Disease Stability in Segmental and Non-Vitiligo-IDOJ study

Disease stability in vitiligo is essential in making therapeutic decisions and in informing patients of the prognosis. Different guidelines exist regarding the duration of stability required before surgical intervention ranging from 6 weeks to 3 years. However, the evidence for these guidelines is unclear. Recently a study regarding disease stability in vitiligo was published in the Indian Dermatology Online Journal.

Materials and Methods

Consecutive patients with a clinical diagnosis of vitiligo, irrespective of their age and gender, who could recall the course of their disease, were recruited from June 2015 to June 2017. Detailed clinical history was taken with an emphasis on the disease course including periods of stability and activity. A period was defined as stable if there were no new lesions or progression of existing lesions for at least 3 months (with or without treatment). We asked about the site of the last new lesion, and when it was noticed, number of new lesions in the past 1 and 3 months, number of stable periods, when different stable periods occurred, and the duration of each stable period, and whether the stable period was associated with or without treatment.

The total duration of the stable periods was calculated as the sum of all individual stable periods. The average duration of a stable period was calculated as the total duration of stable periods divided by the number of stable periods. The proportion of stable period for a patient was calculated as the sum of the duration of all stable periods divided by the total duration of the disease, expressed as a percentage.

Results

Two hundred patients were recruited. The average duration of active and stable periods was 2.2 ± 4.2 years (median 0.75) and 2.6 ± 3.7 years (median 1), respectively in patients with non‑segmental vitiligo (NSV) and 1.6 ± 1.8 years (median 0.75) and 4 ± 4.6 years (median 2.75), respectively in patients with segmental vitiligo (SV). Of the total disease duration, the proportion of active and stable periods in non‑segmental vitiligo were almost similar (45.8 and 54.2%, respectively) while the proportion of stable periods was relatively higher (71.4%) than the active periods (28.6%) in SV.

The relationship between the total duration of their disease and active and stable periods of the disease was assessed. For every 1‑year increase in the duration of the disease, stable and active periods increased by 0.7 and 0.3 years, respectively in NSV (P < 0.001) and by 0.9 and 0.1 years in SV (P < 0.001).

In patients with segmental vitiligo, 72.7% patients with less than 2 years of stability had disease reactivation compared to 30.8% in patients with greater than 2 years of stability. Thus, patients with more than 2 years of stable disease were one‑fifth less likely to develop reactivation of the disease as compared to the patients who had less than 2 years of stability (odds ratio = 0.2, P = 0.004).

On the other hand, reactivation was seen in 80 to 100% of patients with NSV, irrespective of the duration of stable disease (P = 0.072). Thus, the authors could not define any duration of stability in NSV beyond which reactivation was unlikely.

Vitiligo is a disease behaviour of which over long periods of time has not been studied. The authors found that the duration of stability and activity in vitiligo varied with the duration of the disease. Both the duration of active as well as the stable periods increased with increasing duration of the disease, but the increase in stable periods was significantly more than the increase in active periods. These findings indicate that as the duration of the disease progresses patients have more stable disease periods. This can be reassuring for the patient with long‑standing disease.

Thus, even patients with segmental vitiligo may experience reactivation of the disease many years into the condition, though this is uncommon. Patients of NSV may relapse even long after successful repigmentation with either medical or surgical treatment.

Current guidelines recommend surgery for both SV and NSV after at least 1 year of stable disease. This study suggests that stability of at least 2 years may be required in SV for the disease to remain quiescent thereafter.

To conclude the study data indicates that disease stability is likely in patients with SV vitiligo after a period of 2 years of inactivity. However, the risk of reactivation in NSV does not change significantly with the period of inactive disease.

Source- Taneja N, Sreenivas V, Sahni K, Gupta V, Ramam M. Disease stability in segmental and non-segmental vitiligo. Indian Dermatol Online J 2022;13:60-3.