Vitiligo: Epidemiology and Clinical Pattern at King Khalid University Hospital

Introduction

Vitiligo is a circumscribed, acquired, idiopathic depigmentation of skin and hair which is often familial and characterized microscopically by a total absence of melanocytes ^[1]. It affects both sexes with women being affected more, and the general incidence worldwide is about 1% ^[2]. The pathogenesis of vitiligo is unknown, but various hypotheses have been promulgated. Of these, the most accepted theories include genetic, autoimmune, neurogenic, and the melanocyte self-destruction hypothesis ^[3-8].

Vitiligo is a social stigma, particularly in individuals with black skin, due to its cosmetic disfigurement. Despite that, no studies have been published on vitiligo in Saudi Arabia. This retrospective study reports on several cases of vitiligo from the dermatology clinic at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, with regard to the incidence, clinical presentation, and the problems with management.

MATERIAL AND MANAGEMENT

The records of patients who had vitiligo and who were referred to the dermatology clinic from primary care clinics at KKUH over a five year period from December 1985 to December 1990 were reviewed for this study. Information regarding the clinical pattern of the disease, family history of the disease, the associated diseases, and the outcome of treatment were recorded using a SYSTAT program for data analysis and chi-square test was used for statistical analysis when needed.

RESULTS

The five year incidence of vitiligo at KKUH skin clinic was 2.5%. From a total of 203 patients with vitiligo who were studied, 114 (56.2%) were males and 89 (43.8%) were females. Of the Saudis, 134 (68.7%) were from the Central region (including Riyadh), 28 (14.4%) from the Northern, 22 (11.3%) from the Western, and 11 (5.6%) from the Southern regions. Of the non-Saudis, there were three Egyptians, two Sudanese, two Indians and one Jordanian. The majority (59%) were between the age group 10 to 29 years (Table 1) and the average age for the whole group was 28.7 ± 25.0 years while that for the male patients was 25.6 ± 13.7 years and that for the female patients was 21.9 ± 11.8 years. The age difference between males and females is statistically significant(P >0.01). More than half the patients had the lesions for a period between one and nine years, and 17.7% of the patients had their symptoms for more than 15 years (Table 2).

Table 1. Age/sex distribution of 203 cases of vitiligo seen at the skin clinic in King Khalid University Hospital.

Table 2. Duration of symptoms of 203 cases of vitiligo.

Regarding the distribution of the lesions, the most frequently affected parts were the trunk (29%), limbs (28.6%), and the face (19%). In 39 patients (19.2%), the entire body, was affected (Table 3). Of the 161 patients in whom family history was reported, only 12% had a positive family history of vitiligo, and the reported significant associated diseases were as follows: ulcerative colitis (four), bronchial asthma (two), diabetes mellitus (two), hypothyroidism (one), alopecia areata (one), halonevus (one), and rheumatoid arthritis (one).

Table 3. Distribution by site of the lesion in 203 cases of vitiligo.

DISCUSSION

Vitiligo, although a disfiguring disease with social stigma, did not receive much attention by investigators in Saudi Arabia. In the present study, the incidence of vitiligo within the stated period was 2.5%. This is comparable to the incidence of 0.1 to 8.8% reported from different regions of the world ^[1] and higher than the 0.33% incidence reported in Libya ^[9], but lower than 6% that was reported in Nigeria ^[10].

Although vitiligo can occur at any age from birth to senescence, most of the cases are seen in the ages between ten and 30 years ^[1]. About 50% of all vitiligo cases occur below 20 years of age, and 70% to 80% below the age of 30 years ^[2]. In the present study, 64% of the patients were below 30 years of age.

The present study shows that both males and females are vulnerable to the disease, a finding that is supported by other studies ^[2,11]. However, some investigators have recorded a higher incidence in women ^[1,3]. On the contrary, a high incidence in men has also been reported ^[2,4]. It is believed that the generally reported preponderance in females does not represent a real difference. Rather, it is likely that women are more sensitive to cosmetic disfigurement and more likely than men to present themselves for treatment.

Vitiligo is believed to be a hereditary disorder probably transmitted as an autosomal dominant gene, with different expression and incomplete penetrance ^[3,7,12]. However, there is not enough evidence to support an inheritance pattern ^[7] and multifactorial inheritance may in fact apply ^[3]. The incidence of a positive family history has variously been reported with a range between 6.25% to 38% ^[1,2]. George found no family history of vitiligo among the 64 cases he reviewed ^[10]. However, the low incidence of family history of vitiligo in our study (12%) may be artificial due to unawareness of the patients about the occurrence of disease in their relatives. On the contrary, it may reflect the true situation because vitiligo cannot go unnoticed for long in the family. In addition, lack of documentation of this information in a patient’s record is another possible explanation, although this has a negligible role in our study.

The majority of the patients (53%) were having the disease for a duration between one and nine years and only 6.9% had it for less than a year. Also, 17.7% of the patients had the disease for 15 years or more before registration at the clinic. Other investigators reported different frequencies; for example, George stated that 51.6% of the patients had the lesions for one year or less and only one patient (1.6%) had the lesions for 20 years ^[10]. This difference in duration of presentation and delay in seeking medical advice in our study may be because of the notion among general practitioners and the population at large that no treatment is available. Moreover, before the patients register in the dermatology clinic, they have already tried different medications including herbs and traditional home remedies. More than half of the patients in this study had the lesions in exposed areas of the body including face, head, neck, and extremities. The same finding was reported in other studies ^[10,11]. This will have its psychosocial effects and social stigma on patients with vitiligo, particularly in females. Vitiligo may be associated with numerous systemic disorders including diabetes mellitus, thyroid diseases, rheumatoid arthritis, autoimmune hemolytic anemia, and other disorders ^[1,7,12]. It is also associated with skin disorders such as lichen planus, premature gray hair, alopecia areata, and halonevus ^[13]. In our study, few of the patients were found to have an associated systemic disease; one had alopecia areata and one had halonevus. However, one cannot guarantee such information is recorded for every patient. Furthermore, laboratory confirmation of the diagnosis of the associated disease is not always available. The majority of the patients (80%) in this study showed some improvement of their lesions using different treatment modalities; however, it is very difficult to judge the efficacy of treatment in a study of this nature and without studying the compliance rate and follow-up for a longer time.

Certainly many vitiligo patients harbor special feelings about their disease; while some accept their vitiligo as a curiosity, others are deeply distressed. It is shown from this study that vitiligo is a significant problem in Saudi Arabia and needs to be tackled seriously. The psychosocial aspects of the disease on patients, particularly among the more cosmetically conscious, the females, need to be studied.