|Year : 2015 | Volume
| Issue : 1 | Page : 23-28
Clinico-epidemiological profile of childhood vitiligo
Preeti Keyur Sheth, S Sacchidanand, GS Asha
Department of Dermatology, Bangalore Medical College and Research Centre, Bengaluru, Karnataka, India
|Date of Web Publication||16-Jan-2015|
Preeti Keyur Sheth
No. 5, Muni Suvrat Ashish, Cama Lane, Ghatkopar - West, Mumbai - 400 086, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Vitiligo is a depigmenting and psychologically devastating disorder. Childhood-onset vitiligo has different epidemiological and clinical characteristics as compared to adults.
Aim: To study the clinical and epidemiological characteristics of childhood vitiligo.
Materials and Methods: First 100 pediatric patients younger than 18 years, with vitiligo who attended the Pediatric Dermatology Clinic of Victoria Hospital, Bangalore Medical College, Bangalore, India, between April 2013 and December 2013 were included in the study. A detailed history and examination along with autoimmune diseases, laboratory parameters, and vitiligo disease activity score (VIDA) score were recorded.
Results: In the 100 patients who attended pediatric dermatology OPD in 9 months duration of the study, we had 55 female patients (55%) and 45 male patients (45%). The mean age at onset was 8.92 years (ranging day 1-16 years), with duration of disease varying from 2 months to 8 years with mean duration of 1.36 years. According to standard classification most common pattern of vitiligo was vulgaris (46%), followed by focal (36%), mucosal (8%), acro-facial (7%), segmental (3%). The most common site for vitiligo was lower limb (62%), followed by face (46%), upper limbs (30%), scalp (25%), and mucosal (18%). Segmental vitiligo was seen in 3% and nonsegmental vitiligo in 97%. VIDA score +4 was most common and was seen in 81%.
Conclusion: Vitiligo is a common depigmenting disorder with vulgaris being the most common pattern and lower limbs being the most common site seen in pediatric patients. Autoimmune associations were more frequent in nonsegmental vitiligo. Among the cutaneous associations, atopic dermatitis was most frequently encountered. Patients with family history of autoimmune disorders tend to present at an early age.
Keywords: Children, clinico-epidemiological, vitiligo
|How to cite this article:|
Sheth PK, Sacchidanand S, Asha G S. Clinico-epidemiological profile of childhood vitiligo. Indian J Paediatr Dermatol 2015;16:23-8
|How to cite this URL:|
Sheth PK, Sacchidanand S, Asha G S. Clinico-epidemiological profile of childhood vitiligo. Indian J Paediatr Dermatol [serial online] 2015 [cited 2020 Jan 25];16:23-8. Available from: http://www.ijpd.in/text.asp?2015/16/1/23/149425
| Introduction|| |
Vitiligo is a common depigmenting skin disorder characterized by acquired, idiopathic, progressive, circumscribed hypomelanosis of the skin and hair, with a total absence of melanocytes microscopically. It is a psychologically devastating, cosmetically disfiguring disease and is resistant to therapy. Hence, it causes emotional trauma in children that can have long-lasting effects on their self-esteem. Childhood-onset vitiligo has distinct epidemiological and clinical characteristics as compared to those of later-onset disease. There are only few studies from India and other parts of the world that have described the clinico-epidemiological profile of vitiligo in children and thus, there is a paucity of data regarding the same. Hence, this study was undertaken to understand the epidemiological and clinical presentations of vitiligo in children.
| Materials and methods|| |
All pediatric patients with vitiligo who attended the Pediatric Dermatology Clinic of Victoria Hospital, Bangalore Medical College, Bangalore, India, between April 2013 and December 2013 were included in the study. First 100 patients younger than 18 years of age with vitiligo were included in the study. A complete history including age, sex, duration of the disease, family history, history of Koebner's phenomenon, and history of associated diseases, was elucidated and noted.
All the patients were thoroughly examined, and the following data like sites of vitiligo, area of involvement, leukotrichia, and pattern of the vitiligo was noted. The patients were classified into two groups of vitiligo: Localized (focal, segmental, mucosal) and generalized (vulgaris, acro-facial, and universal). Focal vitiligo was defined as single or few lesions localized to one body part not forming any specific pattern. Segmental vitiligo is characterized by presence of depigmented macules arranged unilaterally in a localized area of the body having a dermatomal or blaschkoid pattern. Mucosal vitiligo was defined as unique involvement of oral or genital mucosa. Vitiligo vulgaris was described as multiple lesions predominantly occurring over the trunk, shoulders, arms and thighs. Lesions occurring over face, neck, hands, forearm, feet and legs were termed as acro-facial vitiligo. Lip-tip vitiligo is considered to be a special type of vitiligo where lesions occur over lips and periungual areas. When there is complete or near-complete involvement of the body with depigmentation, it is known as universal vitiligo. Autoimmune and endocrine disorders like thyroid disease, alopecia areata were recorded as a part of history and clinical examination. vitiligo disease activity score (VIDA) score was ascertained for all patients to grade the activity of the disease Laboratory parameters like hemogram, peripheral blood smear, blood glucose, triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone levels were performed in all patients.
| Results|| |
Of the 100 patients who attended Pediatric Dermatology OPD in 9 months duration of the study, 55 patients (55%) were female, and 45 patients (45%) were male. The mean age at onset was 8.92 years (ranging day 1-16 years), with duration of disease varying from 2 months to 8 years with mean duration of 1.36 years.
