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A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS

ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI

Dissertation submitted in partial

fulfillment of the university regulations for

M.D. DEGREE in

DERMATOLOGY, VENEREOLOGY AND LEPROSY

(BRANCH XX)

APRIL 2018

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

CHENNAI TAMIL NADU

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CERTIFICATE FROM THE DEAN

This is to certify that this dissertation entitled " A STUDY ON THE

CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND

VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI

HOSPITAL, MADURAI" submitted by Dr. Deepthi Vijayakumar to The Tamil

Nadu Dr. M.G.R. Medical University, Chennai is in partial fulfillment of the

requirement for the award of M.D.[DERMATOLOGY, VENEREOLOGY AND

LEPROSY] and is a bonafide research work carried out by her under direct

supervision and guidance. This work has not previously formed the basis for the

award of any degree or diploma.

Dr. MARUDHUPANDIYAN M.S. (GENERAL SURGERY)

THE DEAN,

Madurai Medical College,

Government Rajaji Hospital,

Madurai.

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CERTIFICATE FROM THE HOD


CORRELATION OF SERUM CHOLECALCIFEROL LEVEL and VITILIGO

IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL,

MADURAI submitted by Dr. Deepthi Vijayakumar to The Tamil Nadu Dr.M.G.R.

Medical University, Chennai is in partial fulfillment of the requirement for the award

of M.D. [DERMATOLOGY, VENEREOLOGY AND LEPROSY] and is a bonafide

research work carried out by her under direct supervision and guidance. This work has

not previously formed the basis for the award of any degree or diploma.

Dr. G.GEETHARANI M.D., D.D.,

Professor and HOD.

Department of Dermatology,

Madurai Medical College and


Madurai.

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CERTIFICATE FROM THE GUIDE


CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND

VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI

HOSPITAL, MADURAI submitted by Dr.Deepthi Vijayakumar to The Tamil

Nadu Dr.M.G.R. Medical University, Chennai is in partial fulfillment of the

requirement for the award of M.D.[DERMATOLOGY, VENEREOLOGY AND

LEPROSY] and is a bonafide research work carried out by her under my direct

supervision and guidance. This work has not previously formed the basis for the

award of any degree or diploma.

Dr. G.GEETHARANI M.D., D.D.,

Professor and HOD.

Department of Dermatology,

Madurai Medical College and


Madurai.

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DECLARATION

I, Dr. DEEPTHI VIJAYAKUMAR, solemnly declare that the dissertation

titled A STUDY ON THE CORRELATION OF SERUM

CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS ATTENDING

GOVERNMENT RAJAJI HOSPITAL, MADURAI is a bonafide work done by

me at Government Rajaji Hospital during 2015 2018 under the guidance and

supervision of Prof. Dr. G. GEETHARANI M.D., D.D., Professor and Head of the

Department of Dermatology, Madurai Medical College, Madurai. I also declare that

this bonafide work or a part of this work was not submitted by me or any other for any

award, degree and diploma to any university, board either in India or abroad. The

dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical University, towards

partial fulfilment of requirement for the award of M.D.Degree in Dermatology,

Venereology and Leprosy (BRANCH XX).

Place: Madurai.

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ACKNOWLEDGEMENT

I am extremely thankful to Dr. MARUDHUPANDIYAN, M.S, Dean, Madurai

Medical College, and Medical Superintendent, Government Rajaji Hospital,

Madurai for permitting me to use the college and hospital facilities for this study.

I express my sincere and heartfelt gratitude to Prof.Dr.G.Geetharani M.D., D.D.,

Professor and Head of the Department of Dermatology, Madurai medical college,

Madurai, for her excellent guidance and supervision for this dissertation work. Her

commitment, devotion and perfection in work gave me the drive for completing the

project successfully.

I would like to express my deep sense of gratitude to Dr.P.Mohan kumaresh ,

M.D., Professor and Head of the department of Biochemistry for his kindly help of

sharing his wisdom and experience without which this study would not have been

possible.

I profoundly thank Prof.Dr.R.Suganthy Rajakumari M.D., Professor and Head

of the Department of Venereology who has always guided me, by example and

valuable words of advice through the conduct of the study and also during my

postgraduate course. My heartful thanks to Dr. K. Dhanalakshmi M.D., D.V.L,

Associate Professor for her valuable support and guidance throughout the study. I

proudly thank Dr. K.P. Saradha M.D.D.V.L., Associate professor for her valuable

guidance.

I express my deep sense of gratitude and thanks to my teachers

Dr.R.Kothandaraman, Associate Professor, Dr.P.Sathesh and Dr.S.Deva Prabha

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Assistant Professors, for their valuable guidance, timely advice and constant

encouragement.

I would also like to acknowledge my thanks to Dr. S. Sumithra, Dr .R. Sudha,

Dr. S. Durgadevi, and Dr.M.Nithya Assitant Professors of STD for their constant

support during the period of my study.

I would like to convey my regards to fellow post graduates, seniors, juniors and

my family members who have always stood by me in my carrier.

I owe a lot of thanks to my patients without them this study would not have been

possible, and the authors, who have worked on this subject, from whose wisdom and

experience, I have been benefited immensely.

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CONTENTS

S.NO TITLES PAGE NO.

1. INTRODUCTION 10

2. AIM OF THE STUDY 14

3. REVIEW OF LITERATURE 16

4. MATERIALS AND METHODS 54

5. OBSERVATION AND RESULTS 58

6. DISCUSSION 75

7. SUMMARY 85

8. CONCLUSION 89

Annexures

BIBILIOGRAPHY 9 1

PROFORMA 110

CLINICAL PHOTOGRAPHS 123

MASTER CHART 138

ANTI PLAGIARISM CERTIFICATE 146

ETHICAL COMMITTEE APPROVAL FORM 1

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ABBRIEVATIONS

IL- Interleukin

IF ἀ- Interferon alpha

TNF ἀ- Tumour Necrosis Factor alpha

HLA- Human Leukocyte Antigen

NALP- NACHT Leucine rich repeat Protein

NLR- Nod Like Receptor

AIS- Autoimmune Susceptibility

PTPN- Lymphocyte Protein Tyrosine Phosphatase

CTLA4- Antigen 4 of Cytotoxic T Lymphocytes

MITF- Microphthalmia Associated Transcription Factor

ACE- Angiotensin Converting Enzyme

VDR- Vitamin D Receptor

AIRE- AutoImmune Regulator

COMT-Catechol O Methyl Transferase

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INTRODUCTION

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INTRODUCTION

Vitiligo is an autoimmune pigmentary disorder caused by destruction of

functional melanocytes in epidermis and infundibulum of hair, characterized by well

demarcated depigmented patches or macules. It affects both sexes and all races

equally. The inheritance is polygenic or autosomal dominant with variable

penetrance.

The following hypothesis have been postulated regarding its

etiopathogenesis:1,3,4,5

1. Autoimmune hypothesis: This theory is based on the clinical association of

vitiligo with other autoimmune disorders like Hashimoto's thyroiditis, pernicious

anemia, Addisons disease, diabetes mellitus, myasthenia gravis, alopecia areata. Also,

antibodies to human melanocytes have been detected using immunoprecipitant assay

in some patients.

2. Neurogenic hypothesis: This theory suggest that neuropeptide Y released from

peripheral nerve endings may inhibit melanogenesis. Electron microscopy shows

abnormalities in peripheral nerves.

3. Self destruct theory of Lerner: This theory suggest that melanocytes destroy

themselves due to a protective mechanism that removes toxic melanin precursors.

This is based on studies of cutaneous depigmentation caused by chemical compounds

that have selective lethal effects on functional melanocytes.

4. It is suggested that defective keratinocyte metabolism plays a major role and a new

hypothesis relating vitiligo with defective tetrahydrobiopterin and catecholamine

biosynthesis have been postulated.

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Role of vitamin D in melanogenesis:

Vitamin D is synthesized from 7 dehydrocholesterol present in skin which is

converted to 25(OH) cholecalciferol and then to its active metabolite 1,25(OH)2

cholecalciferol and has a role in skin pigmentation.

1.Vitamin D in addition to its regulatory effect in calcium and bone metabolism,

controls cell proliferation and differentiation, exerts immuno regulatory activities via

its nuclear receptor and increases melanogenesis. It increases the tyrosinase content

of cultured human melanocytes by its antiapoptotic effect.6

2.Topical vitamin D increased L-3,4 dihydroxyphenylalanine positive melanocytes6

and is used in combination with other modalities of treatment for vitiligo successfully.

3.Vitamin D exerts immunomodulatory effect by inhibiting the expression of

cytokines IL6, IL8, IL10, IL12, IFἀ, TNFἀ 7,8,9 which are pro inflammatory and

proapoptotic in vitiligo.

4.Another study revealed Apa-I polymorphism9 of vitamin D receptor gene is

associated with vitiligo.

Normal serum vitamin D is 30-70ng/ml (75- 250 nmol/L). Low levels of vitamin

D has been observed in vitiligo and other autoimmune disorders.6-9 The improvement

of serum vitamin D deficiency after UV exposure correlates with clinical

improvement13 as assessed by VASI score.16

Thus, vitamin D and its receptor play a role in etiopathogenesis of skin

pigmentation. But, the exact association of low vitamin D levels and vitiligo needs to

be further evaluated. Hence, It is decided to study on this association among vitiligo

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patients attending the Department of Dermatology, Government Rajaji Hospital,

Madurai.

