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ORIGINAL ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 3  |  Page : 227-230

Halo Nevi in children: A separate entity or a sign of vitiligo?


1 Department of Dermatology, Venereology and Leprology, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 Burjeel Medical Centre, Abu Dhabi, United Arab Emirates

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Romita Bachaspatimayum
Department of Dermatology, Venereology and Leprology, Regional Institute of Medical Sciences, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_88_18

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  Abstract 


Background: Halo nevi (HN) can present either singly or along with vitiligo. Whether they are different entities, remains debatable. Objectives: The objective of the study is to compare clinicoepidemiologic and laboratory factors associated with HN, HN with vitiligo and vitiligo alone, in children. Methodology: A total of 205 children <18 years who presented to the outpatient department were sampled purposively to three groups: (a) HN without vitiligo, (b) HN with vitiligo, and (c) Vitiligo without HN. Results: There were seven patients in Group A, 11 in Group B, and 187 in Group C. A statistically significant difference was noted between Group B and C in the age of onset (0.004) as well as the age of presentation (0.031). Even though the disease process had started in head-and-neck region in more than half of the patients in each group, HN was present mostly on trunk (90.9%) in Group B and in 28.6% in Group A. No statistically significant difference was noted in associated disorders, personal or family history of autoimmune disorders, koebnerization, leukotrichia, or laboratory tests. Conclusions: Our study, particularly done among pediatric population, has failed to demonstrate much significant differences between HN and vitiligo, except in the age of presentation as well as the age of onset. It further gives proof to substantiate the hypothesis that HN can be a part of clinical spectra of vitiligo.

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


How to cite this article:
Hafi N A, Bachaspatimayum R, Soraisham R, Muhammed N C. Halo Nevi in children: A separate entity or a sign of vitiligo?. Indian J Paediatr Dermatol 2019;20:227-30

How to cite this URL:
Hafi N A, Bachaspatimayum R, Soraisham R, Muhammed N C. Halo Nevi in children: A separate entity or a sign of vitiligo?. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Oct 20];20:227-30. Available from: http://www.ijpd.in/text.asp?2019/20/3/227/261879




  Introduction Top


The halo nevus (HNs) phenomenon is relatively common acquired hypomelanosis around preexisting nevi. The associated nevi most commonly are acquired melanocytic which can be a junctional, dermal, or compound nevus.[1] Halo phenomenon surrounding congenital nevi is also reported.[2] In 1916, Sutton described HN as a “leukoderma acquisitum centrifugum.”[3] Happle termed the entity as “Grünewald nevus.”[4] Four stages of evolution are described in HN: (1) appearance of the halo, (2) loss of pigment within the central nevus, (3) disappearance of the nevus, and (4) disappearance of the halo.[5]

HN most often occurs in children and young adults and is unusual in adults over 40 years of age.[5] A similar pathogenesis for HN and vitiligo is proposed because of striking clinical association; up to 26% of patients with HN have vitiligo.[6] In one of the widely accepted theories, oligoclonal T cells are activated against nevus cells which additionally target surrounding melanocytes, resulting in halo formation.[5],[7] However, a recent study negated this concept by demonstrating complete absence of immune cells in HN specimens and proposed a theory based on vascular origin where vascular endothelial cells were found to be replacing melanocytes.[8] In another more recent study, tumor necrosis factor related apoptosis-inducing ligand has been suggested as a plausible causative factor for both HN and vitiligo.[9] The diagnosis of HN is basically clinical, but dermoscopic patterns such as uniform, globular and structureless have been described.[10]

There is a paucity of studies in clinicoepidemiological as well as laboratory characteristics of HN. We could not find any studies in the PubMed database, assessing the prognostic values and significance of HN in children, in relation with vitiligo. Hence, herein, we present the results of a cross-sectional study conducted to assess the relation of HN and vitiligo.

Aims and objectives

To compare clinicoepidemiologic and laboratory factors associated with HN, HN with vitiligo and vitiligo alone.


  Methodology Top


A hospital-based cross-sectional study was carried out for 18 months, from November 2015 to April 2017. A total of 205 cases of children <18 years presented to outpatient department of a tertiary institute in Northeast, India, were sampled purposively to three groups-(a) HN without vitiligo, (b) HN with vitiligo, and (c) Vitiligo without HN, irrespective of gender, race, and treatment status. Ethical clearance was obtained from the Institute Ethics Committee and consents were obtained from the parents. Diagnosis of HN and vitiligo was done clinically, and laboratory investigations were done wherever it was necessary. Analysis of data was done by IBM SPSS software (version 21.0 for windows, Chicago, IL, USA). 0 for windows. Chi-square/Fisher's exact test was used to find the significance of study parameters on a categorical scale between two or more groups, and independent sample t-test/ANOVA test were used for the same in continuous variables. P <0.05 was considered statistically significant.


