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Original Paper

Dermatology DOI: 10.1159/000357807

Circulating Autoantibodies and Autoimmune Comorbidities in Vitiligo Patients: A Multicenter Italian Study

Vito Ingordo a, l Simone Cazzaniga c Beatrice Raone d

Maria Donata Digiuseppe b, l Maria Letizia Musumeci e, l Dario Fai f, l

Michele Pellegrino g, l Enrico Pezzarossa h, l Vito Di Lernia i, l

Vincenzo Claudio Battarra j, l Riccardo Sirna k, l Annalisa Patrizi d, l Luigi Naldi c, l

a Outpatient Department of Dermatology, District No. 6, Health Local Unit, and b Department of Dermatology, ‘SS. Annunziata’ Hospital, Taranto ; c Centro Studi GISED, Fondazione per la Ricerca Ospedale Maggiore, Bergamo ; d Dermatology – Department of Experimental, Diagnostic and Specialized Medicine, University of Bologna, Bologna ; e Department of Dermatology, P.O. ‘G. Rodolico’, A.O.U. Policlinico – Vittorio Emanuele, University of Catania, Catania ; f Outpatient Department of Dermatology, ‘Romasi’ Hospital, Gagliano del Capo ; g Department of Dermatology, University of Siena, Siena ; h Department of Dermatology, Istituti Ospitalieri di Cremona, Cremona ; i Dermatology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia ; j Department of Dermatology, ‘S. Sebastiano e S. Anna’ Hospital, Caserta ; k Department of Dermatology, Health Local Unit Hospital, Grosseto ; l Dermatoepidemiology and Evidence Based Dermatology Study Group of ADOI, Italy

in 61 (41.8%) of 146 subjects who underwent laborato-ry tests. Anti-thyroperoxidase (25.6%), anti-thyroglobulin (23.4%), antinuclear antibodies (16.8%) and anti-gastric pa-rietal cell antibodies (7.8%) were the most noticed autoanti-bodies. 74 (41.5%) autoimmune comorbidities, mainly auto-immune thyroiditis (37%), were reported. Conclusion: The prevalence of autoimmune comorbidities and circulating autoantibodies in this study was in agreement with other surveys conducted on Caucasian patients.

© 2014 S. Karger AG, Basel

Introduction

It has been stated that patients with vitiligo have an increased risk of developing autoimmune diseases: a his-tory and/or clinical findings of thyroid diseases, diabetes mellitus, pernicious anemia, Addison’s disease and auto-

Key Words

Circulating autoantibodies · Autoimmune comorbidities · Vitiligo · Multicenter Italian study

Abstract

Background: Autoimmune comorbidities and circulating autoantibodies have been observed in vitiligo patients, but differences in rate are present according to countries in which the studies were performed, perhaps owing to ethnic diversities or different trigger factors. Objective: To estimate the prevalence of circulating autoantibodies and overt auto-immune diseases in a fairly large sample of Italian vitiligo patients. Methods: 175 outpatients affected by vitiligo and referred to nine dermatological centers were included in the study. Patients were offered routine blood test, serological testing for thyroid function and search for autoantibodies. Results: At least one circulating autoantibody was detected

Received: August 26, 2013 Accepted after revision: December 5, 2013 Published online: March 5, 2014

Vito Ingordo, MD Outpatient Department of Dermatology District No. 6, Taranto Health Local Unit Via B. Calati, IT–74026 Pulsano, Taranto (Italy) E-Mail vito.ingordo   @   alice.it

© 2014 S. Karger AG, Basel1018–8665/14/0000–0000$39.50/0

www.karger.com/drm

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immune chronic gastritis have been reported in these pa-tients [1–3] . The aim of this multicenter observational study, carried out in range of the Dermatoepidemiology and Evidence Based Dermatology Study Group of the Italian Association of Hospital Dermatologists (ADOI), was to estimate the prevalence of autoantibodies as well as of signs and symptoms of autoimmune diseases in a fairly large sample of Italian vitiligo patients.

