Childhood vitiligo: Report of a case associated with psychiatric morbidity in the patient’s mother and an approach to differential diagnosis

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ACHAIKI IATRIKI | 2025; 44(2):102–108

Case Report

Daniel A. Ndidiamaka Onyiriuka

Endocrinology and Metabolism Unit, Department of Child Health, University of Benin Teaching Hospital, PMB 1111, Benin City, Nigeria

Received: 31 Dec 2024; Accepted: 14 Apr 2025

Corresponding author: Daniel A. Ndidiamaka Onyiriuka E-mail: alpndiony@yahoo.com

Key words: Childhood vitiligo, depigmentation, differential diagnosis, parents, psychosocial impact

 

Abstract

This report describes the case of an adolescent 13-year-old Nigerian girl, diagnosed with the non-segmental variant of vitiligo, specifically the acrofacial subtype. She exhibited some clinical features of psychological disturbance as a result of her current depigmentation skin disorder. She developed the tendency to avoid strangers due to a fear of being talked about, which could potentially lead to social isolation. Although the patient’s mother did not have vitiligo herself, she expressed anxiety regarding her daughter’s skin disorder. In this context, her major concern was how the disorder might affect her daughter’s eligibility for marriage as she approached the age of marriage, as well as whether the disease was curable. Thus, childhood vitiligo is a common skin disorder with significant cosmetic concern on the patient and psychosocial impact on both the patient and primary caregiver. Attention should be given to parents of children with vitiligo, because they may suffer quality of life impairment, requiring psychosocial support to promote better treatment outcomes. In addition, this report highlights the recommended guidelines for managing childhood vitiligo and points out some drawbacks regarding their application.

Introduction

Vitiligo is an acquired, chronic and non-contagious disease characterized by depigmentation, resulting from selective immunologic destruction of epidermal melanocytes [1], causing achromatic macules or spots. Pigment cells of the skin, hair follicles and mucous membranes are commonly involved in the destructive process. Reports of recent translational research has linked key mechanisms of the disease to cellular stress, innate immune activation, T-cell mediated elimination of melanocytes from the skin, resulting in clinically obvious white spots, as well as stem cell regeneration that reverses established lesions [2]. Vitiligo can appear at sites of trauma or sunburn (Koebner’s phenomenon). In older children and adolescents, vitiligo may occur as a component of certain hereditary syndromes such as Vogt-Koyanagi-Harada and Alezzandrini syndromes [3]. In both syndromes, vitiligo appears later and is usually persistent, despite therapy.

Worldwide, the prevalence of vitiligo ranges from 0.5% to 2.0%, with approximately 50% appearing before the age of 20 and 25% of cases starting before the age of 10 [1,4]. A hospital-based study of childhood dermatoses in Ile Ife and Ilesha, Nigeria, reported a vitiligo prevalence of 5.3% [5]. The median onset age of childhood vitiligo is 5-10 years [6]. Vitiligo affects people of all ages, genders and races and may be presented anytime from neonatal period to adolescence. In one-third of cases, there is either a positive family history of vitiligo or a halo nevi or premature graying of the hair [7]. It presents as depigmented, well-defined, milk-white macules and patches of different configurations and variable sizes with an unpredictable disease course. With regard to its evolution, vitiligo can change and exhibit three distinct behaviors: stability, progression or regression. Vitiligo is described as stable or inactive if no new lesions have developed over the last 12 months, or an existing lesion shows no sign of progression. It is considered progressive or unstable when new lesions form or develop within 12 months, or when a pre-existing lesion grows larger. Vitiligo is referred to as regressive when spontaneous re-pigmentation of an existing lesion occurs [6]. Childhood vitiligo differs in its clinical characteristics and response to treatment, when compared to adults. The differences in clinical characteristics include higher rates of instability, re-pigmentation, female preponderance and a rarer frequency of association of other autoimmune and endocrine disorders in children compared to adults [4,8]. The frequency of relapses is lower in children than adults.