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AIM OF THE STUDY

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AIM OF THE STUDY

To study the relationship between serum cholecalciferol levels and vitiligo with

respect to type, duration and severity among patients attending dermatology OP (out

patient) at Government Rajaji hospital, Madurai.

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REVIEW OF

LITERATURE

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REVIEW OF LITERATURE

NOMENCLATURE

As to the origin of the term "vitiligo", there are different views. The word may

have evolved from the Latin word "vitium", meaning a blemish17 or "vitelius"

signifying a calf's white patches.18

Leider and Rasenblum19 ascribe the term to the Latin word "vitium" which means a

blemish or a fault.

Bateman20 believed that the glistening white appearance of the vitiligenous patches

bear a striking resemblance to the flesh of calves (vituli).

The term vitiligo was first used by the Roman physician Celsus in the second

centaury AD.21

Documentation of the use of the word vitiligo occurred in the first century AD

when the Roman physician Celsus wrote De Medicina.22

HISTORICAL PERSPECTIVE

Vitiligo is a disease of great antiquity. Vitiligo is cited in many ancient writings.

The earliest authentic reference to vitiligo was made in the ancient Indian sacred book

'Atharva Veda'23 which dates back to 1400 BC.

Indian literature dating to 1500 to 1000 BC refers to the words Kilas ("Kil" means

white, "as" means to cast or throw away) and palita ("pal" implies gray, old and aged)

referring to white patches on the skin.

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In the sacred book of Buddhism "Vinay Pitak" (624-544 BC), persons suffering

from kilas were unable to be ordained.24

In the Indian scripture Manusmriti (200 BC), those members of society suffering

from "Svitra" (spreading whiteness) were not respected.

In the Koran, the word "Baras", meaning white skin, is used to describe a condition

that Jesus cured.25

In the Bible, the white spots were grouped, under the Hebrew word "Zora' at" and

have been described in Leviticus chapter 13 in the Old Testament.

The confusion between vitiligo and leprosy prevailed in ancient times also, as the

term "Zora' at" has been translated as lepra in the Greek as well as the English

translation of Bible. This confusion of leprosy with vitiligo in the Old Testament is an

important cause for the social stigma attached to the white spots on the skin.26

Graphic descriptions are given in other ancient Indian medical treatises like Charak

Samhita (800 BC) and Manu Smriti (200 BC). It was described as "Shweta Kushta"

which probably meant vitiligo21.

Vasuchika, which was identified with the plant called Psoralia corylifolia, the oil

from bouchi seeds contains active furocoumarin27 was given for leukoderma until

1950s. In ancient Chinese literature, similar drug, ‘pu-ku-c’ was given for treating

leukoderma. In the thirteenth century, Ibn Eb Bitar in Egypt mentioned the cure of

leukoderma by an Egyptian herb known as Ammi majus, from the fruit extract of

which important furocoumarins were eventually identified in the twentieth century.28

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EPIDEMIOLOGY

Incidence and prevalence

Vitiligo affects all the races and both the sexes all over the world.

The prevalence of vitiligo worldwide varies from 0.1% to 8.0%29 and in India is

0.46-8.8%,30of which stable vitiligo accounted for 65.21%. Lips are the common site

affected in India (75%). The incidence of vitiligo in India was 0.25%- 2.5%.31 Gujarat

and Rajasthan have the highest prevalence.31

Host factors

Age of onset

Vitiligo can occur at any age. Nearly 50% of all vitiligo cases occur below 20

years of age and 70-80% below the age of 30 years.

Some other studies suggest that the lowest age of onset of vitiligo to be at birth32

and the highest age incidence to be 97 years.33

Halder et al34 reviewed their experience with childhood vitiligo. They found it to

be a distinct subset, showing increased segmental presentation, strong autoimmune or

endocrine background and a high incidence of premature graying of hair in the

families and poor response to PUVA therapy.

Sex incidence

Though vitiligo affects both sexes equally, some series based on out patients

attendance show female preponderance5.

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Skin types

Skin types III and IV 5 are commonly associated with vitiligo.

Dietary factors

Prolonged intake of diet poor in protein and cuprominerals35 for prolonged

period was thought to be contributory and cysteine poor diet was associated with

lower incidence of vitiligo.36 There is no significant association between high vitamin

C ingestion and vitiligo.37

Heredofamilial aspects

Familial incidence in India and abroad vary between 7.5% and 41%.38

Inheritance was thought to be autosomal dominant with variable expression and

incomplete penetrance39-41. Few human leukocyte antigen (HLA) associations like

HLA-DR4 in blacks, HLA-B13 in Moroccan Jews, and HLA- BW35 in Yemenite

Jews with vitiligo have been reported. An association with catalase have been

reported42. VIT1 gene found on chromosome 2p16 has been associated with vitiligo.

Recently, variants of a gene NALP1 found on chromosome 17p13 were associated

with vitiligo, and other autoimmune diseases like thyroiditis. NALP1 is a member of

NLR super family of proteins which is involved in the pathogenesis of vitiligo43.

Precipitating factors

These factors include emotional stress, sunburn, major illness, surgery,

pregnancy, parturition and physical trauma44-46.

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AETIOLOGY AND PATHOGENESIS

Various theories have been proposed regarding the pathogenesis of vitiligo. These

concentrate in the following hypothesis:

Autoimmune

Autocytotoxic

Neural

Genetic

AUTOIMMUNE THEORY

The basis of the autoimmune theory initially developed from studies that

demonstrated an association between vitiligo and autoimmune diseases. The primary

disturbance in the immune system results from the formation of auto antibodies

against some antigens of the melanocytes. As a result melanogenesis may be inhibited

or melanocytes may be destroyed47.

Alternatively, some injury to melanocytes may result in the release of an antigenic

substance so that antibody formation occurs either against the melanogenic process or

the antibodies become cytotoxic to melanocytes47.

Several studies have documented that incidence of vitiligo is higher in patients with

autoimmune diseases as compared to its incidence in the general population44,48-52.

A recent study by Naughten et al53 has demonstrated unequivocally in the serum of

vitiligo patients, the presence of antibodies to surface antigens of melanocytes grown

in cell culture according to the method of Eisinger et al.54

22

Antityrosinase antibodies have also been found in patients with both local and

generalized vitiligo55,56.

Aronson et al (1987)57 demonstrated a sensitive and specific Ig A immunoassay

against human melanoma cells in patients with active disease, although other

investigators found that antipigment Ig G 1,2, and 3 are present in the serum of

vitiligo patients58.

Mozzanica et al(1990)59 found different CD4+ and CD8+ concentrations,

depending on the stability of the disease. Patients with active vitiligo demonstrated

more marked changes and decreased helper and suppressor T cell levels. The use of T

cell antibodies in active vitiligo biopsy specimens showed a decreased CD4+/CD8+

ratio at the active periphery of the vitiligenous lesions.60

Zaman et al61 (1992) demonstrated that leukocyte migration inhibition factor

levels Ig G immunoglobulin, a marker of T lymphocyte function and circulating

immunocomplex levels are markedly elevated in patients with active vitiligo.

An Ig G antibody to melanocytes, naevus cells and melanoma cells have been

reported in the serum of two patients of vitiligo associated with multiple endocrine

insufficiency.52

Linear deposits of Ig G in the basement membrane zone in 70% and 80% of

cases of vitiligo vulgaris and halo naevus respectively have been reported21.

However, natural killer cell and lymphokine activated killed cell cytotoxicity

23

have been shown to be normal in patients with progressive vitiligo according to

Durham Pierre et al(1995).62

Depigmentation possibly occurs secondary to gene expression regulation, as

demonstrated by induction of vitiligo in susceptible chickens with the cytosine

analogue5-azacytidine63. Halder et al64 reported natural killer (NK) cells to be

increased in the peripheral blood of patients with vitiligo.

AUTOCYTOTOXIC THEORY

The autocytotoxic theory stems from the belief that increased melanocyte activity

leads to its own demise.65

Electron microscope examination of interface between vitiligenous and normal

skin in patients with vitiligo demonstrated accumulation of extracellular granular

material and basilar vacuolation of pigmented skin in patients with rapidly

progressing disease. Some studies have demonstrated little, if any, lymphocytic

infiltrate contiguous to melanocytes, substantiating the autocytotoxic theory.66

A second mechanism by which autocytotoxicity may occur is through inhibition

of thioredoxin reductase, a free radical scavenger located on membrane of

melanocytes64. This enzyme is inhibited by calcium which has been shown to be

membrane bound in higher concentrations on vitiligenous keratinocytes relative to

controls. Higher extracellular calcium levels cause increased superoxide radicals that

lead to inhibition of tyrosinase by upsetting the equilibrium of oxidized and reduced

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thioredoxin in the epidermis later causing vacuolization and eventually cell death.68

Levels of catalase, an enzyme that reduces superoxides to water, have also been

shown to be reduced in involved and uninvolved skin in patients with vitiligo causing

cell death.69,70

Certain tyrosinase analogues and intermediates in melanin synthesis are toxic to

melanocytes. The autocytotoxic theory postulates that an intermediate or metabolite in

melanin synthesis is toxic to melanocytes.45

The melanocytes have an inherent protective mechanism that leads to successful

elimination of toxic melanin precursors (dopa, dopachrome, 5,6-dihydroxyindole).

