Update on childhood vitiligo

S1 Guideline: Diagnosis and therapy of vitiligo

Vitiligo is a common skin disorder characterized by immune-mediated destruction of melanocytes. Non-segmental vitiligo, the most common clinical subtype, has usually a chronic course and often results in significant psychosocial consequences for the affected patient. Early recognition, awareness of comorbidity, precise assessment of disease extent and activity, evaluation of impairment of quality of life as well as rapid initiation of treatment based on currently available evidence-based therapies are crucial cornerstones in the management of vitiligo. This S1 guideline helps German dermatologists to better diagnose and treat vitiligo.

Review article: Emerging issues in pediatric skin of color, part 1

Dermatology for the pediatric skin of color population is the application of dermatology to the genetically diverse and distinctive segment of the pediatric population that includes children of non-White racial and ethnic groups with increased pigmentation including individuals of Asian, LatinX, African, Native American, Pacific Island descent, Indigenous Peoples, among others, with overlap in particular individuals, and mixtures thereof. Treating children of color is a unique skill set within the field of pediatric dermatology, requiring knowledge and sensitivity. The discipline of pediatric skin of color can be challenging. Difficulty in diagnosis of common conditions stems from underlying pigmentation, variations in common hairstyling practices, and differences in demographics of cutaneous disease, whereas some conditions are more common in children of color, other conditions have nuances in clinical appearance and/or therapeutics with regard to skin color. This article is the first in a series of two articles looking at recently published skin-related issues of high concern in children of color. Conditions reviewed in Part 1 include (1) hairstyling hair-related concerns (traction alopecia, central centrifugal cicatricial alopecia, endocrine disruption), (2) autoimmune concerns (cutaneous lupus, vitiligo), and (3) infections (tinea capitis, progressive macular hypomelanosis).

Vitiligo: An Updated Narrative Review

BACKGROUND

Vitiligo is a relatively common acquired pigmentation disorder that can cause significant psychological stress and stigmatism.

OBJECTIVE

This article aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis, and management of vitiligo.

METHODS

A Pubmed search was conducted in Clinical Queries using the key term "vitiligo". The search included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English language. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Approximately one quarter of patients with vitiligo have the onset before 10 years of age. Genetic, immunological, neurogenic and environmental factors may have a role to play in the pathogenesis. Vitiligo typically presents as acquired depigmented, well-demarcated macules/patches that appear milk- or chalk-white in color. Lesions tend to increase in number and enlarge centrifugally in size with time. Sites of predilection include the face, followed by the neck, lower limbs, trunk, and upper limbs. The clinical course is generally unpredictable. In children with fair skin, no active treatment is usually necessary other than the use of sunscreens and camouflage cosmetics. If treatment is preferred for cosmesis, topical corticosteroids, topical calcineurin inhibitors, and narrowband ultraviolet B phototherapy are the mainstays of treatment.

CONCLUSION

The therapeutic effect of all the treatment modalities varies considerably from individual to individual. As such, treatment must be individualized. In general, the best treatment response is seen in younger patients, recent disease onset, darker skin types, and head and neck lesions. Topical corticosteroids and calcineurin inhibitors are the treatment choice for those with localized disease. Topical calcineurin inhibitors are generally preferred for lesions on genitalia, intertriginous areas, face, and neck. Narrowband ultraviolet B phototherapy should be considered in patients who have widespread vitiligo or those with localized vitiligo associated with a significant impact on the quality of life who do not respond to treatment with topical corticosteroids and calcineurin inhibitors.

Autoimmunity in Segmental Vitiligo

The autoimmune basis of segmental vitiligo (SV) has only recently been recognized. Systemic autoimmune diseases are less frequently associated compared to non-segmental vitiligo (NSV), but localized skin disorders - in particular linear morphea - have been repeatedly observed in patients with SV. The inflammatory response is documented on a clinical level with cases displaying erythematous borders or a hypochromic stage, on a histopathological level with predominantly CD8 lymphocytes migrating toward the basal layer and by flow cytometry demonstrating the antimelanocyte specificity of these cytotoxic T cells. The increased risk for halo naevi and NSV in these patients further underline the immune-mediated mechanisms of SV. Nonetheless, the localized and unique distribution pattern points to somatic mosaicism. This places SV in a category of similar diseases such as lichen striatus, blaschkitis, linear lupus erythematosus, and linear scleroderma where an immune reaction against genetically mutated skin cells is believed to be the underlying cause. All these disorders are characterized by a young age of onset, a temporary disease activity with spontaneous resolution, limited response to treatment, and often long-term sequelae. Although challenging, genetic research proving this genetic mosaicism could offer crucial insights into the pathogenesis of both segmental and non-segmental vitiligo.

