Scoring Systems in Vitiligo—A Narrative Review

Abstract

Vitiligo is an acquired autoimmune disorder with a worldwide prevalence of 0.5–1%. It is characterized by depigmented macules caused by the absence of melanocytes in the epidermis. The aim of the treatment for vitiligo is disease stabilization and repigmentation. Hence, different scores have been developed to assess disease severity and repigmentation in order to infer the therapeutic efficacy of the chosen treatment. Vitiligo is associated with social stigma and has an immense effect on the patients’ quality of life. Hence, scores have been developed to assess the impact of the disease. A comprehensive literature search was conducted using keywords such as “vitiligo,” “scoring system,” “activity,” “extent,” “area,” “repigmentation,” “quality of life,” “vitiligo disease burden,” and “impact,” individually or in combination. Databases searched included PubMed, Embase, the Cochrane Library, and ScienceDirect. Articles published up to May 2025 were considered for inclusion. These scores are essential for evaluating vitiligo in medical research and clinical practice. These are needed for assessment, treatment evaluation, and monitoring disease progression. This review article summarizes the scoring systems used in day-to-day practice and research trials. Eleven scores assess the extent of disease and/or repigmentation, while nine monitor disease activity. Seven scores evaluate the impact on patients’ or their families’ quality of life. Additional research is needed to assess the validity, reliability, and responsiveness of each score.

Introduction

Vitiligo is an acquired depigmenting disorder due to the loss of epidermal melanocytes.[1] The disease can be cosmetically and psychologically devastating to the patient; any flares and remissions should be appropriately accounted for. Assessment of the progression of the disease and repigmentation in lesions helps in the evaluation of treatment efficacy. To date, several scoring methods have been formulated for the above-mentioned purpose. We intend to summarize the vitiligo-specific scoring systems used to analyze the disease characteristics. The search strategy included the following keywords: “vitiligo,” “scoring system,” “activity,” “extent,” “area,” “repigmentation,” “quality of life,”“vitiligo disease burden,” “impact,”either individually or in combination. The databases searched included PubMed, Embase, the Cochrane Library, and Science Direct. The scoring systems can be divided into three categories depending upon the most dominant factor included in the scoring system [Table 1]. Most of these scores are clinician-reported outcome measures. However, the Self-Assessed Vitiligo Area Scoring Index (SAVASI), Self-Assessment Vitiligo Extent Score (SA-VES), Vitiligo Noticeability Score (VNS), Vitiligo Disease Activity score (VIDA), and Clinical Evolution Vitiligo score (CV-6) are patient-reported outcome measures. Measurement properties of these scores were also assessed.[1,2,3,4]

Table 1.

Various vitiligo scoring systems

Extent and/or repigmentation	Activity	Quality of life or impact	Composite score
Vitiligo Area Scoring Index (VASI)	Vitiligo Disease Activity score (VIDA)	Vitiligo Impact Scale (VIS)	Vitiligo European Task Force (VETF)
Self-Assessed Vitiligo Area Scoring Index (SAVASI)	Vitiligo Signs of Activity Score (VSAS)	Vitiligo Life Quality Index (VLQI)
Facial Vitiligo Area Scoring Index (F-VASI)	Confetti-like depigmentation score (c-VSAS)	Vitiligo Impact Scale-22 (VIS-22)
Vitiligo Extent Score (VES)	Koebner Score (k-VSAS)	Vitiligo-specific Quality-of-Life instrument (VitQoL)
Self-Assessment Vitiligo Extent Score (SA-VES)	Hypochromic areas score (h-VSAS)	The Vitiligo Impact Patient Scale (VIPS)
Vitiligo Extent Score plus (VES plus)	Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS)	Family Vitiligo Impact Scale (F-VIS)
Vitiligo Extent Score for a Target Area (VESTA)	Clinical Evolution Vitiligo score (CV-6)	Vitiligo Burden of Disease (VitBOD)
Physician Global Assessment (PGA)	Koebner’s Phenomenon in Vitiligo Score (K-VSCOR)
Vitiligo Extent Tensity Index (VETI)
Potential Repigmentation Index (PRI)
Vitiligo Noticeability Score (VNS)

Scores for Assessment of Extent and/or Repigmentation of Vitiligo

Vitiligo Area Scoring Index (VASI)

Hamzavi et al.[5] developed the VASI to assess vitiligo severity based on two parameters: the degree of depigmentation and the extent of body surface involvement. The affected body regions—hands, upper extremities, trunk, lower extremities, feet, face, and neck—are assessed using the hand-unit method, where one patient’s palm (including fingers) equals 1% of total body surface area (BSA). Depigmentation is scored as 10%, 25%, 50%, 75%, 90%, or 100%. The categories correspond, respectively, to the presence of only small depigmented spots, predominance of pigmented skin over depigmented areas, equal proportions of pigmented and depigmented skin, predominance of depigmented skin, minimal residual pigment, and complete absence of pigmentation. The final score is calculated by multiplying the extent of depigmentation by the area involved and summing across regions:

VASI = Σ [Hand Units × Residual Depigmentation]

The total possible score is 100.[5] Because it provides an overall disease score, it is also known as total VASI (T-VASI). A ≥50% improvement from baseline within six months is considered a successful therapeutic response.[6] Recently, a standardized scale has been proposed to categorize therapeutic improvement based on VASI change. Treatment response was evaluated by comparing baseline and follow-up VASI scores, with improvement graded as very marked (>50-point increase), marked (25–50), moderate (10–25), or minimal (<10).

