|Year : 2017 | Volume
| Issue : 4 | Page : 292-298
A study of clinico-epidemiological and dermoscopic patterns of vitiligo in pediatric age group
Sneha Gandhi, Murugesh Shamanur, AR Shashikiran, Mamatha Kusagur, Sugareddy, Vijay Bhaskar
Department of Dermatology, Venereology and Leprosy, JJM Medical College, Davangere, Karnataka, India
|Date of Web Publication||29-Sep-2017|
JJM Medical College, Davangere, Karnataka
Source of Support: None, Conflict of Interest: None
Context: Childhood vitiligo although similar to adult vitiligo has several distinct epidemiological, clinical, therapeutic and prognostic profile when compared with adult onset vitiligo.
Aims: This study was conducted in an attempt to ascertain the clinico-epidemiological profile of patients in pediatric vitiligo patients (<18 years) and to conduct a dermoscopic analysis of the vitiligo patches.
Subjects and Methods: This study was designed to study the clinic-epidemiological characteristics of childhood vitiligo between July 2015 and December 2015. A total of eighty childhood vitiligo patients were examined. In addition, 160 patches were studied for dermoscopic patterns to correlate with clinical stability and pattern of pigmentation.
Results: Female to male ratio was 2.2:1. Average duration of the disease was 2.2 years. The mean age of onset was 7.6 years. A positive family history was seen in 18 patients. The pattern of viltigo in descending order of frequency was vitiligo vulgaris, segmental distribution, focal vitiligo, and acral vitiligo. The most common site was trunk. Dermatological associations were, history of atopy in 32 patients, alopecia aearata (1 patient) halo nevi (1 patient), and lichen nitidus (1 patient). The dermoscopic features of disease activity in order of frequency in our study were as follows: Trichrome pattern, nebulous pattern, star burst pattern, comet tailing of the lesion, and amoeboid pattern. 69 patients (43.12%) showed leukotrichia on dermoscopy, 74 (46.25%) showed perifollicular pigmentation, 32 patients (20%) showed marginal pigmentation, 26 (16.25%) showed both patterns whereas the rest did not show the signs of repigmentation. Under ultraviolet light examination, a diffuse white glow was seen in 147 (91.87%) of the patients.
Conclusions: Vitiligo prevalence among children is on the rise and clinicoepidemiological data on this disease in between far and few. We found that dermoscopy was able to pick up disease activity earlier than the clinical onset of disease instability. This is the first study analyzing the dermoscopic pattern in pediatric vitiligo to the best of our knowledge.
Keywords: Childhood vitiligo, dermoscopy, Koebner phenomenon, leukotrichia
|How to cite this article:|
Gandhi S, Shamanur M, Shashikiran A R, Kusagur M, Sugareddy, Bhaskar V. A study of clinico-epidemiological and dermoscopic patterns of vitiligo in pediatric age group. Indian J Paediatr Dermatol 2017;18:292-8
|How to cite this URL:|
Gandhi S, Shamanur M, Shashikiran A R, Kusagur M, Sugareddy, Bhaskar V. A study of clinico-epidemiological and dermoscopic patterns of vitiligo in pediatric age group. Indian J Paediatr Dermatol [serial online] 2017 [cited 2019 Sep 15];18:292-8. Available from: http://www.ijpd.in/text.asp?2017/18/4/292/211802
| Introduction|| |
Vitiligo, the most common acquired hypomelanoses is a psychologically and physically disfiguring disorder. However, vitiligo when it affects children can be even more disfiguring, leading to significant patient morbidity. Low self-esteem, poor body image, and poor quality of life has been found in patients with vitiligo. This is of particular concern for children and adolescents, as they are in their formative years and are still developing their sense of self. Childhood vitiligo although similar to adult vitiligo has several distinct epidemiological, clinical, therapeutic and prognostic profile when compared with adult onset vitiligo. This study was conducted in an attempt to ascertain the clinical and epidemiological profile of patients who are diagnosed with vitiligo in their childhood (<18 years) and also the first study to conduct a dermoscopic analysis of the vitiligo patches and correlate with these findings with clinical stability.
| Subjects and Methods|| |
All pediatric patients with vitiligo who attended the outpatient department of dermatology between July 2015 to December 2015 were included in the study. The study was approved by institutional ethics committee The inclusion criteria were, unequivocal clinical diagnosis of vitiligo and age of onset up to 18 years. The cases whose clinical diagnosis was in doubt, who did not consent to take part in the study were excluded from the study. Relevant differential diagnoses, which mostly included conditions such as leprosy, pityriasis alba, lichen sclerosus et atrophicus among others were ruled out on the basis of clinical assessment and appropriate investigation when required.
