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PubMed1983

Vitiligo in patients with metastatic melanoma: a good prognostic sign.

We have identified and studied twenty-seven patients with melanoma who also had vitiligo. Four patients had vitiligo before the diagnosis of melanoma, and twenty-three developed depigmentation after the diagnosis of malignancy. We also have reviewed published reports about twenty-four other patients with melanoma who developed vitiligo. The clinical course of the melanoma in the fifty-one patients was remarkably similar. Thirty-seven had a melanoma arising at a site which tends to carry a poor prognosis, for example, on the trunk, under the nail, or on the mucous membranes. Forty-nine patients had metastases in regional lymph nodes or at distal sites. Thirty-three patients survived 5 years, and twenty-five survived 10 years. These data suggest that the appearance of vitiligo in patients with metastatic melanoma portends a longer survival than expected. The patients with vitiligo are not necessarily cured and eventually may succumb to metastatic disease. We were unable to determine whether the vitiligo caused retardation of tumor growth or whether the melanoma caused vitiligo.

Adult↗

PubMed1989

Circadian rhythm of natural killer cell activity in vitiligo.

Ten patients with vitiligo, either in the active (six cases) or static (four cases) phase, and twelve healthy control subjects were studied with a standard cytotoxicity assay to evaluate the circadian rhythm of natural killer cell activity from peripheral blood mononuclear cells. The natural killer cell activity was measured at the zero, sixth, twelfth, and eighteenth hours of the day. The results demonstrated that patients with vitiligo had significantly higher natural killer cell activity compared with normal controls. When patients with static and active vitiligo were compared, those with the static form had increased natural killer cell activity at all times except noon, whereas those with active form had increased natural killer cell activity only at 0600 and 1800. These changes shifted the acrophase of the circadian rhythm of each group. Indeed, by cosinor analysis, both patients with vitiligo and normal controls had similar circadian rhythms, but the acrophase was shifted from 0602 in control subjects to 0435 in the ten patients with vitiligo. The acrophase in the six patients with active vitiligo was found to be closest to that of normal controls (0508). These findings indicate that natural killer cell activity abnormalities are more marked in the static rather than in the active form of vitiligo.

Adult↗

PubMed1999

Epidermal grafts for treatment of stable and progressive vitiligo.

BACKGROUND: Previous reports have shown the effectiveness of epidermal grafts for patients with stable vitiligo. OBJECTIVE: Our purpose was to evaluate the effectiveness and complications of epidermal grafts in patients with stable and progressive vitiligo and to compare the results in both groups. METHODS: Epidermal grafting with suction blisters was performed in 40 patients with vitiligo (26 stable and 14 progressive). The grafted sites and donor sites were examined for repigmentation for longer than 3 months, up to 2.5 years. RESULTS: Complete repigmentation was observed in 19 patients with stable (73.1%) and 10 with progressive vitiligo (71.4%). Of the 29 patients who experienced complete repigmentation, we noted recurrences in 2 patients with stable disease (10.5%) and 4 with progressive disease (40%). CONCLUSION: Although patients with progressive vitiligo showed more frequent recurrence than those with stable disease, epidermal grafting may be an effective treatment not only for stable vitiligo but also for progressive vitiligo.

Adolescent↗

PubMed2003

Catecholamines increase in the urine of non-segmental vitiligo especially during its active phase.

Neural factors appear to play a major role in the pathogenesis of vitiligo. To investigate the possible correlation between vitiligo and peripheral monoaminergic system activity, we used high-pressure liquid chromatography and electrochemical detector methods to evaluate the basal urine excretion values of catecholamines [norepinephrine (NE), epinephrine and dopamine (DA)], their relative metabolites [3-methoxy-4-hydroxyphenylglycol (MHPG), normetanephrine (NMN), metanephrine (MN), vanilmandelic acid (VMA) and homovanillic acid], as well as 5-hydroxyindoleacetic acid (5-HIAA), in 35 healthy subjects and in 70 patients, suffering from non-segmental vitiligo at different stages of the disease. Levels of NE, DA, NMN, MN, MHPG, VMA and 5-HIAA were found to be significantly higher in patients than in controls. The patients with progressive vitiligo (n = 56) presented increased urinary excretion values for all parameters (in particular, NE levels) than other patients. Interestingly, in patients at its more recent vitiligo onset (<1 yr), NE values were different to those of subjects affected from 1 to 5 yr and from 6 to 10 yr. This result was confirmed by the significant negative relationship detected between NE excretion values and disease duration. In both vitiligo and control groups, significant correlations were found between monoamines as well as between these monoamines and their metabolites. The increase in catecholamine turnover, mainly occurring at the onset of the disease, is probably due to the stress associated with the appearance of lesions. Moreover, considering that these compounds readily produce toxic free-radicals and that vitiliginous subjects have a defective free radical defence mechanism, they may also contribute to the disappearance of melanocytes in the early phases of vitiligo.

