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E-IJD EPIDEMIOLOGY ROUND
Year : 2015  |  Volume : 60  |  Issue : 5  |  Page : 520
Pattern of childhood onset vitiligo at a tertiary care centre in south- west Rajasthan


Department of Dermatology, Venereology and Leprology, R.N.T. Medical College, Udaipur, Rajasthan, India

Date of Web Publication4-Sep-2015

Correspondence Address:
Ashok K Khare
4-5, Mayurvan Colony, Panerion Ki Madri, Udaipur - 313 002, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.164423

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   Abstract 

Context : Onset of vitiligo during childhood is not uncommon but the data is limited on this subject. Aims : This study was planned to assess the magnitude of childhood onset vitiligo (COV) and adulthood onset vitiligo (AOV), and compare their clinical pattern. Settings and Design : A cross sectional hospital based clinical study. Materials and Methods : Consecutive patients with vitiligo attending the Dermatology OPD of RNT Medical College and MB Government Hospital, Udaipur, from April 2012 to September 2012 were the subjects of this study. A detailed history taking followed by general, systemic and cutaneous examination, and relevant investigations were carried out. The findings were recorded in a proforma for analysis and interpretation of data. Statistical analysis used : Statistical analysis of data was done using chi- square and Z test. Results: Of the 295 patients seen during the study period, 109 (36.95%) were patients with COV while 186 (63.05%) had AOV; the COV: AOV ratio being 1: 1.71. Amongst COV patients, females (65/109; 59.63%) outnumbered males (44/109; 40.37%). Maximum (51; 46.79%) patients of COV had onset of their disease on head and neck, out of which eyelid was the initial site of lesion in 29 (26.61%) patients. None of COV patients had universal and isolated mucosal vitiligo. Conclusions : Female predominance, affection of eyelids as initial site, and less frequent mucosal involvement in COV were the clinical features different from AOV.


Keywords: Vitiligo, Childhood onset vitiligo, Adulthood onset vitiligo, Pigmentary disorder, Melanocytes


How to cite this article:
Kayal A, Gupta LK, Khare AK, Mehta S, Mittal A, Kuldeep C M. Pattern of childhood onset vitiligo at a tertiary care centre in south- west Rajasthan. Indian J Dermatol 2015;60:520

How to cite this URL:
Kayal A, Gupta LK, Khare AK, Mehta S, Mittal A, Kuldeep C M. Pattern of childhood onset vitiligo at a tertiary care centre in south- west Rajasthan. Indian J Dermatol [serial online] 2015 [cited 2021 Aug 3];60:520. Available from: https://www.e-ijd.org/text.asp?2015/60/5/520/164423

What was known?
Vitiligo is a common pigmentary disorder in adults as well as childhood. It has a remarkable psychosocial impact and can adversely affect the quality of life of patients. Female preponderance, higher occurrence of segmental lesions and less frequent association with autoimmune/ endocrinal disorders in childhood vitiligo are some of the clinical features that differentiate it from adult disease.



   Introduction Top


Vitiligo is an acquired pigmentary disorder of skin, mucous membranes, or both, characterized by loss of epidermal melanocytes. [1] Vitiligo occurs worldwide with an estimated prevalence of 0.5-1% in most populations. [2] It may present anytime in life, including the neonatal period and childhood. The onset of vitiligo has been reported to occur before the age of 10 years in 25% of cases. [3],[4] It may have a remarkable psychosocial impact and adversely affect the child's quality of life.

There have been reports [1],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16] that have addressed the issue of childhood vitiligo. However, reports from India are only a few. [6],[7],[10] This study was done to know the clinical pattern of childhood onset vitiligo (COV) and compare it with adulthood onset vitiligo (AOV) among patients attending skin OPD at a tertiary care centre in south-west Rajasthan.


   Material and Methods Top


All the patients with vitiligo attending the Dermatology OPD of RNT Medical College and MB Government Hospital, Udaipur from April 2012 to September 2012 were the subjects of this study. Patients with onset of vitiligo up to the age of 12 years were included in COV group. A detailed history taking followed by general, systemic and cutaneous examination, and relevant investigations were carried out. The extent of involvement and the disease activity were assessed using vitiligo area scoring index (VASI) and vitiligo index of disease activity (VIDA) respectively. [17],[18] The findings were recorded in a proforma for analysis and interpretation of data. The Chi-square and Z test were used to evaluate the statistical significance of the data.