Patients and Methods

175 outpatients affected by vitiligo and referred for the disease to nine dermatological centers (Cremona, Bologna, Reggio Emilia, Siena, Grosseto, Caserta, Taranto, Gagliano del Capo and Catania) from January 1, 2010 to January 31, 2013 were included in the study. The diagnosis of vitiligo was stated on the ground of medi-cal history and clinical examination (i.e. achromic areas of the skin with sharp outline). In doubtful cases, examination by Wood’s lamp was performed. The collected data included physical exami-nation, clinical course and all previous therapies for vitiligo, fam-ily history and presence of other comorbidities. These data were inserted in a common card, resulting from a consensus of the cen-ters on the different parameters to be used. Patients were offered routine blood testing, serological testing for thyroid function and search for autoantibodies. The diagnosis of comorbidities was stat-ed in each center according to medical history, general clinical ex-amination and results of blood test. Because of variations among centers in terms of laboratory facilities, not all patients underwent the complete panel of analyses. 154 patients underwent blood test-ing for free triiodothyronine, free thyroxine and thyroid-stimulat-ing hormone. Thyroid ultrasonography was performed in 64 pa-tients. In 146 subjects a search for antinuclear antibodies (ANAs), anti-smooth muscle antibodies, anti-gastric parietal cell antibod-ies (APCAs), anti-mitochondrial antibodies, anti-thyroglobulin (anti-TG) antibodies, anti-thyroperoxidase (anti-TPO) antibod-ies, anti-endomysium antibodies, anti-tissue transglutaminase (anti-TTG) antibodies and anti-gliadin antibodies was performed. Normal values of these analyses were established according to the methodology of each laboratory. The overall prevalence of positive test results and all variations according to selected disease-related variables were assessed.

Statistical Analysis Continuous variables are presented as means with standard de-

viations and ranges and categorical variables as numbers with per-centages. Univariate analysis with Pearson’s χ 2 test or, where re-quired, Fisher’s exact test was used to assess differences in the prev-alence of autoantibodies according to different categories of selected variables. The Cochran-Armitage test was used to detect a linear trend among increasing levels of ordinal variables when-ever a significant difference was found. For analysis purposes, con-tinuous variables were categorized using their tertiles as cutoff points and rounded to multiples of 5, unless otherwise specified.

All variables with a p value <0.15 in the univariate analysis were included in the multivariate analysis to assess independent factors for the presence of autoantibodies. Multiple logistic regression with forward stepwise selection algorithm was used to identify the

main factors. The influence of selected factors was expressed in terms of odds ratios along with 95% confidence intervals and p values. Statistical differences were considered significant at a p val-ue <0.05. All analyses were carried out using commercial software (SPSS, version 17.0; SPSS, Inc.).

Results

Data of the Sample Concerning Vitiligo The mean age (± standard deviation) of the 175 sub-

jects was 39.5 ± 15.2 years (range 4–84 years); 52 (29.7%) were males and 123 (70.3%) were females. The mean age at vitiligo onset was 28.4 ± 15.6 years (range 3–84 years) and the mean disease duration was 11.3 ± 11.3 years (range 1 month to 57 years). The age at onset was ≤ 13 years in 32 (18.3%) subjects. The main body areas first involved by vitiligo were the face in 46.3% of cases, the hands in 40.6%, the upper limbs in 19.4% and the lower limbs in 12.6%. Disease onset in multiple body sites was reported in 44 (25.1%) patients.

At clinical examination, the mean involved body sur-face area (BSA) was 15.4 ± 16.5% (range 0.2–68.5%). Mul-tiple sites were involved in 147 (84%) cases. The mainly affected areas were the face (84%), the hands (71.4%), the upper limbs (61.1%), the feet (45.1%) and the lower limbs (41.7%). The clinical subtypes of vitiligo were vitiligo vul-garis in 113 (64.6%), focal vitiligo in 24 (13.7%), acrofacial vitiligo in 20 (11.4%), universal vitiligo ( ≥ 50% of BSA in-volved) in 12 (6.9%) and segmental vitiligo in 6 (3.5%) cases.

