Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 1 Monitoring of Vitiligo Patches Over Six Months to Validate Dermoscopic Findings of Lesional Stability Chitra Kamath1, Rachita Dhurat1, Bhavika Shah1, Richa Sharma1, Priyanka Arun Kowe1, Sachin Chamle1 1 Department of Dermatology, Venerology and Leprosy, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India Key words: dermoscopy, lesional stability, active vitiligo, dynamic characteristic of vitiligo Citation: Kamath C, Dhurat R, Shah B, Sharma R, Kowe PA, Chamle S. Monitoring Of Vitiligo Patches Over Six Months To Validate Dermoscopic Findings Of Lesional 98. Dermatol Pract Concept. 2023;13(4):e2023277. DOI: https://doi.org/10.5826/dpc.1304a277 Accepted: June 19, 2023; Published: October 2023 Copyright: ©2023 Kamath et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr Rachita Dhurat, Opd 16, New OPD building, Sion Hospital Mumbai, India 400022. Phone no.- +91-9833394951 Email: rachitadhurat@yahoo.co.in Introduction: Previously laid down criteria for lesional stability of vitiligo are inconsistent. Longitudi- nal data on correlation between dermoscopic features of vitiligo and disease activity is limited. Objectives: To sequentially determine the dermoscopic features of vitiligo and to assess their associa- tion with the dynamic nature of the vitiligo patch. Methods: Sixty patients with 200 vitiligo patches fulfilling the inclusion criteria on medical therapy were subjected to sequential clinical and dermoscopic examination for 6 months. Baseline lesional photographs, dermoscopy and tracing of the patch was made and repeated at 6 months. The follow up tracing was superimposed onto the baseline tracing. Based on the increase or decrease in size, their outcomes were grouped as responsive, progressive and quiescent. Paired analysis of dermoscopic fea- tures was done between baseline, and their follow up after 6 months. Results: Well defined border was associated with static nature of the vitiligo patch and ill-defined borders and trichrome pattern depicted its dynamic nature. Statistically significant increase in leukotri- chia and satellite lesions amongst progressive patches and a decrease amongst responsive patches was observed. Pigment network changes were statistically significant for both responsive and progressive patches. Satellite lesions and micro-Koebner’s phenomena was suggestive of progressive disease, while perifollicular pigmentation and perilesional hyperpigmentation was suggestive of re-pigmenting dis- ease and proved to be an early marker for response to therapy. Conclusions: Repeated dermoscopic evaluation of lesions in a serial manner to assess disease activity helps understand their evolving nature and is a valuable tool in planning appropriate further t reatment. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 Introduction Lesional stability in vitiligo is of paramount importance to provide guidance in selecting patients for surgical interven- tion. Various definitions have been stated to explain disease stability, that are inconsistent and depict conflict amongst one another [1–6]. However, Vitiligo European Taskforce Consensus conference have stated, relying on lesional sta- bility is far better than the overall stability of the disease, as the latter is difficult to define precisely and reliably [7]. Various clinical and experimental studies have tried to assess the lesional stability on the basis of objective biochemical and immunological parameters [8–11]. However, these in- vestigations are not practical, may be invasive and expensive. Off late, dermoscopy has been utilized with respect to the lesional stability of vitiligo. Some cross-sectional studies have tried to correlate the dermoscopic features with disease activity [12–15]. Results are non-homogenous and even contradictory, as