These are synthesized by melanocytes but are also toxic to them. Disruption of the

labile destructive process could permit accumulation of indoles and free radicals,

destructive to melanocytes.45

A phenolic derivative may emerge as a degradation product of melanogenesis and a

cause for tyrosinase inhibition and cell death.21

It has been postulated that faulty enzymatic protective mechanism is an inherited

genetic defect in vitiligo patients.21

NEURAL THEORY

In the genesis of vitiligo, 'neural concept' was postulated first by Lerner.44 His

hypothesis was based on the following:

Clinical evidence of segmental/ dermatomal vitiligo.

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Increased sweating and vasoconstriction in vitiligenous areas implying

increased adrenergic activity.

Depigmentation in animal models with severed nerve fibers.

According to neural theory, certain compounds released at the peripheral nerve

endings inhibit melanogenesis and have toxic effect on melanocytes.71

Chanco turner et al in their studies demonstrated increased cholinergic activity as seen

by surface temperature and sweat production and prolonged bleeding time in the

depigmented macules.72

Breathnach et al demonstrated degenerative changes in the terminal portions of

peripheral nerves in vitiligenous areas.73

As melanocytes originate from the neural crest, their activity may be under neural

control, and degeneration of nerves and nerve endings may be an important link in the

pathogenesis of vitiligo.74

Ultra structural studies have indicated anatomic contact between nerve fibers and

melanocytes.75

Biochemical support for neural hypothesis arises from the observation that

acetylcholine may cause depigmentation , by virtue of its inhibitory effect on dopa

oxidase activity in marginal melanocytes in vitiligo,76 and acetylcholine esterase

activity has been shown to be absent in depigmenting skin.

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Lerner et al77 observed a patient with transverse myelitis of the spinal cord who

developed vitiligo confined to the face and trunk areas above the level of the cord

injury.

Gokhale and co-workers78 in their skin conductivity study found that perspiration

was decreased in patients with generalized vitiligo.

GENETICS IN VITILIGO

Genetic associations of vitiligo with alleles of MHC loci are strongest in patients

and families with various vitiligo-associated autoimmune diseases versus in patients

and families with only generalized vitiligo. In the first genome-wide linkage analysis

of vitiligo, a susceptibility gene, NALP1, on chromosome 17p13, was identified in

families with vitiligo-related systemic lupus erythematosus.

Later analyses identified highly significant linkage to chromosome 1p31.3–p32.2,

the AIS1 locus, as well as linkage to chromosomes 7q and 8p (AIS2 and AIS3,

respectively).

While linkage to the AIS1, AIS2 and NALP1 loci was observed primarily in

autoimmunity-associated families, the evidence for the AIS3 locus was primarily

from non-autoimmunity-associated families, suggesting that generalized vitiligo

might be divided into two distinct phenotypic subcategories. Other genes involved are

PTPN22, CTLA4, MITF, ACE, VDR, AIRE, and COMT.86-89

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FREE RADICAL THEORY

Overproduction of 6- and 7-tetrahydrobiopterins pointed to a metabolic defect in

tetrahydrobiopterin homeostasis in patients with vitiligo.

Such a defect would result in hydrogen peroxide (H2O2) overproduction, and high

levels of epidermal H2O2 have been confirmed in vitiligo skin. Thus there is oxidative

degradation of the porphyrin active site of catalase and deficiency of catalase in

vitiligo patients.90

CLINICAL FEATURES

Vitiligo is characterized by depigmented macules of different shapes and sizes,

which gradually spread peripherally.

Hypomelanotic macules are usually first noted on sun exposed areas of skin, on

the face or dorsa of hands.65 No part of the skin is immune to vitiligo.44

The extent of involvement is extremely variable. There may be one, several, or

upto hundreds of macules that may be small to large in size even in a single patient.

As vitiligo naturally evolves over time, the macules enlarge, coalesce and impart a

scalloped appearance to the interface of the normal and vitiligo skin. When vitiligo

becomes very extensive so that little normal pigment remains, the remaining islands

of normal pigmentation have concave borders, which is a diagnostic clue that

distinguishes this process from hyper pigmented macule on normal extremely fair

skin.45

Spontaneously repigmentation has been observed in 6 to 44%.46

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OCULAR ABNORMALITIES

The pigment epithelium of the retina is derieved from the cephalic neural crest

although the choroid consists of melanocytes from the spinal neural crest.79

Although the colour of the irides do not change in patients with even extensive

vitiligo, depigmented areas in the pigment epithelium and choroid occur in upto 4% of

patients.80-82

The incidence of uveitis in patients with vitiligo is elevated.83

Cowan et al81 and Norlund et al84 have shown a high percentage of ocular

abnormalities in the fundus. There is a report of coexistence of vitiligo and idiopathic

uveitis.85

OTIC ABNORMALITIES

The membranous labyrinth of the inner ear contains melanocytes and the

heaviest pigmentation is present in scala vestibuli.91 Because vitiligo affects all active

melanocytes auditory problems can result in patients with vitiligo.

In a study of patients with vitiligo who were less than 40 years of age, 16% had

hyperacusis in the 2 to8 KHZ range, which was of minimal disturbance to those

affected.92

In addition, two studies described familial vitiligo associated with auditory

anomalies.93,94

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KOEBNERISATION

This is the appearance of new vitiligo lesion on sites of trauma. The common sites

involved are waist band, saree, lungi, shoulder strap, slippers etc.32

LEUKOTRICHIA

Depigmented hair is commonly associated with vitiligo in about 9 to 45% of

patients.46 Extensive white hair may be a poor prognostic marker.46 Apart from

leukotrichia, premature greying occurs in upto 37% of vitiligo patients.

STABILITY OF VITILIGO

Vitiligo is considered as stable vitiligo if

no new lesions occur

no enlargement of older lesions

koebnerisation is negative

for a period of atleast 6 months to 2 years. These patients are ideal for vitiligo

surgeries.

PUNSHI'S SIGN:

White vitiligo macules turn red-pink during menstruation in females.

CLASSIFICATION OF VITILIGO

Vitiligo is classified based on the distribution pattern as below:3

LOCALISED

a) FOCAL: It is a depigmented macule in a localized non dermatomal distribution.

30

b) SEGMENTAL: Occurs in a dermatomal, asymmetric distribution. It is considered

as a special type of vitiligo, because of its earlier onset, recalcitrant course and

decreased association with autoimmune diseases. It affects males and females equally.

Most patients (90%) with this form of vitiligo develop depigmentation before the age

of 20 years compared to only 50% of those with generalized variety.

In a study conducted by Han et al (1996) the mean age of onset of segmental

vitiligo was 15.6 years. He further noted that face was the most common site of

involvement, regardless of sex and 11.5% had a family history of segmental vitiligo.

c) MUCOSAL VITILIGO: Involves only the mucosal surface i.e. oral or genital or

both.

GENERALISED:

a) ACROFACIAL VITILIGO: Encompasses depigmentation of the distal

extremities and facial orifices, the latter in a circumferential pattern.

LIP TIP VITILIGO: Involves lips and all tips i.e. fingers, nipples, penis.

b) VITILIGO VULGARIS: It is the most common presentation with bilateral,

symmetric depigmentation of the face, neck, torso, extensor surfaces or bony

prominences of the hands, wrists and legs, axillae, orifices or mucosal surfaces. Legs

are the most common initial sites of involvement.

c) VITILIGO UNIVERSALIS: Encompasses those cases where the depigmentation

involves the entire or nearly entire body surface area with specks of normally

pigmented areas.

31

MIXED TYPE: This consists of more than one type of vitiligo.

The following are the clinical variants of vitiligo:4

TRICHROME VITILIGO: refers to an uniform tan colour between the normally

pigmented skin and the typically depigmented vitiligo macule.

QUADRICHROME VITILIGO: refers to the fourth colour i.e. a perifollicular

hyperpigmentation.

PENTACHROME VITILIGO: refers to vitiligo with five shades of color (black,

dark brown, medium brown [unaffected skin], tan and white).

VITILIGO PONCTUE: An unusual clinical presentation of vitiligo, is characterized

by small confetti-like or tiny, discrete, amelanotic macules occurring either on

otherwise normal skin or on a hyperpigmented macule.4

INFLAMMATORY VITILIGO: when there is erythema of the margin of a vitiligo

macule.4

BLUE VITILIGO: when vitiligo develops over post inflammatory

hyperpigmentation.4

VALECEO TYPE OF VITILIGO: Emotional trauma and repression have been

noted to be responsible for a very sudden onset, rapid extension and spread of

lesions.21

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HISTOPATHOLOGY

Routine histopathology shows marked absence of melanin granules in vitiligenous

areas. This is best seen in sections stained with silver stains. The dopa reaction also

shows absence of melanocytes.95

Early lesions and peripheral zone of enlarging lesions that are hypopigmented

show a few dopa positive melanocytes and some melanin granules in the basal layer.96

Narayanan et al in his study found that in addition to the absence of melanocytes

there was vacuolated degeneration of langerhans cells and degenerative changes in

keratinocytes suggesting that all the three types of epidermal cells may be involved in

some way in vitiligo.97

At the border of the patches of vitiligo the melanocytes appear large and possess

long dendritic processes filled with melanin granules and the dermis shows

lymphocytic infiltration.84

Basal layer of epidermis show focal areas of vacuolar degeneration in association

with a mild mononuclear cell infiltrate seen in the normal appearing skin adjacent to

vitiliginous areas.66

The melanoytes undergo fibrillar degeneration. As they degenerate, fibrils

accumulate within the cytoplasm.98 These masses of cytoplasmic fibrillar material

form the colloid like masses observed in the basal layer.99 Keratinocytes in pigmented

skin also show degenerative changes.100

33

Histopathologic findings101 have been used to support various theories concerning

the development of vitiligo. Perilesional melanocytes express major

histocompatibility class II antigens and substantially higher intercellular adhesion

molecule 1relative to normal skin controls. These have been found in follicular

epithelium in auto immune thyroiditis and in pancreatic beta cells in type 1 diabetes,

upholding the autoimmune hypothesis.

