VITILIGO- CLINICAL CLASSIFICATION -               George-Sorin Ţiplica                Colentina Clinical Hospital         ...
Gregor Johann Mendel   1822 – 1884   Czech-German Augustinian    monk and scientist   Studied the inheritance of    cer...
Why classifications are useful?   Prognosis evaluation   Treatment options   Clinical studies, meta-analysis   Reimbur...
Classification: general considerations   Classification   system   A   Classification   system   B   Classification   s...
Clinical classification   What can be observed?       Objective criteria            Disease distribution            Sp...
Clinical classification: vitiligo   There is a current lack of consensus in definition and assessment    methods which ma...
Vitiligo - classification    Non-segmental vitiligo (type A)         most common subtype         widespread macules oft...
Non-segmental vitiligo     Universal vitiligo (almost complete      depigmentation of the cutaneous surface)     General...
Clinical classification        FOCAL                    GENERALIZED                            - most common patternMost c...
Associated diseases        Autoimmune origin:               Thyroid disease (hyperthyroidism, hypothyroidism)           ...
Segmental vitiligo    A less common subtype    Unilateral depigmented macules and patches that     completely or partial...
Clinical classification                                                    MIXED FORM          SEGMENTAL                  ...
Facial segmental vitiligo    Not always correspond to dermatomal     distribution    Facial SV classification (based on ...
Clinical variants of vitiligo        Trichrome vitiligo           Both depigmented and hypopigmented macules           ...
Rare syndromes        Vogt-Koyanagi-Harada Syndrome               Vitiligo and uveitis, aseptic meningitis, dysacusis, t...
Vitiligo in children        very rarely at birth        descending order of frequency:               generalized       ...
Differential Diagnosis        According to site               Face: tinea, pityriasis versicolor, pityriasis alba, post-...
Vitiligo: methods of assessment   Vitiligo European Task Force: a system    (derived from SCORAD) which combines       a...
VIDA score       Vitiligo Disease Activity                       Vitiligo Activity              Time Period        VIDA S...
VASI   Introduced by Hamzavi et al. in 2004   A quantitative parametric score   Derived from the PASI (psoriasis area a...
Conclusions   At the moment, impossible to predict future    evolution, localisation and activity of the disease   Lack ...
Thank you!
Vitiligo - clinical classification by Dr. George Tiplica
Vitiligo - clinical classification by Dr. George Tiplica
Vitiligo - clinical classification by Dr. George Tiplica
Vitiligo - clinical classification by Dr. George Tiplica
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Vitiligo - clinical classification by Dr. George Tiplica

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Dr. George Sorin Tiplica

Presentation from the World Vitiligo Symposium 2011. Sponsored by the VR Foundation.

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Vitiligo - clinical classification by Dr. George Tiplica

