Coexistence of Two Autoimmune Diseases: A Case of Colocalized

Vitiligo and Psoriasis in One Person

Ariska Silviani

, Eyleny Meisyah Fitri

, Sammy Yahya

, Yari Castiliani Hapsari

Saskia Retno Ayu Hapsari

Department of Dermatology and Venereology Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo

National Central General Hospital, Indonesia

Department of Dermatology and Venereology Faculty of Medicine Universitas Indonesia/ Tarakan Regional General

Hospital, Indonesia

*Corresponding author

Keywords: Coexistence, psoriasis, vitiligo

Abstract: Vitiligo and psoriasis are autoimmune diseases. The occurrence of both diseases in a single patient,

especially at the same sites, has been considered unusual. Herein, we report a case of coexisting vitiligo and

psoriasis in a patient at the same site. A 40-year-old male visited our Dermatology and Venereology clinic

with a history of white patches all over the body for 20 years and red patches with thick, scaly surfaces for

three years before admission. Physical examination revealed multiple depigmented macules, lenticular-

plaque in size, irregular, circumscribed, discrete-confluent with several erythematous plaques, nummular-

plaque in size, irregular, circumscribed, thick silvery-white scaleswith positive Auspitz sign on the top of

depigmentedmacules. He was diagnosed with vitiligo Vulgaris and Psoriasis Vulgaris and received systemic

therapy, a combination of topical therapy and phototherapy narrowband UVB. The pathogenic mechanism

underlying the coexistence of vitiligo and psoriasis has not been fully elucidated. The Koebner

phenomenon, genetic, and environmental factors have been postulated to be involved in the development of

the two diseases. Comorbid vitiligo and psoriasis is a red flag signaling the need to dig deeper, looking for

potentially associated diseases, including cardiovascular, autoimmune, or psychiatric diagnoses.

1 INTRODUCTION

Vitiligo is a skin depigmentation disease caused

by interactions of genetic and non-genetic factors

causing loss of function of melanocytes, manifesting

as a well-defined depigmented macula surrounded

by healthy skin.(James WD et al., 2011; Jacoeb et

al., 2017). There is no gender difference in vitiligo

and can occur at any age. The incidence of vitiligo is

0.51% of the total population worldwide.(Ezzedine

et al., 2015).

The case of vitiligo with a family

history ranges from 6.2538%, but the genetic

pattern is still debated (Jacoeb et al.,2017).The

etiology of vitiligo is not yet known. Some

hypotheses are related to the etiology of vitiligo,

including the genetic hypothesis, the autoimmune

hypothesis, as well as the biochemical

hypothesis.(Jacoeb et al., 2017;Birlea SA 2012)

The diagnosis of vitiligo can be made based on

history and physical examination.

2,4

Various other

skin disorders that can be found in vitiligo lesions,

including psoriasis Vulgaris, scleroderma, lupus

erythematosus, alopecia areata, Morbus duhring, and

melanoma.

The principle of managing vitiligo is to

induce repigmentation. Spontaneous repigmentation

has been reported in 644% of patients.

Repigmentation is a sign that the lesion is responsive

to therapy. Birlea SA 2012)

Psoriasis is a chronic inflammatory skin disease

with characteristics of changes in epidermal cell

growth and differentiation as well as the presence of

vascular manifestations with a strong genetic basis,

also thought to have a nervous system effect.

The

worldwide incidence and prevalence of psoriasis is

poorly understood. Psoriasis is estimated to effects

about 23% of the world population.(Springate DA

et al., 2017). The etiopathogenesis of psoriasis is still

not clearly known, but the role of autoimmunity and

genetics can be used as a principle of

therapy.(Jacoeb TJA et al., 2017)

Silviani, A., Fitri, E., Yahya, S., Hapsari, Y. and Hapsari, S.

Coexistence of Two Autoimmune Diseases: A Case of Colocalized Vitiligo and Psoriasis in One Person.

