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Comparative Study of Vitiligo, Halo Nevus, and Vitiligoid Variant of Lupus

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Comparative Study of Vitiligo, Halo Nevus, and Vitiligoid Variant of Lupus RevistaN2V80.qxd 06.05.05 11:54 Page 143 143 Investigação Clínica, Epidemiológica, Laboratorial e Terapêutica Estudo comparativo entre vitiligo, nevo halo e lúpus eritematoso vitiligóide por meio de métodos imunológicos, histológicos e imuno-histoquímicos* Comparative study of vitiligo, halo nevus, and vitiligoid variant of lupus erythematosus by immunological, histological, and immunohistochemical methods* Luiz Gonzaga C. Souza Filho1 Evandro A. Rivitti2 Lucy M. Miyauchi3 Mirian N. Sotto4 Durvanei A. Maria5 Shigueko S. T. Puejo6 Venâncio A. F. Alves7 Resumo: FUNDAMENTOS: O estudo compara o vitiligo, o nevo halo (NH) e lúpus eritematoso vitiligóide (LEV) do ponto de vista imunológico, histo- lógico e histoquímico. OBJETIVOS: Avaliar diferenças imuno-histoquímicas entre essas doenças e investigar se a despigmentação do LEV deve-se à destruição pós-inflama- tória ou à agressão imunológica aos melanócitos. MÉTODOS: Foram avaliados 20 pacientes com vitiligo, 17 com vitiligo e NH, cinco com NH isolado e 15 com LEV. Detecção de anticorpos: IF direta e indireta com células névicas e de melanoma. Citotoxicidade: atividade NK contra células de melanoma. Estudo anátomo-histoquímico: exame histológico com hematoxilina e eosina, Fontana-Masson, Dopa e Dopa mais prata (D+P) e exame histoquímico com proteína S-100. RESULTADOS: Doentes com vitiligo, NH e LEV apresentaram anticorpos antimelanócitos. Tanto no vitiligo e NH, como no LEV, demonstrou-se a pre- sença de fatores de risco favorecedores da citotoxicidade celular. A coloração com D+P foi superior às colorações tradicionais e à proteína S-100 na detecção de melanócitos e melanina nas lesões de vitiligo, NH e LEV. CONCLUSÕES: Demonstrou-se a existência de anticorpos antimelanócitos no vitiligo e NH. É possível que a despigmentação no LEV se deva a fenômenos imu- nológicos semelhantes aos do vitiligo e NH. A detecção de melanócitos nas lesões de vitiligo sugere mais inibição funcional do que destruição dessas células. Palavras-chave: Alergia e Imunologia; Lúpus; Nevo pigmentado; Vitiligo. Abstract: BACKGROUND: There are no records of comparative studies on the immunological, histological and immunohistochemical aspects of vitiligo, halo nevus and vitiligoid variant of lupus erythematosus in the literature. The studies available present only descriptive clinical data on leucoderma that accompanies lupus erythematosus in its diverse clinical forms. OBJECTIVES: 1- To evaluate the immunohistochemical differences between vitiligo, halo nevus and vitiligoid variant of lupus erythematosus; 2- To verify whether the depigmentation observed in the diverse clinical forms of lupus is due to post-inflammatory destruction or to specific immunological attack on melanocytes. METHODS: 1- Detection of melanocyte antibodies: by direct and indirect immunofluorescence on nevus and melanoma cells; 2- Cytotoxicity evaluation: study of the activity of NK cells against cultivated melanoma cells; 3- Histopathological study of melanocytes and melanin: histopathology with hematoxylin-eosin, Fontana- Masson, Dopa and Dopa + silver and S-100 protein test by immunoperoxidase. RESULTS: Vitiligo and halo nevus patients presented to antimelanocyte antibodies in 25% of cases. Patients with vitiligoid variant of lupus erythematous also presented these antibodies. The presence of risk factors favoring cellular cytotoxicity was demonstrated in vitiligo and/or halo nevus, as well as in the vitiligoid variant of lupus erythematous.. Staining with Dopa + silver nitrate was superior to traditional staining and to S-100 protein to detect melanocytes and/or melanin in depigmented lesions of vitiligo and/or halo nevus and vitiligoid variant of lupus erythematous. CONCLUSION: The results confirm the existence of antimelanocyte antibodies in vitiligo and halo nevus. It is not possible to rule out some immunological phenomena similar to those occurring in vitiligo and halo nevus in the genesis of vitiligoid lesions in lupus erythematous. The detection of melanocytes in achromic lesions of vitiligo suggests the predominance of a functional inhibitory mechanism rather than cell destruction in the genesis of the disease. Keywords: Allergy and immunology; Lupus; Nevus, pigmented; Vitiligo. Recebido em 03.05.2004. Aprovado pelo Conselho Consultivo e aceito para publicação em 25.02.2005. * Trabalho realizado na Divisão de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (SP). 1 Professor adjunto da Disciplina de Dermatologia do Departamento de Medicina Tropical da Universidade Federal de Pernambuco (PE). 2 Professor titular do Departamento de Dermatologia do Hospital das Clínicas da Universidade de São Paulo (SP). 