Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(4):e2024258 1 Cross-Sectional Descriptive Study of the Utility of Dermoscopy in Assessing the Activity and Stability of Vitiligo Sreevidya Suresh M1, Kethireddi Sushmitha Divya2, Jahnavi Sambangi3, Patnala Guruprasad3 1 Department of Dermatology, Venereology and Leprosy, Sree Narayana Institute Of Medical Sciences, Ernakulam, Kerala, India 2 Department of Dermatology, Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India 3 Department of Dermatology, Venereology and Leprosy, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India Key words: Dermoscopy, Vitiligo, Stability of vitiligo, Activity of vitiligo Citation: Suresh MS, Divya SK, Sambangi J, Guruprasad P.Cross-Sectional Descriptive Study of the Utility of Dermoscopy in Assessing the Activity and Stability of Vitiligo.Dermatol Pract Concept. 2024;14(4):e2024258. DOI: https://doi.org/10.5826/dpc.1404a258 Accepted: July 4, 2024; Published: October 2024 Copyright: ©2024 Suresh 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. M Sreevidya Suresh, Senior Resident, Department of Dermatology, Venereology and Leprosy, Sree Narayana Institute Of Medical Sciences, Ernakulam, Kerala, India. Email: sreevidyamsuresh@gmail.com Introduction: Dermoscopy is an important noninvasive tool that helps to determine the stability and activity of vitiligo. Various dermoscopic findings help classify the disease as stable or unstable. This is important for the management of the disease, as surgical management requires disease stability. Objectives: We aimed to describe the dermoscopic findings in vitiligo and to assess the frequency of various dermoscopic findings in stable and unstable vitiligo. Methods: This was a hospital-based cross-sectional descriptive study of 100 vitiligo patients and various dermoscopic findings. Results are expressed as percentages. Results: The most common dermoscopic findings in stable vitiligo patches were sharp border, marginal and perifollicular pigmentation, and reticulate pigment network. Findings such as polka dot appear- ance, starburst appearance, comet tail, and satellite lesions were seen in unstable vitiligo patches. Conclusions: Dermoscopy is extremely helpful in determining the stability of vitiligo patches. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(4):e2024258 Introduction Vitiligo is an autoimmune disorder which is clinically char- acterized by depigmented macules. Though the disease is considered to be asymptomatic, it has adverse cosmetic and psychological effects on patients. There are multiple man- agement options, including medical and surgical therapy, depending on the disease activity and stability. Assessing the activity of the disease is of paramount value because the sta- bility of the disease is important for surgical management. Dermoscopy is a noninvasive tool that allows the identifica- tion of subtle features in stable and unstable vitiligo that are otherwise invisible to the naked eye. Thus, dermoscopy aids in evaluating disease activity and guides in the management. Objectives The study aimed to describe various dermoscopic findings in stable and unstable vitiligo,including patients who are un- dergoing treatment, and to assess the frequency of various dermoscopic findings in stable and unstable vitiligo Methods This hospital-based cross-sectional descriptive study was carried out over a period of six months in the Department of Dermatology at Andhra Medical College. The study subjects were 100 clinically diagnosed patients of vitiligo who were attending the Dermatology Department of our Institute. All vitiligo patients, including patients who were on treatment, were included in the study. Patients with other causes of hypopigmentation and depigmentation were excluded. Ap- proval from the institutional ethics committee was taken prior to the study. A written informed consent was taken from all study participants. A pre-structured proforma was used to collect the baseline data. Based on the patient’s his- tory, the disease was classified as stable or unstable vitiligo. The criteria for stability included absence of any new lesions, no progression of existing lesions, and absence of Koebner phenomena for the past one year [1]. In addition, repigmentation of depigmented area by medical treatment was also taken as a criteria for stability [2]. After detailed history taking and clinical examination, dermoscopic examination was performed with a DermLite DL4 handheld dermatoscope under polarized light. Pho- tographs