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ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 128-133

Childhood vitiligo: A hospital-based study on 200 patients in Northeast India


1 Department of Dermatology, Iqraa International Hospital, Calicut, Kerala, India
2 Department of Dermatology, Venereology and Leprology, Regional Institute of Medical Sciences, Imphal, Manipur, India
3 Department of Paediatrics, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication29-Mar-2019

Correspondence Address:
Dr. N A Bishurul Hafi
Department of Dermatology, Venereology and Leprology, Iqraa International Hospital, Calicut, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_79_18

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  Abstract 


Background: Vitiligo is a depigmenting disorder which can be psychologically devastating. Childhood-onset vitiligo has different epidemiological and clinical characteristics as compared to adults. Aims and Objectives: The aim was to study the clinico-epidemiological and hematologic investigation profiles of childhood vitiligo. Materials and Methods: First 200 pediatric patients younger than 18 years, with vitiligo who attended the dermatology outpatient department of a tertiary center in Northeast India, between September 2015 and August 2017 were included in the study. A detailed history and examination along with autoimmune diseases and laboratory parameters were recorded. Results: Among the 200 patients, 62% were girls. The mean age was 10.3 ± 4.9 years. The mean age at onset was 9.1 ± 4.9 years (ranging 2 months–17 years), with duration of disease varying from 1 month to 8 years with mean duration of 1.39 ± 1.63 years. Most common pattern of vitiligo was vulgaris (39.5%) followed by focal (25%), segmental (15.5%) genital (10%), acral and lateral lip (8%), and acrofacial (4%). Family history of vitiligo was seen in 12% of patients. In 96% patients, only <5% of body surface area was affected. Nearly 8.5% had Koebnerization while 9% showed leukotrichia. Thyroid-stimulating hormone and antithyroid peroxidase abnormalities were seen in 4.5% and 1% patients, respectively. Low Vitamin D level was seen in 21.5%. Conclusion: Any depigmented lesion in children should be evaluated and followed up properly to rule out vitiligo. Dermatologists and pediatricians should understand the characteristics of childhood vitiligo properly since it behave differently from adult-onset disease.

Keywords: Childhood vitiligo, halo nevi, thyroid profile, Vitamin D


How to cite this article:
Bishurul Hafi N A, Thokchom NS, Singh SC, Bachaspatimayum R. Childhood vitiligo: A hospital-based study on 200 patients in Northeast India. Indian J Paediatr Dermatol 2019;20:128-33

How to cite this URL:
Bishurul Hafi N A, Thokchom NS, Singh SC, Bachaspatimayum R. Childhood vitiligo: A hospital-based study on 200 patients in Northeast India. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Dec 14];20:128-33. Available from: http://www.ijpd.in/text.asp?2019/20/2/128/255213




  Introduction Top


Vitiligo is an acquired hypomelanotic disorder characterized by circumscribed depigmented macules or patches resulting from the loss of functional melanocytes and melanin from the epidermis. Childhood-onset vitiligo has distinct epidemiological and clinical characteristics as compared to those of later-onset disease. Childhood vitiligo deserves special attention as frequently (50%), the disease onset is before 20 years of age, and in 25% of the cases, it starts before the age of 10 years.[1] Childhood vitiligo differs from the adult disease in the following aspects: a female preponderance is observed, segmental presentation is more common, and associated other autoimmune or endocrine disorders are rarer.[2],[3]

Vitiligo is a mentally disturbing disorder for the child as well as parents. Various studies showed the decreased psychological performance of victims of the disease.[4] In India, social stigma, widespread prejudices, ignorance, taboos, lack of scientific appraisal, and confusion of vitiligo with leprosy exist still. Hence, well-documented studies on the clinico-epidemiology of childhood vitiligo and the association with various factors are needed. Unfortunately, only a few studies have been published from India, and there are no studies as yet from its northeast part. The present study was, therefore, undertaken to document the clinical, epidemiological, and investigation profile of childhood vitiligo in Northeast India.


