|Year : 2019 | Volume
| Issue : 2 | Page : 71-77
Association of human leukocyte antigen-DRB1 with the response in patients with vitiligo
Mohamed Abdel Kader Toama1, Fathia M Khattab1, Ayman Marei2
1 Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Microbiology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||03-Jan-2019|
|Date of Acceptance||02-May-2019|
|Date of Web Publication||03-Jul-2019|
Fathia M Khattab
Assistant Professor, Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Zagazig University
Source of Support: None, Conflict of Interest: None
Background Vitiligo is a pigmentary disorder associated with the selective destruction of the skin melanocytes. Among the many human leukocyte antigen (HLA) alleles claimed to be incriminated in establishing vitiligo, HLA-DRB1 is included in many dermatological diseases and has been widely investigated in different studies worldwide.
Aim To examine the susceptibility between HLA-DRB1 gene polymorphism and the therapeutic response of vitiligo.
Patients and methods We performed a cohort study at Dermatology and Venereology Department, Zagazig Institution Hospitals from January 2018 to January 2019 on 80 patients with vitiligo who were subjected to treatment. Response to therapy was observed, and we followed up patients for 6 months. HLA-DRB1 genotyping using real-time PCR was performed once.
Results The results showed that there was a significant statistical association regarding the therapeutic response in our study.
Conclusion Our findings advise that DRB1 *0701 and *0413 are associated with good therapeutic response, whereas DRB1 *8 and *12 alleles are associated with worse therapeutic response among Egyptians.
Keywords: human leukocyte antigen, theraputic response, vitiligo
|How to cite this article:|
Kader Toama M, Khattab FM, Marei A. Association of human leukocyte antigen-DRB1 with the response in patients with vitiligo. Egypt J Dermatol Venerol 2019;39:71-7
|How to cite this URL:|
Kader Toama M, Khattab FM, Marei A. Association of human leukocyte antigen-DRB1 with the response in patients with vitiligo. Egypt J Dermatol Venerol [serial online] 2019 [cited 2019 Aug 22];39:71-7. Available from: http://www.ejdv.eg.net/text.asp?2019/39/2/71/262038
| Introduction|| |
Vitiligo occurs worldwide. Approximately 0.5–1% of the population is affected, and it occurs almost before 20 years of age. Its incidence seems to be equal between men and women, and there is no difference in rates of occurrence according to skin type or race . Patients may view the loss of pigment as a threat to racial identity .
Vitiligo is a polygenic autoimmune disease of unknown etiology characterized by loss of epidermal melanocytes and consequent progressive cutaneous depigmentation . A quantitative approach for estimating and testing the medical conditions of a vitiligo treatment is the latest problem, as there are few quantitative tools for measuring the vitiligo treatment response .
Human leukocyte antigen (HLA) molecules have an important function in regulating the immune response. The relationship between HLA and most autoimmune diseases has been well identified. A relationship has been proposed between different HLA classes I and II and vitiligo, and it is assumed that those with special HLA subtypes are susceptible to the disease more than others ,.
Three loci of two autosomal alleles interacting epistatically (concealing effects of one gene because of appearing of another one) are involved in this disease pathogenesis . Therefore, patients with vitiligo are considered having all three homozygote loci .
Vitiligo is considered as an autoimmune disease in which antibodies (vitiligo antibodies) are created in the human body against melanocytes. It can be transmitted from the patients with vitiligo to those who received marrow graft or lymphocyte infusion .
Within the past 20 years, inheritance, nature of vitiligo, and the probability of being an autoimmune disease provided the possibility of any relationship between vitiligo and polymorphic determinants of HLA system .
Positive and negative relations between vitiligo and HLA in different population races have been described. Depending on race and nationality, the disease and related HLA distribution vary in different parts of the world .
Misri et al.  found the HLA-associated susceptibility to develop vitiligo in Indian patients and detected the role of HLA in familial vitiligo. They concluded that they associate a family history of vitiligo with an early onset of vitiligo. There is no correlation of family history with the vitiligo type, stability of lesions, and areas involved. They did not find an association of severity with family history. Apart from other alleles, alleles A2 and B44 play a significant role in vitiligo in Indian patients.
