Clinical Signs and Symptoms of Active Vitiligo

John E. Harris, MD, PhD, shares the signs and symptoms that dermatologists can look for to identify if a patient has active vitiligo. Dr Harris is the chair of dermatology, founding director of the Vitiligo Clinic and Research Center, and founding director of the Autoimmune Therapeutics Institute at UMass Medical School in Worcester, MA.

Transcript
Dr Harris: Patients with vitiligo could have very active disease, or it could be very stable disease. I've seen patients who've had vitiligo for 20 years, and they say it's just not moving, or it's not changing, or some who've had it for 10 years, and they say, "For 10 years it was stable, and now it's active. What's going on?"

Their definition of active, of course, is new spots or the spots are growing. That's important because if it's active we want to stop the progression as fast as possible. We like to use UVB phototherapy and topicals. There are a number of other things we could use that both stabilize and repigment the skin, but they're not fast.

UVB can take 2 or 3 months to get going and start working. In that time, while we're waiting for that, if the disease is active and spreading fast, they get much worse while we're waiting for the UV to kick in. To control the activity, we'll often give an oral steroid to hold that and stop that while we're doing the UV to get going. It's important for us to be able to recognize that.

The first question I ask patients is, "Do you think it's active? Is it spreading? When was the last time you saw a new spot?" If the answer is anywhere from yesterday, or to a week, to a month, that's active, and we should probably control that.

The important question is what physical signs can you look for that also tell you that it's active in addition to the history? Sometimes people just don't know. Maybe they have fair skin and they're not sure when they got the last spot.

There are four clinical signs that I look for that tell me whether the disease is active. One of them is the Koebner phenomenon. If the skin is scratched, or scraped, or injured, vitiligo likes to go there. That's called Koebner phenomenon, and that only happens when the disease is active. When it's stable, we don't usually see that.

A second is something called confetti-like vitiligo, which typically in vitiligo we think of big spots, big patches. With confetti-like vitiligo we see tiny, tiny little macules of vitiligo that all cluster together. You might see fifty 1-mm spots that are all clustered together, maybe near a larger spot or something. The borders of the vitiligo are fuzzy, and it's hard to tell where they start and stop. That's a clear sign of confetti vitiligo. Fuzzy borders, that's another one, where it's not super clear. You take out the Wood's lamp, and you're not sure where it starts and stops.

Another one, take the Koebner phenomenon, I added fuzzy borders, so you can use that. Confetti vitiligo, another one is trichrome vitiligo. Typically, with vitiligo you have this depigmented skin which is white. You have normal skin which can be shades of dark. Those are two colors. Trichrome vitiligo has a third color in between where the border is hypopigmented. You've got these three zones, so we call it trichrome. That usually indicates that it's active.

Finally, there's a relatively uncommon phenomenon called inflammatory vitiligo where if you look at a spot around the edge, it's pink, and sometimes scaly, and often very itchy. That period might only last for a few weeks, maybe a month, and during that period, vitiligo spreads rapidly.

It's hard to recognize, and it's more common that we give it credit for. When I ask patients, "Hey, has this ever had a pink border and been scaly and itchy?" they say, "Yes," but it goes away so fast that you often don't see it in clinic.

Those are the signs that we look for to indicate active disease, and that will trigger us to use systemic treatment.