The analysis of genetics and associated autoimmune diseases in Chinese vitiligo patients

Metabolic anomalies in vitiligo: a new frontier for drug repurposing strategies

Vitiligo is a chronic autoimmune condition characterized by the destruction of melanocytes, leading to patchy loss of skin depigmentation. Although its precise cause remains unclear, recent evidence suggests that metabolic disturbances, particularly oxidative stress and mitochondrial dysfunction, may play a significant role in the pathogenesis of the disease. Oxidative stress is thought to damage melanocytes and trigger inflammatory responses, culminating in melanocyte immune-mediate destruction. Additionally, patients with vitiligo often exhibit extra-cutaneous metabolic abnormalities such as abnormal glucose metabolism, dyslipidemia, high fasting plasma glucose levels, high blood pressure, out of range C-peptide and low biological antioxidant capacity, suggesting a potential link between metabolic impairment and vitiligo development. This implies that the loss of functional melanocytes mirrors a more general systemic targetable dysfunction. Notably, therapies targeting metabolic pathways, particularly those involving mitochondrial metabolism, such as the peroxisome proliferator-activated nuclear receptor γ (PPARγ) agonists, are currently being investigated as potential treatments for vitiligo. PPARγ activation restores mitochondrial membrane potential, mitochondrial DNA copy number and, consequently, ATP production. Moreover, PPARγ agonists counteract oxidative stress, reduce inflammation, inhibit apoptosis, and maintain fatty acid metabolism, in addition to the well-known capability to enhance insulin sensitivity. Additionally, increasing evidence of a strong relationship between metabolic alterations and vitiligo pathogenesis suggests a role for other approved anti-diabetic treatments, like metformin and fibrates, in vitiligo treatment. Taken together, these data support the use of approaches alternative to traditional immune-suppressive treatments for the treatment of vitiligo.

Risk factors for cardiovascular diseases in patients with vitiligo: an analysis of current evidence

OBJECTIVE

The relationship between vitiligo and cardiovascular diseases remains controversial. This study aimed to systematically review the evidence comparing cardiovascular disease risk factors between patients with vitiligo and controls and to perform a meta-analysis of the results.

DATA SOURCES

A comprehensive database search was performed for all studies in PubMed, EMBASE, and Cochrane Central Register databases from inception to November, 2023. The main keywords used were vitiligo, hypertension, diabetes, hyperlipidemia, metabolic syndrome, obesity, smoking, alcohol consumption, C-reactive protein, and homocysteine.

STUDY SELECTION

Only observational studies and no randomized controlled trials were included. Of the 1269 studies initially selected, the full texts of 108 were assessed for eligibility, and 74 were ultimately included in the analysis.

DATA EXTRACTION AND SYNTHESIS

Three reviewers independently extracted the following data: study design, number and characteristics of participants, inclusion indicators, and disease duration. A meta-analysis of the single-group rates was performed for the diabetes, hypertension, hyperlipidemia, and obesity groups. Random-effects or fixed-effects models were used to calculate the sample-size weighted averages for the indicators included in the studies.

MAIN OUTCOMES AND MEASURES

The primary outcomes were co-morbidity analysis and co-morbidity rates of vitiligo with metabolic syndrome, obesity, hyperlipidemia, hypertension, and diabetes mellitus. Secondary outcomes were factors associated with vitiligo and cardiovascular disease.

RESULTS

This meta-analysis concluded that comorbidities in patients with vitiligo included metabolic syndrome, diabetes, obesity, hyperlipidemia, and hypertension, with comorbidity rates of 28.3%, 6.0%, 38.5%, 43.0%, and 15.8%, respectively. Simultaneously, we showed that the vitiligo group differed significantly from the control group in the following aspects: fasting blood glucose, insulin, systolic and diastolic blood pressure, total cholesterol, triglycerides, low-density lipoprotein, high-density lipoprotein, homocysteine, C-reactive protein, smoking, and alcohol consumption. However, no significant differences were observed between the vitiligo and control groups in terms of waist circumference, body mass index, or phospholipid levels.

LIMITATIONS

The vast majority of the studies were from Eastern countries; therefore, extrapolation of these results to Western populations is questionable. The significant heterogeneity may be due to different protocols, doses, durations, center settings, population registries, etc., which severely compromise the validity of the results.

CONCLUSION

This study summarized not only the factors associated with, but also those not associated with, cardiovascular disease in patients with vitiligo. This study provides a foundation for the prevention and treatment of cardiovascular disease in patients with vitiligo.

A bidirectional autoimmune cluster between vitiligo and rheumatoid arthritis: a large-scale population-based study

A knowledge gap exists regarding the association between vitiligo and rheumatoid arthritis (RA) due to the absence of large-scale cohort studies designed to investigate this association. To investigate the bidirectional epidemiological association between vitiligo and RA. A population-based study was conducted using Clalit Health Services (CHS) database (2002-2019) using both a cohort study and a case-control study design. Adjusted hazard ratio (HR) and odds ratio (OR) were calculated by multivariate Cox and logistic regressions, respectively. Overall, 20,851 vitiligo patients and 102,475 controls were included. The incidence of new-onset RA was 4.1 (95% CI 3.0-5.4) and 2.9 (95% CI 2.4-3.3) cases per 10,000 person-years among patients with vitiligo and controls, respectively. Patients with vitiligo had a significantly increased risk of developing new-onset RA (adjusted HR, 1.44; 95% confidence interval [CI], 1.02-2.02, P = 0.036). The likelihood of having vitiligo was significantly elevated after a preexisting diagnosis of RA (adjusted OR, 1.67; 95% CI, 1.38-2.03; P < 0.001). Relative to the remaining patients with vitiligo, those with vitiligo and comorbid RA demonstrated an elevated risk of all-cause mortality (adjusted HR, 1.61; 95% CI, 1.03-2.51; P = 0.037). Our study confirms the bidirectional association between vitiligo and RA. Physicians treating patients with vitiligo should be aware of the association in clinical practice.

Assessment of serum granulysin and cathepsin-L levels in vitiligo patients

OBJECTIVE

Cellular and humoral immunity plays a role in the pathogenesis of vitiligo. T lymphocytes and natural killer cells involved in cellular immunity carry out their cytotoxic activities through perforin/granzyme-dependent granule exocytosis, in which granulysin and cathepsin-L are also involved. The aim of this study was to investigate the possible role of serum granulysin and cathepsin-L in the etiopathogenesis of vitiligo and their association with disease activity and severity.