The phenomenon of direct nerve contact with melanocytes along the

dermoepidermal junction in depigmented skin of patients with vitiligo75 and a

complete or partial degeneration of the nerves73,74 support the neural hypothesis of

vitiligo.

ASSOCIATED DISORDERS

A) Skin diseases

Premature canities has been reported in about 37% of vitiligo cases.102 Vitiligo is

frequently seen in association with atopic eczema.103

Coexistence of psoriasis and vitiligo and occurence of psoriasis on vitiligo

macules have been documented.104,105

There are reports of association of neurofibromatosis with vitiligo.106

Palmoplantar hyperhidrosis has been reported in 10.5% of vitiligo cases in contrast to

3.5% in the control group.107

34

There have been reports of association of vitiligo with alopecia areata and

DLE,108 pemphigus vulgaris,109,110 lichen planus111 and squamous cell carcinoma112 on

a patch of mucosal vitiligo.

Halo naevi have been estimated to occur in about 50% of cases of vitiligo.113

Alopecia areata has been reported in up to 16% of vitiligo patients.114

Jopling W.H.115 has been found an association of vitiligo with lepromatous

leprosy. In his study conducted among 114 lepromatous leprosy, 8 patients developed

vitiligo after varying years of treatment accounting for incidence of 7%. The

association of vitiligo with lepromatous leprosy has supported the hypothesis that

vitiligo has an autoimmune basis, for a wide variety of autoantibodies have been

described in lepromatous leprosy.

Vitiligo and melanoma frequently occur together. Vitiligo associated with

melanoma carry a poor prognosis.100

Saiham et al (1979) reported vitiligo in association with morphoea.116

B) Systemic disorders

There is ample documentation of the association of vitiligo with autoimmune

disoders.

The increased incidence of hyperthyroidism and Hashimoto's thyroiditis in

vitiligo patients is well recorded.117,118

Higher incidence of vitiligo in elderly women patients of Graves disease,

hyperthyroidism, toxic goitre and thyroditis have been reported.21

35

Vitiligo has been reported to develop in 7% of patients with Graves' disease.51

Pernicious anemia is recorded 30 times more frequent among vitiligo patients

than in general population.119

Fifteen percent of Addison's disease patients have been reported to have

vitiligo.120

The prevalence of diabetes mellitus in vitiligo patients is reported to vary from

1% to 7.1%.117

According to Dawber (1968), diabetes mellitus should be excluded in every

patient with late onset vitiligo.121

Bhargava et al reported a case of congenital leopard vitiligo associated with

multiple sclerosis.122

Satish et al reported a case of vitiligo with oesophageal carcinoma.123

There are reports of vitiligo with ulcerative colitis, myasthenia gravis,124 primary

ovarian failure and juvenile rheumatoid arthritis.125 Some other studies have reported

the association of vitiligo with multiple myeloma, pernicious anemia126 and

dysgammaglobulinemia A.127

SYNDROMES ASSOCIATED WITH VITILIGO

Vogt Koyanagi Harada syndrome128,129 is an apparently rare, multisystem disease

characterised by uveitis, dysacousia, alopecia, poliosis and vitiligo. This syndrome

36

was first described by Vogt in 1906. Harada in 1926, described five cases with

bilateral posterior uveitis with retinal detachment. Koyanagi completed the

description of the syndrome in 1929. It affects both sexes equally and the peak

frequency is in the third decade.

Clinical Features:

Classical Vogt Koyanagi Harada syndrome has 3 phases.

I. Meningoencephalitic phase: manifested by headache, malaise, nausea, vomiting,

confusion, psychosis, paraplegia, and generalised weakness.

II. Ophthalmic auditory phase: characterised by decreased visual acuity,

photophobia, and eye pain. Dysacousia is seen in 50% of patients.

III. Convalescent phase: starts as uveitis begins to abate and is characterised by

alopecia, poliosis and vitiligo.

Criteria for diagnosis for Vogt Koyanagi Harada syndrome are as follows:1

No history of ocular trauma or surgery preceding the initial onset of uveitis.

No clinical or laboratory evidence suggestive of ocular disease entities.

Bilateral ocular involvement

diffuse choroiditis- early sign

ocular depigmentation- late sign

Neurological and auditory findings: meningismus, tinnitus, cerebrospinal fluid

pleocytosis.

Skin and hair changes: alopecia, vitiligo, poliosis.

37

Alezzandrini's syndrome130 is charcterised by a unilateral degenerative retinitis

followed after several months by ipsilateral vitiligo on the face and ipsilateral

poliosis. Deafness may also be present.

SCORING SYSTEMS IN VITILIGO:16

Vitiligo area and severity index (VASI Score):

Percentage of vitiligo involvement is calculated in terms of hand units. One hand

unit (encompass palm and volar surface of all digits) is approximately equivalent to

1% of total body surface area. The degree of depigmentation is estimated to the

nearest of the following percentages:

100%- complete depigmentation

90%- specks of normal pigmentation present

75%- depigmented area exceeds pigmented area

50%- pigmented and depigmented area are equal

25%- normally pigmented area exceeds depigmented area

10%- only specks of depigmentation present

Vitiligo disease activity score (VIDA):

The VIDA is a six-point scale for assessing vitiligo activity.

Scoring is based on the individual's own opinion of the present disease activity

over time. Active vitiligo involves either expansion of existing lesions or appearance

of new lesions. Grading is as follows:

38

VIDA Score 4+ - Activity of 6 weeks or less duration

3+ - Activity of 6 weeks to 3 months

2+ - Activity of 3 - 6 months

1+ - Activity of 6 - 12 months

0 - Stable for 1 year or more

-1 - Stable with spontaneous repigmentation since 1 year or more.

A low VIDA score indicates less activity.

DIFFERENTIAL DIAGNOSIS:1,3,4,5

Congenital normal variant:

Nevus achromicus- Solitary hypopigmented macule well circumscribed with

irregular borders, stable in size, solitary, most often present at birth

Nevus anaemicus- Hypochromic pale lesion with well-defined borders and

irregular margins which are usually solitary and they are located on the trunk.

Histology and electron microscopic examination reveal no abnormality in

melanocytes or melanization

Genetic disorders:

Oculo cutaneous albinism-

Type -1: TYR mutation- 1a- total lack of tyrosinase

1b- partial tyrosinase activity present

Type -2: OCA2 mutation- defective transport of tyrosinase

39

Type -3: TYRP1 mutation- defective oxidation of dihydroxy indole 2

carboxylic acid

Type -4: SLC45A2 mutation- defective melasome transfer

Type -6: SLC24A5 mutation- defective maturation of melanosomes

Oculo cutaneous albinoidism- mild form of tyrosinase positive oculocutaneous

albinism.

Piebaldism- defect in c-kit protooncogene

poliosis

depigmented macules

Hermansky Pudlak syndrome

oculocutaneous albinism

haemmorrhagic diasthesis

pulmonary fibrosis, granulomatous colitis, lupus nephritis

nystagmus, photophobia, visual disturbances

Chediak Higashi syndrome- LYST mutation

squint, photophobia, decreased retinal pigmentation

increased susceptibility to infection

pancytopenia

convulsions, neuropathy

40

hilar lymphadenopathy, jaundice, leukemic gingivitis,

pseudomembranous sloughing of buccal mucosa

Waardenburg syndrome

Type 1- classical- dystopia canthorum, prominent nasal root and

medial eyebrows, congenital sensoryneural hearing loss, heterochromia

irides, white forelock, premature canites.

Type 2- No dystopia canthorum and facial dysmorphism. higher

incidence of deafness and heterochromia

Type 3- associated with musculoskeletal abnormalities

Type 4- associated with Hirschsprung disease

Cross syndrome- geeralised hypopigmentation, mental retardation, spastic

tetraplegia, athetosis, microphthalmos

Griscelli Prunieras syndrome

Type 1- primary CNS dysfunction

Type 2- haemophagocytic lymphohistiocytosis

Type 3- partial albinism

Woolf's syndrome- piebaldism, deafness, mental retardation

Tietz's syndrome

depigmented skin and hair

41

normal eyes

deaf mutism

hypoplasia of eyebrows

Ataxia telangectasia

premature greying of hair

cerebellar ataxia, choreoathetosis

oculocutaneous telangiectasia

bronchiectasis

Tuberous sclerosis- TSC 1 and 2 mutation- ash leaf macules

Hypomelanosis of Ito- hypopigmented linear streaks along blaschko lines,

neurological, ophthalmological, and skeletal defects.

