Report

Clinical Pattern of Vitiligo in Libya

MALKIT SINGH, M.D., GURMOHAN SINGH, M.D., A. J. KANWAR, M.D., AND M. S. BELHAJ, M.B.

ABSTRACT: Patients with vitiligo attending the polyclinics of Benghazi during a 9-month period were reviewed. The proportionate case ratio was 0.33% of all skin cases. The mean age at onset of the disease was 19.38 years; mean age at reporting the disease was 23.06 years. There was more frequent involvement of exposed parts in men compared with women. Vitiligo areata responded better to treatment. The history did not confirm the genetic predisposition of the disease. Association with known autoimmune disease is reported.

The striking clinical features of vitiligo make it an easily recognizable condition; however, despite uni- form clinical features, its distribution, age of onset, response to treatment, and prognosis vary widely from patient to patient. This intriguing disparity de- mands the establishment of its clinical pattern. Al- though such studies are available from other countries, no such study is available from Libya. This article is an attempt to evolve the clinical pattern of this disease in eastern Libya.

Material and Methods

All outpatients presenting with vitiligo for 9 months from August to April were reviewed. A detailed clinical history, including age, sex, duration of the disease, family history, precipitating factors, and associated disease, was recorded in specially prepared and pretested proforma. Special at- tention was given to the presence of leuchotrichia and hyperpigmentation at the periphery of the lesions. Patients were classified according to the precise distribution of the lesions' viz. vitiligo areata (VA) if the lesions were localized to one area and confined to one or few patches; vitiligo zosteriform (VZ) if the lesions were distributed in a segmental fashion; vitiligo acrofacialis (VAF) if the lesions were confined to face and acral region; vitiligo vulgaris (W) if the vitiligo was generalized; and vitiligo mucosae (VM) if only the mucous membranes were involved.

Address for correspondence: Gurmohan Singh, M.D., New D-7 Banaras Hindu University, Varanasi 221005, India.

From the Faculty of Medicine, University of Garyounis, Benghazi, Libya

Observations

Relative Incidence in Skin Outpatients

One hundred ninety-two patients of 58,240 new patients were seen, giving a relative incidence of 0.33% among skin patients.

Age and Sex

There were 97 men (50.52%) and 95 women (49.47%). The majority of the patients (75%) reported the disease between the age group of 10 to 39 years (Table 1). The youngest patient was 1 year old and the oldest 63 years old. The age of onset ranged between 5 and 39 years in most of the patients (73.43%) (Table 2). There was no significant sex difference in the age of onset of the disease except that in the 5-9 years group there were more women (25) than men (7). There was no marked sex difference in the age of reporting; the earliest age of reporting was 10 months and the latest was 58 years.

Duration of the Disease

There was a wide variation in the duration of the disease (Table 2). The bulk of the patients (53.12%) had the disease for 1-4 years, followed by the group with duration of disease less than 1 year.

Clinical Features

Depigmented macular lesions with well- or ill- defined margins, distributed on the different parts of the body, were the classical features. Few of the lesions showed mottled/pigmentation. In a few pa- tients, additional features were leuchotrichia (14.06%)

233

234 INTERNATIONAL JOURNAL OF DERMATOLOGY May 1985 Vol. 24

TABLE 1. Age at Reporting and Age at Onset

Age Age at Reporting Age at Onset Group (Years) Men Women Total Men Women Total

0-4 5-9

10-19 20-29 30-39 40-49 50-59 rM)

1 2 3 (1.56%) 6 14 20(10.41%)

38 41 79(41.14%) 19 13 32 (16.66% 17 16 33(17.18%) 7 5 12 (6.25%) 7 4 11 (5.72%) 2 - 2 I1.044hl

