Healthcare Disparities in Vitiligo: a Population-based Cohort Study in the UK
Conditions: Vitiligo
Sponsor: Momentum Data

1 
 
Healthcare disparities in vitiligo: UK 
population-based cohort study 
 
Author names:  Viktoria Eleftheriadou1, Alia Ahmed2,3, John Nesnas4, Ranjit Nagra4 
 
Author affiliations: 
1 Department of Dermatology, The Royal Wolverhampton NHS Trust, Wolverhampton, 
UK 
2 Frimley Health NHS Foundation Trust, Frimley, UK 
3 Barts Health NHS Trust, London, UK 
4 Pfizer Ltd, Walton Oaks, Walton on the Hill, Tadworth, Surrey, UK 
 
Date of the document: August 25, 2023 
 

2 
 
 
1. Contents 
1. 
Contents .................................................................................................................................................... 2 
2. 
List of abbreviations ............................................................................................................................. 4 
3. 
Introduction ............................................................................................................................................ 5 
3.1 
Background ..................................................................................................................................... 5 
3.2 
Purpose of Analysis...................................................................................................................... 6 
4. 
Study objectives and endpoints ....................................................................................................... 6 
4.1 
Study Objectives ............................................................................................................................ 6 
4.2 
Primary Objectives ....................................................................................................................... 6 
4.2.1 
Objective 1 .............................................................................................................................. 6 
4.3 
Secondary Objectives .................................................................................................................. 6 
4.3.1 
Objective 2 .............................................................................................................................. 6 
4.3.2 
Objective 3 .............................................................................................................................. 7 
4.3.3 
Objective 4 .............................................................................................................................. 7 
4.3.4 
Objective 5 .............................................................................................................................. 7 
4.4 
Primary Endpoints ....................................................................................................................... 7 
4.5 
Secondary Endpoints .................................................................................................................. 7 
5. 
General Study Design and Plan ........................................................................................................ 8 
5.1 
Study design ................................................................................................................................... 8 
5.2 
Total disease burden; cumulative lifetime risk ................................................................ 8 
5.3 
Disparities in the impact of vitiligo on mental health, healthcare utilisation and 
work impact ................................................................................................................................................ 9 
5.4 
Data Source and Read codes .................................................................................................... 9 
5.5 
Data Governance ........................................................................................................................... 9 
5.6 
Data Extraction .............................................................................................................................. 9 
5.7 
General Study Population .......................................................................................................... 9 
5.7.1 
Vitiligo Definition ................................................................................................................. 9 
5.7.2 
Sociodemographic subgroups ....................................................................................... 10 
6. 
Sample Size Calculations .................................................................................................................. 10 
7. 
Populations to be Analysed ............................................................................................................. 10 
7.1 
Inclusion Criteria ........................................................................................................................ 10 
7.2 
Exclusion Criteria ....................................................................................................................... 11 
7.3 
Matching Process ........................................................................................................................ 11 

3 
 
8. 
Statistical Analysis .............................................................................................................................. 12 
8.1 
Statistical Principles .................................................................................................................. 12 
8.2 
Primary Endpoint Analysis ..................................................................................................... 12 
8.3 
Secondary Endpoint Analysis ................................................................................................ 13 
8.4 
Sensitivity Analysis .................................................................................................................... 14 
8.5 
Missing Data ................................................................................................................................. 14 
9. 
Study Limitations ................................................................................................................................ 14 
10. Statistical Software ............................................................................................................................. 15 
11. Ethics ........................................................................................................................................................ 15 
12. Acknowledgments ............................................................................................................................... 16 
13. References .............................................................................................................................................. 17 
14. Appendices ............................................................................................................................................. 18 
 
 
 

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2. List of abbreviations 
 
Abbreviation 
Full Form 
ADEPT 
Anonymised Data Ethics & Protocol Committee 
BMI 
Body Mass Index 
CIOMS 
Council for International Organizations of Medical Sciences 
EMA 
European Medicines Agency 
ENCePP 
European Network of Centres for Pharmacoepidemiology and 
Pharmacovigilance 
EQUATOR 
Enhancing the QUAlity and Transparency Of health Research) 
GEP 
Good Epidemiological Practice 
GP 
General Practitioner 
GPP 
Guidelines for Good Pharmacoepidemiology Practices 
IAPT 
Improving Access to Psychological Therapies and psychiatric reviews 
ICD10 
International Statistical Classification of Diseases and Related Health 
Problems 10th Revision 
IEA 
International Epidemiological Association 
IMD 
Index of Multiple Deprivation 
IQR 
Interquartile Range  
ISPOR 
International Society for Pharmacoeconomics and Outcomes 
Research 
OPCRD 
Optimum Patient Care Research Database 
SD 
Standard Deviation 
SES 
Socio-Economic Status 
SNOMED CT 
Systemized Nomenclature of Medicine – Clinical Terms 
UK 
United Kingdom 
 
 
 

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3. Introduction 
 
3.1 Background 
Vitiligo is an acquired, non-contagious skin disorder characterised by depigmented 
patches of skin that may appear in a localised or very generalised distribution, and 
affecting 0.5-2.0% of the global population.(1) The exact cause of the loss of functioning 
melanocytes in vitiligo remains unknown, but is likely to be resulted from the complex 
interplay of genetics, oxidative stress, and autoimmunity.(2) 
 
Although vitiligo is typically asymptomatic, recent Pfizer-funded research has 
demonstrated the condition substantially affects psychological wellbeing.(3) This 
previous study showed that people with vitiligo have a considerable excess mental health 
burden when compared with people without vitiligo. It also showed that, in people with 
vitiligo, mental health comorbidity is associated with higher levels of healthcare 
utilisation, time off work, and unemployment.(3) This increased burden could be due to 
the unpredictable prognosis, the current lack of cure, the perception and emotional 
burden associated with the visibility of vitiligo, or a combination of these factors.  
 
There is substantial scope to extend the initial analysis, with a comprehensive assessment 
of sociodemographic disparities in healthcare utilisation and in the burden of mental 
health comorbidity in people with vitiligo. Whilst the previous Pfizer-funded study 
demonstrated a difference by ethnicity in the mental health impacts of vitiligo (with 
vitiligo associated with a greater mental health burden in people of non-white ethnicity), 
the study was not designed to assess this as a primary outcome. Further analysis is 
required to fully understand these potential relationships as well as provide critical 
information on whether there is a socio-economic (SES) gradient in the mental health 
impacts of vitiligo. The previous study did not assess other potential disparities in 
management, such as healthcare utilisation of primary care encounters or dermatology 
services. 
 
There is also substantial scope to expand on the previous study to provide, for the first 
time, a greater understanding of the total burden of vitiligo across the population, 
including reporting lifetime risk estimates for vitiligo, across sociodemographic groups. 
It is likely that substantial disease burden differences exist across these groups. 
 
A comprehensive assessment of potential disparities in healthcare utilisation in vitiligo, 
mental health and social impact, and lifetime risk are needed. This research would both 
strongly complement previous Pfizer-funded work and support the use of newer 
therapies in vitiligo. 
 

6 
 
3.2 Purpose of Analysis 
This study will provide the first estimate of the cumulative lifetime risk of vitiligo in the 
population overall, and by important sociodemographic groups, including age, sex, 
ethnicity and SES, which will prevalent key data to show the relative burden of vitiligo 
across the aforementioned groups. These approaches allow creation of cumulative 
lifetime risk plots which provide an excellent and accessible way to display the relative 
disease burden across groups. 
 
This study will provide a detailed assessment of any sociodemographic disparities in 
comorbidities and social impact that occurs in people with vitiligo. This will include any 
differences in mental health impact of vitiligo by sociodemographic. It will also include a 
description of any sociodemographic disparities in time off work (“sick leave”) or 
unemployment in people with vitiligo. 
 
This study will also provide a detailed assessment of any sociodemographic disparities 
in healthcare utilisation in people with vitiligo with comparison across 
sociodemographic. This will include analysis of utilisation of primary care services, 
mental health referrals as well as referrals to secondary care (dermatology). 
 
