Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
 
Users online: 3360  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page


 
Table of Contents 
E-STUDY
Year : 2014  |  Volume : 59  |  Issue : 2  |  Page : 209
Profile of vitiligo in Kumaun region of Uttarakhand, India


Department of Skin and VD, Government Medical College, Haldwani (Nainital), Uttarakhand, India

Date of Web Publication21-Feb-2014

Correspondence Address:
Saurabh Agarwal
Department of Skin and VD, Government Medical College, Haldwani (Nainital), Uttarakhand - 263 139
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.127706

Rights and Permissions

   Abstract 

Background: Vitiligo is a common, acquired, pigmentary disorder characterized by loss of melanocytes resulting in white spots. This disease carries a lot of social stigma in India. Objective: To study the clinico-epidemiological profile of vitiligo patients in Kumaun region of Uttarakhand state in India. Materials and Methods: The clinical presentation of vitiligo was examined and analyzed in 762 vitiligo patients attending the Dermatology outdoor of Government Medical College, Haldwani, which is a referral centre for Kumaun region of Uttarakhand state in India. Results: Male and female patients were found to be affected almost equally. It was observed that onset of vitiligo was most common in 0-10 years age group, as evidenced by 336 cases out of 762 cases. Acrofacial type of vitiligo (339 cases out of 762) was most commonly observed, followed by vitiligo vulgaris, focal, segmental, mucosal, mixed, and universal vitiligo. The most common site of onset was the lower limbs followed by head and neck, upper limbs, trunk, genitalia, and mucasae. Leucotrichia was observed in 33.5%, Koebner's phenomenon in 26.3%, and a positive family history in 19% of the vitiligo patients. The other common conditions associated were thyroid disorders (8.9%), diabetes (5.3%), and atopic dermatitis (4.9%). Conclusion: The study indicates that acrofacial vitiligo is the most common clinical type observed in Kumaun region of Uttarakhand in India. Onset of vitiligo is most common in first decade of life.


Keywords: Clinico-epidemiological profile, Uttarakhand, vitiligo


How to cite this article:
Agarwal S, Ojha A, Gupta S. Profile of vitiligo in Kumaun region of Uttarakhand, India. Indian J Dermatol 2014;59:209

How to cite this URL:
Agarwal S, Ojha A, Gupta S. Profile of vitiligo in Kumaun region of Uttarakhand, India. Indian J Dermatol [serial online] 2014 [cited 2019 Nov 14];59:209. Available from: http://www.e-ijd.org/text.asp?2014/59/2/209/127706



   Introduction Top


Vitiligo is a common, acquired disorder characterized by depigmented cutaneous macules usually devoid of functional melanocytes. These lesions are cosmetically disfiguring and usually cause emotional trauma in both children and adults. Vitiligo affects all races and both sexes almost equally. The population prevalence is estimated to be 0.14-2% in different countries. [1] Vitiligo can develop at any age but the peak incidence is in second or third decade. [2] The precise cause of vitiligo is unknown. Multiple theories have been proposed including theories based on autoimmune, neural, and autocytotoxic phenomenon. [3],[4],[5],[6] The disease has a familial incidence of 1.56-34%. [7],[8],[9],[10],[11] Genetic studies suggest a polygenic inheritance pattern. [12] Vitiligo has been reported in association with several endocrinopathies and other disorders of autoimmune nature. [13],[14] Our objective in this five year prospective study were to explore the nature of vitiligo in Kumaun region of Uttarakhand state in India and to establish the clinical characteristics of vitiligo and its association with other diseases.


