Stages of vitiligo

Vitiligo does not follow a fixed staged ladder like some diseases, but it does move through recognizable phases - and knowing which phase you are in changes what treatment aims to do.

Phase 1 - onset. One or a few small pale patches appear, sometimes after sunburn, skin injury or stress. At this point patches may still be actively losing pigment at their edges. Early treatment here gives the best chance of repigmentation - new patches respond far better than old ones.

Phase 2 - active/progressive. Existing patches enlarge and new ones appear over weeks to months. Signs of activity include ill-defined or inflamed patch borders and new spots at injury sites. The treatment goal in this phase is to stop the spread - usually with immune-calming medicines, sometimes short courses of oral steroids under supervision, plus phototherapy.

Phase 3 - stable. No new patches and no enlargement for at least six to twelve months. Now the goal shifts to repigmentation: phototherapy (narrowband UVB) and topical treatments work on dormant pigment-cell reservoirs, and stable patches - especially segmental ones - become candidates for surgical grafting.

Phase 4 - repigmentation (partial recovery). With treatment, colour returns in a characteristic pattern: small dark islands around hair follicles that slowly merge, and darkening from patch edges inward. Face and trunk repigment best; fingers, toes, lips and bony areas respond poorly.

Long-standing/extensive disease. Patches present for many years, or with white hair inside them, have lost their pigment-cell reservoirs and repigment poorly with medicine; camouflage, grafting (when stable) or, in very extensive cases, depigmentation of remaining skin become the honest options.

Ayurvedic view (interpretive): classical thought speaks of shwitra becoming harder to reverse the longer it is established - a parallel to the above within an interpretive framework of limited evidence.