Assessing the dynamic changes in vitiligo: reliability and validity of the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS).

BACKGROUND: The assessment of the individual evolution of vitiligo is important for therapeutic decision making in daily practice. A fast, simple and validated physician-reported score to assess clinical changes in depigmentation over time in separate parts (activity and improvement) is currently missing. OBJECTIVE: The main objective of the study was to develop and validate the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS). METHODS: The Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS) were evaluated based on a photo set of 66 patients with two different time points. In the first (short) version, only the number of changing body regions was counted based on 15 predefined areas (VDAS15 and VDIS15 ), while in the second (extensive) version the degree of worsening or improvement from +4 to -4 for each body area was added for a more detailed assessment (VDAS60 and VDIS60 ). Content and construct validity were tested. In addition inter-, intrarater reliability and feasibility were evaluated by 7 (test) and 5 (retest) physicians. RESULTS: Evidence for content and construct validity was provided. Overall, VDAS15 , VDIS15 , VDAS60 and VDIS60 demonstrated good to excellent inter-rater reliability [intraclass correlation (ICC): VDAS: range = 0.797-0.900; VDIS: range = 0.726-0.798]. The intrarater reliability ICCs were 0.865 and 0.781 for the VDAS15 and VDIS15 , respectively. Similar results were obtained for the VDAS60 and VDIS60 (ICC = 0.913 and 0.800, respectively). Completion time was short (median: 122 s/patient (first round); 95 s/patient (second round)]. LIMITATIONS: Single tertiary centre mainly of skin phototype 2 to 3. CONCLUSION: The VDAS and VDIS appear to be valid, reliable and feasible instruments to score the evolution of vitiligo lesions. This accommodates the current urgent need for a simple, standardized and practical assessment of vitiligo activity and improvement over time.

The role of phototherapy in the surgical treatment of vitiligo: a systematic review.

Vitiligo is frequently treated with the combination of phototherapy and melanocyte transplantation. However, the additional benefit of phototherapy is unclear. Moreover, the optimal type and regimen of phototherapy are unknown. The objective of this systematic review was to identify whether phototherapy improves the outcome of melanocyte transplantation in vitiligo. We searched and screened for eligible studies in the databases of MEDLINE, EMBASE and CENTRAL. We included all clinical studies investigating melanocyte transplantation combined with phototherapy. After screening and selection of abstracts and full-texts, we found 39 eligible clinical studies with 1624 patients. The eligible studies investigated several phototherapy modalities, such as NBUVB (n = 9), PUVA (n = 19), UVA (n = 1), MEL (n = 4) and active sunlight exposure (n = 9). Four studies directly compared phototherapy versus no phototherapy and two studies confirmed the benefit of phototherapy for melanocyte transplantation. We found no significant differences in repigmentation in studies directly comparing phototherapy modalities. The overall quality of the studies was moderate to poor and high heterogeneity between studies was found. We found limited evidence that phototherapy improves the outcome of melanocyte transplantation in vitiligo. There is insufficient evidence to recommend a specific type or regimen of phototherapy. More studies should be performed investigating the additional benefit of different phototherapies and the preferred moment of phototherapy.

Laser treatment of congenital melanocytic naevi: a systematic review.

Recent studies on congenital melanocytic naevi (CMN) indicate a lower risk of melanoma than has been previously assumed. As a result, the treatment paradigm in CMN has shifted from complete removal to cosmetically acceptable, less invasive treatment options, such as laser treatment. Our objective was to review systematically the efficacy and safety of laser therapy for CMN. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and PubMed. We rated the quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Twenty-four eligible studies (three nonrandomized controlled studies; 21 case series) with 434 patients were included; the majority were of poor quality). Twenty different laser modalities or combinations were evaluated. Overall, the Q-switched laser was used most frequently, although large or giant CMN were generally treated with an ablative laser. Owing to heterogeneity between studies, comparison between laser modalities was hampered and statistical analysis was precluded. Lasers in CMN showed rather good results (albeit with very low-quality evidence) for clearing of hyperpigmentation in the short term. Outcome measures varied widely, patient satisfaction was rarely measured and high incidences of scarring, repigmentation and complications were reported. No malignant change was seen. While most studies report short-term improvement of CMN after laser therapy, there is no high-quality evidence for the efficacy and safety of laser modalities in CMN in the long term. Future research should focus on well-conducted and well-reported prospective studies on different laser modalities for CMN, with the use of recognized and validated outcome measures.

Autologous cell suspension grafting in segmental vitiligo and piebaldism: a randomized controlled trial comparing full surface and fractional CO2 laser recipient-site preparations.

BACKGROUND: Autologous noncultured cell suspension transplantation is an effective treatment for repigmentation in segmental vitiligo and piebaldism. Full surface laser ablation is frequently used to prepare the recipient site before cell suspension transplantation, even though the optimal laser settings and ablation depth are unknown. OBJECTIVES: To assess the efficacy and safety of less invasive recipient-site preparations. METHODS: In a randomized, observer-blinded, controlled trial we compared different recipient-site preparations before cell suspension transplantation in segmental vitiligo and piebaldism. In each patient, we randomly allocated three CO2 laser recipient-site preparations (209 and 144 µm full surface, and fractional) and a control (no treatment) to four depigmentations. After 6 months we assessed repigmentation and side-effects. RESULTS: We included 10 patients with vitiligo (n = 3) and piebaldism (n = 7). Compared with the control site, we found more repigmentation after full surface ablation at 209 µm (median 68·7%, P = 0·01) and 144 µm (median 58·3%, P = 0·007), but no repigmentation after fractional ablation (median 0·0%, P = 0·14). CONCLUSIONS: Superficial full surface ablation with a depth of 144 µm is an effective recipient-site preparation before cell suspension transplantation, while fractional CO2 laser is not.

Focal vitiligo: long-term follow-up of 52 cases.

BACKGROUND: Focal vitiligo is characterized by depigmented patches located in a small area without a typical segmental distribution. Focal vitiligo is classified as an undetermined type of vitiligo, and a more definitive diagnosis can be made when the lesions have not evolved into non-segmental or segmental vitiligo after a period of 1-2 years. However, the chance of progression is not known and may lead to treatment-indecision. OBJECTIVE: The objective was to study the characteristics of patients with focal vitiligo and possible predictors of progression. METHODS: We conducted a survey study in patients with initial diagnosis of focal vitiligo between January 2005 and June 2010. Focal vitiligo was defined as either a small acquired isolated depigmented lesion without typical segmental distribution, or two to three small acquired lesions localized in a non-segmental area with a maximum of 5 cm. The survey comprised of 21 questions concerning the patient's characteristics, the onset of focal vitiligo, progression of depigmentation and treatment history. RESULTS: We identified 128 eligible patients and the response rate was 40.6% (n = 52 completed questionnaires). Progression to non-segmental vitiligo occurred in 23%. The median follow-up duration was 7 years. In 11.5% of the patients, progression to non-segmental vitiligo occurred within 2 years after onset. Nevertheless, even after a first stable period of more than 2 years, another 11.5% of the patients advanced to non-segmental vitiligo. No associated prognostic factors at baseline of progression to non-segmental or long-lasting focal vitiligo were found. CONCLUSION: Focal vitiligo is a rare subtype of vitiligo and most patients have long-lasting focal lesions after onset of the disease. In this study, focal vitiligo progressed to typical non-segmental vitiligo, but not towards typical segmental vitiligo. Progression 2 years after onset of focal vitiligo, occurs in 50% of the patients with eventual progression to non-segmental vitiligo. There seem to be no clinical signs that predict progression in focal vitiligo.