derm.vitiligo.core.v1PRODUCTION

derm.vitiligo.core.v1

Vitiligo (autoimmune depigmentation, dermatology lens)

dermatologychronicadultpediatric

Hard-required inputs

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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC, often progressive/relapsing T-cell-mediated AUTOIMMUNE melanocyte-loss disease (depigmentation, not hypopigmentation) managed on an extent/activity/site-stratified ladder with autoimmune-comorbidity screening + psychological support as first-class outcomes — NOT a benign cosmetic finding. EVERY patient is screened for the autoimmune cluster (thyroid #1, T1DM, alopecia areata, pernicious anaemia, Addison) and for depression/anxiety/stigma (amplified in skin of colour). The treatable/serious not-to-miss is pityriasis versicolor, leprosy, and hypopigmented mycosis fungoides/CTCL masquerading as vitiligo.

Inputs

Actions

Advance rule

Set

Advance when

chronic autoimmune-depigmentation framing set; comorbidity + psychosocial + versicolor/leprosy/CTCL escape routes noted

Patient inputs (16)

subtype_nonsegmental_vs_segmental_vs_mixed*symptom • CONTEXT

Non-segmental (symmetric, autoimmune, progressive/relapsing) vs segmental (unilateral, early-stable, follicular-reservoir-dependent → earlier surgery) vs mixed steers prognosis and the surgical-candidacy decision (BAD 2021 PMID 34160061)

disease_activity_signs*symptom • CONTEXT

Confetti macules, trichrome, Koebner, leukotrichia, rapid spread mark ACTIVE disease — drives the urgency to arrest progression (oral mini-pulse + phototherapy) and contraindicates immediate surgery (BAD 2021 PMID 34160061)

lesion_site_distribution*symptom • CONTEXT

Site predicts repigmentation potential and agent choice — face/neck respond best, acral and leukotrichic lesions respond poorly; face/folds/children favour calcineurin inhibitor, non-facial favours topical steroid (BAD 2021 PMID 34160061)

autoimmune_comorbidity_screen*history • CONTEXT

not present

Vitiligo clusters with autoimmune thyroid disease (#1 — screened via panel.thyroid), T1DM, alopecia areata, pernicious anaemia, Addison — screened/co-managed at presentation (BAD 2021 PMID 34160061)

psychosocial_burden_and_mood_screen*symptom • CONTEXT

Vitiligo carries major QoL impact + increased depression/anxiety/sleep-disturbance (amplified in skin of colour); screening + support is a core outcome (Eleftheriadou et al BJD 2024 PMID 39018020)

depigmentation_extent_and_bsa*symptom • ENTRY

Extent (% BSA, facial vs non-facial, limited vs extensive/universal) is the primary axis gating topical-vs-phototherapy-vs-surgical therapy and the topical-ruxolitinib ≤10% BSA / FDA label (BAD 2021 PMID 34160061; Rosmarin TRuE-V NEJM 2022 PMID 36260792)

koh_scaly_or_anaesthetic_or_atypical_features*symptom • RED_FLAGS

Fine scale + KOH-positive → pityriasis versicolor (route dermatophyte engine); anaesthetic patch + endemic exposure → leprosy; persistent atypical/poikilodermatous → biopsy for hypopigmented mycosis fungoides/CTCL — treatable/serious mimics not to immunosuppress blindly (BAD 2021 PMID 34160061)

age*demographic • TREATMENT

Pediatric ladder + agent age-cutoffs (topical ruxolitinib ≥12 y; topical CNI/steroid + NB-UVB the pediatric mainstay; phototherapy practicality in young children; school/psychosocial differs) (BAD 2021 PMID 34160061; Rosmarin TRuE-V NEJM 2022 PMID 36260792)

fitzpatrick_skin_phototypehistory • CONTEXT

not present

High lesion-to-skin contrast in darker phototypes greatly increases psychosocial impact and changes phototherapy dosing/photoprotection counselling (Eleftheriadou et al BJD 2024 PMID 39018020)