4. Study objectives and endpoints 
 
4.1 Study Objectives 
The overall purpose of the study is to provide an estimate of the lifetime risk of vitiligo in 
the population overall and by important sociodemographic groups. Moreover, to do a 
subgroup analysis in the vitiligo population to identify health-related disparities across 
people in different sex, age, deprivation and ethnicity.  
 
4.2 Primary Objectives 
4.2.1 Objective 1 
Describe the total burden of vitiligo (cumulative lifetime risk) across sociodemographic 
subgroups. 
 
4.3 Secondary Objectives 
4.3.1 Objective 2 
Describe any disparities in the burden of mental health outcomes, including depression 
and anxiety in people with vitiligo across sociodemographic subgroups. 
 

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4.3.2 Objective 3 
Describe any disparities in the association of vitiligo with parasuicide/suicide attempts, 
adjustment disorder and sleep disturbances associated with vitiligo across 
sociodemographic subgroups. 
 
4.3.3 Objective 4 
Describe 
any 
disparities 
in 
vitiligo-associated 
healthcare 
utilisation 
across 
sociodemographic subgroups. 
 
4.3.4 Objective 5 
Describe any disparities in vitiligo-associated work impact (time off work for illness and 
unemployment) across sociodemographic subgroups. 
 
4.4 Primary Endpoints 
Objective 
Endpoints 
1 
An incident diagnosis of vitiligo is the date of the first diagnosis code in 
the record and no alternative diagnosis that merits exclusion (other 
causes of skin hypopigmentation) diagnosed within a one-year period (six 
months before or after their first vitiligo diagnosis code). 
Table 1: Primary endpoints.  
 
4.5 Secondary Endpoints 
Objective 
Endpoints 
2 
Mental health condition outcomes will be assessed up to two years post-
vitiligo diagnosis, including history of prior mental health condition and 
will comprise of depression (record of any depressive episodes and/or 
major recurrent depression diagnosis) and anxiety disorders, defined by 
the International Statistical Classification of Diseases and Related Health 
Problems 10th Revision (ICD10) classification, and identified using 
algorithms validated for use in UK primary care data (See previously 
published codes lists: (4)) 
3 
Other mental health condition outcomes will be assessed up to two years 
post-vitiligo diagnosis and will comprise of parasuicide/suicide attempts, 
adjustment disorder and sleep disturbance, defined by the International 
Statistical Classification of Diseases and Related Health Problems 10th 
Revision (ICD10) classification, and identified using algorithms validated 
for use in UK primary care data (See previously published codes lists: (4)) 

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4 
Healthcare utilisation outcomes will comprise primary care visits, 
dermatology referrals, mental health referrals (including but not limited 
to those via IAPT; Improving Access to Psychological Therapies and 
psychiatric reviews) in the two years post-vitiligo diagnosis.  
5 
Unemployment in the two years post-vitiligo diagnosis will be identified 
using Read codes relating to unemployment recorded in the primary care 
record or the issuing of IB113 or ESA113 forms (See previously published 
codes lists: (4)). 
Time off work in the two years post-vitiligo diagnosis will be indicated by 
the issuing of Med 3 certification from primary care (Statement of Fitness 
for Work certification) (See previously published codes lists: (4)). 
Table 2: Secondary endpoints.  
 
5. General Study Design and Plan 
The study will use retrospectively collected anonymised data from all eligible people 
contributing to the Optimum Patient Care Research Database (OPCRD)(5) at the date of 
data extraction. A matched-cohort design will be used for incident (and prevalent) vitiligo 
related healthcare utilisation, mental health conditions and work impacts. Lifetime risk 
will be calculated using adapted survival analysis to account for the competing risk of 
death and will be estimated for the population overall and separately in 
sociodemographic subgroups of interest. 
 
All adults and adolescents (aged 13+ for disparity objectives 2-5 inclusive) contributing 
to OPCRD during the study period (January 1, 2004 and December 31, 2020 inclusive). 
People who have opted out of record data sharing will not be included (approximately 
1.8% of the adult population) and have not been uploaded to the OPCRD database.  
 
Cumulative lifetime risk of vitiligo will be estimated (using the method described in the 
statistical methods below) using cases of incident vitiligo occurring during the 
observational study period (January 1, 2004 and December 31, 2020 inclusive). A 
matched-cohort design will be used for incident (and prevalent) vitiligo related mental 
health conditions, healthcare utilisation and work impacts. For all analyses, the overall 
result including both adults (aged 18+) and children (aged 13-17) will be published, with 
stratification by age, sex, deprivation and ethnicity. 
 
5.1 Study design 
This is a non-interventional study. 
 
5.2 Total disease burden; cumulative lifetime risk 
A cross sectional design (incidence) will be used to assess the total disease burden of 
vitiligo, stratified by sociodemographic groups. 

9 
 
 
5.3 Disparities in the impact of vitiligo on mental health, 
healthcare utilisation and work impact 
 
A matched-cohort design will be used for incident (and prevalent) vitiligo related: 
Mental health conditions; work impact; healthcare utilisation. 
 
5.4 Data Source and Read codes 
The OPCRD(5) is a well-established primary care network in the UK. The database 
contains complete data on all events and clinical entities coded in UK primary care. These 
include sociodemographic factors and demographic information, clinical diagnoses, 
laboratory test results, primary care issued prescriptions, process of care codes (e.g. 
specialist dermatology reviews), and anthropometric measurements (e.g. BMI), and are 
coded using the Read coding and Systemized Nomenclature of Medicine – Clinical Terms 
(SNOMED CT) coding systems.(6) 
 
5.5 Data Governance 
This study is based wholly on data from the OPCRD (www.opcrd.co.uk) obtained under a 
limited license from Optimum Patient Care Limited and its execution is approved by 
recognised experts affiliated to the Respiratory Effectiveness Group. 
 
Data from the OPCRD are available under license for clinical research which is subject to 
relevant approvals. For additional information visit: www.opcrd.co.uk. 
 
5.6 Data Extraction 
Individual patient data was anonymised at the point of data extraction. All data will 
remain in anonymised form and will be held on a secure server operated by Momentum 
Data. The data will not be used for any purposes other than for the research which is 
described in the respective protocols and which has been approved by the OPCRD ADEPT 
Committee.  
 
5.7 General Study Population 
5.7.1 Vitiligo Definition 
People diagnosed with vitiligo will be identified using diagnostic Read and SNOMED CT 
codes which are specific to vitiligo. (Appendix 1) A diagnostic algorithm will be used to 
facilitate robust case identification, identifying anyone with a specific diagnosis code 
followed by exclusion of anyone with a diagnosis code for an alternative depigmenting 

10 
 
disorder coded within a one-year period (six months before or after their first diagnosis 
code). The list of alternative depigmenting disorders is shown in Appendix 2. 
 
Incident cases will be defined as people with a first ever diagnosis code of vitiligo during 
the study period. People with a diagnosis of vitiligo prior to the study period will be 
excluded. Each case will be assigned an index date at the time of their vitiligo diagnosis. 
 
5.7.2 Sociodemographic subgroups 
Age, sex, deprivation and ethnicity will comprise the sociodemographic factors used for 
stratification of the outcome measures. 
 
Age will be stratified into four age categories: 13-17 (adolescents), 18-20, 30-49, 50+. 
 
Ethnicity will be grouped using the standardised definitions of major UK ethnic groups: 
White, Black, Asian, mixed, and others. (7) 
 
Deprivation will be defined using the national deprivation measure; index of multiple 
deprivation (IMD) and stratified into quintiles of deprivation according to the national 
distribution. (8) IMD is calculated at the point of data extraction, using patient postcode 
(practice postcode where patient postcode is not available). 
 
6. Sample Size Calculations 
A sample size calculation is only applicable to the incidence of mental health conditions 
of anxiety and depression in people diagnosed with vitiligo.  
 
Assuming 80% power, a 5% level of statistical significance and a background population 
prevalence of 15% for anxiety and 10% for depression,(9), our anticipated sample size 
for vitiligo (n = 8,000) will be sufficient to detect a risk difference of 1.11% in anxiety 
between those with and without vitiligo, and 1.12% difference in depression between 
those with and without vitiligo. Sample size calculations were performed in OpenEpi,(10) 
results are presented using methods of Kelsey.(11) 
 
7. Populations to be Analysed 
 
7.1 Inclusion Criteria 
 People must meet all the following inclusion criteria to be eligible for inclusion in the 
study: 
• The cohort for the endpoint analysis will consist of all adults and adolescents (aged 
13+) contributing to OPCRD during the study period. 