METHODS

This randomized, prospective case-control study was conducted with 46 vitiligo patients admitted to the hospital for vitiligo between January and November 2021 and 46 healthy volunteers of similar age and gender. Serum levels of granulysin and cathepsin-L were measured by the enzyme-linked immunosorbent assay method.

RESULTS

The mean serum levels of granulysin and cathepsin-L were statistically significantly higher in vitiligo patients compared with the control group (p=0.048 and p=0.024, respectively). There was no statistically significant correlation between serum granulysin and serum cathepsin-L levels and disease severity in the patient group (r=0.30, p=0.062 and r=0.268, p=0.071, respectively). Disease activity also showed no significant association with serum granulysin and cathepsin-L levels (p=0.986 and p=0.962, respectively).

CONCLUSION

Although granulysin and cathepsin-L are molecules involved in the pathogenesis of vitiligo, the use of these molecules may not be helpful in assessing disease activity and severity. It may be helpful to conduct comprehensive and prospective studies to find new molecules to fill the gap in this area.

Beyond skin white spots: Vitiligo and associated comorbidities

Vitiligo is a common depigmentation disorder of an unknown origin characterized by the selective loss of melanocytes, resulting in typical white macules and patches. However, vitiligo is now recognized as more than just a skin disease, what a dermatologist observes as a white spot of skin is just the "tip of the iceberg" of the condition. We attempt to clarify the classification of comorbidities associated with vitiligo from various reviews and reports, and describe their possible pathogenesis. In conclusion, the literature provides evidence of an association between vitiligo and ocular and auditory abnormalities, autoimmune disorders, other dermatological diseases, metabolic syndrome and related disorders, and psychological diseases. These associations highlight the importance of a multidisciplinary approach in managing vitiligo patients.

Drug delivery of natural products through nano-carriers for effective vitiligo therapy: A compendia review

BACKGROUND

Vitiligo is a depigmenting illness that causes white areas on the skin. Vitiligo's pathogenetic genesis is based on the melanocyte's autoimmune destruction, in which oxidative stress causes melanocyte molecular, organelle, and exposure of antigen, as well as melanocyte cell death, and so plays a role in vitiligo progression. Natural compounds have recently shown a wide range of therapeutic bioactivities against a number of skin disorders.

AIM

The aim of this work is drug delivery of natural products through nano-carriers for effective vitiligo therapy: A compendia review.

METHODS & MATERIALS

An online literature analysis was guided for vitiligo therapy, nanotechnology, phytochemical composition, and, types of vitiligo, types of nanomedicine. Appropriate information were taken from different electronic scientific databases such as Web of Science, Science Direct, Elsevier, Google Scholar, Springer, PubMed, and scripts.

RESULTS

Nano-carriers-based natural compounds provide a great relationship for the enhancement in the efficacy and safety of pharmacotherapeutic agents for the treatment of vitiligo.

DISCUSSION

In this study focuses on natural compounds' effects and processes on vitiligo models. Although topical therapy plays an important role in vitiligo treatment, its utility and patient compliance are hampered by adverse effects or inadequate efficacy. Novel drug delivery techniques can help improve topical medication delivery by improving epidermal localization, reducing side effects, and increasing effectiveness.

CONCLUSION

This paper covers the significant potential of herbal-derived active compounds as anti-vitiligo drugs, as well as new drug delivery as a viable carrier and future possibilities to investigate.

Zusammenhang zwischen Vitiligo und wichtigen Komponenten des metabolischen Syndroms: eine systematische Übersicht und Metaanalyse

HINTERGRUND UND ZIELE

Ziel dieser Studie war die Untersuchung des Zusammenhangs zwischen Vitiligo und dem metabolischen Syndrom (MetS) sowie dessen relevanten Komponenten.

MATERIAL UND METHODEN

Die Datenbanken PubMed, Web of Science, Cochrane Library und Embase wurden von deren Beginn bis zum 30. März 2021 nach relevanten Studien durchsucht. Querschnitts- und Fall-Kontroll-Studien, die entweder die Prävalenz oder die Odds-Ratio [OR] des MetS oder seiner Komponenten bei Vitiligo-Patienten berichteten, wurden eingeschlossen. Die Daten wurden entsprechend der Heterogenität entweder mit einem Zufallseffektmodell oder einem Modell mit festen Effekten gepoolt.

ERGEBNISSE

Es wurden 30 Studien mit insgesamt 28.325 Vitiligo-Patienten eingeschlossen. Signifikante Zusammenhänge wurden zwischen Vitiligo und Diabetes mellitus (gepoolte OR, 3,30; 95 %-Konfidenzintervall [KI], 2,10-5,17) sowie zwischen Vitiligo und Adipositas (gepoolte OR, 2,08; 95 %-KI, 1,40-3,11) ermittelt. Die Gesamtprävalenz der Hypertonie bei Patienten mit Vitiligo betrug 19,0 % (95 %-KI, 2,0 %-36,0 %).

SCHLUSSFOLGERUNGEN

Unserer Ergebnisse lassen auf einen Zusammenhang zwischen Vitiligo und Diabetes mellitus sowie Hypertonie schließen. Dermatologen wird empfohlen diese Zusammenhänge zu berücksichtigen, um potenzielle Begleiterkrankungen bei Vitiligo-Patienten zeitnah zu identifizieren. Zudem wird Vitiligo-Patienten empfohlen, Parameter wie BMI, Blutzuckerspiegel und Blutdruck zu überwachen und bei auffälligen Veränderungen dieser Parameter unverzüglich einen Spezialisten zu konsultieren.

Association between vitiligo and relevant components of metabolic syndrome: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

This study aimed to investigate the association of vitiligo with metabolic syndrome (MetS) and its relevant components.

MATERIAL AND METHODS

We searched PubMed, Web of Science, Cochrane Library and Embase databases from inception to March 30, 2021, for relevant studies. Cross-sectional and case-control studies that reported either the prevalence or odds ratio [OR] of MetS or its components in vitiligo patients were included. Data were pooled using either random-effects model or fixed-effects model according to the heterogeneity.

RESULTS

Thirty studies with a total of 28,325 vitiligo patients were included. Significant associations were found between vitiligo and diabetes mellitus (pooled OR, 3.30; 95 % confidence interval [CI], 2.10-5.17) and between vitiligo and obesity (pooled OR, 2.08; 95 % CI, 1.40-3.11). The overall prevalence of hypertension in the patients with vitiligo was 19.0 % (95 % CI, 2.0 %-36.0 %).