A positive family history for vitiligo was reported by 55 (31.4%) patients. Family members with vitiligo were uncles/aunts in 47.3% of cases, the mother in 23.6%, the father in 14.5%, cousins in 14.5%, grandfathers/grand-mothers in 10.9% and brothers/sisters in 9.1%. In 14.5% of cases several members of the same family were affected.

The reported clinical activity of the disease in the last year was progressive in 92 (52.6%) patients, stable in 55 (31.5%), regressive after therapy in 27 (15.4%) and spon-taneously regressive in 1 patient (0.6%).

Previous antioxidant supplementation was taken by 131 patients (74.9%), in 82 cases (46.9%) topical inhibitors of calcineurin were applied, and 81 cases (46.3%) were treated with topical corticosteroids. A total of 73 (41.7%) patients underwent narrow-band UVB therapy and 32 (18.3%) broad-band UVB therapy; in 15 cases (8.6%) PUVA therapy was reported. Only 25 patients (14.3%) had never received any treatment for vitiligo, whereas in 120 cases (68.6%) multiple therapies were reported.

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Laboratory and Comorbidity Data Circulating Autoantibodies. At least one circulating

autoantibody was detected in 61 (41.8%) of 146 subjects who had undergone laboratory tests. In 12 subjects (8.2%) two or more autoantibodies directed against dif-ferent organs/tissues were simultaneously present. The rates of single autoantibodies detected are reported in table 1 .

Autoimmune Comorbidities. Out of 154 patients who underwent blood tests, 64 (41.5%) autoimmune comor-bidities were reported according to medical history, clin-ical findings and laboratory/instrumental results. The various associated diseases of our cases are reported in table 2 , together with the functional changes detected in autoimmune thyropathies, which were the most fre-quently associated diseases.

Other Comorbidities. During examination other thy-roid diseases were noticed: in 8 cases (5.2%) thyroid nod-ules and in 6 cases (3.9%) thyroid nodules with coexist-ing autoimmune thyroiditis. Five patients (3.2%) had previously undergone thyroidectomy. In 38 out of 175 patients (21.7%) other non-autoimmune comorbidities were also pointed out. The main coexisting diseases were bronchial asthma in 3 (1.7%) cases, type II diabetes mel-litus in 2 (1.1%), hypertension in 9 (5.1%), cardiopathies in 2 (1.1%), constitutional dysgammaglobulinemia in 2 (1.1%), previous melanoma in 2 (1.1%), psoriasis in 7 (4%) and hepatopathies in 4 (2.3%).

Statistical Analysis to Assess the Relation between the Presence of Autoantibodies and Demographic/Clinical Variables of Vitiligo. (a) Any autoantibody: Univariate analysis was performed to assess the relation between the presence of any autoantibody and the following vari-ables: age, age at vitiligo onset, disease duration, gender,

clinical trend (regressive/stable/progressive), clinical subtype, categorized as focal, vulgaris or acrofacial and universal (the segmental form was not considered be-cause of the low number of collected cases), family his-tory and BSA involved (data not shown). The presence of any autoantibody was significantly associated with disease duration, patients’ gender and clinical subtype of vitiligo. A significant linear trend across the different periods of disease duration and across the different clin-ical subtypes was also detected ( table  3 ). All variables with a p value <0.15 in the univariate analysis were in-cluded in the multivariate analysis to assess independent factors for the presence of autoantibodies. A disease du-ration >10 years compared to ≤ 5 years as well as female gender were the only independent factors associated with the presence of at least one circulating autoanti-body ( table 3 ). A similar analysis was also performed to detect the presence of specific autoantibodies, namely ANAs, anti-TPO and anti-TG antibodies (data not shown). The statistical analysis was not performed for other autoantibodies, owing to their low detection rate

Table 1. Rates of autoantibodies detected

Type of autoantibody Number detected

Subjects investigated

%

ANA 20 119 16.8Anti-mitochondrial antibody 3 95 3.2Anti-smooth muscle antibody 5 91 5.5Anti-TPO antibody 30 117 25.6Anti-TG antibody 29 124 23.4APCA 8 103 7.8Anti-endomysium antibody 1 55 1.8Anti-TTG antibody 0 73 0Anti-gliadin antibody 2 72 2.8