Worsening was similarly classified based on VASI reduction as very severe (>50-point decrease), severe (25–50), moderate (10–25), or minimal (<10).[7] VASI remains the most widely cited and utilized instrument for vitiligo assessment in both clinical and research settings.

Self-Assessed Vitiligo Area Scoring Index (SAVASI)

SAVASI, introduced in 2015, is a patient-centered adaptation of VASI that enables self-evaluation of disease extent.[4] Patients visually mark affected areas on a body diagram and estimate involvement using their hand as the reference unit (1 hand = 1% BSA). Depigmentation is scored as 0%, 10%, 25%, 50%, 75%, 90%, or 100%, with reference to a descriptive atlas. In hard-to-see regions, patients may use mirrors or assistance. SAVASI is computed with a possible range from0 to 100.[8]

SAVASI = Σ [Hand Units × Extent of Depigmentation]

Facial Vitiligo Area Scoring Index (F-VASI)

Bae et al.(2022)[9] introduced the F-VASI, which applies the fingertip unit (FTU) concept used in topical therapy quantification. Facial lesions are often small and irregular, making the hand unit method less precise. One FTU, corresponding to the area between two phalangeal joints of digits 2–4, represents 1/9^th of their combined palmar area. This corresponds to approximately 0.9% of the facial surface area (FSA) and 0.03% of the overall BSA. Thus, one finger equals approximately three FTUs (2.7% FSA), and 32 FTUs correspond to one palm.[9] F-VASI is calculated as:

F-VASI = Σ [FTU × Residual Depigmentation]

F-VASI ranges from 0 to 112 FTUs. F-VASI shows higher consistency when used repeatedly on the same patient, though variability in finger size limits interindividual comparison. An improvement of at least 75% compared with baseline values in F-VASI represents a clinically meaningful response in nonsegmental vitiligo.[9]

While VASI-based indices are widely applied, inter-rater variability and the semiquantitative nature of the scales can hinder cross-study comparisons. However, studies have shown good intra-rater and moderate inter-rater reliability for VASI and F-VASI, particularly with modified 10% depigmentation increments. Ezzedine et al. found that improvements of at least 30% in total VASI (T-VASI) and 50% in F-VASI are considered to represent clinically meaningful changes from the patient’s perspective.[10] Therefore, higher thresholds (>50%) improvement in T-VASI may be more appropriate for identifying clinically meaningful treatment responses in clinical trials. Overall, these indices demonstrate strong reliability, validity, and sensitivity to change, supporting their continued use as standardized outcome measures in clinical trials evaluating nonsegmental vitiligo therapies.[11]

Vitiligo Extent Score (VES)

Developed by Van Geel et al.[12] during the Vitiligo European Task Force (VETF)/Global Vitiligo Consensus Conference (2016), the VES is an objective tool to quantify disease extent. It includes 19 body regions illustrated through pictograms showing increasing levels of depigmentation, with 13 sub-options for precision. Patients select images representing their lesions, and scores are summed using a conversion table. Depigmentation grades range from 0 to 6 (0%, 1%, 5%, 10%, 25%, 50%, 75%, respectively).[12,13] VES can be divided into clinical categories, grades 0–6. VES demonstrates excellent inter-rater reliability and strong correlation with VASI in Thai populations with skin type IV, proving reliable even for segmental vitiligo.[14] However, VES values tend to be lower than VASI due to BSA overestimation in hand-unit calculations.[15] One study gave suggestions to modify the VES score in children.[11] The feasibility and validity of calculating VASI, F-VASI and VES using standardised clinical photography in store to forward mode was also tried in one study.[16] VES had slightly higher global treatment response reliability. Minimal important change for VES was 0.5% in one study, which means patients are able to notice small change in BSA involvement as improvement but the study was limited by small sample size and limited ethnicity.[17]

Self-Assessment Vitiligo Extent Score (SA-VES)

The SA-VES, developed by the International Vitiligo Score Working Group in 2017, enables patient self-assessment through a seven-point pictorial scale covering 12 body regions.[18] Like VES, total scores are derived using conversion tables. Validated primarily in the Thai population, SA-VES showed strong correlations with both VES and VASI, and 95% of users found it easy to use.[14] The MIC was reported as 0.2%, suggesting high patient sensitivity to minor improvements, although further cross-ethnic validation is required.[17]

Vitiligo Extent Score Plus (VES Plus)

