Vitiligo Extent Research Articles

Non-surgical treatment of vitiligo

Vitiligo is an acquired depigmenting skin disorder that affects 0.5% to 2% of the population. Skin lesions from vitiligo, white macules and patches on the skin, can pose a substantial psychological burdencan, causing a significant decrease in one’s quality of life. Recent basic and clinical studies have found that vitiligo is an autoimmune disorder, mediated by CD8+ T-cell and interferon-γ-mediated cytokine/chemokines. Although no treatment modality presents a complete cure for vitiligo, current treatment modalities have a modest effect on vitiligo by reversing the disease’s progression, inducing its stabilization, and promoting melanocyte regeneration. Current non-surgical treatment modalities include topical corticosteroids, topical calcineurin inhibitors, systemic corticosteroids, and phototherapy such as narrowband ultraviolet B phototherapy and excimer laser. In addition, clinicians have used and combined non-surgical treatment modalities based on the activity and extent of vitiligo. Moreover, considering the high risk of vitiligo relapse, maintenance therapy for re-pigmented lesions has also been introduced. Lastly, based on the results of recent translational research, new and emerging treatment modalities have been introduced, such as Janus kinase inhibitors. This review presents an overview of the current non-surgical treatment modalities for vitiligo and discusses emerging treatments.

16983 Quality of life in patients with vitiligo: Results from a global patient survey

Vitiligo, a common skin disease characterized by depigmentation, is associated with significant quality of life (QoL) impairment in routine activities, employment, and psychosocial health. The objective of this global population-based survey was to understand the disease burden in patients with vitiligo related to QoL. Participants were aged ≥18 years and were part of an online survey in Europe, the United States, and Japan. Participants with self-reported physician-diagnosed vitiligo were asked to respond to the validated Vitiligo-Specific Health-Related Quality of Life (VitiQoL) instrument. The VitiQoL domains were assessed independently and summarized by total score (higher scores indicate poor QoL). There were 219 participants who self-reported formal vitiligo diagnosis and participated in the full survey. The majority were aged <45 years (68.9% [n = 151]), female (54.1% [n = 118]), and Caucasian (77.7% [n = 146]), and self-reported light brown skin on the Fitzpatrick scale (type 3; 40.2% [n = 88]). Most patients described the extent of vitiligo as low (1-2 on Likert scale [1-6]; 63.9% [n = 140]). Analysis of VitiQol total scores indicated worse QoL among patients with high extent of disease (median 79 [n = 23]) and in patients who started with stable disease that quickly spread later in life (median, 74, [n = 62]). Patients who reported using ≥1 treatment (ie, prescription [off-label] and nonprescription products, surgery, phototherapy; 89.0% [n = 195]) reported higher QoL scores (median 51) than those with no treatment (median 11). This is the first known study to examine the correlation between vitiligo disease characteristics and QoL on a global scale and provides additional evidence of the burden of vitiligo.

Assessing the minimal important change in the vitiligo extent score and the self-assessment vitiligo extent score

To the Editor: There is a need for valid, reliable, and interpretable measurement instruments in vitiligo research.1 The Vitiligo Extent Score (VES) and Self-Assessment Vitiligo Extent Score (SA-VES) are validated, feasible, and user friendly measurement instruments assessing vitiligo extent.2,3 However, the minimal important change (MIC) of these instruments is not known—MIC is the smallest change in scores that patients (/clinicians) perceive as important.4 The MIC is a key element of interpretability of measurement instruments and is an important parameter in studies for determining the number of responders.

Validation of a Patient Global Assessment for extent, severity and impact to define the severity strata for the Self Assessment Vitiligo Extent Score (SA-VES).