Adolescent↗

PubMed2006

Enhanced survival associated with vitiligo expression during maintenance biotherapy for metastatic melanoma.

Vitiligo, an autoimmune skin disorder, was evaluated in 49 metastatic melanoma patients treated with an immunotherapy regimen of maintenance biotherapy (mBT) following induction concurrent biochemotherapy (cBCT). Patients receiving mBT demonstrated a stable or better response to cBCT. The mBT regimen consisted of outpatient subcutaneous injections of low-dose IL-2 (1 MIU/m(2)) 5/7 days weekly, GM-CSF (125 mcg/m(2)) 14 days monthly, and high-dose pulses of in-patient continuous infusion decrescendo IL-2 (54 MIU/m(2)) over 48 hours monthly for the first 6 months and every 2 months thereafter. The majority of patients had poor prognostic features. Forty-nine patients were without evidence of vitiligo at the start of mBT. Of these, 21 patients (43%) developed vitiligo during mBT and had a median overall survival from the start of mBT of 18.2 months (95% CI, 12.3-N/A) compared to 8.5 months (95%CI <6.7-12.7) for 28 non-vitiligo patients (P=0.027). Six of 21 vitiligo patients (29%) expressed IgG antibody titers to tyrosinase-related protein-2 compared to four of 28 non-vitiligo patients (14%) (P=NS). The development of vitiligo in metastatic melanoma patients on cBCT/mBT immunotherapy correlates with a better therapeutic outcome.

Adolescent↗

PubMed2002

Aberrant expression of complement regulatory proteins, membrane cofactor protein and decay accelerating factor, in the involved epidermis of patients with vitiligo.

BACKGROUND: Vitiligo is a pigmentary disorder of the skin characterized by the complete absence of melanocytes from the lesion. Complement-activating antimelanocyte antibodies have been implicated in vitiligo pathogenesis. As membrane regulators of complement activation, membrane cofactor protein, decay accelerating factor and CD59 protect cells from elimination by autologous complement, their absence or downregulation on melanocytes may be associated with autoantibody and complement-mediated melanocyte destruction in vitiligo. OBJECTIVES: We studied the expression of these regulatory proteins in non-lesional, perilesional and lesional vitiligo skin compared with those of control specimens. METHODS: We used immunohistochemistry to study the expression of the regulatory proteins, and flow cytometric analysis of cultured melanocytes to investigate possible constitutive changes in the expression levels of these molecules. We also investigated whether melanocytes can influence keratinocyte susceptibility to autologous complement by regulating keratinocytic decay accelerating factor and membrane cofactor protein expression levels. RESULTS: Immunohistochemical data showed that expression of membrane cofactor protein and decay accelerating factor in whole epidermis was lower in lesional and perilesional skin in comparison with non-lesional skin. The reduced in situ expression appeared to be specific to vitiligo. However, coculture experiments indicated that melanocytes do not influence keratinocyte susceptibility to autologous complement. Further, flow cytometric analysis of cultured melanocytes convincingly demonstrated that non-lesional vitiligo and control melanocytes have comparable decay accelerating factor, membrane cofactor protein and CD59 expression levels. CONCLUSIONS: It is therefore concluded that there is no constitutive melanocyte defect per se that could be related to the in vivo expression of these molecules in vitiligo. Nevertheless, the present data suggest that both keratinocytes and melanocytes in the involved vitiliginous whole epidermis express lower levels of decay accelerating factor and membrane cofactor protein compared with controls that could render them more vulnerable to autologous complement attack.

Antigens, CD↗

PubMed1997

The progression of nonsegmental vitiligo: clinical analysis of 318 patients.