Childhood vitiligo is classified into two major clinical forms: segmental (SV) and non-segmental (NSV) [4,8]. The NSV is further sub-divided into generalized, acrofacial, universal, mucosal and mixed types. In the USA, Patel et al [9] reported that out of 9,118 eligible children and adolescents with vitiligo, two-thirds had the NSV subtype based on clinician-adjudicated prevalence. Similarly, a systematic review and meta-analysis study, involving 17 studies from different countries to evaluate the clinicoepidemiological features of childhood vitiligo conducted by Faradjzadeh et al. [10], found that non-segmental variant was the most common pattern of presentation. On the other hand, two separate studies in Brazil and China found that the SV is a more frequent pattern of presentation of childhood vitiligo [11,12]. Also in Nigeria, Anaba et al [13] found that the segmental variant was more common than the non-segmental variant. These conflicting findings suggest that there may be differences in the patterns of presentation across geographic regions. This view is reinforced by Faradjzadeh et al [10], who stated that the clinicoepidemiological pattern of childhood vitiligo varies from one geographical region to another.

The diagnosis of childhood vitiligo is primarily based on clinical examination, as the lesions have a typical appearance [8]. Wood’s light examination enhances the contrast between pigmented and non-pigmented skin, particularly in light-skinned individuals. Based on severity/extent of body surface area involved, vitiligo can be categorized into four as follows: limited (< 10% involvement), moderate (10-25% involvement), moderately severe (26-50% involvement) and severe (> 50% depigmentation) [14].

Although childhood vitiligo is not typically associated with physical discomfort, it causes great cosmetic concern, not only for the affected person, but also for the primary caregivers because of the associated stigma [15,16]. This concern is more pronounced in darker-skinned individuals, as the contrast between affected and unaffected areas is more noticeable. It has been shown that the psychological effect may persist in adulthood with a negative impact on social development [17]. Vitiligo has been reported to be associated with autoimmune disorders, such as thyroid conditions, type 1 diabetes mellitus, pernicious anaemia, Addison’s disease and alopecia areata [18]. In India, Handa and Dogra [19] found that 1.3% of vitiligo cases in children were linked to an associated autoimmune disorder.

The differential diagnosis includes other causes of widespread acquired leukoderma. The three leading differential diagnoses of childhood vitiligo are: tinea versicolor, post inflammatory hypopigmentation and pityriasis alba [17,19]. The purpose of this case report is to raise awareness among physicians that a patient’s primary caregiver, such as parents, may be affected psychologically and may need screening for adverse mental health impact.

Case Report

A 13-year-old Nigerian post-menarcheal girl presented with a history of whitish skin lesions. They were first noticed five years earlier in the scalp near the forehead, accompanied by a depigmentation of the hair (poliosis). One year later, similar lesions appeared on her face. Over the next two years, the lesions spread to both hands and feet. Parents have applied some cream, but there has been no improvement. In addition, fluid extracted from certain herbs was also applied to the lesions. The lesion was not associated with itching, pain, or a burning sensation and there was no loss of superficial sensation. The patient expressed anxiety as a result of her clinical condition, and she tends to avoid strangers to prevent discussions about her appearance. Her mother’s major concern was her child’s eligibility for marriage and the possibility of a cure. In addition, her mother sometimes feels embarrassed despite the small size of the lesion. Historically, there was no identifiable precipitating factor and there is no history of seizures or intellectual disability.

Physical examination revealed macular depigmented patches on the face, hands and feet. The lesions were milk-white in color, with distinct margins. The lesion in the scalp showed poliosis (leucotrichia) (Figure 1). She had vitiligo lesions on her face, hands and feet (Figures 1 and 2). The extent of skin involvement was less than 5% of body surface area. On palpation of the lesion, there was no change in texture between unaffected skin and depigmented patches. No underlying atrophy or induration was observed, and the overlying surface was not scaly. The patient did not have halo nevi or goitre. Based on clinical presentation and physical examination, a diagnosis of non-segmental childhood vitiligo with the acrofacial subtype was made.

