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A Study on the Correlation of Serum Cholecalciferol Level and Vitiligo in Patients Attending Government Rajaji Hospital, Madurai

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A Study on the Correlation of Serum Cholecalciferol Level and Vitiligo in Patients Attending Government Rajaji Hospital, Madurai A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI Dissertation submitted in partial fulfillment of the university regulations for M.D. DEGREE in DERMATOLOGY, VENEREOLOGY AND LEPROSY (BRANCH XX) APRIL 2018 THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI TAMIL NADU 1 CERTIFICATE FROM THE DEAN This is to certify that this dissertation entitled " A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI" submitted by Dr. Deepthi Vijayakumar to The Tamil Nadu Dr. M.G.R. Medical University, Chennai is in partial fulfillment of the requirement for the award of M.D.[DERMATOLOGY, VENEREOLOGY AND LEPROSY] and is a bonafide research work carried out by her under direct supervision and guidance. This work has not previously formed the basis for the award of any degree or diploma. Dr. MARUDHUPANDIYAN M.S. (GENERAL SURGERY) THE DEAN, Madurai Medical College, Government Rajaji Hospital, Madurai. 2 CERTIFICATE FROM THE HOD This is to certify that this dissertation entitled " A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL and VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI submitted by Dr. Deepthi Vijayakumar to The Tamil Nadu Dr.M.G.R. Medical University, Chennai is in partial fulfillment of the requirement for the award of M.D. [DERMATOLOGY, VENEREOLOGY AND LEPROSY] and is a bonafide research work carried out by her under direct supervision and guidance. This work has not previously formed the basis for the award of any degree or diploma. Dr. G.GEETHARANI M.D., D.D., Professor and HOD. Department of Dermatology, Madurai Medical College and Government Rajaji Hospital, Madurai. 3 CERTIFICATE FROM THE GUIDE This is to certify that this dissertation entitled " A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI submitted by Dr.Deepthi Vijayakumar to The Tamil Nadu Dr.M.G.R. Medical University, Chennai is in partial fulfillment of the requirement for the award of M.D.[DERMATOLOGY, VENEREOLOGY AND LEPROSY] and is a bonafide research work carried out by her under my direct supervision and guidance. This work has not previously formed the basis for the award of any degree or diploma. Dr. G.GEETHARANI M.D., D.D., Professor and HOD. Department of Dermatology, Madurai Medical College and Government Rajaji Hospital, Madurai. 4 DECLARATION I, Dr. DEEPTHI VIJAYAKUMAR, solemnly declare that the dissertation titled A STUDY ON THE CORRELATION OF SERUM CHOLECALCIFEROL LEVEL AND VITILIGO IN PATIENTS ATTENDING GOVERNMENT RAJAJI HOSPITAL, MADURAI is a bonafide work done by me at Government Rajaji Hospital during 2015 2018 under the guidance and supervision of Prof. Dr. G. GEETHARANI M.D., D.D., Professor and Head of the Department of Dermatology, Madurai Medical College, Madurai. I also declare that this bonafide work or a part of this work was not submitted by me or any other for any award, degree and diploma to any university, board either in India or abroad. The dissertation is submitted to The Tamilnadu Dr.M.G.R. Medical University, towards partial fulfilment of requirement for the award of M.D.Degree in Dermatology, Venereology and Leprosy (BRANCH XX). Place: Madurai. 5 ACKNOWLEDGEMENT I am extremely thankful to Dr. MARUDHUPANDIYAN, M.S, Dean, Madurai Medical College, and Medical Superintendent, Government Rajaji Hospital, Madurai for permitting me to use the college and hospital facilities for this study. I express my sincere and heartfelt gratitude to Prof.Dr.G.Geetharani M.D., D.D., Professor and Head of the Department of Dermatology, Madurai medical college, Madurai, for her excellent guidance and supervision for this dissertation work. Her commitment, devotion and perfection in work gave me the drive for completing the project successfully. I would like to express my deep sense of gratitude to Dr.P.Mohan kumaresh , M.D., Professor and Head of the department of Biochemistry for his kindly help of sharing his wisdom and experience without which this study would not have been possible. I profoundly thank Prof.Dr.R.Suganthy Rajakumari M.D., Professor and Head of the Department of Venereology who has always guided me, by example and valuable words of advice through the conduct of the study and also during my postgraduate course. My heartful thanks to Dr. K. Dhanalakshmi M.D., D.V.L, Associate Professor for her valuable support and guidance throughout the study. I proudly thank Dr. K.P. Saradha M.D.D.V.L., Associate professor for her valuable guidance. I express my deep sense of gratitude and thanks to my teachers Dr.R.Kothandaraman, Associate Professor, Dr.P.Sathesh and Dr.S.Deva Prabha 6 Assistant Professors, for their valuable guidance, timely advice and constant encouragement. I would also like to acknowledge my thanks to Dr. S. Sumithra, Dr .R. Sudha, Dr. S. Durgadevi, and Dr.M.Nithya Assitant Professors of STD for their constant support during the period of my study. I would like to convey my regards to fellow post graduates, seniors, juniors and my family members who have always stood by me in my carrier. I owe a lot of thanks to my patients without them this study would not have been possible, and the authors, who have worked on this subject, from whose wisdom and experience, I have been benefited immensely. 