   Materials and Methods Top


The new vitiligo patients who attended the Dermatology outdoor department between January 2006 and December 2010 were included in the study. A complete history including age, sex, duration, site of onset, family history, history of Koebner's phenomenon, and history of associated diseases was elucidated and noted. A complete clinical examination was performed and the sites, area involved, and the pattern of the lesions were noted. The evolution of the disease, as evidenced by the appearance of new lesions and the increase in the size of existing lesions, over the past 3 months was also noted. The vitiligo patients were classified according to recent Bordeaux vitiligo global issues consensus conference classification and consensus nomenclature [15] into three groups, viz. nonsegmental, segmental, and unclassified vitligo. Nonsegmental vitiligo (NSV) was further classified as acrofacial, generalized, universal, mucosal (more than one mucosal sites), and mixed vitiligo. Unclassified vitiligo included focal and mucosal (one site in isolation). Acrofacial vitiligo was defined as multiple, bilateral, symmetrical depigmented macules involving acral region of the extremities and peri-orifacial regions. Vitiligo vulgaris (common vitiligo as per new nomenclature) was defined as scattered macules widely distributed usually symmetrical. Vitiligo was defined as universal if more than 80% body surface area was involved. Mixed vitiligo refers to concomitant occurrence of segmental and NSV. Mucosal vitiligo was defined as involvement of the oral and/or genital mucosae. Segmental vitiligo refers to one or more depigmented macules in a single or multidermatomal configuration. Focal vitiligo was defined as one or more depigmented macules in one area, but not in a dermatomal distribution. The presence of leucotrichia, Koebner's phenomenon was also noted. Screening for autoimmune and endocrine disorders like thyroid diseases, diabetes mellitus, and alopecia areata was also performed by history and clinical examination. Hemogram, peripheral blood smear, blood glucose level, triiodothyronine (T3), thyroxine (T4), thyroid stimulating hormone, and antithyroid antibodies were done in all patients.


   Results Top


A total of 762 vitiligo patients were examined during the study period, accounting for 2.64% of total dermatology outpatients (28842). Three hundred and ninety one patients (51.31%) were male and 371 (48.69%) patients were female, with male:female ratio of 1.05. Duration of the vitiligo at the time of presentation ranged from 1 month to 40 years. The average disease duration at the time of hospital visit was 3.6 years. The most common age group for onset of vitiligo was 0-10 years (31% cases), followed by 11-20 years age group (26.25% cases), as shown in [Figure 1]. The mean age of onset of vitiligo was 24.4 year in male and 19.7 years in female patients (range 1 month to 72 years). Age of the patients at the time of presentation is also depicted in [Figure 1].
Figure 1: Age at the onset and at the time of presentation of vitiligo

Click here to view


Acrofacial type of vitiligo (339 cases out of 762, 44.5%) was observed to be most common, followed by vitiligo vulgaris, focal, segmental, mucosal, mixed, and universal vitiligo, as shown in [Table 1]. Four hundred fifty two patients (59.3%) were having active disease as evidenced either by the appearance of new lesions or the increase in the size of the existing lesions, over the past 3 months. It was observed that 465 (61%) patients had a body surface area involvement of less than 2%, 27% had a body surface area involvement of 2-5%, and 12% patients had more than 5% body surface involvement. One hundred and forty five (19%) patients had a positive family history involving one or more than one family members. Leucotrichia was observed in 255 (33.5%) vitiligo patients. Koebner's phenomenon was found in 200 (26.3%) vitiligo patients. Oral mucosal was involved in 58 (7.6%) vitiligo patients and genital mucosa in 26 (3.4%) patients, while both oral and genital mucosae were involved in 48 (6.3%) patients. Site of onset of the vitiligo lesions in the patients is shown in [Table 2]. The most common site of onset was the lower limbs followed by head and neck upper limbs, trunk, genitalia, and mucosae. Other associated conditions are summarized in [Table 3]. Thyroid disorders were associated with 68 (8.9%) vitiligo patients. Only 12 out of these 68 vitiligo patients were symptomatic for thyroid disorder. Antithyroid antibodies were found in 27 vitiligo patients. No patient complained of deafness.
Table 1: Type of vitiligo