CONCLUSIONS

Our findings suggest the association of vitiligo with diabetes mellitus, obesity, and hypertension. It is recommended for dermatologists to take these associations into account so as to identify potential comorbidities promptly in vitiligo patients. Additionally, vitiligo patients are advised to monitor the indexes including BMI, blood glucose, and blood pressure levels and the consultation with specialists is necessary upon abnormal changes of these indexes.

Inverse association between autoimmunity and elevated IgE among childhood vitiligo

BACKGROUND

Multiple factors contribute to the pathogenesis of childhood vitiligo. The characteristics in a different population under modified environmental factors need further reevaluation. The present study aimed to reevaluate the clinical and laboratory features in consequent children vitiligo patients.

MATERIALS AND METHODS

We retrospectively reviewed consequent children vitiligo patients who visited Children's Hospital of Fudan University (National Children's Medical Center of China). The prevalence rate of thyroid dysfunction, circulating autoantibodies, serum IgE, and associated factors were analyzed.

RESULTS

A total of 244 consequent vitiligo patients were included, of which 20 children had personal autoimmune history. Two hundred and nineteen of the 244 patients took a thyroid function test, and the abnormal rate was only 3.7% (8/219). The elevated IgE rate was 31.7% (52/157), the antinuclear antibody (ANA) positive rate was 9.8% (12/123), and the extractable nuclear antigens (ENA) positive rate was 4.4% (4/91), respectively. The elevated IgE was significantly associated with atopic disease history and male gender. Of note, personal autoimmune history showed a significant inverse association with elevated IgE.

CONCLUSIONS

Thyroid dysfunction rate was low among the consequent children vitiligo patients. Personal autoimmune history was inversely associated with elevated IgE. Various clinical characteristics and pathogenesis might contribute to different long-term outcomes of vitiligo.

Accuracy and Quality of YouTube Videos as a Source of Information on Vitiligo

Purpose

Vitiligo is a skin condition characterized by patchy depigmentation in the skin, affecting not just the physical well-being of patients, but also the mental, emotional, and social aspects of their lives. Social media provides a platform where patients can interact and share experiences, and for physicians and experts to disseminate knowledge on the disease. This study aimed to evaluate the accuracy and overall quality of vitiligo-related content on YouTube.

Methods

Thirty videos were screened by relevance according to the inclusion criteria. Videos were categorized as either healthcare or non-healthcare sources, and viewer engagement ratio was calculated for each. Three independent vitiligo experts rated the content using the following assessment tools: DISCERN, Accuracy in Digital-health Instrument (ANDI), and Global Quality Scale (GQS). Lastly, Cronbach’s alpha was used to estimate the inter-rater reliability and consistency.

Results

Most of the screened videos came from health-care sources (57%). Non-healthcare sources achieved a slightly higher viewer engagement ratio, although the difference is not statistically significant (p = 0.23). DISCERN score was low overall in most videos. However, DISCERN score was higher for health-care sources as compared to non-healthcare sources (30.5 ± 9.4 vs 22.7 ± 4,2, p = 0.009). Scores of ANDI and GQS were higher for health-care sources but not statistically significant. There was a good internal consistency in DISCERN rating among the evaluators (0.86).

Conclusion

Our study shows a low overall accuracy and quality of YouTube videos on vitiligo. It is recommended that health-care sources improve their information material in terms of quality and viewer engagement, as very little can be done to prevent non-healthcare sources in publishing their own videos. Efforts in educating the public on making distinction between evidence and non-evidence-based claims should also be taken.

[The prevalence of autoimmune endocrine diseases in vitiligo patients]

Vitiligo is a common polygenic autoimmune disease in which the foci of depigmentation are formed on the skin and/or mucous membranes as a result of the death of melanocytes. There are several hypotheses for the pathogenesis of the disease, the leading role among them is played the autoimmune hypothesis. This review summarizes the available literature data on the prevalence and structure of comorbid endocrine autoimmune pathology in vitiligo patients. In most studies conducted in Europe, America and Asia the prevalence of autoimmune thyroid diseases (including autoimmune thyroiditis and Graves disease), diabetes mellitus and autoimmune adrenal insufficiency was higher in vitiligo patients than in the general population. The results of some studies indicate a frequent association of vitiligo with autoimmune polyglandular syndromes. In the structure of comorbid pathology the highest prevalence was in autoimmune thyroid diseases. A number of studies have established a higher prevalence of autoimmune endocrine diseases in women, as well as in nonsegmental vitiligo patients and in cases of family history of vitiligo and/or other autoimmune diseases. In addition, it was shown that the prevalence of endocrine diseases increases with increasing area of depigmentation. The data obtained justify the advisability of conducting a timely examination of vitiligo patients with the aim of early detection of comorbid diseases and the appointment of appropriate treatment. Further studies are needed to investigate the effect of the identified associations on the course of vitiligo and comorbid endocrinopathies, as well as the effectiveness of therapy and the quality of life of patients.

The Genetic Basis of Vitiligo

Vitiligo is a complex disease in which autoimmune destruction of epidermal melanocytes results in patches of depigmented white skin. Vitiligo has an estimated prevalence of about 0.2-2% in different populations and approximately 0.4% in the European-derived white (EUR) population. The fraction of disease risk attributable to genetic variation, termed heritability, is high, with estimates from family studies in EUR of 0.75-0.83 and from SNP based studies estimated at 0.78. About 70% of genetic risk comes from common genetic variants and about 30% from rare genetic variants. Through candidate gene, genomewide linkage, and genomewide association studies, over 50 vitiligo susceptibility loci have been discovered. These have been combined into a vitiligo polygenic risk score, which has allowed various aspects of vitiligo genetic architecture in the EUR population to be better understood. Vitiligo has thus proved to be a particularly tractable model for investigation of complex disease genetic architecture. Here, we summarize progress to date including dissection of heritability, discovery of vitiligo susceptibility loci through candidate gene, genomewide linkage, and genomewide association studies, relationships to other autoimmune diseases, polygenic architecture of vitiligo risk, vitiligo triggering, and disease onset, and provide suggestions for future directions.

