichen atrophicus
Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621 Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology, 8th Ed, 2010, vol 3, p 58.46-58.49
Vitiligo: methods of assessment
Vitiligo European Task Force: a system (derived from SCORAD) which combines
analysis of extent: the rule of 9
stage of disease (staging): the disease is staged 0–3 on the largest macule in each body region
disease progression (spreading): based on Wood’s lamp examination
Taıeb A, Picardo M on behalf of the VETF members. The definition and assessment of vitiligo: a consensus report of the Vitiligo European Task Force. Pigment Cell Res. 2007, 20; 27–35
VIDA score Vitiligo Disease Activity
Based on the patient's own opinion of the present disease activity over time Active Vitiligo refers to either one of the following:
Expansion of existing lesions
Appearance of new lesions.
Asses response to treatment
Vitiligo Activity Time Period VIDA Score
Active Under 6 weeks +4
Active 6 weeks - 3 months +3
Active 3 - 6 months +2
Active 6 - 12 months +1
Stable 1 year or more 0
Stable with spontaneous repigmentation
1 year or more -1
www.dermabest.com/Vitiligo_Disease_Activity_score
VASI
Introduced by Hamzavi et al. in 2004
A quantitative parametric score
Derived from the PASI (psoriasis area and severity index) score widely used for psoriasis (Fredriksson and Pettersson, 1978)
VASI regions
hands, upper extremities (excluding hands), trunk, lower extremities (excluding the feet) and feet
the face and neck areas are assessed separately
VASI = S (all body sites)(hand units)·(depigmentation)
Conclusions
At the moment, impossible to predict future evolution, localisation and activity of the disease
Lack of consensus vitiligo classification and assessment methods
Based on pathogenesis
Non-segmental vitiligo
Segmental vitiligo
Thank you!