11 
 
• The cohort for the lifetime risk analysis will consist of all people contributing to 
OPCRD during the study period. 
• The vitiligo cohort consists of people newly diagnosed with vitiligo at any point during 
the study period. 
 
7.2 Exclusion Criteria 
People meeting any of the following criteria will not be included in the study: 
• People with the alternative non-vitiligo diagnoses (other hypopigmenting 
conditions). 
• People with vitiligo diagnosis within 6 months of practice registration. 
• People without vitiligo with less than 1 year of follow up within the dataset. 
• People over the age of 95 (for those reaching age 95 during the follow up period, 
follow up was censored at age 95). 
 
People who have opted out of record sharing are not included (approximately 1.8% of 
the adult population).  
 
7.3 Matching Process 
For objectives 2-5, controls for each vitiligo case will be identified from the pool of people 
without a vitiligo diagnosis registered in the OPCRD database at the time of vitiligo 
diagnosis for the case. Vitiligo cases will be eligible as controls up until the date of their 
vitiligo diagnosis (at which date their follow-up will be censored if selected as a control). 
 
Each case will be assigned an index date at the time of their vitiligo diagnosis. 
Corresponding controls assigned to each case will have the same index date. 
 
Each individual with vitiligo will be matched at their index date with up to four unaffected 
controls. Controls cannot be diagnosed with vitiligo at the date of matching and will 
require at least one year of follow-up time to minimise the risk of a non-recorded existing 
diagnosis of vitiligo. Time-updated exact matching will be performed by age, sex, 
ethnicity and deprivation, selected from the pool of eligible people registered in the same 
GP practice. 
If required, a combination of time-dependent propensity score matching and exact 
matching will be performed to create a baseline matched dataset. 
 
The matching process is subject to change depending on the feasibility of the mentioned 
matching process during the initial exploration of the data. The produced baseline 
matched dataset will be used for all analyses for objective 2-5. 
 

12 
 
8. Statistical Analysis 
 
8.1 Statistical Principles 
Mean, standard deviation (sd) and any other statistical measures, will be reported to one 
decimal place. Continuous data will be summarised in the form of means, sd, median, 
interquartile range (IQR) and range as appropriate. Categorical data will be summarised 
using the frequencies and proportions. Chi-squared and t-tests will be performed to 
compare the frequency of dichotomous variables and the values of continuous variables 
where relevant. 95% CIs will be reported for main effect sizes. Statistical significance will 
be assessed using p<0.05. Actual p-values will be reported except for p-values less than 3 
decimal places which will be reported as “<0.001”. P-values >0.1 will be reported to one 
decimal place, p-values between 0.01 and 0.1 will be reported to 2 decimal places, and p-
values between 0.001 and 0.01 will be reported to three decimal places. 
 
The assessment of any associations with baseline characteristics and the outcomes of 
interest (objectives 2-5) will be assessed using logistic regression (prevalent and incident 
outcomes), Cox proportional hazards (time to event outcomes) and Poisson regression 
(repeated event outcomes) models. Three different adjustment sets will be used for each 
endpoint analysis. These include: an unadjusted model, a sex and age adjusted model, and 
a multivariable model with an adjustment set of: age, sex, BMI, smoking status, alcohol 
use, and common comorbidities: type 2 diabetes, hypertension, atrial fibrillation, angina, 
acute myocardial infarction, stroke, heart failure, chronic liver disease, dementia, 
rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, chronic kidney 
disease stages 3-5, malignancy and inflammatory bowel disease. 
 
Assumptions of statistical approaches will be assessed, and transformations used if 
necessary. 
 
8.2 Primary Endpoint Analysis 
Objective 1 
Lifetime risk of vitiligo will be calculated for the population as a whole and by sex, 
ethnicity, and SES. Ethnicity will be grouped using the standardised definitions of major 
UK ethnic groups: white, black, Asian, mixed, and other.(7) SES will be defined using the 
national deprivation measure; IMD.(12)  
 
Lifetime risk will be calculated using methods to estimate cumulative lifetime risk 
recently published in the Lancet,(13, 14) accounting for the competing risk of death. Key 
outputs will be lifetime risk plots, presenting the cumulative risk of vitiligo against age 
for the whole population and for sociodemographic subgroups. At a particular age, the 
cumulative risk estimate can be interpreted as the lifetime risk of vitiligo up until and 
including the year of age in question. Age of 80 is considered to be the approximate 

13 
 
lifetime expectancy in the UK,(15) and will be the point of comparison at which the 
lifetime risk of vitiligo will be compared across sociodemographic subgroups. 
 
8.3 Secondary Endpoint Analysis 
 
Objective 2 
Anxiety and depression outcomes will be captured if occurring prior to, or within two 
years of, an individuals’ study index date. Binary outcome logistic regression model 
outputs will be used to compare the burden of anxiety and depression in vitiligo cases 
compared to matched controls. Furthermore, additional analyses for new onset anxiety 
and depression outcomes will be conducted, excluding people with a previous record of 
the respective mental health condition. Anxiety and depression outcomes will be defined 
by the first occurrence of a relevant code in the primary care record up to two years post 
index-date. Cox proportional hazards regression will be used to estimate the excess risk 
of anxiety and depression outcomes in vitiligo cases versus controls. Results will be 
described as hazard ratios. 
 
Objective 3 
Parasuicide/suicide attempts will be defined by the first occurrence of a relevant code in 
the primary care record up to two years post index-date. People with a previous record 
of parasuicide/suicide attempt will be excluded from the calculations. Cox proportional 
hazards regression will be used to estimate the excess risk of parasuicide/suicide 
attempts in vitiligo cases versus matched controls. Results will be described as hazard 
ratios. 
Adjustment disorder and sleep disturbance will be defined by the first occurrence of a 
relevant code in the primary care record up to two years post index-date. People with a 
previous record of the adjustment disorder will be excluded from the from the 
adjustment disorder endpoint analysis. Cox proportional hazards regression will be used 
to estimate the excess risk of the relevant condition in vitiligo cases versus matched 
controls. Results will be described as hazard ratios. 
 
Objective 4 
Dermatology referral and mental health referral or reviews will be defined by the first 
occurrence of a relevant code in the primary care record up to two years post index date. 
Cox proportional hazards regression will be used to estimate the excess risk of these 
outcomes in vitiligo cases versus matched controls. 
For primary care encounters reviews, defined as a rate of encounters within two years 
after the index date, will be compared using generalised linear models with time-at-risk 
as an offset. Results will be described as incidence rate ratios. 
 
Objective 5 

14 
 
Only cases and matched controls aged 18-65 will be considered for this analysis. Work 
impact outcomes (unemployment and time off work for illness) will be defined by the 
first occurrence of a relevant code in primary care record up to two years post index date. 
Cox proportional hazards regression will be used to estimate the excess risk of these 
outcomes in vitiligo cases versus matched controls. Results will be described as hazard 
ratios. 
 
8.4 Sensitivity Analysis 
To evaluate the magnitude of potential bias from including, as matched controls, people 
who are registered with GP practices but who do not attend their practice, we will also 
repeat the primary analysis for mental health, healthcare utilisation and work-related 
outcomes including only matched controls with at least one primary care encounter in 
the year preceding their index date.  
 
We will also repeat the primary analysis for mental health, healthcare utilisation and 
work-related outcomes extending the outcome period to four years.  
 
To assess the impact of missing ethnicity data, we will repeat the ethnicity 
sociodemographic subgroup analysis amending missing ethnicity entries to white. 
 
8.5 Missing Data 
These studies will use the missing indicator variable method as missing data are 
considered likely not to be missing at random, meaning multiple imputation approaches 
will lack validity. 
 
Patients will need to be excluded from analyses based on a matched design if they have 
incomplete data in the fields (age, sex) required to run the matching process. In similar 
studies, the exclusion rate due to incomplete data has been very low. (23, 24) 
 
How missing data is handled will be dependent on exploratory and sensitivity analyses 
and is subject to change.  
 
