Vitiligo is an acquired progressive multifactorial depigmenting disorder characterized by the appearance of circumscribed white macules in the skin due to chronic progressive loss of functional melanocytes in the epidermis 1,2.
Vitiligo is a multifactorial polygenic disorder with a complex pathogenesis. It is related to both genetic and nongenetic factors. It is generally agreed upon that there is absence of functional melanocytes in vitiligo skin and loss of histochemically recognized melanocytes owing to their destruction 3.
Vitiligo is the most common of all pigmentary disorders 4. It was first recorded in pharaonic medicine in the Ebers Papyrus (1550 BC) and affects all populations across the world, among different geographic regions and ethnic groups, with diverse prevalence rates 5,6 ranging from 0.1 to 4% 7,8. The disease shows no racial or ethnic predilection, but because of the obvious contrast between depigmented and darker skin tones it is more cosmetically disfiguring in darker racial and ethnic groups 9.
Precipitating factors associated with the development of vitiligo include sunburn, stress, pregnancy, and exposure to cytotoxic compounds, chemical exposure, frequent physical trauma, or sun exposure 10,11. Therefore, identifying risk factors and educating patients on how to avoid these risk factors are important in preventing disease progression 12.
The extent of involvement is highly variable, ranging from focal to generalized, and the onset can be abrupt or gradual and usually starts in childhood or young adulthood. Manifestations begin before 20 years of age in 50% of patients, whereas in 25% the onset is before 14 years of age 13.
Our objective was to study the clinicoepidemiological profile of vitiligo patients in Assiut governorate, Upper Egypt.
Patients and methods
Assiut and Al-Azhar University hospitals in Assiut are tertiary care institutes serving the population of Assiut governorate, Upper Egypt. This observational, cross-sectional, descriptive study was conducted at the phototherapy units of both hospitals. The data were collected from January 2010 through to December 2013. All vitiligo patients (n=283) referred to both phototherapy units were included in the study. Clinical diagnosis was made by two experienced dermatologists. The demographic data of all patients, including age, sex, residence, and occupation, were obtained.
Detailed history of the disease, including onset, course, duration, predisposing factors, family history, and previous treatment, was also obtained.
A complete clinical examination was performed, and the site and pattern of the lesions as well as associated mucosal involvement, the presence of leukotrichia, Koebner phenomenon (KP), halo nevi, and associated cutaneous or systemic diseases were noted. A record was made of the precise distribution of the lesions using the rule of nine, and the patients were classified into six groups according to the standard working classification of clinical types of vitiligo: vulgaris, acrofacial, focal, mucosal, segmental, and universal 14.
The activity of the disease, as evidenced by the appearance of new lesions or the increase in size of existing lesions over the past 6 months, was also recorded. Screening was performed for previously diagnosed autoimmune and endocrine disorders by history and clinical examination. These disorders included thyroid disease, diabetes mellitus, and pernicious anemia. Patients were also examined for clinically apparent deafness or ocular abnormalities.
Patients were classified into three different age groups. We considered childhood as age 0–12 years, adolescence as age 13–18 years, and adulthood as age over 18 years 15.
The study was approved by the Assiut and Al-Azhar of Assiut faculties of medicine research ethical committee. Informed verbal consent was obtained from all participants. Privacy of the interview and confidentiality of data were assured.
Sample size: sample size was estimated using the following equation:
where P is the proportion or best guess about value of proportion of interest; α is 1−confidence interval; d is the difference or tolerance.
We collected data on 283 individuals. Descriptive statistics were expressed as frequencies, percentages, and proportions for qualitative variables and as mean and SD for quantitative variables.
All patients (n=283) with different clinical types of vitiligo were recruited from the dermatology outpatient clinics, Assiut and Al-Azhar University Hospitals. The majority of our patients were females (193, 68.2%) with a mean age±SD of 27.71±15.84 years with a minimum age of 2 years and a maximum of 63 years (Table 1).
Regarding the clinical presentation of patients, the majority had progressive course of the disease and the disease duration was greater than 1 year, whereas the minority of patients had a positive family history (Table 1).
Most of the vitiligo patients were adults (>18 years), as shown in Fig. 1.
Psychic stress was found to be the major precipitating factor of vitiligo in the current study (76/117, 65%), followed by sun exposure (30/117, 25.6%), smoking, and finally exposure to chemicals (Fig. 2).