tsh_thyroid_functionlab • INITIAL_WORKUP

Autoimmune-thyroid screen at presentation (vitiligo clusters with thyroid disease — the #1 comorbidity) — co-managed, does not by itself drive skin therapy (BAD 2021 PMID 34160061)

cbc_with_differentiallab • INITIAL_WORKUP

Screens pernicious-anaemia / autoimmune-comorbidity context; baseline before oral mini-pulse corticosteroid where used (BAD 2021 PMID 34160061)

lftlab • INITIAL_WORKUP

Baseline hepatic function before oral mini-pulse corticosteroid and as autoimmune-comorbidity context (BAD 2021 PMID 34160061)

glucose_hba1c_for_t1dm_screenlab • INITIAL_WORKUP

Type-1-diabetes-cluster screen + corticosteroid-glycaemic-effect baseline if oral mini-pulse is used (BAD 2021 PMID 34160061)

pregnancy_lactationhistory • TREATMENT

not present

Defer topical/oral JAK + systemic mini-pulse steroid + phototherapy initiation in pregnancy/lactation (limited data); topical CNI/steroid used cautiously and minimally — gates the ladder (BAD 2021 PMID 34160061)

disease_stability_duration_for_surgeryhistory • TREATMENT

not present

Surgical melanocyte–keratinocyte transplant requires documented disease stability ≥6–12 mo (no new/expanding lesions, no Koebner) — gates the surgical step (Altalhab et al JEADV 2019 PMID 30793805; Ramos et al 2017 PMID 29186240)

creatininelab • TREATMENT

Baseline renal function for comorbidity (T1DM/CKD) context; CKD-EPI 2021 race-free eGFR (Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement

informationalsevererapidly_progressive_active_vitiligo_arrest_progression
Rapidly enlarging/spreading depigmentation with confetti macules + trichrome lesions + Koebner phenomenon ± leukotrichia — ACTIVE unstable vitiligo
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverehypopigmented_mycosis_fungoides_ctcl_biopsy
Persistent atypical / poikilodermatous / treatment-resistant hypopigmented or depigmented patches (often skin of colour) not behaving like vitiligo
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresevere_psychosocial_distress_or_suicidality
Marked depression/anxiety, social withdrawal, stigma or suicidality attributable to visible depigmentation (amplified by high contrast in skin of colour)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereextensive_cosmetically_disabling_or_universal_disease
Extensive (>facial, widespread) cosmetically disabling non-segmental vitiligo, or near-universal vitiligo where repigmentation is unachievable
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatepityriasis_versicolor_or_leprosy_mimic_do_not_immunomodulate
Fine branny scale + KOH spaghetti-and-meatballs (pityriasis versicolor) OR anaesthetic hypopigmented patch + nerve thickening + endemic exposure (leprosy) masquerading as vitiligo
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatestable_segmental_or_refractory_localised_surgical_candidacy
Segmental or refractory localised vitiligo, documented stable ≥6–12 mo (no new/expanding lesions, no Koebner), unresponsive to topical/phototherapy
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatesymptomatic_autoimmune_comorbidity_detected
Screen-detected symptomatic autoimmune comorbidity (e.g. thyroid dysfunction, type-1 diabetes, pernicious anaemia, Addison disease) in a patient with vitiligo
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatepregnancy_lactation_systemic_gating
Pregnant / planning-pregnancy / lactating patient requiring therapy for active or extensive vitiligo
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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TREATMENToptionalDrives dose adjustment

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Recommended regimen

Vitiligo — extent/activity/site-stratified ladder + photoprotection & psychological support (BAD 2021 / VGICC; FDA-approved topical ruxolitinib)

axis: vitiligo_extent_activity_site_stratified_ladderstep 1 - Step 1 — Photoprotection + camouflage + psychological support (every patient, every severity)

