Key Takeaways
- Segmental vitiligo (SV): unilateral/dermatomal clusters, rapid early spread then stability, frequent leukotrichia, limited systemic autoimmunity, best long-term results with surgery once stable.
- Nonsegmental vitiligo (NSV): bilateral/symmetric distribution, waxing-waning activity, higher autoimmune comorbidity, mainstay is phototherapy + topicals with maintenance to reduce relapse.
- Decide therapy by pattern + stability (e.g., VIDA score) rather than BSA alone; tailor expectations for acral vs facial sites.
Definitions & Phenotypes
- Segmental vitiligo (SV): unilateral or localized pattern often following dermatomal/Blaschkoid lines; early rapid expansion then long stability; frequent leukotrichia.
- Nonsegmental vitiligo (NSV): generalized/bilateral symmetry (acral, facial periorificial, genital, bony prominences); activity fluctuates with relapses.
- Mixed forms can occur (SV with later NSV elsewhere); manage each component per its biology.
Clinical Features: SV vs NSV
| Feature | Segmental (SV) | Nonsegmental (NSV) |
|---|---|---|
| Age at onset | Earlier (often childhood/adolescence) | Any age; peaks in 2nd–4th decades |
| Distribution | Unilateral; dermatomal/patchy cluster | Bilateral/symmetric; acral & facial common |
| Course | Rapid initial spread → stability | Intermittent activity/relapse |
| Hair | Leukotrichia common & persistent | Leukotrichia variably present |
| Koebnerization | Less prominent | Frequent at friction sites |
| Autoimmunity | Low association | Higher (thyroid, etc.) |
| Therapy response | Limited to light/topicals; surgery excels when stable | NB-UVB ± topicals = backbone; JAK topical for face |
Workup & Stability
- Wood’s lamp mapping to define extent; dermoscopy for islands and rim activity.
- Stability: clinical inactivity (no new/enlarging macules) for ≥6–12 months; use VIDA score and photo comparison.
- Comorbidity screen (NSV): targeted thyroid review; see Comorbidities & Labs.
Therapy Algorithms
| Scenario | First-line | Adjuncts/Notes |
|---|---|---|
| SV, early active | Topicals (tacrolimus 0.1% face/neck; steroids short courses off-face) | Targeted excimer 308 nm for edges |
| SV, stable ≥12 mo | Surgery for focal areas | Best for leukotrichia-positive, stable borders |
| NSV, facial | NB-UVB 311 nm + tacrolimus 0.1% | Consider topical JAK within label limits |
| NSV, acral | NB-UVB | Add excimer; counsel on slower kinetics |
| Maintenance (NSV) | Intermittent tacrolimus on high-risk sites | NB-UVB taper; relapse plan (see Relapse & Maintenance) |
When to Consider Surgery
- SV or focal NSV stable ≥6–12 months, no new lesions, borders quiet on Wood’s lamp.
- Options: suction blister, mini/punch grafting, FUE-grafting, MKTP.
- Best outcomes on face/neck; acral sites require careful selection and counseling.
Prognosis & Maintenance
- SV: durable stability after early phase; surgery offers highest fill-in where feasible.
- NSV: relapse reflects TRM/IFN-γ axis; plan maintenance topicals and periodic light boosts for recently repigmented facial zones.
Comparison Tables
| Site | SV | NSV | Notes |
|---|---|---|---|
| Face/neck | High post-surgery | High with NB-UVB + tacrolimus | Fastest islands |
| Trunk/limbs | Moderate | Moderate | Needs sustained therapy |
| Acral | Variable | Low–moderate | Excimer add-on; manage expectations |