|Year : 2019 | Volume
| Issue : 1 | Page : 38-44
Clinico-epidemiological profile of patients with vitiligo: A retrospective study from a tertiary care center of North India
Vikram K Mahajan, Sanket Vashist, Pushpinder Singh Chauhan, Karan Inder Singh Mehta, Vikas Sharma, Anuj Sharma
Department of Dermatology, Venereology and Leprosy, Dr. R. P. Govt. Medical College, Kangra (Tanda), Himachal Pradesh, India
|Date of Web Publication||14-Jan-2019|
Vikram K Mahajan
Department of Dermatology, Venereology and Leprosy, Dr. R. P. Govt. Medical College, Kangra (Tanda)-176 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: We studied clinico-epidemiological features of 945 patients with vitiligo with an objective to delineate epidemiological and clinical aspects of vitiligo from this part of the country. Materials and Methods: The medical records of patients with vitiligo attending outpatient clinic over a 5-year period from January 2013 to December 2017 were analyzed retrospectively for this descriptive, observational study. Results: There were 449 men and 496 women (m:f 1:1.1) aged between 2 and 83 years (mean 24.4 years) and having vitiligo for 1 week to 64 years (mean 5.1 years). The majority, 478 (50.6%) patients were aged ≤20 years and 248 (26.2%) were children aged ≤12 years. The age at the onset was between 6 months and 82 years (mean 20.5 years), and the majority 674 (71.3%) patients had it before 25 years of age. The consultation time was within 5 years in 692 (73.2%) patients. A family history of vitiligo was present in 150 (15.9%) patients. The majority 871 (92.2%) patients had involvement of up to 10% body surface area and vitiligo vulgaris in 562 (59.5%) and focal vitiligo in 117 (18.7%) patients were the most common clinical types. An association with other systemic disorders was in 124 (13.1%) patients and predominately included thyroid abnormalities and diabetes mellitus. Conclusions: Our observations are essentially consistent with the literature. There was no difference in clinico-epidemiological features of vitiligo. Patients with an affected first-degree family member had early onset, but difference was not statistically significant. Screening for concurrent thyroid disorders appears important. However, our inferences remain limited by single center, retrospective, observational, and cross-sectional nature of the study.
Keywords: Alopecia areata, autoimmune thyroiditis, Himachal Pradesh, Koebner's phenomenon, leukotrichia, psoriasis, vitiligo vulgaris
|How to cite this article:|
Mahajan VK, Vashist S, Chauhan PS, Mehta KI, Sharma V, Sharma A. Clinico-epidemiological profile of patients with vitiligo: A retrospective study from a tertiary care center of North India. Indian Dermatol Online J 2019;10:38-44
|How to cite this URL:|
Mahajan VK, Vashist S, Chauhan PS, Mehta KI, Sharma V, Sharma A. Clinico-epidemiological profile of patients with vitiligo: A retrospective study from a tertiary care center of North India. Indian Dermatol Online J [serial online] 2019 [cited 2019 Feb 23];10:38-44. Available from: http://www.idoj.in/text.asp?2019/10/1/38/250063
| Introduction|| |
Vitiligo is a common acquired disorder of skin depigmentation in varying patterns, varying from small macules with scalloping borders to near-total depigmentation of body. The disorder affects nearly 1%–2% of the world population irrespective of race and ethnicity with highest incidence recorded in Indian subcontinent followed by Mexico and Japan., The exact etiology of vitiligo is poorly understood and is often considered as a multifactorial disease with a complex pathogenesis encompassing several postulations implicating autoimmune, cytotoxic, biochemical, oxidant–antioxidant, viral, and neural mechanisms for destruction of the melanocyte function in genetically predisposed. The presence of autoimmune diseases like autoimmune thyroiditis, Grave's disease, Addison's disease, diabetes mellitus, alopecia areata, and pernicious anemia in patients and their first-degree relatives favors its autoimmune etiology. A proportion of up to 30% patients with positive family history vary across regions and ranges from 6% to 18% in general and was as high as 40% in an Indian study., Since its occurrence does not conform to a set pattern of inheritance in studies of whole families and both twins, it is perhaps polygenic or may be determined by an autosomal dominant gene of variable penetrance. Factors such as poor nutrition, emotional stress, autoimmunity, trauma, drugs, infections, sepsis, and exposure to the sun, chemicals, and toxins are often considered to trigger it. Clinically, the usual age of onset is before 20 years of age in nearly half of the cases. It affects both genders equally at any age but most studies report a peak incidence between 18 and 21 years (mean 24 years)., Few studies reporting women being affected almost two times more often than men is attributed to their health seeking behavior for cosmetic concerns as vitiligo can be comparatively more stigmatizing and psychosocially devastating for them., However, in children, vitiligo shows a female preponderance, a higher proportion of segmental presentation than acrofacial and mucosal vitiligo, and association with other autoimmune or endocrine disorders being uncommon., This study was carried out with an objective to document clinico-epidemiological features of vitiligo from this part of the country having varied geo-climatic conditions, rural and semi-urban communities of diverse ethnic backgrounds and living styles differing from rest of the country and especially in view of a recent study demonstrating polymorphism of Liver X receptor-α −6A and + 1257T alleles imparting risk of vitiligo in North Indian population.
