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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 22-25

Systemic and cutaneous associations of vitiligo


Department of Dermatology, MGM Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission20-Apr-2020
Date of Acceptance01-May-2020
Date of Web Publication06-Jun-2020

Correspondence Address:
Dr. Arushi Dudeja
Department of Dermatology, MGM Medical College and Hospital, N6, CIDCO, Aurangabad, Maharashtra.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.MGMJ_33_20

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  Abstract 

Introduction: Vitiligo is a common, acquired, pigmentary disorder of the skin, mucous membrane, and hair, resulting from the destruction of functional melanocytes. Objective: The objective of this study was to describe the cutaneous and systemic manifestations of vitiligo. Materials and Methods: The study comprised 130 patients attending the outpatient department (OPD) of dermatology, MGM Medical College and Hospital, Aurangabad, India. Clinical details were noted in the pro formas, and cutaneous examination was done in relation to the size and type of lesions of vitiligo and other lesions if present. Pure-tone audiometry (PTA) and ophthalmological examinations were also performed to rule out audiometric and ocular changes. Further, lab investigations were conducted. Results: Of 130 patients, the female-to-male ratio was found to be 1.06:1. The most common age-group for the disease onset was 21–30 years. Vitiligo vulgaris and focal vitiligo were found to be the most common types, followed by generalized, acrofacial, segmental, poliosis in 3.8% patients, alopecia in 4.6% cases, hypoacusis was observed in 3.1%, halo nevi in 0.8%, thyroid disease in 7.7%, diabetes mellitus in 3.1%, and psoriasis in 0.8% of cases. Conclusion: Vitiligo vulgaris and focal vitiligo were the most common types found with associated cutaneous and systemic abnormalities such as thyroid disease, diabetes mellitus, and alopecia areata.

Keywords: Abnormalities, acrofacial vitiligo, focal vitiligo, vitiligo vulgaris


How to cite this article:
Dudeja A, Deshmukh A, Khedkar M. Systemic and cutaneous associations of vitiligo. MGM J Med Sci 2020;7:22-5

How to cite this URL:
Dudeja A, Deshmukh A, Khedkar M. Systemic and cutaneous associations of vitiligo. MGM J Med Sci [serial online] 2020 [cited 2021 Oct 21];7:22-5. Available from: http://www.mgmjms.com/text.asp?2020/7/1/22/286106




  Introduction Top


Vitiligo is a common, acquired, pigmentary disorder of the skin, mucous membrane, and hair resulting from the destruction of functional melanocytes. It is characterized by well-circumscribed asymptomatic depigmented/chalky white macules of different sizes and shapes with a tendency to increase in size centrifugally. It affects all ethnic groups and has a worldwide occurrence of 0.3%–1%.[1] Adults and children of both sexes are equally affected, although the greater number of reports among females is probably due to the greater social consequences to women and girls affected by this condition. Vitiligo is considered to be a multifactorial disorder. An assortment of hypothesis, such as genetic, neural, biochemical, and autoimmune, has been put forth to elucidate its etiopathological mechanism.[2]

The autoimmune theory appears to be the most plausible because of its association with autoimmune disorders. The systemic associations also include autoimmune disorders that are usually neglected. Hence, this study was carried out to study those cutaneous and systemic associations of vitiligo.


  Materials and methods Top


This was a cross-sectional study aimed at studying the various systemic and cutaneous associations of vitiligo in patients attending the outpatient department (OPD) of dermatology, MGM Medical College & Hospital, Aurangabad, India, from October 2015 to October 2017, with the approval of the institutional ethics committee. A total of 130 patients were enrolled in the study. The detailed history of each patient was taken based on disease duration, progression, family history, and any other chronic illness. Along with the history, the cutaneous examination was done in relation to the size and type of lesions of vitiligo and other lesions if present. Pure-tone audiometry (PTA) and ophthalmological examinations were also carried out to rule out audiometric and ocular changes. Further, lab investigations were performed in all patients, including complete blood count (CBC), thyroid-stimulating hormone (TSH), random blood sugar (RBS), antinuclear antibody (ANA), and vitamin B 12 levels. A CBC was done to check hemoglobin levels to rule out anemia and its type. TSH levels were checked in all the patients and if found deranged then complete thyroid profile was done. RBS, ANA, PTA, and ophthalmological examination were conducted on all the patients. In the ophthalmological examination, slit lamp examination and retina evaluation were performed. Vitamin B 12 levels were tested only in those patients where anemia due to other causes was ruled out.

