Segmental vs Nonsegmental Vitiligo: Clinical Patterns, Prognosis, and Treatment Pathways

Key Takeaways

Segmental vitiligo (SV): early onset, unilateral/dermatomal streaks, rapid stabilization (months), poor response to light on acral—but excellent surgical candidacy once stable.
Nonsegmental vitiligo (NSV): bilateral/symmetric, waxing/waning activity; best global therapy is NB-UVB 311 nm ± tacrolimus; excimer 308 nm for rims.
Stability matters: two-visit confirmation (3–6 months apart) with photo + Wood’s lamp guides surgical timing in SV and maintenance planning in NSV.

SV: unilateral patch or streak respecting midline; often dermatomal/Blaschkoid hints; early hair involvement (leukotrichia) possible.
NSV: symmetric lesions (face/hands/axillae/periorificial); generalized or acrofacial patterns; frequent border activity episodes.
Map baseline with Wood’s lamp & dermoscopy to capture confetti and islands.

SV: short “active window” (weeks–months) → plateau; limited spread after stabilization.
NSV: chronic relapsing course; site-dependent response (face/neck > trunk/limbs > acral).
Koebnerization (friction/pressure) is chiefly an NSV driver; counsel on gear/shoes and skin care.

SV: better long-term localization; hair whitening predicts slower cutaneous fill-in.
NSV: relapse risk peaks within 6–12 months after stopping therapy—see Relapse & Maintenance.

Table 1. First-line choices by subtype.

Subtype	First-line	Add-ons	Notes
SV (early/active)	Topicals (tacrolimus face/folds; short steroid pulses off-face)	Excimer 308 nm to borders	Goal: calm rim; prepare for stability check
SV (stable)	Surgery (SBEG, punch/minigraft, FUE for leukotrichia)	Post-op NB-UVB/excimer	Color match best with SBEG on face
NSV (generalized)	NB-UVB 311 nm 2–3×/wk	Tacrolimus 0.1% face/folds; steroid pulses off-face	Expect facial islands 4–8 wks
NSV (focal/rims)	Excimer 308 nm	Tacrolimus between light days	Periorificial/hairy sites respond faster

SV: prime candidate after documented stability (no new/enlarging macules; quiet rim on Wood’s lamp) across ≥2 visits 3–6 months apart.
NSV: consider for small refractory plaques after adequate light/topical trials and stability confirmation.
Technique selection and pearls: see Surgical Options Beyond MKTP.

VIDA: activity score (recent spread/Koebner/confetti) helps decide surgery timing and maintenance need.
F-/T-VASI: quantify extent for baseline and milestones; pair with standardized photo protocol.

Table 2. SV vs NSV at a glance.

Feature	SV	NSV
Distribution	Unilateral, dermatomal/Blaschkoid-like	Bilateral/symmetric
Onset	Often early	Any age
Course	Rapid stabilization	Relapsing/remitting
Light response	Variable; limited on acral	Good (face/neck best)
Surgery role	Major after stability	Select cases if stable
Maintenance need	Lower after graft success	Higher; TRM-driven relapse risk