Vitiligo is a chronic skin condition characterized by hypopigmented patches on the skin [1]. It is more noticeable in those with darker skin tones such as indigenous Africans, African- Americans and West Indians [1, 2]. There is widespread misunderstanding of the condition.  It is a disease that impacts poorly on the quality of life of sufferers who almost always experience distress associated with their appearance.  They undergo both self -stigmatization and social discrimination [2]. The underlying cause is due to an autoimmune destruction of melanocytes which are responsible for the production of melanin that protect the skin from sunlight [3]. The prevalence of vitiligo varies from 2-6% in different parts of Nigeria.4-6 Globally the prevalence of vitiligo is estimated to be 0.1-2% with United States of America having an incidence of 1% [7]. The overall lifetime cumulative incidence for vitiligo in those living in United Kingdom was 0.92% at 80 years [8]. Vitiligo is characterized by incomplete penetrance, multiple susceptibility and genetic heterogeneity. There are different theories with regards to its pathogenesis which includes the autoimmune hypothesis and the humoral response, Smith Chicken Model, the oxidant-antioxidant theory, the neural theory and the convergence theory that implicates all theories and mechanisms suggesting vitiligo has a multifactorial cause [7].  The triggering factors include trauma, sunburn, stress and systemic illness [7].

The study population consisted of newly diagnosed cases of vitiligo including those with the possibility of other differential diagnoses seen over a ten year period from January 2006-December 2015 at the dermatology outpatient clinics of the University of Port Harcourt Teaching Hospital (UPTH) Alakahia, Rivers State, Nigeria and that seen over an twelve year period from January 2012- December 2023 at the Rivers State University Teaching Hospital (RSUTH) Port Harcourt. The data was retrieved from the new patient registers of the clinics of the two major tertiary institutions were disorders of the integumentary system are being handled which serves as a referral center for both primary and secondary health care centers in Rivers State and neighboring states as well. Each of these institutions has a weekly clinic on different days of the week run by consultants and residents in dermatology. All clinical diagnoses of vitiligo were included in the study. The bio-data including age and sex The study population consisted of newly diagnosed cases of vitiligo including those with the possibility of other differential diagnoses seen over a ten year period from January 2006-December 2015 at the dermatology outpatient clinics of the University of Port Harcourt Teaching Hospital (UPTH) Alakahia, Rivers State, Nigeria and that seen over an twelve year period from January 2012- December 2023 at the Rivers State University Teaching Hospital (RSUTH) Port Harcourt. The data was retrieved from the new patient registers of the clinics of the two major tertiary institutions were disorders of the integumentary system are being handled which serves as a referral center for both primary and secondary health care centers in Rivers State and neighboring states as well. Each of these institutions has a weekly clinic on different days of the week run by consultants and residents in dermatology. All clinical diagnoses of vitiligo were included in the study. The bio-data including age and sex were noted and the frequency for each year was also documented. The incidence was calculated for each year from each institution. Tables and charts were used to improve data visualization and comprehension. Photographs available from consenting patients were used.

Full access to some data could not be obtained hence the use of available data.

Table 1: Showing gender, age group and incidence in UPTH (2006-2015).

Table 2: Showing gender, age group and incidence in RSUTH (2012-2023).

Table 3: How Vitiligo impacts each decade.

The total number of years for those in UPTH was 6220.75 with average age of 28.4. The age range was 9 months (0.75year) to 84 years.  The total number of years for those in RSUTH was 1580; the average age was 39.5 and the age range was 3-76 years.

Table 4: Morphological Classification.

Table 5: Location.

*There was multi-parts affectation in some of the vitiligo patients. There was no case of vitiligo universalis reported in this study.

There was female preponderance in each institution -RSUTH 57.5% (23) and UPTH 53.9% (118). Vitiligo affected persons of different occupation including students, lawyers, traders, businessmen and administrators with students in the majority (23.1%) of cases at RSUTH. Family history of vitiligo was not documented in the registers. The history of when the first hypopigmented patch on skin was first noticed ranged from 3-10 years. The diagnosis was mainly clinical and only 1 patient in RSUTH had a punch skin biopsy requested to exclude diagnosis however patient was lost to follow up. Differential diagnoses that were considered aside vitiligo were Hansen’s disease (leprosy), chemical leuco derma and pityriasis versicolor.