   Results Top


A total of 295 patients with vitiligo were seen during the study period. Out of these, 109 (36.95%) patients belonged to COV group which included 83 children and 26 adults who had onset of vitiligo during their childhood. One hundred eighty six (63.05%) patients had AOV; the COV: AOV ratio being 1: 1.71.

Maximum patients (50; 45.87%) of COV developed disease between the age of >8-12 years followed by >4-8 year (41; 37.62%) and up to 4 year age group (18; 16.51%). Females (65; 59.63%) outnumbered males (44; 40.37%); the M: F ratio being 1: 1.48 which was statistically significant (P < 0.05). In AOV group, 91 (48.92%) were males and 95 (51.08%) females and this was not significant statistically (P > 0.05). The initial site of vitiligo in COV was head and neck (51; 46.79%) followed by lower extremities (36; 33.03%), trunk (14; 12.84%), upper extremities (7; 6.42%) and mucosa (1; 0.92%). Maximum (69; 37.1%) patients with AOV had disease on lower extremities [Table 1]. Clinical pattern most commonly observed in COV was generalised vitiligo (53; 48.62%) followed by focal (20; 18.35%), acral (16; 14.68%), acrofacial (10; 9.17%) and segmental vitiligo (5; 4.59%) as in AOV group in which generalised vitiligo (85; 45.7%) was most common clinical pattern followed by focal vitiligo (33; 17.74%) and acral vitiligo (32; 17.20%) [Table 2]. The various features seen in association with vitiligo are shown in [Table 3].
Table 1: Site of initial lesion


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Table 2: Clinical patterns of vitiligo


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Table 3: Associated features


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Family history of vitiligo was present in 19.27% of patients with COV and 12.9% of patients with AOV. The difference was not statistically significant (P > 0.05). Family history of diabetes mellitus was more common in COV (13.76%) compared to AOV (6.45%) and it was statistically insignificant (P > 0.05). Majority of patients in COV (102; 93.58%) and AOV (161; 86.56%) had VASI upto 10. A VASI of >10 was noted in 7 (6.42%) patients amongst COV and 25 (13.44%) patients with AOV [Table 4]. In COV group, +4 VIDA was noted in maximum (25.69%) patients followed by + 1, +3 and + 2 VIDA in 24.77, 19.26 and 14.68% patients, respectively. Seventeen patients (15.60%) had stable disease. None showed spontaneous repigmentation in COV. In AOV group, +1 VIDA was observed in maximum (25.27%) patients followed by +4, +3 and +2 VIDA in 23.65%, 20.43% and 13.44% respectively. Disease was stable in 31 patients (16.67%). One patient showed regressive nature of disease with spontaneous repigmentation [Table 5].
Table 4: Vitiligo area scoring index


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Table 5: Vitiligo index of disease activity


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Around 1/5 th of patients in both the groups had elevated serum TSH levels. None of the patient with COV had diabetes mellitus in comparison to AOV group in which it was noted in 6/149 (4.03%) patients.


   Discussion Top


The proportion of COV in our study was found to be 36.95% which is close to another study. [16] Females (65; 59.63%) outnumbered males (44; 40.37%) and this was statistically significant while the sex ratio in AOV group was statistically insignificant. The female predominance in the COV group has also been noted by others. [1],[6],[10],[16] which could possibly be due to social reasons.

The earliest age of onset documented in our study was 6 months. None of the patient in our study group had vitiligo since birth while in a Chinese study [14] on childhood vitiligo, 8 children had skin lesions since birth.

Although the mean age of onset of COV was 7.85 ± 2.94 years, mean age of presentation was 12.13 ± 8.25 years. A variable period usually elapses between the onset of disease and presentation to tertiary care centre as was seen in our study and in other studies [10],[14] as well. This may possibly be on account of illiteracy, lack of awareness and tendency to seek easily accessible treatment first.

Head and neck has been reported to be the commonest site of onset in several studies. [1],[6],[8],[10] However these studies have not taken eyelid as a separate site of affection. In our study also, head and neck was the most common site affected in COV. A significant number of patients in COV, of which in a large number of patients (29; 26.61%) eyelids were the initial site of affection compared to AOV (6, 3.23%) and this was statistically significant (P < 0.001).