Introduced in 2018, VES Plus incorporates perifollicular pigmentation assessment—a key marker of repigmentation—into the original VES.[19] Using pictograms depicting varying perifollicular pigmentation, it enhances evaluation of treatment outcomes, especially after narrowband ultraviolet B (NB-UVB) therapy. Scores for VES, VES Plus, and SA-VES can be computed via the vitiligo calculator (iOS/web: www.vitiligo-calculator.com). Both VES and VES Plus show good-to-excellent inter- and intra-rater reliability, though perifollicular pigmentation was absent in two-thirds of cases in one study.[19] VES Plus demonstrated a strong positive correlation with VASI (ICC = 0.96) and comparable reliability in phototypes III–IV before and after NB-UVB treatment.[20] Despite being user-friendly and less time-consuming, further research is needed to validate VES Plus in skin types IV–VI and to compare it with VASI and VETF in patients exhibiting perifollicular pigmentation. Additionally, it does not account for diffuse and marginal pigmentation.

Vitiligo Extent Score for a Target Area (VESTA)

Introduced in 2019, VESTA is a clinician-reported, lesion-specific tool focusing on local repigmentation rather than whole-body evaluation.[21] It dynamically measures repigmentation over time, emphasizing marginal and perifollicular patterns. The score is calculated using reference images (0–99% for marginal and 0–100% for perifollicular repigmentation) and a formula that sums the fully repigmented and perifollicular areas to derive the total repigmentation rate.[21] Although it does not assess disease worsening, it has been used as an outcome measure for target lesions.[22]

Physician Global Assessment (PGA)

PGA, or Investigator Global Assessment, provides a subjective, overall assessment of vitiligo disease severity and therapeutic response. In 2019, an adapted PGA system categorized disease into five grades—from “no involvement” to “very extensive”—and was validated during an international expert symposium.[23] PGA can complement objective measures like VES, but it lacks defined cut-offs for disease severity. A newer version based on SA-VES has also been proposed, though it is based on limited expert consensus.[24]

Vitiligo Extent Tensity Index (VETI) score

Developed in 2014, the VETI parallels the Psoriasis Area and Severity Indec (PASI) used in psoriasis by combining disease extent and tensity.[25] Disease extent is estimated at five sites, i.e., the head, upper limb, lower limb, trunk, and genitals, using the “Rule of Nines” as applied in burn assessments, while disease tensity is assessed and scored in five stages, with normal skin being staged as 0 and hypopigmentation being stage 1. Stages 2 to 5 represent complete depigmentation, which is further segregated based on the color of hair and perifollicular pigmentation. An area where hair does not exist is typically placed in grade 5 owing to treatment refractoriness. After calculating both, a coefficient is applied as per the body region affected, following which scores for these five regions are summed together, giving a final score rangingfrom 0 to 55.5.[26] Despite its objectivity, VETI’s limited testing across populations and skin types restricts its generalizability. A higher score indicates more severe disease.

Potential Repigmentation Index (PRI)

Benzekri et al. (2013)[27] proposed the PRI to predict repigmentation potential based on lesion characteristics. Lesions >10 cm² are assessed under natural and Wood’s light, and are classified as A (hypopigmented with terminal hair), B (depigmented with terminal hair), C (depigmented with vellus hair), or D (depigmented without hair). PRI = (A + B)/(C + D). It helps guide therapy by identifying responsive versus refractory lesions, though validation remains limited.

Vitiligo Noticeability Score (VNS)

Formulated by Batchelor et al. (2015, validated 2016),[28] VNS is a patient-reported tool assessing posttreatment vitiligo visibility. Patients rate improvement from “no change” to “no longer noticeable.” Scores 4–5 denote successful, 3 partial, and 1–2 unsuccessful treatment response.[29] Although simple and reflective of patient perception, results may vary due to subjective expectations and have primarily been validated in lighter skin types, limiting their wider applicability.

Advantages and disadvantages of the above-mentioned scores are shown in Table 2.

Table 2.

Advantages and disadvantages of vitiligo scoring systems (extent and repigmentation)