During the study period of 6 months, eighty patients (age <18 years) were diagnosed with vitiligo. Informed consent was taken from parents/wards of the patients, following which they were included in the study. A complete history including epidemiological data regarding age and sex, duration of the disease, family history, history of Koebner's phenomenon, and history of associated diseases, was taken using a prestructured questionnaire. History regarding atopy, koebnerization, premature canities, thyroid, and other autoimmune disorders was also taken. All the patients were subjected to a thorough examination, and the following data such as initial site of vitiligo, current site of vitiligo, area of involvement, leukotrichia, and pattern of the vitiligo was noted. On basis of the clinical data collected, the patients were mainly classified into two groups such as segmental and nonsegmental vitiligo (NSV). Laboratory parameters like hemogram, peripheral blood smear, blood glucose, triiodothyronine (T3), thyroxine (T4), and thyroid stimulating hormone levels were performed in patients as and when required. Each patient was also subjected to dermoscopic and Wood's lamp examination where a random of three patches were studied per patient of vitiligo vulgaris or acral vitiligo and all patches in segmental and focal vitiligo.
| Results|| |
Out of 80 patients included in the study, 55 were females and 25 were males. The duration of the disease ranged from 3 months to 12 years, average duration was 2.2 years. The mean age of onset was 7.6 years. A positive family history was seen in 18 patients. The mean age of onset in children with a positive family history of vitiligo was 7.1 years while the mean age of onset in those without such a history was 7.8 years. Among the patterns of vitiligo, 30 patients had vitiligo vulgaris, 24 had segmental distribution [Figure 1] and [Figure 2], focal variant in 16 while 10 showed acral distribution [Figure 3] and [Figure 4]. None of our patients had universal presentation. The most common site was trunk followed by head and neck.
Further, 5% of patients to have mucosal involvement. All patients were found to have oral involvement. Other clinical findings in our study included leukotrichia which was seen in 28 patients, premature greying in 11 patients, koebnerization in 17 patients, nail involvement in 39 of patients with the most common finding being striate leukonychia [Figure 5] followed by pitting [Table 1].
|Figure 5: Striate leukonychia with pitting in a patient of vitiligo vulgaris|
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|Table 1: Salient Clinico-epidemiological features in 80 pediatric patients|
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With regards to autoimmune diseases, in our study, we found 1 patient with hypothyroidism (1.25%) while first degree relatives of 12 patients (15%) reported a history of autoimmune disorder the most common of which was hypothyroidism followed by diabetes mellitus. Dermatological associations in our patients were alopecia areata (1 patient) [Figure 6], history of atopy in 32 patients, halo nevi (1 patient), lichen nitidus (1 patient) [Table 2] and [Figure 7].
|Figure 7: Nevus sebaceous in a 7-year-old boy with segmental vitiligo involving the trunk|
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A total of 160 patches were examined in 80 patients and the results put forward are with consideration to the patches and not to the individual per se. The patterns of vitiligo on dermoscopy were divided into those due to stability and those associated with pigmentation. Out of the total 160 patches, 109 (68.12%) patches were clinical unstable with a history of increase in the size of the patch in the past 1 year. However, dermoscopically, we found 120 (75.25%) of the patches showed signs of disease activity. The dermoscopic features of disease activity in order of frequency in our study were as follows: Trichrome pattern [Figure 8], nebulous pattern [Figure 9], polka dot pattern [Figure 10], star burst pattern, comet tailing of the lesion [Figure 11], and amoeboid pattern [Figure 12]. About 25% of the patients were associated with well-defined hypopigmented patches with irregular but well defined margins. These were taken as stable lesions [Figure 13]. 69 patients (43.12%) showed leukotrichia on dermoscopy [Figure 14] while only 50 (31.25%) showed clinical leukotrichia.