Inborn errors of metabolism:

Phenylketonuria- depigmented skin, hair, eyes, photophobia.

Menke kinky syndrome- ATP7A mutation- hair changes-

monelethrix, pili torti, trichorrhexis nodosa, neurological

deterioration.

Homocystinuria- marfanoid features, mental retardation,

ectopia lentis, depigmented macules, hypopigmented hair.

Endocrinopathy:

Hypopituitarism

42

Hyperthyroidism

Hypogonadism

Nutritional:

Kwashiorkar

Malabsorption

Chemical contact:

Monobenzyl ether of hydroquinone and Hydroquinone

Phenol

Thiouracil

Thiol

Butylated hydroxytoluine

Steroids

Retinoids

Topical imiquimod

Systemic drugs:

chloroquine

fluphenazine

physostigmine

imatinib

43

Post inflammatory:

Mechanical trauma

Thermal injury

Ionizing radiation

Infections:

Bacterial- Leprosy, Syphilis

Viral- Herpes simplex, Herpes zoster

Fungal- Tinea versicolor, Candidiasis

Parasitic- Onchocerciasis

Other dermatological disorders with hypo pigmentation:

Pityriasis alba

Pityriasis rosea

Psoriasis

Lichen stiatus

Lichen planus

Lichen striatus et atrophicans

Discoid lupus erythematosis

Morphea

Sarcoidosis

Bullous dermatitis

Cutaneous lymphoma

44

Others:

Idiopathic guttate hypomelanosis

Progressive macular hypomelanosis

Halo nevus

MANAGEMENT1

First line

Potent topical corticosteroid (e.g. 0.1% betamethasone valerate or 0.05%

clobetasol propionate) is effective at inducing repigmentation of areas of

vitiligo.

It is preferable to use an intermittent regimen (e.g. 15 days per month for 6

months) to avoid local side effects (skin atrophy, telangiectasia, striae, hypertrichosis

and acneform eruptions).

Topical calcineurin inhibitors (pimecrolimus, tacrolimus) has been

reported to be successful, mainly for lesions on the face and neck twice daily

applications are recommended, initially for 6 months.

Topical Vitamin D analogs—calcipotriol ointment (0.005%) and tacalcitol

ointment (20 μg/g) restore pigmentation in vitiligo by inducing skin

immunosuppression, which halts the local autoimmune process, and via direct

activation of melanocytic precursors and melanogenic pathways. When

vitamin D analogs are used in combination therapy, it is more effective

45

probably because of stimulation of both melanocyte growth (with

corticosteroids or UV) and differentiation (with a vitamin D analog).

Vitamin D derivatives are indicated for use in localized disease They lack

adverse effects of skin atrophy. However, their role in vitiligo treatment

remains controversial

Second line

Systemic psoralen photochemotherapy (PUVA) is effective in a proportion

of cases. The use of topical applications of psoralens is more hazardous and

may result in untoward blistering of the skin.

Photosensitizers including khellin have been advocated but there are

concerns over hepatotoxicity and it has not been widely adopted.

UVB therapy can also be used selectively.

Localized targeted phototherapy devices (excimer lamp or lasers with a

peak at 308 nm). There is no consensus as to the optimum treatment duration

of phototherapy. Most often irradiation will be stopped if no repigmentation

occurs within the first 3 months of treatment.

Third line

Grafting techniques

Surgical methods have been proposed as a therapeutic option in patients with stable

vitiligo (e.g. segmental vitiligo). These surgical techniques are based on a common

basic principle: to transplant autologous melanocytes from a normal pigmented area

to the affected depigmented skin.

46

Different surgical techniques for repigmenting vitiligo have been gradually devised

and include

Tissue grafts

full thickness punch grafts

split thickness grafts

suction blister grafts

Cellular grafts

cultured melanocytes

cultured epithelial sheet grafts

non cultured epidermal cellular grafts

Lately, the use of hair follicle outer root sheath cells has been introduced. The

three tissue grafting methods (full thickness punch grafts, split thickness grafts,

suction blister grafts) seem to have comparable success rates in inducing

repigmentation.

Cellular grafting techniques were in general found to be nearly as effective,

although the percentages of patients in whom repigmentation was achieved were

slightly lower than with the tissue grafting techniques. However, cellular grafting can

be used to treat larger areas and has in general better cosmetic results compared to

tissue grafts. Furthermore, adverse events seem to be less frequent with cellular grafts

than with punch or split skin grafts.

47

Depigmenting treatment: In those patients with extensive vitiligo and only a few

residual areas of pigmentation, skin bleaching with

laser therapy (e.g. Q switched alexandrite 755 nm, Q switched ruby 694 nm),

cryotherapy

creams (e.g. 20% monobenzylether of hydroquinone), may be used.

Camouflage and psychological support:

Camouflage:131

Temporary camouflage:

Liquid dyes:

Potassium permanganate, indigo carmine, Bismarck brown and henna pastes are

commonly used. But, they may get washed away easily.

Indigenous preparations (Traditional Indian Preparations)

Iron fillings (Loha Bhasma) and Suvarna Karini (clay mixed with henna and oils) are

used. But, colour matching is difficult.

Foundation-based cosmetic camouflage

Oil-based, water-based, oil-free and water-free forms are available with matte, semi-

matte, moist semi-matte and shiny finishes. Liquid foundations are also available.

Self-tanning products:

Dihydroxyacetone is commonly used self tanning agent but has a mutagenic property

and cause allergic contact dermatitis. colour matching is also difficult.

48

Permanent camouflage:

It is achieved mainly by micropigmentation/medical tattooing. Iron oxide is the most

common pigment used. Various other chemicals used and the respective colors

produced are as follows:

black, camel yellow, light and dark brown (iron oxide)

white (titanium dioxide)

yellow (cadmium sulfide)

red (mercuric sulfide/cinnabar with cadmium sulfide added to make the red

shade brighter).

Complications include colour fading, allergic contact dermatitis, reactivation of

herpes, transmission of HIV and hepatitis B.

Psychological support:

Since vitiligo is associated with social stigma, these patients are more prone for

depression. Psychiatric counselling and family support is necessary in such patients.

49

Role of vitamin D in vitiligo:

Parsad et al.132 first reported the use of vitamin D analogues in combination with

PUVAsol and topical calcipotriol for the treatment of vitiligo. Many studies have

been reported about the use of vitamin D analogues alone or in combination with

ultraviolet light or corticosteroids to enhance repigmentation in vitiligo.133

Birlea et al., concluded that vitamin D3 analogues are effective in combination

with PUVA, NBUVB, or an excimer laser after reviewing 22 studies published on

calcipotriol/tacalcitol used alone or in combination with other agents.134

Oh et al., reported that high concentration of tacalcitol was applied topically

with 308 nm xenon chloride excimer laser to lower the energy threshold to treat non

segmental vitiligo.135

In a recently published case report, it was found low levels of vitamin D

50

inflammatory mediators139 and stimulate melanin production by activating

melanocytes and keratinocytes.140

Melanocytes in the epidermis become swollen with elongated dendrites after UV

exposure. On long term UV exposure, the tyrosinase activity in these melanocytes is

increased by microphthalmia transcription factor (MITF),141 and results in the

deposition of the melanin in the epidermis.

Tomita et al., studied that increased cell size, number of dendrites, and tyrosinase

activity was induced by both vitamin D3 and UV radiation individually.142

Ermis et al., reported that the combination of calcipotriol and PUVA was safe and

more effective in initiating and achieving complete repigmentation than a placebo

with PUVA.143

A marginal type of repigmentation pattern is seen and the onset of repigmentation

induced by calcipotriol was slow.144 In a few cases, treatment failure or no added

response was observed at the end of 3 months with combination therapy with these

vitamin D analogues.133

A recent study on the influence of low-dose narrowband UVB phototherapy on

serum levels of vitamin D145 revealed that UVB phototherapy increased vitamin D

levels in patients with low initial levels of 25-hydroxyvitamin D (25(OH) D) (the

serum marker for vitamin D status), thus indicating the beneficial effect of UVB

depends partially on vitamin D.

51

It has been shown that defective calcium (Ca2+) transport is found in

keratinocytes and melanocytes of vitiliginous skin samples.146 Both plasma membrane

associated and cytosolic thioredoxin reductase is controlled by calcium. Decreased

intracellular Ca2+ inhibits melanin synthesis due to high levels of reduced

thioredoxin which inhibits tyrosinase activity. Moreover, melanocytes express 1,25-

dihydroxyvitamin D3 receptors and regulates melanin synthesis.147,148

Thus, calcipotriol plays a role in Ca2+ regulation through 1,25-dihydroxyvitamin

D3 receptors on melanocytes and/or by the regulation of defective Ca2+

homeostasis.143

Proinflammatory and proapoptotic cytokines, such as IL-6, IL-8, IL-10, IL-12,

INF-ᵧ, and TNF-ἀ, play a role in the pathogenesis of vitiligo.149,150 The expression of

IL-6, IL-8, TNF-ἀ, and TNF-ἀ is inhibited by vitamin D.151 Dendritic cell maturation,

differentiation, and activation in both human and murine culture systems,152 are

modulated by vitamin D probably by VDR-dependent pathway.153

Vitamin D compounds also induce the inhibition of antigen presentation.152,153

Vitamin D protects the epidermal melanin unit and restores melanocyte integrity

by the following mechanisms:

By controlling the activation, proliferation, migration of melanocytes and

pigmentation pathways by modulating T cell activation, which is apparently

related to disappearance of melanocytes in vitiligo.

