Author
Information
Harjitkaur Ankur *, Gupta AS
(*
Fourth Year Resident, ** Professor. Department of Obstetrics and Gynecology, Seth G. S. Medical College & K.E.M. Hospital ,
Mumbai , India
Abstract
Vitiligo is characterized by patchy depigmentation of the
skin due to selective destruction of melanocytes. The exact etiology is
debatable. The most likely cause is an autoimmune disorder. Women are predisposed to autoimmune disorders
and these may be associated with adverse pregnancy outcomes, like recurrent
pregnancy wastage, intrauterine growth restriction (IUGR), and pre-eclampsia.[1]
The outcome of vitiligo in a gravid woman is undescribed in literature. We herein report a rare case of a third gravida
woman who developed hypopigmented patches during pregnancy.
Introduction
Vitiligo is an acquired pigmentary disorder of unknown
etiology. Distinctive clinical feature is the development of white macules on
the skin. It is related to the selective loss of melanocytes. Incidence ranges
from less than 0.1% to greater than 8% worldwide. It is around 1% in the United States and in Europe
and 0.46% in India.[2,3,4,5]. The exact etiology of Vitiligo is unknown, but is
believed to be have an autoimmune component.[6] As with all autoimmune diseases,
course of the disease is unpredictable during pregnancy and it has been
associated with bad obstetrical outcome and recurrent abortions. Because of the
rarity of this disease and its association with pregnancy, there have been no
controlled trials on the management of vitiligo in pregnancy. Herein we report
a case of third gravida woman with previous two abortions, who developed
hypopigmented patches on face, neck and forearm.
Case Report
A 24 year old third gravida with previous 2 abortions at 20 weeks
of gestation came to outpatient department of our tertiary institute with
complaints of hypopigmented patches on face, neck and forearm for 1 week. It
started increasing gradually and was not associated with any itching. On
examination, vital parameters were stable. Systemic examination was normal. On
abdominal examination uterus was 20 weeks in size, external ballottement was
present. Irregular hypopigmented patches (5x7 cm) on neck and (2x2 cm) on
forearm were seen as seen in Figure 1 and 2 respectively.
Figure 1:
Antenatal clinical photograph showing hypopigmented patch over neck.
Figure 2:
Antenatal clinical photograph showing lesion on forearm.
The patient was thoroughly evaluated. Her thyroid profile
showed increased thyroid stimulating hormone (TSH 8.66) for which Thyroxine
supplement 50 microgram on Monday to Friday and 100 microgram on weekend was
started. She had no anti cardiolipin, lupus anticoagulant, and anti microsomal
antibodies. Dermatological reference was done. She was diagnosed as a case of
vitiligo. She was given desonite cream 0.05% for application once a day for one
week. Her hypopigmented patches remained static on the forearm and neck
throughout the remaining pregnancy. She delivered a normal healthy baby of 3.2 kg
at term. In the post partum period as seen in Figure 3 and 4 the patient had a
subjective feeling that patches and their whiteness had decreased both on her
forearm and on her neck.
Figure 3:
Post partum clinical photograph showing lesion on neck.
Figure 4:
Post partum clinical photograph showing lesion on forearm.
Discussion
Vitiligo is an ancient disease and has a
global prevalence.Multiple references in literature have described this
condition and different aspects of its causes and therapy. The cause of vitiligo
is unknown. The autoimmune hypothesis is the best supported causative
hypothesis.[5] There is
evidence that emotional stress can precipitate this disease. It is difficult to
precisely identify the triggering factors for vitiligo. Emotional stress,
pregnancy, drug intake, trauma/injury are some of the triggers leading to
destruction of the melanocytes.
In pregnancy vitiligo poses a threefold
problem; first is by virtue of its autoimmune pathogenesis it is associated
with bad obstetrical outcome and recurrent abortions. Second is the
depigmentation itself and third is the emotional trauma that the patients
suffer from. Besides the clinician is in a dilemma as the outcome of vitiligo
in pregnancy is unpredictable and not well studied.
Our patient had a good pregnancy outcome and
vitiligo did not cause any adverse effects on the mother or the fetus. Most authors also have reported that vitiligo
is not associated with adverse pregnancy and birth outcome. [1,6]
They also observed no change during or immediately following pregnancy, but
extension of the vitiligo immediately after delivery was noted by 31 per cent.[1,6]
In our patient objective improvement post delivery was negligible but the
patient was very positive that some spots had disappeared and a few of them
were less white. An increase in vitiligo during pregnancy was claimed by 7 per
cent and a decrease by 3 per cent.[1,6] The aim of this article is to highlight this
rare association that has an unpredictable course, nevertheless the outcome can
be good in some cases.
References
1.
Horev A, Weintraub
AY, Sergienko R, et al. Pregnancy outcome in women with vitiligo.Int J Dermatol.
2011 Sep;50(9):1083-5
2.
Taieb A, Picardo M. The definition and
assessment of vitiligo: a consensus report of the Vitiligo European Task Force.
Pigment Cell Res 2007;20:27-35
3.
Lu T, Gao T, Wang A
et al. Vitiligo prevalence study in Shaanxi Province, China. Int J Dermatol
2007; 46:47-51.
4.
Howitz J, Brodthagen
H, Schwartz M et al. Prevalence of vitiligo. Epidemiological survey on the Isle
of Bornholm, Denmark. Arch Dermatol 1977; 113:47-52.
5.
Alikhan A, Felsten LM, Daly M et al. Vitiligo:
A comprehensive overview Part I.
Introduction, epidemiology, quality of life, diagnosis, differential diagnosis,
associations, histopathology, etiology, and work-up. J Am Acad Dermatol. 2011
Sep; 65(3):473-91.
6.
Gerson D et al. A study of the prognosis of
vitiligo during pregnancy. Surg Cosmet Dermatol 2013; 5(1):379.
Citation
Ankur H, Gupta AS. Vitiligo In Pregnancy. JPGO Volume 1 Issue 4, April 2014, available at: http://www.jpgo.org/2014/04/vitiligo-in-pregnancy.html