Vitiligo has no numbered stage one to four. Dermatologists stage it by activity, spreading, stable or repigmenting, using the VIDA score, and classify it by pattern: focal, segmental or non-segmental. Those two readings decide almost everything about treatment, including whether surgery is possible.
This is the first thing a dermatologist decides, and it changes almost everything that follows. Segmental disease keeps to one side of the body and stops at the midline. Non-segmental appears in matched pairs — the same site on both sides.
Segmental disease usually becomes stable within a year and is the pattern that responds best to surgical repigmentation. Non-segmental is the immune-driven form, and controlling the immune attack comes before anything else.
Illustration, not a photograph.
Dr. (Lt Col) Khagendra Varada
Reg. No. 10461, Hyderabad State Medical Council
Full background →“I have been going pillar to post to get my son cured of his white spot on his left side of lip and chin. It appeared 8 years back. I was told it’s special type of nerve vitiligo which has no cure. After reporting to him he told us that it is SEGMENTAL VITILIGO and unlikely and difficult to be cleared by medications alone. He suggested for surgical melanocyte transplant… I was amazed after around one month that he started rapidly getting pigmentation. I wholeheartedly suggest please do not waste time like I did.”
“Dark spots are seen in one month… Even before perticular treatment for vitiligo, great”
These behave so differently that they are almost two conditions sharing one name.
Symmetrical, if it appears on one knee it tends to appear on the other. Comes and goes in waves over years, often starting on the hands, face, or around the eyes and mouth.
Confined to one side, often following a nerve territory, and usually starting in childhood or adolescence. It spreads quickly for six to twenty-four months, then typically stops for good.
Focal is where most vitiligo starts and it is not a third disease: it is the label for one or a few patches before the pattern has declared itself. Most focal vitiligo turns out to be early non-segmental disease; some turns out to be segmental; a little stays focal for years.
| Focal | Segmental | Non-segmental | |
|---|---|---|---|
| Where | One or a few patches, no pattern yet | One side of the body, often along a nerve territory, stopping at the midline | Both sides, in matched pairs: hands, face, elbows, knees |
| Who | Any age | Usually children and young adults | Any age; the commonest form, about nine in ten cases |
| Course | Watched; may stay put or evolve into either pattern | Spreads within its segment for six to twenty-four months, then usually stops for good | Comes and goes in waves over years |
| Progression | Cannot be predicted from the first patch; dated photographs decide it | Predictable: burns out and stabilises | Unpredictable; activity is re-judged at every review |
| Treatment | Topicals; excimer for a patch or two; re-classified as it declares | Responds poorly to light; the best candidate for grafting once stable | Immune control first, then narrowband UVB; surgery for stubborn stable sites |
A report that says ‘focal vitiligo’ is a provisional label, not a verdict. The useful question is whether the patch has moved since it was first photographed.
Because it stabilises reliably and rarely returns, segmental disease is where grafting gives its most durable results. It also responds poorly to phototherapy, so recognising it early saves patients months of light treatment that was never going to work.
Whether the disease is currently spreading is read from the margin of the patch, not from how large it is. An advancing edge fades; a settled one is drawn.
This is why the twelve-month wait before surgery is not caution for its own sake. Grafting into active disease means the same immune process destroys the transplanted cells.
Illustration, not a photograph.
There is no stage one to four. The staging that decides treatment is by activity, and the score dermatologists use for it is VIDA, the Vitiligo Disease Activity score: it asks only how recently the disease last moved.
| Stage | VIDA | What you see | What it means for treatment |
|---|---|---|---|
| First patch | — | One or a few patches; the pattern has not declared itself | Examined under the Wood’s lamp; baseline photographs; treated medically |
| Active, fast | +4 to +3 | A new patch or spread within the last six weeks to three months; blurred edges, confetti spots, patches along scratches | Stop the spread first; nothing is rebuilt while this continues |
| Active, slow | +2 to +1 | The last change was between three and twelve months ago | Medical control continues; the twelve-month clock has not run |
| Stable | 0 | No new patch and no spread for at least twelve months | Repigmentation with light; surgery becomes possible |
| Repigmenting | −1 | Stable, and colour returning on its own: islands of pigment around each hair | The best position to treat from; light and topicals consolidate it |
| Universal | any | Over four-fifths of the skin has lost pigment | Repigmentation is impractical; evening out the last colour is discussed instead |
VIDA is a clinical score, from the history and the examination. It is not a blood test, and it is not the same as how much skin is affected: a small patch can be active and a large one stable.