Other skin lesions seen in patients at UPTH were acne in a 25 year old male patient (0.45%), nummular dermatitis in a 16 year old male patient (0.45%), fixed drug eruption in a 20 year old female patient (0.45%) and seborrhoeic dermatitis in one 39 year old female patient (0.45%),   Hypertension and hypothyroidism were seen in 1 (2.5%) patient each at RSUTH; each was referred to the cardiologist and endocrinologist respectively.

Treatment was documented in few cases in the RSUTH register. Prior treatment by patients before visiting the dermatologist included the use of gentimycin and acyclovir prescribed by a patent drug dealer in female teenage secondary student. Another male patient took an unknown oral drug. The treatment prescribed to patients varied from individual. Every patient received counseling and health education about the disease. Sun screen with high protection factor (>50SPF) was recommended depending on the location and extent of the disease. Two patients received meladinine in combination with phototherapy and sun screen while another received topical hydrocortisone with sunscreen. One (1) patient was on tacrolimus and later changed to meladinine with sunscreen. Majority of the patients had poor satisfaction with outcome of treatment. Only 1 patient (0.45%) from UPTH was documented to be improving and 2 (5%) from RSUTH was also indicated has some improvement evidenced by repigmentation.

Figure: Pictures: Courtesy Amadi, ES (Scar Songs).

Scrotal vitiligo( not yet on treatment).

Repigmenting skin on abdomen after using a topical .

The incidence of vitiligo within the time frame in the different cutaneous clinics were 3.7% and 2.1% respectively as seen represented in the table 1 and 2. This gives an average of 2.9% from both institutions; however these two institutions have varying time periods. The values are slightly lower than previous study done within one of the institutions at a different time period which had a prevalence of 4.96% [9]. Onunu & Kubeyinje had 3.2% prevalence in their study in University of Benin Teaching Hospital (UBTH), Ayanlowo et al at Lagos State University Teaching Hospital (LUTH) had a prevalence of         2.8% over a 3 year period [4,5] Amongst children in two towns in the South-Western Nigeria, vitiligo consisted of 5.3% of the paediatric dermatoses over a 3 year period.6 In a study by Amadi et al in University of Port Harcourt Teaching Hospital (UPTH)  amongst the under-fives showed that vitiligo made 3.2% of all dermatologic disorders over ten year period and was the fifth most common [10]. Vitiligo consisted of 5.5% of skin disorders among the elderly within the same institution [11].    Higher incidence rates have been recorded in other studies done in Nigeria. Noruka had an incidence of 5.8% in Enugu over a 2 year period while George had an incidence of 6% in Ibadan. Reported prevalence of vitiligo ranged from 0.18% to 5.3% in Africa and the Middle East, and from 0.04% to 0.57% in Latin America [12,13]. Oceania appears to have the highest (1.2%) number of cases of vitiligo and Asia (0.1%) the least from a world-wide meta-analysis done [15]. The prevalence of vitiligo in India has been invariably reported between 0.25% and 4% of dermatology outpatients across studies from India and up to 8.8% in Gujarat & Rajasthan [16]. In several studies, prevalence was higher among female participants [14].  Onunu & Kubeyinje had a female prevalence of 56.4% , Ayanlowo et al(55%), Altraide et al(54.9%)  Amadi et al (69.2%) in under five years children;  Nnoruka(63.6%), Mahajan et al(52.5%), Abdullahi et al(58.4%), Echekwube et al(60%) [4,5] [9,10] [12] [16-18].   George on the contrary had a higher incidence in men [13]. This greater prevalence in females even amongst children under five years may be attributed to the increased concerns of females and their parents about their cosmetic appearance hence better skin health seeking behavior.

Vitiligo was seen to be more within the 3rd decade (20-29 age group) amongst patients from UPTH while it was more within the 4th decade (30-39 age group) amongst patient from RSUTH as table 3 shows. Onunu & Kubeyinje reported that the peak age was in the second(unlike this study) and third decade(similar to this study) Anyalowo et al also had the third decade (21-30) with the highest incidence consisting of 24.7% however slightly lower than the proportion found in this study as seen in table 3 above  [4]. Altraide et al reported similar age range within their study having those aged 20-30 years as the commonest age [5]. George showed in his study that slightly more than two thirds of the patients were less than 30 years while that done by Mahajan et al showed slightly more than half of the patients were less than 20 years with a mean age of 24.4 and 20.5 years at onset of disease [9]. The average seen in this study was similar to that found in the study carried out by Abdullahi et al in Northern part of Nigeria with patients’ mean age at first onset of vitiligo was 33.5 ±14.84 years and at presentation to be 38.97±13.82  in the vitiligo patients [13] [16].  Amongst adults at tertiary hospital in Ile-Ife the mean age was 35±17 years.18 In USA the mean age was 44.9 ±17.4 years which was slightly higher than this study [17] [19].