BackgroundThe Self Assessment Vitiligo Extent Score (SA‐VES) is a validated, patient‐reported outcome measure to assess the body surface area affected with vitiligo. Information on how to translate the obtained score into extent, severity and impact strata (mild–moderate–severe) is still lacking. Stratification is helpful to define inclusion criteria for trials, enables comparison and pooling of trial results and can be used for epidemiological research.ObjectivesThe aim was to develop extent, severity and impact strata for the SA‐VES based on validated anchor‐based questions.MethodsIn total, 315 patients with vitiligo (non‐segmental; age ≥ 16) recruited at the Ghent University Hospital (Belgium) completed a questionnaire that was conducted in cooperation with the Dutch Society for vitiligo patients to ensure content validity. First three anchor questions included in the questionnaire [Patient Global Assessment (PtGA) for vitiligo extent, severity and impact] were assessed for content validity, construct validity and intrarater reliability. Subsequently, the PtGAs were used to stratify the SA‐VES based on ROC analysis.ResultsFor all PtGAs (PtGA extent, PtGA severity, PtGA impact), at least 75% of hypotheses evaluated for construct validity were confirmed. Intrarater reliability of all PtGAs was good to excellent (ICCs PtGA extent: 0.623; PtGA severity: 0.828; PtGA impact: 0.851). The optimal cut‐off values of the SA‐VES between the three global categories (mild/limited – moderate – severe/extensive) were 1.05% and 6.45% based on PtGA extent, 2.07% and 4.8% based on PtGA severity and 2% and 3.35% based on PtGA impact.ConclusionThis study provides the first guide for the interpretation of the numerical output obtained by the SA‐VES (vitiligo extent) and enables the translation into a global vitiligo grading for extent, severity and impact. As patients’ interpretation of vitiligo extent, severity and impact may vary amongst patients worldwide, future international studies will be required.

Can monocyte to HDL cholesterol ratio and monocyte to lymphocyte ratio be markers for inflammation and oxidative stress in patients with vitiligo? A preliminary study.

Both systemic inflammation and oxidative stress play crucial roles in the pathogenesis of vitiligo. In recent studies, monocyte to high-density lipoprotein cholesterol ratio (MHR), monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) and plateletcrit (PCT) have been shown to reflect inflammation and oxidative stress in chronic inflammatory and autoimmune diseases. In this study, we aimed to investigate the hematological and inflammatory parameters in patients with vitiligo and to evaluate their possible relationship with disease severity. The parameters including MHR, MLR, NLR, PLR, MPV, and PCT were retrospectively investigated in patients with vitiligo and healthy controls. Disease severity was evaluated using the vitiligo extent tensity index (VETI) score. A total of 180 patients with vitiligo, and age-gender-matched 180 healthy controls were enrolled in the study. MHR, MLR, PLR, PCT values were found to be significantly higher in patients with vitiligo (p < 0.05). MPV and NLR values showed no statistically significant difference between the two groups. A positive correlation was also detected between MHR and MLR values, disease duration, and VETI score (p < 0.05). We suggest that MHR and MLR can be used as markers of inflammation and oxidative stress in patients with vitiligo. Both markers may also reflect disease severity.

Childhood vitiligo in Egypt: Clinico-epidemiologic Profile of 483 patients.

Childhood vitiligo is commonly encountered. Pattern and distribution of childhood vitiligo were not clearly described in past. To study clinical characteristics of vitiligo among Egyptian children in relation to epidemiological data and compare them with those of adolescents and adults. Recruited clinically diagnosed vitiligo patients were categorized into three groups: I (children): <12years old (yo), II (adolescents): 12-18 yo, and III (adults): 18-30 yo. Patients were subjected to history taking, general and dermatological examination to determine skin phototype, type, presentation, and distribution of vitiligo, percentage of body area involved using vitiligo extent score (VES), associated mucosal involvement, presence of leukotrichia, koebnerization, and halo nevi. A total of 483 vitiligo patients were included: 220 children, 123 adolescents, and 140 adults. The most common form of vitiligo was nonsegmental vitiligo (NSV). Segmental and active vitiligo were more common in children than in adolescents and adults. The most common site of distribution of NSV in children was the face (periocular) vs arms and forearms in adults followed by thighs and legs in both. The mean age of onset of vitiligo in children was 6.18 (SD 2.93) yo, while mean duration of disease was 2.12 (SD 2.21) y. Face was the most common site of onset of vitiligo in children and adolescents vs arms and forearms in adults. Childhood vitiligo differs from adult onset vitiligo regarding several features as type, site of onset, distribution, extent, and activity of disease.

