Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(1):4648 1 Dermoscopy of Vitiligo and Other Hypopigmented Skin Lesions in Indian Patients: A Cross-Sectional Study Ananya Sharma1, Binod K. Khaitan1, Vishal Gupta1, M Ramam1, Kanika Sahni1 1 Department of Dermatology and Venereology, All India Institute of Medical Sciences, New Delhi Key words: Dermoscopy, Vitiligo, Pigmentary disorders, Hypopigmenting diseases, Ash-leaf macule Citation: Sharma A, Khaitan BK, Gupta V, Ramam M, Sahni K. Dermoscopy of Vitiligo and Other Hypopigmented Skin Lesions in Indian Patients: A Cross-Sectional Study. Dermatol Pract Concept. 2025;15(1):4648. DOI: https://doi.org/10.5826/dpc.1501a4648 Accepted: September 6, 2024; Published: January 2025 Copyright: ©2024 Sharma 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. Binod K. Khaitan, Professor; Department of Dermatology and Venereology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, India. E-mail: binodkhaitan@gmail.com Introduction: Non-vitiligo hypopigmented skin lesions may be close clinical mimickers of vitiligo, resulting in a diagnostic dilemma. Dermoscopic features of vitiligo have been studied, but those of other hypopigmentation disorders are not well-characterized. Objectives: We aimed to describe and compare the dermoscopic features of vitiligo and other hypopigmented skin lesions. Methods: This was a cross-sectional study including 105 vitiligo and 137 other hypopigmented skin lesions, including ash-leaf macules (N=17), nevus depigmentosus (N=16), post-inflammatory hypopig- mentation (N=16), pityriasis alba (N=15), pityriasis versicolor (N=14), idiopathic guttate hypomela- nosis (IGH) (N=14), lichen sclerosus (N=12), leprosy (N=9), and others. Dermoscopic findings were recorded by concordance of at least two qualified dermatologists. Results: Common dermoscopic findings in vitiligo were intermediate or ill-defined margins (96/105, 91.4%) and a complete absence of pigment network (70/105, 66.7%). Nevus depigmentosus lesions were mostly hypopigmented, with a faint pigment network throughout the lesion. In 15/17 (88.2%) ash-leaf macules, a characteristic pattern of sharply demarcated areas of normal pigment network was seen with- in a depigmented lesion. Almost all lesions of IGH had a sharply defined margin with completely absent pigment network; discernible eccrine openings within the lesion were seen in 9/14 (64.3%). Dermoscopic findings of a complete absence of pigment network, perifollicular retention of pigment, presence of vas- cular pattern, loss of discernibility of eccrine openings within the lesion, and lack of scaling were statisti- cally significantly more common in vitiligo than other hypopigmented skin lesions (P <0.001). Conclusion: Vitiligo, nevus depigmentosus, ash-leaf macule, and IGH have distinctive dermoscopic fea- tures. Dermoscopy can aid in the differential diagnosis of vitiligo and other hypopigmented skin lesions. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(1):4648 Introduction Dermoscopy in hypopigmented conditions has largely been studied in the context of establishing stability of disease in vitiligo [1,2]. There is a lack of studies comparing dermo- scopic features of vitiligo with non-vitiligo hypopigmenta- tion disorders [3]. Data available on dermoscopic features of these common non-vitiligo hypopigmented lesions is also limited. Patients with innocuous hypopigmentation diseases such as pityriasis alba and nevus depigmentosus often pres- ent with apprehension and concern that the disease is vitiligo [4]. Some disorders presenting with hypopigmented macules, such as tuberous sclerosis manifesting as ash-leaf macules and hypopigmented macules of leprosy, may warrant a more extensive evaluation. We studied the dermoscopic features of vitiligo as well as other common hypopigmentation disor- ders and compared their findings. Methods This was a cross-sectional comparative study conducted in the outpatient department and pigmentation clinic of a ter- tiary care hospital in North India from September 2019 to February 2021, after obtaining institutional ethics clearance (Ref. no. IECPG-420/30.08.2018). Patients presenting with hypo-depigmented skin lesions with a confirmed