The distribution and morphological patterns can be seen in able 4 and 5 in this study.  Though majority of the cases were not specified, the localized form has a higher frequency for the cases in RSUTH while the generalized was more in the UPTH cases. Onunu et al had localized focal type as the most common in their study with almost 80% presenting in this form [4]. Other studies that had predominantly localized focal form were that carried out by Anyalowo et al (35%) and Mahajan et al(18.7%). Generalized was seen more in the studies carried out by Altraide at al (35.4%),  Abdhulllahi et al (37.7%) and Echekwube et al (56%).  Nnoruka had acrofacial as the highest form( 21.5%) with a majority (32.8%)  with less than 1% body surface affectation.12 Ghandi  et al reported non-segmental vitiligo  (0.77% ) as the major form out of the self-reported (1.38%)   vitiligo cases in an American population which is about 56% of all the vitiligo cases seen in the study [5], [16 -18], [9]. The head and neck region is the most affected region as seen in table 5 which consists of the scalp, face and lips in this study. The acral region such as ears and nose can also be affected however this was not specified in this study [19].  The head and neck region was also noted to be more affected in studies carried out by Echekwube et al (82%),  Abdullahi et al(71.4%), Ayanlowo et al(55.9%), Mahajan et al(40.4%) and Altraide et al(28%). This study clearly shows that exposed parts are the most affected as clearly noted in studies done by Nnoruka (67%) and George (63%) [5], [9],[16-18]. This finding supports the role of sunlight being a trigger and a precipitating factor as reported in studies carried by Ayanlowo et al and Echekwube et al [12-13]. Vitiligo can also affect the  non-exposed area such as the genital area(penis and vulva) as this study shows which is comparable to that done by  Ayanlowo  et al who had 2.1%  of  vitiligo cases involving the penis, Mahajan et al had 2.3%  of cases affecting the anogenital area,  Echekwube et al had 4%  of vitiligo cases involving the genitalia and  Abdullahi et al had 24.1% of their cases involving the perineum and genital areas [5],[18] . Vitiligo commonly affects the genitalia in men and may be the only site affected [5],[12], [16-18],[20].

 Vitiligo was known to affect different people in varying professions, students of all categories were more in this study and this may be associated with the young age seen in vitiligo hence many patients are still within the school age at the time of the first affectation either in primary, secondary or tertiary. Echekwube et al reported similar findings; noting students, civil servants and traders to be have the highest frequency. Their occupation is highly interactive hence facing constant embarrassment by the disfiguration caused by vitiligo. Echekwube et al also reported majority of those affected had high level of education causing better health seeking behavior unlike the study carried out by Abdullahi et al that showed most vitiligo patients were of lower socio-economic class and almost one quarter had no formal education [18]. Family history of vitiligo was not documented in the data used for this study, hence it cannot be fully rule out that there was none among the patients. George and Ayanlowo et al in their own studies reported none however other studies done within the same region had varying frequencies [17,18].  Onunu & reported 18%, Altraide et al (7.3%), Nnoruka(2.3%), Mahajan (15.9%), Abdullahi et al (37.7%)  and Echekwube(12%)  of their cases had family history of vitiligo. [4], [9],[12], [16-18]. 