Table 2. Autoimmune diseases noticed on the basis of history, clin-ical findings and laboratory/instrumental results, together with functional changes detected in autoimmune thyropathies

Diseases Number detected

Subjects investigated

%

Autoimmune thyropathy 57 154 37.0SLE in clinical remission 1 154 0.6Alopecia universalis 1 154 0.6Type I diabetes mellitus 1 154 0.6Ankylosing spondylitis 1 154 0.6Autoimmune polyglandular syndromea 1 154 0.6Chronic autoimmune gastritis 2 154 1.3

Functional changes in autoimmune thyropathies (57 cases)Instrumental autoimmune thyroiditis

with euthyroidism 15 57 26.3

Overt hyperthyroidism 2 57 3.5Overt hypothyroidism 3 57 5.3Overt hyperthyroidism under therapy 3 57 5.3Overt hypothyroidism under therapy 27 57 47.4Subclinical hypothyroidismb 3 57 5.3Subclinical hyperthyroidismb 2 57 3.5Other 2 57 3.5

SLE = Systemic lupus erythematosus. a Thyropathy with hypo-thyroidism, chronic autoimmune gastritis and vitamin B12 defi-ciency. b Low/raised thyroid-stimulating hormone and normal free triiodothyronine and free thyroxine value.

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in the subjects’ sera. (b) ANAs: The presence of ANAs was not significantly associated with any variable con-sidered in the analysis. (c) Anti-TPO antibodies: In the univariate analysis, the presence of anti-TPO antibodies was significantly associated with disease duration and with a positive family history. A significant linear trend across the different periods of disease duration was de-tected ( table 3 ). Variables considered in the multivariate analysis included disease duration, clinical subtypes, gender, family history of vitiligo and BSA involved. Only family history of vitiligo showed an independent signif-icant association with the presence of anti-TPO anti-bodies ( table 3 ). (d) Anti-TG antibodies: The presence of anti-TG antibodies by univariate and multivariate analysis was significantly associated only with female gender ( table 3 ).

Discussion

The true etiology and pathogenesis of vitiligo is still un-clear. Many theories have been proposed in this regard; the autoimmune theory is the most popular one [4, 5] . An in-creased prevalence of autoimmune disorders associated with vitiligo and the presence of various autoantibodies have been described in the literature and are in favor of this mechanism. Nevertheless the analysis of existing data is dif-ficult, owing to the heterogeneity of examined samples of patients and the diversity of searched autoantibodies. From our review of the literature, the prevalence of reported au-toimmune diseases, according to history and/or clinical and instrumental findings, ranged from 2.7 to 55% [2, 6–18] . The rates of autoimmune comorbidities in vitiligo patients appear to differ based on the population under study, ac-

Table 3. Univariate and multivariate analysis of clinical and demographic variables according to the presence of any antibody, anti-TPO antibodies and anti-TG antibodies

Univariate analysis Multivariate analysis

total n % p value OR (95% CI) p value

Presence of any autoantibodyDuration of vitiligo, years

≤5.005.01 – 10.00≥10.01

672257

228

31

32.836.454.4

0.045(0.016)a

11.21 (0.43 – 3.36)2.30 (1.10 – 4.82)

0.7180.027

GenderFemaleMale

9749

4714

48.528.6

0.021 2.19 (1.03 – 4.64)1

0.041

Clinical subtypesb

FocalAcrofacial/vulgarisUniversal

21107

12

546

8

23.843.066.7

0.050(0.018)a

Presence of anti-TPO antibodiesDuration of vitiligo, years

≤5.005.01 – 10.00≥10.01

511947

93

18

17.615.838.3

0.036(0.021)a

Family historyNoYes

7839

1515

19.238.5

0.025 12.68 (1.13 – 6.38)

0.026

Presence of anti-TG antibodiesc

GenderMaleFemale

4480

425

9.131.2

0.005 14.54 (1.47 – 14.09)

0.009

OR = Odds ratio; CI = confidence interval. a Cochran-Armitage test for linear trend. b 6 patients with segmen-tal vitiligo were not included in this analysis. c The result of the multivariate analysis, by using forward stepwise selection algorithm, was equal to that of the univariate analysis.