| Materials and Methods|| |
The medical records of all patients with vitiligo attending outpatient clinic during Jan 2013 to Dec 2017 were analyzed retrospectively for this descriptive observational study. The study was approved by the Institutional Protocol Review Board and Institutional Ethics Committee. The diagnosis of vitiligo was essentially clinical, confirmed by at least three senior dermatologists. Clinically ambiguous cases and lesions not accentuating under Woods' light were excluded. They were also evaluated for presence of other cutaneous and systemic disorders. The extent of body surface area involvement was measured by Wallace rule of nine and various clinical patterns were classified according to Vitiligo Global Issues Consensus Conference 2011–12 report.
MS Word Excel software was used to tabulate and analyze the data. The continuous data are presented as means and categorical variables are presented as frequencies and percentages. The two-sample t-test was used to determine whether the difference between means is significant. A P value <0.05 calculated at 95% confidence limit was considered statistically significant.
| Results|| |
The study comprised 945 patients with vitiligo accounting for 0.43% of 2, 17, 518 patients attending dermatology outpatient clinic during the study period. Their clinico-epidemiological profile, frequency of vitiligo patterns, and associated disorders are shown in [Table 1] and [Table 2]. There were 449 men and 496 women (m:f 1:1.1) aged between 2 and 83 years (mean 24.4 years) at presentation. The patients were distributed across all age groups and the majority 478 (50.6%) patients were aged ≤20 years and also comprised 248 (26.2%) children aged up to 12 years. The age at onset was between 6 month and 82 years (mean 20.5 years) and the majority 674 (71.3%) patients had developed it before 25 years of age. The duration of vitiligo varied between 1 week and 64 years (mean 5.1 years) at presentation and majority 692 (73.2%) patients had presented within 5 years. Lower limbs in 257 (27.2%), scalp, face, and neck in 249 (26.3%), trunk in 171 (18.1%), upper limbs in 118 (12.5%), eyelids in 103 (10.9%), and lips in 30 (3.2%) patients, respectively, were the usual sites of onset in order of frequency. Twenty-two (2.3%) patients had noted first lesion appearing over anogenital skin.
|Table 1: Clinico-epidemiological features of vitiligo patients (n = 945)|
Click here to view
|Table 2: Extent of body involvement and clinical patterns of vitiligo (n = 945)|
Click here to view
Family members of 150 (15.9%) patients had vitiligo and included first-degree relatives in 90 or second/third-degree relatives in 60 patients and none had history of other autoimmune disorders. The onset of vitiligo in patient with affected family members was between 1.5 and 65 years (mean 18.3 years) compared with 6 months and 82.5 years (mean 20.8 years) in other 795 patients and the difference was not statistically significant. Only 189 (20%) patients implicated physical trauma (in 125 patients), surgery, medical or psychological illness (in 41 patients), and pregnancy/parturition (in 23 patients) as trigger factors.
The majority 871 (92.2%) patients had involvement of up to 10% body surface area and it was <50% in 193 (96.5%) patients. The nonsegmental vitiligo involving multiple body sites was the most common clinical presentation seen in 914 (97%) patients compared with segmental pattern in 29 (3%) patients only [Figure 1]a and [Figure 1]b. Vitiligo vulgaris in 562 (59.5%) patients and focal vitiligo in 117 (18.7%) patients [Figure 2] remain the most common forms of nonsegmental vitiligo. Acrofacial vitiligo [Figure 3] accounted for 89 (9.4%) cases. Mixed pattern in 105 (11.1%), facial vitiligo in 77 (8.1%), and vitiligo universalis in 12 (1.3%) patients [Figure 4] were other clinical forms of vitiligo. Confetti-like [Figure 5] and trichrome [Figure 6] morphology was present in 91 (9.6%) patients only. Leukotrichia [Figure 7] and kobnerization [Figure 8]a and [Figure 8]b were occurred in 309 (32.7%) and 260 (27.5%) patients, respectively.