Selected step "Step 1 — Photoprotection + camouflage + psychological support (every patient, every severity)" — All patients, continuously — depigmented skin lacks melanin photoprotection; vitiligo carries major QoL/psychiatric burden (amplified in skin of colour); support + camouflage are first-class outcomes, not afterthoughts

photoprotection_broad_spectrum_sunscreen_and_sun_avoidance
first line
supportive_care
BAD 2021 (PMID 34160061) — depigmented skin has no melanin photoprotection (burns readily, ↑ actinic damage); broad-spectrum high-SPF sunscreen + behavioural sun protection also reduces lesion–skin contrast and Koebnerising sunburn.
cosmetic_camouflage_and_psychological_support
first line
supportive_care
Eleftheriadou et al BJD 2024 (PMID 39018020) + BAD 2021 (PMID 34160061) — vitiligo increases depression/anxiety/sleep-disturbance and time off work (amplified by high contrast in skin of colour); camouflage + structured psychological support + mood screening are core management, independent of pharmacotherapy response.
maintenance_topical_after_repigmentation_to_prevent_relapse
add on
supportive_care
triggers: repigmentation_achieved_relapse_prevention
BAD 2021 (PMID 34160061) — relapse at previously repigmented sites is common after stopping; intermittent maintenance topical (e.g. calcineurin inhibitor 1–2×/wk) to repigmented sites reduces relapse.

outpatient playbook — drug actions (4)

1. photoprotection + cosmetic camouflage + psychological support + (post-repigmentation) maintenance topical
n/a • supportive/topical • daily / every visit
trigger: All patients (core QoL + photoprotection of melanin-deficient skin) (BAD 2021 PMID 34160061; Eleftheriadou BJD 2024 PMID 39018020)
Depigmented skin has no melanin photoprotection; vitiligo carries major psychosocial burden; support + camouflage are first-class outcomes
2. topical ruxolitinib 1.5% (FDA-approved, ≥12 y, ≤10% BSA) / topical CNI (face-folds-children) / topical corticosteroid (non-facial)
rxcui 2570750
1.5% cream BID • topical • BID
trigger: Limited stable non-segmental ≤10% BSA — site-directed (TRuE-V NEJM 2022 PMID 36260792; BAD 2021 PMID 34160061)
Topical ruxolitinib is the only FDA-approved repigmentation therapy; calcineurin inhibitor for face/folds/children; topical steroid for non-facial
3. narrowband-UVB phototherapy ± topical / 308-nm excimer (localised) / oral mini-pulse steroid (arrest active disease)
rxcui 8640
NB-UVB 2–3×/wk; mini-pulse short course • phototherapy / PO • NB-UVB 2–3×/wk; mini-pulse pulsed
trigger: Active/progressive or extensive disease (Xiao et al 2014 PMID 25102894; Singh et al 2015 PMID 26278124)
NB-UVB is the mainstay for widespread/active disease; excimer for localised; mini-pulse arrests rapid progression — chronic systemic steroids AGAINST
4. autologous melanocyte–keratinocyte transplant (stable ≥6–12 mo) or monobenzone depigmentation (extensive recalcitrant universal)
rxcui 17145
surgical / monobenzone 20% (IRREVERSIBLE) • surgical / topical • procedure / as directed
trigger: Stable segmental/refractory localised → surgery; extensive recalcitrant universal → depigmentation (Ramos 2017 PMID 29186240; Altalhab JEADV 2019 PMID 30793805)
Surgical transplant for documented-stable disease (best face/neck + segmental); monobenzone permanently depigments residual skin — irreversibility counselling