DOI: 10.5220/0009987503070311

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 307-311

ISBN: 978-989-758-469-5

307

Clinically, a classic description of psoriasis in the

form of a white squamous encompassing

erythematous plaques with bleeding points if the

scale is released, the lesion can be the size of a

needle tip to a plaque that covers most areas of the

body, usually symmetrical lesions. In addition to the

skin, the involvement of nails, mucosa, and joints

can be found.(Ezzedine K et al., 2015). Psoriasis

diagnosis can be made based on history and physical

examination. Psoriasis treatment aims to reduce the

severity of the disease so that patients can move in

social life, work and prosperity, and also remain in a

condition of good quality of life.

Psoriasis and vitiligo are autoimmune diseases.

Yet the pathogenesis of the association between

these two dermatoses is still unknown. It is

uncommon that the occurrence of both these

diseases in the same patient, especially at the same

sites.Coexistence psoriasis lesions on the top of

vitiligo lesions made this becomes important for

discussion because it is a red flag signaling the need

to dig deeper looking for potentially associated

diseases, including cardiovascular, autoimmune, or

psychiatric diagnoses. Herein, we report on a case of

coexisting vitiligo and psoriasis in the same

individual at the same site.

2 CASE

A 40-year-old male admitted to Dermatology and

Venereology clinic at Tarakan Regional General

Hospital due to thick scaleson red spots since three

years ago that appeared on several white spots

throughout the body since 20 years ago. Initially,

white spots appear on the face, near the lips. Spots

are round, milky white, firmly defined, with a

diameter of about one centimeter. There was no

history of itch, pain, numbness, and redness before.

About five months later, the spots began wider, and

more numerous appear on both hands, legs, thighs,

calves, buttocks, lower back, stomach, and head.

Twenty years ago, the patient went to dermato-

venereologist in Cianjur Hospital. He was diagnosed

with vitiligo and was given a concoction cream that

was applied twice a day and two types of unknown

oral drug that taken one time per day. He was treated

as an outpatient clinic at a hospital in Cianjurfor

approximately three years. However, because there

was no excellent clinical response, then he went to

dermato-venereologist at one of General Hospitals in

Sukabumi. Seventeen years ago, he went to dermato-

venereologist at Sukabumi General Hospital and was

diagnosed with vitiligo. He was treated with liquid

Delsoralen® once a dayand asked to bask for 15

minutes after applying the drug. He was also given

concoction capsules that taken three times per day.

He was treated for five years, but still, there was no

excellent improvement, so that he was referred to

Hasan Sadikin Hospital, Bandung.Twelve years ago,

the patient went to Hasan Sadikin Hospital andwas

diagnosed with vitiligo. The patient is also treated

with liquid Delsoralen® once a dayand asked to

bask after applying the drug.He was treated at Hasan

Sadikin Hospital for about one year. White patches

had not expanded, and there were no new white

spotsnorimprovement.Eleven years ago, the patient

returned to dermato-venereologist in Cianjur. He

seeks treatment in about five of different dermato-

venereologist. Various drugs given by these doctors,

the patient does not remember the details of what

drugs each doctor gave and the duration of treatment

for each doctor. The patient treated for about three

years and received various drugs such as ointment

applied twice a day, pills taken 12 times a day, and

liquid Delsoralen®. Feeling tired and hopeless

because the vitiligo hasn’t healed, the patient didn’t

continue treatment for about eight years. Finally, the

patient went to dermato-venereologist of Tarakan

General Hospital on the advice of the patient's

relatives and because the spots grew wider and

added thick scales on red spots.

Three years ago, the patient complained of reddish-

scaly patches on several white spotsat almost the

entire body. Initially, small red spots appear on the

lower back, left and right elbows and left and right

thighs. Sometimes red patches feel an itch. By the

time, the red spots are more widespread and white

scales thicker than before and also appear in other

areas of the body.

The patient has a history ofuncontrolled

hypertensionsince 1.5 years ago. He denies contact

with chemicals before spots appear. A history of

reddish spots shaped like butterflies on both cheeks

when exposed to the sun, fever, migrating joint pain,

swellingor stiffness in the joints, fatigue, thirst,

hunger, weight loss, natural sweating, palpitation,

trembling in both hands is also denied by the patient.