According to standard classification most common pattern of vitiligo [Figure 1] was vulgaris (n = 46, 46%) [Figure 2], followed by focal (n = 36, 36%) [Figure 3], mucosal (n = 8, 8%) [Figure 4] and [Figure 5], acro-facial (n = 7, 7%), segmental (n = 3, 3%) [Figure 6]. Of the 7 patients with acro-facial pattern, 2 patients had lip-tip [Figure 7] pattern of vitiligo. The most common site for vitiligo was lower limb seen in 62 patients (62%), followed by face (46%), upper limbs (30%), scalp (25%), and mucosal (18%). Of the mucosal site (18%) of vitiligo, as noticed in our study, 13 patients had oral mucosal involvement, and 5 patients had genital. In the above group of mucosal site involvement, 8 patients had isolated mucosal involvement, and 10 patients had mucosa along with other sites involved. None of our patients had universal presentation. In another classification, vitiligo was divided into segmental and nonsegmental vitiligo. We had only 3 patients (3%) with segmental vitiligo and 97 patients (97%) had nonsegmental vitiligo. Leukotrichia was seen in 25 patients (25%), whereas Koebner's phenomenon was positive in 21 patients (21%). A positive family history of vitiligo was seen in 14 patients (14%), in which vitiligo was observed in the first-degree relatives of 5 patients.
In our study, autoimmune associations were seen in 17 patients (17%). Cutaneous associations with vitiligo were seen in 13 patients (13%) with atopic dermatitis, 1 patient (1%) with alopecia areata, 3 patients (3%) with halo nevi [Figure 8]. Systemic associations with vitiligo were seen in one patient with hypothyroidism. Familial association of vitiligo in our study includes hypothyroidism (n = 7 patients, 7%) and atopic dermatitis (n = 7 patients, 7%). Children with familial association had a mean age of onset of 6.8 years, which was earlier than age of onset of children with no familial association of 9.26 years.
The VIDA was performed in all patients that varied from −1 to 4. In our study, VIDA score +4 was most commonly seen in 81 patients, followed by +3 seen in 6 patients, +1 and +2 seen in 2 patients each. VIDA score 0 and −1 were seen in 4 and 5 patients respectively. Spreading nature (VIDA score 1-4) of disease was seen in 91 patients (91%) with 81 patients (81%) having increased activity of the disease in past 6 weeks (VIDA +4). Nonspreading progression of the disease (VIDA score −1, 0) was seen in 9 patients (9%). [Table 1] shows clinic epidemiological profile of childhood vitiligo as stated above.
|Table 1: Clinico-epidemiological profile of childhood vitiligo of the present study |
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| Discussion|| |
Vitiligo is a common, acquired disorder, characterized by depigmented macules and absence of functional melanocytes.  The incidence in India is highest which ranges from 1.25% to 8.8%
whereas incidence is about 0.15% to 8% in different countries.  It affects all races and geographic regions of the world. It can develop at any age, but the largest group of patients have onset before the age of 20 years. 
Most of the studies shows a female preponderance, barring a few ,, in which the sex ratio is almost equal. Studies from the Indian sub-continent have also shown higher female incidence with 57.1% in north India and 61.1% in south India. , In another recent study too, higher incidence (56.7%) of childhood vitiligo in girls was seen.  This higher preponderance in female may be attributed to early medical help by parents in view of cosmetically disfiguring nature of the disease. Our study also confirms the same female gender (55%) preponderance with male incidence being 45%.
The disease onset is usually seen below 10 years of age. The mean age at onset of childhood vitiligo in Indian studies was 6.2 years,  5 years,  6.9 years.  The similar results were shown in other studies like from Korea (5.6 years),  China (7.28 years)  and Kuwait  between ages of 8-12 years. In our study, mean age at onset of disease was 8.92 years (ranging day 1-16 years). In a Chinese study on childhood vitiligo (n = 541), eight children had skin lesions present at birth (focal 7, acro-facial 1),  whereas we had one child presenting at birth with focal pattern of vitiligo. In an Indian study, the duration of the disease at the time of presentation varied from 1-month to 10 years, with a mean duration of 18.6 months.  Our study showed mean duration of disease to be 1.36 years ranging from 2 months to 8 years.
