Childhood Vitiligo: A hospital based retrospective study in Coastal South India

Background: Vitiligo is an acquired, multifactorial disorder of depigmentation and is overwhelming and distressing to the patients and the care givers. Childhood vitiligo has different characteristics as compared to adult-onset vitiligo. Every parent wants to know if the disease will progress or regress. Aims and Objectives: To study the epidemiological, clinical and hematological patterns of children with vitiligo. Materials and Methods: First 50 patients with vitiligo, younger than 12 years of age, who visited the Dermatology outpatient department of Vinayaka Missions Hospital, a tertiary care center in Karaikal, between January 2015 and January 2020 were included. They were assessed for the natural history, clinical features, family history and associated abnormalities of vitiligo. Results: There were 19 boys and 31 girls (boys: girls 1:1.63) out of 50 patients. Mean age of onset of vitiligo was 5.8 years and mean duration was 1.4 years. The most common site was the head and the neck, followed by the extremities, trunk and genitalia and the most prevalent type was vitiligo vulgaris (60%). Then, it was acrofacial vitiligo (26.5%), focal vitiligo (23.7%) and segmental vitiligo (2.6%). 5 patients had a positive family history. Involvement of mucosa in 12%, Leukotrichia in 11% and Koebnerization was seen in 10% children. Body involvement is bilateral in 72% and unilateral in 28% children. Majority of patients (49%) had multiple lesions (more than 5) and most (96%) had <5% body surface area involved. Conclusion: In children, any depigmented/hypopigmented lesion should be evaluated and followed up properly to rule out vitiligo. The patterns and characteristics of childhood-onset vitiligo should be understood properly by Dermatologists as it presents in a different manner from adult-onset disease and its management should take several factors into consideration like extension, psychological effects on children and parents, avoidance of treatment side effects and probable association with other autoimmune diseases.


Introduction
Vitiligo is a chronic, acquired, multifactorial disorder of depigmentation of skin, characterized by well-defined white macules or large macules due to loss of functional melanocytes and melanin from the epidermis. Childhoodonset vitiligo has distinguishable epidemiological and clinical features as compared to adult-onset vitiligo. It starts before 20 years of age (before 10 years in 25% cases). A female prevalence, segmental presentation is common and association with other endocrine or autoimmune disorders is rare.
Vitiligo is a psychologically distressing disorder for the children as well as the care givers. Social stigmas, preconceptions, unawareness, prohibitions, and confusion about vitiligo are widespread in India. Hence, this study was undertaken to record various patterns of childhood vitiligo in Coastal South India.

Methodology
Demographic details of all patients like the age of onset, initial site involved, duration of disease, associated mucosal involvement and diseases and family history were obtained from the clinical notes.

Results
There were 19 (38%) boys and 31 (62%) girls out of the total 50 children with vitiligo. So, a female predominance is observed.
The mean age of onset of vitiligo was 5.8 years and the mean duration of disease was 1.4 years with majority of patients (44%) having more than 1-year duration.

Family History
Frequency % Vitiligo in 1o relative 4% Vitiligo in 2o relative 6% Thyroid in 1o relative 2% Thyroid in 2o relative 2% Alopecia Areata 2% Bilateral involvement is seen in 72% patients and unilateral involvement in 28% of patients.

Discussion
Vitiligo is an acquired, chronic, multifactorial disorder of depigmentation of skin characterized by well-defined white macules and large macules due to loss of functional melanocytes and melanin from the epidermis. Female predominance is seen in the present study (62% vs. 38%), similar to the results in studies done by Jaisankar et al and Al-Jabari et al. 1 [3][4][5][6] So, there is more concern amongst parents in India when a girl is developing depigmented lesion than a boy as cosmetic appearance and related social and marital problems are more among girls in Indian structure.
Most of our patients (56%) were in 6-12 years of age group like in the study by Sheth 2,7,9 In this study, head-and-neck region was the most common site of onset with 23 patients (46%), much higher than the finding (25.71%) by Jain et al. 10 Despite that, trauma prone sites like the lower limbs, hands and face may develop vitiligo lesions more easily in genetically susceptible individuals.The most prevalent type of vitiligo in boys in our study was vulgaris (63.1%) and in girls was focal (29.03%). The reason behind this finding could be a bigger worry in parents seeing even a single white patch in girls than in boys, making them consult the doctors early.
Family history findings of vitiligo in our study (firstdegree relatives-affected in 4% patients, second degree in 6%) were similar to the Indian studies by Handa and Dogra (12%) and Jain et al. (17.5%) but much lesser than in the study by Nicolaidou et al. (35%). [10][11][12] In this study, 28% patients had unilateral vitiligo and the rest had bilateral involvement. Involvement of mucosa was seen in 12% of patients, like in the study by Sheth et al. (18%) and genitalia were more affected (11%) than lips (6%). 7 In a North Indian study, 8 out of 625 children (1.3%) had an associated autoimmune disease like alopecia areata, thyroid disease, diabetes mellitus, pemphigus vulgaris or Addison's disease. 12 In our study, 1 out of 50 children (2%) had associated autoimmune disease like alopecia areata similar to study findings in Halder et al. study (2.4%).

Conclusion
As observed in our study, vitiligo can start at 2 months of age in children and is more prevalent in the age group of 6-12 years (56%). Thus, any depigmented patch in babies and children should be investigated carefully and followed-up regularly. Regional studies will help the clinicians practicing in these areas to be acquainted with its clinical and epidemiological patterns and be prepared for the management.

Limitations
The design of this study does not establish causal relationship. Sample size is small. Prospective studies with a larger sample size are required for this.

Source of Funding
None.

Conflict of Interest
None.