Inclusion criteria

All diagnosed cases of vitiligo. They included the history or evidence of developing any cutaneous or systemic manifestations in association with vitiligo.

Exclusion criteria

Cases showing white patches due to secondary causes such as leukoderma.

Statistical methods applied

For sample size calculation, an allowable error was taken at 2 with a prevalence at 1%. The sampling design used was purposive sampling. Data were statistically described in a number of cases and percentages, wherever found appropriate. A chi-square test was used as a test of significance. All statistical calculations were carried out using computer programs Statistical Package for Social Science (IBM-SPSS), version 20.0, for Microsoft Windows. Findings were considered significant with a P value <0.05.


  Results Top


In our study, a total of 130 patients of vitiligo were included. A detailed history was taken, and examination was performed. Further, lab investigations were carried out. All the patients were divided into six age-groups. The maximum percentage of patients was in the age-group of 21–30 years. Among 130 patients, 63 (48.5%) were males and 67 (51.5%) were females, giving a female-to-male ratio of 1.06:1 [Table 1]. Of 130 patients, 56 (43.1%) patients had progressive vitiligo, whereas 74 (56.9%) had nonprogressive vitiligo [Table 2]. Family history was found to be positive in 33 (25.4%) patients, whereas it was negative in 97 (74.6%) patients [Table 3]. Statistically, no significant association was found between vitiligo and family history. The most common type of vitiligo found was vitiligo vulgaris and focal vitiligo, involving 35.4% patients each, followed by generalized (23.1%), acrofacial (3.8%), and segmental (2.3%) [Table 4]. Among cutaneous findings, alopecia was the most common finding observed in 6 (4.6%), followed by poliosis in 3.8% and halo nevus, psoriasis, and systemic lupus erythematosus (SLE) in 0.8% cases each. Among the systemic associations, hypothyroidism was found in 10 (7.7%) patients [Table 5]. Autoimmune disorders were found to be present in 4 (3.1%) cases. Hypoacusis was found in 4 (3.1%) cases. Further, conductive deafness was found to be present in 3 (2.3%) cases, and sensorineural deafness in 1 (0.8%) case [Table 6]. Among the ophthalmological findings, refractive error was found in 11.5% cases, followed by nasal pterygium in 1.5% cases, and diabetic retinopathy and chorioretinitis in 0.8% cases each [Table 7]. Among 130 patients, 4 (3.1%) patients were found to have diabetes mellitus. No significant association was found between diabetes and vitiligo.
Table 1: Distribution of age group

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Table 2: Disease Progression

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Table 3: Presence of family history

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Table 4: Types of vitiligo

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Table 5: Associated diseases

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Table 6: Assessment by pure tone audiometry

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Table 7: Associated ophthalmological diseases

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  Discussion Top


The prevalence of vitiligo is high in India. The relative prevalence varies between 0.46% and 8.8%. The varying ethnic backgrounds of the population residing in different geographic regions with varying environmental conditions may contribute to the wide variation in the prevalence of vitiligo in India. In our study, the female-to-male ratio was found to be 1.06:1. Thus, males and females were affected almost equally. This was found to be similar in studies reported by Handa and Kaur,[3] Sarin and Kumar,[4] Koranne et al.[5] Although few studies showed female preponderance such as in Mutairi and Sharma,[6] Shajil et al.,[7] and Martis et al.,[8] it may be presumably explained by more awareness of the women to cosmetic disfigurement, and therefore more likely to seek treatment.