9. Study Limitations 
Disparities between sociodemographic subgroups will be interpreted based on the 
assumption of the primary/secondary outcomes being related to the vitiligo. We have no 
definite way to identify that every occurrence of an outcome is related to vitiligo in the 
context of healthcare utilisation and work impact outcomes and therefore causal 
interpretation is not possible. 
 
This is an ecological study limited to the UK population and may not be generalisable to 
other populations. 

15 
 
 
We expect some missing data for the ethnicity variable, this is a limitation of the dataset 
itself and could result in bias. Necessary sensitivity analyses will be undertaken to 
circumvent this and limit any impact this could have in interpretation of results in our 
analysis. 
 
We expect low number of occurrences for the outcomes of referrals for adjustment 
disorder and parasuicide/suicide, thus reporting of the results for these two endpoints 
will depend on the sufficiency of numbers available. 
 
10. Statistical Software 
All statistical analyses will be performed using R version 4.2.3 or higher. 
 
11. Ethics 
The study will be conducted in accordance with legal and regulatory requirements, as 
well as with scientific purpose, value and rigor and follow generally accepted research 
practices described in: 
• Guidelines for Good Pharmacoepidemiology Practices (GPP). Public Policy 
Committee, International Society of Pharmacoepidemiology. Pharmacoepidemiology 
and Drug Safety 2016; 25:2-10. 
• Good Practices for Outcomes Research issued by the International Society for 
Pharmacoeconomics and Outcomes Research (ISPOR) 
• Good practices for real-world data studies of treatment and/or comparative 
effectiveness: Recommendations from the joint ISPOR-ISPE Special Task Force on 
real-world evidence in health care decision making 
• International Ethical Guidelines for Epidemiological Studies issued by the Council for 
International Organizations of Medical Sciences (CIOMS) 
• European 
Medicines 
Agency 
(EMA) 
European 
Network 
of 
Centres 
for 
Pharmacoepidemiology and Pharmacovigilance (ENCePP) Guide on Methodological 
Standards in Pharmacoepidemiology 
• The ENCePP Code of Conduct for scientific independence and transparency in the 
conduct of pharmacoepidemiological and pharmacovigilance studies 
• Good Epidemiological Practice (GEP) guidelines issued by the International 
Epidemiological Association (IEA). 
• Study reporting will be conducted in accordance with the relevant EQUATOR 
(Enhancing the QUAlity and Transparency Of health Research) guidelines. 
 
The NHS Health Research Authority (NHS HRA) has approved OPCRD for clinical research 
purposes (REC reference: 20/EM/0148). The protocol for this project was approved by 
the OPCRD affiliated study approvals committee. The study did not require formal 
research ethics committee as it used anonymised routinely collected healthcare data, 
based on outputs from the National Health Service (NHS) Health Research Authority 

16 
 
research decision tool (http://www.hra-decisiontools.org.uk/research/). No patient 
identifiable information was available to researchers. All patients who chose to opt out of 
data sharing did not have their data processed. The authors assert that all procedures 
contributing to this work comply with the ethical standards of the relevant national and 
institutional committees on human experimentation and with the Helsinki Declaration of 
1975, as revised in 2008. 
 
The study will be registered on the clinical trial database (clinicaltrials.gov) 
 
12. Acknowledgments 
 
This Study will be based wholly on data from the Optimum Patient Care Research 
Database (www.opcrd.co.uk) obtained under a limited licence from Optimum Patient 
Care Limited and its execution is approved by recognised experts affiliated to the 
Respiratory Effectiveness Group. However, the interpretation and conclusions contained 
in this report will be those of the author/s alone.  
Patients and practices who are members of the OPC network, who allow their data to be 
shared for surveillance, research, quality improvement, and education. Data access 
support from the OPCRD team. Statistical input and medical writing from Serhan Bahit 
(Serhan.bahit@momentumdata.co.uk) 
and 
Dr 
Charlotte 
Curtis 
(charlotte.curtis@momentumdata.co.uk) at Momentum Data. Project management 
support from Emma Jones (emma.jones@momentumdata.co.uk) at Momentum Data. 
 
 
 

17 
 
 
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https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015. 
9. 
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, 
and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey 
Replication. Arch Gen Psychiatry. 2005;62(6):617-27. 
10. 
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for 
Public Health  [updated 06/04/2013. Available from: www.OpenEpi.com. 
11. 
Kelsey JL, Whitemore AS, Evans AS, Thompson WD. Methods in Observational 
Epidemiology. 2nd ed. New York: Oxford University Press; 1996. 
12. 
Department for Communities and Local Government. The English Indices of 
Deprivation. 
2015.2015. 
Available 
from: 
https://www.gov.uk/government/statistics/english-indices-of-deprivation-2015. 
13. 
Gershon AS, Warner L, Cascagnette P, Victor JC, To T. Lifetime risk of developing 
chronic obstructive pulmonary disease: a longitudinal population study. Lancet (London, 
England). 2011;378(9795):991-6. 
14. 
Rapsomaniki E, Timmis A, George J, Pujades-Rodriguez M, Shah AD, Denaxas S, et 
al. Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy 
life-years lost, and age-specific associations in 1·25 million people. Lancet (London, 
England). 2014;383(9932):1899-911. 
15. 
Minton J, Fletcher E, Ramsay J, Little K, McCartney G. How bad are life expectancy 
trends across the UK, and what would it take to get back to previous trends? Journal of 
Epidemiology and Community Health. 2020;74(9):741. 
 
 

18 
 
14. Appendices 
 
Appendix 1 
Codes to be used to identify cases of vitiligo and important exclusion conditions. 
 
Read and SNOMED codes to be used to identify cases of vitiligo  
Read V2 Code 
Term ID 
Description 
M2951 
All 
Vitiligo 
M293. 
All 
Hypopigmentation disorder 
F4E53 
All 
Vitiligo of eyelid  
M295. 
All 
Leucoderma 
M295z 
All 
Leucoderma NOS 
Read CTV3 Code 
Term ID 
Description 
M2951 
All 
Vitiligo 
M293. 
All 
Hypopigmentation disorder 
F4E53 
All 
Vitiligo of eyelid  
M295. 
All 
Acquired hypomelanosis 
M295z 
All 
Leucoderma NOS 
SNOMED Code 
Term ID 
Description 
56727007 
 
Vitiligo (disorder) 
87666009 
 
Vitiligo of eyelid (disorder) 
721539008 
 
Vitiligo of eyelid and periocular area (disorder) 
 403271008 
 
Kobner vitiligo (disorder) 
403270009 
 
Trichrome vitiligo (disorder) 
403267005 
 
Localised vitiligo (disorder) 
403268000 
 
Segmental vitiligo (disorder) 
402621008 
 
Idiopathic vitiligo (disorder) 
403269008 
 
Generalised vitiligo (disorder) 
330931000119106 
 
Vitiligo of skin of left eyelid and periocular area (disorder) 
330931000119104 
 
Vitiligo of skin of right eyelid and periocular area (disorder) 
330911000119101 
 
Vitiligo of skin of left upper eyelid and periocular area (disorder) 
330881000119101 
 
Vitiligo of skin of right upper eyelid and periocular area (disorder) 
726608002 
 
Spastic paraparesis, vitiligo, premature greying, characteristic 
facies syndrome 
23006000 
 
Hypopigmentation of skin (disorder) 
89031001 
 
Hypopigmentation (morphological abnormality) 
68210006 
 
Hypopigmentation of eyelid  
18655006 
 
Dipigmentation 
23267004 
 
Achromia of skin (disorder) 
402807009 
 
Circumscribed hypomelanosis (disorder) 
 
 

19 
 
 
 