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cording to ethnic differences [18] . In a large-scale retro-spective analysis of 2,441 vitiligo patients in the USA, Sheth et al. [18] reported differences in rate of coexistent autoim-mune diseases among Afro-American/Black, Asian, His-panic/Latino and Caucasian/White people, showing a rate of 38.4% in Caucasian/White subjects, which was higher than rates observed in the other ethnic groups. This value is very similar to our data, which were detected in a fairly large sample of Italian vitiligo patients.

Moreover, the autoimmune etiopathogenesis of vitiligo and its association with other autoimmune comorbidities, resulting in variable rates in the overall surveys available in the literature, is strengthened by the recent genome-wide association studies [19] . Large-scale genome-wide associa-tion studies detected in generalized vitiligo an association with a number of non-major histocompatibility complex loci, almost all of which encode immunoregulatory proteins. These genes (PTPN22, CTLA4 2 , LPP, CCR6, IL2RA, LRP1, UBASH3A, XPB1, C1QTNF6, FOXP3) have been detected also in many other autoimmune diseases [19] . Therefore the different rates of clinical autoimmune comorbidities/circu-lating autoantibodies detected in epidemiological studies should lead to different expression of the aforesaid genes in the various populations studied, owing to ethnic differences or different environmental trigger factors.

From our review of the literature, the presence of differ-ent circulating autoantibodies in vitiligo patients varied from 2 to 70% [7, 9, 10, 20, 21] ; these data are also roughly in agreement with our observations.

Laberge et al. [22] pointed out a significant association between coexisting autoimmune diseases and familial vit-iligo, while Karelson et al. [23] observed no association be-tween coexisting autoimmune diseases and familial vitiligo and between circulating total autoantibodies and familial vitiligo. Our data are in agreement with the latter.

The presence of circulating autoantibodies has been cor-related both with a long duration of vitiligo [7] and with an older age of onset of the disease [10] . In our series the uni-variate and multivariate analysis showed a significant asso-ciation between the presence of at least one circulating au-toantibody and a longer duration ( ≥ 10.1 years) of the der-matosis and between the presence of at least one circulating autoantibody and female gender.

We were not able to find studies assessing the presence of total circulating autoantibodies according to the clinical course of vitiligo. In our sample no statistically significant difference was shown between groups reporting progres-sion, regression or stability of the disease.

Circulating ANAs were observed in the literature in rates ranging from 2.5 to 33.3% ( table 4 ) [9, 12, 18, 21, 23–28] .

We detected a rate of ANA positivity of 16.8%, which is consistent with previous reports. In studies including a con-trol group, no difference between vitiligo patients and con-trols was noticed [9, 13, 24–26] . In our sample, none of the patients’ clinical and demographic variables considered was statistically associated with the presence of ANAs. Accord-ing to the aforesaid observations of the literature and taking into account the only one case of systemic lupus erythema-tosus in clinical remission observed by us, we believe that the detection of circulating ANAs in Italian vitiligo patients has a limited clinical importance.

APCAs were detected in vitiligo patients in rates ranging from 2.5 to 35.4% ( table 4 ) [7, 9–12, 23, 24, 26–33] . We de-tected an APCA prevalence of 7.8% in our series consistent with the lower estimates from other studies. The clinical relevance of circulating APCAs in vitiligo patients is de-bated. Only about half of the papers including a control group showed statistical differences between vitiligo pa-tients and controls ( table 4 ) [7, 9, 10, 12, 26, 27, 29, 30, 33] . Anemia perniciosa has been described with a prevalence ranging from 2.7 to 8.7% [16, 34] . Sawicki et al. [34] noticed a statistical difference in the prevalence of anemia perni-ciosa between their vitiligo patients and the general popula-tion in Canada. Autoimmune gastritis confirmed by histol-ogy was observed in 3.5% [24] and 15% [11] of cases of vitiligo in Italy, but data on the prevalence of this autoim-mune disease in the general population are lacking. In the study performed by Betterle et al. [7] , 94% of vitiligo pa-tients with circulating APCAs were affected by autoim-mune gastritis. In their cases, Rodríguez-Martín et al. [12] observed a correlation between the severity of vitiligo and the detection of circulating APCAs and suggested to per-form screening for these antibodies in vitiligo patients. We detected overt autoimmune gastritis in 1.9% of our cases and circulating APCAs in 7.8%. This observation is consis-tent with a limited association between vitiligo and autoim-mune gastritis in Italian vitiligo patients.