Zamani et al.  at the University of Amsterdam showed that the association of the antigens of the HLA system with vitiligo varies according to ethnic origin. In that, HLA-DR4 prevails among white Americans, HLA-DR4, and HLA-DQW3 prevail in the blacks, HLA-DR7 and HLA-DQW3 in the north of Italy, HLA-DR53 in the population of Kuwait, and HLA-DRW12 in the north of Germany.
Nejad et al.  tested HLA-typing class I in patients with vitiligo to determine antigens suspecting or preventing HLA in vitiligo. They concluded that HLA-A2, HLA-B49, HLA-CW3, HLA-CW3, and HLA-CW7 are regarded as genetic susceptibility factors for the manifestation of the disease and HLA-A3, HLA-B8, HLA-BW4, and HLA-BW6 as genetic susceptibility factors for a manifestation of vitiligo.
This study aims to perform genotyping of HLA class II genes on Egyptians vitiligo population to identify susceptible and protective HLA alleles in vitiligo.
| Patients and methods|| |
A total of 80 patients clinically diagnosed as having vitiligo were selected from the Outpatient Clinic of the Dermatology and Venereology Department of Zagazig University Hospitals. Their age ranged from 9 to 52 years. The patients comprised 28 males and 52 females. All patients were subjected to the treatment of vitiligo over 24 months (January 2018–January 2019), and subdivided according to response into two groups (A and B).
Inclusion criteria are patients of different age groups (pediatrics and adult) with vitiligo of different sites, sizes, and durations, with no concurrent use of systemic or topical treatments.
Exclusion criteria are patient refusal or caregivers’ refusal, a history of associated other dermatological diseases, a history of associated other systemic diseases, and concomitant intake of immunosuppressive drugs.
Moreover, patients with skin disorders such as generalized eczema or urticaria, malignancies and infections, pregnancy and lactation were excluded.
Ethical consideration: we took an informed written consent from each individual after explaining the investigation and the purpose of the study under the ethical standards of the responsible Regional Committee. Participants’ data were kept confidential. We got institutional approval from the Institutional Review Board committee.
In our cohort study, all patients were subjected to history taking including personal history, present and past clinical history, general examination, complete dermatological examination, treatment in each according to their conditions, and their response to the treatment as assessed by vitiligo disease activity (VIDA) score.
Patients were assigned into two groups: group A included 53 patients with vitiligo who have a response to the vitiligo treatment, and group B included 27 patients with vitiligo who have no response to the vitiligo treatment.
- The diagnosis was based on the typical history of depigmented lesions with or without progression and clinical examination, which was confirmed by Wood’s lamp examination and dermoscopic assessment.
- HLA-DRB1 genotyping done for all treated patients, whether being responders or not, using real-time PCR (DNA Technology, MagNA Pure LC DNA Isolation Kit I, Roche, Germany).
Collection of blood samples
Two milliliters of blood was withdrawn from each patient under complete aseptic condition by venipuncture and collected in EDTA-containing tubes (2.0 mg EDTA/ml blood). The tubes were shaken thoroughly to mix the blood, and they were then stored with the anticoagulant at −20°C until used for HLA-DRB1 genotyping ([Figure 1]).
DNA extraction was done using PREP-RAPID genetics DNA Extraction Kit (DNA Technology). The basis of the extraction step was lysis of blood cells using heat, followed by the removal of PCR inhibitors.
- Simultaneous DNA amplification and detection of HLA-DRB1 alleles by real-time PCR (DNA Technology) was done using HLA-DRB1 alleles genotyping kit which is intended for simultaneous detection of 14 alleles and groups of alleles of human major histocompatibility complex DRB1.([Figure 2])
- Evaluation of the clinical response of patients was done by VIDA score .
VIDA score is a six-point scale for testing vitiligo activity. Individuals own opinion is the base for VIDA score. VIDA score is based on patients’ opinion divided into six stages: VIDA score +4: activity of 6 weeks or fewer period; +3: activity of 6 weeks to 3 months; +2: activity of 3–6 months; +1: activity of 6–12 months; 0: stable at least for 1 year; and −1: stable at least for 1 year with spontaneous repigmentation.
