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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 3  |  Page : 1026-1030

Correlation between serum vitamin D levels and severity of vitiligo


1 Department of Dermatology, Andrology and STDs, Faculty of Medicine, Menoufia University, Al Minufya, Egypt
2 Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Menoufia University, Al Minufya, Egypt
3 Department of Dermatology, Ministry of Health, Menoufia, Egypt, Egyp

Date of Submission29-Jan-2019
Date of Decision04-Mar-2019
Date of Acceptance05-Mar-2019
Date of Web Publication30-Sep-2020

Correspondence Address:
Mai M Gamal
Nasr City, Cairo 32717
Egyp
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_29_19

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  Abstract 


Objective
To correlate between serum vitamin D levels and severity of vitiligo.
Background
Vitiligo is an acquired depigmentary disorder that affects more than 0.5–1% of the worldwide population. Vitamin D has been implicated in the pathogenesis of various autoimmune diseases. The correlation between vitiligo and vitamin D is discussed in this study.
Patients and methods
This case–control study was conducted on 60 patients with vitiligo and 60 age-matched and sex-matched healthy individuals. All patients were recruited from the Outpatient Clinic of Dermatology and Andrology Department of Shebeen El-Kom University Hospital between 1 May 2018 and 31 August 2018. Blood samples were taken, and serum levels of vitamin D were measured by enzyme-linked immunosorbent assay technique. Serum levels of vitamin D were statistically analyzed in relation to Vitiligo Area Severity Index (VASI) score using Spearman coefficient test.
Results
The patients had higher serum vitamin D levels than the controls with highly significant difference (P < 0.001). There was no significant correlation between vitamin D and VASI score in patients (P = 0.966).
Conclusion
There was no significant correlation between vitamin D levels and VASI score. Future larger controlled studies are required to obtain a wider assessment of the relationship between vitamin D level and vitiligo disease severity.

Keywords: correlation, severity, vitamin D, vitiligo


How to cite this article:
El-Farargy SM, Ghanayem NM, Yasien HA, Gamal MM. Correlation between serum vitamin D levels and severity of vitiligo. Menoufia Med J 2020;33:1026-30

How to cite this URL:
El-Farargy SM, Ghanayem NM, Yasien HA, Gamal MM. Correlation between serum vitamin D levels and severity of vitiligo. Menoufia Med J [serial online] 2020 [cited 2020 Oct 29];33:1026-30. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/1026/296656




  Introduction Top


Vitiligo is an acquired depigmentary disorder characterized by the loss of functioning epidermal melanocytes and affects more than 0.5–1% of the worldwide population, with devastating psychological and social consequences [1]. The exact pathologic mechanism has not been clarified yet; however, the autoimmune hypothesis is the most widely accepted explanation [2]. Vitamin D is a steroid hormone, and besides its known metabolic function, it was shown to have noncalciotropic immunomodulatory role through its varied effects on T and B lymphocytes, macrophages, and dendritic cells, which express nuclear vitamin D receptors [3]. Vitamin D protects the epidermal melanin unit and restores melanocyte integrity via several mechanisms including controlling the activation, proliferation, and migration of melanocytes and pigmentation pathways by modulating T cell activation, which is apparently correlated with melanocyte disappearance in vitiligo [4]. Vitamin D deficiency is defined as a 25-hydroxyl vitamin D level below 20 ng/ml, very low levels as 15 ng/ml, insufficiency as 21–29 ng/ml, and sufficiency as a 25(OH)D level of 30–100 ng/ml [5]. It has been reported that vitamin D level in patients with vitiligo and another immune disorder is low, and patients with autoimmune diseases have a low level of vitamin D [6]. Different scoring systems have been reported to evaluate and measure the severity of vitiligo such as vitiligo disease activity score [7], Potential Repigmentation Index [8], Vitiligo European Task Force, and Vitiligo Area Severity Index (VASI) score [9]. The degree of depigmentation was measured by VASI determined by the product of the area of vitiligo in hand units (set as 1%/U) and the extent of depigmentation within each hand unit-measured patch [10].

The aim of this study was to find out a correlation between serum levels of vitamin D and the severity of the disease in patients with vitiligo.