In our study, the most common age-group for disease onset was 21–30 years, which was consistent with studies such as in Shajil et al.[7] and Koranne et al.[5] However, Howitz et al.[9] showed the age of onset to be between 40 and 60 years. At the time of presentation, 56 (43.1%) patients had progressive vitiligo. Hann et al.[10] reported 88.8% of their patients showed a progression in the disease. Positive family history was reported in 25.4% of the patients in our study. Handa and Kaur[3] reported 11.5%, Mutairi and Sharma[6] reported 18.9%, and Shajil et al.[7] reported 21.93% of cases with a positive family history. Vitiligo has a polygenic or autosomal-dominant inheritance pattern with incomplete penetrance and variable expression.[11],[12] Familial occurrence has been reported to vary from 6.25% to 30%.[13] Positive family history is considered to be a poor prognostic factor for vitiligo.

In our study, vitiligo vulgaris and focal vitiligo were found to be the most common types, followed by generalized, acrofacial, and segmental. The frequency of the distribution of clinical types of vitiligo varies in different studies. Our findings were found to be similar as reported by Shajil et al.,[7] Singh et al.,[14] and Handa and Kaur.[3] In a few studies reported by Singh et al.[14] and Agarwal et al.,[15] acrofacial vitiligo was the most common type found. Most patients begin with focal vitiligo and progress to different phenotypes of vitiligo as the disease progresses. It is difficult to interpret the mechanism and determinants underlying the clinical patterns of vitiligo. Poliosis was seen in 3.8% of patients in this study. It was reported to be 9.2% in a study by Shajil et al.,[7] and 6.3% in Reghu and James.[16] Alopecia was found to be in 4.6% of the patients in our study. Other studies such as Reghu and James[16] reported 12.5%, Shajil et al. reported 1.18%,[7] and Singh et al.[17] reported 2%. It is considered as a poor prognostic factor.

In our study, psoriasis was present in 0.8% of the patients. It was reported to be 1.9% in a study by Agarwal et al.,[15] 0.24% in Shajil et al.,[7] and 0.5% in Singh et al.[17] Halo nevi were present in 0.8% cases. Halo nevi coexisting with vitiligo lesions are not commonly seen in adult-onset vitiligo. In this study, autoimmune diseases were seen in 3.1% cases. The association with thyroid disease was 7.7%, followed by diabetes mellitus in 3.1% cases, and SLE in 0.8% of cases. In an article by Arycan et al. reported 4.4% cases, Singh et al. reported 12% and 0.24% cases were seen by Shajil et al. In our study, Diabetes was reported in 3.1%. Similar findings was reported by Singh et al. On the contrary, it has been reported up to 69.23% in a study by Mutairi and Sharma.[6] The mechanism destroying the melanocyte in the skin could also affect other melanocytic organs. Several ocular and audiological abnormalities have been reported in patients of vitiligo. Hypoacusis was observed in 3.1% cases in our study. Mutairi and Sharma[6] reported 22.37% cases, whereas Singh et al.[17] reported none. Specific ophthalmological abnormality, such as chorioretinitis, was observed in 1% cases.[18] Other findings were diabetic retinopathy, nasal pterygium, and refractive error, which have not been found to be related to vitiligo. Gopal et al.[19] reported 20% cases of ophthalmological abnormality, whereas Reghu and James[16] and Singh et al.[17] reported none.


  Conclusion Top


Vitiligo vulgaris and focal vitiligo were the most common types found with associated cutaneous and systemic abnormalities such as thyroid disease, diabetes mellitus, and alopecia areata.

  • What is known—Vitiligo is associated with cutaneous and systemic abnormalities.


  • What is new—Chorioretinitis was found to be associated with vitiligo in a patient of SLE.