Read codes and SNOMED codes to be used to identify alternative depigmenting disorders 
for exclusion  
Congenital and Genetic Hypomelanoses 
Read V2 Code 
Term 
ID 
Description 
C302A 
All 
Piebaldism 
PK5.. 
All 
Tuberous sclerosis 
PKy54 
All 
Waardenburg's syndrome 
C3029 
All 
Hermansky-Pudlak 
PKy92 
All 
Menke's syndrome 
Read CTV3 Code 
Term 
ID 
Description 
X78Ve 
All 
Hypomelanosis of Ito 
XaZqX 
All 
Piebaldism 
PK5.. 
All 
Tuberous sclerosis 
X78E7 
All 
Ash leaf spot, tuberous sclerosis 
X78E8 
All 
Shargreen patch 
X78E9 
All 
Adenoma sebaceum 
X20Ex 
All 
Hermansky-Pudlak syndrome 
X20ij 
All 
Griscelli syndrome with immunodeficiency 
PKy92 
All 
Menkes syndrome 
SNOMED Code 
Term 
ID 
Description 
 218358001 
 
Incontinentia pigmenti achromians syndrome (disorder) 
718122005 
 
Piebaldism (disorder) 
7199000 
 
Tuberous sclerosus syndrome (disorder) 
254243001 
 
Ash leaf spot, tuberous sclerosis (disorder) 
 36025004 
 
Fibrous skin tumor of tuberous sclerosis (disorder) 
254244007 
 
Shagreen patch (disorder) 
9311003 
 
Hermansky-Pudlak syndrome (disorder) 
37548006 
 
Hypopigmentation-immunodeficiency disease (disorder) 
59178007 
 
Menkes kinky-hair syndrome (disorder) 
47434006 
 
Waardenburg's syndrome (disorder) 
715952000 
 
Waardenburg syndrome co-occurrent with Hirschsprung disease 
(disorder) 
773575001 
 
Ocular albinism with congenital sensorineural deafness (disorder) 
765325002 
 
Peripheral demyelinating neuropathy, central dysmyelinating 
leukodystrophy, Waardenburg syndrome, Hirschsprung disease 
(disorder) 
Post-inflammatory Hypomelanoses 
Read V2 Code 
Term 
ID 
Description 
M2920 
All 
Post inflammatory hypopigmentation 
M170. 
All  
Lichen planus 

20 
 
M1700 
All  
Lichen planus actinicus 
M1701 
All  
Lichen planus annularis 
M1702 
All  
Lichen planus atrophicus 
M1703 
All  
Lichen planus bullosus 
M1704 
All  
Lichen planus hypertrophicus  
M1705 
All  
Lichen planus linearis 
M1707 
All  
Lichen planus obtusus 
M1708 
All  
Subacute active lichen planus 
M1709 
All  
Follicular lichen planus 
M170z 
All  
Lichen planus NOS 
M17y0 
All  
Lichen ruber moniliforme  
M1650 
All 
Pityriasis alba 
M2102 
All 
Lichen sclerosus and atrophicus 
K276. 
All 
Balanitis xerotica obliterans 
Read CTV3 Code 
Term 
ID 
Description 
Xa0WM 
All 
Post inflammatory hypopigmentation 
M170. 
All 
Lichen planus 
X507Y 
All 
Confluent lichen planus 
X507Z 
All 
Micropaplular lichen planus 
X507a 
All 
Guttate lichen planus  
X507b 
All 
Follicular lichen planus 
M1703 
All 
Bullous lichen planus 
M1701 
All 
Annular lichen planus 
M1704 
All 
Hypertrophic lichen planus 
M1702 
All 
Atrophic lichen planus 
M1705 
All 
Linear lichen planus 
X507c 
All 
Zosteriform lichen planus 
M1700 
All 
Acintic lichen planus 
X507d 
All 
Post inflammatory hyperpigmentation in lichen planus 
X507e 
All 
Wickham's striae in lichen planus 
X507f 
All 
Lichen planus - lupus erythematosus overlap 
X507g 
All 
Lichen planus pemphigoides 
X507h 
All 
Site-specific lichen planus 
X507i 
All 
Lichen planus of scalp 
X507j 
All 
Lichen planus of palms and soles 
X507k 
All 
Ulcerative lichen planus of palms and soles 
X507n 
All 
Mutilating lichen planus of fingers and toes 
X507l 
All 
Lichen planus of nail 
X507w 
All 
Genital lichen planus 
X408F 
All 
Lichen planus of vuvla 
X507y 
All 
Erosive lichen planus of vulva 
X507z 
All 
Lichen planus of penis 
X5080 
All 
Lichen planus of glans penis  
M1707 
All 
Lichen planus obtusus 

21 
 
M1708 
All 
Subacute active lichen planus 
M170z 
All 
Lichen planus NOS 
Myu32 
All 
[X]Other lichen planus 
M17y0 
All  
Lichen ruber moniliforme  
M1650 
All 
Pityriasis alba 
M2102 
All 
Lichen sclerosus 
X50FC 
All 
Genital lichen sclerosus 
K276. 
All 
Balanitis xerotica obliterans 
X50FE 
All 
Lichen sclerosus of vulva 
X50FF 
All 
Extra genital lichen sclerosus 
X50FG 
All 
Guttate lichen sclerosus 
SNOMED Code 
Term 
ID 
Description 
277787003 
 
Post-inflammatory hypopigmentation (disorder) 
403272001 
 
Post-infective hypomelanosis (disorder) 
403276003 
 
Acquired hypomelanosis of uncertain etiology (disorder) 
4776004 
 
Lichen planus (disorder) 
263797007 
 
Lichen planus-like (qualifier value) 
4459000 
 
Linear lichen planus (disorder) 
6111009 
 
Bullous lichen planus (disorder) 
238666005 
 
Lichen planus of lips (disorder) 
201001005 
 
Lichen planus obtusus (disorder) 
200999007 
 
Actinic lichen planus (disorder) 
238658001 
 
Lichen planus of nail (disorder) 
238668006 
 
Genital lichen planus (disorder) 
201000006 
 
Annular lichen planus (disorder) 
238647005 
 
Guttate lichen planus (disorder) 
237112004 
 
Lichen planus of vulva (disorder) 
400108007 
 
Flexural lichen planus (disorder) 
238655003 
 
Lichen planus of scalp (disorder) 
44509000 
 
Linear lichen planus (disorder) 
25858008 
 
Atrophic lichen planus (disorder) 
238670002 
 
Lichen planus of penis (disorder) 
238645002 
 
Confluent lichen planus (disorder) 
717061002 
 
Lichen planus pigmentosus (disorder) 
238648000 
 
Zosteriform lichen planus (disorder) 
238653005 
 
Lichen planus pemphigoides (disorder) 
68266006 
 
Hypertrophic lichen planus (disorder) 
238646001 
 
Micropapular lichen planus (disorder) 
64540004 
 
Lichen planopilaris (disorder) 
238654004 
 
Site-specific lichen planus (disorder) 
238652000 
 
Lichen planus-lupus erythematosus overlap (disorder) 
403198004 
 
Lichenoid actinic keratosis (disorder) 
723003004 
 
Acute eruptive lichen planus (disorder) 
238671003 
 
Lichen planus of glans penis (disorder) 