	VASI	SAVASI	F-VASI	VES	SA-VES	VES Plus	VESTA	VETI	PRI	VNS	VETF
CROM/PROM	CROM	PROM	CROM	CROM	PROM	CROM	CROM	CROM	CROM	PROM	PROM
Clinical utility	All age groups;	Tested only in>18 years of age;	All age groups;	Modification is required in pediatric population;	More than 6 years, modification is required in the pediatric population;	All age groups,	All age groups;	More studies are needed to comment on this	All age groups;	All age groups;	All age groups;
	NSV and SV types	NSV and SV types	NSV and SV types	NSV	NSV	modification is required in the pediatric population; NSV	NSV		NSV	NSV, SV	NSV
Extent/repigmentation	Extent/repigmentation	Extent/repigmentation	Extent/repigmentation	Extent/repigmentation	Extent/repigmentation	Extent/repigmentation	Repigmentation	Extent	Repigmentation	Repigmentation	Extent, repigmentation, activity
Validity	High evidence of convergent and construct validity	Low evidence of convergent and construct validity	Low evidence of validity studies	Done in a development study in the Thai population. High evidence of convergent and construct validity	Validated only in Thai and Egyptian populations; needs studies in skin type 6. High evidence of convergent and construct validity	Done in a development study. High evidence of convergent and construct validity	Not available- convergent and construct validity	Studies are needed	Studies are needed	Moderate evidence of discriminative construct validity	Studies are needed
Responsiveness	High evidence	Not applicable	Very low evidence	Moderate evidence	Not applicable	High evidence	Studies are needed	Studies are needed	Studies are needed	Not applicable	Moderate evidence of VETF extent
Reliability	High evidence of inter-rater and moderate evidence of intra-rater reliability	Moderate evidence of intra-rater reliability	Moderate evidence of inter-rater and high evidence of intra-rater reliability	High evidence of inter- and intra-rater reliability	Moderate evidence of intra-rater reliability	High evidence of inter- and intra-rater reliability	Moderate evidence for intra-rater and inter-rater reliability	More inter-rater differences	Studies are needed	Moderate evidence for intra-rater reliability	Moderate evidence for intra- and inter-rater reliability (VETF extent); high evidence for inter-rater reliability (VETF staging)
Clinical trial use	Widely used	Useful in epidemiological studies	Commonly used	More studies are needed	Useful in epidemiological studies. More studies are needed	More studies are needed	The score can be used but less precise than digital image analysis system and not applicable in retrospective studies if images not taken	Itcan be used	Itcan be used to select patients for different pigment potentials	Itcan be used	Itcan be used
Clinical practice use	Time-consuming, challenging to use	Clinical practice use is limited	Time-consuming, difficult to use	Easy to use	Easy to use	Easy to use	Can be used	Time-consuming and a bit tedious	Easy to use	Can be used	Cumbersome
Strengths	Does consider follicular repigmentation	Can improve patients’ disease insight and treatment adherence	Very handy to evaluate scattered, smaller vitiligo lesions, especially over complex regions like the mouth, ear, nose, genitals, etc., with great precision	Shorter average time for calculation, making it a user-friendly and easy-to-use score	Single scale for all, overcoming any language barrier	Shorter average time for calculation, making it a user-friendly and easy-to-use score	Clear, simple, and user-friendly	Constant and reproducible number	Strong correlation between PRI and prediction of repigmentation	Response to treatment can be assessed by patient
	No need for expensive instruments		Usually correlates well with the patient’s psychosocial distress, as facial lesions are more stressful for a patient	Good sensitivity to detect even smaller, subtle clinical changes			Itcan be incorporated in retrospective studies with inadequate photographic documentation and incompatible photographs	Incorporates VASI, VETF and part of PRI		Specific focus on face
				Can be used in small areas, like the face			Consider marginal pigmentation also
Limitations	BSA overestimated—a patient’s palm represents~0.76% of BSA, not 1%.	Generalizability of score	Concept of FTU assumes that all 3, i.e., index, middle and ring fingers, are of the same size. However, in clinical practice variations exist	Does not account for follicular repigmentation.	Does not account for follicular repigmentation.	More studies are needed in skin types IV–VI	Does not account for diffuse pigmentation	Studies on its use are lacking	Does not give importance to cosmetically important areas	It is preferable to assess the score at the end of treatment once the residual hyperpigmentation has resolved since initial scores may be spuriously high	Assessment subjects to availability of Wood’s lamp
	Uniform scale—same scoring for all Fitzpatrick types, though higher types show greater psychological distress at similar VASI scores.	Difficult for patients to understand and calculate.	Not suitable for acromegaly, dwarfism, deformities, or amputations.	Palms, soles, genitals and the back of the scalp are not included	Does not show separate analysis of left and right arm, hand or feet, posterior area of neck, upper and lower part of face, leading toinaccurate estimation of any focal lesion in these areas.		Focus primarily on target repigmentation rather than disease in total		Not an index for extent/severity of disease	The score cannot be applied for anatomical sites other than high expression sites (face and hand)	Gives equal weightage to both cosmetically appealing and non-cosmetic body regions
	Poor psychosocial correlation—equal scores for cosmetically important (face, neck) and covered areas	Semi-objective score	Cumbersome for extensive vitiligo lesions	Validated mostly in skin types 2–3; applicability to others uncertain.	Requires basic computer skills.		Cannot estimate individual lesion size		Requires Wood’s lamp
	Semi-objective score	Time-consuming	Difficult to compare the severity between individuals due to variations in finger size		Tendency for variation in extensive vitiligo		Does not tell about extent of the disease		Not useful for monitoring therapy results

