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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 25-32

Dermoscopy in Vitiligo: An emerging armamentarium in diagnosis and activity assessment


Department of Dermatology, Venereology, and Leprosy, Sri Guru Ram Das Institute of Medical Sciences & Research Amritsar, Punjab, India

Date of Submission09-Jan-2021
Date of Decision12-Mar-2021
Date of Acceptance08-Jul-2021
Date of Web Publication16-May-2022

Correspondence Address:
Dr. Guneet Awal
469, East Mohan Nagar, Opp. DSP Park, Sultanwind road, Amritsar, Punjab 143001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/pigmentinternational.pigmentinternational_

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  Abstract 


Context: Vitiligo is an autoimmune depigmentary disorder characterized by loss of epidermal melanocytes. It can be diagnosed clinically, however, dermoscopy aids in its differentiation from other hypopigmentary and depigmentary conditions and also helps in evaluating disease activity. Aims: To study the dermoscopic patterns of vitiligo and evaluate their correlation with disease activity. Settings and Design: This is a cross-sectional and observational study conducted in the outpatient department of dermatology of a tertiary care hospital at Sri Amritsar. Methods and Materials: Fifty patients complaining of depigmented lesions were diagnosed clinically for vitiligo. Histopathological confirmation was done in difficult to diagnose cases. Patients with clinically stable vitiligo, unstable vitiligo, and vitiligo under treatment were included. A dermoscopic examination was done with a Dermlite DL4 dermoscope. The photographs were taken using a standard phone and the dermoscopic findings were documented.Statistical Analysis Used: The results were tabulated and expressed as percentages. The Pearson correlation coefficient was calculated between dermoscopic patterns of vitiligo and disease activity. Results: On examination with the dermoscope, pigmentary patterns observed were marginal hyperpigmentation, perifollicular pigmentation, reticulate hyperpigmentation, and altered pigment network. Morphological patterns seen on dermoscopy included leukotrichia, micro-Koebner phenomena, polka dots, and starburst appearance. Conclusions: Marginal hyperpigmentation, perifollicular pigmentation, and reticulate pigmentation were the markers of disease stability. Leukotrichia was seen in patients of stable vitiligo majority being treatment refractory. Altered pigment network, micro-Koebner phenomena, starburst appearance, and polka dots indicated unstable vitiligo. Presence of erythema and telangiectasias indicated response to treatment. Hence, dermoscopy can be used as an effective tool for the diagnosis of vitiligo and evaluation of disease activity.

Keywords: Dermoscopy, stability, vitiligo


How to cite this article:
Awal G, Kaur J, Kaur K. Dermoscopy in Vitiligo: An emerging armamentarium in diagnosis and activity assessment. Pigment Int 2022;9:25-32

How to cite this URL:
Awal G, Kaur J, Kaur K. Dermoscopy in Vitiligo: An emerging armamentarium in diagnosis and activity assessment. Pigment Int [serial online] 2022 [cited 2022 Jun 27];9:25-32. Available from: https://www.pigmentinternational.com/text.asp?2022/9/1/25/345300



Key messages: utility of dermoscopy in diagnosis and evaluation of vitiligo has not been sufficiently explored. dermoscopic evaluation of vitiligo is worthwhile both for the clinician and patient as it not only aids in diagnosis of the disease but also guides through the treatment plan to be followed by assessment of disease activity.


  Introduction Top


Vitiligo is an acquired, autoimmune, and idiopathic disorder of depigmentation that develops as a result of loss of functional melanocytes in the epidermis. Clinically, the disease is characterized by presence of achromic macules and patches of varying sizes and shapes.[1] The evolving lesions of vitiligo simulate various other hypopigmentary and depigmentary conditions posing a diagnostic dilemma to the clinician.[2] Dermoscopy has gained ground as a non-invasive tool for the diagnosis of vitiligo that not only aids in the visualization of subtle features of vitiligo lesions, but also helps in assessing the evolution of the disease and the treatment response.