far as asso- ciation with disease activity/stability is concerned. In these studies, stability was assessed based on patient’s history which can be unreliable, and carries a degree of recall bias. Ideally, serial clinical and dermoscopic analysis must be per- formed to establish lesional stability and there have been paucity of studies achieving the same. This unique study was planned to prospectively document the changes in dermos- copy in vitiligo patches over six months and correlate them with lesional activity. Objectives To determine the dermoscopic changes of vitiligo patches se- quentially and correlate with its clinical outcome and estab- lish dermoscopic criteria for prognosis of the disease. Methods Two hundred vitiligo patches from 60 patients were selected. Study was conducted as a monocenter observational longitu- dinal study at a tertiary hospital over a period of 18 months from April 2021 to October 2022. The study was approved by the institutional ethics committee. Inclusion Criteria 1. All patients of vitiligo of any age group. 2. Patients who are willing to give consent and take treat- ment for the disease. Exclusion Criteria Mucosal and scalp vitiligo lesions, close differentials of hypo- depigmented lesions, patients on phototherapy, previ- ously surgically treated patches, any changes to primary morphology of lesion like manual excoriation and patches less than 1 cm2 in size. Study Data Detailed patient history and lesional clinical photographs were obtained. Change in size of patches over six months was monitored by tracing the lesion on graph paper with the help of a transparent sheet. The area of the patch was calculated using the point counting method at baseline and at six months. The follow up tracing of the patch was su- perimposed on the baseline record of the same patch on the transparent sheet. The clinical outcomes of these patches were documented as follows: 1. Responsive-Patch having a minimum of 10% reduction in size from baseline. 2. Progressive-Patch having a minimum of 10% increase in size from baseline. 3. No change, ie quiescent -no variation in size of the patch at baseline and follow up period. 4. Resolved- complete repigmentation achieved within the patch. Dermoscopy was performed for each vitiligo patch in a clockwise direction, using Dinolite video dermoscope (Model number AF4115ZT) with 20X magnification un- der polarized light. Pre-defined dermoscopic parameters [16] of border, pigment network, perilesional hyperpig- mentation, perifollicular pigmentation, leukotrichia, micro- koebnerisation, satellite lesions and trichrome pattern were recorded at baseline and follow-up (Table 1). All patches were treated with tailor-made topical/ systemic therapy based on the patient’s subsequent response. The dermoscopic findings and size were documented at baseline and at 6 months. Der- moscopic findings based on their clinical outcomes were an- alyzed and compared to previously established criteria laid down for the stability of vitiligo. Statistical Analysis Data analysis was done using online software of SPSS 23.0. The comparison of two groups was done using one-way Chi Square test. Comparison of mean between two inter- vals within the group was done using Fischer exact test. A P <0.05 was taken as statistically significant. Results Two hundred vitiligo patches from 60 patients were ana- lyzed. Of these, there was a loss to follow-up of three pa- tients (eight patches), and nine patches showed complete resolution; and these were not considered for final analy- sis. The average age of the patients was 24.21 ± 09.40 years Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 3 (range of 05 – 70 years). Of the 183 patches studied, 102 patches (55.73%) were observed in females and the remain- ing 81 (44.27%) in males. The descending order of