BSA—Body surface area, CROM-Clinician-reported outcome measure, FTU—Fingertip unit, F-VASI—Facial Vitiligo Area Severity Index, NSV—Non-segmental vitiligo, PROM—Patient-reported outcome measure, SAVASI—Self-Assessed Vitiligo Area Severity Index, SA-VES—Self-Assessment Vitiligo Extent Scale, SV—Segmental vitiligo, VASI—Vitiligo Area Severity Index, VES—Vitiligo Extent Scale, VES plus—Vitiligo Extent Scale plus, PRI—Potential Repigmentation Index, VESTA—Vitiligo Extent Score for a Target Area, VETF—Vitiligo European Task Force, VETI—Vitiligo Extent Tensity Index , VNS—Vitiligo Noticeability Score

Vitiligo Scores for Disease Activity

Vitiligo Disease Activity score (VIDA)

The VIDA score, developed by Njoo et al.[30] in 1999, evaluates disease activity based on patient recall. Patients report the most recent occurrence of disease activity, including new lesions or expansion of existing ones. It is graded on a six-point scale: −1 (stable for at least 12 months with repigmentation), 0 (stable for at least 12 months), +1, +2, +3 (active in the last 12, 6, 3 months, respectively), and + 4 (active in the last 6 weeks). Higher scores indicate greater activity. Though widely used in clinical trials, it is subjective, prone to recall bias, and has limited sensitivity to subclinical changes and anatomical site variability.

Vitiligo Signs of Activity Score (VSAS)

Developed and validated by Van Geel et al.[31] in 2020, VSAS is a clinician-reported, examination-based score that assesses visible signs of activity. It evaluates three signs—(i) confetti-like depigmentation (c-VSAS), (ii) Koebner phenomenon (k-VSAS), and (iii) hypochromic borders (h-VSAS)—across 15 predefined anatomic regions (anterior/posterior head and neck, upper limbs, trunk, lower limbs, hands, feet, inguinal, and gluteal areas). Each site is scored as 0 (absent) or 1 (present), generating a total score (0–15) or sub-scores (c-VSAS, k-VSAS, h-VSAS). It is applicable to both segmental and nonsegmental vitiligo and is useful in detecting early or subclinical activity. However, it is time-consuming, requires expertise, and lacks large-scale validation. Correlation with VIDA is significant for total, h-VSAS, and k-VSAS sub-scores but not for c-VSAS, supporting the need for combined examination-based tools.[20]

Vitiligo Disease Activity Score (VDAS) and Vitiligo Disease Improvement Score (VDIS)

Van Geel et al.[32] developed VDAS and VDIS as dynamic tools, unlike the static VSAS. They assess improvement or worsening across 15 predefined regions, grading each from −4 (very much worsened) to +4 (completely improved), producing total scores of -60 to +60 (VDAS60 and VDIS60). These allow quantification of disease evolution over time and complement VSAS for both static assessment and dynamic assessment. Further validation is needed across different populations and skin types.

Clinical Evolution Vitiligo score (CV-6)

The CV-6, introduced by Peralta-Pedrero et al.[33] (2021), evaluates nonsegmental vitiligo progression through a six-question, patient-reported questionnaire that classifies patients into three groups: those who improve, those who remain unchanged, and those who deteriorate. Each question score ranges from 0 to 1, except for questions 3 and 4, which range from 0 to 2. This evolution is assessed using three parameters: cumulative damage (question 1) at present moment, progression (questions 2, 3, and 5), and regression (question 6) in the previous two months. Total score ranges from 0 (best clinical evolution) to 8 (worst clinical evolution). It is simple, quick, and suitable for clinical use, but is not sensitive to subclinical activity and lacks broad validation.

Koebner’s Phenomenon in Vitiligo Score (K-VSCOR)

Developed by Diallo et al.[34] in 2013, the K-VSCOR estimates the probability of vitiligo developing at trauma-prone sites. It incorporates seven independent variables: disease duration >3 years, involvement of the forehead/scalp, eyelids, wrists, genital/belt areas, knees, and tibial crests. Each factor is scored as 1 (present) or 0 (absent), and is weighted, giving a total score ranging from 0 to 56. It predicts koebnerization risk but requires clinical expertise and has limited validation and utility in patients without the Koebner phenomenon.

Table 3 highlights the advantages and disadvantages of these scores.

Table 3.

Advantages and disadvantages of vitiligo scoring systems (Activity scores)