PSY23 QUALITATIVE STUDY OF THE SELF-ASSESSMENT VITILIGO EXTENT SCORE (SA-VES) MEASURE AMONG ADULTS AND ADOLESCENTS WITH VITILIGO

Vitiligo is an autoimmune depigmentation disorder that affects patients’ appearance and health related quality of life. This research evaluated the content validity of the Self-Assessment Vitiligo Extent Score (SA-VES) measure.

Vitiligo expansion and extent correlate with durable response in anti-programmed death 1 antibody treatment for advanced melanoma: A multi-institutional retrospective study.

Vitiligo is an autoimmune disorder resulting from the destruction of melanocytes. Several reports indicate the association between vitiligo and treatment response in advanced melanoma during immunotherapy. It has not been investigated, however, if an increase of vitiligo while on treatment with anti-programmed death 1 (PD-1) antibodies is associated with more durable responses. The aim of this study is to evaluate the correlation between the vitiligo dynamics and clinical efficacy of anti-PD-1 antibodies. This study included advanced melanoma patients who were treated with nivolumab or pembrolizumab and developed vitiligo thereafter. Correlation between vitiligo expansion (defined as an increase of lesion size at two separate time points at least 4weeks apart) as well as vitiligo extent (body surface area [BSA] affected) and clinical efficacy based on response rate, progression-free survival and overall survival was assessed. We retrospectively reviewed 29 patients. The median time from the initiation of anti-PD-1 antibody to vitiligo onset was 4.3months in patients who showed a response and 5.5months in patients who showed no response (P=0.31). Twelve patients showed vitiligo expansion, and in nine of these patients, vitiligo increased to grade 2 (covering ≥ 10% BSA). Vitiligo expansion and grade 2 vitiligo showed no improvement in treatment response (P=0.59 and 0.25) but were associated with prolonged progression-free survival (P=0.019 and 0.04). Grade 2 vitiligo also showed a trend for prolonged overall survival (P=0.07). Trend of expansion and larger vitiligo extent may be predictive factors of prolonged survival during anti-PD-1 antibody in melanoma patients.

Sensitivity of serum S100B protein as a disease activity marker in Egyptian patients with vitiligo (case-control study)

Background Vitiligo is a depigmented skin disease. S100B is a damage-associated molecular pattern protein proposed as a marker of melanocyte cytotoxicity. Aim To detect the sensitivity of serum levels of S100B as a disease activity marker in vitiligo patients. Methods Four patient groups of both sexes: twenty segmental vitiligo, twenty non-segmental active vitiligo patients, twenty non-segmental stable vitiligo patients and thirty healthy controls age and sex-matched, patients were subjected to vitiligo disease activity score (VIDA score) and Vitiligo Extent Tensity Index (VETI) score. Results An increased level of S100B was observed in patients with vitiligo compared to control, there was statistically significant increase in its level in non- segmental-active than non-segmental stable and segmental-stable. Roc analysis for S100B to predict cases vs control was confirmed by getting cut off point 80.2 pg/ml, with high sensitivity 96.67 and high specificity 96.67. Roc analysis for S100B to predict non-segmental-active versus segmental and non-segmental was also confirmed by getting cut off point 118.3 pg/ml, with sensitivity 80.0 and specificity 77.50. Conclusion S100B can be used as indicators for disease activity with high sensitivity and specificity in Egyptian vitiligo patients.

Comparative analysis of the body surface area calculation method used in vitiligo extent score vs the hand unit method used in vitiligo area severity index.

Vitiligo Area and Severity Index (VASI) is standing on the top of the cited and implemented scoring tools for vitiligo. However, an easily applicable and time-saving tool has been a need. This cross-sectional study aimed at comparing the body surface area (BSA) calculation method used in Vitiligo Extent Score (VES) in comparison with the hand unit method used in VASI and to consider the implementation of VES as a user-friendly tool by doctors as applied to observed clinical patterns of NSV in our population. For each patient with NSV, vitiligo was assessed using both VES and VASI as well as vitiligo disease extent by hand units. Vitiligo extent score and VASI scores showed a strong significant correlation. Both scores were found reliable in spite of the presence of unrepresented areas in the VES with tendency of the values for the BSA by the VES to be lower than that by hand units. In comparison with VASI, VES has proven to be a clear, user-friendly score for vitiligo assessment. However, special concern is to be given for required modification for pediatric population. A slight modification may be required regarding the pediatric population.