  Materials and Methods Top


It was a hospital based cross-sectional study conducted in dermatology outpatient department of a tertiary institute in Northeast India. Duration of the study was 24 months with effect from September 2015 to August 2017. First 200 consenting cases of vitiligo in patients <18 years of age were included in the study irrespective of their treatment status.

Analysis of data was done by IBM SPSS (version 20.0 for Windows, Chicago, IL, USA) software, version 21.0 for windows. Descriptive statistics such as mean, standard deviation (SD), and percentage were used. For inferential statistics, Chi-square/Fisher's exact test was employed and a P < 0.05 was taken as statistically significant. Ethical approval for this study was obtained from the Institutional Ethics Committee before the commencement of the work. Consent was obtained from the parents of the subjects.


  Results and Observations Top


Among 200 patients assessed, 62% were females (M:F = 0.63:1). Maximum of our patients (43%) were between 5 and 12 years of age followed by 12–18 years (43%), 1–5 years (12%), and least in infancy (6%) [Table 1]. Mean age was 10.3 ± 4.9 years, whereas that for boys and girls was 10.81 ± 5.34 years and 10.01 ± 4.7 years, respectively. The difference was not statistically significant. There were 20 cases (10%) of early-onset vitiligo (<3 years) and rest of the patients had a later onset of disease (>3 years). Mean duration in the patients with early-onset disease was 0.73 ± 1.51 years and the same in late onset was 1.57 ± 1.66 years and it was again significant (P = 0.028). Mucosal vitiligo was significantly more associated with later onset group (P = 0.020).
Table 1: Distribution of patients by characteristics from history

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Lesions were symptomatic (itchy) among 10% patients. Among symptomatic cases, genital vitiligo was the subtype with maximum prevalence (45%), followed by acrofacial (25%), generalized (6.3%), and focal vitiligo (4.9%). None of the cases of lip and acral vitiligo were symptomatic. Trauma was a precipitating or aggravating factor in 8% patients; out of them, maximum were having generalized vitiligo (P = 0.003).

Head and neck region was the most common site of onset with 56% patients followed by trunk 16%, genitalia 11.5%, acral 10.5%, and other regions in 6%. Among the head and neck region, disease started mostly on the face (34%), followed by the neck (14.5%) and least on the scalp (7.5%). Family history of vitiligo was seen among first- and second-degree relatives of 5.5% and 6.5% patients, respectively [Table 2]. Similarly, clinical hypothyroidism was seen in the first- and second-degree relatives of 1.5% and 1% patients, respectively.
Table 2: Distribution of patients by family history

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Most common pattern of vitiligo was vulgaris (39.5%) followed by focal (25%), segmental (15.5%), genital (10%), acral and lateral lip (8%), and acrofacial (4%) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. Vulgaris type was more common among boys (51.9%) while focal among girls (44.7%), and the difference was statistically significant (P = 0.032). Most patients (49%) were having multiple lesions (>5%), followed by 1–5 lesions (27%) and single lesions (24%), while majority of the patients (96%) were affected <5% body surface area only [Table 3]. Segmental lesions were seen in 15.5% patients, of which 59.3% were girls. Koebnerization and leukotrichia were seen in 8.5% and 9% patients, respectively. Mucosal involvement was seen in 19.5% patients and genital (12.5%) involvement was more than oral (7%). Halo nevus was seen in 5.5% of patients, with all patients having late onset of disease [Figure 6].
Figure 1: Generalized vitiligo with lesions mainly over extremities

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Figure 2: Generalized vitiligo affecting genitalia with leukotrichia

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Figure 3: Mucosal vitiligo affecting genitalia

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Figure 4: Distribution of patients by type of vitiligo

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Figure 5: Generalized vitiligo involving lips and oral mucosa

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Table 3: Distribution of patients by clinical examination findings