Lower vitiligo disease activity scores show less activity
At each visit, regimentation was assessed and graded in a topographical area: minimal-mild less than or equal to 50% and moderate-complete more than 50%. A patient showing no response or less than 25% regimentation after 50 exposures was considered as nonresponder and excluded from the study. Mean regimentation in an individual patient was calculated by adding the extent of regimentation achieved in each topographical area after therapy and then dividing the figure with the total number of topographical areas bearing vitiligo lesions.
Follow-up evaluation was done every month for 6 months after completion of the treatment.
The data were put into a computer and statistically analyzed using the Statistical Package for the Social Science program, version 18.0 (IBM Corp, Armonk, NY, USA). We represented qualitative data as frequencies and relative percentages. χ2 test used to calculate the difference between qualitative variables. We expressed quantitative data as mean±SD. Multivariate logistic regression analysis was used to illuminate the interrelation within and between significant predictors for the specific variable. It determined the level of significance for all statistical tests. The threshold of significance was set at 5% level. P value of more than 0.05 shows nonsignificant results, and P value of less than 0.05 shows significant results. Fisher’s exact test was used to assess the level of significance of the allele or haplotype.
| Results|| |
The included study patients’ age ranged between 9 and 52 years. There were 52 female patients and 28 male patients. According to the site of vitiligo among the two studied groups, there were 32 patients who had lesions on the arm, 26 patient in the abdomen, 34 patient in the back, 37 patients in the chest, and 36 in the leg. Demographic data among the studied group is present in [Table 1].
According to the treatment used among the two studied groups, we had treated 72 patients with the narrow band, 24 with topical tacrolimus, 16 with systemic steroids, 40 with topical corticosteroids, and eight with calcipotriol. The 80 patients were treated, and we estimated their response to treatment with VIDA score, which was used to divide the group into a responsive group (53 patients) and a nonresponsive group (27 patients) ([Table 2]).
There were no significant differences between patients not responding to vitiligo treatment and patients responding to vitiligo treatment regarding sex (P>0.05). There was no significant difference between patients not responding to vitiligo treatment and patients responding to vitiligo treatment regarding the site of vitiligo (P>0.05).
[Table 3] shows the association between different HLA-DRB1 haplotypes and the therapeutic response to treatment, with a statistically significant association. Fisher’s exact test was used to assess the level of significance of allele or haplotype. We used the χ2 test to calculate the difference between qualitative variables in different groups. Our findings suggest that DRB1 *0701 and *0413 and RB1 *0701 and *0413 are associated with good therapeutic response, whereas DRB1 *8 and *12 alleles are associated with bad therapeutic response among the Egyptian population ([Table 4], [Figure 1] and [Figure 2]).
|Table 3 Relation between human leukocyte antigen genotyping among the studied groups|
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|Table 4 Relation between alleles of human leukocyte antigen genotype among the studied groups|
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| Discussion|| |
Vitiligo is a chronic stigmatizing disease, already known for millennia, which mainly affects melanocytes from the epidermis basal layer, leading to the development of hypochromic and achromic patches. Its estimated prevalence is 0.5% worldwide. The involvement of genetic factors controlling susceptibility has been studied over the past decades .
The major histocompatibility complex region, encoding the HLA glycoprotein, comprises a complex set of genes on chromosome 6p21. It is now recognized that HLA is a major contributing factor for susceptibility to autoimmune diseases. The frequent association of vitiligo with autoimmune diseases and abnormal expression of HLA class II molecules by perilesional melanocytes are evidence that HLA loci play an important role in the development of vitiligo .
In our study, we focused on HLA class II. The association of multiple HLA class II antigens and alleles has been suggested for vitiligo. Elgendy et al.  showed that when all the patients with vitiligo are compared with controls, a significantly increased frequency of HLA-A1, A19, B16, CW4, CW6, DR4, DR7, and DQ3 and a significantly decreased frequency of CW3 and DQ1 are found. The studied group age ranged between 9 and 52 years (mean±SD, 27.73±12.44). However, in the studied group of Bouayad et al. , average age (years, mean±SD) was 36.7±17.2. Regarding age in our study, there were significant differences found.