	VIDA	VSAS	VDIS/VDAS	CV-6	K-VSCOR
CROM/PROM	PROM	CROM	CROM	PROM (Spanish [Original], English)	CROM
Clinical utility	All age groups;	All age groups	All age groups	Used in adult patients;	All age groups;
	all vitiligo types	all vitiligo types	Uses in SV are not specified	NSV	NSV
Validity	High evidence of convergent and construct validity	High evidence of convergent and construct validity	High evidence of convergent and construct validity	Studies are needed	Studies are needed
Responsiveness	High evidence	-	-	Low evidence	Studies are needed
Reliability	Intra rater and inter rater reliability is not applicable	Moderate evidence of inter-rater and intra-rater reliability	Moderate evidence of inter-rater and intra-rater reliability	Low evidence of intra-rater reliability	Studies are needed
Clinical trial use	Widely used	More studies are needed	More studies are needed	Can be used in epidemiological studies	More studies are needed
Clinical practice use	Easy to use, history based	More studies are needed, examination based	More studies are needed	Simple to use and yields a single score for all body parts.	More studies are needed
Strengths	Easy to understand and communicate for both patients and clinicians; hence can be incorporated into regular practice	Reproducible quantification of disease activity signs	VDIS—Activity (improvement)	Detects changes in the evolution of disease	Gives quantification of Koebner phenomenon in a time period
	Shows change with respect to treatment and hence useful to assess efficacy of therapeutic modality used.	It addresses signs of activity.	VDAS—Activity (worsening)	Indicate recent disease activity	It can guide therapeutic modality
			It measures activity and improvement in same site in the same patient as both can occur simultaneously	It includes persistence of pigmentation gain
Limitations	High chances of recall bias	Each body area has the same impact on the total score	There is a need for standardized (optimal) baseline images for comparison of two time points	Vitiligo usually has a slow evolution, thereby only subtle changes can be observed in subsequent follow-ups	Does not consider clinical markers of disease progression, such as confetti-like depigmentation or trichrome border.
	One scale for all Fitzpatrick skin types, does not give importance to cosmetically important areas	Provides only a static assessment of the disease.	More studies are needed on it and its subscores in different international setups, skin types IV–VI, translation into categories, and responsiveness	Does predict current activity but no comments on long-term prognosis
	Does not measure signs linked to disease activity	More studies are needed on it and its subscores in different international setups, skin types IV–VI, translation into categories, and responsiveness
	It gives no information on magnitude of change

CROM—Clinician-reported outcome measure, CV-6—Clinical Evolution Vitiligo score, K-VSCOR—Koebner’s phenomenon in vitiligo score, NSV—Non-segmental vitiligo, PROM—Patient-reported outcome measure, SV—Segmental vitiligo, VDAS/VDIS—Vitiligo Disease Activity Score and Vitiligo Disease Improvement Score, VIDA—Vitiligo Disease Activity score, VSAS—Vitiligo Signs of Activity Score

Vitiligo Scores for Impact on Quality of Life

Vitiligo Impact Scale (VIS)

Krishna et al.[35] developed the VIS in 2012 to assess the psychosocial impact of vitiligo. It is a 27-item questionnaire, with 19 items for all participants, five for married individuals, and one each for unmarried, working, and studying patients. Each item is scored from 0 (“not at all”) to 3 (“very much”), giving a total score of 0–81, with higher scores indicating greater impact. VIS outperforms Dermatology Life Quality Index (DLQI) and Skindex-16 in differentiating mild from moderate distress.[35,36,37] However, it is time-consuming, and patients with low health literacy or language barriers may find it challenging to complete.

Vitiligo Life Quality Index (VLQI)

Senol et al.[38] developed the VLQI in 2013, consisting of 25 items scored from 1 (“never”) to 4 (“all the time”), yielding a total score of 25- 100. It is assessed using six domains: emotional well-being, interpersonal relationships, anxiety levels, impact on work or academic activities, leisure participation, and symptoms. Higher scores reflect greater impairment of quality of life. VLQI requires broader validation across languages and cultural settings for consistency.

Vitiligo Impact Scale-22 (VIS-22)

Developed by Gupta et al.[39] in 2014, the VIS-22 represents a revised version of the original VIS questionnaire that reduces the number of marriage-specific items from five to one, resulting in 22 items and scores ranging from 0 to 66. Higher scores indicate greater impairment. A change of ≥5 points signifies a clinically meaningful change.[40] Band sets categorize scores as follows: no effect (0–5), mild (6–15), moderate (16–25), large (26–40), and very large effect (41–66). VIS-22 demonstrates responsiveness, but its length limits routine clinical use, and cross-cultural applicability remains to be explored.

Vitiligo-specific Quality of Life (VitQol) instrument

Lilly et al.[41] developed the VitQol in 2013, incorporating 15 vitiligo-specific items plus a sixteenth item on disease severity. Items are rated on a seven-point scale from 0 (“never”) to 6 (“all the time”), emphasizing stigma, participation limitation, and behavior. The total score ranges from 0 to 90, where higher values reflect greater impairment in quality of life. The Persian adaptation shortened the Likert scale to five points for clarity.[42] VitQoL is widely used and cross-culturally validated, though it still requires time to administer.

The Vitiligo Impact Patient Scale (VIPS)

Developed by Salzes et al. in 2016,[43]the VIPS assesses burden according to skin phototype. The scale consists of 29 items overall, including 19 universally applicable items, three designed for fair skin (FS), and seven tailored to dark skin (DS).VIPS-DS has 26 items, and VIPS-FS has 22 items, scored on a 0–5 Likert scale, with total scores ranging from 0–130 (higher = greater burden). A short form (SF), VIPS-SF, contains 12 items.[44] VIPS is time-consuming and requires cross-cultural validation.