Click here to view
Table 2: Site of onset of vitiligo


Click here to view
Table 3: Association of vitiligo with other diseases


Click here to view



   Discussion Top


Vitiligo is characterized by chalky or milky-white colored macules of variable shapes and sizes with or without leucotrichia and lacks any epidermal changes. It is the most common depigmentary disorder having social and psychological aspects. The population prevalence is estimated to be 0.14-2% in different countries based primarily on clinical records of hospitals and dermatology clinics. The results of hospital based data may be biased because of factors like gender, age, educational level, and social factors. Compared with the prevalence of vitiligo in hospital-based studies, data derived from population surveys are more reliable. A recent study from Shaanxi Province, China, showed prevalence of vitiligo only to be 0.093% and stated that the presumed vitiligo prevalence of 1-2% is overestimated. [16] In an extensive survey in India in and around the city of Surat, prevalence of vitiligo was 0.47% in the rural population and 1.78% in the urban population. [17] Men and women were affected equally. Another study from Calcutta, India showed prevalence of 0.5% with equal sex distribution. [18] The variation in the prevalence of vitiligo in India is probably due to the varying ethnic backgrounds of the population in different geographic regions. The incidence of vitiligo in the present study was found to be 2.64%. The incidence of vitiligo reported in other studies is 4% by Dutta and Mandal, [19] 2.9% by Sehgal, [8] and 2.5% by Handa and Kaur. [20]

Vitiligo can develop at any age and is reported from birth to 81 years of age. [21] In most of the studies from India, [9],[22] age of onset of vitiligo was mainly in second and third decade; but in our study, 57.2% (436 cases out of 762) of the patients had age of onset of vitiligo in first or second decade, indicating that vitiligo may start at a younger age. However, Howitz et al. [2] reported the age of onset of vitiligo to be between 40 and 60 years. Akrem et al. [23] found that 73.3% vitiligo patients had age of onset beyond 18 years of age. The onset of vitiligo in our patients ranged from 1 month to 72 years of age. The mean age of onset of vitiligo were 24.4 years in male and 19.7 years in female patients comparable to the previous epidemiological data from India, [17] showing mean age of onset among males and females to be 24.8 years and 19.3 years, respectively. The mean age of onset reported from other countries is as low as 10 years (Turkey), [24] 18.8 years (China), [25] 19.3 years (Libya), [10] 28.5 years (Estonia), [26] and as high as 37.7 years (Denmark). [2] A study by Zhang et al. [27] has concluded that onset of vitiligo is possibly affected by genetic backgrounds, common environmental factors and clinical type of vitiligo.

Males and females were affected almost equally in our study, which is similar to various other studies. [1],[2],[17],[18],[19],[20],[25] However, female predominance in some studies [8],[24],[26] may be presumably explained by more awareness of the women to cosmetic disfigurement and therefore more likely to seek treatment. Age at the time of presentation of vitiligo was corresponding to the age of onset of vitiligo. The duration of the disease varied widely from 1 month to 40 years, with a mean duration of 3.6 years. The long duration of the disease could probably be attributed to its slow progression and asymptomatic nature.

If there are several affected individuals within an extended family, it suggests a genetic component to the cause. The presence of vitiligo in monozygotic twins and the occurrence of HLA-DR4-associated vitiligo in black Americans lend support to this theory. [28],[29] In a study from India, the relative risk of vitiligo for first-degree relatives was increased by 4.5 times. [18] Vitiligo is not transmitted in a simple mendelian autosomal dominant or recessive manner. Rather, the transmission seems to be complex and polygenic. Familial occurrence has been reported to vary from as low as to 1.56% reported by Singh et al. [10] (Libya) to as high as to 34% reported from Boisseau-Garsaud et al. [11] (French West Indies). There was family history of vitiligo in 19% of vitiligo cases studied by us which is comparable to various other studies.