involve- ment of these patches were lower limbs (36.97%), upper limb (33.86%), trunk (15.10%) and 4.69% each for the face, neck and back. At the end of 6 months, 124 (64.58%) patches were responsive, 37 (19.28%) were progressive, and 22 (11.45%) had no change in size from the baseline to the follow-up period. Dermoscopic Analysis The changes in border (P = 0.0001) and trichome pattern (P = 0.02) in responsive vitiligo patches from baseline to six- month follow-up were statistically significant. A significant number of patches had ill-defined borders among both re- sponsive and progressive groups. Ill-defined borders were present in 82.2% of responsive patches at their baseline. Of these patches, 98.04% continued to show ill-defined borders at the follow up period. Among progressive patches, 78.38% had ill-defined borders at baseline, of which 100% remained ill-defined at follow up. Well defined borders of quies- cent patches (81.82%) showed no change over 6 months (Table 2). Findings of leukotrichia and satellite lesions decreased from baseline to follow-up in responsive patches, and in- creased in progressive patches, and the differences seen for both of these parameters were statistically significant (Tables 3 and 4). There was also a statistically significant increase of per- ifollicular pigmentation and perilesional hyperpigmentation amongst responsive patches at follow up, and a decrease in the same for progressive patches, when compared to their respective baselines (Table 3). A statistically significant difference in the perifollicular pigmentation were noted in those that had terminal hair versus those that had vellus hair within responsive patches. Pigment network changes were seen in both responsive and progressive patches, whose differences from baseline to follow up period were statistically significant (Table 5). Conclusions In the present study, dermoscopic parameters were studied by observing dynamic changes in a vitiligo patch over a pe- riod of 6 months while receiving therapy, to verify the le- sional stability. Table 1. Definition of dermoscopic parameters. SrNo Dermoscopic feature Definition 1 Margins Ill defined- at least 25% of the margins are ill-defined. Well-defined or ill- defined margins are mutually exclusive. 2 Perilesional Hyperpigmentation Accentuated pigment network in at least 25% of the perilesional/marginal uninvolved skin of a vitiligo patch 3 Satellite lesions White structureless areas of size >1mm in diameter in the perilesional skin which may not be apparent on clinical examination 4 Micro-Koebner phenomenon Linearly arranged areas of depigmentation, which are not easily perceived by naked eye examination 5 Leukotrichia It is defined as the presence of depigmented hair in at least 25% of total hair follicles. 6 Pigment network changes (interfollicular regions) At baseline • Absent pigment network refers to no pigment in interfollicular regions. • Reduced pigment network refers to pigment dilution or decreased pigment as compared to the normal skin At follow-up • Initiation of Pigment network refers to onset of new pigmentation on a previously absent pigment network • Well-formed pigment Network -Formation of a reticular pigment network on follow up period. • Status Quo- A patch with absent pigment network at baseline shows the same pigment network on follow up and similarly a patch with reduced pigment network at baseline depicts same findings of pigment network on follow up period as well. 7 Perifollicular Pigmentation Pigment network around hair follicles, in at least 25% of the hair follicles. Perifollicular re-pigmentation: refers to reappearance of pigment network around hair follicles, which previously had a complete loss of pigment network in at least 25% of the hair follicles. 