BACKGROUND: Vitiligo is an acquired disorder with destruction of melanocytes and is characterized by cutaneous depigmentation with a progressive clinical course. We attempted to evaluate whether there was a relationship between the initial site and ultimate progression of nonsegmental vitiligo. METHODS: Three hundred and eighteen nonsegmental vitiligo patients were examined. Questionnaires regarding age, sex, duration of disease, family history, distribution of initial lesions, progression, and clinical type were recorded from personal interviews and case notes. RESULTS: Two hundred and eighty nine (90.9%) of the 318 patients showed progression of vitiligo at the time of examination. When the initial sites were the posterior trunk, hands, or feet, there was more progression of vitiligo to other body areas. The progression pattern was usually contiguous to the initial site. When the hands were the initial site, however, vitiligo most commonly progressed to the face. CONCLUSIONS: There may be a possible relationship between the initial site and ultimate progression of nonsegmental vitiligo. The progression pattern is usually contiguous to the initial site.

Back↗

PubMed2003

Narrow-band UV-B micro-phototherapy: a new treatment for vitiligo.

BACKGROUND: Vitiligo is a common, acquired, often familial, melanocytopenic disorder with focal depigmentation of the skin. There are several new treatments, that appear to have higher success rates than previous therapies for the treatment of vitiligo. Among these, the most promising one appears to be narrow-band UV-B therapy. OBJECTIVE: The aim of this open study is to evaluate the efficacy of the BIOSKIN micro-phototherapy in the treatment of vitiligo in 734 patients. SUBJECTS AND METHODS: Seven hundred and thirty-four individuals affected by vitiligo (segmental and non-segmental) were treated for 12 months with a new device called BIOSKIN that can produce a focused beam of narrow UV-B (microphoto-therapy) on vitiligo patches only. Photographs of the subjects were taken at the beginning of the therapy and every month thereafter for 12 months. The response to treatment was estimated in two comparable photographs using planimetry. The duration of the clinical study was of 2 years and 8 months. At the end of this period 734 patients had received each a mean of 24 sessions of treatment during a period of 12 months. RESULTS: Five hundred and ten subjects (69.48%) of the 734 achieved normal pigmentation on more than 75% of the treated areas. In particular, 112 of these were totally repigmented. One hundred and fifty-five (21.12%) individuals achieved 50-75% pigmentation of the treated areas, and 69 (9.40%) showed less than 50% repigmentation. No patients showed acute or chronic relevant adverse effects. CONCLUSION: BIOSKIN UV-B microphototherapy seems highly effective in restoring pigmentation in patients affected by vitiligo. As no side-effects have been observed, this could represent the treatment of choice for vitiligo limited to less than 30% of the skin surface.

Adolescent↗

PubMed2002

Transfer of vitiligo after allogeneic bone marrow transplantation.

Adoptive transfer of donor immunity has been demonstrated in animals after bone marrow transplantation (BMT). In humans, several autoimmune diseases have been similarly transferred. Although BMT may, per se, be associated with a modulation of the recipient's immune system, which could trigger or even cause autoimmune diseases, both animal experiments and experience with humans show the likeliness of adoptive transfer of donor immunity to the recipient. We describe a patient with multiple myeloma in whom generalized vitiligo developed within 3 months after allogeneic BMT from his HLA-matched sister with vitiligo. We believe that a form of adoptive transfer of donor immunity to the recipient might play a role in the development of vitiligo. In spite of this, neither de novo development of vitiligo in a genetically predisposed patient nor autoimmune phenomena associated with graft-versus-host disease can be completely excluded as a contributing factor for development of vitiligo in our patient. To our knowledge, this is the first case report of transfer of vitiligo after BMT from a donor with vitiligo.

Adult↗

PubMed2003

Narrowband ultraviolet B radiation therapy for recalcitrant vitiligo in Asians.

