2. Presented by Alaa Eldin Khalil Ibrahim M.B., B.Ch. Ain Shams
University
3. Introduction Vitiligo is an autoimmune depigmenting
disorder, it is one of the most common skin disorders with
prevalence of 1-2% of the world's population. Reduced serum level
of vitamin B12 and folic acid have been found in patients with
vitiligo (Montes et al., 1992;El- Batawi et al., 2001). And, it has
been reported that vitiligo improves after treatment with vitamin
B12 and folic acid (Juhlin and Oslen, 1997).
4. vitamin B12 and folic acid are required as cofactors by the
enzyme homocysteine methyltransferase to convert homocysteine to
methionine. So nutritional deficiency in either of these two
vitamins can results in increase in homocysteine level in
circulation. Homocysteine histidase tyrosinase oxidative stress on
melanocytes mediate its destruction Interfere with normal
melanogenesis
5. Aim of the work The aim of this work was to estimate the
serum level of homocysteine in vitiligo patients to evaluate its
role in the pathogenesis of the disease and its relation to disease
severity.
6. This study was performed on 2 age and sex matched groups.
The first group was patients with vitiligo and the second group
healthy controls. Patients: included 30 adult vitiligo patients
(group 1) who were recruited from the outpatients' clinic of Al hud
Al marsod hospital in the period between february and july
2012.
7. Exclusion criteria: 1) Patients taking any drug that could
alter serum level of Hcy as: Folic acid, vitamin B, lipid lowering
drugs, antidiabetics, anti parkinson, chemotherapy. 2)Patients with
diseases known to affect Hcy level as Homocystienuria,
Hypothyroidism and Chronic renal failure. 3)Patients who are
physically active (manual workers and athletes) as physical
activity lowers plasma Hcy level . 4)Patients with head and neck
affection as vitiligo area scoring index (VASI) doesn't include
head and neck region severity.
8. Controls: Thirty age and sex matched healthy controls (group
2) for homocysteine level determination. Methods: An informed
consent was taken before inclusion of the subjects into the study.
All subjects were subjected to the following:- 1)Full history
taking: Personal history. History of present illness : onset,
course, duration of vitiligo and current treatments. Family history
of vitiligo. Medical and drug history of medical importance.
9. 2) Dermatological examination: Clinical assessment of extent
of vitiligo in patients was done according to a quantitative and
severity parametric score named vitiligo area scoring index (VASI)
Which was introduced by Hamzavi et al., 2004. The total body VASI
is calculated using this formula: VASI = Hand Units of all body
sites Residual Depigmentation. One hand unit (the palm plus the
volar surface of all the digits) is approximately 1% of the total
body surface area. It is used as a guide to estimate the extent
percentage of vitiligo involvement.
10. The body is divided into five regions: upper extremities ,
lower extremities, trunk, hands and feet. The axillary region is
included with the upper extremities while the buttocks and inguinal
areas are included with the lower extremities. The residual
depigmentation is expressed using VASI visual chart (0%, 10%, 25%,
50%, 75%, 90%, or 100%).
11. 100% depigmentation.no pigment is present. 90%only specks
of pigment are present. 75%the depigmented area exceeds than
pigmented area. 50%...the depigmented area equals the pigmented
area. 25%...the pigmented area exceeds the depigmented area.
10%...only specks of depigmentation are present.
12. 3) Homocysteine level determination: The laboratory
assessment of Hcy used in this study was enzyme linked
immunosorbant assay (ELISA) and Hcy values are interpreted as
follows: 5 - 15 mol/L in healthy adults. 15 - 30 mol/L in mild
homocysteinemia. 30 - 100 mol/L in intermediate homocysteinemai.
>100 mol/L in severe homocysteinemia.
13. In this study, there was insignificant difference between
mean age among groups (P value = 0.968).
14. there was no difference between gender distribution among
groups (P value = 1.00).
15. There was insignificant difference between indoor/outdoor
occupation distribution among groups (P value = 0.118).
16. there was insignificant difference between family history
among groups (P value = 0.150).
17. There was insignificant difference between medical history
among groups (P value = 0.206).
18. There was insignificant difference between mean Hcy level
among groups (P value = 0.191).