Acrofacial vitiligo was the most common clinical type of vitiligo affecting 339 (44.5%) of the patients. This was followed by vitiligo vulgaris, focal, segmental, mucosal, mixed, and universal vitiligo. This pattern of predominance of acrofacial type of vitiligo in our study is contrary to various other studies from India [8],[9],[19],[20],[22] and other countries [11],[23],[24],[25],[26] in which vitiligo vulgaris has been reported to be the most common type of vitiligo. A single study from Libya by Singh et al. [10] has reported acrofacial vitiligo to be most common type affecting 40.6% vitiligo patients. The studies [30],[31] from Benin and Lagos Cities of Nigeria reported localized focal vitiligo to be the most common type of vitiligo affecting 77% and 35% of the vitiligo patients, respectively. The time duration between disease onset and presentation is not mentioned in the study from Benin City. [30] Most patients begin with focal vitiligo and progress to different phenotype of vitiligo as the disease progresses. [25] It is difficult to interpret the mechanism and determinants underlying the clinical patterns of vitiligo. The study by Zhang et al. [27] has indicated that different phenotypes of vitiligo had different pathogenesis and genetic background. As India is a vast country having racial, ethnic, and genetic diversities, predominance of acrofacial vitiligo in clinical patterns of vitiligo can be explained on this basis in this north-western region of the country.

The coexistence of SV and NSV was first reported in a pediatric NSV patient treated with UVB, which left a recalcitrant segmental lesion suggestive of pre-existing SV. [32] Additional cases were subsequently reported, with the term "mixed vitiligo" proposed to designate this form of diseases [33] and a case series subsequently proposed definition criteria. [34] We also observed three patients with mixed vitiligo, two male and one female.

Leucotrichia has been reported in 9-48.4% of the patients with vitiligo. [8],[19],[20],[26],[29],[35] Significance is attached to this finding as these cases also showed resistance to therapy. It may also be considered as poor prognostic factor. Leucotrichia was seen in 255 (33.5%) of our vitiligo patients. Koebner phenomenon has been reported to occur in up to 33.0% of vitiligo patients. [28] It was seen in 26.3% of our vitiligo patients similar to other studies. However, it was less prevalent in the studies done by Handa et al. [20] and Akay et al. [24] (5% and 7.3%, respectively). Lower limbs were the most common sites for the onset in 257 (33.7%) patients. It is in concordance with many studies [7],[19],[23] though some studies [8],[27] report face as the most common site of onset of vitiligo. Karelson et al. [26] has reported upper limbs as most common site of vitiligo. The exact significance of this observation is difficult to appreciate. Nevertheless, we believe that exposed and trauma-prone sites, such as the lower limbs and hands, may develop vitiligo lesions more easily in genetically predisposed individuals.

Vitiligo has been reported in association with several endocrinopathies and other disorders of autoimmune nature. We observed an association of vitiligo with cutaneous diseases such as atopic dermatitis (4.9%), alopecia areata (2.6%), and psoriasis (1.9%) and with systemic disorders such as diabetes mellitus (5.9%). Three cases of Down syndrome also had vitiligo. Antithyroid antibodies were found in 27 vitiligo patients (not all symptomatic for thyroid dysfunction). Handa and Kaur [20] observed atopic dermatitis in 1.4% of their patients, alopecia areata in 0.4%, bronchial asthma in 0.7%, diabetes mellitus in 0.6%, and thyroid diseases in 0.5%. Kovacs [35] stated that patients with vitiligo have an increased risk of developing autoimmune diseases. He also noted that autoantibodies against different organ systems may be present in vitiligo patients without clinical correlation. None of our patients showed clinically apparent deafness or ocular abnormalities. As the inner ear contains melanocytes and the pigment epithelium of the retina and the choroids are rich in melanocytes, and since vitiligo affects all active melanocytes, auditory and ocular problems may result with vitiligo. [36],[37] Sensorineural hypoacusis was found in 37.7% of the vitiligo patients in a recent study by Akay et al. [24]


   Conclusion Top


This clinico-epidemiological study of vitiligo in the Kumaun region of Uttarakhand has shown that acrofacial vitiligo is the most common clinical type observed. The onset of vitiligo is most common in first decade of life and lower limbs are the most common sites of onset. We also observed an association of vitiligo with cutaneous diseases such as atopic dermatitis, alopecia areata, and psoriasis and with systemic disorders such as thyroid disorder and diabetes mellitus.