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Figure 6: Halo nevus on upper back along with depigmented patches on distant sites

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Blood and urine routine examinations did not reveal any significant findings. Liver and kidney function tests also were within normal limits. Change in thyroid-stimulating hormone (TSH) level was seen in 4.5% patients, increased in 4% and decreased in 0.5% [Table 4]. Among the patients with increased TSH levels, low levels either of T3 or T4 or both seen only in 1% cases. None of the patients had known hypo- or hyperthyroidism. Anti-thyroid peroxidase (TPO) levels were high in 1% cases [Table 5]. Antinuclear antibodies were normal in all patients with reports available while anti-dsDNA was higher among 1%. Among the 60 patients with Vitamin D reports, 71.6% showed a lower titer out of which 24 patients had localized vitiligo and 19 had generalized type [Table 6]. Among the 17 normal reports, 11 were localized. The association of type of vitiligo and Vitamin D level was found to be statistically strongly significant (P = 0.001). Mean Vitamin D was 7 ± 11.6.
Table 4: Distribution by thyroid function test results

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Table 5: Distribution by anti-thyroid peroxidase level

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Table 6: Distribution by Vitamin D level

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  Discussion Top


Vitiligo is an acquired pigmentary disorder characterized by circumscribed depigmented macules and patches that result from a progressive loss of functional melanocytes. The exact etiology of vitiligo is still unknown and it is considered to be multifactorial. Different theories help to explain etiopathogenesis of different clinical varieties.

Girls clearly outnumbered boys in the present study (62% vs. 38%), similar to the observations done by Al-Jabari et al. and Jaisankar et al.[5],[6] A higher proportion of girls was seen in other studies by Agarwal et al., Sheth et al., and Handa andDogra too.[7],[8],[9] No study with a higher prevalence of male population was found among children in contrast to that among adults (Alzolibani et al. [52.63%], Shankar et al. [51.25%], Kar [51.6%], and Singh et al. [56%]).[10],[11],[12],[13] This can be attributed to greater concern of parents when a girl developing depigmented lesion than a boy as cosmetic disfigurement, and related social and marital problems are more among girls in Indian scenario.

Most of our patients (43%) were between 5 and 12 years of age followed by 12–18 years (39%), similar to the findings by Sheth et al. and Mu et al.[8],[14] The age group of 10–20 years was most prevalent even among studies on vitiligo patients including adult population as seen in studies by Shah et al. (32.82%) and Rajpal et al. (41.7%).[15],[16] The mean age was (10.3 ± 4.9 years) higher compared to other studies by Al-Jabari et al. (7.9 years), Agarwal et al. (6.9 years), and Sheth et al (8.92 years).[5],[7],[8] In our study, head-and-neck region was the most common site of onset with 112 patients (56%) which was much higher to the finding (25.71%) by Jain et al.[17] The study by Fatani et al. found the face to be the most common site of onset while Habib also found head and neck to be same.[18],[19] It was followed by extremities in the study by Jain et al., but we found trunk outnumbering other sites.[17] The exact significance of this observation is difficult to appreciate. Nevertheless, we believe that exposed and trauma-prone sites, such as the lower limbs, hands, and face, may develop vitiligo lesions more easily in genetically predisposed individuals.

Family history of vitiligo was seen in 12% of the patients, out of which first-degree relatives were affected in 5.5% patients while second degree in 6.5%. It was similar to the Indian studies by Handa andDogra (12%) and Jain et al. (17.5%) but much lesser to the findings by Nicolaidou et al. (35%).[3],[9],[17] Mean age of disease onset was more in patients with positive family history (10.11 ± 4.7 vs. 8.9 ± 4.9), but the difference was not significant (P = 0.198), and this finding is contradictory to the study by Sheth et al. who observed lower age of onset in patients with positive family history (6.8 vs. 9.26).[8]