|Figure 8: Trichrome pattern: A zone of normal pigmentation surrounds a hypopigmented rim around depigmented patch|
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|Figure 9: Nebulous pattern: A dense white depigmented pattern with ill-defined margins that merge indistinctly into the surrounding. The lesion also shows a trichrome pattern|
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|Figure 10: Polka dot appearance: Several depigmented macules in a polka dot appearance (unstable lesion). Few macules show perifollicular pigmentation as well|
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|Figure 11: Comet tail: Unstable lesion showing depigmented patch with koebnerisation in a comet tail pattern|
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|Figure 12: Amoeboid pattern: Relatively well defined margins of the depigmented patch sending out pseudopod like extensions|
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|Figure 13: Petalloid pattern: A well-defined depigmented macule with pigmented polycyclic margins showing perifollicular pigmentation. This pattern correlated with clinical stability|
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|Figure 14: Leucotrichia: A fairly well defined amoeboid appearance of vitiligo patch demonstrating leucotrichia|
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With regards to pigmentation, 74 (46.25%) showed perifollicular pigmentation, 32 patients (20%) showed marginal pigmentation, 26 (16.25%) showed both patterns whereas the rest did not show signs of repigmentation. 14 out of 160 patients showed telangiectasias in our study.
Under ultraviolet light examination, a diffuse white glow [Figure 15] was seen in 147 (91.87%) of the patients.
|Figure 15: Ultraviolet light: A depigmented macule with diffuse white glow when examined under ultraviolet light. Leucotrichia is also better appreciated in ultraviolet light|
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| Discussion|| |
Vitiligo is a common, acquired disorder, clinically characterized by depigmented macules and histologically characterized by the absence of functional melanocytes in the epidermis. The mean age of onset found in the literature is 6.2 years  according to Indian study, 5.6 years according to Korean study  and 7.28 according to a study in China. We found a slightly higher age of onset than the Indian literature at 7.6 years. We also found two cases of congenital vitiligo (2.5%). Hu et al. studied 541 children with vitiligo and reported 1.5% of children with congenital vitiligo.
Out of 80 patients included in the study, 55 were females and 25 were males; 2.2:1. Literature review shows a divided opinion on gender difference in vitiligo with few studies quoting a statistical difference in the occurrence of vitiligo among boys and girls, whereas others have not recorded such a difference. The increased frequency in female can probably be explained by the increased anxiety related to the cosmetic appearance of the disease in the parents of a female child.
Pajvani et al. studied the relationship between family medical history and childhood vitiligo and concluded that family members of the affected children have a higher incidence of vitiligo and other autoimmune disorders compared to controls. A positive family history was seen in 18 (22.5%) patients. Different studies have reported similar association ranging from 11% to 46%.,
Pajvani et al. in addition also have reported an earlier onset of vitiligo in children in whom family history of the disease, leukotrichia or other autoimmune disorders were present. However, we did not notice any difference in the mean age of onset in patients who had a positive family history of vitiligo (7.1 years) versus those who did not a report a positive family history (7.8 years).
Among the patterns of vitiligo, 30 patients had vitiligo vulgaris, 24 had segmental distribution, focal variant in 16 whereas 10 patients showed acral vitiligo. None of our patients had universal presentation. Vitiligo vulgaris is the most common clinical type observed in various clinical studies, followed by focal vitiligo and segmental vitiligo (SV),,, while the rarest type seen during childhood is the universal vitiligo.
Different studies have quoted variable incidence of mucosal vitiligo in children with Halder et al. reporting 0%, Handa and Dogra  0.6% and Jaisankar et al. 13.8% in their respective studies. In our study, four patients (5%) had oral mucosal vitiligo. However, we did not come across a case of genital mucosa involvement in our study.
The most common site of involvement in our study was trunk followed by head and neck. This is in contrast to Hann and Lee  who reported that the most common initial site of onset of both NSV and SV in children is the face and neck. In the series of patients with SV studied by Hann and Lee, trigeminal segment was the most common dermatome involved, followed by thoracic, cervical, lumbar, and sacral.