Recent Progress and Future Directions: The Nano-Drug Delivery System for the Treatment of Vitiligo

Vitiligo is a depigmentation disease that seriously affects the physical health, mental health and quality of life of a patient. Therapeutic aim at control immunoreaction by relieving oxidative stress. Unfortunately, the cuticle barrier function and lack of specific accumulation lead to unsatisfactory therapeutic outcomes and side effects. The introduction and innovation of nanotechnology offers inspiration and clues for the development of new strategies to treat vitiligo. However, not many studies have been done to interrogate how nanotechnology can be used for vitiligo treatment. In this review, we summarize and analyze recent studies involving nano-drug delivery systems for the treatment of vitiligo, with a special emphasis on liposomes, niosomes, nanohydrogel and nanoparticles. These studies made significant progress by either increasing drug loading efficiency or enhancing penetration. Based on these studies, there are three proposed principles for topical nano-drug delivery systems treatment of vitiligo including the promotion of transdermal penetration, enhancement of drug retention and facilitation of melanin regeneration. The presentation of these ideas may provide inspirations for the future development of topical drug delivery systems that will conquer vitiligo.

Epidemiology of alopecia areata, ophiasis, totalis, and universalis: A systematic review and meta-analysis

BACKGROUND

Alopecia areata (AA) is a common autoimmune alopecia with heterogeneous severity and distribution. Previous studies found conflicting results about AA epidemiology.

OBJECTIVE

To determine the prevalence, incidence, and predictors of AA, alopecia totalis, alopecia ophiasis, and alopecia universalis.

METHODS

A systematic review of all published cohort and cross-sectional studies that analyzed AA and its subtypes. MEDLINE, Embase, LILACS, Scopus, Cochrane Library, and GREAT were searched. At least 2 reviewers performed study title/abstract review and data extraction. Random-effects meta-analysis was used because of significant heterogeneity (I² = 99.97%).

RESULTS

Ninety-four studies met the inclusion criteria. The pooled prevalence (95% confidence interval, N) of AA overall was 2.11% (1.82-2.42, N = 302,157,365), with differences of population-based (0.75% [0.49-1.06%], N = 301,173,403) and clinic-based (3.47% [3.01-3.96], N = 983,962) studies. The prevalences of alopecia totalis, ophiasis, and universalis were 0.08% (0.04-0.13, N = 1,088,149), 0.02% (0.00-0.06, N = 1,075,203), and 0.03% (0.01-0.06, N = 1,085,444), respectively. AA prevalence (95% confidence interval) increased over time (<2000: 1.02% [0.85-1.22]; 2000-2009: 1.76% [1.51-2.03]; >2009: 3.22% [2.59-3.92]; P < .0001) and differed by region. AA prevalence was significantly lower in adults (1.47% [1.18-1.80]) than children (1.92% [1.31-2.65]; P < .0001).

CONCLUSIONS

AA affects 2% of the global population. AA prevalence is lower in adults than children, is increasing over time, and significantly differs by region.

Comorbidities in vitiligo: comprehensive review

Vitiligo is a common skin disorder characterized by idiopathic, progressive cutaneous hypomelanosis. Vitiligo is associated with several comorbid autoimmune, systemic, and dermatological diseases, primarily thyroid disease, alopecia areata, diabetes mellitus, pernicious anemia, systemic lupus erythematosus, rheumatoid arthritis, Addison's disease, inflammatory bowel disease, Sjögren's syndrome, dermatomyositis, scleroderma, ocular and audiological abnormalities, psoriasis, and atopic dermatitis. It is essential to increase awareness of these comorbidities in order to improve the disease burden and quality of life of patients with vitiligo. Herein, we review the association with the most frequent comorbidities associated with vitiligo.

The Prevalence of Thyroid Disorders in Patients With Vitiligo: A Systematic Review and Meta-Analysis

Background: Associations between vitiligo and thyroid disorders have been suggested, However, the prevalence of thyroid disorders in vitiligo vary widely. Purpose: To conduct a systematic review and meta-analysis assessing the prevalence of thyroid disorders in patients with vitiligo. Method: The PubMed, Cochrane Library, EMBASE, CNKI (China National Knowledge Infrastructure), Chongqing VIP database, and Wanfang database from inception to August 2, 2018 were systematically searched. The pooled prevalence and its 95% confidence interval (CI) were calculated. Results: A total of 77 eligible studies were identified and included, published from 1968 to 2018. Six thyroid disorders including subclinical hyperthyroidism, overt hyperthyroidism, subclinical hypothyroidism, overt hypothyroidism, Graves disease, and Hashimoto thyroiditis were described. The numbers of relative studies were 54 in overt hypothyroidism, 50 in overt hyperthyroidism, 25 in subclinical hypothyroidism, 19 in Hashimoto thyroiditis, 16 in Graves disease, and 10 in subclinical hyperthyroidism. The highest prevalence was 0.06 (95% CI: 0.04-0.07) in subclinical hypothyroidism, and the lowest was 0.01 in subclinical hyperthyroidism (95% CI: 0.00-0.01) or Graves disease (95% CI: 0.01-0.02). Conclusion: Six thyroid disorders showed various prevalence in vitiligo. The highest prevalence was in subclinical hypothyroidism, and the lowest was in subclinical hyperthyroidism or Graves disease. Screening vitiligo patients for thyroid disorders seem plausible, in an effort to detect potential thyroid diseases or to assess the risk of future onset.

Autoimmune comorbidity in chronic spontaneous urticaria: A systematic review

BACKGROUND AND OBJECTIVE

Numerous autoimmune diseases (AIDs) have been linked to chronic spontaneous urticaria (CSU). Here, we provide the first extensive and comprehensive evaluation of the prevalence of AIDs in patients with CSU and vice versa.

METHODS

A Pubmed and Google Scholar search was performed to identify studies reporting the prevalence of various AIDs in CSU and vice versa published before April 2017.

RESULTS

The prevalence of individual AIDs in CSU is increased (≥1% in most studies vs ≤1% in the general population). AIDs with relatively high prevalence in the general population are also quite common in CSU patients, whereas those with low prevalence remain a rare finding in CSU. The rates of comorbidity in most studies were ≥1% for insulin-dependent diabetes mellitus, rheumatoid arthritis (RA), psoriasis and celiac disease (CD), ≥2% for Graves' disease, ≥3% for vitiligo, and ≥5% for pernicious anemia and Hashimoto's thyroiditis. Organ-specific AIDs are more prevalent in CSU than systemic (multiorgan or non organ-specific) AIDs. >2% of CSU patients have autoimmune polyglandular syndromes encompassing autoimmune thyroid disease (ATD) and vitiligo or pernicious anemia. Antithyroid and antinuclear antibodies are the most prevalent AID-associated autoantibodies in CSU. >15% of CSU patients have a positive family history for AIDs. The prevalence of urticarial rash in AID patients is >1% in most studies. This rash is more prevalent in eosinophilic granulomatosis with polyangiitis, ATD, systemic lupus erythematosus, RA and CD.