Vitiligo: A Review

Vitiligo, a common depigmenting skin disorder, has an estimated prevalence of 0.5–2% of the population worldwide. The disease is characterized by the selective loss of melanocytes which results in typical nonscaly, chalky-white macules. In recent years, considerable progress has been made in our understanding of the pathogenesis of vitiligo which is now clearly classified as an autoimmune disease. Vitiligo is often dismissed as a cosmetic problem, although its effects can be psychologically devastating, often with a considerable burden on daily life. In 2011, an international consensus classified segmental vitiligo separately from all other forms of vitiligo, and the term vitiligo was defined to designate all forms of nonsegmental vitiligo. This review summarizes the current knowledge on vitiligo and attempts to give an overview of the future in vitiligo treatment.

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.

Hypomelanosis of Ito

Hypomelanosis of Ito, initially referred to as incontinentia pigmenti achromians, is a rare neurocutaneous disorder. Hypopigmented lesions following the lines of Blaschko are usually the presenting feature. Multiple organ systems can be involved including brain, musculoskeletal, cardiovascular, eyes, kidneys, and teeth. The neurologic complications can include seizures, hemimegalencephaly, developmental delay and abnormalities in tone. Genetic mosaicism is the most likely explanation for its inheritance. It must be distinguished from incontinentia pigmenti because at early stages, skin lesions can appear similar between the two conditions. Consensus recommendations for screening of associated extracutaneous conditions do not exist and management is symptomatic, but regular evaluation of somatic growth, neurodevelopment, endocrine status, eyes, and teeth should occur. Initial screening of renal function has also been recommended. Awareness of this disorder will allow for diagnosis, genetic counseling and appropriate screening.

Vitiligo

Vitiligo, an acquired pigmentary disorder of unknown origin, is the most frequent cause of depigmentation worldwide, with an estimated prevalence of 1%. The disorder can be psychologically devastating and stigmatising, especially in dark skinned individuals. Vitiligo is clinically characterised by the development of white macules due to the loss of functioning melanocytes in the skin or hair, or both. Two forms of the disease are well recognised: segmental and non-segmental vitiligo (the commonest form). To distinguish between these two forms is of prime importance because therapeutic options and prognosis are quite different. The importance of early treatment and understanding of the profound psychosocial effect of vitiligo will be emphasised throughout this Seminar.

Vitiligo

Vitiligo is an acquired depigmenting disorder that affects 0.5% to 2% of the world population. Three different forms are classified according to the distribution of lesions; namely non-segmental, segmental and mixed vitiligo. Vitiligo is associated with polymorphisms in genes involved in the immune response and in melanogenesis. However, environmental factors are required for the development of manifest disease. In general, the diagnosis is clinical and no laboratory tests or biopsies are required. Metabolic alterations are central to current concepts in pathophysiology. They induce an increased generation of reactive oxygen species and susceptibility to mild exogenous stimuli in the epidermis. This produces a senescent phenotype of skin cells, leads to the release of innate immune molecules, which trigger autoimmunity, and ultimately causes dysfunction and death of melanocytes. Clinical management aims to halt depigmentation, and to either repigment or depigment the skin, depending on the extent of disease. New therapeutic approaches include stimulation of melanocyte differentiation and proliferation through α-melanocyte-stimulating hormone analogues and through epidermal stem cell engineering. Several questions remain unsolved, including the connection between melanocyte depletion and stem cell exhaustion, the underlying degenerative mechanisms and the biological mediators of cell death. Overall, vitiligo is an excellent model for studying degenerative and autoimmune processes and for testing novel approaches in regenerative medicine. For an illustrated summary of this Primer, visit: http://go.nature.com/vIhFSC.

Common skin problems in children

Childhood dermatological problems contribute about one-third of all consultations in the setting of both pediatrics and dermatology outpatient services. Skin disorders in children may cause anxiety to parents. General Practitioners should be familiar with the common prevalent skin problems as immediate pediatric dermatology consultation may not be possible. Infections, infestations and dermatitis are the most prevalent diseases among Indian children. The scope of this review is to briefly highlight these common and other important dermatological problems in children.