  Patients and Methods Top


The study was approved by Ethical Committee of Medical research Faculty of Medicine, Menoufia University, and written prepared consent with justification about the reason, methods, results, and complications was obtained from each participant. This case–control study was conducted at Dermatology, Venerology and Andrology and Medical Biochemistry Departments of Faculty of Medicine, Menoufia University, between 1 May 2018 and 31 August 2018. Sixty patients with vitiligo and 60 age-matched and sex-matched healthy controls were included in this study. Their age ranged from 10 to 40 years. Exclusion criteria were as follows: patients taking oral or topical vitamin D, patients with systemic disease, patients with chronic inflammatory disease, patients with segmental vitiligo, pregnancy women, and lactating mothers. Full history taking was done, including personal history; detailed history of vitiligo regarding onset, course, and duration; and family history. Complete general examination was done. Detailed dermatological examination was done for assessment of distribution of vitiliginous lesions, activity of vitiligo, previous treatment, and assessment of vitiligo severity using VASI score. In VASI score, the body is divided into five separate and mutually exclusive regions, which are the hands, upper extremities (excluding hands), trunk, lower extremities (excluding the feet), and feet. The axillary and inguinal regions are included with the upper and lower extremities, respectively, whereas the buttocks are included with the lower extremities. The face and neck areas are not included in the overall evaluation. One hand unit, which encompasses the palm plus the volar surface of all the digits, is ~1% of the total body surface area and is used as a guide to estimate the baseline percentage of vitiligo involvement of each body region. Depigmentation within each area was estimated to the nearest of one of the following percentages: 0, 10, 25, 50, 75, 90, or 100%. For each body region, the VASI is determined (by direct clinical examination) by the product of the area of vitiligo in hand units (which were set at 1%/U) and the extent of depigmentation within each hand unit-measured patch (possible values of 0, 10, 25, 50, 75, 90, or 100%).

The total body VASI is then calculated using a formula by considering the contributions of all body regions (possible range: 0–100): VASI=Σ (all body sites) (hand units)×(depigmentation). Overall, three milliliters of venous blood was collected by venipuncture from every subject under complete aseptic condition, allowed to clot, and then centrifuged. The serum obtained was stored at − 20°C until the time of analysis. 25(OH) D levels were measured by enzyme-linked immunosorbent assay using Calbiotech kit from a Life Science Company (New Brunswick, NJ, USA) [5].

Sample size calculation

The sample size was relied upon 95% confidence interval with 80% power, using unpaired t-test and assuming a (two-sided) α of 0.05. Based on a previous study, the mean of vitamin D level among patient group was 15.3 ng/ml, whereas that of control group was 10.71 ng/ml and SD was 8.98, with case–control ratio of 1: 1. The number of participants was 60 for each group.

Statistical analysis

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (IBM Corp., Armonk, New York, USA) Qualitative data were described using number and percent. The Kolmogorov–Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, SD and median. Significance of the obtained results was judged at the 5% level. The tests that were used were as follows: χ2-test was used for categorical variables, to compare between different groups; Student's t-test was used for normally distributed quantitative variables, to compare between two studied groups; Mann–Whitney test was used for abnormally distributed quantitative variables, to compare between two studied groups; and Spearman coefficient was used to correlate between two distributed abnormally quantitative variables.


  Results Top


This case–control study was carried out on 120 patients who were divided into two main groups. The first group A included 60 patients with vitiligo. Their age ranged from 10 to 40 years, with 20.25 ± 10.78 years as a mean ± SD value. There were 15 (25%) males and 45 (75%) females, with a male to female ratio of 1: 3. The second group B included 60 age-matched and sex-matched healthy patients as a control group. Their age ranged from 10 to 40 years, with 23.30 ± 9.35 as a mean ± SD value. There were 18 (30%) males and 42 (70%) females, with a male to female ratio of 1: 2.3. There was no significant difference between cases and controls regarding age and sex (P = 0.540 and 0.101, respectively; [Table 1]). The study showed that the mean ± SD of 25(OH)D level in group A (patients) was 61.18 ± 31.82 ng/ml, and the mean ± SD of 25(OH)D level in group B (controls) was 25.32 ± 6.28 ng/ml. There was a significant increase in the level of vitamin D in patients compared with controls [Table 2] and [Figure 1]. Additionally, the mean level of 25(OH) D in female patients was 59.62 ± 30.91 ng/ml, which was lower than that in male patients, which was 65.87 ± 35.09 ng/ml, with a nonsignificant difference. Regarding the results, there was a nonsignificant negative correlation between vitamin D level and each of age and duration of vitiligo, whereas a nonsignificant positive correlation existed with VASI score [Table 3] and [Figure 2]. From other point of view, the mean level of 25(OH) D in patients who received narrowband ultraviolet B (NBUVB) was 62.66 ± 26.82 ng/ml, whereas it was 59.12 ± 38.24 ng/ml in patients who did not receive NBUVB, with no statistically significant difference (P = 0.341). Furthermore, the mean VASI score in patients who received NBUVB was 5.67 ± 5.49, whereas it was 3.14 ± 2.37 in patients who did not received NBUVB, so there is a significant statistical difference (P = 0.013; [Table 4]).
Table 1: Comparison between the two studied groups according to demographic data

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Table 2: Comparison between the two studied groups according to vitamin D level

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Figure 1: Comparison between the two studied groups according to vitamin D.

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Table 3: Correlation coefficient between vitamin D and each of age, duration of vitiligo, and Vitiligo Area Severity Index score among cases (group A) (n=60)

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Figure 2: Correlation between vitamin D (ng/ml) and Vitiligo Area Severity Index score (n = 60).