CONCLUSIONS

CSU patients have an increased risk of AIDs, especially adult female patients and those with a positive family history and a genetic predisposition for AIDs, who should be screened for signs and symptoms of AIDs.

A holistic review on the autoimmune disease vitiligo with emphasis on the causal factors

Vitiligo is an idiopathic systemic autoimmune disease affecting skin, hair and oral mucosa. This genetic yet acquired disease characterized by melanin loss is a cause of morbidity across all races. Though thyroid disturbance has been recognized as a key trigger of this pathology, an array of other factors plays critical role in its manifestation. Multiple hormones (corticotropin-releasing hormone, adrenocorticotropic hormone, α-melanocyte-stimulating hormone, melatonin, calcitriol, testosterone, estrogen), genes (Human leukocyte antigen (HLA), Cytotoxic T lymphocyte-associated antigen 4 (CTLA-4), Forkhead box D3 (FOXD3), Cluster of differentiation 117 (CD117), Estrogen receptor (ESR) 1, Cyclooxygenase-2 (COX2), Vitiligo-associated protein 1 (VIT1)), and lifestyle choices (stress, diet, cosmetic products, and medications) have been suspected as drivers of this disorder. The pathological mechanisms have been understood in recent times, with the aid of genomic studies; however a universally-effective therapy is yet to be achieved. This review discusses these under-investigated facets of vitiligo onset and progression; hence, it is expected to enrich vitiligo research.

Autoimmune vitiligo in rheumatic disease in the mestizo Mexican population

Vitiligo is a chronic disease characterized by the dysfunction or destruction of melanocytes with secondary depigmentation. The aim of the present study was to determine the prevalence of vitiligo associated with autoimmune rheumatic diseases. The clinical records from a 10-year database of patients with rheumatic diseases and associated vitiligo was analysed, with one group of patients having autoimmune rheumatic disease and another non-autoimmune rheumatic disease. Available serum samples were used to assess the anti-melanocyte antibodies. A total of 5,251 individual clinical files were archived in the last 10 years, and these patients underwent multiple rheumatology consultations, with 0.3% of the group presenting with vitiligo. The prevalence of vitiligo in the autoimmune rheumatic disease group was 0.672%, which was mainly associated with lupus and arthritis. However, patients with more than one autoimmune disease had an increased relative risk to develop vitiligo, and anti-melanocyte antibodies were positive in 92% of these patients. By contrast, the prevalence was 0.082% in the group that lacked autoimmune rheumatic disease and had negative autoantibodies. In conclusion, the association between vitiligo and autoimmune rheumatic diseases was relatively low. However, the relative risk increased when there were other autoimmune comorbidities, such as thyroiditis or celiac disease. Therefore, the presence of multiple autoimmune syndromes should be suspected.

Genetic polymorphism of the Nrf2 promoter region is associated with vitiligo risk in Han Chinese populations

The nuclear factor erythroid‐derived two‐like 2‐antioxidant response element (Nrf2‐ARE) pathway and its downstream antioxidant enzyme heme oxygenase‐1 (HMOX1 or HO‐1) play essential roles in H₂O₂‐induced oxidative damage in human melanocytes. However, the link between Nrf2 promoter polymorphisms and susceptibility to oxidative stress‐related diseases such as vitiligo is unknown. This study evaluated the association of the Nrf2 and HO‐1 genes polymorphisms with vitiligo susceptibility. In this case–control study of 1136 Han Chinese vitiligo patients and 1200 controls, Nrf2 (rs35652124 and rs6721961) and HO‐1 (rs2071746) genes were genotyped by PCR‐restriction fragment length polymorphism analysis. Overall, a significantly decreased risk of vitiligo was found to be associated with Nrf2 rs35652124 CC and combined (CT+CC) genotypes [odds ratio (OR) 0.64, 95% confidence interval (CI) 0.50–0.83 and OR, 0.84, 95% CI 0.71–0.99, respectively], as well as among subgroups: female, onset age ≤20 and never smoker. We subsequently found that Nrf2 rs35652124 C allele had higher transcriptional activity in the luciferase reporter assay compared with Nrf2 rs35652124 T allele. Furthermore, we investigated serum HO‐1 activity was associated with the rs35652124 CT+CC genotype and lower in patients than in controls (P = 0.024). Logistic regression analysis showed a dose–response relationship between lower vitiligo risk and increased HO‐1 activity in rs35652124 CT+CC genotype carriers (P_trend < 0.05). These findings indicate that the C allele of rs35652124 located in the promoter region of Nrf2 gene is associated with protective effect on vitiligo in a Han Chinese population.

Increased expression of CXCR3 and its ligands in patients with vitiligo and CXCL10 as a potential clinical marker for vitiligo

BACKGROUND

Vitiligo is a skin disorder characterized by loss of melanocytes from the epidermis. A recent study reported that CXCL10 is critical for the progression and maintenance of depigmentation in a mouse model of vitiligo, but there is very limited clinical data regarding this issue and little is known about the dynamic changes or correlations with disease severity of these chemokines throughout the disease course.

OBJECTIVES

To present clinical data that supports and identifies the pathway of CXCR3 and its ligands in T-lymphocytic cell recruitment in vitiligo.

METHODS

Cytometric bead array, flow cytometry, quantitative real-time polymerase chain reaction and immunohistology were used to examine their systemic and local expression in 80 patients with vitiligo and 40 controls.

RESULTS

We showed that serum CXCL9 and CXCL10 were significantly elevated in patients with vitiligo and were higher in patients in progressive stages than in stable stages. The relative expression of CXCR3 mRNA in peripheral blood mononuclear cells was higher in vitiligo. There were higher percentages of both circulating CXCR3(+) CD4(+) and CXCR3(+) CD8(+) T cells in patients with progressive vitiligo compared with controls, while only the expression of CXCR3(+) CD8(+) T cells increased in patients with stable vitiligo. Histological findings also demonstrated an abundance of CXCR3(+) cells within vitiligo lesions. Furthermore, serum CXCL10 levels were associated with Vitiligo Area Scoring Index scores of patients with progressive vitiligo and were reduced after successful treatment.