  Subjects and methods Top


The present cross-sectional and observational study was conducted with an aim to study the dermoscopic patterns of vitiligo and evaluate their correlation with disease activity on 50 patients presenting with the complaint of depigmented lesions in the outpatient department of Dermatology, Venereology, and Leprosy of a tertiary care hospital in Sri Amritsar. Patients with clinically stable vitiligo, unstable vitiligo, and vitiligo under treatment were included. Clinically, a patient was diagnosed to have stable vitiligo in absence of new lesions, no progression of already present lesions, and absence of Koebner’s phenomenon during past 1 year.[3] Detailed history was taken followed by clinical examination and dermoscopic examination with a Dermlite DL4 dermoscope (3Gen) attached to a One Plus 6 phone camera. Patients with clinically stable vitiligo, unstable vitiligo, and vitiligo under treatment were included. Histopathological confirmation was done in cases that were difficult-to-diagnose clinically and in those patients who were ready to give the consent for the investigation. The photographs were taken using a standard phone and the dermoscopic findings were documented. An informed consent was taken from each patient. The results were tabulated and expressed as percentages. The Pearson correlation coefficient was calculated between dermoscopic patterns of vitiligo and disease activity.


  Results Top


Out of 50 patients of vitiligo, there were 28 females and 22 males.

In the current study, there were 25 patients of unstable vitiligo, 13 patients of vitiligo on treatment, and 12 patients of stable vitiligo. The various dermoscopic features seen in all the stages of disease included perifollicular pigmentation (PFP), reticular hyperpigmentation (RH), marginal hyperpigmentation (MH), and altered pigment network. The dermoscopic findings specific to disease activity included leukotrichia, polka dots, starburst appearance, micro-Koebner phenomenon, and erythema and telangiectasia.

The Pearson coefficient correlation between dermoscopic patterns of vitiligo and disease activity came out to be 0.6 showing a positive association between the two variables.

Altered pigment network that included absent pigmentary network [Figure 1] and [Figure 2] and reduced pigmentary network [Figure 3]and [Figure 4] was seen in 22 (88.8%) patients of unstable vitiligo and one (8.3%) patient of stable vitiligo. PFP [Figure 5] and [Figure 6] was seen in 10 (83.3%) patients of stable vitiligo, seven (53.8%) patients of vitiligo on treatment, and three (12%) patients of unstable vitiligo. RH [Figure 7] was seen in 10 (83.3%) patients of stable vitiligo, six (46.1%) patients of vitiligo on treatment, and five (20%) patients of unstable vitiligo. MH [Figure 8] was seen in 11 (91.6%), patients of stable vitiligo, six (46.1%) patients of vitiligo on treatment, and two (8%) patients of unstable vitiligo [Table 1].
Figure 1 Depigmented patches of vitiligo.

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Figure 2 Absent pigmentary network (10× magnification of DL4 dermoscope).

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Figure 3 Multiple depigmented patches of vitiligo.

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Figure 4 Reduced pigmentary network (10× magnification of DL4 dermoscope).

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Figure 5 Repigmentation on vitiligo patch.

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Figure 6 Perifollicular pigmentation (10× magnification of DL4 dermoscope).

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Figure 7 Reticular hyperpigmentation (10× magnification of DL4 dermoscope).

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Figure 8 Marginal hyperpigmentation (10× magnification of DL4 dermoscope).

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Table 1 Dermoscopic features of stable vitiligo, unstable vitiligo, and vitiligo on treatment.

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Leukotrichia [Figure 9] and [Figure 10] was seen in eight (66%) of 12 patients of stable vitiligo. Micro-Koebner phenomena was seen in three (12%) of 25 patients of unstable vitiligo. Polka dots [Figure 11] were seen in two (8%) of 25 patients of unstable vitiligo. Starburst appearance [Figure 12] was seen in three (12%) of 25 patients of stable vitiligo. Erythema and telangiectasia [Figure 13] were seen in two (15.3%) of 13 patients of vitiligo on treatment. [Table 2].
Figure 9 Depigmented patch of vitiligo with leucotrichia.

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Figure 10 Leucotrichia (10× magnification of DL4 dermoscope).