|Figure 1: (a) Segmental vitiligo involving right side of forehead. (b) Segmental vitiligo involving left side of chest|
Click here to view
|Figure 2: Focal vitiligo in a child showing few vitiligo macules over right temporal area without a particular distribution that has not evolved into segmental vitiligo over a period of 1–2 years|
Click here to view
|Figure 3: Vitiligo lesions involving face, perioral, and periocular regions, and distal extremities in acrofacial vitiligo|
Click here to view
|Figure 4: Near-total depigmentation of skin in vitiligo universalis, a form of vitiligo vulgaris with extensive body involvement especially over face, hands, fingers, and trauma-exposed sites|
Click here to view
|Figure 5: Vitiligo punctata or confetti-like depigmented macules over neck in a vitiligo patient|
Click here to view
|Figure 6: Trichrome vitiligo showing depigmentation surrounded by varied hues of hyper pigmentation |
Click here to view
|Figure 7: Patchy alopecia areata of scalp in patient with vitiligo. Note leukotrichia in vitiligo lesions over neck|
Click here to view
|Figure 8: (a) Koebner's isomorphic phenomenon: Vitiligo lesions localization over iliac crests which are prone to friction. (b) Koebner's isomorphic phenomenon: Vitiligo lesions localization over scratch marks|
Click here to view
Associated systemic autoimmune disorders were present in 124 (13.1%) patients and included diabetes mellitus in 14 patients, clinical or subclinical thyroid disorders (hypo- or hyperthyroidism) in 57 patients, and elevated serum antithyroperoxidase antibody levels (autoimmune thyroiditis) in 67 patients [Table 3]. Cutaneous associations in 58 (6.1%) patients included halo nevus [Figure 9] in 35, plaque psoriasis [Figure 10] in 8, canities or familial premature hair graying in 6 patients without scalp vitiligo, alopecia areata [Figure 7] in 4, and lichen planus in 3 patients in order of frequency.
| Discussion|| |
The prevalence of vitiligo in India has been invariably reported between 0.25% and 4% of dermatology outpatients across studies from India and up to 8.8% in Gujarat and Rajasthan., Vitiligo affects both genders almost with equal frequency in most reports or with a predilection for women being affected two times more often than men as an exception.,, Vitiligo affected 0.43% of dermatology outpatients of both genders almost with equal frequency in this study conforming to these epidemiological patterns. The mean duration (5.1 years) of vitiligo in our patients at consultation is also similar and corroborates its slow progression and asymptomatic nature.
Although vitiligo may develop anytime in life, the onset in early infancy or old age is uncommon. Genetic factors, as in patients with affected first-degree relatives, too have suggested to influence the age of onset of vitiligo but no significant difference in onset of vitiligo with affected family members compared with those having no vitiligo-affected family member was observed in this study.,,, The mean age of onset is before 20 years of age in case of childhood vitiligo but varies between 18 and 32 years in adults., In contrast, its onset was between the ages of 40 and 60 years in a study from Denmark and the prevalence declined after 70 years of age. Though the mean age of onset at 20.5 years in our study indicates that vitiligo predominantly affects the younger population, its onset in a 6-month-old child and adults aged above 80 years is, however, notable.