Generalised vitiligo (48.62%) was the most common clinical type followed by focal (18.35%), acral (14.68%), acrofacial (9.17%) and segmental (4.59%) in COV group as has been documented in other published reports [5],[6],[10],[14],[16] also. In AOV also, generalised vitiligo (45.70%) was the most common type observed followed by, focal (17.74%), acral (17.20%), acrofacial (4.30%), mucosal (2.69%), universal (2.15%) and segmental (0.54%) vitiligo. The incidence of segmental vitiligo has been found to be more common in children than adults. Different studies [6],[10],[14],[15] have quoted variable incidence of segmental vitiligo in children ranging from 4.6% to 22%. In our study, however, segmental vitiligo was recorded in 4.59% patients with COV, an incidence almost similar (4.6%) to Handa et al. [10] None of COV patients had universal and isolated mucosal vitiligo. Mucosal lesions were, however, associated with other type of vitiligo in 5 patients. Halder et al.[5] also did not record any patient of isolated mucosal vitiligo in their study. Handa et al.[10] observed isolated mucosal vitiligo in 0.6% patients while in 6% mucosal involvement was associated with other clinical type of vitiligo. Jaisankar et al.[6] reported incidence of mucosal vitiligo to be 13.3%.

In childhood vitiligo, the family history of vitiligo varying between 11% and 46% has been reported. [5],[8],[10],[14],[19] In our study, family history of vitiligo was present in 19.27% and 12.90% patients of COV and AOV respectively, a finding consistent with some previous reports. [5],[6],[8] First degree relatives were affected in 14 patients of COV and 19 patients of AOV while 7 and 5 patients of COV and AOV respectively had affected second degree relatives. More than one family member were affected in 2 patients of COV.

Vitiligo is known to be associated with many primary autoimmune disorders most notably thyroid disorders, present in as many as 24% of vitiligo patients. [4],[20] Children with vitiligo are reported to have lower rates of associated autoimmune/endocrine disorders compared with adults. [8],[21] In our study, however, there was no statistically significant difference in the frequency of these disorder between COV (20/99; 20.20%) and AOV (29/149; 19.46%). That the incidence of thyroid disease in children and adolescent with and without vitiligo does not differ has also been reported by Cho et al. [22] In none of the patients with COV, blood sugar abnormality was detected in our study.

An increased frequency of autoimmune/ endocrine disorders in first and second degree relatives of childhood vitiligo patients, as compared to adults, has been reported. [5],[10],[19] However, this was not observed in our study.

A history of trauma was obtained in 39.45% patients of COV. Koebner phenomenon was noted in 36.70% patients of COV compared to 28.50% of AOV. Koebnerization may be more frequent in COV on account of frequent trauma due to higher mobility and playfulness in this group.

Some newer parameters like VASI and VIDA have been used to measure the extent and percentage of de/repigmentation, and disease activity respectively. [17],[18] In our study, majority of patients had VASI upto 10 in COV (93.58%) and AOV group (86.56%). Only 7 (6.42%) patients in COV group had VASI > 10 while in AOV a score of >10 was noted in 25 patients (13.44%) which was statistically insignificant (P > 0.05). The mean of VASI of COV group was 4.05 ± 5.84 while the mean of AOV was 7.14 ± 15.32. On comparision with the Mann _Whitney test, this is statistically significant (P = 0.045). In most of COV (92/109; 84.40%) and AOV (154/186; 82.80%) patients, VIDA revealed that the disease was progressive. This could be accounted by the fact that the parents/patients usually reach tertiary care centre in the event of progression of their disease extent and severity. They have a tendency to seek easily available treatment first. Our study showed that COV does not differ much in its clinical presentation compared to AOV. However, some of the important distinguishing features noted in COV were female predominance, initiation of disease on eyelids and absence of isolated mucosal affection. One of the limitation of the study is relatively small sample size and analysis of data on a larger number of patients from different population groups may further help to substantiate the clinico-epidemiological findings.

 
   References Top

1.
Pajvani U, Ahmed N, Wiley A, Levy RM, Kundu R, Mancini AJ, et al. The relationship between family medical history and childhood vitiligo. J Am Acad Dermatol 2006;55:238-44.  Back to cited text no. 1
    
2.
Ezzedin K, Lim HW, Suzuki T, Katayama I, Hamzavi I, Lan CC, et al. Revised classification/nomenclature of vitiligo and related issues: The Vitiligo Global Consensus Conference. Pigment Cell Melanoma Res 2012;25:E1-E13.  Back to cited text no. 2
    
3.
Palit A, Inamadar AC. Childhood vitiligo. Ind J Dermatol Venereol Leprol 2012;78:30-41.  Back to cited text no. 3
    
4.
Lacovelli P, Sinagra JL, Vidolin AP, Marenda S, Capitanio B, Leone G, et al. Relevance of thyroiditis and of other autoimmune diseases in children with vitiligo. Dermatology 2005;210:26-30.  Back to cited text no. 4
    