Financial support and sponsorship

MGMIHS.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Majumder PP. Genetics and prevalence of vitiligo. In: Hann SK, Norlund JJ, editors. Vitiligo: A Monograph on the Basic and Clinical Science. 1st ed. Bangalore, India: Blackwell Science; 2000. p. 18-20.  Back to cited text no. 1
    
2.
Kar PK. Vitiligo: A study of 120 cases. Indian J Dermatol Venereol Leprol 2001;67:302-4.  Back to cited text no. 2
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3.
Handa S, Kaur I. Vitiligo: Clinical findings in 1436 patients. J Dermatol 1999;26:653-7.  Back to cited text no. 3
    
4.
Sarin RC, Kumar AS. A clinical study of vitiligo. Indian J Dermatol Venereol Leprol 1977;43:311-4.  Back to cited text no. 4
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5.
Koranne RV, Sehpgal VN, Sachdeva KG. Clinical profile of vitiligo in north India. Indian J Dermatol Venereol Leprol 1986;52:81-2.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Mutairi N, Sharma AK. Profile of vitiligo in Farwaniya region in Kuwait. Kuwait Medical J 2006;38:128-31.  Back to cited text no. 6
    
7.
Shajil EM, Marfatia YS, Begum R. Acetylcholine esterase levels in different clinical types of vitiligo in Baroda, Gujarat. Indian J Dermatol 2006;51:289-91.  Back to cited text no. 7
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8.
Martis J, Bhat R, Nandakishore B, Shetty JN. A clinical study of vitiligo. Indian J Dermatol Venereol Leprol 2002;68:92-3.  Back to cited text no. 8
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9.
Howitz J, Brodthagen H, Schwartz M, Thomsen K. Prevalence of vitiligo. Epidemiological survey on the Isle of Bornholm, Denmark. Arch Dermatol 1977;113:47-52.  Back to cited text no. 9
    
10.
Hann SK, Chun WH, Park YK. Clinical characteristics of progressive vitiligo. Int J Dermatol 1997;36:353-5.  Back to cited text no. 10
    
11.
Bleehen SS, Ebling FJ, Champion RH. Disorders of skin color. In: Champion RH, Burton JL, Ebling FJ, editors. Textbook of Dermatology. London, UK: Blackwell Scientific Publications; 1992. p. 1561-622.  Back to cited text no. 11
    
12.
Moscher DB, Fitzpatrick TB, Hori Y, Ortonne JP. Disorders of pigmentation. In: Fitzpatick TB, Isen AZ, Wolff K, Freedberg IM, Austen KF, editors. Dermatology in General Medicine. New York: McGraw Hill; 1993. p. 903.  Back to cited text no. 12
    
13.
Shajil EM, Agrawal D, Vagadia K, Marfatia YS, Begum R. Vitiligo: Clinical profiles in Vadodara, Gujarat. Indian J Dermatol 2006;51:100-4.  Back to cited text no. 13
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14.
Singh M, Singh G, Kanwar AJ, Belhaj MS. Clinical pattern of vitiligo in Libya. Int J Dermatol 1985;24:233-5.  Back to cited text no. 14
    
15.
Agarwal S, Ojha A, Gupta S. Profile of vitiligo in Kumaun region of Uttarakhand, India. Indian J Dermatol 2014;59:209.  Back to cited text no. 15
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16.
Reghu R, James E. Epidemiological profile and treatment pattern of vitiligo in tertiary care teaching hospital. Int J Pharm Sci 2011;3:137-41.  Back to cited text no. 16
    
17.
Singh S, Pandey U, Pandey SS. Epidemiological profile of vitiligo in northern India. J Applied Pharm Sci 2011;01:211-14.  Back to cited text no. 17
    
18.
Arycan O, Koc K, Ersoy L. Characteristics in 113 Turkish vitiligo patients. Acta Dermatoven 2008;17:129-32.  Back to cited text no. 18
    
19.
Gopal KV, Rama Rao GR, Kumar YH, Appa Rao MV, Vasudev P, . Srikant Vitiligo: A part of a systemic autoimmune process. Indian J Dermatol Venereol Leprol 2007;73:162-5.  Back to cited text no. 19
[PUBMED]  [Full text]  



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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