 
   References Top

1.Majumder PP. Genetics and prevalence of vitiligo vulgaris. In: Hann SK, Nordlund JJ, editors. Vitiligo. Oxford: Blackwell Science Ltd.; 2000. p. 18-20.  Back to cited text no. 1
    
2.Howits J, Brodthagen H, Schwarts M, Thomsen K. Prevalence of vitiligo. Epidemiological survey the Isle of Bornholm, Denmark. Arch Dermatol 1977;113:47-52.  Back to cited text no. 2
    
3.Cui J, Arita Y, Btstryn J. Cytolytic antibodies to melanocytes in vitiligo. J Invest Dermatol 1993;100:812-5.  Back to cited text no. 3
    
4.Yu HS, Kao CH, Yu CL. Co-existence and relationship of antikeratinocyte and antimelanocyte antibodies in patients with non segmental type vitiligo. J Invest Dermatol 1993;100:823-8.  Back to cited text no. 4
    
5.Al' Abadie, Senior MS, Bleehen SS, Gaekrodger DJ. Neuropeptide and neuronal marker studies in vitiligo. Br J Dermatol 1994;131:160-5.  Back to cited text no. 5
    
6.Lerner AB. On the etiology of vitiligo and grey hair. Am J Med 1971;51:141-7.  Back to cited text no. 6
[PUBMED]    
7.Lerner AB. Vitiligo. J Invest Dermatol 1959;32:285-310.  Back to cited text no. 7
[PUBMED]    
8.Sehgal VN. A clinical evaluation of 202 cases of vitiligo. Cutis 1974;14:439-45.  Back to cited text no. 8
    
9.Koranne RV, Sehgal VN, Sachdev KG. Clinical profile of vitiligo in North India. Indian J Dermatol Venereal Leprol 1986;52:81-2.  Back to cited text no. 9
    
10.Singh M, Singh G, Kanwar AJ, Belhaj MS. Clinical pattern of vitiligo in Libya. Int J Dermatol 1985;24:233-5.  Back to cited text no. 10
[PUBMED]    
11.Garsaud AM, Garsaud P, Cales-Quist D. Epidemiology of vitiligo in the French West Indies (Isle of Martinique). Int J Dermatol 2000;39:18-20.  Back to cited text no. 11
    
12.Sun X, Xu A, Wei X, Ouyang J, Lu L, Chen M, et al. Genetic epidemiology of vitiligo: A study of 815 probands and their families from south China. Int J Dermatol 2006;45:1176-81.  Back to cited text no. 12
    
13.Dawber RPR. Clinical association of vitiligo. Postgrad Med J 1970;46:276.  Back to cited text no. 13
    
14.Allison JR, Curtis AC. Vitiligo and pernicious anemia. Arch Dermatol 1955;72:407.  Back to cited text no. 14
    
15.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.  Back to cited text no. 15
    
16.Lu T, Gao T, Wang A, Jin Y, Li Q, Li C. Vitiligo prevalence study in Shaanxi province, China. Int J Dermatol 2007;46:47-51.  Back to cited text no. 16
    
17.Mehta NR, Shaha KC, Theodore C, Vyas V, Patel A. Epidemiological study of vitiligo in Surat area, South Gujarat. Indian J Med Res 1973;61:145-54.  Back to cited text no. 17
    
18.Das SK, Mazumdar PP, Chakraborty R, Majumdar TK, Haldar B. Epidemiological profile in Calcutta. India Genet Epid 1985;2:71-8.  Back to cited text no. 18
    
19.Dutta AK, Mandal SB. A clinical study of 650 cases of vitiligo and their classification. Indian J Dermatol 1969;14:103-5.  Back to cited text no. 19
    
20.Handa S, Kaur I. Vitiligo: Clinical findings in 1436 patients. J Dermatol 1999;26:653-7.  Back to cited text no. 20
    