Figure 1. Vitiligo lesions on the forehead and face.

Discussion

The index patient presented with non-segmental vitiligo (NSV) of the acrofacial subtype. This form of vitiligo is characterized by sparse lesions that generally appear bilaterally over the face and distal extremities. As in the index patient, truncal lesions are usually not seen in the initial stages but may develop over time as acrofacial variants evolve into generalized vitiligo [20]. In line with the findings of several studies [4-7,21,22], the diagnosis of childhood vitiligo in the index patient was based entirely on clinical evaluation, as the lesions have a typical appearance. With regard to severity, the index patient had a limited form of vitiligo as less than 10% of her body surface area was involved [14]. The patient’s skin lesion was progressive, starting from the forehead, and spreading to the face, followed by the limbs (Figures 1 and 2). The progressive pattern demonstrated in the index patient aligns with non-segmental vitiligo (NSV), whereas segmental vitiligo (SV) is known to usually stabilize within six months to two years [8,23]. However, some SV may progress to generalized vitiligo over time. Considering that Mazereeuw-Hautier et al [24] reported that vitiligo-associated-autoimmune disorders in childhood occur largely in children with NSV, we determined the patient’s fasting blood glucose, thyroid function tests and full blood count. All the results were within normal limits, supporting the reported low incidence of vitiligo-associated-autoimmune disorders in childhood [6,23]. In this context, Handa and Dogra in India found a prevalence of only 1.3% [19].

Figure 2. Vitiligo lesion on the feet and hands.

 Regarding the differential diagnosis of childhood vitiligo, clinicians must recognize conditions with similar presentation to avoid misdiagnosis. The common acquired clinical conditions in the differential diagnoses of childhood vitiligo are tinea versicolor, post-inflammatory hypopigmentation and pityriasis alba [25]. Vitiligo is probably the most common disorder of skin pigmentation encountered by primary care physicians. Therefore, a simplified approach to differential diagnosis may be helpful. The common differential diagnoses of childhood vitiligo are presented in tabular form (Table 1). Other significant differential diagnoses include the ash-leaf macule of tuberous sclerosis (lesions typically present at birth or early in infancy) and morphea (the skin of the lesion is usually smooth, thickened and has shiny appearance), whereas vitiligo lesions maintain the same texture as the surrounding skin.

The index patient was an adolescent girl aged 13 years and manifested some clinical features of psychological disturbance as a result of her current skin disorder. As previously reported, in India [26], the index patient developed the tendency to avoid strangers to prevent discussions about her. This behavior often drives patients into social isolation and introversion, particularly when the condition affects the exposed parts of the body. It is known that adolescence is a critical period for developing self-identity and self-esteem [15]. Developmentally, the patient belongs to an age group where self-image is being formed, and social acceptance is of great importance. Thus, the patient’s skin disorder has negatively affected her self-confidence and social interactions, leading to diminished quality of life. Despite the fact that the patient’s mother did not have vitiligo, she expressed anxiety regarding her daughter’s skin disorder. In this context, the mother’s major concern was its potential in affecting her daughter’s eligibility for marriage, as she approaches the age of marriage. As highlighted in previous reports [16,26,27], parents of children with vitiligo are often considered hidden victims of this relatively common childhood skin disorder. The mother who represents the closest and most caring relationships to her affected daughter becomes a hidden victim. In consideration of the psychological impact of the patient’s skin disorder on the mother, it is important to recognize parental quality of life impairment and provide psychological support to promote treatment adherence and decrease the family burden of chronic skin disorder. The patient was accompanied only by her mother during clinic visits, which indicates higher maternal concern regarding the condition. This observation suggests that mothers may be more distressed than the father with regard to the child’s skin disorder. A similar observation has been alluded to in the report by Ameer et al [16] in China. The report of some previous studies suggested that because of the cosmetic concern in vitiligo, patients/parents tend to seek medical attention early [28,29]. In contrast, the mother of the index patient sought medical attention five years after the first lesion appeared, despite its progressive nature and involvement of the face in the index case, suggesting poor health-seeking behavior, is probably due to a lack of symptoms in the patient.