  Results and Observations Top


Of 205 patients, only seven patients had HN without vitiligo (Group A, 3.4%), 11 patients had HN with vitiligo (Group B, 5.4%), and 187 patients had vitiligo without HN (Group C, 91.2%). Male to female ratio in each group was 0.4:1, 1.8:1, and 0.6:1, respectively. Mean age was higher among Group A (13 ± 3 years; range of 9–17.8 years) and Group B (13.9 ± 2.8 years; range of 9–17.9 years) than that of Group C (10.1 ± 4.9 years; range of 2 months–17.8 years), and the difference was significant by ANOVA test. However, the significance has seen only between Group B and C (P = 0.031). Similarly, age of onset was higher among Group A (12.2 ± 3.1 years; range of 7.6–17 years) and Group B (13.5 ± 5.3 years; range of 7–17.2 years) than Group C (8.7 ± 4.8 years; range of 1 month–17 years), and the difference was significant between Group B and C (P = 0.004). In Group C, 19 patients were complaining of itching while only one among Group A and nil among Group B experienced the same.

Disease started mostly in head and neck area in all the three groups, with Group A having higher prevalence (71.4%) than Group B (60%) and Group C (50.8%) [Table 1]. In Group A, HN was found on head and neck in five patients (71.4%), trunk in two patients while one patient had it on lower limb also whereas in Group B, ten patients (90.9%) had it on the trunk and only one patient had it on face [Table 1]. Only one patient in Group A had multiple HN, rest all patients in Group A and B had only single HN. Group A patients had associated atopic dermatitis (n = 1), hypomelanosis of Ito (n = 1), and nevus spiluf (n = 1) [Figure 1] while those in Group B had atopic dermatitis (n = 2), keloid (n = 1), and pelvic inflammatory disease (n = 1). The family history of vitiligo among first or second degree relatives was found in 14%, 18%, and 11.7% patients in each group. No family history of thyroid disorder was noted in Group A and B while 2.7% patients in Group C had the same. The difference of associated or family history of other autoimmune disorders was not statistically significant across the groups. Three patients in Group B had focal vitiligo, rest had segmental vitiligo. Segmental type was seen in only one patient in Group B. while 31 patients in Group C (16.6%) reported the same. One patient (9%) in Group B had leukotrichia which was similar in Group C also (17 patients; 9.1%) (P = 0.854). Koebnerization was seen in 8% in Group C, 9.1% in Group B, and nil in Group A, and the difference was not significant (P = 0.866).
Table 1: Clinico-epidemiologic profiles of the patients

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Figure 1: Halo phenomenon around nevus spilus

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Figure 2: Halo nevus around melanocytic nevus on cheek

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Figure 3: Halo nevus around melanocytic nevus on chest with vitiligo patch on shoulder

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Routine investigations including complete hemogram, blood sugar, urine routine, liver and kidney function tests were normal in all patients in all groups. About 25% of the patients in Group A had subclinical hypothyroidism while no patient in Group B and 8.6% in Group C showed the same but the difference was not significant [Table 2]. 16.6% patients in Group C had increased serum antithyroid peroxidase while Group A and B patients showed normal range. No abnormal values of antinuclear antibody was detected in any patients across the groups while 2.9% patients in Group C showed elevated anti-ds DNA values. An insufficient value of vitamin D was seen in 66.6% in Group A, 83.3% in Group B, and 69.2% in Group C, and the difference was not statistically significant.
Table 2: Laboratorial profiles of the patients

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  Discussion Top


Hypopigmented skin lesions in children are often a cause of parental anxiety and unhappiness which leads to obsessive thoughts and decrease in quality of life.[11] HN is an acquired depigmentation surrounding a preexisting nevus. Even though it is present in 1% of the general population, it is more common in children, especially, teenagers.[12] In the present study, no HN case was reported with age of onset <7 years. Also age of onset was significantly higher in vitiligo patients with HN than without. This is in contrast with the results of studies done by Ezzedine et al. and van Geel et al. where vitiligo with HN showed lower age of onset with high significance.[1],[13] However, these studies included adult population also and the medians of the age of onset of HN were <18 years in both studies which is the sole study population in the present study.