Narrowband Ultraviolet B Phototherapy versus Excimer Laser in the Treatment of Vitiligo: A Retrospective Analysis

Introduction: Vitiligo is an acquired autoimmune disorder of depigmentation with a global prevalence of 1%. Phototherapy with Narrowband Ultraviolet B (NBUVB) light and excimer laser are both FDA approved treatments for vitiligo. Studies comparing the two modalities are few in patients with different skin colors. Aim: To compare the efficacy and safety of NBUVB versus excimer laser in vitiligo in terms of re-pigmentation achieved during treatment and side effects. Materials and Methods: This study was a retrospective chart review of vitiligo patients attending the phototherapy unit from January 2016 to August 2018. Patient profiles including age, gender, site and extent of vitiligo, type of phototherapy treatment (NBUVB vs excimer laser), sessions per week, sessions required for onset of repigmentation, sites of repigmentation, and side effects were noted. Qualitative variables were analysed using Chi-square test. Quantitative variables were analysed using mean and Standard Deviation (SD). A p-value of &lt;0.05 was considered statistically significant. Results: A total of 146 patients aged 4-70 years were included. Ninety-six patients received excimer laser and 50 patients were on NBUVB. Initial repigmentation occurred after a mean±SD of 28.91±16.61 sessions in the NBUVB group and 24.26±17.57 sessions in the excimer laser group. The difference was not statistically significant (p=0.18). Repigmentation occurred faster on the face followed by the trunk in both groups. Side effects were higher with excimer laser compared to NBUVB (90.6% versus 76%) and the difference was statistically significant (p=0.017). Side effects were, however, mild and did not warrant treatment discontinuation. Conclusion: Number of sessions required for onset of repigmentation was similar in both groups. Side effects, although more frequent with excimer laser, were mild and required dose reduction rather than discontinuation of treatment.

Standardizing serial photography for assessing and monitoring vitiligo: A core set of international recommendations for essential clinical and technical specifications

Clinicalphotography is an important component of the initial assessment and follow-up of patients with vitiligo in clinical practice and research settings. Standardization of this photographic process is essential to achieve useful, high-quality, and comparable photographs over time. The aim is to develop an international consensus for a core set of recommendations for standardized vitiligo clinical photography. Based an international meeting of vitiligo experts, a standard operating procedure was developed for vitiligo photography in daily practice and research settings. This protocol was subsequently reviewed by 20 vitiligo experts until agreement was reached. The resulting protocol includes a set of 10 and 15 photographs for clinical practice and research purposes, respectively. The photographic series are based on anatomic units included in the Vitiligo Extent Score. Furthermore, graphic representations of standardized positioning and suggestions for guidelines to standardize the process (background color, lighting, position marking, scales, materials, instruments) for both color and ultraviolet photographs are described. This consensus-based protocol for vitiligo photography will harmonize imaging for both clinical practice, translational research, and clinical trials. It can improve outcome assessment, foster multicenter collaboration, and promote better communication with patients regarding outcomes of treatment.

Validation of a physician global assessment tool for vitiligo extent: Results of an international vitiligo expert meeting.

Currently, vitiligo lacks a validated Physician Global Assessment (PGA) for disease extent. This PGA can be used to stratify and interpret the numeric scores obtained by the Vitiligo Extent Score (VES). We investigated the interrater reliability of a 5-point PGA scale during an international vitiligo workshop. Vitiligo experts from five different continents rated photographs of non-segmental vitiligo patients with varying degrees of extent with the PGA score. Good interrater agreements (intraclass correlation coefficient >0.6) were observed between the raters overall and within each continent. All hypotheses to evaluate construct validity were confirmed. Median VES values per category were for limited 1.10 [IQR: 0.21-1.67], moderate 3.17 [IQR: 1.75-6.21], extensive 9.58 [IQR: 6.21-13.03] and very extensive 42.67 [IQR: 21.20-42.67]. Defined categories for vitiligo extent can be valuable for inclusion criteria and may impact future reimbursement criteria.