The natural history of vitiligo involves periods of remission and exacerbation, with complete spontaneous re-pigmentation being unusual. Partial or temporary re-pigmentation has been reported in children, particularly for lesions of less than two years’ duration and during summer. The re-pigmentation process is slow, with the face and trunk typically responding better than the dorsa of hands and feet [30]. In the case of the index patient, the duration of the lesion was five years (exceeding the two-year threshold associated with re-pigmentation), potentially making spontaneous re-pigmentation less probable.

The treatment of vitiligo in children is very challenging, as many of available modalities of therapy cannot be applied to them. The two main goals of therapy of childhood vitiligo are (i) stabilization of active disease and (ii) promotion of re-pigmentation [31]. Factors influencing the choice of treatment plan include the patient’s age, disease duration, extent and severity of the condition, presence of Koebner phenomenon and the association of other autoimmune conditions [31]. Other factors include the socio-economic status of the patient’s family and availability of treatment options. According to the 2021 guidelines of the British Association of Dermatologist, the first-line option for managing vitiligo is topical non-steroid therapy [32]. In this regard, the use of tacrolimus is considered the first-line option in the treatment of childhood vitiligo because of the delicate nature of children’s skin, which exposes them to a higher risk of skin atrophy from the use of topical corticosteroids (TCs). Additionally, the surface area-to-volume ratio in children increases the risk of the occurrence of adverse effects of steroids. Oral corticosteroids can interfere with growth in children; therefore, their use requires caution. Regarding therapy for childhood vitiligo, Raju et al [33] suggested that moderately potent topical corticosteroids (TCs) are considered as first-line therapy in children with localized vitiligo. Topical calcineurin inhibitors (TCIs) such as tacrolimus/pimecrolimus are good alternative to TCs and are recommended localized forms of vitiligo, as well as for areas with thin skin like eyelids where potential side effects of corticosteroids are high. TCIs cannot be used in children less than two years old because of the risk of skin cancer and lymphoma. In addition, TCIs are expensive and are not readily available in the environment where we practice. A synthetic vitamin D3 analogue (calcipotriol) though less effective than topical corticosteroids can stimulate melanogenesis and inhibit the destruction of melanocytes by T-cells. The combination of phototherapy (NB-UVB), psoralen and UAV (PUAV) is considered a second-line treatment option. Phototherapy acts as an immunosuppressant and stimulates melanocyte activity [34]. The third-line treatment option is surgical therapy. Though not commonly used in children, suction blister epidermal grafting is preferred. Surgical procedures are not performed in very young children because segmental or stable focal lesions in younger children extend proportionate to their body growth. In addition, success of many surgical procedures depends on post-operative immobility of the operated part which is more difficult to achieve in young children [31]. Other potential treatment modalities of childhood vitiligo are displayed in Table 2.

Other modalities of treatment include (i) cosmetic camouflage (ii) Total depigmentation, using 20% Monobenzyl ether of hydroquinone (MBEH) [31].

In summary, a practical conclusion from this report is that increasing the use of psychiatric screening questionnaires might enhance recognition of psychiatric morbidity and the adverse mental health impact on mothers of children with vitiligo, ultimately leading to early intervention.

Conflict of interest disclosure

None to declare.

Declaration of funding sources

None to declare.

Author Contributions

DNO confirms sole responsibility for all aspects of the manuscript, including conceptualization, methodology, data collection, analysis, writing, and final approval of the submitted version.

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