Vitiligo may present in childhood in various morphological patterns. The most common pattern seen in most studies is vitiligo vulgaris, followed by focal and segmental vitiligo, ,,, whereas acro-facial and mucosal vitiligo have a lower incidence. In a recent Indian study,  acro-facial type of vitiligo (38.1%) was observed to be the most common clinical type in children, followed by vitiligo vulgaris (27.2%), segmental vitiligo (16.8%), focal vitiligo (16.8%), and mucosal vitiligo (1.1%). No child had universal vitiligo. Scalp incidence was found to be 25% of patients in the study by Cho et al.  In our study, most common pattern was vulgaris (46%) followed by focal (36%), mucosal (8%), acro-facial (7%) and segmental (3%). The most common site for vitiligo was lower limb as seen in 62 patients (62%), followed by face (46%), upper limbs (30%), scalp (25%), and mucosal (18%). Mucosal vitiligo had a varied incidence ranging from 0.6% in Handa and Dogra 7 study to 13.8% in Jaisankar et al.  study. In our study, we found 8% of isolated mucosal involvement. None of our patients had universal presentation. Alternatively, vitiligo can also be divided into segmental and nonsegmental types. We had only 3 patients (3%) with segmental vitiligo and 97 patients (97%) with nonsegmental vitiligo.
The findings of leukotrichia have been varied from 3.7% to 25% of childhood vitiligo.  In a recent Indian study, the incidence of leukotrichia was higher (32.5%) and was seen more frequently in the vitiligo vulgaris type (72%), followed by segmental and then focal vitiligo.  In the same study, Koebner phenomenon was seen in 65 (24.3%) of pediatric patients.  The increased incidence of koebnerization may be explained by increased activity among the pediatric population, and its occurrence is correlated with the activity of the disease.  In our study, leukotrichia was seen in 25 patients (25%). It was seen most commonly in vulgaris (56%) followed by focal (32%), as similar to other studies. Koebner phenomenon was seen in 21 patients (21%) in our study. As similar to another study,  the Koebner phenomenon in our study too, was more frequently associated with nonsegmental vitiligo.
Among various studies, the correlation between childhood vitiligo and positive family history in childhood vitiligo ranges between 11%  and 46%.  Similarly, in an Indian study, familial association was seen in 24.3% of children.  In children with positive family history of vitiligo or other autoimmune disorders, an early onset of disease was noted by Pajvani et al. In our study, familial association was seen in 14 patients (14%), among which 5 patients had vitiligo in the first degree relatives.
Association of autoimmune disorders in children with vitiligo is far less as compared to adults.  Among the Indian studies, Handa and Dogra  showed 1.3% of autoimmune association, while Jaisankar et al.  showed no associations in their patients. Similarly in other studies, Halder et al.  noted 2 cases of alopecia areata among 82 children with vitiligo, and Schallreuter et al.  showed a higher frequency of thyroid disease with childhood vitiligo. Iacovelli et al.  demonstrated exclusive association between nonsegmental vitiligo and autoimmune diseases. Among the cutaneous associations of vitiligo, the incidence of various disorders includes halo nevi (2.5-34%,) ,,, atopic dermatitis (9.3%), alopecia areata (3.4%), and psoriasis (1.5%).  In the same study, thyroid abnormalities were found in 9% of children.  [Table 2] shows clinico-epidemiological profile of childhood vitiligo of different Indian studies as stated.
|Table 2: Clinico-epidemiological profiles of Indian studies of childhood vitiligo |
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We noticed autoimmune association of vitiligo in 17 patients (17%). The most common association with vitiligo in children was atopic dermatitis in 13 patients (13%), while hypothyroidism was seen in one patient. Among the other cutaneous associations, halo nevi were observed in 3 patients (3%) and alopecia areata in 1 patient (1%). All these autoimmune disorders were found exclusively in patients with nonsegmental vitiligo in our study also. Familial association like thyroid abnormalities and atopic dermatitis were noted in 7 patients (7%) each. These too were found in children with nonsegmental vitiligo. Children with familial association had a mean age of onset of 6.8 years, which was earlier than age of onset of children with no familial association of 9.26 years.
Vitiligo disease activity score is a six-point scale for assessing vitiligo activity. Scoring is based on the individual opinion of the present disease activity over time. VIDA score +1 to +4 indicate activity ranging from the past 6 weeks to 1-year whereas score 0 and −1 indicate stability for at least 1-year and spontaneous repigmentation respectively. In our study, VIDA score +4 was most commonly seen in 81 patients, followed by +3 seen in 6 patients, +1 and +2 seen in 2 patients each. VIDA score 0 and −1 were seen in 4 and 5 patients respectively.
| Conclusion|| |
Vitiligo is a common depigmenting disorder with a mean age of onset being around 8.92 years and with female preponderance. The most common pattern of presentation was vulgaris, followed by the focal type of vitiligo while the universal pattern was rare in childhood. The most common site of vitiligo was lower limbs followed by face and upper limbs. Autoimmune associations were more common in nonsegmental vitiligo. Among the cutaneous associations, atopic dermatitis was most frequently encountered. Patients with family history of autoimmune disorders tend to present at an early age.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2]