As regards the clinical type of vitiligo, vitiligo vulgaris was the most frequent type reported (73.9%) (Table 2). Sex distribution among different clinical types of vitiligo showed a higher percentage of female patients, as shown in Fig. 3. Moreover, the subdistribution of clinical types of vitiligo in relation to age showed that the predominant clinical type in children was focal (40.6%), that in adolescents was acrofacial (30.4%), and that in adults was segmental (78.6%) (Table 3).
The most common site of vitiligo lesions in our study was the lower limbs (211/283, 74.5%), followed by the upper limbs (187/283, 66.1%), the face (113/283, 40%), the abdomen (112/283, 39.6%), the back (109/283, 38.5%), the neck (73/283, 25.7%), and the genitalia (30/283, 10.6%).
On studying the association of vitiligo with other cutaneous affections, we found that leukotrichia was recorded in 119 (42%) patients, KP in 70 (24.7%) patients, halo nevus in 17 (6%) patients, and associated mucosal affection in nine (3.2%) patients. Association with other cutaneous diseases was found in 5% of patients (alopecia areata, atopic dermatitis, and psoriasis) and associated systemic disorders were found in 22% (thyroid abnormalities, diabetes mellitus, hypertension, hyperlipidemia, and ischemic heart disease). However, none of our patients showed clinically apparent deafness or ocular abnormalities.
To our knowledge, there is no study yet on vitiligo and its clinical patterns in Assiut, Upper Egypt. In most patients, vitiligo develops early in life 16. In the present study, the mean age at onset of vitiligo was less than 20 years. This is in agreement with previous studies 6,17–20, which reported the peak incidence of vitiligo to be in the first and second decades of life. However, in other studies, it was reported in the second or third decade of life 20–24. The study by Behl et al.25 found that age at onset was 20 years or less in 45.4% of patients and 40 years or more in 15.4% of patients, which implies that younger people are being affected with this disorder at an increasingly higher frequency. They explained this by the fact that children are more vulnerable to congenital diseases 25. To our knowledge, vitiligo is an inherited disease; however, congenital vitiligo may be rarely present.
In the current study, the male to female ratio was 1 : 2. This female predominance was reported in previous studies 17,19,22–24,26–29. The reason for this female predominance is the high cosmetic concern in the female population. However, equal sex incidence in vitiligo was reported by other authors 6,30–34.
A positive family history of vitiligo was seen in 22.6% of our patients. Positive family history for vitiligo varied across studies: 21.9% in the study by Shajil et al.23, 26% in the study by Betterle et al. 24, 18.6 in the study by Nawaf and Ashok 26, 27.5% in the study by Onunu and Kubeyinje 22, 36% in the study by Gopal et al.35, 15.9% in the study by Dogra et al.20, 11.5% in the study by Arcan et al.31, 8% in the study by Martis et al.27, and 1.6% in the study by Liu et al.33. This widely variable difference in percentages is probably because of the mode of transmission of vitiligo, which is quite complex. It is probably polygenic, with variable penetrance 36.
This study showed that 82.3% of patients had a progressive course, which agrees with other studies that have reported that vitiligo is a slowly progressive disease 37,38.
Many provoking factors have been described for vitiligo, but epidemiological data are scarce 39. Emotional stress was indicated as the major precipitating factor in 65% of our patients. This is in agreement with the observation made by Vrijman et al.39, who recorded it in 55.4% of patients. However, lower percentages were reported in other studies (15.1% in the study by Alissa et al.40 and 12.8% in the study by Jeon et al.12). The mechanism by which UV aggravates vitiligo has not been clearly determined; however, fragile melanocytes in patients with vitiligo are thought to be easily destroyed through apoptosis and necrosis after overexposure to UV 12. In our study, only 25% of patients showed that overexposure to sunlight was the aggravating factor for their vitiligo lesions. Similarly, Jeon et al.12 reported overexposure to sunlight in 22.6% of vitiligo patients. We found that 17.9% of patients were smokers and 6.8% of patients had been exposed to chemicals. In a Dutch study conducted by Vrijman et al.39 16.4% of vitiligo patients indicated a chemical factor and a Korean study by Jeon et al.12 recorded exposure to cleaning products/disinfectants/chemicals in 4.9% of vitiligo patients. This variation could be explained by differences in the environment and the ethnicity of patients who participated in the study.
In the current study, the most common type of vitiligo was vulgaris (73.9%), followed by focal (11.3%), acrofacial (8.1%), segmental (4.9%), and universal (1.8%). In previous studies also vitiligo vulgaris was the most common pattern seen 15–17,20,23,24,26–28,31,41.