4 Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 Ta b le 2 . D er m os co pi c fe at ur es – B or de r an d T ri ch ro m e pa tt er n ac co rd in g to o ut co m e pa ti en ts a t B as el in e an d Fo llo w -u p of t he le si on in t he s tu dy p op ul at io n. D er m o sc o p ic fe at u re s R es p o n si ve (1 24 ) N (% ) Pr o g re ss iv e( 37 ) N (% ) N o c h an g e( 22 ) N (% ) 1. B or de r W el l D efi ne d (B as el in e) 2 2 (1 7. 74 ) Il l d efi ne d ( B as el in e) 10 2 (8 2. 2) W el l D efi ne d (B as el in e) 08 ( 21 .6 2) Il l d efi ne d (B as el in e) 2 9 (7 8. 38 ) W el l D efi ne d (B as el in e) 18 ( 81 .8 2) Il l d efi ne d (B as el in e) 04 ( 18 .1 8) W el l d efi ne d (F U ) 06 ( 27 .2 7) Il l d efi ne d (F U ) 16 ( 72 .7 3) W el l d efi ne d (F U ) 02 ( 1. 96 ) Il l de fin ed ( FU ) 10 0 (9 8. 04 ) W el l d efi ne d (F U ) 01 ( 12 .5 ) Il l d efi ne d (F U ) 07 ( 87 .5 ) W el l d efi ne d (F U ) 0 (0 ) I ll de fin ed (F U ) 29 ( 10 0) W el l d efi ne d (F U ) 18 ( 10 0) Il l d efi ne d (F U ) 0 (0 ) W el l d efi ne d (F U ) 0 (0 ) Il l d efi ne d (F U ) 4 (1 00 ) p va lu e = 0. 00 01 p va lu e = 1 p va lu e =1 2. T ri ch ro m e Pr es en t (B as el in e) 52 ( 41 .9 4) A bs en t (B as el in e) 72 ( 58 .0 6) Pr es en t (B as el in e) 17 ( 45 .9 5) A bs en t (B as el in e) 20 ( 54 .0 5) Pr es en t (B as el in e) 02 ( 9. 09 ) A bs en t (B as el in e) 20 ( 90 .9 1) Pr es en t (F U ) 24 ( 46 .1 4) A bs en t ( FU ) 28 ( 53 .8 5) Pr es en t (F U ) 07 ( 9. 72 ) A bs en t (F U ) 65 ( 90 .2 8) Pr es en t (F U ) 12 ( 70 .5 9) A bs en t ( FU ) 05 ( 29 .4 1) Pr es en t (F U ) 07 ( 35 ) A bs en t ( FU ) 13 ( 65 ) Pr es en t (F U ) 01 ( 50 ) A bs en t ( FU ) 01 ( 50 ) Pr es en t (F U ) 0 (0 ) A bs en t ( FU ) 20 ( 10 0) P = 0. 02 P = 0. 70 04 P = 1 FU = f ol lo w -u p. Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 5 Ta b le 3 . D er m os co pi c fe at ur es o f le uk ot ri ch ia , p er if ol lic ul ar p ig m en ta ti on a nd p er ile si on al p ig m en ta ti on a cc or di ng t o ou tc om e of p at ie nt s at b as el in e an d fo llo w -u p of t he le si on in t he s tu dy p op ul at io n. D er m o sc o p ic fe at u re s R es p o n si ve (N = 12 4) Pr o g re ss iv e (N = 37 ) N o c h an g e (N = 22 ) L eu ko tr ic hi a Pr es en t- B as el in e 38 ( 30 .6 5) A bs en t - B as el in e 86 ( 69 .3 5) Pr es en t - B as el in e 15 ( 40 .5 4) A bs en t - B as el in e 22 ( 59 .4 6) Pr es en t - B as el in e 9 (4 0. 91 ) A bs en t - B as el in e 13 ( 59 .0 9) Pr es en t (F U ) 18 (4 7. 37 ) A bs en t (F U ) 20 (5 2. 63 ) Pr es en t (F U ) 3 (3 .4 9) A bs en t (F U ) 83 (9 6. 51 ) Pr es en t (F U ) 11 (7 3. 33 ) A bs en t (F U ) 04 (2 6. 67 ) Pr es en t (F U ) 08 (3 6. 36 ) A bs en t (F U ) 14 (6 3. 64 ) Pr es en t (F U ) 0 8 (8 8. 89 ) A bs en t (F U ) 0 1 (1 1. 11 ) Pr es en t (F U ) 0 1 (7 .6 9) A bs en t (F U ) 12 (9 2. 31 ) P = 0. 00 01 P = 0. 03 P = 0. 96 Pe ri fo lli cu la r pi gm en ta ti on Pr es en t - B as el in e 65 ( 52 .4 2) A bs en t - B as el in e 59 ( 47 .5 8) Pr es en t - B as el in e 13 ( 35 .1 4) A bs en t - B as el in e 24 ( 64 .8 6) Pr es en t - B as el in e 05 ( 22 .7 3) A bs en t - B as el in e 17 (7 7. 27 ) Pr es en t (F U ) 64 (9 8. 46 ) A bs en t (F U ) 1 (1 .5 4) Pr es en t (F U ) 41 (6 9. 49 ) A bs en t (F U ) 18 (3 0. 51 ) Pr es en t (F U ) 08 (6 1. 54 ) A bs en t (F U ) 05 (3 8. 46 ) Pr es en t (F U ) 02 (8 .3 3) A bs en t (F U ) 22 (9 1. 67 ) Pr es en t (F U ) 0 2 (4 0) A bs en t (F U ) 03 (6 0) Pr es en t (F U ) 01 (5 .8 8) A bs en t (F U ) 16 (9 4. 12 ) P = 0. 00 00 1 P = 0. 00 05 P = 0. 67 Pe ri le si on al H yp er - pi gm en ta io n Pr es en t - B as el in e 60 ( 48 .3 9) A bs en t - B as el in e 64 ( 51 .6 1) Pr es en t - B as el in e 13 ( 35 .1 4) A bs en t - B as el in e 24 ( 64 .8 6) Pr es en t - B as el in e 04 ( 18 .1 8) A bs en t - B as el in e 18 ( 81 .8 2) Pr es en t (F U ) 57 (9 5) A bs en t (F U ) 03 (5 ) Pr es en t (F U ) 33 (5 1. 