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acquired well-demarcated chalk/milky-white DEPIGMENTED (not merely hypopigmented) macules/patches, often acral/periorificial, symmetric — vitiligo entry (BAD 2021 PMID 34160061); Wood-lamp bright chalk/blue-white accentuation with sharp margins (true depigmentation) vs poor accentuation in hypopigmentation — the pivotal bedside discriminator (BAD 2021 PMID 34160061); Unilateral, segmental/blaschkoid depigmentation, often early childhood onset, early-stabilising → segmental subtype + earlier surgical-candidacy entry (BAD 2021 PMID 34160061).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Vitiligo (autoimmune depigmentation, dermatology lens)** (derm.vitiligo.core.v1).
Phenotype framing: Terminal leukoderma differential with named pivots: vitiligo (acquired progressive symmetric DEPIGMENTATION + Wood-lamp bright accentuation + acral/periorificial + Koebner/confetti pivot) vs pityriasis versicolor (fine scale + KOH spaghetti-and-meatballs + dull-yellow fluorescence pivot — route derm.tinea-dermatophytosis.core.v1) vs pityriasis alba (atopic child + fine-scale facial HYPOpigmentation pivot — derm.atopic-dermatitis.core.v1) vs post-inflammatory hypopigmentation (antecedent dermatosis/injury + not bright on Wood-lamp pivot) vs idiopathic guttate hypomelanosis (small stable porcelain macules on sun-exposed limbs pivot) vs nevus depigmentosus / piebaldism (congenital, stable, non-progressive ± hyperpigmented islands pivot) vs nevus anaemicus (vasoconstrictive — disappears on diascopy pivot) vs halo nevus (depigmented rim around melanocytic naevus pivot) vs lichen sclerosus (atrophic genital white plaques + sclerosis pivot) vs leprosy (anaesthetic patch + nerve thickening + endemic pivot) vs chemical/occupational leukoderma (phenol/catechol exposure pivot) vs hypopigmented mycosis fungoides/CTCL (persistent atypical/poikilodermatous + BIOPSY pivot — NOT vitiligo).
Scope: Frame as a CHRONIC, often progressive/relapsing T-cell-mediated AUTOIMMUNE melanocyte-loss disease (depigmentation, not hypopigmentation) managed on an extent/activity/site-stratified ladder with autoimmune-comorbidity screening + psychological support as first-class outcomes — NOT a benign cosmetic finding. EVERY patient is screened for the autoimmune cluster (thyroid #1, T1DM, alopecia areata, pernicious anaemia, Addison) and for depression/anxiety/stigma (amplified in skin of colour). The treatable/serious not-to-miss is pityriasis versicolor, leprosy, and hypopigmented mycosis fungoides/CTCL masquerading as vitiligo.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Vitiligo — extent/activity/site-stratified ladder + photoprotection & psychological support (BAD 2021 / VGICC; FDA-approved topical ruxolitinib)** — step "Step 1 — Photoprotection + camouflage + psychological support (every patient, every severity)".
1. photoprotection_broad_spectrum_sunscreen_and_sun_avoidance (supportive_care, first line) — BAD 2021 (PMID 34160061) — depigmented skin has no melanin photoprotection (burns readily, ↑ actinic damage); broad-spectrum high-SPF sunscreen + behavioural sun protection also reduces lesion–skin contrast and Koebnerising sunburn.
2. cosmetic_camouflage_and_psychological_support (supportive_care, first line) — Eleftheriadou et al BJD 2024 (PMID 39018020) + BAD 2021 (PMID 34160061) — vitiligo increases depression/anxiety/sleep-disturbance and time off work (amplified by high contrast in skin of colour); camouflage + structured psychological support + mood screening are core management, independent of pharmacotherapy response.
3. maintenance_topical_after_repigmentation_to_prevent_relapse (supportive_care, add on) — BAD 2021 (PMID 34160061) — relapse at previously repigmented sites is common after stopping; intermittent maintenance topical (e.g. calcineurin inhibitor 1–2×/wk) to repigmented sites reduces relapse.

