Vitiligo Emergency: 3 Warning Signs to Know

In "Vitiligo Emergency: 3 Warning Signs to Know," the panel turns to the physical findings that separate stable disease from an emerging emergency.

Dr. Hamzavi distinguishes stable vitiligo, defined by the absence of new patches over serial photography, from active disease, which he calls a one-time clinical judgment rather than a multi-step process. He describes three physical findings that flag high-risk, unstable disease: confetti depigmentation, in which small one- to two-millimeter macules surround a larger patch; trichrome vitiligo, where normal, hypopigmented, and depigmented skin sit side by side and are accentuated under a Wood's lamp; and Koebnerization, a scratch mark that itself depigments. When all three appear together, he says, elevated CXCL9 and CXCL10 levels in the surrounding tissue often confirm active inflammation, and without systemic, phototherapy, or topical intervention, new lesions are highly likely, a scenario he frames as a vitiligo emergency.

Asked about scoring, Dr. Hamzavi, who helped develop the VASI score, admits he does not use it in daily practice because it was built for research. Instead he documents affected body regions, body-surface-area estimates, and specific high-impact sites such as the face and hands, and tracks follicular or marginal repigmentation as a sign of improvement. Dr. Desai similarly charts body-surface-area with mild, moderate, or severe modifiers and records prior therapies tried and failed. He criticizes payer-mandated step therapy that forces patients through topical steroids before newer options like topical ruxolitinib, calling it a disservice, and urges the managed-care community to understand that early, aggressive treatment such as topical JAK inhibitors, oral therapy, or phototherapy is meant to halt disease progression and repigment skin as quickly as possible, reducing burden on patients and the broader healthcare system rather than adding to it.

In "Multidisciplinary Care for Vitiligo: Beyond Dermatology," the discussion widens to the full care team needed to manage vitiligo's psychological and systemic burden.