In the present study, 80 patients with vitiligo of both sexes, comprising 52 female and 28 male, were included. Bouayad et al.  found that in their 100 patients with vitiligo of both sexes, 65 were female and 35 were male. There is an increased incidence of female more than male, because of considering the vitiligo an autoimmune disease with a higher incidence in female besides the cosmetic consideration.
On clinical examination, we found that there were 32 patients who had lesions on the arm, 26 on the abdomen, 34 on the back, 37 on the chest, and 36 on the leg. In a study by Tastan et al.  among 41 patients, 34 had generalized, three acrofacial, one universal, and three had focal vitiligo. Regarding the sites of affection for vitiligo in our study, there was no significant finding (P<0.05). However, they reported a positive association of vitiligo with HLA-DR4 antigen and negative association with HLA-DR3 antigen. Because of the HLA gene polymorphism, the results vary according to the population studied.
Regarding clinical type, we showed that individuals with extensive lesions had a higher frequency of HLA-A30 and CW6 antigens . Venkataram et al.  suggested the association of HLA-DR7 antigen with the acrofacial involvement.
Regarding HLA genotyping among our study groups, there was an increase in the frequency of DRB1 *0703, *0701, and *0413, which is in agreement with a positive association of DRB1 *0701 in Slovak population .
In this study, a positive association was found between HLA-DRB1 *04, DRB1 *07, and DRB1 *03 and vitiligo, which suggested a pathogenic effect of this allele for vitiligo. This is in agreement with a study on Turkish patients with vitiligo, which showed the increased frequency of HLA-DRB1 *03, DRB1 *04, and DRB1 *07 , and also agreed with a positive association of DRB1 *07 in Slovak population .
In contrary to our finding, a protective role of the DRB1 *03 was found in patients from India . The disease heterogeneity and distinctness may explain these apparently discordant results in statistical methods applied.
Schallreuter et al.  detected HLA-DRW12 and A2 antigens in a population of white Germans. In Hungary, Polly et al.  detected the association with HLA-DR1. Orecchia et al.  studied Italian individuals and observed a high frequency of HLA-A30, CW6, and DQW3 antigens.
The HLA-DR4 antigen is more frequent in patients with vitiligo with early development (<20 years old), whereas they associate HLA-DRW6 antigen with late development .
We treated the 80 patients according to their conditions by different treatment and estimated their responsiveness with VIDA score, which divided the studied group into the responsive group (53 patients) and nonresponsive group (27 patients). Regarding VIDA score, there were significant differences among the two studied groups.
HLA genotyping among the two studied group showed significant differences with increased DRB1 *0413 and *0701 in the responder group of patients, suggesting a curable (good response) effect of this allele for vitiligo.
However, there were significant differences regarding alleles of HLA, showing increasing in DRB1 *8 and *12 in the nonresponder group, suggesting a low response to the vitiligo treatment.
Genotyping of the HLA complex showed the differences in the association of HLA in vitiligo in our study with other studies, which can be attributed to the racial group variation, sample size, and methods used in the study. As it is an autoimmune condition associated with the HLA system, we expect differences in the results of distinct studies, especially because they cover populations with diverse ethnical backgrounds.
| Conclusion|| |
We investigated HLA genotyping of class II MHC in 80 Egyptian patients with vitiligo using PCR assay. The frequency of DRB1 *0701 and *0413 was increased significantly in a responsive group of patients compared with nonresponsive group (P=0.04 and 0.04, respectively), whereas DRB1 *8 and *12 alleles were significantly increased in the nonresponsive group compared with the responsive group (P=0.01 and 0.04, respectively).
Our findings suggest that DRB1 *0701 and *0413 and RB1 *0701 and *0413 are associated with good therapeutic response, whereas DRB1 *8 and *12 alleles are associated with bad therapeutic response among the Egyptian population.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]