Family Vitiligo Impact Scale (F-VIS)

The F-VIS developed by Agrawal et al.[45] in 2022, evaluates the psychosocial impact on adult family members. It consists of 16 items across 12 domains, scored 0–48, with a score greater than 13 indicating significant impact. Primarily validated in India, it needs translation and adaptation for international use.

Vitiligo Burden of Disease (VitBOD)

The VitBOD, developed by Sheth et al.[46] in 2015, measures disease burden across eight, 36-Item Short Form Survey (SF-36) domains. Ten items are rated on a 10-cm visual analog scale (0 = “never,” 10 = “always”), yielding a total score of 0–100 (higher scores indicate greater burden). It is only available in English, is time-consuming, and has limited use in clinical practice.

Advantages and disadvantages of these scores are shown in Table 4.

Table 4.

Advantages and disadvantages of vitiligo scoring systems (quality of lifeimpact scores)

	VIS	VLQI	VIS-22	VitQoL	VIPS	F-VIS	VitBOD
CROM/PROM	PROM	PROM	PROM	PROM	PROM	PROM	PROM
Clinical utility All age groups All vitiligo types	More than 16 years of age, both married and unmarried patients; all vitiligo types	15 years or more; all vitiligo types	15 years or more; all vitiligo types	15 years or more; all vitiligo types.	15 years or more; all vitiligo types	All age groups; all vitiligo types	Above 18 years of age; all vitiligo types
Validity	Moderate evidence of convergentconstruct validity	High evidence of convergentconstruct validity, and moderate evidence of discriminativevalidity	Moderate evidence of convergent and discriminative validity	High evidence of convergent, structural, and discriminative validity	High evidence of convergentconstruct validity	More studies are needed	More studies are needed
Responsiveness	Responsiveness was not investigated	-	Low evidence	More studies are needed	Responsiveness has not been assessed	Responsiveness has not been assessed	Responsiveness was not investigated
Reliability	Test–retest reliability is suboptimal	More studies are needed	Intra rater and inter rater reliability not applicable but have excellent test-retest reliability	Moderate evidence of intra-rater reliability	Low evidence	Low evidence	Test–retest reliability was not checked.
Clinical trial use	Has been used in a study conducted in Nepal	Has not been used in a clinical trial	Has been used in a clinical trial	Has been used in a clinical trial	Has been used in a clinical trial	A Chinese version of F-VIS has been validated.	Has not been used in aclinical trial.
Clinical practice use	Simple and easy to use Questionnaire is available in English and Hindi	Questionnaire is available only in English	Questionnaire is available in English, Hindi, Kannada, Chinese, Urdu, and Arabic language	Questionnaire is available in English, Polish, Persian, Brazilian, and Portuguese language	Questionnaire is available in French and other languages	Questionnaire is available in English, Hindi and Mandarin	Questionnaire is available in English
Strengths	Separate item for students, working, and unmarried people	Relationship with the extent of disease present	Dedicates an equal number of items to married and unmarried individuals; hence more precise.	Has proper relation to the diseaseseverity	Specific vitiligo burdentool according to skinphototype	Easy to understand and communicate for both patients and clinicians	Easy and speedy administration for less number of questions
Limitations	Cannot differentiate patients with moderate impact from patients with severe impact No grading of score More items for married people than unmarried, leading to an erroneously high score for married individuals	Only validated for patients with skin type II to IV	The score has been tested only in the population of India which has high social stigma attached with the disease.	Patients with minor psychological issues were not excluded	Elaborate questionnaire No grading available	Scale scores are higher for exposed sites owing to greater social stigma and tend to decrease with time owing to family disease acceptance	Does not take into accountthe financial impact of disease

CROM—Clinician-reported outcome measure, F-VIS—Family Vitiligo Impact Scale, NSV—Non-segmental vitiligo, PROM—Patient-reported outcome measure, SV—Segmental vitiligo, VIPS—Vitiligo Impact Patient Scale, VLQI—Vitiligo Life Quality Index, VIS—Vitiligo Impact Scale, VIS-22—Vitiligo Impact scale-22, VitBOD—Vitiligo Burden of Disease, VitQoL—Vitiligo-specific Quality-of-Life instrument

Composite Score

Vitiligo European Task Force (VETF)

The VETF, developed by Taieb and Picardo in 2007, is a clinician-reported score assessing vitiligo based on three parameters: disease extent, staging, and progression.[47] Body regions are divided into five areas using the “rule of nine,” similar to VASI. Staging involves assessing both skin and follicular pigmentation in the largest lesion within each anatomical region via Wood’s lamp, graded as 0 (normal/incomplete pigmentation), 1 (spotty/trichrome), 2 (complete depigmentation with <30% hair whitening), and 3 (>30% hair whitening). Progression is graded dynamically as -1 (regressive), 0 (stable), or +1 (progressive).[47,48] Examination involves natural light inspection, followed by Wood’s lamp comparison. VETF provides a detailed assessment across age groups and captures treatment-related changes, making it useful for evaluating therapeutic efficacy. However, it is time-consuming, requires a Wood’s lamp, and may be subject to inter-observer variability. In contrast, VASI is simpler, more consistent, and easier to apply in routine clinical practice.