6 5 7 25

40 34 17 18 16 12 4 4 4 - - -

11 (5.72%) 32 (16.66%) 74 (38.54%) 35 (18.22%) 28 (14.58%) 8 (4.16%) 4 (2.08%) -

and peripheral hyperpigmentation (1 6.66%). In all of the patients, the lesions were asymptomatic. The distribution according to the different clinical variants of the disease is shown in Table 3. Most patients had VAF (78%), followd by W (45), VA (43), and VZ (1 7). V M affected the smallest group of patients (10). Distribution of the lesions according to the affected site is shown in Table 4. The maximally involved areas were extremities followed by the face, abdo- men, neck, mucous membrane, and back. The neck and mucous membrane were more commonly in- volved in men compared with women, in whom the breast was more frequently involved. Involvement of multiple sites in the majority of patients was a striking feature. One site alone was involved in very few patients (Table 4).

Family History

patients.

Associated Disease

mellitus, and two had discoid lupus erythematosus.

Discussion The relative incidence of vitiligo among skin pa-

tients in this study was 0.33% which is perhaps the lowest figure reported in the literature, which has figures that range from 1.39% to 4.30%.’-’ This

Definite positive history was present in 3 (1.56%)

Ten patients had alopecia areata, two had diabetes

TABLE 2. Duration of the Disease ~ ~~

Duration Men Women Total ~~

0-11 months 24 28 52 (27.08%) 1-4 years 56 46 102 (53.12%) 5-9 years 6 10 16 (8.33%)

10- 19 years 6 8 14 (7.29%) 20-29 years 2 2 4 (2.08%) 30-39 years 2 - 2 (1.04%)

TABLE 3. Clinical Variants

Clinical Variants Men Women Total

V. areata 19 24 43 (22.39%) V. acrofacialis

Acral 18 11 29 (15.10%) Acrofacialis 26 23 49 (25.52%)

V. vulgaris 21 24 45 (23.43%) V. zosteriformis 10 7 17 (8.85%) V. mucosae 7 3 10 (5.20%)

shows that vitiligo is a relatively less common com- plaint among Libyans. The relative incidence of this disease in various clinics does not necessarily indicate the prevalance of the disease. It varies from clinic to clinic, depending on its popularity, and the interest and attitude of the dermatologists in the disease. The incidence of disease did not differ significantly by sex, as in most other ~tudies.*.~.~ Of a population of 331,000, there were 192 vitiligo patients in 9 months, an incidence of 0.8 per 1,000 per year. This data represents the total number of subjects who sought treatment during this period.

Most of the patients reporting with the disease were young, with a mean age of 23.06 years. This is

TABLE 4. Site of lnvolvernent

Site Men Women

Face Alone Along with other areas

Neck Chest

Alone Along with other areas

Alone Along with other areas

Upper and lower extremities Alone Along with other areas

Upper limb Alone Along with other areas

Lower limb Alone Along with other areas

Mucous membranes (oral

Back

and genital) Oral mucosa only Genital mucosa only

Abdomen Alone Along with other areas

30 (29.1%) 12 (11.6%) 18 ( 1 7.46%) 20 (20.61%) 8 (8.24%) 1 (1.03%) 7 (7.21%) 8 (8.42%) 3 (3.09%) 7 (7.21%)

40 (41.23%) 9 (9.27%)

31 (31.95%) 10 (10.30%) 6 (6.31%) 4 (4.21%)

13 (13.40%) 7 (7.21%) 6 (6.81%)

9 (9.27%) 18 (18.55%) 16 (1 6.49%) 24 (24.74%)

24 (24.74%) -

25 (23.75%) 7 (7.36%)

18 (18.94%)

10 (10.52%)

8 (8.42%) 13 (13.68%)

13 (13.68%) 35 (36.84%)

6 (6.31%) 29 (30.52%)

7 (7.36%) 1 (1.05%) 6 (6.31%)

10 (10.52Oh) 5 (5.26%) 5 (5.26Yo)

9 (3.47%)

-

-

1 (1.05%) 11 (1 1.57%)

1 (1.05%) 20 (21.05°/o)

20 (21.05%) -

N = 192 (97 men, 95 women).

