Vitiligo is a skin disease characterized by loss of melanocytes resulting in depigmentation of skin, hair, or mucous membranes. Several theories exist to discern the pathogenesis of melanocyte loss, or loss of function.¹ The strong association of vitiligo with other comorbid autoimmune conditions suggests that vitiligo should be categorized as an autoimmune disease. The vast array of autoimmune conditions associated with vitiligo, together with other comorbid conditions, are highlighted below. 

Autoimmune diseases 

Autoimmune diseases are closely correlated with vitiligo. In the United States, an estimated 10% to 15% of patients with vitiligo have one or more comorbid autoimmune disorders as opposed to 3% in the general population.^2,3 Thyroid disease is among the most commonly associated autoimmune diseases, however, vitiligo is associated with a multitude of other autoimmune diseases as listed below.^4,5 It is important to note that associations with comorbid diseases vary widely based on the study population and geographical locations of patient populations. 

Autoimmune comorbidities with a higher prevalence among patients with vitiligo^4,5: 

• Alopecia areata 
• Diabetes mellitus Type 1 
• Discoid lupus erythematosus 
• Guillain-Barre syndrome • Inflammatory bowel disease 
• Linear morphea 
• Myasthenia gravis 
• Pernicious anemia
• Rheumatoid arthritis 
• Sjögren syndrome 
• Systemic lupus erythematosus 
• Systemic sclerosis 
• Thyroid disease 

Thyroid disease 

Of the long list of autoimmune conditions associated with vitiligo, thyroid disease is one of the most well-studied. Patients with vitiligo have shown a higher prevalence of autoimmune thyroiditis, hypothyroidism, hyperthyroidism, Graves’ disease, Hashimoto thyroiditis, and thyroid cancer.⁵ The prevalence of thyroid disease in patients with vitiligo varies widely, with estimates ranging from 1.61% to 37% compared to 1% of the general population.⁴ 

Psychiatric comorbidities 

Patients with vitiligo also have a higher prevalence of some psychiatric diseases, including body dysmorphic disorder, adjustment disorders, impulse control disorders, developmental disorders, risk of suicide or self-inflicted injury, attention deficit hyperactivity disorder, disruptive behavioral disorders, and obsessive-compulsive disorder.⁵ Interestingly, some studies have shown patients with vitiligo may have lower odds of developing an anxiety disorder, depression and mood disorders, schizophrenia, and substance abuse disorders.⁵ 

Other comorbidities 

Melanocytes are present in the eye (uveal tract and retinal pigment epithelium) and ear (membranous labyrinth of the inner ear),⁴ and ocular abnormalities including hypopigmented spots of the iris and retinal pigment epithelium have been identified. Patients with vitiligo may have decreased visual acuity, increased risk of dry eye syndrome, and normal tension glaucoma. Sensorineural hearing loss is found in patients with vitiligo in higher proportion than in the general population.⁴ 

Vitiligo is linked to a higher proportion of chronic skin diseases such as atopic dermatitis, psoriasis, lichen planus, and chronic urticaria in various studies.^4,5 Patients with vitiligo have also been found to have higher prevalence of asthma, allergic rhinitis, and metabolic diseases such as metabolic syndrome and diabetes mellitus.⁵ 

Conclusion 

Vitiligo is a disease that results in skin depigmentation. However, the comorbid conditions associated with vitiligo go beyond the skin as the disease is associated with several comorbid conditions that providers should be aware of. Patients with vitiligo should be appropriately assessed for comorbid autoimmune diseases, ocular, and audiology deficits when indicated. Providers should also be cognizant of the psychosocial impact that vitiligo may have on patients. 

Vitiligo is a disease that results in skin depigmentation, but the comorbid conditions associated with it go beyond just the skin. Patients with vitiligo should be appropriately assessed for autoimmune diseases, ocular, and audiology deficits when indicated. Providers should also be cognizant of the psychosocial impact that vitiligo may have on patients. 

With many comorbidities associated with this disease, it’s vital that clinicians explore these conditions to ensure comprehensive care for their patients with vitiligo. 

References: 

1. .Rashighi M, Harris JE. Vitiligo pathogenesis and emerging treatments. Dermatol Clin. 2017;35(2):257-265. doi:10.1016/j.det.2016.11.014 
2. Gill L, Zarbo A, Isedeh P, Jacobsen G, Lim HW, Hamzavi I. Comorbid autoimmune diseases in patients with vitiligo: a cross-sectional study. J Am Acad Dermatol. 2016;74(2):295-302. doi:10.1016/j.jaad.2015.08.063 
3. Cooper GS, Stroehla BC. The epidemiology of autoimmune diseases. Autoimmun Rev. 2003;2(3):119-125. doi:10.1016/s1568-9972(03)00006-5 
4. Dahir AM, Thomsen SF. Comorbidities in vitiligo: comprehensive review. Int J Dermatol. 2018;57(10):1157-1164. doi:10.1111/ijd.14055 
5. Lee JH, Ju HJ, Seo JM, et al. Comorbidities in patients with vitiligo: a systematic review and meta-analysis. J Invest Dermatol. 2023;143(5):777-789.e6. doi:10.1016/j.jid.2022.10.021