clinical di- agnosis (based on two dermatologists’ opinion) including but not limited to vitiligo, idiopathic guttate hypomelano- sis, pityriasis alba, pityriasis versicolor, nevus depigmento- sus, ash-leaf macule, lichen sclerosus, leprosy, piebaldism, pigmentary mosaicism, hypopigmented mycosis fungoides, post kala-azar dermal leishmaniasis, and post-inflammatory hypopigmentation were included in the study after informed consent. Patients were excluded if the diagnosis could not be made clinically based on two dermatologists’ opinion, or the results of relevant investigations done to establish diagno- sis were inconclusive (KOH mount for pityriasis versicolor, biopsy for lichen sclerosus, biopsy and slit skin smear for leprosy, biopsy and immunohistochemistry for hypopig- mented mycosis fungoides, and biopsy and tissue smear for post kala-azar dermal leishmaniasis). Lesions with second- ary changes of infection, trauma, or irritation over the lesion were also excluded. Vitiligo macules were categorized as pro- gressive, stable, or repigmenting based on patient’s history and/or previous photographs. A lesion of vitiligo which had appeared longer than three months earlier with no increase or decrease in size subsequently was classified as  stable.  If the lesion had decreased in size within the previous three months, it was classified as repigmenting. Lesions that had increased in size or had appeared anew within the previous three months were classified as progressive lesions. Sample Size Estimation A feasibility-based sample size of a minimum of 200 lesions was set on the basis of sample size of previous similar studies ranging from 115 [5] to 176 [3]. Dermoscopic Examination A maximum of three representative lesions in each patient were selected, and dermoscopy was done by at least two dermatologists (A.S., V.G., B.K.) using a hand-held dermo- scope (DermLite DL3N hybrid pocket dermatoscope 3Gen Inc). Findings were noted by consensus of the two dermatol- ogists, under the following headings (as per previous avail- able literature, preliminary observations, and guided by the 2015 consensus statement of the International Dermoscopy Society [6]): (i) margins (well-defined, ill-defined or of  ‘in- termediate’  sharpness); (ii) background color; (iii) pigment network (distribution and type); (iv) perifollicular changes; (v) perilesional changes; (vi) vascular pattern; (vii) surface changes; (viii) hair density and color (leukotrichia); (ix) discernibility of eccrine openings; (x) any other additional findings. The primary objective was to describe the dermoscopic features of various hypopigmentation skin disorders. The secondary objectives were to compare and contrast the der- moscopic features of vitiligo against all other hypopigmen- tation disorders and to compare the dermoscopic features of progressive and non-progressive vitiligo. Statistical Analysis Continuous variables are presented as mean ± deviation (SD) and categorical variables as frequencies and percentages. Continuous variables were compared using the Student’s t- test, and categorical variables using the Chi-squared test and Fischer’s Exact test as applicable, setting level of significance as P ≤0.05. All statistical analyses were performed using Stata 14 software (StataCorp. 2015). Results Two hundred and forty-two hypopigmented lesions in 97 pa- tients were included in this study: 105 vitiligo (38 patients) and 137 non-vitiligo (59 patients) (Table 1). The mean age of the patients was 23.33 ± 14.08 years (range 0.75- 71 years), 49 (50.5%) were males, and 48 (49.5%) were females. The Fitzpatrick skin type of patients was IV or V. Dermoscopic Findings of Vitiligo Most (96/105, 91.4%) vitiligo lesions showed intermediate- to-ill-defined margins (Figure 1A), with only 9 (8.6%) lesions showing a well-defined margin. The background color of Original Article | Dermatol Pract Concept. 2025;15(1):4648 3 most vitiligo lesions (63.8%) was depigmented (Figure 1B). Two-thirds of vitiligo lesions (66.7%) showed complete ab- sence of pigment network (Figure 1B), and a further 26.7% showed only a partially present network (Figure 1A).  