  1. 1. VITILIGO- CLINICAL CLASSIFICATION - George-Sorin Ţiplica Colentina Clinical Hospital Bucharest, Romania
  2. 2. Gregor Johann Mendel 1822 – 1884 Czech-German Augustinian monk and scientist Studied the inheritance of certain traits in pea plants Founder of genetics
  3. 3. Why classifications are useful? Prognosis evaluation Treatment options Clinical studies, meta-analysis Reimbursment, DRG system
  4. 4. Classification: general considerations Classification system A Classification system B Classification system C Classification system D Validation by  Patho-mechanism  Treatment  Evolution / prognosis Classification system B
  5. 5. Clinical classification What can be observed?  Objective criteria  Disease distribution  Speed of spreading  Lesion aspect (shape, dimension, color)  Subjective criteria  Symptoms  Quality of life Who can observe?  General practitioner / dermatologist  Patient  Computer
  6. 6. Clinical classification: vitiligo There is a current lack of consensus in definition and assessment methods which makes difficult any classification Initial site involvement does not predict future evolution, localisation and activity of the disease Many attempts to classify the disease Several subtypes of vitiligo Based on the distribution of lesions
  7. 7. Vitiligo - classification  Non-segmental vitiligo (type A)  most common subtype  widespread macules often symmetrically placed  frequently involves acral areas, skin surrounding body orifices and extensor surfaces  Segmental vitiligo (type B)  dermatomal or blaschkolinear distributionKoga M. Vitiligo: a new classification and therapy. Br J Dermatol. 1977 Sep;97(3):255-61.
  8. 8. Non-segmental vitiligo  Universal vitiligo (almost complete depigmentation of the cutaneous surface)  Generalized vitiligo (most frequent form)  Acrofacial vitiligo (limited to acral and areas surrounding the orifices)  Mucosal vitiligo (limited to mucosa)  Focal (depigmented macules located in an isolated area without a dermatomal distribution)  Koebner phenomenon present  Characteristics  usually slowly progressive  spontaneous repigmentation in 10-20% of patientsHanda S, Kaur I. Vitiligo: clinical findings in 1436 patients. J Dermatol 1999; 26:653.
  9. 9. Clinical classification FOCAL GENERALIZED - most common patternMost common distribution: - symmetrical distribution-trigemminal nerve-neck-trunck Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
  10. 10. Associated diseases  Autoimmune origin:  Thyroid disease (hyperthyroidism, hypothyroidism)  Addison’s disease  Pernicious anemia  Alopecia aerata  Diabetes mellitus  Myasthenia gravis  Halo nevus  Malignant melanomaBologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology, 8th Ed, 2010, vol 3, p 58.46-58.49
  11. 11. Segmental vitiligo A less common subtype Unilateral depigmented macules and patches that completely or partially occur in a dermatomal or blaschkolinear distribution Characteristics  earlier age of onset  spreads rapidly after initial appearance  less commonly associated with other autoimmune diseases  pathogenesis: a neurogenic sympathetic abnormality or a disorder of cutaneous mosaicismTaïeb A, Picardo M. Clinical practice. Vitiligo. N Engl J Med 2009; 360:160.Hann SK, Lee HJ. Segmental vitiligo: clinical findings in 208 patients. J Am Acad Dermatol 1996; 35:671.Mazereeuw-Hautier J, Bezio S, Mahe E, et al. Segmental… J Am Acad Dermatol 2010; 62:945.Halder, RM, Taliaferro, SJ. Vitiligo. In: Fitzpatricks Dermatology in General Medicine, 7th ed,Wolff, K, Goldsmith LA, Katz, SI, et al (Eds), McGraw Hill 2008.
  12. 12. Clinical classification MIXED FORM SEGMENTAL – combines segmental,- does not cross the middle line acrofacial and/or-usually in children generalized distribution Bologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920 Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
  13. 13. Facial segmental vitiligo Not always correspond to dermatomal distribution Facial SV classification (based on morphological similarities in numerous clinical observations)  Type I-a:mid-level face from the forehead to the lower cheek (28,8%)  Type I-b: forehead and scalp hair  Type II: lower face and the neck area (16%)  Type III: lower face and the neck area (14,4%)  Type IV: mid-level face from the forehead to the lower cheek, but selectively appeared on the right side of the face and did not cross the midline  Type V: lesions were distributed mostly around the right orbital areaKim, D.-Y., Oh, S. H., Hann, S.-K. Classification of segmental vitiligo on the face: clues for prognosis.British Journal of Dermatology; May2011, Vol. 164 Issue 5, p1004-1009.
  14. 14. Clinical variants of vitiligo  Trichrome vitiligo  Both depigmented and hypopigmented macules  Hypopigmented macules become depigmented over time  Qvadrichrome vitiligo  Also associates marginal and perifollicular hyperpigmentation  Darker skin types  More often in areas of repigmentation  Pentachrome vitiligo (vary rare)  Blue-gray hyperpigmentation (dermal melanine incontinence, areas affected by postinflammatory hyperpigmentation in which vitiligo develops)  Confetti type (vitiligo ponctue)  Very numerous small, discrete hypopigmented macules  Inflammatory vitiligo  Erythema of the marginsBologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
  15. 15. Rare syndromes  Vogt-Koyanagi-Harada Syndrome  Vitiligo and uveitis, aseptic meningitis, dysacusis, tinnitus, poliosis, alopecia  T-cell mediated autoimmune disease  Associated with other autoimmune disorders  Alezzandrini Syndrome  Facial vitiligo and poliosis, deafness, unilateral retinal degenerationFitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621
  16. 16. Vitiligo in children  very rarely at birth  descending order of frequency:  generalized  focal  segmental  acrofacial  mucosal  universal  Halo nevus present – search for vitiligoPaller A, Mancini A. Hurwitz Clinical Pediatric dermatology, 3rd Ed, 2006, p 226-229
  17. 17. Differential Diagnosis  According to site  Face: tinea, pityriasis versicolor, pityriasis alba, post- inflammatory hypopigmentation, chemical leucoderma, sarcoidosis, piebaldism, hypopigmentation after cosmetic procedures  Hands: chemical leucoderma, scleroderma  Trunk: scleroderma, pityriasis versicolor, tuberous sclerosis  Anogenital: lichen sclerosus, lichen atrophicusBologna JL, Jorizzo J, Rapini R. Dermatology, 2nd Ed, 2008, p 913-920Fitzpatrick’s Dermatology in Internal Medicine, 7th Ed. 2008, vol 2, p 616-621Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology, 8th Ed, 2010, vol 3, p 58.46-58.49
  18. 18. Vitiligo: methods of assessment Vitiligo European Task Force: a system (derived from SCORAD) which combines  analysis of extent: the rule of 9  stage of disease (staging): the disease is staged 0–3 on the largest macule in each body region  disease progression (spreading): based on Wood’s lamp examinationTaıeb A, Picardo M on behalf of the VETF members. The definition and assessment of vitiligo:a consensus report of the Vitiligo European Task Force. Pigment Cell Res. 2007, 20; 27–35
  19. 19. VIDA score  Vitiligo Disease Activity Vitiligo Activity Time Period VIDA Score Active Under 6 weeks +4 Active 6 weeks - 3 months +3 Active 3 - 6 months +2 Active 6 - 12 months +1 Stable 1 year or more 0 Stable with spontaneous 1 year or more -1 repigmentation  Based on the patients own opinion of the present disease activity over time  Active Vitiligo refers to either one of the following:  Expansion of existing lesions  Appearance of new lesions.  Asses response to treatmentwww.dermabest.com/Vitiligo_Disease_Activity_score
  20. 20. VASI Introduced by Hamzavi et al. in 2004 A quantitative parametric score Derived from the PASI (psoriasis area and severity index) score widely used for psoriasis (Fredriksson and Pettersson, 1978) VASI regions  hands, upper extremities (excluding hands), trunk, lower extremities (excluding the feet) and feet  the face and neck areas are assessed separately VASI = S (all body sites)(hand units)·(depigmentation)
  21. 21. Conclusions At the moment, impossible to predict future evolution, localisation and activity of the disease Lack of consensus vitiligo classification and assessment methods Based on pathogenesis  Non-segmental vitiligo  Segmental vitiligo
  22. 22. Thank you!

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