Setting playbook (outpatient) — Confirm vitiligo clinically + Wood-lamp (true depigmentation; exclude pityriasis versicolor, leprosy, hypopigmented MF/CTCL and other leukoderma), assign subtype × activity × extent × site, screen EVERY patient for the autoimmune-comorbidity cluster (thyroid #1) + mood/stigma, deliver photoprotection + camouflage + psychological support as core outcomes, and escalate the extent/activity/site-stratified ladder gated on pregnancy/age/stability (BAD 2021 PMID 34160061; Rosmarin TRuE-V NEJM 2022 PMID 36260792)
4. photoprotection + cosmetic camouflage + psychological support + (post-repigmentation) maintenance topical n/a supportive/topical daily / every visit — All patients (core QoL + photoprotection of melanin-deficient skin) (BAD 2021 PMID 34160061; Eleftheriadou BJD 2024 PMID 39018020) (Depigmented skin has no melanin photoprotection; vitiligo carries major psychosocial burden; support + camouflage are first-class outcomes)
5. topical ruxolitinib 1.5% (FDA-approved, ≥12 y, ≤10% BSA) / topical CNI (face-folds-children) / topical corticosteroid (non-facial) 1.5% cream BID topical BID — Limited stable non-segmental ≤10% BSA — site-directed (TRuE-V NEJM 2022 PMID 36260792; BAD 2021 PMID 34160061) (Topical ruxolitinib is the only FDA-approved repigmentation therapy; calcineurin inhibitor for face/folds/children; topical steroid for non-facial)
6. narrowband-UVB phototherapy ± topical / 308-nm excimer (localised) / oral mini-pulse steroid (arrest active disease) NB-UVB 2–3×/wk; mini-pulse short course phototherapy / PO NB-UVB 2–3×/wk; mini-pulse pulsed — Active/progressive or extensive disease (Xiao et al 2014 PMID 25102894; Singh et al 2015 PMID 26278124) (NB-UVB is the mainstay for widespread/active disease; excimer for localised; mini-pulse arrests rapid progression — chronic systemic steroids AGAINST)
7. autologous melanocyte–keratinocyte transplant (stable ≥6–12 mo) or monobenzone depigmentation (extensive recalcitrant universal) surgical / monobenzone 20% (IRREVERSIBLE) surgical / topical procedure / as directed — Stable segmental/refractory localised → surgery; extensive recalcitrant universal → depigmentation (Ramos 2017 PMID 29186240; Altalhab JEADV 2019 PMID 30793805) (Surgical transplant for documented-stable disease (best face/neck + segmental); monobenzone permanently depigments residual skin — irreversibility counselling)

Non-pharmacologic actions:
- Counsel the often progressive/relapsing course + realistic site-dependent repigmentation expectations (face/neck best; acral, bony-prominence, leukotrichic poor; segmental more stable but less topical-responsive) (BAD 2021 PMID 34160061)
- Photoprotection education (depigmented skin burns — no melanin photoprotection) + cosmetic camouflage + peer-support / patient-organisation signposting (Eleftheriadou BJD 2024 PMID 39018020)
- Mental-health referral for significant depression/anxiety/stigma; explicit irreversibility counselling before any monobenzone depigmentation (BAD 2021 PMID 34160061)
- Skin biopsy ONLY for diagnostic uncertainty or to exclude hypopigmented MF/CTCL; KOH if pityriasis versicolor plausible (BAD 2021 PMID 34160061)

AVOID / contraindication checks:
- Topical ruxolitinib jak class label and bsa duration limit (Rosmarin TRuE V NEJM 2022 PMID 36260792 — FDA label: nonsegmental, ≥12 y, ≤10% BSA, ≤60 g/wk; topical JAK class labelling; limit BSA/duration; application site acne/pruritus)
- Against chronic continuous systemic corticosteroids mini pulse only (BAD 2021 PMID 34160061 — only a short oral mini pulse to arrest rapidly progressive disease; chronic continuous use AGAINST)
- Monobenzone causes irreversible permanent depigmentation and contact leukoderma (BAD 2021 PMID 34160061 — extensive recalcitrant universal vitiligo only, explicit irreversibility + photoprotection counselling)
- Phototherapy cumulative dose photodamage skin cancer and photosensitiser caution (Xiao et al 2014 PMID 25102894; BAD 2021 PMID 34160061 — track cumulative NB UVB dose; caution with concomitant photosensitisers; periodic photodamage/skin cancer surveillance)
- Surgical transplant requires documented stability 6 to 12 months not active disease (Altalhab et al JEADV 2019 PMID 30793805 — active disease/Koebner contraindicates surgery; non segmental + fingertip involvement predict higher relapse)
- Defer jak systemic and phototherapy in pregnancy lactation cautious minimal topical only (BAD 2021 PMID 34160061 — limited safety data; defer JAK/mini pulse/phototherapy; minimal cautious topical CNI/steroid only)
- Pityriasis versicolor leprosy and hypopigmented ctcl must be excluded not blindly immunomodulated (BAD 2021 PMID 34160061 — KOH for versicolor; leprosy work up for anaesthetic patch; biopsy for atypical/treatment resistant; route OUT)