HN was present in only 5.5% of vitiligo patients. This was widely variable in previous literatures ranging from 1% to 48%.[13] Girls outnumbered boys, except in Group B and this can be attributed to the higher parental concern on hypopigmented lesions in girls. Only one patient among Group A and B complained of preceding pruritus, which can be a clinical manifestation of autoimmunity or inflammation. A similar observation was made by Ezzedine et al. too.[1] Significance was not found in the family history of autoimmune disorders, and no patient was having other diagnosed autoimmune disorders at the time of presentation. This is in contrast with the observations made by van Geel et al., where he found a significant increase in associated personal autoimmune disorders as well as familial vitiligo, among patient with vitiligo than without. However, other confounding factors like age were not eliminated, and childhood vitiligo is well known for lower association with autoimmune disorders than adults.[14] Another study by de Vijlder et al. also demonstrated a lower association of autoimmune disorders in patients with vitiligo and HN.[15]

In vast majority (91%) of the Group B patients, HN was located on trunk similar to the observation by van Geel et al., while 71% of Group A patients had it on head-and-neck region. It can be because of selection bias, as even a single HN on exposed areas of head and neck may alarm patient or parent to consult the doctor, whereas same on the trunk may be ignored or even unnoticed. Ezzedine et al. also observed trunk to be more frequently involved in vitiligo with HN than without.[1] Congenital melanocytic nevus was not associated in any of the cases. One case of nevus spilus was present which is very rarely reported with HN. Only 5.5% of patients had multiple HN while literatures observed the same on at least 25% of patients with HN.[12] The patient with multiple HN (n = 8) did not have associated vitiligo in concordance with the finding mentioned by van Geel, that patients with ≥3 HN had significantly low risk of associated vitiligo.[13]


  Conclusions Top


The exact pathogenesis of HN and vitiligo is still debatable. Various studies have shown a significant association between both entities, whereas some differed in findings which led to the hypothesis that HN can be a separate entity unrelated with vitiligo. But our study, particularly done among pediatric population has failed to demonstrate significant differences between both except in the age of presentation as well as the age of onset. It further gives proof to substantiate that HN can be a part of clinical spectra of vitiligo. However, a follow-up study on much larger sample size is required to comment on whether HN is a forerunner of vitiligo in children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Concha-Garzón MJ, Hernández-Martín A, Faura-Berruga C, Dávila-Seijo P, Torrelo A. Spontaneous partial repigmentation of halo nevi around congenital melanocytic nevus and vitiligo in a 13-year-old boy. Indian J Dermatol Venereol Leprol 2014;80:69-70.  Back to cited text no. 2
    
3.
Sutton RL. An unusual variety of vitiligo (leukoderma acquisitum centrifugum). J Cutan Dis 1916;34:797-800.  Back to cited text no. 3
    
4.
Happle R. Grünewald nevus. Hautarzt 1994;45:882-3.  Back to cited text no. 4
    
5.
Ortonne JP, Passeron T. Vitiligo and other disorders of hypopigmentation. In: Bolognia JL, Jorizzo JL, Schaffer JV, editors. Textbook of Dermatology. 3rd ed. China: Elsevier Saunders; 2012. p. 1023-48.  Back to cited text no. 5
    
6.
Stierman SC, Tierney EP, Shwayder TA. Halo congenital nevocellular nevi associated with extralesional vitiligo: A case series with review of the literature. Pediatr Dermatol 2009;26:414-24.  Back to cited text no. 6
    
7.
Bishop JA. Lentigos, melanocytic nevi and melanoma. In: Burns T, Beathnach S, Cox N, Griffi ths C, editors. Rook's Textbook of Dermatology. 8th ed. United Kingdom: Wiley Blackwell; 2010. p. 54.19-20.  Back to cited text no. 7
    
8.
Iyengar B. Halo nevus – The vascular connection. Pigmentary Disord 2015;188:1-5.  Back to cited text no. 8
    
9.
Zhou H, Han J, Mao R, Tang X, Cao G, Chan X, et al. A clinicopathological study of TRAIL expression in halo nevi. Int J Clin Exp Med 2016;9:19390-8.  Back to cited text no. 9
    
10.
Kamińska-Winciorek G, Szymszal J. Dermoscopy of halo nevus in own observation. Postepy Dermatol Alergol 2014;31:152-8.  Back to cited text no. 10
    
11.
Pahwa P, Mehta M, Khaitan BK, Sharma VK, Ramam M. The psychosocial impact of vitiligo in Indian patients. Indian J Dermatol Venereol Leprol 2013;79:679-85.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Russak JE, Dinulose JE. Pigmented lesions in children. Semin Plast Surg 2006;20:169-79.  Back to cited text no. 12
    
13.
van Geel N, Vandenhaute S, Speeckaert R, Brochez L, Mollet I, De Cooman L, et al. Prognostic value and clinical significance of halo naevi regarding vitiligo. Br J Dermatol 2011;164:743-9.  Back to cited text no. 13
    
14.
Sheth PK, Sacchidanand S, Asha GS. Clinicoepidemiological profile of childhood vitiligo. Indian J Paediatr Dermatol 2015;16:23-8.  Back to cited text no. 14
  [Full text]  
15.
de Vijlder HC, Westerhof W, Schreuder GM, de Lange P, Claas FH. Difference in pathogenesis between vitiligo vulgaris and halo nevi associated with vitiligo is supported by an HLA association study. Pigment Cell Res 2004;17:270-4.  Back to cited text no. 15
    


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