56 ) A bs en t (F U ) 31 (4 8. 44 ) Pr es en t (F U ) 05 (3 8. 46 ) A bs en t (F U ) 08 (6 1. 54 ) Pr es en t (F U ) 02 (8 .3 3) A bs en t (F U ) 22 (9 1. 67 ) Pr es en t (F U ) 01 (2 5) A bs en t (F U ) 03 (7 5) Pr es en t (F U ) 0 (0 ) A bs en t (F U ) 18 (1 00 ) P = 0. 00 01 P = 0. 02 P = 1 FU = f ol lo w -u p. 6 Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 Ta b le 4 . D er m os co pi c fe at ur es o f sa te lli te le si on s an d m ic ro ko eb ne ri sa ti on a cc or di ng t o ou tc om e of p at ie nt s at b as el in e an d fo llo w -u p of t he le si on in t he s tu dy p op ul at io n. D er m o sc o p ic fe at u re s R es p o n si ve (N = 12 4) Pr o g re ss iv e (N = 37 ) N o c h an g e (N = 22 ) Sa te lli te L es io ns Pr es en t - B as el in e 36 ( 29 .0 3) A bs en t - B as el in e 88 ( 70 .9 7) Pr es en t - B as el in e 13 ( 35 .1 4) A bs en t - B as el in e 24 ( 64 .8 6) Pr es en t - B as el in e 03 ( 13 .6 4) A bs en t - B as el in e 19 ( 86 .3 6) Pr es en t (F U ) 13 (3 6. 11 ) A bs en t ( FU ) 23 (6 3. 89 ) Pr es en t ( FU ) 04 (4 .5 5) A bs en t ( FU ) 84 (9 5. 45 ) Pr es en t ( FU ) 10 (7 6. 92 ) A bs en t ( FU ) 03 (2 3. 08 ) Pr es en t ( FU ) 09 (3 7. 5) A bs en t ( FU ) 1 5 (6 2. 5) Pr es en t ( FU ) 0 3 (1 00 ) A bs en t ( FU ) 0 (0 ) Pr es en t ( FU ) 0 (0 ) A bs en t ( FU ) 19 (1 00 ) P = 0. 00 1 P = 0 .0 2 P = 1 M ic ro ko eb ne ri sa ti on Pr es en t - B as el in e 16 ( 12 .9 0) A bs en t - B as el in e 10 8 (8 7. 10 ) Pr es en t - B as el in e 08 ( 21 .6 2) A bs en t - B as el in e 29 ( 78 .3 8) Pr es en t - B as el in e 1 (4 .5 5) A bs en t - B as el in e 21 ( 95 .4 5) Pr es en t (F U ) 06 (3 7. 5) A bs en t ( FU ) 10 (6 2. 5) Pr es en t ( FU ) 04 (3 .7 ) A bs en t ( FU ) 10 4 (9 6. 3) Pr es en t ( FU ) 07 (8 7. 5) A bs en t ( FU ) 01 (1 2. 5) Pr es en t ( FU ) 06 (2 0. 69 ) A bs en t ( FU ) 23 (7 9. 31 ) Pr es en t ( FU ) 1 (1 00 ) A bs en t ( FU ) 0 (0 ) Pr es en t ( FU ) 0 (0 ) A bs en t ( FU ) 21 (1 00 ) P = 0. 32 P = 0. 00 04 P = 1 FU = f ol lo w -u p. Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 7 a common consensus. Previous studies have laid down der- moscopic characteristics of “unstable” and “stable” vitiligo with inconsistent conclusions. Dermoscopic parameters of ill- defined borders, trichrome pattern, satellite lesions, Lesional stability and the disease stability of vitiligo do not go hand in hand. A patient with unstable vitiligo can have several stable vitiligo patches. Various studies have aimed to define the stability of vitiligo but failed to reach Table 5. Dermoscopic features of pigment network according to outcome of patients at Baseline and Follow-up of the lesion in the study population. Pigment Network Baseline N (%) Change Follow-up (6 months), N(%) P - Value Responsive (124) Absent 88 (70.97) Absent (SQ) 58(65.91) 0.0001 IPN 25(28.41) WFPN 05(5.68) Reduced 36 (29.03) Reduced (SQ) 15(41.67) WFPN 20(55.56) Absent 01(2.78) Progressive (37) Absent 29 (78.38) Absent (SQ) 24(82.76) 0.0001 WFPN 0(0) IPN 05(17.24) Reduced 08 (21.62) WFPN 0(0) Reduced (SQ) 01(12.5) Absent 07(87.5) No Change (22) Absent 20 (90.91) Absent (SQ) 18(90) 1 IPN 02(10) WFPN 0(0) Reduced 02 (9.09) Absent 0(0) WFPN 0(0) Reduced (SQ) 02(100) IPN = initiation of pigment network; SQ = status quo; WFPN = well-formed pigment network. Table 6. Summary of dermoscopic findings of our study. Dermoscopic finding Findings of previous studies Conclusions of our study Well defined border Marker of stability [15,19,20] Marker of static nature of disease which has poor tendency for marginal re-pigmentation Ill-defined border Marker of instability [15,17], activity of the disease, poor prognosis [18] Marker of dynamic nature of the patch which has a potential to re-pigment (upgrade) with treatment. Hence, not