No. 4 VlTlLlGO IN LIBYA

in agreement with reports from other c o ~ n t r i e s . * ~ ~ ~ ~ The pattern was similar for age of onset in both sexes, with a mean age at onset of disease of 19.38 years. The average period between the onset of the disease and reporting for treatment was relatively low, perhaps because facilities in Libya are accessible and health care is free. The duration of the disease varied from 1 month to 39 years, but most of the patients presented within 4 years of onset.

Involvement of the different regions of the body showed wide variation in different patients. The ex- posed parts were more commonly involved in men than in women. The breasts and back were more commonly involved in women, which is in contrast to other studies.’ In our patients, frequent involve- ment of the exposed parts in men may be due to trauma caused by sun exposure; women in Libya keep most of their body covered. Women who showed involvement of exposed parts were of youn- ger age group; their dress differs from that of elderly Libyan women, in whom acral parts are exposed. This signifies the importance of Koebner’s phenom- enon in vitiligo.

Classification of vitiligo according to distribution of the lesions is of practical importance in assessing the prognosis of the disease. Cases of VN showed better response to therapy than those of VAF, W, and VM. The VAF and VM were most resistant to treatment. Similar results have been reported in other coun-

The cause and prognosis of the disease varied greatly. Younger age, short duration, involvement of small area, absence of leuchotrichia, presence of peripheral hyperpigmentation, and absence of lesions on exposed body surfaces were favorable prognostic signs.

* Singh et a/. 235

Despite the claims made in different studies’,” of genetic predisposition of vitiligo, in our study only three patients had positive family history. Association of different diseases with vitiligo viz. alopecia areata, diabetes mellitus, DLE, rheumatoid arthritis, myas- thenia gravis, and psoriasis has been reported in the literature. In our study, 10 patients had alopecia areata, whereas DLE and diabetes mellitus was present in 2 patients each. Although association of alopecia areata is well documented? incidence of other au- toimmune diseases viz. diabetes mellitus and DLE in our study, which was well over I%, is also of signif- icant importance in favor of autoimmune theory of etiology of vitiligo.1°

References

1. Sehgal VN. Clinical evaluation of 202 patients of vitiligo. Cutis.

2. Lerner AB. Vitiligo. j Invest Dermatol. 1959;32:285. 3. Sehgal VN, Rege VL, Mascarenhas F, et al. I Dermatol. 1976;3:

4. Grover HD. Leucoderrna. Ind I Dermatol. 1962;7126. 5. Behl PN, Aganval RS, Singh C. Aetiological studies in vitiligo

and therapeutic response to standard treatment. Ind I Derrnatol. 1961;6:101-110.

6. Levei M. A study of certain contributory factors in the devel- opment of vitiligo in South Indian patients. Arch Dermatol. 1958;73:364-371.

7. Dutta AK, Mandal SE. A clinical study of 650 vitiligo cases and their classification. Ind J Dermatol. 1969;14:103-111.

8. Dawber RPR. Vitiligo in mature onset diabetes mellitus. Br I Dermatol. 1968;80:275-278.

9. Dawber RPR. Clinical associations of vitiligo. Postgrad Med 1. 1970;46276-277.

10. Mackay IR. Autoimmune aspects of three skin diseases: pem- phigus, cutaneous lupus erythematosus and vitiligo. Aust j Dermatol. 1967;9113-121.

11. Mohan L, Singh G , Kaur P, et al. Genetic prognosis in vitiligo. Ind I Dermatol. 1982;27:115-118.

12. Rook A, Wilkinson DS, Ebling FIG. Textbook of Dermatology. 1st ed. Oxford: Blackwell, 1968;1146.

1974;14:439-445.

49.

Erratum

We apologize for a printing error in “Antinuclear Antibodies (ANA): How Useful is the ANA Test Today?“ (1985; 1:41-44). On page 43, the second sentence under Nuclear Substrates should read: Mouse liver sections used by Provest et a1.18 do not demonstrate certain ANA patterns as well as do human spleen imprints and human tumor cell lines.”