3 Bióloga do Departamento de Dermatologia do Hospital das Clínicas da Universidade de São Paulo (in memoriam) (SP). 4 Professora adjunta do Departamento de Anatomia Patológica da Universidade de São Paulo (SP). 5 Técnico do Laboratório de Investigação em Hematologia da Faculdade de Medicina da Universidade de São Paulo (SP). 6 Técnica do Laboratório de Cultura Celular da Disciplina de Oncologia do Departamento de Clínica Médica da Universidade de São Paulo (SP). 7 Professor adjunto do Departamento de Anatomia Patológica da Universidade de São Paulo (SP). ©2005 by Anais Brasileiros de Dermatologia An Bras Dermatol. 2005; 80(2):143-8. RevistaN2V80.qxd 06.05.05 11:54 Page 144 144 Souza Filho LGC, Rivitti EA, Miyauchi LM, Sotto MN, Maria DA, Puejo SST, Alves VAF. INTRODUÇÃO O vitiligo caracteriza-se pela destruição progres- térios de positividade adotados foram os padronizados siva dos melanócitos com conseqüente diminuição ou para cada uma das técnicas. As reações de IF eram lidas ausência da produção de melanina. É possível que por três observadores e só consideradas positivas com a configure síndrome, com mecanismos etiopatogêni- concordância de todos. Desenho do estudo: transversal. cos diversos que se exteriorizam com padrão clínico semelhante. Três hipóteses etiológicas se destacam: MÉTODOS LABORATORIAIS neurogênica, autodestrutiva e imunológica.1,2 A) Estudo imunológico Embora os fatores etiopatogênicos possam A1) Para detecção de anticorpos antimelanócitos atuar isolada ou conjuntamente, a hipótese imunoló- Utilizou-se como substrato lesões de nevo nevo- gica é a que apresenta evidências clínicas e experi- celular dos doentes e células de melanoma cultivadas. As mentais mais consistentes. A antigenicidade dos mela- reações foram: 1) imunofluorescência direta (IFD), 2) nócitos é fortemente sugerida, no nevo halo, pela pre- imunofluo- rescência indireta (IFI) e 3) imunofluores- sença de infiltrado linfocitário, pela regressão espon- cência indireta contra células de melanoma em cultura tânea da área pigmentada, com destruição das células (IFM). O método estatístico foi o teste exato de Fisher. névicas e dos melanócitos perinévicos, levando ao halo acrômico e pela presença, ocasional, de leuco- A2) Avaliação da citotoxicidade dermia no melanoma maligno. A associação com Foi empregada a avaliação da atividade NK de doenças auto-imunes é também argumento importan- linfócitos periféricos contra células de melanoma em te na comprovação dessa hipótese. cultura. O método estatístico foi o teste de Wilcoxon. São de observação freqüente lesões acrômicas e hipocrômicas no lúpus eritematoso, especialmente nas B) Estudo anátomo-histoquímico dos melanóci- formas discóide e subaguda. Sendo o lúpus eritemato- tos e detecção de melanina so sistêmico (LES) uma doença com auto-anticorpos Objetivou-se detectar melanócitos ou melanina múltiplos, objetivou-se investigar, por métodos imuno- na pele sã e acrômica de doentes com vitiligo, NH e lógicos, histológicos e imuno-histoquímicos, se nessas LEV. Foram utilizados o exame histopatológico com variantes clínicas a despigmentação ocorre exclusiva- HE, Fontana-Masson, dopa e dopa adicionada à prata mente por destruição pós-inflamatória ou se poderia amoniacal (D+P)3 e o exame histoquímico com mar- resultar de agressão imunológica aos melanócitos, cadores de melanócitos e proteína S-100 pelo método como se admite ocorrer no vitiligo e no nevo halo (NH). da avidina-biotina-peroxidase.4 O método estatístico empregado foi o teste exato de Fisher. PACIENTES E MÉTODOS Pacientes de ambos os sexos, com idades supe- RESULTADOS riores a 12 anos, que forneceram o consentimento 1) Estudo imunológico livre e esclarecido, eles mesmos ou seus responsáveis O estudo compreendeu 42 doentes de vitiligo e quando menores de 18 anos. NH, 16 do sexo masculino e 26 do sexo feminino, assim Os controles das reações de imunofluorescência distribuídos: 18 casos de vitiligo vulgar disseminado; dois (IF) foram amostras de pele e de sangue de indivíduos casos de vitiligo vulgar localizado; 17 casos de NH associa- sãos. Os controles das reações com nevo melanocítico do a vitiligo, sendo 15 com vitiligo vulgar disseminado e foram cortes de nevos autológos e de indivíduos sãos. dois com vitiligo localizado; cinco casos de NH não asso- Critérios de inclusão: pacientes de ambos os ciado a vitiligo vulgar. A média de idade foi 23,9 anos. Os sexos, com idade mínima de 12 anos e que concorda- casos de LEV foram em número de 15, sendo nove de vam em participar do trabalho. Critérios de exclusão: lúpus discóide vitiligóide, quatro de lúpus subagudo viti- pacientes portadores de problemas mentais, doenças ligóide e dois de lúpus sistêmico vitiligóide. A média de auto-imunes ou de possível etiologia auto-imune idade foi de 30,2 anos. Eram colhidas amostras sangüí- outras, como diabetes mellitus,
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