Monitoring

Regimen monitoring:
- repigmentation by VASI F-VASI T-VASI and Vitiligo Noticeability Scale at 3 6 9-12 months — slow; counsel ≥3–6 mo before judging; face/neck best, acral/leukotrichic poor; success = 80–100% target-lesion repigmentation (Eleftheriadou INFO/VGICG BJD 2018 PMID 30030843; Rosmarin TRuE-V pooled @52wk PMID 40156697)
- disease activity re-assessment new confetti Koebner trichrome → re-escalate to arrest progression (BAD 2021 PMID 34160061)
- topical ruxolitinib: application-site acne/pruritus + JAK class label + ≤10% BSA / duration limit (Rosmarin TRuE-V NEJM 2022 PMID 36260792)
- oral mini-pulse corticosteroid: SHORT course only — glycaemic/BP/mood/sleep vigilance; NOT chronic (Singh et al Dermatology 2015 PMID 26278124; BAD 2021 PMID 34160061)
- phototherapy: cumulative NB-UVB/excimer dose + photodamage/skin-cancer surveillance (Xiao et al 2014 PMID 25102894)
- topical corticosteroid: atrophy/striae/telangiectasia surveillance at non-facial sites; cycle and reassess at 3 mo (BAD 2021 PMID 34160061)
- autoimmune thyroid T1DM AA pernicious-anaemia Addison comorbidity surveillance — re-screen thyroid (BAD 2021 PMID 34160061)
- psychosocial mood re-screen + relapse-after-stopping counselling — maintenance topical to prevent relapse (Eleftheriadou BJD 2024 PMID 39018020; BAD 2021 PMID 34160061)

Setting (outpatient) monitoring:
- Reassess repigmentation (VASI/F-VASI/T-VASI + Vitiligo Noticeability Scale) + activity at 3/6/9–12 mo (slow — counsel ≥3–6 mo before judging) (Eleftheriadou INFO/VGICG BJD 2018 PMID 30030843)
- Drug-class safety on schedule (topical ruxolitinib application-site/JAK label + BSA limit; mini-pulse short-course glycaemic/BP/mood; phototherapy cumulative-dose/skin-cancer; topical-steroid atrophy) + autoimmune-comorbidity + mood re-screen (BAD 2021 PMID 34160061)

Follow-up plan: Chronic-disease maintenance: counsel the often progressive/relapsing course + realistic site-dependent repigmentation expectations (face/neck best; acral, bony-prominence, and leukotrichic lesions poor; segmental more stable but less topical-responsive), maintenance topical 1–2×/wk after repigmentation to prevent relapse, lifelong autoimmune (thyroid #1, T1DM, AA, pernicious anaemia, Addison) + mental-health surveillance, photoprotection (depigmented skin burns, no melanin photoprotection) + camouflage + peer-support signposting, irreversibility counselling before any monobenzone depigmentation, and step-up/step-down + surgical-candidacy (stable ≥6–12 mo) criteria. Dermatology continuity; re-evaluate diagnosis (biopsy) if the course is atypical or treatment-resistant (hypopigmented MF/CTCL).
- Close-out criterion: course/relapse + site-dependent repigmentation-expectation counselling + maintenance + comorbidity + mental-health surveillance + photoprotection/camouflage documented

