Nutritional deficiencies may precipitate vitiligo in children of color

Boston – Promising breakthroughs in treating children of color include the discovery that nutritional deficiencies may have implications in vitiligo, said Nanette Silverberg, M.D., at the 2012 American Academy of Dermatology Summer Academy Meeting.

Research has shown that 13.3 percent of children (all older than age 3) and adults with vitiligo have very low vitamin D levels (<15 ng/mL; Silverberg JI, Silverberg AI, Malka E, Silverberg NB. J Am Acad Dermatol. 2010;62(6):937-941).

"This deficiency was associated with a greater risk of secondary autoimmunities such as thyroid disease, systemic lupus erythematosus and alopecia areata," says Dr. Silverberg, director of pediatric dermatology at St. Luke’s-Roosevelt Hospital Center and Beth Israel Medical Center and clinical professor of dermatology at Columbia University School of Medicine, New York. As a result, monitoring vitamin D levels may help to identify children with greater susceptibility to other forms of autoimmunity, she says.

Newer therapies that may be of benefit for children of color with vitiligo include the following:

• Topical tacrolimus, which has been shown to be more effective in children and adults of darker skin tones (Silverberg JI, Silverberg NB. J Drugs Dermatol. 2011;10(5):507-510).
• Narrowband UVB phototherapy (Kanwar AJ, Dogra S, Parsad D, Kumar B. Int J Dermatol. 2005;44(1):57-60).
• Non-cultured epidermal suspension transplantation, which caused more than 90 percent repigmentation in 79 percent (n=15) of 19 lesions in 13 patients (Sahni K, Parsad D, Kanwar AJ. Clin Exp Dermatol. 2011;36(6):607-612).

Considering eye color
According to Dr. Silverberg, genome-wide association analyses (for which she was co-author) recently have identified 13 new susceptibility loci for generalized vitiligo. Ongoing studies are looking at the genetic association with race and ethnicity, she says, but the recent genome-wide association study linked vitiligo with brown eye color, suggesting that individuals of color may have more risk for this disease (Jin Y, Birlea SA, Fain PR, et al. Nat Genet. 2012;44(6):676-680).

FACE challenges
Another condition, periorificial dermatitis, consists of monomorphic, possibly erythematous papules that appear around the eyes, nose and lips primarily of young children after topical steroid use, Dr. Silverberg says. Children of color can experience a variant called facial Afro-Caribbean eruption (FACE).

"Various agents have been reported in medical literature to be effective for this entity," she says. These include topical metronidazole and oral erythromycin.

"One of the problems we've encountered recently is that oral erythromycin suspension was very difficult to obtain for an extremely long time," Dr. Silverberg says. As an alternative, she says she has found topical dapsone 5 percent to be effective in two female patients who had failed multiple other treatments.

While dapsone 5 percent has been shown to be safe in children age 12 to 15 with facial acne (Raimer S, Maloney JM, Bourcier M, et al. Cutis. 2008;81(2):171-178), there is some concern that topical dapsone could lower blood counts, as systemic dapsone does, she says.

Therefore, "It's important to monitor blood counts before and during treatment for children under the age of 12 years,” Dr. Silverberg says. “Oral dapsone can cause hemolysis, which is most severe in patients with G6PD (an enzyme that breaks down dapsone) deficiency. This is an X-linked disorder which commonly afflicts African-American males but can be seen in the heterozygous state in females." Neither of the African-American girls that Dr. Silverberg treated for FACE with dapsone experienced alterations in blood counts, she says.

Disclosures: Dr. Silverberg has been a consultant and/or investigator for Astellas, Galderma, Johnson & Johnson and Leo Pharma.

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