52

Immunomodulatory action of VDR on immune cells lead to coordination of T

cell activation mainly by the inhibition of T cell transition from the early to the

late G1 phase and by the inhibition of several cytokine genes encoding TNF-ἀ

and IFN-ᵧ.154

The mechanism through which vitamin D exerts its effects on melanocytes is not

yet fully understood. Vitamin D helps in coordinating melanogenic cytokines like

endothelin-3 and the activity of the SCF/c-Kit system, which regulates melanocyte

maturation.154

There is also an antioxidant role of vitamin D in vitiligo by regulating reative

oxygen species.

The active form of vitamin D produces IL-6 and reduces the apoptotic activity of

keratinocytes155 and melanocytes 156 induced by UVB.

In another study, melanocytes protected from apoptosis through the formation of

sphingosine-1-phosphate by vitamin D,also opposes apoptotic action in diverse

melanoma cell lines.157

Vitamin D-It acts on specific T cell by inhibiting the expression of several

proinflammatory cytokines genes (TNFἀ, IFᵧ)

1, 25-Dihydroxyvitamin D3- It protects human melanocytes from apoptosis by

formation of sphingosine-1-phosphate

53

1,25-Dihydroxyvitamin D3- It has anti apoptotic effects and decreased

cyclobutane pyrimidine dimers damage by up to 60%

Tacalcitol- a vitamin D analogue plays a role in Ca2+ regulation by vitamin D

receptor (VDR) on melanocytes

Vitamin D receptor- is the nuclear receptor that mediates the effects of vitamin

D through regulating the transcription of other genes

54

MATERIALS and

METHODS

55

MATERIALS AND METHODS

This is a hospital based case control study with a sample size of 180 including

120 cases and 60 controls.

The study was done for 6 months from December 2016 to May 2017 in

dermatology out patient department, Government Rajaji hospital.

Clinically diagnosed cases of vitiligo attending dermatology department

constitute the cases. Age matched and sex matched healthy volunteers comprised the

control group. Ethical committee approval was obtained.

Informed consent were obtained from all those who were included in this study.

All were interrogated for a detailed history and a meticulous examination of each case

was carried out and recorded in a special proforma separately for cases and controls.

History of precipitating factors such as trauma, chemicals, stress, associations

were specifically asked for and noted. History suggestive of thyroid disease, atopy,

diabetes was noted.

A complete general physical examination was done in all those who were

included in the study. A thorough systemic examination was also made for associated

disorders and the findings were noted. Detailed dermatological examination including

the mucosa was carried out to classify the disease, to know the extent of vitiligo and

to study the specific features such as trichrome, quadrichrome, and leukotrichia.

All those who were included in this study were subjected to the following

investigations: complete hemogram, blood sugar, renal function test, liver function

56

test, serum fasting lipid profile, serum proteins, antinuclear antibody, and serum 25

hydroxy cholecalciferol.

The patients were categorized based on the type, duration, and severity of vitiligo.

The patients were classified based on the following clinical types:

Focal

segmental

mucosal

acrofacial

vitiligo vulgaris

vitiligo universalis

The patients were categorized on the basis of duration as follows:

0-5 years

6-10 years

11-15 years

16-20 years

>21 years

Severity of vitiligo was assessed using VASI score.16

The patients are categorized based on VASI score as follows:

0-10%

11-25%

57

26-50%

51-75%

76-100%

Serum 25-OH cholecalciferol levels were calculated using Euro immune ELISA

kit. The cases and controls were categorized based on serum 25-OH cholecalciferol

levels as follows:158

Serum 25-OH cholecalciferol level (ng/ml) Implication

150 Intoxication

58

OBSERVATIONS

and RESULTS

59

OBSERVATION and RESULTS:

In this study comprising of 120 cases and 60 controls done in the dermatology OP,

Government Rajaji hospital, Madurai, the following observations are found.

60

AGE DISTIBUTION OF THE STUDY: The study included 26 cases and 13

controls in the age 60 years thus matching the age of

cases and controls.

Age (in years) Group

Case n (%) Control n (%)

≤ 20 26 (21.7) 13 (21.7)

21 - 40 43 (35.8) 23 (38.3)

41 - 60 43 (35.8) 21 (35.0)

>=61 8 (6.7) 3 (5.0)

Total 120 (100.0) 60 (100.0)

Mean±SD 37.6±17.2 36.2±15.8

Min, Max 4, 68 6,68

p value 0.968 - Not Significant

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

≤ 20 21 - 40 41 - 60 >=61

21.7

35.8 35.8

6.7

21.7

38.335.0

5.0(in p

erce

nta

ge)

Age group (in yrs)

Age Distribution

Case

Control

61

SEX DISTRIBUTION OF THE STUDY: This study included 59 males and 61

females among cases and 29 males and 31 females in controls.

Gender Group


Male 59 (49.2) 29 (48.3)

Female 61 (50.8) 31 (51.7)

Total 120 (100.0) 60 (100.0)


59 61

29 31

0

10

20

30

40

50

60

70

Male Female

SEX DISTRIBUTION

Cases

Control

62

SEX DISTRIBUTION IN THE TYPE OF VITIIGO: This study included 5 males

and10 females in focal vitiligo, 7 males and 10 females in mucosal vitiligo, 10 males

and 4 females in segmental vitiligo, 9 males and 4 females in acrofacial vitiligo, 26

males and 28 females in vitiligo vulgaris, 2 males and 5 females in vitiligo

universalis.

Type of Vitiligo Sex

Male n (%) Female n (%)

Focal 5 (8.5) 10 (16.4)

Mucosal 7 (11.9) 10 (16.4)

Segmental 10 (16.9) 4 (6.6)

Acrofacial 9 (15.3) 4 (6.6)

Vulgaris 26 (44.1) 28 (45.9)

Universalis 2 (3.4) 5 (8.2)

Total 59 (100.0) 61 (100.0)

p value 0.155 – Not Significant

57

10 9

26

2

10 10

4 4

28

5

0

5

10

15

20

25

30

Focal Mucosal Segmental acrofacial Vulgaris universalis

SEX DISTRIBUTION IN THE TYPE OF VITILIGO

Male

Female

63

SEX DISTRIBUTION IN THE DURATION OF VITILIGO: This study included

49 males and 48 females in 20

SEX DISTRIBUTION IN VITILIGO DURATION

Male

Female

64

S. CHOLECALCIFEROL LEVELS IN CASES vs CONTROLS : There were 9

cases and 1 control with very severe deficiency, 22 cases and 4 controls with severe

deficiency, 39 cases and 17 controls with deficiency, 28 cases and 12 controls with

suboptimal levels, 22 cases and 26 controls with normal levels and 1 patient had

above normal value.

Serum VIT D3(ng/ml) Group


Very severe deficiency(< 5) 9 (7.5) 1 (1.7)

Severe deficiency(5.1 - 10) 22 (18.3) 4 (6.7)

Deficiency (10.1 - 20) 39 (32.5) 17 (28.3)

Sub optimal(20.1 - 30) 28 (23.3) 12 (20.0)

Normal (30.1 - 50) 17 (14.2) 17 (28.3)

Upper normal (50.1 - 70) 4 (3.3) 9 (15.0)

Above normal (> 70) 1 (0.8) -

Total 120 (100.0) 60 (100.0)

Mean±SD 19.8±13.6 29.5±17.1

Min, Max 2.1, 82.0 4.7, 69.4

p value < 0.004 Sig

9

22

39

28

17

411

4

1712

17

9

00

10

20

30

40

50

< 5 5.1 - 10 10.1 - 20 20.1 - 30 30.1 - 50 50.1 - 70 > 70

SERUM VIT D3

COMPARISON OF SERUM VIT D3 (CASES VS

CONTROLS)

Case

Control

65

CHOLECALCIFEROL IMPLICATION IN CASES vs CONTROLS: In order to

avoid confusion, those people with very severe and severe deficiency of

cholecalciferol levels 30ng/dl were clubbed

together as normal with 22 cases and 26 controls.

Implication Group


Severe Deficiency (30) 22 (18.3) 26 (43.3)

Total 120 (100.0) 60 (100.0)

p value

66

CORRELATION OF S. CHOLECALCIFEROL WITH TYPE OF VITILIGO:

The study showed deficiency and severe deficiency of serum cholecalciferol in

patients with vitiligo vulgaris and universalis thus suggesting significant correlation

with the type of vitiligo. Ten vitiligo vulgaris patients with normal values could be

explained by the fact that they were on phototherapy and are clinically improving.