First degree relatives amongst those who had vitiligo was reported by Halder &Taliaferro to be almost 20% and the relative risk was increased in relatives of vitiligo patients by 7-10 fold while Abdullahi et al reported 86.2% of those with family history of vitiligo had their first degree family affected [7]. The duration of the first hypopigmented patch to first presentation at the clinic is varying. Mahajan showed 1-5 years (30.6% ) as the highest frequency in their study,  Ayanlowo  et al had the duration of within 1 year (62%) as the most common in their study so did Abdullahi et al (67.5%) and Echekwube et al in their study had 46% of patients with duration of vitiligo less than 2 years while 54% have duration greater than 2 years before presentation to the clinic [17]. The diagnosis of vitiligo is mainly clinical as other studies have shown [5], [16-18]. The diagnosis of vitiligo is made based on the findings of depigmented macules and/or patches with sharply demarcated margins, normal texture, intact sensation and no scaling.18 Doing a biopsy is to rule out other possible causes of hypopigmentation or depigmentation such as leprosy where there is loss of sensation. Vitiligo patients also suffer from social stigmatization because of its confusion with leprosy; 4 although these two can coexist.  Nnoruka in her study reported seven cases of vitiligo co-existing with lepromatous leprosy 12 this can be a source of diagnostic dilemma to the physician [5]. Other possible differentials that can be mistaken for vitiligo include chemical leukoderma, chronic dermatitis, pityriasis vesicolor, pityriasis alba, post inflammatory hypopigmentation and sarcoidosis. Other dermatological conditions can also co-exist with vitiligo just as it was in this study. Nnoruka reported 39.7% of cases had co-existing poliosis in her study [5],[7]. Atopic dermatitis has been commonly reported in the studies done by Altraide et al (2.4%) and Nnoruka (1.3%). Medical conditions such as thyroid problems were commonly reported in other studies such as this study has shown [12]. Hypothyroidism (4.1%) and hyperthyroidism (0.42%) was also seen in vitiligo cases in the study carried out by Mahajan while Onunu & Kubeyinje had   hyperthyroidism in 0.6% of their patients while Nnoruka had 1.2% had unspecified thyroid disease [9],[12]. Ayanlowo had 6.6% with thyroid diseases with three-quarters of the patient having hyperthyroidism and the remaining hypothyroidism. Like this study hypertension was also reported by Ayanlowo in 1.1% (2) of vitiligo patients [4-5],[12],[16]. Hypertension is a common chronic medical condition affecting dark skinned individuals and the elderly. Diabetes mellitus and alopecia area are two common medical conditions reported in other studies done within the same region. These three medical conditions are known to be autoimmune diseases which share similar autoimmune mechanisms with vitiligo hence should be explored in vitiligo patients [4-5],[16]. The use of non-effective medication was reported in our study. The same was reported in the study by Abdullahi et al and Kiprono et al. The modalities of treatment received were mainly medical in this study just as reported in others done within same region [17],[21]. Steroids, psolaren, phototherapy and are commonly prescribed by dermatologists in Nigeria as this study also shows as these are the readily available and affordable therapies in the country [5],[12], [17],[18]. Meladinine also called methoxsalen is a common type of psolaren. Tacrolimus has been known to help in stabilize the area of depigmentation halting the progression of the disease in some patients [2],[22]. Modalities of management include patient education about aetiology, care including sun screen, progression, treatment and outcome is important [23]. The outcomes are not usually satisfying as this study has shown which resonates what has been reported in other studies [12],[22-23].  Spontaneous repigmentation can reoccur but in few cases however most times repigmention is incomplete and the disease can progress involving greater body surface area leading to vitiligo universalis [4-5],[9],[12-13],[16-18]. In the of vitiligo universalis complete depigmentation is carried out  using monobenzyl ether of  hydroquinone (MBEH) cream  which is the mainstay of depigmentation therapy. Patients who do not respond fully to MBEH or who are intolerant to the drug can be managed by Alexandrite laser treatment, chemical peels such as trichloroacetic acid, cryotherapy, Q-switched Nd: YAG laser or Q switched Ruby laser. Cosmetic camouflage can be used for focal face affectation [24]. Surgical interventions such as punch grafting, suction blister transportation, split thickness skin grafting and transplantation of cultured autologous melanocytes can also be done [7]. Psycho-social support is also very important hence the need for support groups, family counseling and co-colleagues counselling [3],[7],[2],[ 7].

Creating Awareness is vital in helping patients globally. World Vitiligo Day which is 25th June has been held annually since 2011.  The date was chosen to honour Michael Jackson who died on that day in 2009. He was a vitiligo patient. Ogo Maduewesi, a Nigerian vitiligo patient and founder of ‘Vitiligo Support and Awareness Foundation (VITSAF)’ has been a global voice for vitiligo sufferers. She played a vital role in establishing this awareness day for vitiligo.  The first World Vitiligo Day held on 25th June 2011 and it was celebrated at Silverbird Galleria's Atrium in Lagos, Nigeria [25].

The finding about vitiligo in Rivers State, Nigeria is similar to other studies within the same country and it is comparable to results globally. The treatment for vitiligo has not been satisfactory for most persons. Psycho-social important in tackling self and social stigmatization.

• There is need for more awareness about vitiligo, hence World Vitiligo day should be well publicized by all physicians particularly skin doctors and other skin care professionals
• Psycho-social support should be improved and new therapies should developed focusing on the skin colour and the sourcing materials from our own local environment.

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