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

Disclosures

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

In This Article

What is the Natural History of Vitiligo?

Introduction

Despite being a common condition that may cause severe and long-lasting disability, the epidemiology of vitiligo has not been established with clarity.

Methods

No studies on the natural history of vitiligo were identified by the search of the literature. Evidence and recommendations are based on consensus views.

Evidence Statements

The natural history for the condition remains unclear, as no long-term follow-up study has been performed. This is relevant to the large number of therapeutic studies that have been carried out on vitiligo, as few have attempted to assess the longevity of any therapeutic response. There is no convincing evidence to suggest that any treatment has an effect on the natural history of vitiligo.

Textbooks of dermatology usually fail to comment on the natural history of vitiligo. Although some patients have been reported to undergo spontaneous repigmentation, this is probably uncommon. More typically, vitiligo is a chronic persistent disorder that progresses in a step-wise fashion with long periods when the disease is relatively inactive or static interspersed with shorter periods when areas of pigment loss extend. The genetic basis for vitiligo postulates a contribution from multiple recessive alleles at unlinked autosomal loci.[7]

The most detailed attempt at an epidemiological study was performed on the island of Bornholm in 1970-71.[8] This involved a single attempt to establish the prevalence of vitiligo in a population of sufficient size (47033) to eliminate (or minimize) bias. Age-specific rates were established and showed that vitiligo is rare in the 0-9-year age group, with prevalence rising steadily thereafter to a peak at 60-70years. Although this does not prove the natural history, it provides indirect evidence consistent with the notion that vitiligo is a life-long condition, with new cases in each age-band joining others who previously developed the condition. This study did not attempt a cross-sectional sample, which might have diagnosed more patients including those who were unaware of the study, or who had mild disease unapparent to them or who chose not to come forward.

A study from South Korea reported progressive disease in >90% of a series of 318 patients with vitiligo.[9] This was a selected group and the methods used to assess disease progression were crude (patient recall on questionnaire). Nevertheless, it suggested that progression rather than spontaneous resolution is the norm. Finally, an epidemiological study from South America used a case-control design, identifying significant differences in age at presentation between unilateral (younger) and generalized vitiligo,[10] but no differences for rate of disease progression between the two groups (level of evidence 4).

Evidence to Recommendations

No study has specifically determined the natural history of vitiligo. Indirect evidence and clinical experience of the GDG suggest that, in most cases, vitiligo is a chronic and persistent disorder characterized by periods of disease activity and often long periods of relative inactivity or stasis. Response to treatment should be considered in the light of this, recognizing that spontaneous repigmentation may occur, albeit uncommonly.

Recommendation

  1. The response to treatment of vitiligo should be considered in the context of the natural history, recognizing that spontaneous repigmentation may occur but is uncommon.

    Grade of recommendation D
    Level of evidence 4

     

Research Recommendation

  1. A longitudinal epidemiological study is needed to define the natural history of vitiligo. This should use photographs combined with computerized image analysis, to quantify how the vitiligo changes with time.

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