5.
Halder RM, Grimes PE, Cowan CA, Enterline JA, Chakrabarti SG, Kenney JA, et al. Childhood vitiligo. J Am Acad Dermatol 1987;16:948-54.  Back to cited text no. 5
    
6.
Jaisankar TJ, Baruah MC, Garg BR. Vitiligo in children. Int J Dermatol 1992;31:621-23.  Back to cited text no. 6
    
7.
Kanwar AJ, Dhar S, Kaur S. Vitiligo in children. Indian J Dermatol 1993;38:47-52.  Back to cited text no. 7
    
8.
Cho S, Kang HC, Hahm JH. Characteristics of vitiligo in Korean children. Pediatr dermatol 2000;17:189-93.  Back to cited text no. 8
    
9.
Prcic S, Djuran V, Poljacki M. Vitiligo in children. Med Pregl 2002;55:475-80.  Back to cited text no. 9
    
10.
Handa S, Dogra S. Epidemiology of childhood vitiligo: A study of 625 patients from North India. Pediatr Dermatol 2003;20:207-10.  Back to cited text no. 10
    
11.
Kurtev A, Dourmishev AL. Thyroid function and autoimmunity in children and adolescents with vitiligo. J Eur Acad Dermatol Venereol. 2004;18:109-11.  Back to cited text no. 11
    
12.
Al-Mutairi N, Sharma AK, Al-Sheltawy M, Nour-Eldin O. Childhood vitiligo: A prospective hospital based study. Australian Journal of Dermatology 2005;46:150-53.  Back to cited text no. 12
    
13.
Kakourou T, Kanaka-Gantenbein C, Papadopoulou A, Kaloumenou E, Chrousos GP. Increased prevalence of chronic autoimmune (Hashimoto's) thyroiditis in children and adolescents with vitiligo. J Am Acad Dermatol. 2005;53:220-23.  Back to cited text no. 13
    
14.
Hu Z, Liu JB, Ma SS, Yang S, Zhang XJ. Profile of childhood vitiligo in China: An analysis of 541 patients. Pediatr Dermatol 2006;23:114-16.  Back to cited text no. 14
    
15.
Mazereeuw-Hautier J, Bezio S, Mahe E, Bodemer C, Eschard C, Viseux V, et al. Segmental and non segmental childhood vitiligo has distinct clinical characteristics: A prospective observational study. J Am Acad Dermatol 2010;62:945-49.  Back to cited text no. 15
    
16.
Nicolaidou E, Antoniou C, Miniati A, Lagogianni E, Matekovits A, Stratigos A, et al. Childhood- and later-onset vitiligo have diverse epidemiologic and clinical characteristics. J Am Acad Dermatol 2012;66:954-58.  Back to cited text no. 16
    
17.
Hamzavi I, Jain H, Mclean D, Shapiro J, Zeng H, Lui H. Parametric modeling of narrowband UV-B phototherapy for vitiligo using a novel quantitative tool, the vitiligo area scoring index. Arch Dermatol 2004;140:677-83.  Back to cited text no. 17
    
18.
Njoo MD, Das PK, Bos JD, Westerhof W. Association of the Koebner Phenomenon with Disease Activity and Therapeutic Responsiveness in Vitiligo Vulgaris. Arch Dermatol 1999;135:407-13.  Back to cited text no. 18
    
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Prcic S, Djuran V, Mikov A, Mikov I. Vitiligo in children. Pediatr Dermatol 2007;24:666.  Back to cited text no. 19
[PUBMED]    
20.
Alikhan A, Felsten LM, Daly, Petronic-Rosic V. Vitiligo: A comprehensive overview. J Am Acad Dermatol 2011;65:473-91.  Back to cited text no. 20
    
21.
Grimes P, Billings M. Childhood vitiligo: Clinical spectrum and therapeutic approaches. In: Hann SK, Nordlund JJ, eds. Vitiligo: A monograph on the basic and clinical science. Oxford: Blackwell Science Ltd, 2000:61-75.  Back to cited text no. 21
    
22.
Cho SB, Kim JH, Cho S, Park JM, Park YK, Oh SH. Vitiligo in children and adolesdents: Association with thyroid dysfunction. J Eur Acad Dermatol Venereol 2011;25:64-7.  Back to cited text no. 22
    

What is new?
Female preponderance, eyelids as initial site of affection and less frequent mucosal involvement were observed in childhood onset vitiligo (COV) compared to adulthood onset vitiligo (AOV).



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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    Abstract
   Introduction
   Material and Methods
   Results
   Discussion
    References
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