22 
 
68266006 
 
 Hypertrophic lichen planus (disorder) 
201002003 
 
Subacute active lichen planus (disorder) 
720493003 
 
Annular atrophic lichen planus (disorder) 
238651007 
 
Wickham's striae in lichen planus (disorder) 
201001005 
 
Lichen planus obtusus (disorder) 
402349005 
 
Chronic lichen planus (disorder) 
238668006 
 
Genital lichen planus (disorder) 
238656002 
 
Lichen planus of palms and soles (disorder) 
402352002 
 
Poikiloderma due to lichen planus (disorder) 
721171007 
 
Hypertrophic lichen planus of vulva (disorder) 
402348002 
 
Köbner reaction from lichen planus (disorder) 
238657006 
 
Ulcerative lichen planus of palms and soles (disorder) 
238660004 
 
Mutilating lichen planus of fingers and toes (disorder) 
726476005 
 
Lichen planus co-occurrent with onycholysis (disorder) 
238649008 
 
Post-inflammatory hyperpigmentation in lichen planus (disorder) 
402296004 
 
Pityriasis alba (disorder) 
402298003 
 
Diffuse pityriasis alba (disorder) 
402297008 
 
Localised pityriasis alba (disorder) 
25674000 
 
Lichen sclerosus et atrophicus (disorder) 
402423004 
 
Adult lichen sclerosus (disorder) 
782666006 
 
Lichen sclerosus of anus (disorder) 
238934003 
 
Guttate lichen sclerosus (disorder) 
238932004 
 
Genital lichen sclerosus (disorder) 
700082001 
 
Lichen sclerosus of penis (disorder) 
26348009 
 
Lichen sclerosus et atrophicus of the vulva (disorder) 
402424005 
 
Childhood lichen sclerosus (disorder) 
403566002 
 
Anogenital lichen sclerosus (disorder) 
238933009 
 
Extragenital lichen sclerosus (disorder) 
402714001 
 
Lichen sclerosus of male genitalia (disorder) 
402715000 
 
Lichen sclerosus of female genitalia (disorder) 
402422009 
 
Bullous extragenital lichen sclerosus (disorder) 
721199003 
 
Prepubertal lichen sclerosus of vulva (disorder) 
403568001 
 
Localized extragenital lichen sclerosus (disorder) 
402421002 
 
Generalized extragenital lichen sclerosus (disorder) 
403564004 
 
Lichen sclerosus of penis, childhood form (disorder) 
111023000 
 
Lichen sclerosus et atrophicus, bullous type (disorder) 
403565003 
 
Vulval lichen sclerosus, childhood form (disorder) 
198033005 
 
Balanitis xerotica obliterans (disorder) 
Post Traumatic Leukoderma 
SNOMED Code 
Term 
ID 
Description 
402622001 
 
Hypomelanosis due to scarring (disorder) 
18655006 
 
Depigmentation (morphologic abnormality) 
23006000 
 
Hypopigmentation of skin (disorder) 
398656003 
 
Acquired hypomelanotic disorder (disorder) 

23 
 
Para-Malignant Hypomelanoses 
Read V2 Code 
Term 
ID 
Description 
B621. 
All 
Mycosis fungoides 
B6210 
All 
Mycosis fungoides of unspecified site 
B6211 
All 
Mycosis fungoides of lymph nodes of head, face and neck 
B6212 
All 
Mycosis fungoides of intrathoracic lymph nodes 
B6213 
All 
Mycosis fungoides of intra-abdominal lymph nodes 
B6214 
All 
Mycosis fungoides of lymph nodes of axilla and upper limb 
B6215 
All 
Mycosis fungoides of lymph nodes of inguinal region and leg  
B6216 
All 
Mycosis fungoides of intrapelvic lymph nodes  
B6217 
All 
Mycosis fungoides of spleen 
B6218 
All 
Mycosis fungoides of lymph nodes of multiple sites 
B621z 
All 
Mycosis fungoides NOS 
BBI.. 
All 
[M]Mycosis fungoides 
BBI0. 
All 
[M]Mycosis fungoides 
BBI1. 
All 
[M]Sezary's disease 
BBIz. 
All 
[M]Mycosis fungoides NOS 
B62xX 
All 
0th and unspecif peripheral & cutaneous T-cell lymphomas 
B62E7 
All 
Subcutaneous panniculitis like T-cell lymphoma 
BBmD. 
All 
[M]Cutaneous lymphoma  
B622. 
All 
Sezary's disease 
B6220 
All 
Sezary's disease of unspecified site 
B6221 
All 
Sezary's disease of lymph nodes of head, face and neck 
B6222 
All 
Sezary's disease of intrathoracic lymph nodes 
B6223 
All 
Sezary's disease of intra-abdominal lymph nodes 
B6224 
All 
Sezary's disease of lymph nodes of axilla and upper limb 
B6225 
All 
Sezary's disease of lymph nodes of inguinal region and leg  
B6226 
All 
Sezary's disease of intrapelvic lymph nodes  
B6227 
All 
Sezary's disease of spleen 
B6228 
All 
Sezary's disease of lymph nodes of multiple sites 
B622z 
All 
Sezary's disease NOS 
BBEA. 
All 
Amelanotic melanoma 
Read CTV3 Code 
Term 
ID 
Description 
B621. 
All 
Mycosis fungoides 
XaQbT 
All 
Poikiloderma vasculare atrophicans 
X78hm 
All 
Mycosis fungoides of skin 
B6210 
All 
Mycosis fungoides of unspecified site 
B6211 
All 
Mycosis fungoides of lymph nodes of head, face and neck 
B6212 
All 
Mycosis fungoides of intrathoracic lymph nodes 
B6213 
All 
Mycosis fungoides of intra-abdominal lymph nodes 
B6214 
All 
Mycosis fungoides of lymph nodes of axilla and upper limb 
B6215 
All 
Mycosis fungoides of lymph nodes of inguinal region and leg  
B6216 
All 
Mycosis fungoides of intrapelvic lymph nodes  

24 
 
B6217 
All 
Mycosis fungoides of spleen 
B6218 
All 
Mycosis fungoides of lymph nodes of multiple sites 
B621z 
All 
Mycosis fungoides NOS 
B622. 
All 
Sezary's disease 
B6220 
All 
Sezary's disease of unspecified site 
B6221 
All 
Sezary's disease of lymph nodes of head, face and neck 
B6222 
All 
Sezary's disease of intrathoracic lymph nodes 
B6223 
All 
Sezary's disease of intra-abdominal lymph nodes 
B6224 
All 
Sezary's disease of lymph nodes of axilla and upper limb 
B6225 
All 
Sezary's disease of lymph nodes of inguinal region and leg  
B6226 
All 
Sezary's disease of intrapelvic lymph nodes  
B6227 
All 
Sezary's disease of spleen 
B6228 
All 
Sezary's disease of lymph nodes of multiple sites 
B622z 
All 
Sezary's disease NOS 
X78hn 
All 
Sezary's disease of skin 
X78hl 
All 
Cutaneous lymphoma 
XaYin 
All 
Cutaneous follicle centre lymphoma 
Xa0Sz 
All 
Cutaneous/peripheral T-cell lymphoma 
XaYjf 
All 
Subcutaneous panniculitis like T-cell lymphoma 
ByuDD 
All 
[X]0th and unspecif peripheral & cutaneous T-cell lymphomas 
XaYjl 
All 
Primary cutaneous CD30 antigen positive large T-cell lymphoma 
XaOCE 
All 
Amelanotic malignant melanoma of skin  
SNOMED Code 
Term 
ID 
Description 
90120004 
 
Mycosis fungoides (morphologic abnormality) 
118618005 
 
Mycosis fungoides (disorder) 
765328000 
 
Classic mycosis fungoides (disorder) 
404115006 
 
Bullous mycosis fungoides (disorder) 
94714002 
 
Mycosis fungoides of spleen (disorder) 
404117003 
 
Spongiotic mycosis fungoides (disorder) 
681291000119105 
 
History of mycosis fungoides (situation) 
418628003 
 
Follicular mycosis fungoides (morphologic abnormality) 
404113004 
 
Tumour stage mycosis fungoides (disorder) 
404118008 
 
Syrngotropic mycosis fungoides (disorder) 
404112009 
 
Granulomatous mycosis fungoides (disorder) 
404114005 
 
Erythrodermic mycosis fungoides (disorder) 
404110001 
 
Hypomelanocytic mycosis fungoides (disorder) 
404109006 
 
Folliculotropic mycosis fungoides (disorder) 
404108003 
 
Pokilodermatous mycosis fungoides (disorder) 
404107008 
 
Patch/plaque stage mycosis fungoides (disorder) 
404116007 
 
Mycosis fungoides with systemic infiltration (disorder) 
94708009 
 
Mycosis fungoides of intrapelvic lymph nodes (disorder) 
94707004 
 
Mycosis fungoides of intra-abdominal lymph nodes (disorder) 
188627002 
 
Mycosis fungoides of  lymph nodes of multiple sites (disorder) 
404111002 
 
Lymphomatoid papulosis-associated mycosis fungoides (disorder) 

25 
 
404104001 
 
Lymphomatoid papulosis type B mycosis fungoides-like (disorder) 
94715001 
 
Mycosis fungoides of extranodal AND/OR solid organ site (disorder) 
94709001 
 
Mycosis fungoides of intrathoracic lymph nodes (disorder) 
94711005 
 
Mycosis fungoides of lymph nodes of head, face AND/OR neck 
(disorder) 
94710006 
 
Mycosis fungoides of lymph nodes of axilla AND/OR upper limb 
(disorder) 
188627002 
 