Of the 91 lesions that showed follicles within the lesion, leukotri- chia was seen in 28 (30.7%), and 35 (38.6%) lesions showed perifollicular retention of pigment (Figure 1B). A vascular pattern (linear vessels, dotted vessels, or both) was seen in 45/105 (42.8%) vitiligo lesions. Of these, 39 (86.7%) were on some form of treatment, most commonly topical cortico- steroids, calcineurin inhibitors, or some form of photother- apy or photochemotherapy. Only a single lesion of vitiligo showed scaling. Amongst segmental vitiligo, leukotrichia was seen in all but one lesion (8/9, 88.9%). An inverse pig- ment network was seen in three lesions only, all of which were repigmenting lesions located on bony prominences (knee, elbow, and just above lateral malleolus). Comparison of Dermoscopic Features of Progressive and Non-Progressive Vitiligo In terms of activity, 39 (37.1%) lesions were progressive, 36 (34.3%) stable, and 30 (28.6%) repigmenting. For the purpose of clinically meaningful analysis, stable and repigmenting vitiligo lesions were taken together to repre- sent non-progressive vitiligo, then compared with progres- sive vitiligo  (Table 2). The majority of progressive lesions showed an ill-defined margin (20/39. 51.3%) (odds ratio (OR)=4.2).  A complete absence of pigment network was seen more often in non-progressive vitiligo (48/66, 72.02%) as compared to progressive vitiligo (22/39, 56.41%) (P = 0.044). Faint pigment network was seen more often in the progressive group (P = 0.014, OR=3). Perifollicular pig- ment retention was more commonly seen in non- progressive group (P = 0.009)  (Sensitivity (Sn) 48.3%, Specificity (Sp) 80.6%).  Perilesional hyperpigmentation was more fre- quently a feature of non-progressive group, seen in 19.7% (13/66) (P = 0.001) (Sp 97.4%, Sn 19.6%). Leukotrichia was observed in 23/66 (34.8%) non-progressive vitiligo lesions, compared to 5/39 (16.1%) of progressive lesions. A vascular pattern was more likely to be seen in non-progressive group (P <0.001). Eccrine openings or white dots were discernible within a depigmented lesion of vitiligo, more commonly in the progressive group (Figure 1). Dermoscopic Findings of Non-Vitiligo Hypopigmented Lesions Nevus depigmentosus (N=16) (Figure 2): Margins of most of the lesions (14/16, 87.5%) were of intermediate definition. The background color of most (87.5%) lesions was hypopig- mented. The majority of lesions (10/16, 62.5%) had a pig- ment network present throughout the lesion, whereas it was partially present in three, similar to that of ash-leaf macule in two, and completely absent in one. Most of the lesions had no perifollicular and perilesional changes. Three (18.8%) le- sions showed partial leukotrichia. Ash-leaf macules (N=17)  (Figure 3):  Pigment network in the majority of lesions (15/17, 88.2%) had a character- istic patchy pattern of sharply demarcated areas of normal pigment network with jagged margins, within the depig- mented lesion. The specificity of this “ALM-like” (“ash-leaf macules”-like) pigment network for ash-leaf macule (com- pared to all other diagnosis) was 97.23%, with sensitivity of 88.2% and a negative predictive value (NPV) of 99.1%. The positive predictive value (PPV) was 71.4%, with four lesions of pigmentary mosaicism and two lesions of nevus depigmentosus showing a similar pattern. Additional differences from nevus depigmentosus in- cluded the background color, being depigmented in ash-leaf macules (P <0.001), and lack of leukotrichia in any of the lesions examined. Pityriasis alba (N=15) (Figure 4): Most (13/15, 86.7%) lesions had ill-defined margins. The majority (73.3%) of lesions had a hypopigmented background, with a normal or faint network present throughout the lesion in 93.3% Table 1. Number of Lesions and Number of Patients Included for Each Diagnosis. Diagnosis Number of lesions Number of patients Vitiligo 105 38 Ash-leaf macule (ALM) 17 6 Nevus depigmentosus 16 11 Post-inflammatory hypopigmentation (PIH) 16 6 Pityriasis alba (P.alba) 15 6 Idiopathic guttate hypomelanosis (IGH) 14 5 Pityriasis versicolor (PV) 14 5 Lichen sclerosus (LS) 12 5 Leprosy 9 4 Piebaldism 6 4 Pigmentary mosaicism 6 2 Discoid lupus erythematosus (DLE) 5 2 Post kala-azar dermal leishmaniasis (PKDL) 3 1 Chronic arsenic toxicity 3 1 Hypopigmented mycosis fungoides 1 1 Total 242 97 4 Original Article | Dermatol Pract Concept. 