Few studies on the prevalence in vitiligo of autoantibod-ies present in celiac disease are available. Shahmoradi et al. [35] detected anti-endomysium and anti-TTG antibodies in 3.1% of their vitiligo patients with a significant difference when compared with controls. We observed a prevalence of 1.8% for anti-endomysium antibodies, no presence of anti-TTG circulating antibodies and no overt celiac disease in our sample, which is consistent with a limited prevalence of celiac disease in Italian vitiligo patients.

The association between vitiligo and disorders of the thyroid is frequently described in the literature, but their relevance is conflicting. Results of more recent studies on the association between vitiligo and disorders of the thyroid

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Reference Patients Controls Overt thyroid disease, % (clinical and laboratory data)

Subclinical hypo-/hyper-thyroidisma, %

Anti-thyroid antibodies, %

Statistical difference vs. controls

Studies on coexistence of vitiligo and thyroid disease or anti-thyroid circulating antibodiesBetterle et al., 1985 [7] 373 373 7.5 2.1 18.4c n.s.*Hegedüs et al., 1994 [36] 35 35 22.8 – 25.7 p < 0.05Schallreuter et al., 1994 [33] 321

(205b)103 7.8 20 20.8c

12.3ep < 0.01**

Mandry et al., 1996 [10] 20 20 – – 50c

40ep < 0.05

Frati et al., 1999 [37] 890 – 25 – – –Dave et al., 2003 [38] 35 30 40 – 31.4 p < 0.05**Zettinig et al., 2003 [9] 106 38 17.9 5.6 21d

18ep < 0.01

Mason and Gawkrodger, 2005 [6] 41 – 34 – – –Daneshpazhooh et al., 2006 [39] 94 96 3.1 – 18.1d p < 0.05***Sedighe and Gholamhossein, 2008 [40] 109 – 30.1 12.9 36.7d –

32.1e

Reference Patients Controls ANAs, % Statistical difference vs. controls

Studies on coexistence of vitiligo and ANAsBrostoff, 1969 [25] 80 80 5 n.s.Woolfson et al., 1975 [26] 42 42 33.3 n.s.Grimes et al., 1983 [27] 70 70 4.2 n.s.Zettinig et al., 2003 [9] 106 38 17 n.s.Amerio et al., 2010 [24] 113 normal population 3 n.s.Ingordo et al., 2011 [28] 40 – 2.5 –Rodríguez-Martín et al., 2012 [12] 196 160 18.3 n.s.Karelson et al., 2012 [23] 173 – 3.2 –Shankar et al., 2012 [21] 80 – 5 –Sheth et al., 2013 [18] 438 – 41 –Present study 119 – 16.8 –

Reference Patients Controls APCAs, % Statistical difference vs. controls

Studies on coexistence of vitiligo and APCAsBor et al., 1969 [29] 62 62 35.4 p < 0.05Howitz and Schwartz, 1971 [30] 102 102 19.6 p < 0.05Woolfson et al., 1975 [26] 42 42 33.3 n.s.Barsky et al., 1979 [32] 50 – 4 –Grimes et al., 1983 [27] 70 70 4.2 n.s.Korkij et al., 1984 [31] 31 – 32.2 –Betterle et al., 1985 [7] 373 373 10.4 p < 0.05Zauli et al., 1986 [11] 65 – 15 –Schallreuter et al., 1994 [33] 321 103 16.2 n.s.Mandry et al., 1996 [10] 20 20 30 p < 0.05Zettinig et al., 2003 [9] 106 38 13 n.s.Amerio et al., 2010 [24] 113 – 3.53 –Ingordo et al., 2011 [28] 40 – 2.5 –Karelson et al., 2012 [23] 173 – 11.2 –Rodríguez-Martín et al., 2012 [12] 196 160 14.4 p < 0.05Present study 103 – 7.8 –

