Guideline for the Diagnosis and Management of Vitiligo

D.J. Gawkrodger; A.D. Ormerod; L. Shaw; I. Mauri-Sole; M.E. Whitton; M.J. Watts; A.V. Anstey; J. Ingham; K. Young

The British Journal of Dermatology. 2008;159(5):1051-1076.

What is the Accuracy of Wood's Light Compared With Naked Eye Examination in the Diagnosis of Vitiligo?

Introduction

Wood's light is a hand-held ultraviolet (UV) irradiation device that emits UVA. It has been used to identify areas of depigmentation that may not be visible to the naked eye, especially in pale skin.

Methods

The GDG considered the limited evidence, consisting of two observational studies, and consensus statements regarding Wood's light.

Evidence Statements

Wood's light delineates areas of pigment loss. Actively depigmenting areas may appear larger under UV illumination than with visible light, whereas areas showing repigmentation can appear larger or smaller with UV than with visible light. Thus combined assessment of a selected area in natural and Wood's light is useful.^[5] Photography using a UV camera is also reported as useful in documenting pigmentary disorders.^[6] Although Wood's light has not been scientifically evaluated, it has potential as a tool for objective assessment of vitiligo in research and clinical trials.

Evidence to Recommendations

Wood's light can give the dermatologist additional information about the extent and activity of patches of vitiligo. Experience is needed in the use of the machine and evaluation of the results (level of evidence 4).

Recommendation

Wood's light may be of use in the diagnosis of vitiligo and in the demonstration of the extent and activity of the disease in subjects with skin types I and II. Wood's light can be of use in monitoring response to therapy.

Grade of recommendation D

Level of evidence 4

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

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References

Table 1 Levels of Evidence (from Scottish Inter-Collegiate Guidelines Network)
	Levels of evidence
1++	High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+	Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2-	Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3	Nonanalytical studies, e.g. case reports, case series
4	Expert opinion

RCT = randomized controlled trial.

Table 2. Grades of Recommendation (from Scottish Inter-Collegiate Guidelines Network)
	Grades of recommendation
A	At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B	A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++
D	Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

RCT = randomized controlled

Table 1 Levels of Evidence (from Scottish Inter-Collegiate Guidelines Network)
	Levels of evidence
1++	High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias
1+	Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1-	Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++	High-quality systematic reviews of case-control or cohort studies High-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+	Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2-	Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3	Nonanalytical studies, e.g. case reports, case series
4	Expert opinion

RCT = randomized controlled trial.

Table 2. Grades of Recommendation (from Scottish Inter-Collegiate Guidelines Network)
	Grades of recommendation
A	At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results
B	A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+
C	A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++
D	Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

RCT = randomized controlled

Table 3. Differential Diagnosis of Vitiligo
Halo naevus
Hypopigmented naevus
Idiopathic guttate hypomelanosis
Leprosy
Lichen sclerosus (for genital vitiligo)
Melanoma-associated leucoderma
Melasma
Mycosis fungoides-associated depigmentation
Naevus anaemicus
Naevus of Ito
Piebaldism
Pityriasis alba
Pityriasis versicolor
Postinflammatory depigmentation, e.g. scleroderma, psoriasis, atopic eczema
Post-traumatic depigmentation
Topical or drug-induced depigmentation
Tuberous sclerosis

Table 4. Skin Types*
Skin type	Typical features	Tanning ability
I	Pale white skin, blue/hazel eyes, blond/red hair	Always burns, does not tan
II	Fair skin, blue eyes	Burns easily, tans poorly
III	Darker white skin	Tans after initial burn
IV	Light brown skin	Burns minimally, tans easily
V	Brown skin	Rarely burns, tans darkly easily
VI	Dark brown or black skin	Never burns, always tans darkly

*from http://www.dermnetnz.org

Appendix 1.

Key recommendations:
The main points of note.