2025;15(1):4648 Figure 1. A) Dermoscopy of a progressive vitiligo lesion showing ill-defined margins, partially pres- ent pigment network, perilesional white globules (red arrows), and lack of perifollicular changes. No vascular changes are seen, and no eccrine openings are discernible within this lesion (DL3, 10X, polarized). B) Dermoscopy of a non-progressive (stable) vitiligo lesion showing well-defined margin with complete absence of pigment network and perifollicular pigment retention (blue circle). Mar- ginal hyperpigmentation is also seen (black arrow), and no eccrine openings are discernible within the lesion (DL3 10X, polarized). Table 2. Dermoscopic Findings of Vitiligo and Comparison by Activity of Disease. Diagnosis Findings Progressive N=39 Non-progressive N=66 p-value Total (All vitiligo) n=105 Margins p=0.001 Well-defined 4 (10.6%) 5 (7.6%) 9 (8.6%) Intermediate 15 (38.5%) 48 (72.7%) 63 (60%) Ill-defined 20 (51.3%) 13 (19.7%) 33 (31.4%) Pigment Network- distribution p=0.044 Complete presence 5 (12.8%) 2 (3%) 7 (6.7%) Complete absence 22 (56.4%) 48 (72.7%) 70 (66.7%) Partially present 12 (30.8%) 16 (24.2%) 28 (26.7%) Pigment network- type, when present (N=35) p=0.029 Normal 1 (5.9%) 4 (22.2%) 5 (14.3%) Faint 16 (94.1%) 11(61.1%) 27 (77.1%) Inverse 0 3 (16.7%) 3 (8.6%) Absent 22 48 70 Other features Depigmented background 25 (64.1%) 42 (63.6%) p=0.962 67 (63.8%) Perifollicular pigment retention (n=91) 6/31 (19.4%) 29/60 (48.3%) p=0.009 35 (38.5%) Perilesional hyperpigmentation 1 (2.6%) 13 (19.7%) p=0.001 14 (13.3%) Perilesional white globules 11 (28.2%) 5 (7.6%) p=0.009 16 (15.2%) Leukotrichia (N=91) 5/31 (16.1%) 23/60 (34.8%) p=0.035 28 (30.7%) Vascular pattern 5 (12.8%) 40 (60.6%) p<0.001 45 (42.9%) Eccrine openings discernible 11 (28.2%) 2 (3%) p=0.002 13 (12.4%) Scaling 0 2 (3%) p> 0.05 2 (1.9%) Erythema 4 (10.3%) 15 (22.8%) p=0.118 19 (18.09%) Original Article | Dermatol Pract Concept. 2025;15(1):4648 5 Figure 2. A) and B) Dermoscopic features of nevus depigmentosus showing intermediate margin with background hypopigmentation and faint pigment network present throughout the lesion, with lack of surface, vascular, or other changes (DL3, 10x, polarized). Figure 3. A) and B) Dermoscopy  of  ash-leaf  macule  showing characteristic pigment network (‘ALM-like’) in ash-leaf macule with sharply demarcated islands of normal pigment network with jagged margins (blue arrow) within the depigmented lesion (DL3, 10X, polarized). lesions. Erythema was seen in 60% lesions and scaling in one-third. Pityriasis versicolor (N=14)  (Figure 5):  All the lesions had intermediate-to-ill-defined margins and a hypopig- mented background. Six of 14 (42.9%) lesions had complete presence of pigment network throughout the lesion, and 50% had partial presence. Perifollicular hypopigmentation was seen in 5 (35.7%) lesions, and white globules were seen in the perilesional area in half the lesions. Scaling was a fre- quent finding, seen in 85.7% of lesions. Idiopathic guttate hypomelanosis (IGH) (N=14) (Figure  6): Almost all the lesions (13/14, 92.8%) had a sharply defined margin. In all 14 lesions, the background was depigmented, and the pigment network was completely absent. There were no vascular, surface, or other changes in any of the lesions. Nine of 14 (64.3%) lesions had dis- cernible eccrine openings outlined by a brown line, within the lesion. Lichen sclerosus (LS) (N=12): The striking feature was presence of structureless white areas (9/12, 75%), which would become less evident on switching to non-polarized mode. Half the lesions also showed shiny white streaks. Two-thirds of the lesions showed comedo-like openings/fol- licular plugs. Two-thirds of the lesions also showed loss of hair over the lesion. Leprosy (N=9) lesions (one borderline tuberculoid and 4 borderline lepromatous patients) were most often ill-defined, with complete or patchy presence of pigment network. Hair loss was seen in only one lesion, and there was no loss of eccrine openings. 6 Original Article | Dermatol Pract Concept. 