Type of Vitiligo

Implication

Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

Focal 2 (6.5) 12 (17.9) 1 (4.5)

Mucosal 2 (6.5) 10 (14.9) 5 (22.7)

Segmental 5 (16.1) 6 (9.0) 3 (13.6)

Acrofacial - 10 (14.9) 3 (13.6)

Vulgaris 17 (54.8) 27 (40.3) 10 (45.5)

Universalis 5 (16.1) 2 (3.0) -

Total 31 (100.0) 67 (100.0) 22 (100.0)

p value 0.025 – Significant

0

10

20

30

40

50

60

6.5 6.5

16.1

54.8

16.117.9

14.99

14.9

40.3

34.5

22.7

13.6 13.6

45.5

(in p

erce

nta

ge)

Type of Vitiligo Vs ImplicationSevere Deficiency

Deficiency

Normal

patients under

phototherapy

& natural

sunlight

exposure

67

CORRELATION OF S. CHOLECALCIFEROL WITH DURATION: This study

shows significant correlation (P value-0.001) with duration of vitiligo. Among

patients with vitiligo for > 5 years duration, only 5 show normal values and all these

patients were under phototherapy and showed clinical improvement. Majority of the

patients were suffering from vitiligo for

68

CORRELATION OF S.CHOLECALCIFEROL WITH SEVERITY (VASI

Score): This study shows significant correlation with the severity of vitiligo. Among

patients with VASI score >26%, 2 out of 19 patients had normal value which could

probably be explained by previous phototherapy. They also showed clinical

improvement.

VASI

Implication of s.cholecalciferol

Severe

Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

< 10 % 10 (32.3) 43 (64.2) 17 (77.3)

11 - 25 % 8 (25.8) 20 (29.9) 3 (13.6)

26 - 50 % 8 (25.8) 2 (3.0) -

51 - 75% - - 2 (9.1)

> 75% 5 (16.1) 2 (3.0) -

Total 31 (100.0) 67 (100.0) 22 (100.0)

p value 75%

32.3

25.8 25.8

16.1

64.2

29.9

3 3

77.3

13.69.1

(in p

erce

nta

ge)

VASI Score Vs Implication

Severe Deficiency

Deficiency

Normal

patients under

phototherapy

69

VARIATION OF S. CHOLECALCIFEROL WITH AGE AMONG CASES: In

age ≤20 years, 11 have severe deficiency, 15 have deficiency. In 21-40 years, 12 have

severe deficiency, 22 have deficiency and 9 have normal values. In 41-60 years, 8

have severe deficiency, 25 have deficiency, and 10 have normal values. In ≥ 61 years,

5 have deficiency and 3 have normal values while none show severe deficiency.

Age (in years)


Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

≤ 20 11 (35.5) 15 (22.4) -

21 - 40 12 (38.7) 22 (32.8) 9 (40.9)

41 - 60 8 (25.8) 25 (37.3) 10 (45.5)

≥ 61 - 5 (7.5) 3 (13.6)

Total 31 (100.0) 67 (100.0) 22 (100.0)


0

5

10

15

20

25

30

35

40

45

50

≤ 20 21 - 40 41 - 60 ≥ 61

35.538.7

25.822.4

32.8

37.3

7.5

40.945.5

13.6

(in p

erce

nta

ge)

Age (in yrs)

Age Vs Implication ( Among Cases)

Severe Deficiency

Deficiency

Normal

70

VARIATION OF S. CHOLECALCIFEROL WITH AGE AMONG

CONTROLS: In age ≤20 years, 12 have deficiency, 1 has normal value. In 21-40

years, 4 have severe deficiency, 10 have deficiency and 9 have normal values. In 41-

60 years, 6 have deficiency and 15 have normal values. In ≥ 61 years, 2 have

deficiency and 1 has normal value.

Age (in years)


Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

≤ 20 - 12 (40.0) 1 (3.8)

21 - 40 4 (100.0) 10 (33.3) 9 (34.6)

41 - 60 - 6 (20.0) 15 (57.7)

≥ 61 - 2 (6.7) 1 (3.8)

Total 4 (100.0) 30 (100.0) 26 (100.0)


0

20

40

60

80

100

≤ 20 21 - 40 41 - 60 ≥ 61

100

4033.3

20

6.73.8

34.6

57.7

3.8

(in p

erce

nta

ge)

Age (in yrs)

Age Vs Implication (Among Controls)

Severe

Deficiency

Deficiency

71

VARIATION OF S. CHOLECALCIFEROL WITH SEX AMONG CASES:

There are 11 males and20 females with severe deficiency, 37 males and30 females

with deficiency and 11 males and 11 females with normal values. Thus, there was no

significant variation with sex among cases in deficient and normal groups. But severe

deficiency was commonly seen in females.

Sex


Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

Male 11 (35.5) 37 (55.2) 11 (50.0)

Female 20 (64.5) 30 (44.8) 11 (50.0)

Total 31 (100.0) 67 (100.0) 22 (100.0)


0

10

20

30

40

50

60

70

Severe Deficiency Deficiency Normal

35.5

55.2

50

64.5

44.8

50

(in p

erce

nta

ge)

Gender Vs Implication (Among Cases)Male

Female

72

VARIATION OF S. CHOLECALCIFEROL WITH SEX AMONG

CONTROLS: Among controls, there are 0 males and 4 females with severe

deficiency, 16 males and 14 females with deficiency and 13 males and 13 females

with normal values. Thus, here also severe deficiency is more with females.

Sex


Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

Male - 16 (53.3) 13 (50.0)

Female 4 (100.0) 14 (46.7) 13 (50.0)

Total 4 (100.0) 30 (100.0) 26 (100.0)


0

10

20

30

40

50

60

70

80

90

100

Severe Deficiency Deficiency Normal

53.350

100

46.750

(in p

erce

nta

ge)

Gender Vs Implication (Among Controls)

Male

Female

73

CORRELATION OF S.CHOLECALCIFEROL WITH UV EXPOSURE IN

CASES: Among those exposed to UV rays, there are 6 cases with severe deficiency,

15 cases with deficiency and 21 with normal values. In comparison, in those who are

not exposed to UV rays, there are 25 had severe deficiency, 52 had deficiency and

only 1 had normal value thus suggesting significant correlation with UV exposure

either due to phototherapy or due to natural sunlight exposure.

UV Exposure

Implication of s. cholecalciferol

Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

Exposed to UV

rays 6 (19.4) 15 (22.4) 21 (95.5)

Not Exposed to

UV rays 25 (80.6) 52 (77.6) 1 (4.5)

Total 31 (100.0) 67 (100.0) 22 (100.0)

p value

74


CONTROLS: Among the controls of those who were exposed to UV rays, none had

severe deficiency, 2 had deficiency and 7 had normal values. In those controls who

were not exposed to UV rays, 4 had severe deficiency, 28 had deficiency and 19 had

normal values. Though those who show deficiency and severe deficiency of

cholecalciferol levels are more in non UV rays exposed group, the association is not

significant (P value-0.073)

UV Exposure


Severe Deficiency

n (%)

Deficiency

n (%)

Normal

n (%)

Exposed to UV

rays - 2 (6.7) 7 (26.9)

Not Exposed to

UV rays 4 (100.0) 28 (93.3) 19 (73.1)

Total 4 (100.0) 30 (100.0) 26 (100.0)


0

10

20

30

40

50

60

70

80

90

100

Severe

Deficiency

Deficiency Normal

6.7

26.9

10093.3

73.1

(in p

erce

nta

ge)

Implication with uv exposure (Among Controls)

Exposed to Sunlight

Not Exposed to

Sunlight

75

DISCUSSION

76

DISCUSSION:

Out of the total 180 people included in this study, 120 were vitiligo cases and 60 were

age and sex matched controls.

Indian case control study done by Prakash D et al,159 45 cases and 45 age and sex

matched controls were compared. In another Iranian study,160 30 cases were compared

with 30 age and sex matched controls. In a Turkish study by Karagun E.,161 50 vitiligo

patients and 47 controls were compared. In another Turkish study by Takci Z., 162 44

vitiligo vulgaris patients were compared with 43 controls. Thus, this study included

more number of cases and controls when compared with other studies.

AGE DISTRIBUTION:

The study included 26 cases and 13 controls in the age 60 years. Thus, the age of cases and controls were matched with a p value

of 0.968. The mean age of cases is 37.6 + 17.2 and that of controls is 36.2±15.8.

In the Indian case control study done by Prakash D et al,159 mean age of patients was

43.78 ± 14.70 SD. In the Iranian study,160 the mean age was 30.2 + 0.91 in cases and

34.76 + 1.07 in controls. In the study by Karagun E.,161 the mean ages of the patient

and control groups were 30.96 ±10.57 and 31.45 ±8.33 years, respectively. In the

study by Takci Z., 162 a total of 44 patients with mean age of 34.5 + 16.1 years

(range: 16–60 years) and 43 controls with mean age of 33.0 + 12.6 years (range: 17 –

60 years) were included in the study.

77

SEX DISTRIBUTION:

In this study, out of the 120 cases, 59 were males and 61 were females and out of

the 60 controls included 29 were males and 31 were females. Thus, the sex of cases

and controls are matched with a p value of 0.916.

In the study done by Prakash D et al,159 out of 45 cases, 26 were male and 19 were

female, with a male: female sex ratio of 1.5:1. In the Iranian study,160 60 cases

comprised of 32 males (53%) and 28 females (47%). In the study by Karagun

E.,16128 (56%) males and 22 (44%) females were included in the study group. The

control group consisted of 30 (63%) males and 17 (37%) females. In the study by

Takci Z., 162 44 cases included 20 females and 24 males while 43 controls included

33 females and 10 males. Thus the genders in this study are matched equally like that

of the other studies.