Monitoring phase: Disease: repigmentation response by VASI/F-VASI/T-VASI + Vitiligo Noticeability Scale at 3 / 6 / 9–12 mo (slow — counsel ≥3–6 mo before judging; facial responds best, acral/leukotrichic poorly; INFO/VGICG success = 80–100% target-lesion repigmentation, PMID 30030843; TRuE-V F-VASI75 50.3% @52 wk continuous, PMID 40156697). Activity re-assessment (new confetti/Koebner/trichrome → re-escalate to arrest). Drug safety: topical ruxolitinib application-site acne/pruritus + JAK class label + BSA/duration limit; oral mini-pulse — short-course glycaemic/BP/mood vigilance, NOT chronic; phototherapy cumulative-dose + photodamage/skin-cancer surveillance; topical-steroid atrophy at long-term/facial sites. Autoimmune-comorbidity surveillance (re-screen thyroid). Relapse after stopping — maintenance counselled.

Disposition

Current setting: outpatient — Confirm vitiligo clinically + Wood-lamp (true depigmentation; exclude pityriasis versicolor, leprosy, hypopigmented MF/CTCL and other leukoderma), assign subtype × activity × extent × site, screen EVERY patient for the autoimmune-comorbidity cluster (thyroid #1) + mood/stigma, deliver photoprotection + camouflage + psychological support as core outcomes, and escalate the extent/activity/site-stratified ladder gated on pregnancy/age/stability (BAD 2021 PMID 34160061; Rosmarin TRuE-V NEJM 2022 PMID 36260792)

Disposition criteria:
- Manage entirely outpatient with dermatology continuity (phototherapy/topical-JAK/surgery via dermatology) (BAD 2021 PMID 34160061)
- Step up the ladder by extent/activity after an adequate trial; pediatric extensive → pediatric-dermatology + phototherapy/topical-ruxolitinib-eligibility pathway
- Route mimics OUT (versicolor → dermatophyte engine; leprosy → ID; hypopigmented MF/CTCL → biopsy + cutaneous-lymphoma care); refer mental-health as indicated

Escalation triggers (move to higher acuity):
- Pityriasis versicolor (fine scale + KOH-positive) → antifungal; route derm.tinea-dermatophytosis.core.v1 — do NOT immunomodulate
- Anaesthetic hypopigmented patch + nerve thickening + endemic exposure → urgent leprosy work-up + appropriate infectious-disease pathway
- Persistent atypical/poikilodermatous or treatment-resistant patches → skin biopsy for hypopigmented mycosis fungoides/CTCL before chronic immunomodulation (route OUT to cutaneous-lymphoma care)
- Severe psychosocial distress / suicidality (stigma, amplified in skin of colour) → urgent mental-health referral + accelerate definitive therapy (Eleftheriadou BJD 2024 PMID 39018020)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Rapidly enlarging/spreading depigmentation with confetti macules + trichrome lesions + Koebner phenomenon ± leukotrichia — ACTIVE unstable vitiligo
- [SEVERE] Persistent atypical / poikilodermatous / treatment-resistant hypopigmented or depigmented patches (often skin of colour) not behaving like vitiligo
- [SEVERE] Marked depression/anxiety, social withdrawal, stigma or suicidality attributable to visible depigmentation (amplified by high contrast in skin of colour)