BACKGROUND: Narrowband ultraviolet B (NBUVB) has recently been reported to be effective therapy for vitiligo. However, reports on its efficacy in recalcitrant vitiligo are lacking. OBJECTIVE: Our objective was to assess the efficacy of NBUVB in patients with vitiligo who did not respond to either topical therapy or oral psoralen plus ultraviolet A (PUVA). METHOD: This was a retrospective analysis of patients with vitiligo who were treated with NBUVB from February 1998 to January 2001. They received NBUVB treatment 2 times per week, with an initial dose of 100 mJ/cm(2). The dose was increased by 10% to 20% per treatment for 20 treatments. The dose was then increased by 2% to 5% per treatment until 50% repigmentation was observed or persistent erythema developed. The treatment was continued until maximum repigmentation was achieved. The treatment was terminated if the patient showed less than 25% improvement after 40 to 50 exposures. RESULTS: There were 60 patients: 22 men and 38 women, aged 11 to 61 years. The mean duration of vitiligo was 8.2 +/- 7.1 years. There were 53 cases of generalized and 7 cases of localized vitiligo. The lesions covered from less than 5% to 50% of body surface. Twenty-five patients were skin type III, 33 patients were skin type IV, and 2 patients were skin type V. Every case had been previously treated with topical steroid with or without topical psoralen with solar light exposure. Thirty-six patients (60%) had been treated with oral PUVA before NBUVB therapy. After NBUVB treatment, 25 of 60 patients (42%) achieved more than 50% repigmentation on face, trunk, arms, and legs. However, hand and foot lesions showed less than 25% repigmentation in all cases. There was no significant difference between the responders and nonresponders in age, sex, duration of diseases, and skin type. The response rate of patients who had not been previously treated with PUVA was significantly higher than that of patients who had been previously treated with PUVA (67% vs 36%, P =.003). CONCLUSION: This retrospective, open study demonstrated that NBUVB therapy was effective in 42% of Asian patients with recalcitrant vitiligo without serious side effect. The only clinical parameter that could differentiate nonresponders from responders was previous exposure to PUVA.

Adult↗

PubMed2002

Treatment of vitiligo vulgaris with narrow band UVB (311 nm) for one year and the effect of addition of folic acid and vitamin B12.

Narrow band UVB is succeeding psoralen and UVA irradiation as the main treatment of vitiligo vulgaris in several European countries. Vitamin B12 and folic acid deficiency in some vitiligo patients has prompted researchers to investigate the efficacy of these vitamins in the treatment of vitiligo. In the present controlled study we investigated the value of narrow band UVB phototherapy in the treatment of vitiligo and the possible additive effect of vitamin B12 and folic acid. Twenty-seven patients with long-term stable vitiligo were included and randomized in a "UVB only" (UVB) or "UVB combined with vitamin B12 and folic acid" (UVB+) group. Patients were irradiated thrice weekly for one year, whilst repigmentation was carefully monitored. In 92% (25/27) of the patients up to 100% repigmentation was seen. Repigmentation was notable in lesions on the face, neck and throat, lower arm, chest, back and lower legs, whilst repigmentation on the hands, wrists, feet and ankles proved to be minimal. Maximum repigmentation rates did not differ significantly between the UVB group and the UVB+ group. Our study reconfirms that narrow band UVB phototherapy is an effective treatment for vitiligo and shows that co-treatment with vitamin B12 and folic acid does not improve the outcome of treatment of vitiligo with narrow band UVB phototherapy.

Analysis of Variance↗

PubMed2006

Treatment of vitiligo using the 308-nm excimer laser.

OBJECTIVE: The aim of this study was to study the effectiveness of the 308-nm xenon chloride excimer laser in the treatment of vitiligo and to determine factors that favor a good response to treatment. BACKGROUND DATA: Targeted phototherapy using the 308-nm xenon chloride excimer laser represents an effective therapy for the management of vitiligo. However, studies on a large number of patients are few despite the increasing use of the excimer laser to treat patients with vitiligo. METHODS: A retrospective chart review of 97 patients with chronic stable vitiligo was done with a total of 221 vitiligo patches treated. RESULTS: Out of 221 vitiligo patches treated, 50.6% showed 75% pigmentation or more, 25.5% achieved 100% pigmentation of their patches, and 64.3% showed 50% pigmentation or more. Lesions on the face responded better than lesions elsewhere. CONCLUSION: The 308-nm xenon chloride excimer laser is an effective and safe modality for the treatment of vitiligo, with good results achieved in a relatively short duration of time.

Adolescent↗

PubMed2004

Inflammatory changes in vitiligo: stage I and II depigmentation.