Mycosis fungoides of lymph nodes of multiple sites (disorder) 
94712003 
 
Mycosis fungoides of lymph nodes of inguinal region AND/OR lower 
limb (disorder) 
28054005 
 
Cutaneous T-cell lymphoma, no International Classifcation of 
Diseases for oncology subtype (morphologic abnormality) 
40012207 
 
Primary cutaneous T-cell lymphoma (disorder) 
277613000 
 
Cutaneous/peripheral T-cell lymphoma (disorder) 
404128004 
 
CD-30 negative cutanoeus T-cell lymphoma (disorder) 
419283005 
 
Primary cutaneous T-cell lymphoma - category (morphologic 
abnormality) 
128804002 
 
Primary cutaneous CD30 antigen positive T-cell lymphoproliferative 
disorder (morphologic abnormality) 
450908002 
 
Primary cutaneous gamma-delta T-cell lymphoma (morphologic 
abnormality) 
122571000119106 
 
History of primary cutaneous T-cell lymphoma (situation) 
419018000 
 
Primary cutaneous large T-cell lymphoma - category (morphologic 
abnormality) 
402880009 
 
Primary cutaneous large T-cell lymphoma (disorder) 
404133000 
 
Subcutaneous panniculitic cutaneous T-cell lymphoma (disorder) 
404128004 
 
CD-30 negative cutaneous T-cell lymphoma (disorder) 
787198005 
 
Primary cutaneous acral CD8 positive T-cell lymphoma 
(morphologic abnormality) 
397352006 
 
Primary cutaneous anaplastic large T-cell lymphoma, CD30-positive 
(morphologic abnormality) 
733627006 
 
Primary cutaneous gamma-delta-positive T-cell lymphoma 
(disorder) 
404129007 
 
CD-30 negative anaplastic large T-cell cutaneous lymphoma 
(disorder) 
122571000119106 
 
History of malignant cutaneous T-cell lymphoma (situation) 
404130002 
 
CD-30 negative pleomorphic large T-cell cutaneous lymphoma 
(disorder) 
404126000 
 
CD-30 positive pleomorphic large T-cell cutaneous lymphoma 
(disorder) 
419283005 
 
Primary cutaneous T-cell lymphoma - category (morphologic 
abnormality) 
450908002 
 
Primary cutaneous gamma-delta T-cell lymphoma - category 
(morphologic abnormality) 
765136002 
 
Primary cutaneous CD8 positive aggressicve epidermotropic 
cytotoxic T-cell lymphoma (disorder) 
128875000 
 
Primary cutaneous CD30 antigen positive large T-cell lymphoma 
(disorder) 
733895005 
 
Primary cutaneous CD8 positive aggressicve epidermotropic 
cytotoxic T-cell lymphoma (morphologic abnormality) 

26 
 
419586003 
 
Primary cutaneous T-cell lymphoma, large cell, CD30-negative 
(morphological abnormality) 
118611004 
 
Sezary's disease (disorder) 
4950009 
 
Sezary's disease (morphologic abnormality) 
255101006 
 
Sezary disease of skin (disorder) 
95263006 
 
Sezary's disase of spleen (disorder) 
188632001 
 
Sezary's disase of intra-abdominal lymph nodes (disorder) 
188635004 
 
Sezary's disase of intrapelvic lymph nodes (disorder) 
188631008 
 
Sezary's disase of intrathoracic lymph nodes (disorder) 
188637007 
 
Sezary disease of lymph nodes of multiple sites (disorder) 
95264000 
 
Sézary's disease of extranodal AND/OR solid organ site (disorder) 
 188633006 
 
Sézary's disease of lymph nodes of axilla and upper limb (disorder) 
95260009 
 
Sézary's disease of lymph nodes of head, face AND/OR neck 
(disorder) 
188634000 
 
Sézary's disease of lymph nodes of inguinal region and lower limb 
(disorder) 
95261008 
 
Sézary's disease of lymph nodes of inguinal region AND/OR lower 
limb (disorder) 
419392005 
 
Primary cutaneous lymphoma (morphologic abnormality) 
82321000000106 
 
Tumour and germline whole genome sequencing for anaplastic 
lymphoma kinase negative anaplastic large cell lymphoma including 
primary cutaneous subtypes (procedure) 
403274000 
 
Hypomelanosis surrounding malignant melanoma (disorder) 
402563000 
 
Metastatic malignant melanoma with diffuse hypermelanosis 
(disorder) 
276751004 
 
Amelanotic malignant melanoma of skin (disorder) 
70594002 
 
Amelanotic melanoma (morphologic abnormality) 
404110001 
 
Hypomelanotic mycosis fungoides (disorder) 
402623006 
 
Hypomelanosis surrounding melanocytic neoplasm (disorder) 
Occupational/drug induced hypomelanoses 
Read V2 Code 
Term 
ID 
Description 
M293. 
All 
Hypopigmentation 
Read CTV3 Code 
Term 
ID 
Description 
X508z 
All 
Occupational vitiligo 
X78VE 
All 
Chemically-induced hypomelanosis 
X50Gx 
All 
Drug-induced hypomelanosis  
Xa1aV 
All 
Chemically-induced hypomelanosis 
M2950 
All 
Leucoderma aestivale 
M295. 
All 
Acquired hypomelanosis 
SNOMED Code 
Term 
ID 
Description 
238713002 
 
Occupational vitiligo (disorder) 
280962005 
 
Chemically-induced hypomelanosis (disorder) 
402622001 
 
Hypomelanosis due to scarring (disorder) 

27 
 
403807001 
 
Phylloid hypomelanosis (disorder) 
398656003 
 
Acquired hypomelanotic disorder (disorder) 
238999005 
 
Drug-induced hypomelanosis (disorder) 
403698000 
 
Laser-induced hypopigmentation (disorder) 
402622001 
 
Hypomelanosis due to scarring (disorder) 
280962005 
 
Chemically-induced hypomelanosis (disorder) 
403692004 
 
Hypomelanosis due to cryotherapy (disorder) 
403744007 
 
Arsenic-induced "rain-drop" hypomelanosis (disorder) 
403698000 
 
Laser-induced hypopigmentation (disorder) 
 201290009 
 
Leukoderma estivale (disorder) 
Para-infectious hypopigmentation 
Read V2 Code 
Term 
ID 
Description 
AB10. 
All 
 
Pityriasis versicolor 
 
Read CTV3 Code 
Term 
ID 
Description 
AB10. 
All 
Pityriasis versicolor 
SNOMED Code 
Term 
ID 
Description 
56454009 
 
Pityriasis versicolor (disorder) 
18097004 
 
Malassezia (organism) 
721794002 
 
Infection caused by Malassezia (disorder) 
402133004 
 
Malassezia infection of the skin (disorder) 
29619007 
 
Malassezia furfur (organism) 
Others (including Melasma, Morphoea, Idiopathic guttate hypomelanosis, Xeroderma pigmentosum, 
Progressive macular hypomelanosis, Nevus depigmentosus, Cutaneous sarcoidosis) 
Read V2 Code 
Term 
ID 
Description 
M290. 
All 
Melasma 
M2900 
All 
Chloasma bronzinum 
M2901 
All 
Chloasma cachecticorum 
M2902 
All 
Chloasma caloricum 
M2903 
All 
Chloasma gravidarum 
M2903 
All 
Chloasma gravidarum 
M2903 
All 
Chloasma gravidarum 
M290z 
All 
Chloasma NOS 
M2103 
All 
Morphoea 
M2104 
All 
Linear Morphoea 
M210. 
All 
Circumscribed scleroderma 
M2100 
All 
Unspecified circumscribed scleroderma 
M2101 
All 
Localised dermatosclerosis 
M210z 
All 
Circumscribed scleroderma NOS 
PH322 
All 
Xeroderma pigmentosum 
BBE9. 
All 
[M]Nonpigmented naevus 
AD530 
All 
Lupus Pernio 

