The long road to valid outcomes in vitiligo

Comparative Analysis of the Most Used Versus the Recently Developed Vitiligo Activity and Extent Scores and Their Change with Treatment

INTRODUCTION

There are diverse assessment tools for vitiligo, with no standardized approach that helps unify treatment outcome measures. Thus, comparing different treatment modalities and developing evidence-based recommendations for vitiligo management has been quite challenging.

OBJECTIVES

We compared the most commonly used tools assessing both vitiligo activity and extent, namely, Vitiligo Disease Activity Score (VIDA) and Vitiligo Area and Severity Index (VASI) score to their newly developed counterparts, namely, Vitiligo Extent Score Plus (VES plus) and Vitiligo Signs of Activity score (VSAS), to provide insights that would help set recommendations for a unified outcome assessment protocol for vitiligo patients.

METHODS

Thirty-six active non-segmental vitiligo cases were recruited, 30 of whom completed 48 sessions of narrow band ultraviolet B (NB-UVB). Patients were assessed for both extent and activity both before and after treatment with NB-UVB. Scores were correlated. Additionally, VES plus was assessed for its reliability in comparison to VASI score.

RESULTS

Both extent (VASI and VES plus) and activity scores (VIDA and VSAS) showed significant improvement following treatment. Additionally, VES plus and VASI were positively correlating both before and after treatment as well as their percent change. Furthermore, VES plus proved as reliable as VASI. Regarding activity scores, total, hypochromic and Koebner VSAS only correlated with VIDA following treatment. Confetti VSAS neither correlated with VIDA before nor after treatment.

CONCLUSIONS

VES plus and VASI scores have proven of comparable reliability. While examination-based VSAS score comes as an additive tool to the history-based VIDA score.

Assessing the dynamic changes in vitiligo: reliability and validity of the Vitiligo Disease Activity Score ( VDAS ) and Vitiligo Disease Improvement Score ( VDIS )

Background

The assessment of the individual evolution of vitiligo is important for therapeutic decision making in daily practice. A fast, simple and validated physician‐reported score to assess clinical changes in depigmentation over time in separate parts (activity and improvement) is currently missing.

Objective

The main objective of the study was to develop and validate the Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS).

Methods

The Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS) were evaluated based on a photo set of 66 patients with two different time points. In the first (short) version, only the number of changing body regions was counted based on 15 predefined areas (VDAS₁₅ and VDIS₁₅), while in the second (extensive) version the degree of worsening or improvement from +4 to −4 for each body area was added for a more detailed assessment (VDAS₆₀ and VDIS₆₀). Content and construct validity were tested. In addition inter‐, intrarater reliability and feasibility were evaluated by 7 (test) and 5 (retest) physicians.

Results

Evidence for content and construct validity was provided. Overall, VDAS₁₅, VDIS₁₅, VDAS₆₀ and VDIS₆₀ demonstrated good to excellent inter‐rater reliability [intraclass correlation (ICC): VDAS: range = 0.797–0.900; VDIS: range = 0.726–0.798]. The intrarater reliability ICCs were 0.865 and 0.781 for the VDAS₁₅ and VDIS₁₅, respectively. Similar results were obtained for the VDAS₆₀ and VDIS₆₀ (ICC = 0.913 and 0.800, respectively). Completion time was short (median: 122 s/patient (first round); 95 s/patient (second round)].

Limitations

Single tertiary centre mainly of skin phototype 2 to 3.

Conclusion

The VDAS and VDIS appear to be valid, reliable and feasible instruments to score the evolution of vitiligo lesions. This accommodates the current urgent need for a simple, standardized and practical assessment of vitiligo activity and improvement over time.

Oral mini-pulse therapy in vitiligo: a systematic review

BACKGROUND

There is limited evidence supporting the use of alternative treatments for patients with nonstable vitiligo.

OBJECTIVE

This study aimed to review the effects of oral mini-pulse (OMP) therapy in the management of nonsegmental vitiligo.

METHODS

The following databases were searched between inception and May 2020 for relevant studies: Scopus, Web of Science, MEDLINE, and Embase. All randomized controlled trials that compared OMP therapy with any other active treatment or placebo for nonstable vitiligo were included. The Cochrane's risk of bias tool was used to evaluate the risk of bias (ROB) in selected studies, and the overall quality of evidence of each outcome was assessed using the Grading Recommendations, Assessment, Development, and Evaluations (GRADE) system.

RESULTS

Four studies met our selection criteria. All of them were conducted in India and included 246 patients. OMP therapy included betamethasone or dexamethasone. The duration of treatment was 6 months in all studies. Up to 32% of patients achieved a repigmentation rate of >75% when OMP therapy was administered as monotherapy. No difference was observed between OMP therapy and other treatments in arresting the disease, and weight gain was the most frequent adverse effect. The overall ROB in all included studies was relatively high because of the randomization process, outcome measurement and informed selection of outcomes.

CONCLUSION

Based on the findings of these studies, OMP therapy did not demonstrate additional value compared with other treatments. Hence, there is an urgent need to conduct high-quality clinical trials to evaluate this therapy.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.