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Figure 11 Polka dots (10× magnification of DL4 dermoscope).

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Figure 12 Star burst pattern (10× magnification of DL4 dermoscope).

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Figure 13 Erythema and telangiectasias (10× magnification of DL4 dermoscope).

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Table 2 Dermoscopic features in accordance with disease activity.

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Vitiligo was diagnosed clinically in 40 (80%) patients. Histopathological confirmation was done in 10 (20%) patients who were difficult-to-diagnose clinically. Among these 10 patients, melanocytes were reduced in four (40%) patients and absent in three (30%) patients. Melanocytes were normal in number in three (30%) patients Perivascular and lymphocytic infiltrate at dermo-epidermal junction was seen in five (50%) patients [Figure 14].
Figure 14 Hematoxylin and eosin staining showing reduced melanocytes with lymphocytic infiltrate on 40× magnification.

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  Discussion Top


Vitiligo is a disorder manifesting as loss of pigmentation due to autoimmune destruction of melanocytes. It is one of the oldest maladies affecting 1% to 2% of the world’s population.[4] In India, the prevalence of vitiligo is 0.1% to 8.8%.[5] It is characterized by depigmentation patterns varying from localized ivory white macules to near total involvement. Various theories have been proposed for the damage occurring to the melanocytes such as immune mediated, neural hypothesis, melanocytorrhagy, composite theory, autoimmune theory, and apoptotic theory.[6] However, it is usually asymptomatic and benign but the cosmetic and psychological effects are devastating. In a country of darker skin type, overwhelming psychological burden is seen due to the social outcast and stigma faced by the patients. It has been observed that repigmentation decreases the suffering and improves the quality of life.

The diagnosis of vitiligo can be made on the basis of clinical examination. But few cases such as evolving lesions of vitiligo can be missed even with careful clinical examination and proper history taking, thus they require a diagnostic tool for confirmation. The various methods available for diagnosis of vitiligo includes digital photography with computerized image analysis, dermoscopy, reflectance confocal microscopy, and invasive methods such as skin biopsy.[7],[8],[9] Dermoscopy also known as skin surface microscopy or digital epiluminescence microscopy has emerged as an non-invasive and reliable technique that causes magnification at manifold and allows appreciation of subtle features invisible to naked eye.[2] This technique may be performed using a hand-held dermoscope or by video dermoscopy. Video-dermoscope aids in high resolution viewing, whereas hand-held dermoscope is an easy-to-use tool for quick evaluation.[2] It not only aids in diagnosis of vitiligo but also allows to evaluate the treatment response.[10] The use of dermoscopy has been mainly studied for the examination of melanomas, pigmented lesions, and hairloss. Its use in evaluation and diagnosis of hypopigmented lesions is relatively novel.[11]

In the current study, 50 patients presenting with depigmented lesions were evaluated clinically and diagnosis of vitiligo was made on the basis of clinical evaluation. Histopathological confirmation was done in difficult to diagnose cases. Patients with clinically stable vitiligo, unstable vitiligo, and vitiligo under treatment were included. This was followed by dermatoscopic examination and the findings were noted.

The dermoscopic features depicting changes in pigmentary network included PFP, RH, MH, and altered pigment network. Various morphological features specific to disease activity included leukotrichia, polka dots, starburst appearance, micro-Koebner phenomenon, and erythema and telangiectasia.

There is paucity of data on the dermoscopic features of vitiligo. In a study conducted by Chuh and Zawar,[7] pattern of residual PFP was observed with depigmentation indicating presence of locally focally active or repigmenting vitiligo. In another study conducted by Meng et al.,[12] 176 patients with various types of depigmentation were studied, out of which 97 had vitiligo. Residual PFP was observed in 57 (91.9%) of 62 patients with progressing vitiligo and 22 (62.9%) of 35 with stable vitiligo. The presence of telangiectasia, early reservoirs of pigmentation, and perilesional hyperpigmentation was related to stage of vitiligo and treatment history.