It remains difficult to precisely identify factors inciting vitiligo.,, Among a multitude of triggers such as allergens, chemicals, stress, occupations, systemic illness, diet, and sunlight, the physical trauma perhaps remains the most implicated factor both for onset and development of vitiligo and tendency of lesions localizing over trauma-prone sites (Koebner's phenomenon). This is also evident in this study from common sites of onset irrespective of its clinical type being upper or lower extremities in majority which are more exposed to friction and injuries of daily activities. The presence of Koebner's phenomenon, a frequent occurrence in 20%–60% vitiligo patients and in our 27.5% patients also corroborates this observation. Similarly, scalp, face, and/or neck in 26.3% patients in this study too have been frequent site of onset of vitiligo in many reports and attributed to sunlight/UV light-induced Koebnerization.,,,,,
The vitiligo vulgaris in our 59.5% followed by focal vitiligo in 18.7% patients, facial involvement in nearly 8%, and lip-tip variety in 0.4% patients, respectively, in that order conforms to their reported frequencies. Segmental vitiligo constituted only 3% patients in our study against reported prevalence of 5%–27.9% of all cases of vitiligo. The overall distribution of clinical forms of vitiligo was similar in our study with minor differences but such variability of their distribution frequencies are well known.,,, Trichrome vitiligo in our 9.6% patients also conforms to its reported prevalence between 8% and 66% across studies.,,
At least one additional autoimmune disorder and circulating antibodies against thyroid gland, gastric parietal cells, and adrenal gland have been reported in up to 30% vitiligo patients with or without clinical manifestations and were observed in our 13% cases as well. Autoimmune thyroiditis manifesting clinically or as antithyroid peroxidase antibodies, thyroid microsomal antibodies, and/or antithyroglobulin antibodies in 0.27%–50% vitiligo patients and 21% in cases versus 3% in controls remains the commonly linked disorder., Although all patients were not investigated, 39 of our patients had pre-existing or newly diagnosed hypothyroidism, and elevated serum anti-TPO antibody levels in 67 patients with apparent euthyroid state suggests autoimmune thyroiditis. A causal relationship too has been suggested between diabetes and vitiligo as both are associated with HLA DR3 and HLA DR4, and 1%–7% of vitiligo patients have insulin-dependent diabetes, whereas 4.8% of all diabetic patients may have vitiligo. The prevalence of non-insulin-dependent diabetes varies from 2% to 16% in Indian studies and was observed in our 14 cases as well.,
The presence of halo nevus in 1%–35% of vitiligo patients is considered a clinical marker for heralding onset of vitiligo and of cell-mediated immunity against abnormal melanocytes/nevocytes or a risk factor for development of vitiligo mostly in children., Similarly, canitis in vitiligo represents a form of vitiligo and favors involvement, at least partly, of an autoimmune pathway. Among 6.1% patients with cutaneous abnormalities, we also observed halo nevi in 35 and canities in 6 patients. Similarly, coexistent plaque psoriasis and alopecia areata involving scalp or beard observed by us have been well reported in 0.49%–14% of vitiligo patients., The presence of other dermatoses appears fortuitous in our patients.
The study may not reflect exact attributes of general population due to its retrospective, observational, hospital-based, cross-sectional nature, whereas duplicate registration of outpatient attendees remains possible. To distinguish between rural versus urban versus tribal patients was not part of this retrospective analysis. Not screening for associated autoimmune or other systemic disorders, antithyroid antibodies other than anti-TPO antibody, abnormal thyroid functions, or autoimmune thyroiditis in all patients, and no follow-up for their development or therapeutic outcome remain other limitations.
| Conclusions|| |
Vitiligo appears to secularly affect both genders and all age groups irrespective of differing geo-environmental, living conditions and lifestyles, or ethnicities, has onset at early adulthood, and is slowly progressive in most cases, whereas vitiligo vulgaris and focal vitiligo remain the most common forms and physical trauma the important inciting factor. The patients with an affected first-degree family member may have more chances of onset at an early age compared with others but without a significant difference. Screening these patients for concurrent thyroid disorders that may have a bearing on prognosis and therapeutic outcome needs to be emphasized.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alikhan A, Felsten LM, Daly M, Petronic-Rosic V. Vitiligo: A comprehensive overview part I. Introduction, epidemiology, quality of life, diagnosis, differential diagnosis, associations, histopathology, etiology, and work-up. J Am Acad Dermatol 2011;65:473-91.
Kr−ger C, Schallreuter KU. A review of the worldwide prevalence of vitiligo in children/adolescents and adults. Int J Dermatol 2012;51:1206-12.
Kutlubay Z, Karakus O, Engin B, Serdaroglu S. Vitiligo as an autoimmune disease. J Turk Acad Dermatol 2012;6:1262.
Kostovic K, Pasic A. New treatment modalities for vitiligo: Focus on topical immunomodulators. Drugs 2005;65:447-59.
Behl PN, Agarval A, Srivastava G. Etiopathogenesis of vitiligo: Are we dealing with an environmental disorder? Indian J Dermatol Venereol Leprol 1999;65:161-7.
] [Full text]
Jeon IK, Park CJ, Lee MH, Lee DY, Kang HY, Hann SK, et al.
Amulticenter collaborative study by the Korean society of vitiligo about patients' occupations and the provoking factors of vitiligo. Ann Dermatol 2014;26:349-56.
Iacovelli P, Sinagra JL, Vidolin AP, Marenda S, Capitanio B, Leone G, et al.
Relevance of thyroiditis and of other autoimmune diseases in children with vitiligo. Dermatology 2005;210:26-30.