were taken, and findings were documented. The frequency of each finding was calculated separately for sta- ble and unstable vitiligo patches. Data analysis was done using Microsoft Office 2021, and results are expressed as percentages. Results This study comprised 62 male patients and 38 female pa- tients. The most common age group involved was between 3-40 years. Among the study participants, 56 (56%) patients had clinically stable vitiligo, and 44 patients had unstable vitiligo. Dermoscopic examination revealed three patterns of borders in vitiligo patches: sharp border, irregular border and trichrome pattern (Figure 1A-C). Among the 56 stable vitiligo patients, the most commonly observed pattern was sharp border (n=44, 78.6%), followed by irregular border (n=10, 17.9%). Trichrome pattern was seen only in two pa- tients with stable vitiligo (3.6%). In patients with unstable vitiligo, irregular border (n=22, 50%), followed by trichrome pattern (n=20, 45.5%) were commonly observed (Table 1). Four types of pigment network patterns were observed in vitiligo patches: reticular pigment pattern, reduced pigment network, absent pigment network, and reverse pigment net- work (Figure 2A-D). Among these, reticular pigment network was most commonly seen in stable vitiligo patches (n=32, 57.1%), whereas in unstable vitiligo, absent pigment net- work was most frequent (n=22, 50%) (Table 2). The other dermoscopic findings that were noted in most of the stable vitiligo patches were marginal hyperpigmentation (n=44, 78.6%) and perifollicular hyperpigmentation (n=40, 71.4%). Marginal pigmentation was seenonly in patients with unsta- ble vitiligo (Table 3). Leukotrichia was noted in 28 patients with stable vitiligo and 18 patients with unstable vitiligo (Figure 3; Table 4). Few findings were seen only in Figure 1. Dermoscopic examination with polarized light showing borders of vitiligo patches: (A) sharp border, (B) irregular border, (C) trichrome pattern. Original Article | Dermatol Pract Concept. 2024;14(4):e2024258 3 Table 1. Frequency of Distribution of Various Dermoscopic Patterns Vitiligo Border Patches in Stable and Unstable Vitiligo. Sharp Border Irregular Trichrome Stable 44(78.6%) 10(17.9%) 2(3.6%) Unstable 2(4.5%) 22(50%) 20(45.5%) On treatment 10(33.3%) 14(46.7%) 6(20%) Figure 2. Dermoscopic examination of pigmentary network in vitiligo patches with polarized light: (A) reticular pigment network, (B) reduced pigment network, (C) absent pigment network, (D) reverse pigment network. Table 2. Frequency of Distribution of Pigmentary Network Pattern on Dermoscopy Among Stable and Unstable Vitiligo Patches. Stable Unstable On treatment Absent pigment network 14(25%) 22(50%) 10(33.3%) Reticular pigment network 32(57.1%) 2(4.5%) 8(26.7%) Reduced pigment network 10(17.9%) 8(18.2%) 8(26.7%) Reverse pigment network 0 12(27.3%) 4(13.3%) Table 3. Frequency of Distribution of Marginal and Perifollicular Pigmentation Among Stable and Unstable Vitiligo Patches. Marginal Hyperpigmentation Perifollicular Hyperpigmentation Stable 44(78.6%) 40(71.4%) Unstable 4(9.1%) 6(13.63%) On treatment 16(53.33%) 12(40%) unstable vitiligo patches, including polka dot appearance (n=18, 40.9%), starburst appearance (n=10, 22.7%), comet tail appearance (n= 8, 18.2%), and satellite lesions (n=18, 40.9%) (Figure 4A-D). Patients who were on treatment with either steroids or NBUVB had erythema and telangiec- tasia in addition to the above-mentioned findings (Table 5; Figure 5A-B). Discussion Out of 56 clinically diagnosed stable vitiligo patients, the most common dermoscopic findings observed were sharp border in 44 (78.6%), marginal hyperpigmentation in 44 (78.6%), perifollicular hyperpigmentation in 40 (71.4%), and reticular pigment network in 16 (57.14%). Among the 44 unstable vitiligo cases, frequent findings were irregu- lar border in 22 (50%), trichrome pattern in 20 (45.4%), polka dot appearance in 18 (40.9%), and satellite lesions in Figure 3. Dermoscopic examination with polarized light showing leukotrichia within the vitiligo patch. 4 Original Article | Dermatol Pract Concept. 