Citations

- British Association of Dermatologists guidelines for the management of people with vitiligo 2021 (Eleftheriadou et al, Br J Dermatol; PMID 34160061, DOI 10.1111/bjd.20596 — subtype/activity assessment, NB-UVB + topical CNI/corticosteroid first-line, 308-nm excimer for localised, oral mini-pulse to arrest active disease, surgery for documented-stable disease, monobenzone depigmentation for extensive recalcitrant universal disease, autoimmune-comorbidity + psychological screening, against chronic continuous systemic steroids) anchored by pivotal evidence: TRuE-V1/TRuE-V2 phase-3 topical ruxolitinib cream (Rosmarin et al, NEJM 2022; PMID 36260792, DOI 10.1056/NEJMoa2118828 — FDA-approved repigmentation) + pooled subgroup @52 wk (PMID 40156697, DOI 10.1007/s13555-025-01381-7) + F-/T-VASI psychometrics (PMID 39078582, DOI 10.1007/s13555-024-01223-y); INFO/VGICG repigmentation-outcome consensus (Eleftheriadou et al, Br J Dermatol 2018; PMID 30030843, DOI 10.1111/bjd.17013); UK lifetime-risk + psychosocial/ethnicity impact (Eleftheriadou et al, Br J Dermatol 2024; PMID 39018020, DOI 10.1093/bjd/ljae282); NB-UVB systematic review (Xiao et al, J Dermatolog Treat 2014; PMID 25102894, DOI 10.3109/09546634.2014.952610); oral-minipulse vs methotrexate unstable-vitiligo RCT (Singh et al, Dermatology 2015; PMID 26278124, DOI 10.1159/000433424); melanocyte–keratinocyte transplant outcomes (Ramos et al, An Bras Dermatol 2017; PMID 29186240, DOI 10.1590/abd1806-4841.20175700) + 6-yr relapse-factor follow-up (Altalhab et al, JEADV 2019; PMID 30793805, DOI 10.1111/jdv.15411) [PMID:34160061](https://pubmed.ncbi.nlm.nih.gov/34160061/)
- Cited evidence (PMID 36260792) [PMID:36260792](https://pubmed.ncbi.nlm.nih.gov/36260792/)
- Cited evidence (PMID 40156697) [PMID:40156697](https://pubmed.ncbi.nlm.nih.gov/40156697/)
- Cited evidence (PMID 39078582) [PMID:39078582](https://pubmed.ncbi.nlm.nih.gov/39078582/)
- Cited evidence (PMID 30030843) [PMID:30030843](https://pubmed.ncbi.nlm.nih.gov/30030843/)

Last reconciled with current guidelines: 2026-05-22.

References

British Association of Dermatologists guidelines for the management of people with vitiligo 2021 (Eleftheriadou et al, Br J Dermatol; PMID 34160061, DOI 10.1111/bjd.20596 — subtype/activity assessment, NB-UVB + topical CNI/corticosteroid first-line, 308-nm excimer for localised, oral mini-pulse to arrest active disease, surgery for documented-stable disease, monobenzone depigmentation for extensive recalcitrant universal disease, autoimmune-comorbidity + psychological screening, against chronic continuous systemic steroids) anchored by pivotal evidence: TRuE-V1/TRuE-V2 phase-3 topical ruxolitinib cream (Rosmarin et al, NEJM 2022; PMID 36260792, DOI 10.1056/NEJMoa2118828 — FDA-approved repigmentation) + pooled subgroup @52 wk (PMID 40156697, DOI 10.1007/s13555-025-01381-7) + F-/T-VASI psychometrics (PMID 39078582, DOI 10.1007/s13555-024-01223-y); INFO/VGICG repigmentation-outcome consensus (Eleftheriadou et al, Br J Dermatol 2018; PMID 30030843, DOI 10.1111/bjd.17013); UK lifetime-risk + psychosocial/ethnicity impact (Eleftheriadou et al, Br J Dermatol 2024; PMID 39018020, DOI 10.1093/bjd/ljae282); NB-UVB systematic review (Xiao et al, J Dermatolog Treat 2014; PMID 25102894, DOI 10.3109/09546634.2014.952610); oral-minipulse vs methotrexate unstable-vitiligo RCT (Singh et al, Dermatology 2015; PMID 26278124, DOI 10.1159/000433424); melanocyte–keratinocyte transplant outcomes (Ramos et al, An Bras Dermatol 2017; PMID 29186240, DOI 10.1590/abd1806-4841.20175700) + 6-yr relapse-factor follow-up (Altalhab et al, JEADV 2019; PMID 30793805, DOI 10.1111/jdv.15411) — PMID:34160061
Cited evidence (PMID 36260792) — PMID:36260792
Cited evidence (PMID 40156697) — PMID:40156697
Cited evidence (PMID 39078582) — PMID:39078582
Cited evidence (PMID 30030843) — PMID:30030843