Probing vitiligo's psychological basis in children

Key Points

Santiago, Chile - Results from a study exploring personality traits in children with vitiligo lend support to the concept that vitiligo is a complex, integrated psychoneuroimmune cutaneous disease, say researchers from the University of Chile, Santiago.

"Current theories about the loss of epidermal melanocytes in vitiligo center on four main mechanisms - genetic, autoimmune, autotoxicity and neural. Various reports in the literature link psychological factors and stressful life events to the onset of the depigmentation, but no studies have more formally explored a possible pathogenic association," says Rodrigo J. Schwartz, M.D., a dermatologist at the University of Chile.

"Our research indicates some children may have a generic temperamental predisposition for developing vitiligo as a reaction to stressful life events and suggests further research in this area is warranted because of its potential implications for diagnosis, management and prognosis."

Dr. Schwartz collaborated in his study with J.E. Sepulveda, M.D., a psychiatrist at the University of Chile.

To explore whether vitiligo may have a psychological basis, they studied three patient groups: vitiligo patients (n = 21), their unaffected siblings (n = 14) and a second control group of healthy children and adolescents who were age-and gender-matched, and selected from two local schools. The three study groups were similar with respect to their sociodemographic characteristics.

Two different questionnaires were administered to study associations between personality and vitiligo - the Junior Temperament and Character Inventory (JTCI) and the Qualitative Psychosocial Development Survey (QPDS).

The JTCI was administered to the parents of the vitiligo patients and both groups of controls, while the patients, parents and sibling controls completed the QPDS. In addition, vitiligo patients were surveyed with the Life Event Checklist (LEC) and the Children's Dermatologic Life Quality Index (CDLQI) to investigate possible associations between onset of vitiligo and negative life events occurring during the preceding year and the effect of their disease on quality of life.

Results

The results of the JTCI showed a significant difference comparing the vitiligo patients with the controls only in the harm avoidance (HA) domain.

The vitiligo patients had a significantly higher score, indicative of being more passive, pessimistic, cautious and insecure, and having a higher tendency to be easily fatigued.

"Children with a high score on the HA domain tend to anticipate pain and failure with pessimistic thoughts and to suffer long-term after experiencing humbling or embarrassing events," Dr. Schwartz explains.

The higher HA score in the vitiligo patients was consistent with the results of the QPDS and LEC. On the QPDS, more than twice as many vitiligo patients compared with their siblings were found to be fearful of strangers. Almost 80 percent of the vitiligo patients compared with only 8 percent of their siblings indicated having fear and inhibition toward emotional change in an emotionally relevant person.

"Previous studies have shown that children with greater inhibitions develop physiological responses to stress at a lower threshold than their uninhibited counterparts. Knowing that increased mental stress results in increases in levels of chemical mediators implicated in vitiligo pathogenesis, including norepinephrine, epinephrine, cortisol, interleukin-6, TNF-alpha, beta-endorphin and melatonin, provides a biological basis for suggesting vitiligo is a psychoneuroimmunological disease," Dr. Schwartz says.

The LEC results showed the children with vitiligo had experienced, on average, 3.2 negative life events during the year before the development of their skin disease. However, their experiences showed a wide range, with the number of reported negative events ranging from zero to nine.

"The most common of the negative events involved emotionally relevant persons and pets, which is consistent with the results of the QPDS. Situations of parental quarreling, parental absence from the home or death of a pet were reported by about 30 to 43 percent of the vitiligo patients," Dr. Schwartz says.

The children with vitiligo had a mean CDLQI score of 3.76. The score indicates moderate impairment and is relatively low in comparison to CDLQI scores measured in children with other dermatoses, including psoriasis, atopic dermatitis or epidermolysis bullosa, Dr. Schwartz notes.

Correlation analyses

The investigators also performed correlation analyses between the JTCI and CDLQI and found a statistically significant negative correlation between the character dimension of self-directedness and the CDLQI score.

"That finding might suggest that therapy aimed at improving self-directedness might be helpful to mitigate quality of life impairment in children with vitiligo," Dr. Schwartz tells Dermatology Times.