2024;14(4):e2024258 Awar et al. concluded that presence of erythema and telan- giectasia indicated treatment response [1]. In our study, only patients who were undergoing treatment had erythema or tel- angiectasia on dermoscopy. A study by Thatte et al. found that 90% of the evolving vitiligo patches had white glow in der- moscopic examination [5]. In our study, we did not mention diffuse white glow, as most of the lesions were depigmented. Aljasser mentioned the use of dermoscopy in detecting leu- kotrichia in facialpatches that are otherwise invisible to the naked eye [6]. In our study also, we found that dermoscopy- helped to detect subtle leukotrichia, which are not seen on the normal clinical examination. Abhijeet et al. described post- graft trichrome and Manchurian gravy signs on dermoscopy as a predictor of disease activity after skin grafting [7]. In our study, none of the patients underwent any surgical procedures. 18 (40.9%). Erythema and telangiectasia were noted only in patients who were on treatment (33.3% and 26.6%, respectively). A study done by Purnima et al. noticed marginal hy- perpigmentation in 100% of stable vitiligo patients [2]. In our study, 78.6% of patients with stable vitiligo showed marginal hyperpigmentation. Nirmal et al. proposed that absence of satellite lesions and absence of micro-Koebner phenomena (comet tail) were the most sensitive markers of stable vitiligo [3]. Similarly, in our study, none of the patients with stable vitiligo had satellite lesions or comet tail appear- ance. In another study, Nirmal mentioned the utility of blue light in dermoscopy to diagnose stable lesions in vitiligo, as the blue light increases the contrast between areas with pre- served melanin and those with melanin loss [4]. Figure 4. Dermoscopic examination with polarized light showing:(A) polka dot appearance, (B) starburst appearance, (C) comet tail appearance, (D) satellite lesions. Table 4. Frequency of Distribution ofLeukotrichia Among Stable and Unstable Vitiligo Patches. Number of Patients Stable 28(50%) Unstable 18(40.9%) On treatment 10(33.3%) Table 5. Frequency of Distribution of Erythema and Telangiectasia Among Stable and Unstable Vitiligo Patches On Treatment. Erythema Telangiectasia Stable 2(3.57%) 0 Unstable 8(18.2%) 8(18.2%) On treatment 10(33.3%) 8(26.6%) Figure 5. Dermoscopic examination with polarized light in vitiligo patients who are on treatment showing (A) erythema and (B) telangiectasia. Original Article | Dermatol Pract Concept. 2024;14(4):e2024258 5 References 1. Awal G, Kaur J, Kaur K. Dermoscopy in Vitiligo: An emerging armamentarium in diagnosis and activity assessment. Pigment International. 2022 Jan 1;9(1). DOI: 10.4103/pigmentinternational .pigmentinternational_143_21. 2. Purnima G, Tejaswitha Gudivada NA, Narasimharao TV. Dermoscopy—a tool to assess stability in vitiligo. Int J Contemp Med Res. 2017;4(10):2066-8. 3. Nirmal B, Antonisamy B, Peter CD, George L, George AA, Dinesh GM. Cross-sectional study of dermatoscopic findings in relation to activity in vitiligo: BPLeFoSK criteria for stability. Journal of Cutaneous and Aesthetic Surgery. 2019 Jan;12(1):36. DOI: 10.4103/JCAS.JCAS_147_18. 4. Nirmal B. Utility of blue light in dermoscopy for diagnosing stable lesions in vitiligo. Dermatology Practical & Conceptual. 2021 Jan 29:e2021141-. DOI: 10.5826/dpc.11041a. 5. Thatte SS, Khopkar US. The utility of dermoscopy in the diagno- sis of evolving lesions of vitiligo. Indian Journal of Dermatology, Venereology and Leprology.2014 Nov 1;80:505. DOI: 10.4103 /0378-6323.142074. 6. AlJasser MI. Dermoscopy for facial leukotrichia in vitiligo: An important step for a better treatment decision. Dermatol Pract Concept. 2022 Jul;12(3). DOI: 10.5826/dpc.1203a. 7. Jha AK, Sonthalia S, Lallas A, Chaudhary RK. Post-graft trichrome and Manchurian gravy signs on dermoscopy can pre- dict disease activity in vitiligo lesions post-skin grafting. Int J Dermatol. 2018 Aug 3;57(11):e144-5. DOI: 10.1111/ijd.14141. Limitations The patient history may not be reliable in some cases to as- sess the activity of vitiligo to correlate clinically. Histopa- thologyor any other confirmatory investigations werenot done for any of the cases. Conclusions Dermoscopic findings like sharp border, perifollicular and marginal hyperpigmentation, and reticular pigment network suggest stability. Irregular border and trichrome pattern were the most common dermoscopic findings noted in unstable vitiligo patches. Patterns like polka dots, satellite lesions, re- verse pigment network, and starburst appearance were seen only in unstable vitiligo patches. Patients who were on treat- ment showed erythema and telangiectasia in addition. Thus, dermoscopy is useful in assessing the activity of vitiligo and response to treatment. Since stability of vitiligo is necessary for surgical management, dermoscopic examination helps to guide the management of the disease by assessing the activity and stability.