Diagnosis: Stable Vitiligo
The dermoscopic finding of perifollicular depigmentation with sharp borders and no scales is diagnostic of stable vitiligo, and this patient should be considered for topical therapies or phototherapy depending on the extent of involvement. 1, 2
Dermoscopic Confirmation of Diagnosis
Perifollicular depigmentation is the hallmark dermoscopic feature that predicts stable vitiligo, distinguishing it from active/progressive disease which shows perifollicular pigmentation instead 1, 2
Sharp borders are characteristic of stable vitiligo lesions, whereas diffuse borders, comet tail appearance, or satellite lesions indicate unstable/progressive disease 3, 2
The absence of scales helps exclude other hypopigmentary disorders such as pityriasis alba or tinea versicolor 4
Additional dermoscopic features supporting stable vitiligo include reduced or absent pigment network in the center of lesions and marginal hyperpigmentation at the periphery 3, 2
Disease Activity Assessment
This patient has stable disease based on the perifollicular depigmentation pattern, which is critical for treatment selection 1, 2
Stable vitiligo is defined by the British Journal of Dermatology as no new lesions, no Koebner phenomenon, and no extension of existing lesions for at least 12 months 5, 6
Perifollicular depigmentation indicates either stable untreated vitiligo or poor response in treated lesions 3, 1
Progressive vitiligo would show perifollicular pigmentation, starburst appearance, tapioca sago pattern, or comet tail appearance on dermoscopy 1, 2, 7
Treatment Recommendations Based on Extent
For Localized Disease (Face, Hands, Limited Areas):
Initiate a trial of potent or very potent topical corticosteroid for no more than 2 months to avoid skin atrophy 5
Topical calcineurin inhibitors (pimecrolimus or tacrolimus) should be considered as alternatives with better safety profiles, particularly for facial involvement or in children 5, 6
In adults with symmetrical vitiligo, topical pimecrolimus is specifically recommended based on evidence showing comparable efficacy to highly potent steroids with fewer side effects 5
For Widespread Disease (>50% Body Surface Area):
Narrowband UVB phototherapy is preferred over PUVA due to greater efficacy 6
Safety limits recommend no more than 200 treatments with narrowband UVB for skin types I-III 5
Depigmentation therapy with monobenzone should be reserved for patients with >50% involvement who cannot or choose not to pursue repigmentation and who accept permanent depigmentation 5, 8
For Stable Disease (No Progression for 12 Months):
Surgical treatments can be considered for cosmetically sensitive sites once stability is confirmed 5, 6
Split-skin grafting provides better cosmetic results than minigraft procedures 5
Autologous epidermal suspension applied to laser-abraded lesions followed by phototherapy is optimal but requires specialized facilities 5
Essential Workup
Check thyroid function tests and thyroid autoantibodies in all vitiligo patients, as autoimmune thyroid disease occurs in approximately 34% of adults with vitiligo 6
Wood's lamp examination can help delineate areas of pigment loss, especially in lighter skin types 6
Common Pitfalls to Avoid
Do not use potent topical steroids beyond 2 months due to high risk of skin atrophy 5, 6
Do not proceed with surgical interventions unless disease has been stable for at least 12 months, as surgery is contraindicated in active disease 5, 6
Do not overlook the psychological impact of vitiligo, which significantly affects quality of life regardless of extent; psychological interventions should be offered 5, 6
Failing to screen for thyroid disease misses an important treatable comorbidity 6