2025;15(1):4648 Figure 5. Dermoscopy of pityriasis versicolor showing hypopig- mented background with presence of faint network, perifollicular hypopigmentation and fine gray-white scaling (blue arrow)  (DL3, 10X, polarized). Figure 6. Dermoscopy of idiopathic guttate hypomelanosis show- ing well-defined lesion with depigmented background, complete ab- sence of pigment network, and brown outlined discernible eccrine openings (black arrows) (DL3 10X, polarized). Figure 4. Dermoscopy  of  pityriasis alba  showing ill-defined hy- popigmented lesion with faint pigment network present throughout the lesion and subtle erythema (DL3, 10X, polarized). Lesions of piebaldism (N=6) showed a complete loss of pigment network (5/6, 83.3%) and both follicular and non-follicular islands of pigmented skin within the lesion. All the patients had complete leukotrichia, and in most (5/6, 83.3%), it also extended beyond the lesion. Lesions of post-inflammatory hypopigmentation of un- diagnosed etiology (N=16) showed variable pigment net- work, and most lesions (81.3%) showed changes other than pigmentary change, such as vascular patterns, erythema, scaling, pigmented dots, and shiny white streaks Comparison of Dermoscopic Features of Vitiligo Versus Other Hypopigmentation Disorders As a group, non-vitiligo lesions more often showed a well- defined margin (32/137, 23.4%) than did vitiligo (9/105, 8.6%) (P <0.001). A complete absence of pigment network was  seen in 66.7% of vitiligo lesions, whereas it was seen in 30.6% of non-vitiligo group, making a lesion 10 times more likely to be a vitiligo lesion when it showed this feature (OR=10) (Table 3). Perifollicular retention of pigment and leukotrichia, al- though present in only 38.5% and 30.8% of lesions of vit- iligo, respectively, were important points of differentiation from the non-vitiligo group, with perifollicular pigment re- tention having a specificity of 93.9% for vitiligo (P <0.001) (Table 3). There were no significant differences in perile- sional changes between the two groups. In lesions on hair bearing sites, leukotrichia was present in 28/91 (30.8%) of vitiligo lesions and in 9/137 (7.8%) of non-vitiligo lesions (P <0.001). Eccrine openings were discernible in 70.8% of non-vitiligo lesions  but  only  in  12.4% lesions of vitiligo (P <0.001). Lesions of vitiligo were more likely to show Original Article | Dermatol Pract Concept. 2025;15(1):4648 7 a vascular change and less likely to show surface changes like scaling (P <0.001 for both parameters), though 73.3% lesions of vitiligo were being treated by topical, photother- apy, or systemic agents, which may have been a confound- ing factor. On comparing nevus depigmentosus with vitiligo, pat- terns of pigment network between the two groups were significantly different (P <0.001). the background color of most nevus depigmentosus lesions was hypopigmented, whereas the background color of most vitiligo lesions was depigmented (P <0.001). Perifollicular pigment retention, a feature of vitiligo, was not seen in nevus depigmentosus (P = 0.009). A vascular pattern was more frequently seen in vitiligo (P = 0.020). Leukotrichia was more frequently seen in vitiligo, though was also seen in three cases of nevus de- pigmentosus and was not statistically significant (P = 0.328). Eccrine openings were discernible within nevus depigmento- sus lesions, but not in vitiligo (P <0.001). Pityriasis alba lesions showed an ill-defined margin much more frequently compared to vitiligo.  A  complete absence of pigment network  was  90.91%  sensitive and Table 3. Dermoscopic Findings of Vitiligo vs Non-Vitiligo Lesions. Diagnosis Findings Vitiligo N=105 Non-vitiligo N=137 p-value Margins p=0.008 Well-defined 9 (8.57%) 32 (23.4%) Intermediate 63 (60%) 64 (46.7%) Ill-defined 33 (31.4%) 41 (29.9%) Pigment Network- Distribution P < 0.001 Complete presence 7 (6.7%) 42 (30.7%) Complete absence 70 (66.7%) 42 (30.7%) Partially present 28(26.7%) 32(23.4%) Ash-leaf macule like* 0 21 (15.3%) Pigment network- type, when present (N=35) (N=95) p<0.001 Normal 5 (14.3%) 38 (40%) Faint 27 (77.1%) 54 (56.8%) Inverse 3 (8.6%) 2 (2.1%) Other features Depigmented background 67 (63.8%) 53 (50.5%) p<0.001 Perifollicular pigment retention 35/91 (38.5%) 10/115 (8.7%) p<0.001 Perilesional changes 33 (31.4%) 43 (31.4%) p=0.994 Leucotrichia 28/91 (30.8%) 9/115 (7.8%) p<0.001 Vascular pattern 45 (42.8%) 29 (21.2%) p<0.001 Eccrine openings discernible 13(12.4%) 97(70.8%) p<0.001 Scaling 1 (1%) 29 (21.2%) p<0.001 Erythema 19 (18.1%) 33 (24.1%) p=0.261 Structureless areas 4 (3.8%) 14 (10.2%) p=0.060 93.33% specific for vitiligo when compared with pityriasis alba, which most frequently showed a complete presence of pigment network. Scaling and erythema were both pointers to pityriasis alba over vitiligo (OR=69 for scaling, OR=6.7 for erythema for a diagnosis of pityriasis alba over vitil- igo) (P <0.001). Leukotrichia was not seen in pityriasis alba. IGH lesions more often had a well-defined margin com- pared to vitiligo (P <0.001). Distinct eccrine openings with a brown outline, distinctive in IGH (64.3%), were discern- ible in a minority of vitiligo lesions only (13/105, 12.4%) (P <0.001). Leukotrichia was exclusive to vitiligo lesions. Discussion Clinical differential diagnosis of hypopigmented skin lesions can be broad and challenging. There is a need for a handy, noninvasive tool like dermoscopy to reliably distinguish these entities. In this study, we found certain dermoscopic features that may be useful in distinguishing vitiligo from other hy- popigmented skin lesions, such as a complete absence of pigment network, perifollicular retention of pigment, the 8 Original Article | Dermatol Pract Concept. 2025;15(1):4648 The dermoscopic features of nevus depigmentosus (faint pigment network throughout the lesion) in our study are consistent with previous case reports [12-14]. Malakar et al. [13] differentiated this finding from areas of reticular net- work as well as zones of total loss of pigment network seen in ash-leaf macules. We also noted  this  characteristic pat- tern in 88.2% lesions of ash-leaf macules. This pattern was seen elsewhere only  in lesions of pigmentary mosaicism, and  in  one lesion of segmental nevus depigmentosus, sig- nifying possible correlation of this patchy pattern to mosa- icism.  This dermoscopic feature could thus be potentially used to screen neonates for ash-leaf macules and hence tu- berous sclerosis. Dermoscopic features of idiopathic guttate hypomela- nosis have been well studied and are similar to those seen in our study. Well-defined margins (termed “amoeboid” and “petaloid” previously) are considered characteristic of IGH [8,15]. Studies also mention  “homogenous whitish areas” [16]  and  “shiny porcelain-white macules” [8], likely per- taining to a depigmented white background with complete loss of pigment network, as in our study. A recent multi- center study also recognized  “periostial (follicles/eccrine sweat glands) brown pigmentation” in 91.7% cases of IGH (N=12), which emerged as a strong point of difference from vitiligo in our study [17]. Nayak et al. [18]  examined 15 cases of pityriasis alba and reported “well-circumscribed pinkish patch with irreg- ular scales” for all the lesions. The pinkish hue likely refers to erythema, although their finding of well-defined lesions and universal scaling differs from our study. For pityriasis versicolor, our findings are consistent with previous stud- ies, including the largest series (N=164) by Mathur et al. [19]  In lichen sclerosus, previous studies mention white or white-yellow structureless areas in 66.8% to 88.6% [20-22], and comedo-like openings/follicular plugs in 77.8% to 80% [20-22], corroborated in our study. We found only one previous study comparing the der- moscopic findings in vitiligo with other hypopigmentation disorders. Meng et al. [3] studied 176 patients with various depigmented skin lesions, including 97 patients with vitiligo. They found residual perifollicular pigmentation as a pointer to vitiligo, which was corroborated in our study. In addition, we found other dermoscopic differences between vitiligo and other hypopigmented skin lesions: a complete absence of pigment network, perifollicular retention of pigment, leu- kotrichia, the presence of a vascular pattern, a lack of dis- cernibility of eccrine openings within the lesion, and a lack of scaling. We propose a provisional guiding algorithm for dermoscopic approach to the diagnosis of hypopigmented lesions