Vitiligo Classification and Stages
Vitiligo is classified primarily by distribution pattern and disease activity rather than traditional "stages," with the two main types being non-segmental (symmetrical) vitiligo and segmental (unilateral) vitiligo, distinguished by their clinical behavior and prognosis. 1
Primary Classification System
Type-Based Classification
Non-segmental vitiligo (vitiligo vulgaris) is characterized by symmetrical depigmented patches that typically increase in size over time, representing the most common presentation with average onset around age 20 years 1
Segmental vitiligo presents as unilateral, asymmetrical depigmentation confined to one body segment, often following dermatomes or Blaschko's lines, and typically stabilizes more quickly than non-segmental disease 1, 2
Mixed vitiligo combines features of both segmental and non-segmental patterns 3
Activity-Based Classification
The British Journal of Dermatology guidelines emphasize classifying vitiligo by disease activity, which is clinically more relevant than traditional staging 1:
Stable disease is defined by no new lesions, no Koebner phenomenon (trauma-induced depigmentation), and no extension of existing lesions for at least 12 months 4, 1
Active/progressive disease shows new lesion development, spreading of existing patches, or positive Koebner phenomenon 1
Activity signs include confetti-like lesions (57.1% of experts consider this significant), hypochromic borders (50%), and Koebner phenomenon (57.1%) 5
Assessment Tools for Extent and Severity
Clinical Measurement Systems
The Vitiligo European Task Force (VETF) system combines analysis of extent (using rule of nines), stage of disease based on cutaneous and hair pigmentation, and disease progression assessed by Wood's light examination 4
The Vitiligo Area Scoring Index (VASI) quantifies overall depigmented area and degree of repigmentation, correlating well with physician and patient assessments (P = 0.05 and P = 0.001, respectively) 4
Wood's light examination helps delineate areas of pigment loss, particularly useful in lighter skin types 1, 2
Distribution Patterns
Focal vitiligo involves localized areas and responds better to treatment 4
Generalized vitiligo affects multiple body regions symmetrically 3
Common sites include fingers, wrists, axillae, groins, and body orifices (mouth, eyes, genitalia) 1, 2
Clinical Implications of Classification
Treatment Selection Based on Type
Localized/stable disease can be treated with potent topical steroids (limited to 2-month trials) or calcineurin inhibitors (pimecrolimus or tacrolimus) with better safety profiles 1
Widespread disease requires narrowband UVB phototherapy, which is preferred over PUVA due to greater efficacy 4, 1
Surgical interventions (split-skin grafting, autologous epidermal suspension) are reserved exclusively for stable disease with no progression for 12 months, and should only be used for cosmetically sensitive sites 4, 1
Prognostic Factors
Segmental vitiligo achieved best surgical results with >75% repigmentation in 71% of cases, compared to inferior results in generalized or mixed vitiligo 3
Facial and small areas respond better than larger areas or acral sites for both phototherapy and surgical treatments 4
Age under 20 years and focal/segmental disease show higher success rates (50% with suction blister transfer plus PUVA) 4
Active generalized vitiligo shows only 14% achieving 90-100% coverage with surgical techniques, compared to 90-100% in localized disease 4
Common Pitfalls to Avoid
Failing to assess disease stability before considering surgical interventions, which are absolutely contraindicated in active disease with progression within 12 months 4, 1
Extended use of potent topical steroids beyond 2 months can cause irreversible skin atrophy 1
Not screening for autoimmune thyroid disease, which occurs in approximately 34% of adults with vitiligo and represents a treatable comorbidity 1
Overlooking psychological impact regardless of extent or classification, as vitiligo significantly impairs quality of life, particularly in women and those with darker skin 4, 1
Using aggressive laser/IPL settings without test spots, as laser-induced depigmentation can occur even in patients with stable vitiligo (58% of laser-induced cases had stable disease >12 months) 5