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Table 4: Effect of narrowband ultraviolet B on the level of serum vitamin D (ng/ml) and Vitiligo Area Severity Index score in group A (n=60)

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  Discussion Top


Vitamin D is an essential hormone that is synthesized in the skin via a photochemical reaction, following the exposure of the skin to UVB wavelength present in sunlight. It has been used to treat psoriasis, vitiligo, and other skin diseases for many years [11]. Vitamin D has a multitude of biologic effects that are noncalcemic in nature, mainly interacting with the adaptive and innate immune response via regulating the differentiation of B cells, T cells, and dendritic cells and expression of toll-like receptors, mainly leading to downregulation of the immune response. Furthermore, a proposed mechanism involving vitamin D in the protection of skin is based on its antioxidant properties and regulatory function toward the reactive oxygen species that are produced in excess in vitiligo epidermis [12]. Vitiligo is a common pigmentary disorder characterized by well-demarcated depigmented patches or macules of different shapes and sizes and is caused by the destruction of functional melanocytes in the epidermis [13].

The pathogenesis of vitiligo is complex, and the exact pathogenesis is not well known. It is a multifactorial disease involving the interplay of several factors [14]. Prevalent hypotheses include the autoimmune, genetic, neural, self-destruction, growth factor deficiency, viral, and convergence theories, which have served as the basis for treatment formulations [15]. This study aimed to find out a correlation between serum levels of vitamin D in patients with vitiligo and the severity of the disease. This study results showed that there was no statistical difference between the two groups regarding age and sex (P = 0.101 and 0.540, respectively). This was similar to the results of Karagün et al.[16], in which 50 patients with vitiligo and 47 controls were enrolled in total, comprising 28 (56%) males and 22 (44%) females in the case group and 30 (63%) males and 17 (37%) females in the control group. The mean ages of the patient and control groups were 30.96 ± 10.57 and 31.45 ± 8.33 years, respectively. There was no significant difference between the patient and controls in terms of age (P = 0.53) or sex (P = 0.43I). The duration of the disease ranged from 1 to 360 months, and the mean duration was 46.92 ± 56.75 months.

Moreover, the study results of Ramalingam and Tang [17] revealed that duration of the disease ranged from 2 to 360 months.

In group A, this study showed that seven (11.7%) patients had family history of vitiligo. This was in agreement with Singla et al.[18], who in their case–control study on 150 patients found that of 75 patients diagnosed with vitiligo, 12 (16%) had family history of vitiligo. Others mentioned that most cases of vitiligo are sporadic, but ∼10–36% of the patients have positive family history [19]. This study results revealed that the mean level of 25(OH) D in patients (group A) was 61.18 ± 31.82 ng/ml and in control group (group B) was 25.32 ± 6.28 ng/ml, with highly statistically significant difference between both groups (P < 0.001). In group A, 50 (83.3%) patients had sufficient level of 25(OH)D, nine (15%) patients had insufficient, and only one patient had deficiency of vitamin D, whereas in group B, 22 (36.7%) subjects had sufficient level of 25(OH)D, 38 (63.3%) insufficient, and no one had deficiency of vitamin D, with highly statistically significant difference between both groups (P = 0.001).

In this regard, the average vitamin D level in the patient group was higher than that of the control group. This may be explained by the fact that 35 (58.3%) of our patients were treated with NBUVB therapy. This is consistent with Omidian and Asadian [20], who also found that patients with vitiligo under NBUVB therapy showed an increase in serum vitamin D level, where the average primary vitamin D in the patient group was 15.30 ± 14.65 and 10.71 ± 6.51 ng/ml in the control group, and the relationship was significant (P = 0.01). Sehrawat et al. [21] in India also supported our finding as their patients who underwent NBUVB therapy showed an increase in serum vitamin D level. Khurrum and Al-Ghamdi [22] study results revealed that patients had higher circulating vitamin D levels than controls, but this difference was not significant (P = 0.25).

Another study by Ustun et al. [23] revealed that the mean levels of vitamin D in patient and the control group were 15.2 ± 5.2 and 14.4 ± 6.2 ng/ml, respectively (P > 0.05), with no statistically significant difference. This study results showed that there was no statistically significant difference regarding mean vitamin D levels between males and females in group A (P = 0.556). Of 45 female patients, seven (15.6%) had insufficient vitamin D, and of 15 males, two (13.3%) had insufficient vitamin D. This was against the study results of Singla et al.[18], who found that of 33 female patients in vitiligo cases, 32 (97%) had insufficient vitamin D3 levels and of 42 male patients in vitiligo cases, 30 (71.4%) had insufficient vitamin D3 levels. Statistically, the data were significant (P = 0.004). In group A, this study showed that there was no statistically significant correlation between vitamin D levels and VASI score (P = 0.548). Omidian and Asadian [20] supported our findings, as they found no correlation between level of serum vitamin D and the VASI score. This study showed that there was no statistically significant correlation between vitamin D levels and age of patients and duration of the disease (P = 0.290 and 0.827, respectively). Similarly, the study by Singla et al. [18] revealed that there were no significant correlations between vitamin D levels and age, VASI score, and duration of the disease (P = 0.567, 0.738, and 0.081, respectively).


  Conclusion Top


This study concludes that vitamin D could be a promising biomarker in patients with vitiligo. Further study is required to find out the relationship between vitamin D and vitiligo and to ascertain whether serum vitamin D level affects the severity of disease in patients with vitiligo.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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