What are the different classifications of vitiligo?

Vitiligo Classification

Vitiligo is classified into two main types: non-segmental (vitiligo vulgaris) and segmental vitiligo, distinguished by their distribution pattern, symmetry, and clinical behavior. 1

Primary Classification System

Non-Segmental Vitiligo (Vitiligo Vulgaris)

• Symmetrical depigmented patches that typically increase in size over time 1
• Represents the most common presentation of vitiligo 1
• Characterized by bilateral distribution affecting similar areas on both sides of the body 1
• Can develop at any age with average onset around 20 years 1
• Associated with progressive loss of functioning epidermal and hair follicle melanocytes 1

Segmental Vitiligo

• Unilateral, asymmetrical depigmentation confined to one segment of the body 1
• May follow dermatome distribution or Blaschko's lines 1
• One segment is typically involved, though two or more segments on the same or opposite sides may be affected 1
• Tends to stabilize more quickly than non-segmental forms 2
• More common in younger patients 2

Subtypes of Non-Segmental Vitiligo

The British Journal of Dermatology guidelines recognize several topographical presentations within non-segmental vitiligo: 3

• Generalized (vulgaris): Widespread distribution affecting multiple body areas 3
• Acrofacial: Affecting distal extremities (fingers, wrists) and face, particularly around body orifices (mouth, eyes, genitalia) 4, 3
• Mucosal: Involving mucous membranes 3
• Universal: Near-complete depigmentation affecting most of the body surface 5

Localized Vitiligo

• Focal: Limited to one or few patches in a single area 6
• Represents an early stage that may progress to generalized vitiligo in most cases 2
• In 15 of 44 patients studied, localized vitiligo developed into type A (non-segmental) vitiligo, with new patches appearing as early as 9 months 2
• A small subset may represent early segmental vitiligo if new patches develop within the same dermatome within 12 months 2

Alternative Classification Framework

Research literature also describes a Type A/Type B classification system: 2

• Type A (Non-dermatomal): Corresponds to non-segmental vitiligo; appears at any age and progresses throughout life 2
• Type B (Dermatomal): Corresponds to segmental vitiligo; affects younger patients and stabilizes within a few years 2

Activity-Based Classification

Beyond morphological distribution, vitiligo should be classified by disease activity: 5

• Progressing/Active: Characterized by expanding lesions, new patch development, confetti-like depigmentation, trichrome vitiligo, inflammatory borders, or Koebner phenomenon 5, 6
• Stable: No new lesions, no Koebner phenomenon, and no extension of existing lesions for at least 12 months 1

This activity classification is critical because surgical treatments are reserved exclusively for stable disease with no progression for 12 months 1

Morphological Variants

Several morphological presentations exist within these classifications: 3

• Trichrome vitiligo: Three zones of pigmentation (normal, intermediate, depigmented) 3
• Inflammatory vitiligo: Depigmented patches with erythematous, raised borders indicating active disease 6, 3
• Blue vitiligo: Bluish hue in depigmented areas 3

Clinical Implications of Classification

Diagnostic Approach

• Classical symmetrical presentations can be diagnosed confidently in primary care 1
• Atypical presentations require referral to dermatology for expert assessment 1, 4
• Wood's light examination helps delineate pigment loss, particularly useful in lighter skin types 1, 4

Treatment Selection Based on Classification

• Segmental vitiligo: Often requires more aggressive early treatment as it may stabilize quickly; surgical options may be considered earlier once stable 1, 2
• Non-segmental vitiligo: Typically requires long-term management with topical therapies or phototherapy depending on extent 1
• Localized disease: Topical potent steroids (maximum 2 months) or calcineurin inhibitors 1
• Widespread disease: Narrowband UVB phototherapy preferred over PUVA 1

Common Pitfalls

• Failing to assess disease activity before considering surgical interventions, which are contraindicated in active disease 1
• Not screening for autoimmune thyroid disease, which occurs in approximately 34% of vitiligo patients 4
• Misclassifying early localized vitiligo as a stable entity when most cases represent early-stage progressive non-segmental disease 2
• Overlooking psychological impact, as vitiligo causes significant quality of life impairment regardless of classification 1