Introduction: D.J. Gawkrodger
Includes method of guideline development, aims, scope, audience, process, funding, declaration of interests and review.

Symptoms and Signs: A.D. Ormerod
What symptoms and signs are suggestive of vitiligo?

Wood's Light: A.D. Ormerod
What is the accuracy of Wood's light compared with naked eye examination in the diagnosis of vitiligo?

Natural history: A.V. Anstey
What is the natural history of vitiligo?

Quality of Life: L. Shaw, I. Mauri-Sole
What is the quality of life in patients with vitiligo compared with other skin diseases?

Scoring indices: M.J. Watts, M.E. Whitton
In all patients with vitiligo, what is the accuracy of a scoring index in showing the outcome of common treatments compared with simple photography?

Topical treatments: D.J. Gawkrodger
Includes: In all patients with vitiligo, what is the efficacy of applying betamethasone, clobetasol, fluocinolone, fluticasone or mometasone vs. placebo or other active treatment in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of applying calcipotriol or tacalcitol vs. placebo or an active treatment in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of applying tacrolimus or pimecrolimus vs. placebo or an active treatment in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of applying p-(benzyloxy)phenol (monobenzyl ether of hydroquinone) vs. placebo or an active treatment in terms of reducing areas of pigmentation?

Phototherapy: A.V. Anstey
Includes: In all patients with vitiligo, what is the efficacy of a course of narrowband UVB including high-intensity light sources compared with placebo in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of a course of PUVA or PUVA-sol compared with placebo in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of a course of khellin with sunlight UVA or UVB compared with PUVA or PUVA-sol in terms of progression, area reduction and quality of life score?

Late complications of PUVA or narrowband UVB therapy in patients with vitiligo: are patients who have received large doses of PUVA (more than 150 treatment sessions) or narrowband UVB (more than 150 treatment sessions) at increased risk of developing premalignant or malignant skin changes?

Combination Phototherapy: A.V. Anstey
Includes: In all patients with vitiligo, what is the efficacy of a course of narrowband UVB with a vitamin D analogue compared with narrowband UVB with placebo in terms of condition progression, area reduction and quality of life score?

In all patients with vitiligo, what is the efficacy of a course of PUVA with a vitamin D analogue compared with PUVA with placebo in terms of condition progression, area reduction and quality of life score?

Systemic Therapies: D.J. Gawkrodger
In all patients with vitiligo, what is the efficacy of systemic (i.e. orally and parenterally administered) treatments, including corticosteroids, ciclosporin and other immunosuppressive agents, in terms of condition progression, area reduction and quality of life score?

Surgical Treatments: A.D. Ormerod
In patients with vitiligo what is the efficacy of a skin graft and of various forms of placebo in terms of condition progression, area reduction and quality of life score? This may include punch grafts, full-thickness skin graft, split-thickness skin graft, autologous epidermal cell suspension, and autologous skin equivalent (commercial skin equivalent).

Psychological Treatments: L. Shaw, I. Mauri-Sole
In all patients with vitiligo, what is the efficacy of cognitive therapy vs. psychological support or no treatment in terms of condition progression, area reduction and quality of life score?

Research recommendations:
Areas for future research to improve treatment of vitiligo are suggested.

Final recommendations:
An approach to the overall management of vitiligo is outlined based on the evidence evaluated in this guideline.

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Guideline for the Diagnosis and Management of Vitiligo

What is the Accuracy of Wood's Light Compared With Naked Eye Examination in the Diagnosis of Vitiligo?

Introduction

Methods

Evidence Statements

Evidence to Recommendations

Recommendation

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Guideline for the Diagnosis and Management of Vitiligo

What is the Accuracy of Wood's Light Compared With Naked Eye Examination in the Diagnosis of Vitiligo?

Introduction

Methods

Evidence Statements

Evidence to Recommendations

Recommendation

Tables

Tables

Tables

Tables

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

Appendix

Appendix 1.

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