There is no history of steroid use or long-term drugs,

drug, and food allergies. There is no history of blood

transfusion. The patient also has no history of

anemia and diabetes mellitus.There were complaints

of white spots on other family members, namely the

patient's mother and sister. The patient is married,

lives with his wife and four children in Cianjur,

West Java. He is a teacher who works indoors every

dayand rarely exposed to the sun.

Physical examination revealed hypertension

(180/110 mmHg) and the presence of multiple

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

308

depigmented macules, lenticular-plaque in size,

irregular, circumscribed, discrete-confluent with

several erythematous plaque, nummular-plaque in

size, irregular, circumscribed, silvery-white thick

scales with positive Auspitz sign on the top of

depigmented macules on the scalp, face, bilateral

earlobe, abdomen, back and buttocks, and also

bilateral upper and lower limbs. (Figure 1) There

were also pitting nails in the entire finger of both

hands. Body Surface Area (BSA) of vitiligowas

28%while that of psoriasiswas 25% with Psoriasis

Area and Severity Index (PASI) score was

9.5.Laboratory examination including complete

blood counts, differential leukocyte counts, liver

function test, renal function test, and thyroid

function test was within normal limits,

excepthyperglycemia(324 mg/dL) and positive

antinuclear antibody with the titer of 1:320.

Based on the history and physical examination, a

clinical diagnosis of coexisting vitiligo Vulgaris and

psoriasis Vulgaris was made. He was treated with

systemic corticosteroids, a combination of topical

therapy and narrowband UVB phototherapy.

Methylprednisolone 8 mg twice a day was given as

systemic therapy for two daysper week. He applied a

combination of 3% ichthyol and 10% zinc oxide in

0.025% fluocinoloneacetonide cream twice a day on

white patches, and a combination of 3% salicylic

acid, 5% liquor carbonic detergent, and0.25%

desoximetasone ointment twice a day on

erythematous plaques. Patients also

underwentwhole-body narrowband UVB

phototherapy twice a week with an initial dose of

200 mg/cm

and increased by 10% per

visit.Hesubsequently consulted the internist to

control his blood pressure and to evaluate his blood

glucose.

Figure 1. Presence of multiple depigmented macules,

lenticular-plaque in size, irregular, circumscribed,

discrete-confluent with several erythematous plaques,

nummular-plaque in size, irregular, circumscribed, thick

silvery-white scales with positiveAuspitz sign on the top

of depigmented macules.

3 DISCUSSION

The coexistence of psoriasis and vitiligo is rare.

Relatively few reports of concomitant and

colocalized psoriasis and vitiligo are available. In

this case, diagnosis vitiligo Vulgaris and psoriasis

Vulgaris were established based on history and

physical examination.The location of the patient's

depigmented lesions was almost the entire body's

area which is categorized in general vitiligo or

vitiligo Vulgaris. Vitiligo Vulgaris is characterized

by lesions in the form of multiple homogeneous

milky white macules which are clearly demarcated,

scattered, and less symmetrical.(Jacoeb et al 2017).

Vitiligo Vulgaris is associated with a number of

conditions and autoimmune diseases.Genetic factors

are thought to play a role in the onset of vitiligo

lesions, the percentage ranges from 6.25%–38% and

the genetic pattern is still debated. (Ezzedine

K et

al., 2015). In this patient, genetic predisposition was

found where the older siblings of the patient's

mother suffered from vitiligo.

The clinical variants of psoriasis include

psoriasis Vulgaris, gutata psoriasis, pustular

psoriasis, nail psoriasis, arthritis psoriasis, and

erythroderma. (Jacoeb TJA et al., 2017) Psoriasis

Vulgaris is found in about 90% of psoriasis patients.

Lesions generally begin with an erythematous

macula less than one centimeter in size or in the

form of a papule that extends, and several lesions

Coexistence of Two Autoimmune Diseases: A Case of Colocalized Vitiligo and Psoriasis in One Person

309

coalesce so that the size can reach several

centimeters.Lesions are usually found in the scalp,

elbow, knee, back, lumbar, and retro auricular.

(Jacoeb TJA et al., 2017). Theclinical manifestation

and predilection sites on this patient are categorized

in psoriasis Vulgaris. Determination of psoriasis

severity is vital to determine the treatment given to

patients. It measures the severity of psoriasis,

including BSA, PASI, dermatology life quality

index (DLQI). Mild psoriasis is categorized with

BSA of less than 3%, and severe psoriasis with BSA

more than 10%.