Vitiligo Extent Tensity Index (VETI) score: a new definition, assessment and treatment evaluation criteria in vitiligo

Although skin is the largest organ of the body, there are no standardized reproducible methods for assessing severity of many skin diseases. Due to lack of consensus, methods of assessment and inexistence of precise scoring system, there is no application for vitiligo estimation in real practice. In this paper the author describes VETI score as a new treatment evaluation criteria and severity assessment method for vitiligo. This new tool, as does the PASI score in psoriasis, may be able to produce a constant and reproducible number and to help clinical research on vitiligo patients. Additionally it has a potential to be a source of any computed application for researchers working on vitiligo patients.

Systematic Review of Clinimetric Instruments to determine the severity of Non-segmental Vitiligo.

This systematic review of measurement instruments for vitiligo outcomes included validation articles published from 2011 to May 2018. According to the PRISMA statement, the search was carried out in EMBASE (via OvidSP); MEDLINE (via OvidSP and PubMed). The COSMIN taxonomy will be used to define the measurement properties. Inclusion criteria were original studies reporting measuring properties. Exclusion criteria were clinical trials using scales whose measurement properties were not assessed, studies of cross-cultural adaptation, scales focused on other aspects of the disease such as quality of life, satisfaction, disease's burden. Fourteen studies were identified, which described 15 instruments to measure vitiligo outcomes. Nine of them, measured properties related to the severity of the disease: Vitiligo extent score (VES), Self-Assessment Vitiligo Extent Score (SA-VES), Self-Assessed Vitiligo Area Scoring Index (SAVASI), Vitiligo Area Scoring Index (VASI), Vitiligo European Task Force assessment (VETFa), Vitíligo Noticeability Scale (VNS), Koebner's phenomenon in vitiligo score (K-VSCOR), Vitiligo Extent Tensity Index (VETI), Potential Repigmentation Index (PRI). The most effective tool to asses affected Body Surface Area (BSA) is VES. The VASI is useful to stratify by severity. There is not enough evidence to recommend the use of SAVASI. The VETFa does not offer any difference to calculate the affected BSA compared with the rule of 9's. The VNS and K-VSCOR lack of reliability evidence.

New insights into leukotrichia in nonsegmental vitiligo: A cross-sectional study.

Leukotrichia has been considered a predictor of poor outcome in vitiligo. However, studies considering the different clinical aspects of leukotrichia in vitiligo patients are few. Our aim was to conduct a detailed clinical study to provide insights into the relevance and associations of leukotrichia in non-segmental vitiligo. In this cross-sectional study, vitiligo patients attending the dermatology outpatient clinic and phototherapy unit at Cairo University Hospital over a period of 6 months (April-September 2016) were included. Family history, clinical details, the Vitiligo Global Issues Consensus Conference classification, the Dermatology Life Quality Index, Vitiligo Area and Severity Index, Vitiligo Extent Score, Vitiligo Disease Activity Score and Vellus Score were determined and these measurements were correlated to leukotrichia. Out of the 101 patients studied, leukotrichia was found in 47 (46.5%) patients, with vellus hair involved in 37 (78.7%), terminal hairs in 30 (63.8%) and both in 20 (42.5%) patients. Vellus hair involvement was significantly higher in generalized bilaterally symmetrical vitiligo than in acrofacial or unclassified vitiligo. The incidence of scalp leukotrichia also was higher in generalized symmetrical vitiligo than in acrofacial vitiligo. The Vellus Score showed significant associations with Vitiligo Area and Severity Index, Vitiligo Extent Score and the Dermatology Life Quality Index. This was a short-term study with a small sample size. Prognostic and therapeutic correlations were not studied; prospective longitudinal studies are needed for further evaluation. Leukotrichia was found in almost half of the studied sample and its frequency varied among the different types of vitiligo.

Development and validation of the Vitiligo Extent Score for a Target Area (VESTA) to assess the treatment response of a target lesion.