necessarily a poor prognostic factor. Trichrome pattern Marker of activity/ progressive nature of the disease/ poor prognostic factor [20,23-26] Marker of both re-pigmentating and progressive vitiligo and not a reliable marker to define prognosis and instability of the condition. Leukotrichia Poor prognosis [15,27] Marker of instability Leukotrichia may reverse after therapy. Patches with leukotrichia may still show re-pigmentation, hence it is not necessarily a poor prognostic factor Perifollicular pigmentation and perilesional hyperpigmentation Marker of stability Marker for re-pigmentation [16,21] Aids in re-pigmentation of patch Marker of response to therapy Satellite lesion and microkoebnerisation Marker of activity /unstable nature of the disease [15,16,29,30] Marker of activity/ progressive nature of vitiligo patch 8 Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 Figure 1. (A) Well-defined border; (B) Ill-defined border; (C) Trichrome pattern; (D) Satellite lesions. Figure 2. (A) Perifollicular pigmentation; (B) Perilesional Hyperpigmentation (black arrows); (C) Micro-koebnerisation; (D) Leukotrichia. leukotrichia and micro-koebnerisation were largely linked with unstable vitiligo, and well-defined borders, perilesional hyperpigmentation and an absent/reduced pigment network as positive predictive markers for stability [15,17-19]. They linked the stability of a vitiligo patch to its static nature or a good prognostic factor, and the term “unstable” was synonymous with progressive disease. Dermoscopic fea- tures of unstable vitiligo described by previous authors were seen even in the responsive patches. These studies failed to document the dynamic changes of the disease, due to their cross-sectional nature and the results derived were not corroborative. Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 9 possibility of re-pigmentation is minimal. In contrast, our study revealed reversal of leukotrichia amongst responsive patches. Hence it is not necessarily a poor prognostic factor. Our study found that responsive patches with leukotrichia at baseline exhibited evidence of re-pigmentation, which contributes to the development of pigmentation within the patch. Additionally, it was seen in progressive patches, that the color of pigmented hair disappeared over time (increase in incidence of leukotrichia) along with depigmentation of the skin, which was attributed to the natural progression of the disease. Overall incidence of perifollicular pigmentation in- creased in responsive patches from 52.4% at baseline (65 out of 124) to 84.67% (105 out of 124). Perifollicular pigmentation can be due to two reasons: 1. perifollicular pigment retention in a vitiliginous patch re- fers to the pigment around hair follicle retained; 2. perifollicular re-pigmentation, refers to appearance of new pigmentation from follicular melanocytes in a vit- iligo patch. These findings can be assessed only when a patch is mon- itored over a period of time. Of 65 responsive patches, 64 showed perifollicular pig- mentation at baseline and follow up period, ie perifollicular pigment retention. The perifollicular pigmentation of such patches was enhanced and notably darker than at baseline. Of responsive patches that had no perifollicular pigmenta- tion at baseline, 69.5% developed perifollicular pigmenta- tion at follow up period, ie perifollicular re-pigmentation. Increase in findings of perifollicular pigmentation in respon- sive patches and its decrease amongst progressive patches were both statistically significant. This is consistent with findings from previous studies where perifollicular re- pigmentation was found to be associated with re-pigment- ing disease [16,21] but in contrast to few other studies that have claimed perifollicular pigmentation to be a marker of active disease [28,29]. It is merely impossible to comment Few prospective studies have tried to assess dermoscopic parameters of vitiligo patches to monitor their therapeutic response [21,22]. However, these studies lacked data on lesional stability. Erichetti et al, checked perifollicular pig- mentation, non-follicular pigmentation, leukotrichia and follicular red dots. They found perifollicular pigmentation to be associated with response to NB-UVB phototherapy [21]. Gupta et al analyzed 60 active vitiligo lesions over 12 weeks, on treatment [16]. They found perifollicular re-pigmentation to be a marker for response, and perifollicular depigmenta- tion, satellite lesions micro-koebnerisation to be a marker for activity of the disease and did not draw any conclusion with respect to perilesional hyperpigmentation and disease activity. However, there is paucity of data evaluating lesions over a longer duration with a larger sample size to validate findings of lesional stability. In various studies, well-defined borders have been re- ported as a marker of stability or good prognosis of the disease [15,19,20]. The present study confirmed that well defined borders is associated with a static nature of vitiligo patch with low chances of marginal re-pigmentation. Hence, the term “stable” cannot always be used to represent a good prognosis for the disease Ill-defined borders were seen in both responsive and progressive patches and hence it is re- lated to the dynamic characteristic of the patch. Such bor- ders have potential to re-pigment with optimum treatment, and hence it is not necessarily a poor prognostic factor. Trichrome pattern also reflects the dynamic character of the patch and not a reliable marker to define prognosis and instability of the condition, contrary to the findings of previ- ous studies [20,23–26]. The present study found statistically significant change in trichrome pattern during follow up pe- riod amongst responsive patches. Incidence of leukotrichia from baseline decreased in responsive patches, and increased in progressive patches, with these changes being statistically significant. It has been considered as a poor prognostic factor [15,27] prob- ably because it indicates that the melanocyte reservoir within the hair bulb has been destroyed indicating that the Figure 3. (A) Absent pigment network; (B) Reduced pigment network. 10 Original Article | Dermatol Pract Concept. 2023;13(4):e2023277 cell transplantation. Arch Dermatol. 2004;140(10):1211-1215. DOI: 10.1001/archderm.140.10.1211. PMID: 15492183. 7. Ezzedine K, Lim HW, Suzuki T, et al. Revised classification/ nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference. Pigment Cell Melanoma Res. 2012;25(3):E1-E13. DOI: 10.1111/j.1755-148X.2012.00997.x. PMID: 22417114. PMCID: PMC3511780. 8. Ardigo M, Malizewsky I, Dell’anna ML, Berardesca E, Picardo M. Preliminary evaluation of vitiligo using in vivo reflectance con- focal microscopy. J Eur Acad Dermatol Venereol. 2007;21(10): 1344-1350. DOI: 10.1111/j.1468-3083.2007.02275.x. PMID: 17958840. 9. Rao A, Gupta S, Dinda AK, et al G. Study of clinical, biochem- ical and immunological factors determining stability of disease in patients with generalized vitiligo undergoing melanocyte transplantation. Br J Dermatol. 2012;166(6):1230-1236. DOI: 10.1111/j.1365-2133.2012.10886.x. PMID: 22329760. 10. Majid I, Mysore V, Salim T, et al. Is Lesional Stability in Vitiligo More Important Than Disease Stability for Performing Surgical Interventions? Results from a Multicentric Study. J Cutan Aes- thet Surg. 2016r;9(1):13-19. DOI: 10.4103/0974-2077.178538. PMID: 27081244. PMCID: PMC4812882. 11. Morrone A, Picardo M, de Luca C, Terminali O, Passi S, Ippolito F. Catecholamines and vitiligo. Pigment Cell Res. 1992;5(2):65-69. DOI: 10.1111/j.1600-0749.1992.tb00003.x. PMID: 1321419. 