In this case, psoriasis BSA is about

25% which is categorized in severe psoriasis.

Topical corticosteroid has been used for vitiligo

as monotherapy or combination with other

modalities, such asfluocinoloneacetonide cream,

betamethasone cream, and clobetasol propionate

cream.Systemic corticosteroid was givenfor

progressive vitiligo. It helps to halt the progression

of the disease and inducingrepigmentation. There are

only several studies published the efficacy and

safety of corticosteroid in vitiligo. The available

reports are case series and lack of well-validated

randomized controlled trials. Systemic corticosteroid

in vitiligo can be administered by oral mini pulse

therapy, daily corticosteroid, and intravenous pulse

therapy.(Lahiri K et al., 2014;Lee J et al., 2016).

reported that oral mini pulse therapy of

methylprednisolone 0.5mg/kg body weight on 2

consecutive days per week with narrowband UVB

phototherapy for 3 months is useful in arresting

vitiligo progression and rapidly inducing

repigmentation with minimal side effect. In this

case, we administered 8 mg oral methylprednisolone

twice a day for two days per week, which

combination with narrowband UVB phototherapy

twice a week, as well as topical corticosteroid.

Several theories have been proposed to explain

the co-occurrence of vitiligo and psoriasis. Reports

of the concomitant disease often describe underlying

autoimmune conditions, suggesting that these

diseases may develop through similar autoimmune

mechanisms. (Puri N et al., 2013).reported that the

presence of psoriasis lesions above the vitiligo

lesions showed an association with increased

production of IL-17A produced by Th17 cells and an

increase in the number of regulatory T cells in the

two entities. Several genetic locus vulnerabilities in

psoriasis and vitiligo have been mapped. The genetic

locus for vitiligo, namely AISI found on the IP 31

chromosome, is located close to the genetic

susceptibility locus for psoriasis, PSORS7.

A recent case-control study of 463 vitiligo

patients, 27 with concomitant psoriasis (2 cases of

colocalized disease), was conducted to investigate

possible associations between vitiligo and

psoriasis.(Bassiouny DA, 2010). The strongest

predictors of concomitant psoriasis were

inflammatory-type vitiligo and a positive family

history of cardiovascular disease.(Arunachalam M et

al., 2014).The authors suggest that common

inflammatory pathways and genetic susceptibility

may explain this association of psoriasis, vitiligo,

and cardiovascular risk factors.

The coexistence of psoriasis Vulgaris limited to

the area of vitiligo lesions can be produced from the

Koebnerphenomenon.

Occurrence of lesions of both

these diseases at same sites predominantly over the

extensors of joints is probably due to chronic minor

friction/ trauma over these sites. (Chakraborty D rt

al., 2017).Coexistence of both vitiligo and psoriasis

lesions over the extensors of joints and his

extremities in the present case can be explained by

this Koebner’s phenomenon.

Other factors that are thought to be for

coexistencevitiligo with psoriasis, namely

cytokines.Cytokines such as TNF-α may have

played a vital role in the pathogenesis of the

coexistent diseases.(Shaequie KE et al., 2017). TNF-

 is the main cytokine whose levels are elevated in

psoriasis lesions, where the increase is also found to

increase in the lesion of vitiligo patients, so TNF-

is thought to be associated with the condition of both

diseases.(Park JM et al., 2009).

4 CONCLUSION

Coexistence of vitiligo and psoriasis in a single

patient furthermore at the same location is a rare

occurrence. An underlying autoimmune condition

has to be thought for when such coexistence is seen.

Pathogenesis of the coexistence between psoriasis

and vitiligo, are still not well understood. The

pathogenic factors for each disease, includes

cytokines, autoimmunity, and the Koebner

phenomenonhave been studied, but further

evaluation is needed regarding the mechanism of its

pathogenesis.Coexistence vitiligo and psoriasis is a

red flag signaling the need to dig deeper, looking for

potentially associated diseases, including

cardiovascular, autoimmune, or psychiatric

diagnoses.

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