Every treatment decision hangs on this. Active disease must be quietened before anything is rebuilt; stable disease can be rebuilt, including surgically. Getting it wrong in either direction wastes months.
There is no blood test for stability. It is a clinical judgement made from the history, the appearance of the patch margins, and, most reliably, photographs taken at intervals and compared properly.
A Wood’s lamp is a handheld ultraviolet light. Under it, skin that has lost pigment fluoresces bright chalk-white with a sharp border, while normal skin stays dark — so patches that are invisible in ordinary light, and edges that look vague, both become obvious.
This is how the true extent of the disease is judged, and how a vague-looking border is confirmed as genuinely advancing. It is also the examination most often skipped.
Illustration, not a photograph.
| Sign | What it means | What it changes |
|---|---|---|
| New patches in 6 months | The disease is producing fresh lesions | Stop the spread before repigmenting |
| Blurred, ill-defined edges | The patch is expanding outward | Surgery deferred |
| Trichrome appearance | A pale zone between normal and white skin | Marker of ongoing activity |
| Koebner phenomenon | New patches where skin was cut or scratched | A strong argument against grafting now |
| Confetti-like macules | Small scattered spots around a patch | Suggests rapid progression |
| White hairs in the patch | Follicular pigment reserve is depleted | Medical repigmentation less likely to work |
None of these is decisive alone. A Wood’s lamp examination and dated photographs together are how the judgement is actually made.
Grafting into disease that is still active does two things, both bad: the transplanted cells are attacked like the original ones, and the donor site can develop its own patch.
Twelve months without a new patch, without expansion at any margin, and without koebnerisation is the accepted threshold. It is not an arbitrary wait. It is the interval that separates a graft that takes from a graft that fails.
What graft surgery involvesOne new patch in month ten resets the count. This is frustrating and it is also the honest answer.
Dated images at fixed distance and lighting are worth more than anyone’s recollection of what the patch looked like last year.
Vitiligo is staged by activity rather than by number. Active disease has produced a new patch or spread within the last twelve months; the VIDA score grades how recently, from +4 for the last six weeks down to +1 for the last year. Stable disease has not changed for twelve months, scored 0, and repigmenting disease is stable with colour returning on its own, scored −1. Surgery is only considered at 0 or −1.
Focal vitiligo is one or a few patches with no pattern yet; it is a provisional label. Segmental vitiligo keeps to one side of the body, often along a nerve territory, spreads within that segment for a year or two and then usually stops. A focal patch on one side may become segmental; a focal patch that later pairs up on the other side has declared itself non-segmental.
Sometimes, and it cannot be predicted from the first patch. That is why the first visit records it under the Wood’s lamp and photographs it at a fixed distance: the next set of photographs answers the question that the first cannot.
If no new patch has appeared and no existing patch has grown for twelve months, and cuts or scratches have not turned white, it is likely stable. It is confirmed clinically with a Wood’s lamp and by comparing dated photographs. Not by how it feels to you.
Non-segmental vitiligo on the face and trunk responds best to phototherapy. Segmental vitiligo responds poorly to light but does very well with surgery once it has burnt out.
Typically not. It spreads within its segment for six to twenty-four months and then usually stops permanently. That predictability is what makes it a good surgical candidate.
New vitiligo appearing exactly where the skin was injured: a cut, a scratch, a burn, a tight strap. It is a marker of active disease and an argument against operating until things settle.
Segmental disease does not usually become non-segmental. But a person can have both, and focal disease that has not declared itself may evolve into either, which is why the first classification is sometimes provisional.
The clinical statements on this page follow the guidance and evidence below. They are independent sources. None of them is connected to this clinic, and none of them sells the treatments described here.
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