CONCLUSIONS

The CXCL10/CXCR3 axis mediates T-cell recruitment into the skin in progressive vitiligo. Blocking this chemotactic mechanism may present a new form of therapy. Serum CXCL10 may be a novel biomarker in monitoring disease activity and guiding treatment of progressive vitiligo.

Motor nerve conduction velocity is affected in segmental vitiligo lesional limbs

To evaluate the effects of segmental vitiligo (SV) on nerve conduction velocity (NCV) in different nerves, we compared the patient's lesional side of their body to the contralateral normal side. The 106 participants were selected from outpatients visiting the dermatological clinics of Huashan Hospital, Fudan University, from November 2011 to March 2014. NCVs were measured on the limbs and the face, including both motor and sensory nerves. The parameters for NCVs included motor nerve conduction velocity (MCV) and its distal conduction latency, sensory nerve conduction velocity, sensory nerve action potentials amplitude, and compound muscle action potential amplitude. MCV on the limbs was compromised by SV state, which was significantly slower on the lesional side of the body compared with the normal contralateral side (P = 0.006). Furthermore, SV at the stable stage significantly impaired MCV compared with the SV at progressive stage. There was no significant difference in the other parameters of NCV between lesional and normal sides of the body. Compound muscle action potentials in the face did not differ between lesional and healthy sides. Motor nerves in the limbs were compromised by SV, particularly when the disease was at the stable stage.

Genetic Susceptibility to Vitiligo: GWAS Approaches for Identifying Vitiligo Susceptibility Genes and Loci

Vitiligo is an autoimmune disease with a strong genetic component, characterized by areas of depigmented skin resulting from loss of epidermal melanocytes. Genetic factors are known to play key roles in vitiligo through discoveries in association studies and family studies. Previously, vitiligo susceptibility genes were mainly revealed through linkage analysis and candidate gene studies. Recently, our understanding of the genetic basis of vitiligo has been rapidly advancing through genome-wide association study (GWAS). More than 40 robust susceptible loci have been identified and confirmed to be associated with vitiligo by using GWAS. Most of these associated genes participate in important pathways involved in the pathogenesis of vitiligo. Many susceptible loci with unknown functions in the pathogenesis of vitiligo have also been identified, indicating that additional molecular mechanisms may contribute to the risk of developing vitiligo. In this review, we summarize the key loci that are of genome-wide significance, which have been shown to influence vitiligo risk. These genetic loci may help build the foundation for genetic diagnosis and personalize treatment for patients with vitiligo in the future. However, substantial additional studies, including gene-targeted and functional studies, are required to confirm the causality of the genetic variants and their biological relevance in the development of vitiligo.

Evaluation between Association of Psoriasis and Vitiligo

BACKGROUND

Although the occurrence of psoriasis and vitiligo is reported in a few studies, no proper relationship has been found between these two diseases.

OBJECTIVE

The aim of this study was to identify the frequency of the coincidence of these two diseases.

METHOD

A descriptive and cross-sectional study was conducted on 6,200 patients referred to dermatology clinics from September 2004 to June 2005.

RESULTS

Among these patients, 219 and 154 patients suffered from psoriasis (3.53%) and vitiligo (2.48%), respectively, and 12 patients (0.19%) had psoriasis and vitiligo simultaneously. The coincidence in the psoriasis group was 5.48% and in the vitiligo group was 7.79%, so the coincidence of both diseases was greater than the incidence of each alone. This association was significant (p = .004).

CONCLUSION

Coincidence of these two diseases was seen, but more studies should be done to find common genetic and immunologic factors.

Differential expression analysis of miRNA in peripheral blood mononuclear cells of patients with non-segmental vitiligo

Vitiligo is a common depigmentary skin disease that may follow a pattern of multifactorial inheritance. The essential factors of its immunopathogenesis is thought to be the selective destruction of melanocytes. As a new class of microregulators of gene expression, miRNA have been reported to play vital roles in autoimmune diseases, metabolic diseases and cancer. This study sought to characterize the different miRNA expression pattern in the peripheral blood mononuclear cells (PBMC) of patients with non-segmental vitiligo (NSV) and healthy individuals and to examine their direct responses to thymosin α1 (Tα1) treatment. The miRNA expression profile in the PBMC of patients with NSV was analyzed using Exiqon's miRCURY LNA microRNA Array. The differentially expressed miRNA were validated by real-time quantitative polymerase chain reaction. We found that the expression levels of miR-224-3p and miR-4712-3p were upregulated, and miR-3940-5p was downregulated in the PBMC. The common clinical immune modulator Tα1 changed the miRNA expression profile. Our analysis showed that differentially expressed miRNA were associated with the mechanism of immune imbalance of vitiligo and that Tα1 could play an important role in changing the expression of these miRNA in the PBMC of patients with NSV. This study provided further evidence that miRNA may serve as novel drug targets for vitiligo therapeutic evaluation.

Vitiligo--part 1

Vitiligo is a chronic stigmatizing disease, already known for millennia, which mainly affects melanocytes from epidermis basal layer, leading to the development of hypochromic and achromic patches. Its estimated prevalence is 0.5% worldwide. The involvement of genetic factors controlling susceptibility to vitiligo has been studied over the last decades, and results of previous studies present vitiligo as a complex, multifactorial and polygenic disease. In this context, a few genes, including DDR1, XBP1 and NLRP1 have been consistently and functionally associated with the disease. Notwithstanding, environmental factors that precipitate or maintain the disease are yet to be described. The pathogenesis of vitiligo has not been totally clarified until now and many theories have been proposed. Of these, the autoimmune hypothesis is now the most cited and studied among experts. Dysfunction in metabolic pathways, which could lead to production of toxic metabolites causing damage to melanocytes, has also been investigated. Melanocytes adhesion deficit in patients with vitiligo is mainly speculated by the appearance of Köebner phenomenon, recently, new genes and proteins involved in this deficit have been found.

Fractional laser for vitiligo treated by 10,600 nm ablative fractional carbon dioxide laser followed by sun exposure

BACKGROUND

Vitiligo is an acquired disorder of the skin and mucous membranes. Many patients with vitiligo remain in the refractory state despite the availability of numerous potential treatments. To the best of our knowledge, only one trial considers ablative fractional CO2 laser in the treatment of vitiligo.