Table 4. Studies on coexistence of vitiligo and ANAs, APCAs and thyroid disease/anti-thyroid circulating antibodies

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Reference Patients Controls Overt thyroid disease, % (clinical and laboratory data)

Subclinical hypo-/hyper-thyroidisma, %

Anti-thyroid antibodies, %

Statistical difference vs. controls

Tanioka et al., 2009 [17] 144 – 7.4 – – –Amerio et al., 2010 [24] 113 – 23.8 – 30d

25e–

Akay et al., 2010 [16] 80 – 31.2 – – –Ingordo et al., 2011 [28] 40 – 5.0 2.5 22.5d

27.5e–

Nunes and Esser, 2011 [41] 67 – 20.9 1.5 32.8d –Kasumagic-Halilovic et al., 2011 [42] 33 33 18.2 – 27.3d

24.2ep < 0.05

Sawicki et al., 2012 [34] 300 general population

12 3.7 – p < 0.05

Kumar et al., 2012 [43] 50 – 0 28 28d –Rodríguez-Martín et al., 2012 [12] 196 160 10.5 – 15.5d

7.2ep < 0.05****

Kroon et al., 2012 [44] 434 Whickham survey

10.3 4.6 13.5d p < 0.05*****Karelson et al., 2012 [23] 186 – – – 32.7d –Sheth et al., 2013 [18] 2,441f

89h

5i

– 11.8 – –44.9d

0e

–

Present study 154g

117h

124i

– 32.5 3.2 –25.6d

23.4e

–

Childhood vitiligoKurtev and Dourmishev, 2004 [46] 58 – 5.1 8.6 50c

50d–

Iacovelli et al., 2005 [47] 121 – 5.7 2.4 5.8d

9.1e–

Kakourou et al., 2005 [48] 54 302 7.4 16.6 24.1d

20.4ep < 0.05

Pagovich et al., 2008 [49] 67 – 10.4 – – –Fernandes and Campos, 2009 [50] 50 40 – 2 – n.s.Yang et al., 2010 [51] 363 93 11.4 – – p < 0.05Prćić et al., 2011 [52] 75 – 25.3 – – –Uncu et al., 2011 [53] 50 50 8 10 8d

2ep < 0.05

Kroon et al., 2013 [45] 260 general healthy population

6.2 – 10.6d p < 0.05

Table 4 (continued)

n.s. = Not significant.a Low/raised thyroid-stimulating hormone and normal free triio-

dothyronine and free thyroxine values. b Patients undergoing studies on thyroid function and determination of anti-thyroid autoantibod-ies. c Anti-microsomal antibodies. d Anti-TPO antibodies. e Anti-TG antibodies. f Data collected searching the problem lists of patients.g Number of patients undergoing routine blood test. h Number of pa-tients in whom anti-TPO antibodies were searched. i Number of pa-tients in whom anti-TG antibodies were searched.

* The difference was not significant considering total samples of patients/controls; evaluating data according to sex: females: p = n.s.; males: p < 0.05. ** The difference was significant considering both latent auto-antibodies and overt thyroid disease. *** The dif-ference was significant only considering auto-antibodies in total samples of patients/controls; evaluating data according to sex: fe-males: p < 0.05; males: p = n.s. **** The difference was significant only for anti-TPO antibodies. ***** The difference was significant only for overt hypothyroidism.

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gland are reported in table 4 [6, 7, 9, 10, 12, 16–18, 23, 24, 28, 33, 34, 36–53] . Most surveys involving a control group showed a significant statistical difference in the prevalence of thyroid gland disorders between vitiligo patients and controls. We detected a rate of 32.5% overt autoimmune thyropathies in our sample, which is consistent with the conclusion that this disorder is the most represented in vit-iligo patients also in Italian population. This is in agreement with the data of many other studies of the literature.

