INTRODUCTION
The reality of dermatology practice is that doctor-patient encounters are often limited to minutes, making it critical to optimize each visit, particularly for conditions like non-segmental vitiligo (NSV). Patients frequently present with concerns about disease progression, treatment options, and psychosocial implications. With a structured and efficient approach, dermatologists can address key concerns and provide meaningful care while remaining efficient.
DISCUSSION
Skin Exam and Subjective Assessment
Begin with a thorough history and a full skin examination to assess phototype, disease duration, and extent, as these factors inform therapeutic decisions.1 NSV is typically diagnosed clinically, with Wood's lamp examination.2 While Wood's lamp enhances visualization of depigmented areas lacking melanocytes, its utility varies by skin tone. In lighter skin types, the contrast under natural light is subtle, making Wood's lamp particularly valuable. Conversely, in darker skin types (Fitzpatrick IV-VI), the contrast is naturally more pronounced, diminishing the necessity of this tool.3 In some circumstances, dermatoscopy may be a valuable tool, especially when looking for lesional and/or peri-lesional inflammation or leukotrichia. Gauging lesion severity, stability, and recent progression further refines management. For the estimation of the body surface area (BSA) involved, the palm print method can be utilized, where the patient's palm, with fingers adducted, is considered approximately equivalent to 1% of their total body surface area.4 Although this method is quick, requires no specialized tools, and is reasonably accurate in clinical settings, it may overestimate BSA by 10–20% since the hand with fingers represents only about 0.8% of BSA in men and 0.7% in women.4 The 5-point Physician Global Assessment (PGA) scale can be used as a standardized tool with high interrater validity for stratifying disease severity in NSV.5 An image of a target area or lesion included in the medical record and also on the patient’s own phone allows tracking of progression or response to therapy. In addition, for NSV in lighter-skinned individuals, digital images guide topical applications.2
Laboratory Assessment
Given NSV's association with autoimmune disorders, relevant laboratory tests include thyroid-stimulating hormone (TSH), thyroid peroxidase (TPO) antibodies, Anti-Nuclear Antibody (ANA), and vitamin D levels.6 Vitamin D plays a pivotal role in skin pigmentation by enhancing tyrosinase activity and melanogenesis while exerting immunoregulatory effects. Deficiency has been linked to several autoimmune diseases, including systemic lupus erythematosus, diabetes mellitus, rheumatoid arthritis, multiple sclerosis, and alopecia areata. However, studies evaluating serum vitamin D levels in vitiligo patients have yielded mixed results, necessitating further research to elucidate its role in disease pathogenesis and treatment response.7
Streamlined Treatment Discussion
Therapeutic strategies for NSV may be efficiently categorized into topical and systemic approaches. First-line topical treatments include corticosteroids, calcineurin inhibitors, and vitamin D analogs, particularly for localized or stable disease. Ruxolitinib 1.5% cream, the first FDA-approved topical Janus kinase (JAK)
Begin with a thorough history and a full skin examination to assess phototype, disease duration, and extent, as these factors inform therapeutic decisions.1 NSV is typically diagnosed clinically, with Wood's lamp examination.2 While Wood's lamp enhances visualization of depigmented areas lacking melanocytes, its utility varies by skin tone. In lighter skin types, the contrast under natural light is subtle, making Wood's lamp particularly valuable. Conversely, in darker skin types (Fitzpatrick IV-VI), the contrast is naturally more pronounced, diminishing the necessity of this tool.3 In some circumstances, dermatoscopy may be a valuable tool, especially when looking for lesional and/or peri-lesional inflammation or leukotrichia. Gauging lesion severity, stability, and recent progression further refines management. For the estimation of the body surface area (BSA) involved, the palm print method can be utilized, where the patient's palm, with fingers adducted, is considered approximately equivalent to 1% of their total body surface area.4 Although this method is quick, requires no specialized tools, and is reasonably accurate in clinical settings, it may overestimate BSA by 10–20% since the hand with fingers represents only about 0.8% of BSA in men and 0.7% in women.4 The 5-point Physician Global Assessment (PGA) scale can be used as a standardized tool with high interrater validity for stratifying disease severity in NSV.5 An image of a target area or lesion included in the medical record and also on the patient’s own phone allows tracking of progression or response to therapy. In addition, for NSV in lighter-skinned individuals, digital images guide topical applications.2
Laboratory Assessment
Given NSV's association with autoimmune disorders, relevant laboratory tests include thyroid-stimulating hormone (TSH), thyroid peroxidase (TPO) antibodies, Anti-Nuclear Antibody (ANA), and vitamin D levels.6 Vitamin D plays a pivotal role in skin pigmentation by enhancing tyrosinase activity and melanogenesis while exerting immunoregulatory effects. Deficiency has been linked to several autoimmune diseases, including systemic lupus erythematosus, diabetes mellitus, rheumatoid arthritis, multiple sclerosis, and alopecia areata. However, studies evaluating serum vitamin D levels in vitiligo patients have yielded mixed results, necessitating further research to elucidate its role in disease pathogenesis and treatment response.7
Streamlined Treatment Discussion
Therapeutic strategies for NSV may be efficiently categorized into topical and systemic approaches. First-line topical treatments include corticosteroids, calcineurin inhibitors, and vitamin D analogs, particularly for localized or stable disease. Ruxolitinib 1.5% cream, the first FDA-approved topical Janus kinase (JAK)