21.Ortonne J, Moscher D, Fitzpatrick T. Hypomelanotic disorders in vitiligo and other hypomelanoses of hair and skin. Plenum 1983;15:129-310.  Back to cited text no. 21
    
22.Sarin RC, Kumar AJ. A clinical study of vitiligo. Indian J Dermatol Venereal Leprol 1977;43:311-4.  Back to cited text no. 22
    
23.Akrem J, Baroudi A, Aichi T, Houch F, Hamdaoui MH. Profile of vitiligo in the south of Tunisia. Int J Dermatol 2008;47:670-4.  Back to cited text no. 23
    
24.Akay BN, Bozkir M, Anadolu T, Gullu S. Epidemiology of vitiligo, associated autoimmune diseases and audiological abnormalities: Ankara study of 80 patients in Turkey. J Eur Acad Dermatol Venereol 2010;24:1144-50.  Back to cited text no. 24
    
25.Liu JB, Li M, Yang S, Gui JP, Wang HY, Du WH, et al. Clinical profile of vitiligo in China: An analysis of 3742 patients. Clin Exp Dermatol 2005;30:327-31.  Back to cited text no. 25
    
26.Karelson M, Kimgo K, Salum T, Kõks S, Silm H. An Adult's Vitiligo in Estonia: Study of 155 patients. Open Dermatol J 2009;3:68-72.  Back to cited text no. 26
    
27.Zhang XJ, Liu JB, Gui JP, Li M, Xiong QG, Wu HB, et al. Characteristics of genetic epidemiology and genetic models for vitiligo. J Am Acad Dermatol 2004;51:383-90.  Back to cited text no. 27
    
28.Hann SK, Chun WH, Park PK. Clinical characteristics of progressive vitiligo. Int J Dermatol 1997;36:353-55.  Back to cited text no. 28
    
29.Cho S, Kang HC, Hahm J. Characteristics of vitiligo in Korean children. Pediatr Dermatol 2000;17:189-93.  Back to cited text no. 29
    
30.Onunu AN, Kubeyinje EP. Vitiligo in the Nigerian African: A study of 351 patients in Benin City, Nigeria. Int J Dermatol 2003;42:800-2.  Back to cited text no. 30
    
31.Ayanlowo O, Olumide YM, Akinkugbe A, Ahamneze N, Otike-Odibi BI, Ekpudu VI, et al. Characteristics of Vitiligo in Lagos, Nigeria. West Afr J Med 2009;28:118-21.  Back to cited text no. 31
    
32.Gauthier Y, Cario Andre M, Taieb A. A critical appraisal of vitiligo etiologic theories. Is melanocyte loass a melanocytorrhagy?. Pigment Cell Res 2003;16:322-32.  Back to cited text no. 32
    
33.Mulekar SV, Al Issa A, Asaad M, Ghwish B, Al Eisa A. Mixed vitiligo. J Ctan Med Surg 2006;10:104-7.  Back to cited text no. 33
    
34.Ezzedine K, Gauthier Y, Leaute-Labreze C, Marquez S, Bouchtnei S, Jouary T, et al. Segmental vitiligo associated with generalized vitiligo (mixed vitiligo): A retrospective case series of 19 patients. J Am Acad Dermatol 2011;65:965-71.  Back to cited text no. 34
    
35.Kovacs OS. Vitiligo. J Am Acad Dermatol 1998;38:647-66.  Back to cited text no. 35
    
36.Wolff D. Melanin in the ear. Arch Otolaryngol 1931;14:195-211.  Back to cited text no. 36
    
37.Albert DM, Wagoner MD, Pruett RC, Norlund JJ, Lerner AB. Vitiligo and disorder of retinal pigment epithelium. Br J Opthalmol 1983;67:153-6.  Back to cited text no. 37
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

Top
Print this article  Email this article
 
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (595 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed3135    
    Printed55    
    Emailed1    
    PDF Downloaded160    
    Comments [Add]    

Recommend this journal