Remarkably high rates of circulating anti-thyroid anti-bodies in the general population have been described in Germany [54] and Norway [55] , ranging from 2.8 to 25.8%, with differences between males and females. Because of this observation and according to results of their study, Kroon et al. [44] proposed that screening including anti-TPO an-tibodies was advisable only in older female patients with vitiligo and in subjects affected by vitiligo with a positive family history for thyroid disease.

Few studies have evaluated the association between the presence of anti-thyroid antibodies and clinical or demo-graphic features of vitiligo: no association was documented between anti-thyroid antibodies and disease activity [28, 44] , percentage of BSA involved [28, 39, 44] and disease du-ration [39] . These observations are in agreement with the results of our multivariate analysis. Nunes and Esser [41] showed an association between circulating anti-TPO anti-bodies and late onset of vitiligo. In the multivariate analysis, no association between the presence of circulating anti-TPO antibodies and late onset or clinical subtypes of vitili-go was shown in our sample; this observation is in agree-ment with the report of Daneshpazhooh et al. [39] , but not with the data published by Kasumagic-Halilovic et al. [42] .

A family history of vitiligo was the only variable statisti-cally associated with the presence of circulating anti-TPO antibodies in our sample. This observation is at variance with the report of Karelson et al. [23] , which showed no dif-ferences for this variable between familial and non-familial vitiligo in their patients.

The only variable significantly associated with the pres-ence of circulating anti-TG antibodies in our study was fe-male gender. We were not able to detect in the literature any observation regarding a difference between genders con-cerning anti-TG antibodies. On the contrary, contradictory data exist about the relation between gender and the pres-ence of anti-TPO antibodies in vitiligo patients [7, 39, 41] . It is well established that anti-TPO antibody (historically referred to as antimicrosomal antibody) is a sensitive tool for the detection of early subclinical autoimmune thyroid disease and for the identification of patients at risk of au-toimmune thyroid diseases [56] , and it has more correla-

tion with thyroid dysfunction than anti-TG antibody [57] ; hence, the detection of anti-TG antibodies in vitiligo pa-tients has probably a limited clinical significance.

Concomitant autoimmune thyropathies in vitiligo have been reported, with rates ranging from 3.1 to 34% in adults and from 5.1 to 25.3% in children ( table 4 ). It has been sug-gested that vitiligo precedes the onset of overt thyroid dys-function [7, 9, 48] , and therefore routine screening in vit-iligo patients has been recommended [3, 4] . However, data not supporting this statement also exist [44] . A recent sys-tematic review from Vrijman et al. [58] included 48 studies out of 1,167 examined of which only 6 were of good meth-odological quality. The review concluded that there is evi-dence of an increased prevalence and an increased risk of autoimmune thyroid disease in vitiligo patients, and that the risk seems to increase with age.

Our study was conducted on a fairly large sample of Ital-ian vitiligo patients well distributed around Italy, and it is the first survey with these peculiarities performed in our country. The study has limitations, including the lack of a control group and the lack of centralized assessment of lab-oratory data. The prevalence of circulating autoantibodies in our vitiligo patients is mainly represented by anti-thyroid antibodies and is in agreement with other studies. The rate of detected autoimmune thyroiditis was rather high in our sample, confirming that these diseases are those most fre-quently associated with vitiligo in the Italian population, in agreement with data from others countries. On the con-trary, the prevalence of other overt autoimmune diseases was very low, and we were unable to identify strong predic-tors of concomitant autoimmunity in our vitiligo patients. Despite the aforesaid limitations, we believe that our obser-vations should provide some indications for blood and in-strumental investigations to perform in vitiligo patients in our country. Future studies should try to better standardize definitions and outcome measures and should rely on a suitable control group.

Acknowledgements

We would like to thank Capt (I) Andrea Giovanni Tortora, MD, for his help in linguistic revision of the manuscript.

Disclosure Statement

The authors declare no conflict of interest. There were no fund-ing sources supporting this work.

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