on the basis of our findings, which could be tested in a larger sample size by future researchers (Figure 7). presence of vascular pattern, a lack of discernibility of ec- crine openings within the lesion,  and a lack of scaling. In addition, we found that nevus depigmentosus, ash-leaf mac- ules, and IGH have distinctive dermoscopic features. Our findings in vitiligo are largely similar to those in pre- vious studies. Metaphorical terms like “starburst” and “neb- ulous”  pattern used previously for margins are likely analogous to the ill-defined margins seen in our study. An ab- sent pigment network has been previously reported in about 30–40% of vitiligo lesions [1,7]. This was seen in two-thirds of vitiligo lesions (70/105, 66.7%) in our study. Perifollicu- lar pigmentation has previously been reported to be seen in 40–75% lesions of vitiligo [1,2,8-10] and was seen in 38.6% lesions in our study.  Marginal or perilesional hyperpigmen- tation was seen in our study in 13.3% lesions, slightly less frequently than in previous studies (20–40%) [1,2,8-10]. It has been strongly correlated in the literature to stable dis- ease, which was corroborated in our study, being a specific, but not a sensitive finding. The association of perifollicular changes with stability is controversial in the literature, with two studies reporting an association with stability similar to our study [2,8], whereas Jha et al. [1] found that most lesions with this finding were of progressive nature. Thatte et al. [7]  included only cases of evolving vitiligo and found this feature in 2/30 cases (6.7%) only, possibly supporting the as- sociation with non-progressive disease. The modest variation in frequencies of various findings could possibly be due to different proportions of active and stable lesions at various stages included in previous studies and to the higher propor- tion of progressive disease presenting to a tertiary care cen- ter. An absent pigment network and leukotrichia were also consistent pointers to stability of disease [1,11]. This stabil- ity may also suggest complete loss of pigment and therefore an endpoint, where further progression is not seen.  Mean- while,  perilesional white globules (encompassing  “polka dot appearance”,  “satellite lesions,”  or  “tapioca sago ap- pearance”) was seen in progressive disease, also consistent with previous studies [1,2,10,11]. We observed an inverse pigment network in only three cases, all repigmenting le- sions, contrary to an association with progressive disease as previously reported [1,7]. All three lesions were located on acral areas or bony prominences, and it was further observed that dermoscopy of normal skin of some healthy individuals also showed such a pattern on acral sites. We postulate that increased skin markings on acral sites may contribute to the appearance of an inverse pigment network, rather than to disease activity. An interesting finding which has not been previously commented upon in the literature was that the eccrine openings, which are seen as white dots outlined by a brown line throughout normal skin, were often not discern- ible within a depigmented lesion of vitiligo (87.6%). Original Article | Dermatol Pract Concept. 2025;15(1):4648 9 Patient Consent on File: Consent for the publication of recognizable patient photographs or other identifiable mate- rial was obtained by the authors and included at the time of article submission to the journal stating that all patients gave consent with the understanding that this information may be publicly available. Data Availability Statement: The data underlying this article are available in the article, and further data  will be shared on reasonable request to the corresponding author. References 1. Jha AK, Sonthalia S, Lallas A, Chaudhary RKP. Dermoscopy in vitiligo: Diagnosis and beyond. Int J Dermatol 2018;57 (1):50–4. DOI: 10.1111/ijd.13795. PMID: 29076154. 2. Purnima G, Gudivada NAT, Narasimharao T. Dermoscopy - A tool to assess stability in vitiligo. Int J Contemp Med Res 2017;4 (10):2066–8. url: https://www.ijcmr.com/uploads/7/7/4/6 /77464738/ijcmr_1704_v1.pdf 3. Meng R, Zhao G, Cai R, Meng X, Jiang Z. 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