DISTRIBUTION OF VITILIGO TYPE:

This study included 5 males and 10 females in focal vitiligo, 7 males and 10

females in mucosal vitiligo, 10 males and 4 females in segmental vitiligo, 9 males and

4 females in acrofacial vitiligo, 26 males and 28 females in vitiligo vulgaris, 2 males

and 5 females in vitiligo universalis. This study shows preponderance of vitiligo

vulgaris (45%) which is in accordance with other studies.

Focal, mucosal and universal vitiligo were commonly seen in females (41%)

while segmental and acrofacial vitiligo were commonly seen in males (32.2%) in this

study.

78

In the study done by Prakash D et al,159 there were 53% patients with vitiligo vulgaris

type. In the study by Karagun E.,161 all the patients belonged to generalised vitiligo. In

the study by Takci Z., 162 6.8% had localized vitiligo and 93.2% had the generalized.

DISTRIBUTION OF VITILIGO DURATION:

This study included 49 males and 48 females in

79

controls (56.7%). Thus significant correlation exists between vitiligo and

cholecalciferol. (P value

80

universalis which implies a significant correlation (P value- 0.025) with the type of

vitiligo. Ten persons (18.5%) with normal values in vitiligo vulgaris were under

phototherapy and are clinically improving.

But, in the study done by Prakash D et al,159 there is no change in cholecalciferol

levels with the type of vitiligo.

CORRELATION OF S. CHOLECALCIFEROL WITH DURATION:

In < 5 years duration, 19(61.3%) patients had severe deficiency, 61(91%) had

deficiency and 17(77.3%) had normal values. In 6-10 years duration, 8(25.8%)

patients had severe deficiency, 6(9%) had deficiency and 1(4.5%) had normal value.

In 11-15 years duration, 3(9.7%) patients had severe deficiency, none had deficiency

and 1(4.5%) patient on phototherapy had normal value. In 16-20 years duration,

1(3.2%) had severe deficiency and 1(4.5%) patient on phototherapy had normal value.

In >21 years duration, 2(9.1%) patients on phototherapy had normal values and none

had deficiency or severe deficiency. This study shows significant correlation (P value-

0.001) with duration of vitiligo. Among patients with vitiligo for > 5 years duration,

only 5 show normal values and all these patients were under phototherapy and

showed clinical improvement. Majority of the patients were suffering from vitiligo for

81

CORRELATION OF S.CHOLECALCIFEROL WITH SEVERITY (VASI

Score):

In VASI 75%, 5 patients had severe

deficiency, 2 had deficiency and none had normal values.

This study shows significant correlation (P value26%, none of them show normal values, except 2 (9.1%)

who were under phototherapy were clinically improving.

But, in the study by Takci Z., 162 there was no change in cholecalciferol levels with

the severity of vitiligo patients.

VARIATION OF S. CHOLECALCIFEROL WITH AGE AMONG CASES:

In age ≤20 years, 11 have severe deficiency, 15 have deficiency and none had

normal values. In 21-40 years, 12 have severe deficiency, 22 have deficiency and 9

have normal values. In 41-60 years, 8 have severe deficiency, 25 have deficiency, and

10 have normal values. In ≥ 61 years, 5 have deficiency and 3 have normal values

while none showed severe deficiency.

Thus, in the age group of 60years, none of them showed severe deficiency. This indirectly shows the minimal

82

sun exposure among younger age groups and higher outdoor activities in older age

group. Moreover, phototherapy is started in comparatively older age group.

In the study done by Prakash D et al,159 there is no change in cholecalciferol levels

with the age of vitiligo patients. In the study by Karagun E.,161 there is no change in

cholecalciferol levels with the age of vitiligo patients. In the study by Takci Z., 162

there is no change in cholecalciferol levels with the age of vitiligo patients.

VARIATION OF S. CHOLECALCIFEROL WITH AGE AMONG

CONTROLS:

In age ≤20 years, none had severe deficiency, 12 had deficiency, 1 had normal

value. In 21-40 years, 4 had severe deficiency, 10 had deficiency and 9 had normal

values. In 41-60 years, none had severe deficiency, 6 had deficiency and 15 had

normal values. In ≥ 61 years, none had severe deficiency, 2 had deficiency and 1 had

normal value.

Thus, in age group40 years, those with normal values are

greater than those with deficiency. None of the studies compared age of the controls

with cholecalciferol.

83

VARIATION OF S. CHOLECALCIFEROL WITH SEX AMONG CASES:

There are 11 males and 20 females with severe deficiency, 37 males and 30 females

with deficiency and 11 males and 11 females with normal values.

In the study done by Prakash D et al,159 there is no change in cholecalciferol

levels with the sex of vitiligo patients. In the Iranian study,160 Male patients had lower

levels of vitamin D compared to controls (7.25 ng/ mL vs. 13.31ng/mL, P=0.03) while

no significant difference was observed between female patients and controls (14.12

ng/mL vs. 16.25 ng/mL, P=0.51). In the study by Karagun E.,161 there is no change in

cholecalciferol levels with the sex of vitiligo patients. In the study by Takci Z., 162

there is no change in cholecalciferol levels with the sex of vitiligo patients.

In this study, in both cases and controls, there is no sex prediliction (P value- 0.191)

for serum cholecalciferol in normal and deficient groups which was consistent with

other studies, though females show a greater preponderance to severe deficiency.

VARIATION OF S. CHOLECALCIFEROL WITH SEX AMONG

CONTROLS:

Among controls, there are 0 males and 4 females with severe deficiency, 16 males

and 14 females with deficiency and 13 males and 13 females with normal values.

Thus, here also severe deficiency is more commonly seen with females. Otherwise,

there was no significant correlation of cholecalciferol with sex . None of the other

studies compared cholecalciferol variation in sex of control group.

84


CASES:

Among those exposed to UV rays by phototherapy or natural sun exposure, there are

6 cases with severe deficiency, 15 cases with deficiency and 21 with normal values. In

comparison, in those who are not exposed to UV rays, there are 25 with severe

deficiency, 52 with deficiency and 1 with normal value thus suggesting significant

correlation of serum cholecalciferol (P value

85

SUMMARY

86

SUMMARY

Of the total 180 people included in this study, 120 were vitiligo cases and 60

were age and sex matched controls.

The study included 26 cases and 13 controls in the age 60 years. Thus, the age of cases and controls are matched

with a p value of 0.968.

This study included 59 cases, 29 controls in male gender and 61 cases, 31

controls in female gender. Thus, the sex of cases and controls are matched

with a p value of 0.916.

This study shows higher preponderance of vitiligo vulgaris (45%).

Focal, mucosal and universal vitiligo were commonly seen in females (41%)

while segmental and acrofacial vitiligo were commonly seen in males

(32.2%).

Majority (80.83%) of the patients included in this study are affected by vitiligo

for less than 5 years duration. Thus it implies the early health seeking

behaviour due to the social stigma of the disease.

Serum cholecalciferol is low in cases (81.6%) compared to controls (56.7%).

Normal cholecalciferol values among the remaining vitiligo patients could be

attributed to UV radiation either in the form of phototherapy and regular

exposure of sun due to their occupation. The patients under phototherapy

showed clinical improvement following phototherapy.

87

Serum cholecalciferol deficiency is more commonly associated with vitiligo

vulgaris (36.66%) and universal vitiligo (5.83%). Ten patients of vitiligo

vulgaris having normal values are under phototherapy and show clinical

improvement. Thus, there is significant correlation of serum cholecalciferol

with the type of vitiligo (P value- 0.025).

Serum cholecalciferol deficiency is noted in patients irrespective of the

duration of vitiligo. But, in patients with disease duration of >5 years, all the 5

who had normal values are under phototherapy and show clinical

improvement and others have either deficiency or severe deficiency. Thus

there is significant correlation (P value-0.001) of serum cholecalciferol with

the duration of vitiligo.

In patients with VASI > 26%, almost all had deficiency, except 2 patients

under phototherapy and they show clinical improvement. Thus, significant

correlation exist between serum cholecalciferol level and vitiligo severity (P

value40 years of age

suggesting significant correlation with age. (P value-0.041 for cases and 0.002

for controls)

In both cases and controls, there is no sex prediliction (P value- 0.191 for

cases and 0.131 for controls) for serum cholecalciferol in normal and deficient

groups, though females show a greater preponderance to severe deficiency.

In both cases and controls, normal serum cholecalciferol levels were seen

more commonly in those exposed to UV rays compared to those who are not

88

exposed. Significant correlation is seen in cases with P value of

89

CONCLUSION

90

CONCLUSION

In this study, there is a significant correlation between serum cholecalciferol and

vitiligo. There is also significant correlation of cholecalciferol with the clinical type,

duration and severity of vitiligo. The study showed deficient cholecalciferol levels in

certain clinical types like vitiligo vulgaris and universalis, with vitiligo of longer

duration and of VASI score >26%. Those patients receiving phototherapy showed

normal cholecalciferol and were improving clinically. The observation made in this

study favours the role of low vitamin D level in the pathogenesis of vitiligo and the

role of vitamin D supplementation in the management of vitiligo.

a study on the correlation of serum cholecalciferol … · 3 certificate from the hod this is to...

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