Pediatric vitiligo

Vitiligo is a disease of pigment loss. Most investigators currently consider vitiligo to be a disorder that occurs as a result of autoimmune destruction of melanocytes, supported by identification of antimelanocyte antibodies in many patients, and the presence of comorbid autoimmune disease in patients with and family members of individuals with vitiligo. One-half of vitiligo cases are of childhood onset. This article presents a current overview of pediatric vitiligo including comorbidities of general health, psychological factors, therapeutic options, and long-term health considerations.

Concise review of recent studies in vitiligo

Vitiligo is an acquired pigmentry disorder of the skin and mucous membranes which manifests as white macules and patches due to selective loss of melanocytes. Etiological hypotheses of vitiligo include genetic, immunological, neurohormonal, cytotoxic, biochemical, oxidative stress and newer theories of melanocytorrhagy and decreased melanocytes survival. There are several types of vitiligo which are usually diagnosed clinically and by using a Wood's lamp; also vitiligo may be associated with autoimmune diseases, audiological and ophthalmological findings or it can be a part of polyendocrinopathy syndromes. Several interventions are available for the treatment for vitiligo to stop disease progression and/or to attain repigmentation or even depigmentation. In this article, we will present an overall view of current standing of vitiligo research work especially in the etiological factors most notably the genetic components, also, types and associations and various and newer treatment modalities.

Stress involvement as trigger factor in different skin conditions

Dermatological conditions are intimately related to stress. There was a great interest in this field in the last years. Stress could be involved as a trigger factor for a lot of cutaneous diseases: alopecia areata, psoriasis, vitiligo, lichen planus, acne, atopic dermatitis, urticaria. For other conditions: seborrheic dermatitis, hyperhydrosis, herpes, pemphigus, a.s.o, there are anecdotal notices. On the other hand, the skin disease itself could induce a secondary stress for the patient, influencing his quality of life. The stress per se is less important than the “perceived stress”, the patient’s perception of the stressful situation. This perception could be influenced by the psychological state of the patient. Anxiety, depression could change the perception of the event. It is important to take care of these aspects during the consultation. A good cooperation with psychiatrist or/and psychologist could improve the results, besides the specific therapy.

Dermatologic manifestations of endocrine disorders

PURPOSE OF REVIEW

The diagnosis of many childhood endocrine disorders can be facilitated by an awareness of the associated dermatologic findings. In this review, we will survey examples of endocrine disorders in children that include a prominent or diagnostic dermatologic sign/symptom.

RECENT FINDINGS

A key concept is that skin findings often accompany hormonal conditions, both those of hormone excess and hormone deficiency/resistance. Some dermatologic signs may also represent the hallmark lesion, or provide the first clinical sign in childhood, for both familial tumoral and nontumoral syndromes. Moreover, skin as an endocrine organ itself may provide new avenues both to understand disease mechanisms as well as to provide targeted therapy.

SUMMARY

Early diagnosis, often aided by recognition of a keynote dermatologic lesion, may permit prompt, timely treatment that, in some cases, may even prove life saving. Conversely, when these associated signs go undetected or misdiagnosed, therapeutic intervention may be delayed unnecessarily.

Incidence of vitiligo in children with Graves' disease and Hashimoto's thyroiditis

Background

Limited data are available on the association between vitiligo and autoimmune thyroid disease in pediatric patients. In addition, reported studies of pediatric patients have been based on a population known to have vitiligo and subsequently evaluated for the presence of thyroid function abnormalities.

Methods

A retrospective chart review was performed on 333 children who had been followed for thyroid disorders by endocrinologists at the Yale Pediatric Thyroid Center over the last 5 years for autoimmune thyroid disease. Demographical and clinical features of patients found to have thyroid disease and vitiligo were recorded. These studies were approved by the Yale Human Investigation Committee.

Results

Of the total 333 children and adolescents, 9 (2.7%) were noted to have vitiligo. Four patients (44%) had Graves' disease and 5 patients (66%) had Hashimoto's thyroiditis. For patients with Graves' disease and vitiligo, the average age of onset of thyroid disease was young at 4 ± 0.7 years, and the diagnosis of vitiligo usually preceded that of thyroid disease. For children with Hashimoto's thyroiditis and vitiligo, thyroid disease was diagnosed at an average age of 13.25 ± 2.8 years.

Conclusion

In our population, 4.6% of children with Graves' disease and 2.0% of children with Hashimoto's thyroiditis had vitiligo. Interestingly, when vitiligo presents with Graves' disease, it occurs in younger rather than older children.