Frequent failure of early studies to demonstrate inflammatory changes in vitiligo led many investigators to consider the disease as noninflammatory. However, others found an inflammatory element in vitiliginous lesions. In this study we tried to verify that assumption. Twenty-five patients (10 males and 15 females) with common vitiligo and 11 normal healthy individuals were included. Histopathologic studies were carried out using epon-embedded sections stained with modified toluidine blue stain. Comparisons of the results of histopathologic examination of the stained specimens of vitiliginous lesions (both stage I and II), marginal areas, and uninvolved normal skin of vitiligo patients with normal healthy control were performed. Focal spongiosis was observed in 48% of the specimens of vitiligo patients and largely limited to the marginal areas and stage I vitiligo lesions. Epidermal mononuclear cell infiltration was seen in 80% of both the marginal areas and stage I vitiligo specimens. The number of these cells was significantly higher than that in stage II lesions and uninvolved skin. Many of the epidermotropic lymphocytes were grouped together, forming clusters resembling Pautrier microabscesses. The extent of epidermal mononuclear cell invasion did not always parallel the density of the subjacent dermal infiltrate. Vitiligo is an inflammatory disease, and the epidermal lymphocytic infiltration is most likely the primary immunologic event.

Adolescent↗

PubMed2004

Is there any relationship between hepatitis C virus and vitiligo?

GOALS AND BACKGROUND: Hepatitis C virus (HCV) is a hepatotropic and lymphotropic virus. This agent can promote development of a panel of autoimmune diseases. The relationship between HCV infection and vitiligo, in which autoimmune mechanisms are believed to play a role is not yet elucidated. In this study we investigated HCV seropositivity in vitiligo patients and compared this with non-vitiligo population. STUDY: A total of 102 consecutive patients with vitiligo were included in the study (47 male, 55 female, mean age: 36.8 +/- 16.9 years, range: 5-75). Control population was 670 age and sex matched healthy blood donors (406 male, 264 female, mean age: 32.8 +/- 11.3 years, range: 20-58). Third generation enzyme immunoassay was used for serum anti-HCV determination. When positive, qualitative confirmation was performed by HCV-RNA determination using RT-PCR. RESULTS: Anti-HCV antibody was detected only in 1 patient and confirmed by RT-PCR test. This patient was a 6-year-old girl with a non-segmental form of vitiligo, which is more frequently associated with autoimmune disorders, hence the incidence of HCV seropositivity found as 0.98%. There was no statistically significant difference between this figure and 0.6% prevalence in healthy blood donors. CONCLUSION: Seroprevalence of HCV in vitiligo patients is not different from that of a control group in Turkey, and HCV infection may not be involved in the pathogenesis of vitiligo despite case reports showing co-existence of these 2 diseases.

Adult↗

PubMed1982

Demonstration of tyrosinase in the vitiligo skin of human beings by a sensitive fluorometric method as well as by 14C(U)-L-tyrosine incorporation into melanin.

Tyrosinase activity (Monophenol, dihydroxyphenylalanine: oxygen oxidoreductase EC 1.14.18.1) in vitiligo and normal epidermal homogenates of skin from human beings was measured by estimating beta 3,4-dihydroxyphenylalanine (dopa) by a highly sensitive fluorometric method described in this paper. The tyrosine activity in the vitiligo skin was about 4 to 37% of corresponding normal skin. The activity of tyrosinase in normal human skin from different individuals and from different regions of the body was in the range of 4 to 140 picomoles of beta 3,4-dihydroxyphenylalanine formed per min/mg protein of epidermal homogenate. The enzyme from vitiligo and normal skin was severely inhibited by substance(s) of low molecular weight. The enzyme exhibits a lag of about 4 hr in the absence of added beta 3,4-dihydroxyphenylalanine and 1 hr in presence of 5 microM dopa. Tyrosinase from the normal and vitiligo skin was inhibited by excess concentration of tyrosine. The homogenates from vitiligo skin could synthesize melanin from C14(U)-L-Tyrosine. The rate of tyrosine incorporation into melanin by the epidermal homogenates is increased by 3,4-dihydroxyphenylalanine (dopa) disproportionate to its effect on tyrosinase activity. Based on the data presented in this paper it is concluded that melanocytes are present in the vitiligo skin. A tentative hypothesis is put forward to explain the lack of melanin synthesis by the vitiligo skin under in vivo conditions, although melanocytes are present.

Cadaver↗

PubMed1992

Molecular heterogeneity of the fourth component of complement (C4) and its genes in vitiligo.