Artificial Intelligence-based Vitiligo Tools

Artificial intelligence (AI)-driven tools have been integrated into vitiligo assessment, offering objective and consistent analysis compared to traditional subjective scoring systems. Some deep learning-based tools used in the diagnosis or classification of vitiligo are shown in Table 5.[49,50,51,52,53,54] These deep learning-based models, achieving over 90% accuracy, enhance diagnostic precision but remain limited by insufficient validation. Automated VASI scoring is also available, which uses AI and digital image analysis to objectively measure vitiligo severity from photos. A recent systematic review emphasized the need for further research and standardization.[55] As AI evolves, its integration into clinical practice may improve disease monitoring, treatment evaluation, and overall management of vitiligo.

Table 5.

Recently used artificial intelligence (AI) tools in vitiligo

	ML technique	ML technique	Dataset source	Use	Dataset size (number of images)
Kantoria et al., 2020[49]	KNN, SVM, CNN, LR	Deep learning	Public dataset	Classification	696
Zhang et al., 2021[50]	CNN	Deep learning	Public dataset	Diagnosis	2876
Guo et al., 2022[51]	CNN	Deep learning hybrid-based	Public dataset	Assessment	3982
Sharma et al.,[52] 2023	Naïve Bayes, CNN, RF, DT	Deep learning	Public dataset	Classification	1202
Zhong et al., 2024[53]	ResNet networks, SwinTransformer networks	Deep learning framework	Department of Dermatology at Xijing Hospital	Diagnosis	4320
Dixit and Sharma, 2024[54]	Naive Bayes, CNN, RF, DT	Deep learning	Public dataset	Prediction and categorizing	NA

CNN: Convolutional neural network, DT: Decision tree, KNN: k-nearest neighbors, LR: Logistic regression, NA – Not available, RF –Radiofrequency, SVM: Support vector machine, ML: Machine learning

Scores Evaluating the Stigma of Vitiligo

Patients with vitiligo also experience stigma, and several studies have used scoring systems to assess stigma in these patients. One study has used the participation scale (P-scale).[56] The P-scale, validated in India, Nepal, and Brazil, assesses participation in common social activities, a core aspect of social life affected by stigma. It is an 18-item, five-point scale, with scores categorizing participation restriction from none (≤12) to 13–90, representing restriction at different intensities: 13–32 as moderate, 33–52 as severe, and 53–90 as extreme restriction. The Patient Unique Stigmatization Holistic tool in Dermatology (PUSH-D) score is another comprehensive instrument designed to assess stigma experienced by dermatology patients. It evaluates emotional, social, and functional impacts of skin disease in a patient-centered manner.[57] Higher scores indicate greater perceived stigmatization and psychosocial burden. The Feelings of Stigmatization Questionnaire (FSQ), comprising 33 questions that examine stigma across multiple dimensions, has been used in one recent study.[58] One point to highlight is that none of these scales is disease-specific.

Limitations and Future Directions

Vitiligo scoring systems are widely used in clinical practice and trials to assess disease extent, activity, repigmentation, quality of life, and treatment response. Selecting a tool that is reliable and time-efficient remains challenging, as most rely on subjective clinical assessment, leading to inter- and intra-observer variability. Standardized training is often lacking, particularly in multicenter studies. Many tools inadequately consider anatomical site sensitivity, such as the face and neck, or skin phototype, which affects lesion visibility and patient-perceived burden. Facial and neck lesions should be weighted more heavily, and assessments should account for Fitzpatrick skin types (I–VI), as darker skin (IV–VI) often carries greater psychosocial impact than lighter tones (I–III).

Current activity measures, including the VIDA and signs like confetti-like depigmentation or Koebner phenomenon, depend heavily on patient recall and visual inspection, limiting sensitivity to subtle or early changes. Objective biomarkers are lacking, and definitions of “activity” vary, complicating comparisons. Future research should focus on validated composite scores integrating clinical signs, patient-reported outcomes, and imaging data. High-resolution techniques, such as dermoscopy, reflectance confocal microscopy, and AI-enhanced Wood’s lamp analysis, may detect subclinical activity.

Quality-of-life measures are mostly adult-focused and often lack cultural validation. Pediatric patients face unique psychological and social challenges that may be underrecognized, and parental assessments may not reflect the child’s distress. AI-based tools can provide objective, reproducible evaluation of disease extent, activity, and treatment response, enhancing lesion segmentation, quantifying repigmentation, and detecting subtle changes. Training AI on diverse datasets and validating across real-world populations are essential for improving accuracy and reducing bias.

Author’s contributions

The authors confirm that all authors have read and approved the manuscript for submission. All authors meet authorship criteria, and the manuscript represents honest work.

Data availability statement

No new data were generated or analyzed during the study, and therefore, data sharing is not applicable

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)

The preparation of this manuscript was carried out entirely by the authors without the use of artificial intelligence technologies.

Funding Statement

Nil.