Liu JB, Li M, Yang S, Gui JP, Wang HY, Du WH, et al.
Clinical profiles of vitiligo in china: An analysis of 3742 patients. Clin Exp Dermatol 2005;30:327-31.
Arýcan O, Koç K, Ersoy L. Clinical characteristics in 113 Turkish vitiligo patients. Acta Dermatovenerol Alp Pannonica Adriat 2008;17:129-32.
Firooz A, Bouzari N, Fallah N, Ghazisaidi B, Firoozabadi MR, Dowlati Y, et al.
What patients with vitiligo believe about their condition. Int J Dermatol 2004;43:811-4.
Borimnejad L, Parsa Yekta Z, Nikbakht-Nasrabadi A, Firooz A. Quality of life with vitiligo: Comparison of male and female muslim patients in Iran. Gend Med 2006;3:124-30.
Pajvani U, Ahmad N, Wiley A, Levy RM, Kundu R, Mancini AJ, et al.
The relationship between family medical history and childhood vitiligo. J Am Acad Dermatol 2006;55:238-44.
Agarwal S, Kaur G, Randhawa R, Mahajan V, Bansal R, Changotra H, et al.
Liver X receptor-α polymorphisms (rs11039155 and rs2279238) are associated with susceptibility to vitiligo. Meta Gene 2016;8:33-6.
Ezzedine K, Lim HW, Suzuki T, Katayama I, Hamzavi I, Lan CC, et al.
Revised classification/nomenclature of vitiligo and related issues: The vitiligo global issues consensus conference. Pigment Cell Melanoma Res 2012;25:E1-13.
Vora RV, Patel BB, Chaudhary AH, Mehta MJ, Pilani AP. A clinical study of vitiligo in a rural set up of Gujarat. Indian J Community Med 2014;39:143-6.
] [Full text]
Shah H, Mehta A, Astik B. Clinical and sociodemographic study of vitiligo. Indian J Dermatol Venereol Leprol 2008;74:701.
] [Full text]
Fatani MI, Al Sharif SH, Alfif KA, Khan AS, Hussain WA, Banjar AA. The clinical patterns of vitiligo “hospital-based study” in Makkah region, Saudi Arabia. J Dermatol Dermatol Surg 2014;18:17-21.
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.
Jin Y, Birlea SA, Fain PR, Gowan K, Riccardi SL, Holland PJ, et al.
Genome-wide analysis identifies a quantitative trait locus in the MHC class II region associated with generalized vitiligo age of onset. J Invest Dermatol 2011;131:1308-12.
Shankar DS, Shashikala K, Madala R. Clinical patterns of vitiligo and its associated co morbidities: A prospective controlled cross-sectional study in South India. Indian Dermatol Online J 2012;3:114-8.
Vrijman C, Hosseinpour D, Bakker JG, Wolkerstorfer A, Bos JD, van der Veen JP, et al.
Provoking factors, including chemicals, in Dutch patients with vitiligo. Br J Dermatol 2013;168:1003-11.
van Geel N, Speeckaert R, Taieb A, Picardo M, Böhm M, Gawkrodger DJ, et al.
Koebner's phenomenon in vitiligo: European position paper. Pigment Cell Melanoma Res 2011;24:564-73.
Handa S, Pandhi R, Kaur I. Vitiligo: A retrospective comparative analysis of treatment modalities in 500 patients. J Dermatol 2001;28:461-6.
Altaf H. Shah IH, Ahmad QM. Evaluation of thyroid function and presence of anti-thyroid peroxidise antibodies in patients with vitiligo. Egypt Dermatol Online J 2010;6:3.
Alkhateeb A, Fain PR, Thody A, Bennett DC, Spritz RA. Epidemiology of vitiligo and associated autoimmune diseases in Caucasian probands and their families. Pigment Cell Res 2003;16:208-14.
Mason CP, Gawkrodger DJ. Vitiligo presentation in adults. Clin Exp Dermatol 2005;30:344-5.
Garg S, Mahajan VK, Mehta KS, Chauhan PS, Gupta M, Rawat R. Vitiligo and associated disorders including autoimmune diseases: A prospective study of 200 Indian patients. Pigment Int 2015;2:91-6. [Full text]
Ezzedine K, Diallo A, Léauté-Labrèze C, Seneschal J, Mossalayi D, AlGhamdi K, et al.
Halo nevi association in nonsegmental Vitiligo affects age at onset and depigmentation pattern. Arch Dermatol 2012;148:497-502.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3]