Since localized treatment for vitiligo is as essential as systemic treatment, a reliable instrument for target evaluation is needed besides those for whole body evaluation. We developed the Vitiligo Extent Score for a Target Area (VESTA) using reference images of both marginal and perifollicular repigmentation to measure the repigmentation rate (%) in a target lesion. In the validation study, a total of 65 dermatologists in 10 institutes evaluated 17 pairs of vitiligo images (pre- and post-treatment) using both a rough estimate and the VESTA. The VESTA (concordance correlation coefficient: 0.949, 95% confidence interval [CI] 0.942-0.955) was significantly more accurate than the rough estimate (0.896, 95% CI: 0.883-0.908). It was also associated with better inter-rater reliability over the rough estimate, albeit not significant. The VESTA can afford intuitive, convenient, and reliable assessment of the treatment response in a target area, and would be useful in clinical practice as well as retrospective studies.

Cytokine profile (IL-2, IL-6, IL-17, IL-22, and TNF-α) in vitiligo-New insight into pathogenesis of disease.

Vitiligo is an autoimmune disease associated with alteration in levels of various cytokines. However, there are very few studies in this regard. To assess the serum levels of cytokines secreted by Th1 (IL-2, TNF-α), Th2 (IL-6), and Th17 cells (IL-17, IL-22) in patients with localized vitiligo and generalized vitiligo and to correlate their levels with the extent, duration, and activity of disease. Sixty patients of vitiligo (30 each of localized and generalized) and 30 controls were recruited in the study. Serum IL-2, -6, -17, -22, and TNF-α levels were measured by enzyme-linked immunosorbent assay (ELISA) in all patients and healthy controls, and their levels were correlated with the extent, duration, and activity of vitiligo. We observed significantly raised levels of IL-2, -6, -17, -22, and TNF-α in both localized vitiligo and generalized vitiligo (P < .05). IL-2 was significantly raised (P = .028) in localized vitiligo, whereas IL-17 and IL-22 were significantly raised in generalized vitiligo (P = .00 and P = .019, respectively). Activity of disease showed positive correlation with serum TNF-α levels (P = .015) in localized vitiligo. Positive correlation of IL-17 (R = .238) with body surface area (BSA) was observed in patients with generalized vitiligo. Our study shows that cytokines secreted by Th17 cells play an important role in maintenance and spread of vitiligo as they increase in line with extent of disease. Also TNF-α increases in proportion with activity of disease, hence may act as biomarker for identifying patient with aggressive disease.

The Vitiligo Extent Score (VES) and the VESplus are responsive instruments to assess global and regional treatment response in patients with vitiligo

The Vitiligo Extent Score (VES) and the VESplus are responsive instruments to assess global and regional treatment response in patients with vitiligo

Plasma Thiol Levels are Associated with Disease Severity in Nonsegmental Vitiligo.

Background:Vitiligo is a depigmenting cutaneous disorder with complex pathogenesis. Thiol compounds are well-known organic structures that play a major role in melanogenesis.Aim:The aim of this study was to determine the association between plasma thiol level and disease severity in patients with nonsegmental vitiligo.Methods:A total of 73 patients with nonsegmental vitiligo (57 generalized and 16 localized type) and age- and sex-matched 69 healthy controls were enrolled in the study. Plasma levels of native thiols, disulfides, and total thiols were measured by a novel and automated assay. Disease severity of vitiligo was assessed with Vitiligo Area Scoring Index (VASI) score. The extent, stage, and spread of vitiligo of patients were evaluated according to the Vitiligo European Task Force (VETF) system.Results:The native and total thiol levels of vitiligo patients were higher than those of healthy control group (P≤0.001 and 0.001, respectively). The median VASI score of patients was 0.7 (0.02–28.30). Univariate analyses showed that plasma native thiol levels, VETF spread score, disease duration, and vitiligo type significantly correlated with VASI scores (r=0.237, P=0.043; r=0.458, P<0.001; and P<0.001, respectively). Stepwise multivariate analysis revealed that disease duration (β=0.017; P=0.005) and spread score (β=1.301; P=0.001) were found statistically significant as independent factors on VASI score.Conclusion:Although plasma native thiol level significantly correlated with VASI scores of patients, it is not a predictive factor for vitiligo severity.