We observed various dermoscopic findings according to the disease activity and treatment of disease. The dermoscopic findings that were associated with stability and repigmentation of vitiligo in the present study included marginal and perifollicular hyperpigmentation and reticular pigmentation. Similar dermoscopic features in stable and repigmenting vitiligo were observed in a study conducted by Thatte et al.[13] PFP is a well-described phenomenon mainly seen in stable and repigmenting vitiligo. The presence of PFP in these stages of disease activity is attributed to the fact that the loss of melanocytes in the interfollicular area is seen in the initial phase of disease followed by loss of melanocytes in the perifollicular area.[7]

Purnima et al.[14] conducted a dermoscopic study on 50 patients of vitiligo and observed PFP in 87.5% patients of stable vitiligo, 44.4% patients of vitiligo on treatment, and 18% patients of unstable vitiligo that is in comparison to our findings [Table 1]. In a similar study, RH was seen in 81.2% patients of stable vitiligo, 44.4% patients of vitiligo on treatment, and 18% patients of unstable vitiligo that is in accordance with the present study.[14]

MH was seen in 11 (91.6%) patients of stable vitiligo, six (46.1%) patients of vitiligo on treatment, and two (8%) patients of unstable vitiligo in current study that was similar to the findings of Purnima et al.[14]

Jha et al.[2] studied dermoscopy in 60 patients of vitiligo and observed altered pigment network in 91.4% patients of unstable vitiligo and 8.6% patients of stable vitiligo. Similar findings were reported in the present study where altered pigment network constituted absent pigment network, reduced pigment network, and reversed pigment network. In a dermoscopic study of vitiligo lesions by Thatte et al.[13] pigmentary network was reduced in 12 patients, absent in nine patients, and reversed in six patients.

Apart from the changes involving the pigmentary network, we also observed some morphological appearances on dermoscopy with specific relation to the disease activity.

Leukotrichia is a localized patch of white hair seen in vitiligo in which depigmentaion can involve both skin and body hair, whether vellus or terminal. It can precede or follow the depigmentation of surrounding epidermis. It develops as a result of loss of melanocytes present in the hair bulb.[15] Jha et al.[2] observed leukotrichia in 71.4% patients of stable vitiligo. In the present study, leukotrichia was seen in eight (66%) patients of stable vitiligo, majority of which were treatment refractory.

The presence of isomorphic linear band of depigmentation along the traumatic area around the vitiliginous patch is referred to as micro-Koebner phenomena.[16] In current study, micro-Koebner phenomena was seen exclusively in patients of unstable vitiligo that was similar to the findings of Jha et al.[2] [Table 2].

Starburst appearance was seen in 12% patients in the present study that is comparable to the findings of Jha et al.[2]

Purnima et al.[14] observed polka dots in 9% patients of unstable vitiligo that is in accordance with our findings. Jha et al.[2] observed erythema and telangiectasia 16.7% patients of stable and repigmenting vitiligo that is in comparison to the present study (15.3%).

Dermoscopy can be used as an effective tool for diagnosis of vitiligo, evaluation of disease activity, and assessment of therapeutic response. It also aids in differentiation of vitiligo from other hypopigmentary and depigmentary disorders. Since stability of disease mandates the surgical intervention of vitiligo, dermoscopic evaluation can provide enormous help in defining the disease activity in presence of other unequivocal clinical parameters available.


  Conclusion Top


To conclude, MH was the most common dermoscopic feature in stable vitiligo and altered pigment network was the most common dermoscopic feature in unstable vitiligo. PFP, reticulate hyperpigmentation, and marginal pigmentation were the dermoscopic markers of stable vitiligo and repigmenting vitiligo. Perilesional erythema and telangiectasias were seen in patients of vitiligo on treatment. Leukotrichia was seen in patients of stable vitiligo, majority being treatment refractory. Altered pigment network, patterns like micro-Koebner phenomena, starburst, and polka dots suggested unstable vitiligo. Histopathology is a gold standard technique for diagnosis of vitiligo but being an invasive method, it is not frequently accepted by the patients. Hence, dermoscopy has emerged to be novel tool for diagnosis of vitiligo that obviates the need for skin biopsy.