Koebnerization was seen in 17 patients (21.25%) in our study, while Raju et al. has reported 24.6% and Jain et al. have reported 34.2% children showed positive Koebner phenomena. Koebner phenomenon may be noted in both SV and NSV in children, more commonly in the latter type. In SV, koebnerization is confined to the involved segment only. Koebnerization may be more frequent in childhood vitiligo because of higher mobility and playfulness in this age group. The presence of koebnerization is indicative of the disease activity.,
We found evidence of scalp involvement in 11 patients (13.75%) with only 1 patient showing premature graying in the absence scalp involvement. Hann and Lee has reported scalp involvement in 25% of the children with vitiligo.
Other clinical findings in our study included leukotrichia which was seen in 28 patients (35%), nail involvement in 39 (48.75%) of patients with the most common finding being striate leukonychia (27 patients) followed by pitting (19 patients).
Vitiligo may be associated with other autoimmune disorders like alopecia areata, diabetes mellitus, pernicious anemia, Addison's disease, and thyroid disorder. With regards to autoimmune diseases, in our study, we found 1 patient with hypothyroidism (1.25%) while first degree relatives of 12 patients (15%) reported a history of autoimmune disorder the most common of which was hypothyroidism followed by diabetes mellitus. Dermatological associations in our patients were history of atopy in 32 patients, alopecia aearata (1 patient), halo nevi (1 patient), lichen nitidus (1 patient), and sebaceous nevi (1 patient).
Handa and Dogra  studies 625 patients of vitiligo and found 1.3% of the children were associated with autoimmune disease while Hann and Lee  exclusively studied 208 patients of SV and found an autoimmune association of 3.4% in children with SV. This is in contrast to several other reports where authors have reported vitiligo-associated autoimmune disorders occurring exclusively in children suffering from NSV., A comparison of various clinico-epidemiological features of different studies conducted in India.
Out of the total 160 patches, 109 (68.12%) patches were clinical unstable with a history of increase in the size of the patch in the past 1 year. However, dermoscopically, we found 120 (75.25%) of the patches showed signs of instability or disease activity. The dermoscopic features of disease activity in order of frequency in our study were as follows: Trichrome pattern, nebulous pattern, star burst pattern, comet tailing of the lesion, and amoeboid pattern.
Sixty-nine patients (43.12%) showed leukotrichia on dermoscopy, whereas only 50 (31.25%) showed clinical leukotrichia.
Very few workers have studied the utility of dermoscopy in the diagnosis of vitiligo and to the best of our knowledge this is the first attempt to study the dermoscopic patterns in childhood vitiligo.
With regards to pigmentation, 74 (46.25%) showed perifollicular pigmentation, 32 patients (20%) showed marginal pigmentation, 26 (16.25%) showed both patterns while the rest did not show signs of repigmentation. We did not find reverse pigmentary network in our study. This in contrast to Thatte and Khopkar study where only 6.7% and 3.3% of patients showed perifollicular and marginal pigmentation respectively. Meng et al., studied 176 patients with various types of depigmentation of whom 97 had vitiligo. They observed residual perifollicular pigmentation in 81.44% if the patients. Such a huge contrast can be explained as Thatte and Khopkar study was mainly based on evolving lesions of vitligo while we considered patches in all stages of vitiligo. Similarly, Meng et al. had more of stable disease in their study sample while majority of our patients were unstable hence less likely to demonstrate perifollicular pigmentation. In a study by Kanwar et al, majority of children had stable disease.
The finding of telangiectasia on dermosocopy in vitiligo has been attributed to treatment and is generally taken a good prognostic sign.
Thatte and Khopkar  have reported in their study that up to 90% of patients had a diffuse white glow while we found similar finding in 91.87% of our patients.
| Conclusions|| |
Vitiligo prevalence among children is on the rise and clinicoepidemiological data on this disease in between far and few. We found a mean age of onset being around 7.6 years and with female preponderance. The most common pattern of presentation was vulgaris, followed by the focal type of vitiligo while the most common site of vitiligo was trunk. Atopic dermatitis was the most common association and was seen predominantly in SV while autoimmune associations were more common in NSV. We found that dermosocpy was able to pick up disease activity earlier than the clinical onset of disease instability. This is the first study analyzing the dermoscopic pattern in pediatric vitiligo to the best of our knowledge.
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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
[Table 1], [Table 2]