19. According to course of the disease, there was insignificant
difference between Hcy level and VASI (P value = 0.595 &
0.093)
20. According to onset of the disease, there was insignificant
correlation between Hcy level and VASI (P value = 0.459 and
0.906)
21. There was insignificant correlation between Hcy level and
gender of groups.(P value = 0.622 and 0.743)
22. There was significant correlation between Hcy level and age
of patients and controls.(P value = 0.043 and 0.010)
23. There was insignificant correlation between Hcy level and
VASI according to duration of the disease (P value = 0.966 and
0.654)
24. Our study was performed on 30 adult patients with vitiligo
and 30 adult healthy age and sex matched controls to estimate serum
level of Hcy and evaluate its role in the pathogenesis of the
disease and its relation to disease severity . We excluded patients
taking drugs or have disease that can affect serum level of Hcy,
patients who are hyperactive as athletes or manual workers and
patients with head and neck vitiligo affection. In this study,
There was insignificant difference between groups regarding to age
(P value = 0.96).
25. Both patient's and control groups included 15 males and 15
females. So there was insignificant difference between groups
regarding gender (P value = 1.00). Family history of vitiligo was
found to be positive in 2 patients and negative in 28 patients and
it was negative in all control subjects, This shows insignificant
difference between family history among all groups (P value =
1.15). regarding occupation, 16 vitiligo patients were working
indoor and 14 patients were working outdoor, in controls, there
were 10 persons working indoor and 20 were working outdoor. This
shows insignificant difference among groups( P value= 0.11).
26. Regarding medical history, only 1 patient was anaemic and 2
patients were hypertensive and the medical history of controls was
irrelevant. The medical history relevance among both groups was
insignificant(P value = 0.20). Our study showed that there was
insignificant difference between groups regarding mean serum Hcy
level (P value = 0.191). Our finding was in agreement with Kim et
al., (1999); Balci et al., (2009); Gnl et al., (2010) who reported
that serum Hcy, vitamine B12 and folic acid levels do not play a
role in the etiopathogenesis of vitiligo
27. Balci et al., (2009) performed a Turkish study on 48
patients with vitiligo and 31 age and sex matched healthy controls.
they reported that there was insignificant correlation between Hcy,
folic acid and vitamine B12 and VASI with p value < 0.05. Gnl et
al., (2010) also performed a study on 42 vitiligo patients and 36
sex and age matched healty controls. They found that vitamine B12
and folic acid do not play a role in the etiopathogenesis of
vitiligo and did not vary according to the duration and activity of
vitiligo.
28. Kim et al., (1999) measured the serum levels of folic acid
and vitamin B12 in 100 Korean patients with vitiligo and found that
their was no significant difference compared to the normal control
group. Contrary to our results, Shaker and El Tahlawi, (2008);
Silverberg and Silverberg, (2011); Singh et al.,(2011 ) reported
that serum Hcy level was significantly more elevated in patients
with vitiligo than in controls.
29. The difference with our study may be due to the method of
vitiligo scoring as we used VASI which is a qualitative and
quantitative method that can record vitiligo extent and severity in
the same equation for every patient but Shaker et al., (2008)
recorded only extent of the disease by the rule of nine. Also they
excluded patients with vitiligo extent less than 30% of body
surface area.
30. According to our study, there was a significant correlation
between Hcy level and age of all subjects as Hcy level increases
with age. This explained by the deterioration of renal function and
weak renal exceretion of Hcy, this finding was in agreement with
Wilcken and Gupta, (1979); Kang et al., (1987); Hu et al.,(2004)
and Guo et al., (2006). According to this study, there was no
correlation between course of vitiligo and serum level of Hcy, this
was in agreement with Karadag et al., (2012) .
31. Also our study found no significant correlation between
duration of vitiligo and serum level of Hcy. This finding was in
agreement with Shaker and El Tahlawi, (2008). Our study recorded no
significant correlation between gender of patients or controls with
serum level of Hcy, This was in agreement with Silverberg and
Silverberg, (2011).
32. This study concludes that: serum Hcy may not be a
precipitating factor for vitiligo in the predisposed individuals.
It has been found that serum Hcy level related to age of the
patients but not for activity, duration of the disease or gender of
patients.