  Limitations Top


Histopathology was done in only those patients who were willing to undergo the investigation and were ready to give the consent for same. The patients did not accept the procedure because of the cosmetic concerns. The IHC studies could not be performed because of insufficient resource availabilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tarlé RG, Nascimento LM, Mira MT, Castro CC. Vitiligo − part 1. An Bras Dermatol 2014;89:461-70.  Back to cited text no. 1
    
2.
Jha AK, Sonthalia S, Lallas A, Chaudhary RKP. Dermoscopy in vitiligo: diagnosis and beyond. Int J Dermatol 2018;57:50-54.  Back to cited text no. 2
    
3.
Parsad D, Gupta S. Standard guidelines of care for vitiligo surgery. Indian J Dermatol Venereol Leprol 2008;74 suppl:S37-45.  Back to cited text no. 3
    
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Mahajan VK, Vashist S, Chauhan PS, Mehta KIS, Sharma V, Sharma A. Clinico-epidemiological profile of patients with vitiligo: a retrospective study from a tertiary care center of North India. Indian Dermatol Online J 2019;10:38-44.  Back to cited text no. 4
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Sehgal VN, Srivastava G. Vitiligo: compendium of clinico-epidemiological features. Indian J Dermatol Venereol Leprol 2007;73:149-56.  Back to cited text no. 5
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Speeckaert R, van Geel N. Vitiligo: an update on pathophysiology and treatment options. Am J Clin Dermatol 2017;18:733-44.  Back to cited text no. 6
    
7.
Chuh AA, Zawar V. Demonstration of residual perifollicular pigmentation in localized vitiligo-a reverse and novel application of digital epiluminescence dermoscopy. Comput Med Imaging Graph 2004;28:213-7.  Back to cited text no. 7
    
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Nugroho H, Ahmad Fadzil MH, Shamsudin N, Hussein SH. Computerised image analysis of vitiligo lesion: evaluation using manually defined lesion areas. Skin Res Technol 2013;19:e72-7.  Back to cited text no. 8
    
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Kang HY, le Duff F, Passeron T, Lacour JP, Ortonne JP, Bahadoran P. A noninvasive technique, reflectance confocal microscopy, for the characterization of melanocyte loss in untreated and treated vitiligo lesions. J Am Acad Dermatol 2010;63:e97-100.  Back to cited text no. 9
    
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Lee DY, Kim CR, Park JH, Lee JH. The incidence of leukotrichia in segmental vitiligo: implication of poor response to medical treatment. Int J Dermatol 2011;50:925-7.  Back to cited text no. 10
    
11.
Haldar SS, Nischal KC, Khopkar U. Dermoscopy: applications and patterns in diseases of the brown skin. In: Khopkar U, editor. Dermoscopy and Trichoscopy in Diseases of the Brown Skin: Atlas and Short Text. 1st ed. New Delhi: Jaypee; 2012. p. 1-9.  Back to cited text no. 11
    
12.
Meng R, Zhao G, Cai R, Meng X, Jiang Z. Application of polarized light dermoscopy in the early diagnosis of vitiligo and its differential diagnosis from other depigmented diseases. Chin J Dermatol 2009;42:810-3.  Back to cited text no. 12
    
13.
Thatte SS, Khopkar US. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. Indian J Dermatol Venereol Leprol 2014;80:505-8.  Back to cited text no. 13
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14.
Purnima G, Tejaswitha Gudivada NA, Narasimharao TV. Dermoscopy—a tool to assess stability in vitiligo. Int J Contemp Med Res 2017;4:2066-8.  Back to cited text no. 14
    
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Mogawer RM, Elmasry MF, Mostafa WZ. New insights into leukotrichia in nonsegmental vitiligo: a cross-sectional study. Indian J Dermatol Venereol Leprol 2019;85:374-9.  Back to cited text no. 15
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Nirmal B, Antonisamy B, Peter CVD, George L, George AA, Dinesh GM. Cross-sectional study of dermatoscopic findings in relation to activity in vitiligo: BPLeFoSK criteria for stability. J Cutan Aesthet Surg 2019;12:36-41.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2]



 

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