28 
 
AD53. 
All 
Sarcoidosis of skin 
Read CTV3 Code 
Term 
ID 
Description 
M290. 
All 
Melasma 
Xa1aM 
All 
Drug-induced melasma 
M2900 
All 
Chloasma bronzinum 
M2901 
All 
Chloasma cachecticorum 
M2902 
All 
Chloasma caloricum 
M2904 
All 
Chloasma hepaticum 
M2905 
All 
Chloasma toxicum 
M2906 
All 
Chloasma traumaticum 
M290z 
All 
Chloasma NOS 
M2903 
All 
Melasma of pregnancy 
Xa1aM 
All 
Drug-induced melasma 
M2103 
All 
Morphoea 
X7053 
All 
Generalised morphoea 
M2101 
All 
Localised morphoea  
M2100 
All 
Unspecified circumscribed scleroderma 
M210z 
All 
Circumscribed scleroderma NOS 
X7055 
All 
Linear morphoea 
PH322 
All 
Xeroderma pigmentosum 
X78Cz 
All 
Xeroderma pigmentosum group A 
X78D0 
All 
Xeroderma pigmentosum group B 
X78D1 
All 
Xeroderma pigmentosum group C 
X78D2 
All 
Xeroderma pigmentosum group D 
X78D3 
All 
Xeroderma pigmentosum group E 
X78D4 
All 
Xeroderma pigmentosum group F 
X78D5 
All 
Xeroderma pigmentosum group G 
X78D6 
All 
Xeroderma pigmentosum XP variant  
X78D7 
All 
De Sanctis-Cacchione syndrome 
X78D8 
All 
Xerodermoid, pigmented 
X50lw 
All 
Symmetrical progressive leucopathy 
X20GW 
All 
Cutaneous sarcoid 
X20GX 
All 
Orofacial sarcoid 
X20GY 
All 
Lupus pernio 
X5089 
All 
Acute skin sarcoidosis 
X508A 
All 
Sarcoidosis-induced erythema nodosum 
X508B 
All 
Lofgrens syndrome 
X508C 
All 
Maculopapular sarcoidosis 
X508D 
All 
Chronic skin sarcoidosis 
X508E 
All 
Sarcoidosis in scar 
X508F 
All 
Papular sarcoidosis 
X508G 
All 
Lichenoid sarcoidosis 
X508H 
All 
Nodular sarcoidosis 
X508I 
All 
Angiolupoid sarcoidosis 

29 
 
X00YQ 
All 
Sarcoid skin of eyelid  
X20G5 
All 
Sarcoid dactylitis 
X50Dy 
All 
Subacute nodular migratory panniculitis  
X50Dz 
All 
Subcutaneous lipogranulomatosis 
SNOMED Code 
Term 
ID 
Description 
36209000 
 
Melasma 
201274009 
 
Chloasma bronzinum (disorder) 
201275005 
 
Chloasma cachecticorum (disorder) 
201276006 
 
Chloasma caloricum (disorder) 
201277002 
 
Chloasma hepaticum (disorder) 
201278007 
 
Chloasma toxicum (disorder) 
280955001 
 
Drug-induced melasma (disorder) 
79840007 
 
Idiopathic chloasma (disorder) 
111208003 
 
Melasma gravidarum (disorder) 
54397000 
 
Symptomatic chloasma (disorder) 
201279004 
 
Chloasma traumaticum (disorder) 
201049004 
 
Morphea (disorder) 
128458002 
 
Plaque morphea (disorder) 
22784002 
 
Linear scleroderma (disorder) 
403521006 
 
Guttate morphea (disorder) 
201048007 
 
Localised morphea (disorder) 
7513007 
 
Generalized morphea (disorder) 
403522004 
 
Subcutaneous morphea (disorder) 
51156002 
 
Coup de sabre scleroderma (disorder) 
403523009 
 
Disabling pansclerotic morphea of children (disorder) 
128460000 
 
Diffuse cutaneous scleroderma (disorder) 
403524003 
 
Scleroderma-like secondary cutaneous sclerosis (disorder) 
 1717003 
 
Idiopathic guttate hypomelanosis (disorder) 
711154007 
 
Guttate hypopigmentation and punctate palmoplantar keratoderma 
with or without ectopic calcification (disorder) 
44600005 
 
Xeroderma pigmentosum (disorder) 
56048001 
 
Xeroderma pigmentosum, group E (disorder) 
25784009 
 
Xeroderma pigmentosum, group C (disorder) 
36454001 
 
Xeroderma pigmentosum, group G (disorder) 
1073003 
 
Xeroderma pigmentosum, group B (disorder) 
68637004 
 
Xeroderma pigmentosum, group D (disorder) 
42530008 
 
Xeroderma pigmentosum, group F (disorder) 
43477006 
 
Xeroderma pigmentosum, group A (disorder) 
73663008 
 
 Neurologic xeroderma pigmentosum (disorder) 
88877002 
 
Xeroderma pigmentosum, variant form (disorder) 
7806002 
 
Non-neurologic xeroderma pigmentosum (disorder) 
719819004 
 
Xeroderma pigmentosum and Cockayne syndrome complex 
(disorder) 
239083007 
 
Symmetrical progressive leucopathy (disorder) 

30 
 
763368004 
 
Familial progressive hyper and hypopigmentation of skin (disorder) 
403541001 
 
Nevus depigmentosus 
112680001 
 
Naevus depigmentosus 
55941000 
 
Cutaneous sarcoidosis (disorder) 
238680003 
 
Papular sarcoidosis (disorder) 
 238679001 
 
Sarcoidosis in scar (disorder) 
402369000 
 
Atrophic sarcoidosis (disorder) 
402371000 
 
Verrucous sarcoidosis (disorder) 
 238681004 
 
Lichenoid sarcoidosis (disorder) 
238674006 
 
Acute skin sarcoidosis (disorder) 
402370004 
 
Ulcerative sarcoidosis (disorder) 
58870009 
 
Sarcoidosis, anular type (disorder) 
54515008 
 
Sarcoidosis, plaque type (disorder) 
80941006 
 
Subcutaneous sarcoidosis (disorder) 
 870334009 
 
Palmoplantar sarcoidosis (disorder) 
238678009 
 
Chronic skin sarcoidosis (disorder) 
238677004 
 
Maculopapular sarcoidosis (disorder) 
402368008 
 
Ichthyosiform sarcoidosis (disorder) 
402373002 
 
Hypomelanotic sarcoidosis (disorder) 
9529007 
 
Sarcoidosis, erythrodermic type (disorder) 
72470008 
 
Sarcoidosis, lupus pernio type (disorder) 
402372007 
 
Subcutaneous nodular sarcoidosis (disorder) 
 238675007 
 
Sarcoidosis-induced erythema nodosum (disorder) 
238676008 
 
Lofgrens syndrome (disorder) 
31541009 
 
Lupus pernio of Besnier 
231799005 
 
Sarcoid skin of eyelid (disorder) 

31 
 
Appendix 2 
Potential differential diagnoses for vitiligo which will be used as exclusion criteria if they 
appear as diagnoses in the medical record within six months of the initial diagnosis of 
vitiligo (six months before or after the vitiligo diagnosis). *As these conditions are 
extremely uncommon in the UK they will not be used in the exclusion process. Codes for 
these conditions are listed in Appendix 1. 
 
Condition group 
Conditions/causes included 
Congenital and genetic hypomelanoses 
Piebaldism 
Tuberous sclerosis 
Hypomelanosis of Ito 
Waardenburg syndrome 
Hermanski-Pudlak syndrome 
Griscelli syndrome 
Menkes syndrome 
Post-inflammatory hypomelanoses 
Post-inflammatory leukoderma including after 
Atopic eczema or Psoriasis 
Lichen planus 
Pityriasis alba 
Lichen sclerosus 
Post traumatic leukoderma 
Post traumatic leukoderma 
Para-malignant hypomelanoses 
Cutaneous T-cell lymphoma (mycosis fungoides) 
Melanoma associated depigmentation 
Occupational/drug induced 
hypomelanoses 
Occupational vitiligo 
Other induced hypomelanoses  
Para-infectious hypopigmentation 
Pityriasis versicolor (or tinea versicolor) 
Leprosy* 
Leishmaniasis* 
Others 
Melasma 
Morphoea 
Idiopathic guttate hypomelanosis  
Xeroderma pigmentosum 
Progressive macular hypomelanosis  
Nevus depigmentosus 
Cutaneous sarcoidosis