Key Takeaways
- Segmental vitiligo (SV): early onset, unilateral/dermatomal distribution, rapid stabilization; best surgical candidate once stable.
- Nonsegmental vitiligo (NSV): bilateral/symmetric spread, relapsing course (TRM biology), responds to light + topical immunomodulators; needs proactive maintenance.
- Decision pivot: prove stability (VIDA=0, quiet rim on Wood’s lamp) before surgery; otherwise optimize medical/light therapy.
Phenotype & Natural History
| Feature | Segmental (SV) | Nonsegmental (NSV) |
|---|---|---|
| Distribution | Unilateral, dermatomal/semi-dermatomal | Bilateral, symmetric; periorificial/hands common |
| Onset/course | Early, rapid spread → stabilization in months | Chronic relapsing; waxing/waning borders |
| Leukotrichia | Frequent within plaque | Variable; predicts slower fill-in |
| Wood’s lamp rim | Often quiet when stable | Confetti/trichrome when active |
| Best responders | Surgery if stable (sheet/punch/FUE) | NB-UVB/excimer + topicals by zone |
Activity & Stability Assessment
- Document VIDA and F-/T-VASI every 8–12 weeks (see diagnosis & photo protocol).
- Active signs: confetti flecks, trichrome borders, Koebner streaks (NSV>SV).
- Stable SV: unchanged borders ×6–12 months, quiet rim on Wood’s lamp → consider surgery.
- NSV stability is relative; plan for maintenance even after fill-in.
Therapy Pathways
NSV (generalized or multifocal)
- Backbone: NB-UVB 311 nm 2–3×/wk; excimer 308 nm for rims and acral.
- Topicals by zone: tacrolimus 0.1% face/folds; off-face short steroid pulses → tacrolimus.
- Combination rules & spacing: see combination algorithms.
SV (localized, stable)
- Trial of light/topicals may help borders, but plateau is common.
- Proceed to surgery once stability proven (below).
When Surgery Fits
- SV (prime indication): excellent candidates after stability proof; options in surgery guide.
- NSV focal/stable plaques: consider if localized and refractory, with realistic expectations (acral < face).
- Adjunct light: NB-UVB/excimer post-take to spread islands.
Maintenance & Relapse Prevention
- NSV: taper NB-UVB to weekly → q2wk; continue tacrolimus 2–3 nights/week on relapse-prone sites; excimer mini-cycles for border sparkles (see TRM plan).
- SV post-surgery: short NB-UVB/excimer course after healing; then PRN boosters; protect from friction/trauma.