12. Purnima G, Tejaswitha Gudivada NA, Narasimharao T V. Dermoscopy—a tool to assess stability in vitiligo. Int J Contemp Med Res. 2017;4(10):2066-2068. ISSN (Online): 2393-915X; (Print): 2454-7379 13. Awal G, Kaur J, Kaur K. Dermoscopy in Vitiligo: An emerging armamentarium in diagnosis and activity assessment. Pigment International. 2022;9(1):25. DOI:10.4103/pigmentinternational. pigmentinternational_4_21 14. Thatte SS, Khopkar US. The utility of dermoscopy in the diag- nosis of evolving lesions of vitiligo. Indian J Dermatol Venereol Leprol. 2014;80(6):505-508. DOI: 10.4103/0378-6323.144144. PMID: 25382506. 15. Nirmal B, Antonisamy B, Peter CVD, George L, George AA, Dinesh GM. Cross-Sectional Study of Dermatoscopic Findings in Relation to Activity in Vitiligo: BPLeFoSK Criteria for Stabil- ity. J Cutan Aesthet Surg. 2019;12(1):36-41. DOI: 10.4103/JCAS .JCAS_75_18. PMID: 31057267. PMCID: PMC6484572. 16. Gupta P, Vinay K, Bishnoi A, Kumaran MS, Parsad D. A prospec- tive observational study to sequentially determine the dermo- scopic features of vitiligo and its association with disease activity in patients on medical treatment: Dermoscopy and disease activ- ity in vitiligo. Pigment Cell Melanoma Res. 2023;36(1):33-41. DOI: 10.1111/pcmr.13069. PMID: 36112075. 17. Benzekri L, Gauthier Y. Clinical markers of vitiligo activity. J Am Acad Dermatol. 2017;76(5):856-862. DOI: 10.1016/j.jaad .2016.12.040. PMID: 28245942. 18. . Zhang L, Chen S, Kang Y, et al. Association of Clinical Markers With Disease Progression in Patients With Vitiligo From China. JAMA Dermatol. 2020;156(3):288-295. DOI: 10.1001/jamadermatol .2019.4483. PMID: 31968061. PMCID: PMC6990655. 19. Khaled HN, Elkazzaz AKH, Bazid HASE. Role of dermoscopy in the diagnosis of vitiligo and evaluating its clinical stability. Menoufia Medical Journal. 2022;35(3):1088. 20. Bhat YJ, Khare S, Nabi N. Dermoscopy of disorders of hypopig- mentation. Pigment International. 2022;9(1):4. DOI: 10.4103 /pigmentinternational.pigmentinternational_ on whether perifollicular pigmentation is a marker of active disease on cross sectional observation. Our study shows that perilesional hyperpigmentation is a marker of re-pigmenting vitiligo in concurrence with a study by Gupta et al [16]. Many cross-sectional studies have stated it to be a marker of stable disease [28,30]. There is paucity of studies observing this finding in a longitudinal manner. Hence, more such studies with larger sample size will help to reach a conclusive statement regarding this finding. Satellite lesion and micro-Koebner phenomenon reflect similar features of perilesional disease activity. There was a significant increase of these findings at follow-up visits for progressive patches supporting the fact that these findings are considered as markers of active disease [15,16,29,30]. Lesions showing these features clinically or on dermoscopy are expected to progress if left untreated. Changes in pigment network, are consistent with dynamic nature of a patch. We observed that interfollicular pigment network may take lon- ger to appear as compared to perifollicular or perilesional pigmentation while on therapy. Our study concluded that a well-defined border is asso- ciated with the static nature of a vitiligo patch. However, lesions with an ill-defined border and trichrome pattern suggest the dynamic nature of the patch and are not reli- able markers to define the prognosis and instability of the condition. Perifollicular pigmentation and perilesional hy- perpigmentation are a marker of re-pigmenting vitiligo and can predict the response to therapy. Dermoscopic findings of leukotrichia, satellite lesions and micro-koebnerisation are significantly associated with progressive vitiligo. Leukotri- chia may reverse after therapy. 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