OBJECTIVE

To investigate the effects of fractional CO2 laser followed by systemic sun exposure on non-segmental vitiligo (NSV).

METHODS

Ten patients presenting refractory NSV were enrolled in this study. The patients underwent three sessions, one month apart, of fractional CO2 laser therapy on the affected areas of the skin (L-group). Five days after each laser treatment, patients were asked to expose themselves to the sun for 2 hours on a daily basis. Objective and subjective clinical assessments were performed at the beginning and at the end of the treatment. The L-group was then compared to a control group (C-group) that consisted of vitiligo lesions in the same patients but with sun exposure as the exclusive therapy.

RESULTS

Compared to the C-group, the L-group showed better improvement in both objective and subjective assessments. There were no noticeable adverse events in terms of scarring and Koebner phenomenon among others.

CONCLUSIONS

All patients treated with both, laser sessions and sun exposure, improved their chronic NSV lesions. Improvement was less significant in patients who exhibited vitiligo lesions over articular surfaces such as elbows and underarms. The best results were observed in vitiligo plaques located on the face, neck and legs. Consequently, fractional CO2 laser followed by sun exposure could be considered as an alternative modality for the treatment of refractory vitiligo, especially in sunny regions.

Vitiligo as a systemic disease

Vitiligo is an acquired depigmentary skin disorder of unknown etiology. Vitiligo is not only a disease of melanocytes of the skin. Human melanocytes are derived from the neural crest and are located on various parts of the body. The involvement of skin melanocytes is the most visible one, but a systemic involvement of melanocytes can be observed. Some types of vitiligo (nonsegmental vitiligo) may also be associated with various diseases, mainly with autoimmune pathogenesis. Vitiligo represents a spectrum of many different disorders with different etiologies and pathogeneses, causing a common phenotype: the loss of melanocytes and/or their products. This phenotype is always consistent with a systemic involvement.

Effect of Age at Onset on Disease Characteristics in Vitiligo

Background:

Vitiligo is a multifactorial disease in which genetic, immunologic, and environmental factors play an important part. Late-onset vitiligo is a poorly defined entity.

Materials and Methods:

Case records of patients who attended the pigmentary clinic at our institute from January 2001 to December 2010 were reviewed. Patients with a diagnosis of vitiligo were analyzed with respect to their demographic characteristics with special reference to their age at onset.

Results:

Patients with disease onset after 30 years had a significantly higher association with precipitating factors such as trauma, stress, and drugs in comparison with early-onset vitiligo ( p < .004). However, the difference did not reach statistical significance when these factors were analyzed individually. There was a significantly higher association with other nonautoimmune diseases ( p = .05), a higher incidence of positive family history ( p < .0001), and a higher association with leukotrichia ( p < .002) in late-onset disease. Early-onset nonsegmental vitiligo was associated with a higher incidence of photosensitivity and pruritus compared to early-onset segmental vitiligo.

Conclusion:

Late-onset vitiligo has certain distinguishing features compared to early-onset vitiligo.

How do autoimmune diseases cluster in families? A systematic review and meta-analysis

BACKGROUND

A primary characteristic of complex genetic diseases is that affected individuals tend to cluster in families (that is, familial aggregation). Aggregation of the same autoimmune condition, also referred to as familial autoimmune disease, has been extensively evaluated. However, aggregation of diverse autoimmune diseases, also known as familial autoimmunity, has been overlooked. Therefore, a systematic review and meta-analysis were performed aimed at gathering evidence about this topic.

METHODS

Familial autoimmunity was investigated in five major autoimmune diseases, namely, rheumatoid arthritis, systemic lupus erythematosus, autoimmune thyroid disease, multiple sclerosis and type 1 diabetes mellitus. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Articles were searched in Pubmed and Embase databases.

RESULTS

Out of a total of 61 articles, 44 were selected for final analysis. Familial autoimmunity was found in all the autoimmune diseases investigated. Aggregation of autoimmune thyroid disease, followed by systemic lupus erythematosus and rheumatoid arthritis, was the most encountered.

CONCLUSIONS

Familial autoimmunity is a frequently seen condition. Further study of familial autoimmunity will help to decipher the common mechanisms of autoimmunity.

Vitiligo and Associated Autoimmune Disease: Retrospective Review of 300 Patients

Background:

Vitiligo, the most common cutaneous depigmentation disorder, has reported associations with other autoimmune diseases. However, literature on the strengths of the associations is conflicting, and no data on the subject exist from a Canadian population.

Objective:

To determine autoimmune disease associations with vitiligo and which, if any, screening bloodwork is appropriate in vitiligo patients.

Methods:

A retrospective review of vitiligo patients admitted to the Toronto Western Hospital phototherapy unit was conducted from January 1, 2000, to August 30, 2009. Data regarding patient characteristics, vitiligo clinical features (family history, age at onset, type, extent), associated diseases in the patient and family, and admission bloodwork (hemoglobin, vitamin B12, thyroid-stimulating hormone [TSH], antinuclear antibody) were recorded and compared, using the Fisher exact test where applicable.

Results:

A total of 300 patient charts were reviewed (average age 41.5 ± 15.5 years; 47% male, 53% female). Hypothyroidism was present in 12.0% and pernicious anemia in 1.3% of patients—significant increases over the population prevalence. No other differences in prevalence were seen compared to the general population. TSH was increased in 3.7% of patients without a history of hypothyroidism. Hemoglobin and vitamin B12 were decreased in 0.3% of vitiligo patients without a history of pernicious anemia.

Conclusion:

We found a significantly higher prevalence of hypothyroidism and pernicious anemia in vitiligo patients.

Generalized vitiligo and associated autoimmune diseases in Japanese patients and their families

BACKGROUND

Generalized vitiligo is an acquired disorder in which depigmented macules result from the autoimmune loss of melanocytes from the involved regions of skin. Generalized vitiligo is frequently associated with other autoimmune diseases, particularly autoimmune thyroid diseases (Hashimoto's thyroiditis and Graves' disease), rheumatoid arthritis, adult-onset type 1 diabetes mellitus, psoriasis, pernicious anemia, systemic lupus erythematosus, and Addison's disease.

METHODS

One hundred and thirty-three Japanese patients with generalized vitiligo were enrolled in this study to investigate the occurrence of autoimmune diseases in Japanese patients with generalized vitiligo and their families.