7 CONTENTS S.NO TITLES PAGE NO. 1. INTRODUCTION 10 2. AIM OF THE STUDY 14 3. REVIEW OF LITERATURE 16 4. MATERIALS AND METHODS 54 5. OBSERVATION AND RESULTS 58 6. DISCUSSION 75 7. SUMMARY 85 8. CONCLUSION 89 Annexures BIBILIOGRAPHY 9 1 PROFORMA 110 CLINICAL PHOTOGRAPHS 123 MASTER CHART 138 ANTI PLAGIARISM CERTIFICATE 146 ETHICAL COMMITTEE APPROVAL FORM 149 8 ABBRIEVATIONS IL- Interleukin IF ἀ- Interferon alpha TNF ἀ- Tumour Necrosis Factor alpha HLA- Human Leukocyte Antigen NALP- NACHT Leucine rich repeat Protein NLR- Nod Like Receptor AIS- Autoimmune Susceptibility PTPN- Lymphocyte Protein Tyrosine Phosphatase CTLA4- Antigen 4 of Cytotoxic T Lymphocytes MITF- Microphthalmia Associated Transcription Factor ACE- Angiotensin Converting Enzyme VDR- Vitamin D Receptor AIRE- AutoImmune Regulator COMT-Catechol O Methyl Transferase 9 INTRODUCTION 10 INTRODUCTION Vitiligo is an autoimmune pigmentary disorder caused by destruction of functional melanocytes in epidermis and infundibulum of hair, characterized by well demarcated depigmented patches or macules. It affects both sexes and all races equally. The inheritance is polygenic or autosomal dominant with variable penetrance. The following hypothesis have been postulated regarding its etiopathogenesis:1,3,4,5 1. Autoimmune hypothesis: This theory is based on the clinical association of vitiligo with other autoimmune disorders like Hashimoto's thyroiditis, pernicious anemia, Addisons disease, diabetes mellitus, myasthenia gravis, alopecia areata. Also, antibodies to human melanocytes have been detected using immunoprecipitant assay in some patients. 2. Neurogenic hypothesis: This theory suggest that neuropeptide Y released from peripheral nerve endings may inhibit melanogenesis. Electron microscopy shows abnormalities in peripheral nerves. 3. Self destruct theory of Lerner: This theory suggest that melanocytes destroy themselves due to a protective mechanism that removes toxic melanin precursors. This is based on studies of cutaneous depigmentation caused by chemical compounds that have selective lethal effects on functional melanocytes. 4. It is suggested that defective keratinocyte metabolism plays a major role and a new hypothesis relating vitiligo with defective tetrahydrobiopterin and catecholamine biosynthesis have been postulated. 11 Role of vitamin D in melanogenesis: Vitamin D is synthesized from 7 dehydrocholesterol present in skin which is converted to 25(OH) cholecalciferol and then to its active metabolite 1,25(OH)2 cholecalciferol and has a role in skin pigmentation. 1.Vitamin D in addition to its regulatory effect in calcium and bone metabolism, controls cell proliferation and differentiation, exerts immuno regulatory activities via its nuclear receptor and increases melanogenesis. It increases the tyrosinase content of cultured human melanocytes by its antiapoptotic effect.6 2.Topical vitamin D increased L-3,4 dihydroxyphenylalanine positive melanocytes6 and is used in combination with other modalities of treatment for vitiligo successfully. 3.Vitamin D exerts immunomodulatory effect by inhibiting the expression of cytokines IL6, IL8, IL10, IL12, IFἀ, TNFἀ 7,8,9 which are pro inflammatory and proapoptotic in vitiligo. 4.Another study revealed Apa-I polymorphism9 of vitamin D receptor gene is associated with vitiligo. Normal serum vitamin D is 30-70ng/ml (75- 250 nmol/L). Low levels of vitamin D has been observed in vitiligo and other autoimmune disorders.6-9 The improvement of serum vitamin D deficiency after UV exposure correlates with clinical improvement13 as assessed by VASI score.16 Thus, vitamin D and its receptor play a role in etiopathogenesis of skin pigmentation. But, the exact association of low vitamin D levels and vitiligo needs to be further evaluated. Hence, It is decided to study on this association among vitiligo 12 patients attending the Department of Dermatology, Government Rajaji Hospital, Madurai. 13 AIM OF THE STUDY 14 AIM OF THE STUDY To study the relationship between serum cholecalciferol levels and vitiligo with respect to type, duration and severity among patients attending dermatology OP (out patient)
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