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Letter
Assessment scale used in vitiligo
Delwar Hossain, DD
To the Editor: During the last 5 years, several researchers have published their papers on different treatments for vitiligo. They used varied assessment scales to categorize the outcomes of their studies (Table I). Studies show a fair agreement in grading poor and excellent responses (0%-25% and 76%-100%, respectively) and a disagreement in grading other responses (those falling in the range of 26%-50% and 51%-75%). For instance, Radakovic-Fijan et al1 labeled them as moderate and marked responses, respectively, while Grimes et al2 considered them as mild and moderate responses. And another group (Scherschun et al3) recognized both ranges collectively as poor response.
| Percent clearance and classification | |||||
|---|---|---|---|---|---|
| Treatment type | 0%-25% | 26%-50% | 51%-75% | 76%-100% | Authors |
| Medical | |||||
| Poor | Fair | Good | Excellent | Hann et al6 | |
| Poor | Moderate | Good | Excellent | Yalcin et al7 | |
| Slight | Moderate | Marked | Excellent | Radakovic-Fijan et al1 | |
| Minimal | Mild | Moderate | Excellent | Grimes et al2 | |
| Narrowband ultraviolet B radiation | |||||
| <25% Response | Between 26%-75% response | >75% response | Njoo et al8 | ||
| Poor response | Best response | Scherschun et al3 | |||
| Surgical | |||||
| Grade 1 | Grade 2 | Grade 3 | Spencer et al4 | ||
| <10% as no repigmentation | >10%-<95% as partial repigmentation | >95% as complete repigmentation | Kim et al5 |
Surgical studies leave the reader more puzzled. For example, Spencer et al4 graded 50% and 80% responses as considerable and excellent, respectively, while Kim et al5 labeled them as partial response only.
Moreover, almost all researchers had considered more than 75% response as equivalent to “complete response” behind the scenes. In fact, it may reflect a great achievement for the researchers/physicians, but it may not be significant to the same extent to patients with lesions over exposed anatomical sites who live with intense psycho-social suffering, and who usually desire to consider only 100% remission in all the treated lesions as a “complete cure.”
From the above mentioned facts, it can be concluded that existing assessment scales are not unambiguous. Instead, they are full of subjectivity, they do not reflect therapeutic outcomes accurately, and they do not reflect the patient's desire properly.
We know that vitiligo lesions usually show three patterns of response (diffuse yellowish tint, gradual reduction in size, and folliculo-centric re-pigmentation). And hence we should have a scale that reflects all these therapeutic responses accurately yet remains objective.
We have developed such an assessment scale (Table II). It has 5 grades: no response (-), mild response (+), moderate response (++), marked response (+++), and complete response (++++). It is more scientific, simple, unambiguous, and objective. It reflects treatment status more accurately and is more in line with a patient's acceptance. It is well fitted for scientific studies. We hope that this will eliminate the inherent drawbacks of the existing scale used in assessing the outcome of medical treatment of vitiligo. We also hope that this scale will get its due consideration and recognition.
| Parameter | - | + | ++ | +++ | ++++ |
|---|---|---|---|---|---|
| Change in color | No change | Yellowish tint | Slight contrast between lesion color and surrounding skin color | No contrast between lesion color and surrounding skin color | 100% remission in all treated lesions |
| Change in size | No change | Up to 5 mm reduction in diameter | Up to 10 mm reduction in diameter | More than 10 mm reduction in diameter | |
| Folliculocentric repigmentation | No repigmentation | Up to 5 mm perifollicular repigmentation | Up to 10 mm perifollicular repigmentation | More than 10 mm perifollicular repigmentation | |
| -, No response; +, mild response; ++, moderate response; +++, marked response; ++++, complete response. | |||||