RESULTS

Twenty-seven of the patients with generalized vitiligo (20.3%) had autoimmune diseases, particularly autoimmune thyroid disease (sixteen patients, 12%) and alopecia areata (seven patients, 5.3%). Thirty-five patients (26.3%) had a family history of generalized vitiligo and/or other autoimmune diseases. Familial generalized vitiligo was present in fifteen (11.3%), including four families with members affected by autoimmune disorders. Twenty (15.0%) had one or more family members with only autoimmune disorders.

CONCLUSIONS

Among Japanese vitiligo patients, there is a subgroup with strong evidence of genetically determined susceptibility to not only vitiligo, but also to autoimmune thyroid disease and other autoimmune disorders.

Profile of vitiligo patients attending a training and research hospital in Central Anatolia: a retrospective study

Clinical characteristics of vitiligo had been reported in different countries previously. This is the second report from Turkey and it is from a different region of Turkey, middle Anatolia, and a more detailed study. The age and sex of patients, onset age, duration, areas of involvement, course, clinical types and severity of the disease, family history of vitiligo, associated disorders, the values of vitamin B12, folic acid, ferritin, iron and hemoglobin, antithyroglobulin and antithyroid peroxidase antibodies and positivity of viral markers were obtained from the records of the patients retrospectively. The study involved 93 vitiligo patients with a mean age of 37.4±17.05 years. The median age of onset disease was 33 years and onset age of disease was significantly lower in women. Of the patients, 24.8% had family history. The most frequent form of vitiligo was vitiligo vulgaris. Facial involvement was the most common localization. Trunk involvement was significantly higher in women but anogenital involvement was significantly higher in men. Of the patients, 40.3% had another autoimmune disease, 19.7% of the patients had low ferritin levels, 12% had low iron levels, 9.9% had anemia, 4.9% had low vitamin B12 levels, 3.8% had low folic acid levels and 4.3% had positivity of viral markers. The age of onset and the incidence of family history were higher and sites of involvement according to sex were different from the published work. The knowledge of clinical characteristics, course and associated conditions of vitiligo may improve the approach of dermatologists to vitiligo patients.

Vitiligo: a review of the published work

Vitiligo is a common depigmenting skin disorder, characterized by acquired, idiopathic, progressive, circumscribed hypomelanosis of the skin and hair, with total absence of melanocytes microscopically. It occurs worldwide, with an incidence rate of between 0.1% and 2%. Vitiligo is an important skin disease having a major impact on the quality of life of the patient suffering from it. The causes of this condition are uncertain but seem to be dependent on the interaction of genetic, immunological and neurological factors. Vitiligo coexists with other autoimmune disorders, Sutton or halo nevus, and malignant melanoma. The substantial disfigurement associated with vitiligo can cause serious emotional stress for the patient, which necessitates treatment. Because its pathogenesis is still not understood, there is a plethora of different treatments. Among them, topical steroids and narrowband ultraviolet B monotherapy were the most common as current treatments for localized and generalized vitiligo, respectively. Cosmetic improvement can be achieved by camouflage products and self-tanning dyes. The course of vitiligo is unpredictable, but often progressive. Spontaneous repigmentation may occur in a few people (10–20%), mainly in children, but this tends to be only partial and on sun-exposed areas. In this article, we review vitiligo as a whole, including epidemiology, pathogenesis and etiology, histopathology, clinical manifestations, classification, clinical variants, diagnosis and differential diagnoses, specific investigation, treatment, prognosis, psychosocial view and its association with other disorders.

Comparisons of clinical features of HLA-DRB1*07 positive and negative vitiligo patients in Chinese Han population

BACKGROUND

Human leucocyte antigen (HLA)-II alleles have been found to be associated with vitiligo in different populations, and several studies also suggested that HLA class II alleles/haplotypes were associated with a different type vitiligo. Of HLA class II alleles, DRB1*07 has consistently shown a positive association with vitiligo in Chinese Han population.

OBJECTIVE

To further explore the relationship between DRB1*07 and vitiligo and to evaluate the DRB1*07 effect on the clinical features of vitiligo in Chinese Han population.

METHODS

This study investigated DRB1*07 allele distribution in 1178 unrelated Chinese vitiligo patients and 1743 healthy controls using polymerase chain reaction/sequence specific primer method and observed clinical differences between DRB1*07 positive and DRB1*07 negative patients.

RESULTS

The analysis of the 1178 cases and 1743 controls revealed a highly association between DRB1*07 allele and vitiligo [odds ratio (OR) = 1.97, P = 2.13 × 10(-17) ]. DRB1*07 positive patients had early disease onset (OR = 1.49, P = 0.001), higher frequency of family history (OR = 1.44, P = 0.006) compared with DRB1*07 negative patients.

CONCLUSIONS

The DRB1*07 showed significant association with vitiligo in the study population. This study confirmed that DRB1*07 positive patients had some obvious clinical differences from DRB1*07 negative patients in the Chinese Han population.

Genome-wide association study for vitiligo identifies susceptibility loci at 6q27 and the MHC

We conducted a genome-wide association study of generalized vitiligo in the Chinese Han population by genotyping 1,117 cases and 1,429 controls. The 34 most promising SNPs were carried forward for replication in samples from individuals of the Chinese Han (5,910 cases and 9,916 controls) and Chinese Uygur (713 cases and 824 controls) populations. We identified two independent association signals within the major histocompatibility complex (MHC) region (rs11966200, Pcombined=1.48x10(-48), OR=1.90; rs9468925, Pcombined=2.21x10(-33), OR=0.74). Further analyses suggested that the strong association at rs11966200 might reflect the reported association of the HLA-A*3001, HLA-B*1302, HLA-C*0602 and HLA-DRB1*0701 alleles and that the association at rs9468925 might represent a previously unknown HLA susceptibility allele. We also identified one previously undescribed risk locus at 6q27 (rs2236313, Pcombined=9.72x10(-17), OR=1.20), which contains three genes: RNASET2, FGFR1OP and CCR6. Our study provides new insights into the genetic basis of vitiligo.

Alopecia Areata Associated with Localized Vitiligo

Alopecia areata is a common cause of noncicatricial alopecia that occurs in a patchy, confluent or diffuse pattern. It may occur as a single, self-limiting episode or may recur at varying intervals over many years. The association of alopecia areata with localized vitiligo has not been reported. The association of alopecia areata with localized vitiligo in the same patient is documented here; it is the first of its kind.