In view of evidence suggesting vitiligo is an autoimmune disease, we investigated whether vitiligo is associated with inherited deficiencies of the fourth (C4) and second (C2) component of complement and with certain human leukocyte antigens (HLA). Analysis of functional activities of C4 and C2 in sera of patients with vitiligo (n = 42) showed that 17% of them had a heterozygous C4 deficiency and 5% had a heterozygous C2 deficiency. In the normal control group (n = 30), 3% had a heterozygous C4 deficiency and none had a C2 deficiency. C4 typing by Western blot analysis showed the frequency of the C4A*Q0 allele in the vitiligo patient group to be close to normal. However, the frequency of one C4B*Q0 allele was three times higher, and that of two C4B*Q0 alleles five times higher in the vitiligo patient group than the reported frequencies in normal control groups. Southern blot analysis of Taq1 digests of DNA using C4 and 21-hydroxylase probes showed that two patients with two C4B*Q0 alleles had a deletion of a 21-OHA-C4B segment. In the other patients, having one or two C4B*Q0 alleles, these null alleles probably occurred due to a loss of C4 gene expression. HLA analysis did not show any allelic association of C4A*Q0 or C4B*Q0 with any HLA antigen in vitiligo, but confirmed the previous findings of a negative association with HLA-DR3 and a positive association with HLA-DR4. These results suggest that abnormalities of the C4B gene and the above-mentioned associations with HLA antigens may be some of the risk factors in vitiligo.

Adrenal Hyperplasia, Congenital↗

PubMed1992

Epidermal changes in active vitiligo.

Light and electron-microscopic studies were performed on the vitiligo and adjacent, normal appearing skin from 97 patients with actively spreading vitiligo and 19 patients with stable vitiligo. The vitiliginous skin revealed complete loss of pigment and melanocytes. In addition to degenerative changes in melanocytes, vacuolar changes of basal cells, epidermal infiltration of lymphocytes, dermal infiltration of lymphocytes, and melanophages in the upper dermis were also seen in the normal appearing skin adjacent to vitiliginous skin. These epidermal and dermal changes are more prominent in the skin of actively spreading vitiligo than in stable vitiligo. These findings suggest that the adjacent, normal appearing skin of actively spreading vitiligo shows some characteristic histopathologic findings, especially in the epidermis, indicating that cellular immunity could be involved in the pathogenesis of vitiligo.

Acute Disease↗

PubMed2002

Decreased total numbers of peripheral blood lymphocytes with elevated percentages of CD4+CD45RO+ and CD4+CD25+ of T-helper cells in non-segmental vitiligo.

Vitiligo is a disorder involving progressive skin depigmentation caused by host mediated destruction of melanocytes. Its pathogenesis is known to correlate with elevated levels of activated skin-infiltrating T lymphocytes and is presumed to be autoimmune in nature. In the present study, we characterize the immunophenotype of peripheral blood T cells from vitiligo patients, with the objective of developing an investigative and diagnostic tool for the disease, using analysis of peripheral blood. Subjects for this investigation included 32 patients diagnosed with non-segmental vitiligo and 28 age-and gender-matched, normal, healthy control participants. Whole venous blood taken from each subject was analyzed using 2-color flow cytometry for immunologically-relevant lymphocyte subsets. When compared with healthy control subjects, peripheral blood from individuals with vitiligo was found to have lower total numbers of lymphocytes (p<0.039). Vitiligo patients also had elevated percentages of memory (CD4+CD45RO+) T cells; (p<0.05), but NK-T cells (CD3+CD16+CD56+) and naive T cells (CD4+CD45RA+) were present at lower total numbers and percentages than in healthy controls (p<0.01 and 0.05 respectively). Blood from severely afflicted subjects exhibited elevated CD3+HLADR+ and CD4+CD45RO+ as well as lower percentages of NK-T cells (p<0.05) when compared with mild cases. In conclusion, disease-associated, peripheral blood lymphocyte immunophenotypic profiles of vitiligo patients are consistent with the hypothesis of T cell activation as a major feature of the disorder. These include elevated memory and reduced naive T cell percentages and increased expression of the activation-associated surface antigen CD25. These changes presumably reflect increased antigen-mediated activation. Moreover, because a corollary effect is increased activation-induced cell death (AICD), lower overall lymphocyte counts observed in vitiligo-afflicted subjects is also expected.

Adolescent↗