Most common type of vitiligo among boys was vulgaris (51.9%) while focal type was maximum among girls (44.7%), and the difference was statistically significant (P = 0.032). It can be because of the greater concern in parents seeing even a single white patch in girls than in boys, which may prompt them for early consultation to the specialists. Comparative analysis of clinical characteristics with other Indian studies has been described in [Table 7].
Table 7: Comparison with clinico-epidemiological profiles of other Indian studies

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Even though unilateral vitiligo was found among 27% patients, only 15.5% patients had segmental vitiligo (SV). It is closely similar to the finding by Agarwal et al. (16.8%), lesser to Jaisankar et al. (21.1%), and higher than the observations by Sheth et al. (3%) and Handa andDogra (4.6%).[6],[7],[8],[9] Head-and-neck area and trunk were more common sites of disease onset among SV (P = 0.004). Face was the most common area affected followed by trunk, neck, and extremities in that order. Most common dermatomes affected were trigeminal and thoracic dermatomes (40.6% each), followed by cervical (12.5%) and lumbar dermatomes (6.25%).

Mucosal involvement was seen among 19.5% of patients, similar to the findings by Sheth et al. (18%).[8] Out of them, genitalia was more affected (12.5%) than lips (7%), again similar to the above-mentioned study (13% vs. 5%). In 61.5% patients, mucosa was involved alone while there were coexisting skin lesions in the rest.

Halo nevi (HN) were found in 5.5% cases. Sheth et al. observed lower prevalence (3%) while a higher incidence was seen by Jain et al. (8.6%).[8],[17] Proportion of boys were very high in HN group compared to total cases (1.75:1 vs. 0.58:1) (P = 0.083). All the patients with HN had a later onset of disease (P = 0.255). This is in contrast with the results of studies by Ezzedine et al. and van Geel et al. where vitiligo with HN showed significantly lower age of onset of disease.[20],[21] However, these studies included adult population also, and the median age of onset of HN was <18 years in both studies which is the sole study population in the present study.

Analysis of laboratory characteristics was incomplete because of unavailability of some tests in the institute. In 7.1% cases, anemia was seen while urine R/E, Random blood sugar, liver, and kidney function tests were seen normal in all the available cases. Of the 101 cases with thyroid function report, 9 cases (8.9%) showed change in TSH level, increased in 7.9% and decreased in 1%. Subba et al. found a higher incidence of abnormalities in TSH among 18.18%, but they had included adult patients also. A decreased T3 or T4 levels were seen in only 0.5% of the patients. It is comparatively too less compared to the findings by Subba et al. (15.15 and 10.6 each).[22] There was no patient with clinical hypo- or hyperthyroidism. Girls had higher incidence of thyroid abnormalities (5.2% vs. 8.9%) but were not significant (P = 0.580). There was no significant difference between thyroid levels of localized and generalized vitiligo (P = 0.489). Among the reports available (in 14 patients), 14.3% had a raised anti-TPO level. A somewhat similar value (16.6%) was found in the study of Jishna et al. among patients <12 years.[23]

Vitamin D values ranged from 5 to 38 ng/ml and the mean was 7 with a SD of 11.6. In the study by Karagün et al., Vitamin D levels ranged from 6 to 42 ng/ml (mean: 12.04 ± 8.84 ng/ml).[24] Among the 60 patients with Vitamin D reports, 71.6% showed a lower titer out of which 40% patients had localized vitiligo. The association of type of vitiligo and Vitamin D is found to be statistically strongly significant (P = 0.001).


  Conclusion Top


Our study revealed that vitiligo may start at a younger age as early as 2 months and is more common among the age group of 5–12 years (43%). Hence, any depigmented lesion in babies should be evaluated carefully with regular follow-up. Studies conducted on regional basis will aid the clinicians practicing in concerned areas to be aware of its clinico-epidemiological behavior. The cross-sectional design of this study does not permit to establish causal relationship. Prospective controlled studies with a larger sample size need to be taken up in this regards.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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