Similar to our findings, Handa and Dogra 42 and Al-Jabri and Al-Raddadi 41 found that focal vitiligo was the second most common presentation in children. However, some studies reported that segmental vitiligo was the least frequent type encountered 43,44. In the current study, universal vitiligo was the least frequent (1.8% of patients). This type was also the least frequent type reported in Kuwait, China, and North India (1.1, 0.4, and 0.3%, respectively) 42,45,46.
The isolated mucosal type of vitiligo was not observed among our patients. This is in agreement with the study by Esfandiarpour and Farajzadeh 16 on 825 Iranian vitiligo patients. However, associated involvement of the mucosae with other clinical variants (acrofacial or vulgaris) was seen in 3.2% of the patients, which was similar to the results of Handa and Dogra 42, who reported associated mucosal involvement in 6% of patients.
The lower limbs were the most common site of involvement in this study (74.5%). This is in concordance with other studies in which the lower limbs were found to be the site initially developing depigmentation in the majority of patients 16,47. However, the head and neck was the most common early site of involvement in other studies 20,41.
Depigmented hairs are commonly found in isolated vitiligo macules 26. In the present study, leukotrichia was the most commonly encountered associated abnormality (42%), followed by KP, associated systemic diseases, halo nevus, associated cutaneous diseases, and associated mucosal affection.
The incidence of leukotrichia varied across studies: 7.5% in the study by Nawaf and Ashok 26, 9.2% in the study by Shajil et al.23, 43.2% in the study by Dave et al.19, and 77.8% in the study by Esfandiarpour and Farajzadeh 16. Leukotrichia indicates poor prognosis for repigmentation.
The incidence of KP also varied across studies. It was observed in 25% of the patients in the present study. Similarly, it was seen in 23% of patients in the study by Nawaf and Ashok 26, in 18% in the study by Arcan et al.31, and in 18.4% in the study by Akrem et al.15. Occurrence of KP may reflect the existence of vitiligo or be a marker of the skin predisposed to develop vitiligo lesions 34. KP may be explained by the release of antigens of injured melanocytes into the blood and production of antibodies against them resulting in further loss of melanocytes 48.
Halo nevus was detected in 6% of our patients, which is consistent with the results of Handa and Dogra 42 and Dogra et al.20, who observed it in 4.4 and 3.8% of patients, respectively.
The association of vitiligo with other diseases has been a subject of great interest. Vitiligo was associated with cutaneous diseases (including autoimmune diseases such as alopecia areata and psoriasis in 5% of our patients, and systemic diseases including diabetes mellitus and autoimmune thyroid disorders in 22% of them). This is consistent with the results of Esfandiarpour and Farajzadeh 16, who reported the occurrence of alopecia areata in 3.7% of patients and the association with systemic diseases (such as diabetes mellitus and thyroid disorders) in 18.5% in late-onset and in 23.1% of patients in early-onset vitiligo. Similarly, Dogra et al.20 showed that 21.4% of vitiligo patients were associated with other diseases including autoimmune disorders.
Auditory disability and ocular involvement in vitiligo patients have attracted attention, because it is known that the inner ear contains melanocytes and also the pigment epithelium of the retina and the choroid are rich in melanocytes 49. As vitiligo affects all active melanocytes, auditory and ocular problems can occur in patients with vitiligo 14. However, none of our patients showed clinically apparent deafness or ocular abnormalities, which agrees with the results of Akrem et al.15.
From this study, a hypothesis was generated outlining a profile for vitiligo patients in Assiut, Upper Egypt. We concluded that vitiligo most commonly occurs in the first two decades of life and is more common in the female population. Vitiligo vulgaris was the most common clinical type observed. The minority had a positive family history, whereas the majority had progressive course of diseases. Leukotrichia was the most commonly associated abnormality, whereas associated systemic diseases were less frequently detected. However, autoimmune cutaneous disorders were observed in the minority of patients.
As this is a descriptive study, we could only generate a hypothesis to be tested by other analytical studies. Thus, these findings need to be re-evaluated by other studies such as prevalence surveys for vitiligo in that area to know the real magnitude of the problem. Also, we recommend case–control studies to identify risk factors for vitiligo in Assiut governorate and in other areas of Upper Egypt.
Conflicts of interest
There are no conflicts of interest.
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