Serum vitamin B12, folate, ferritin and iron levels in Turkish patients with vitiligo

Muzeyyen Gonul, Seray Kulcu Cakmak, Secil Soylu, Arzu Kilic, Ulker Gul

 Ankara Numune Education and Research Hospital, 2nd Dermatology Clinic, Ankara, Turkey

Correspondence Address:
Muzeyyen Gonul
Baris Mah. Guzelyaka Cad, Demetkent sit, B-2 Blok No: 44, Yenimahalle, Ankara
Turkey

Sir,

Vitiligo is a multifactorial polygenic disorder with a complex pathogenesis. The most probable pathological mechanisms are immune-mediated and damage of melanocytes due to free radicals. ^[1]

Oxidative stress, characterized by an increase in free-radical production exceeding the intracellular antioxidant defence, has been proposed as a possible pathogenetic mechanism for vitiligo. ^[1] Iron is involved in antioxidative system and large amounts of iron is sequestered by ferritin. Ferritin is an important acute phase reactant and its serum level is increased in some autoimmune disorders. ^[2] There is only one report investigating serum ferritin levels in vitiligo. ^[3] We retrospectively investigated the levels of serum vitamin B12, folate, ferritin and iron levels in vitiligo patients.

Fourty-two vitiligo patients and 36 sex and age matched healty controls were included in this study within eight months period retrospectively. Age, sex, duration, activity and family history of vitiligo were recorded. Exclusion criteria were disorders and drug use that could alter levels of vitamin B12, ferritin, iron and folate and other autoimmune disorders. Vitiligo patients were divided into two groups as active and stable according to the progression of the disease in the last two months. Vitamin B12, folate, ferritin and iron levels in vitiligo patients were compared with the control group and also the parameters in vitiligo were statistically compared with age and sex of the patients, duration, activity and family history of vitiligo by Mann-Whitney U test, and Spearmann correlation analysis.

Twenty-four (57%) of vitiligo patients were males and 18 (42.9%) were females. The mean age was 36.3 ± 16.9 (ranged from 8 to 72 years). The median time of vitiligo was 36 months (ranged from 1 to 360 months). Twenty-three (56%) of the patients had active vitiligo and 18 (44%) had stable disease. Low levels of hemoglobin, vitamin B12, ferritin, folate and iron were detected in 4, 3, 9, 2 and 12 vitiligo patients, respectively. When the number of low levels of hemoglobin, vitamin B12, ferritin, folate and iron were compared between the patient and the control group, no statistically significant difference was found ( P >0.05). Also, no significant difference was found between the patient and the control groups in levels of these hematinic parameters ( P >0.05) [Figure - 1]. Folate and vitamin B12 levels did not show significant difference according to sex, age, family history, duration and activity of disorder ( P >0.05). Iron, ferritin, hemoglobin levels were significantly lower in females than males in the patient group ( P =0.035, P =0.006, P =0.001 respectively).

Immune-mediated and free radical damage to melanocytes is the most probable pathological mechanism for vitiligo. ^[1] Although the exact immunopathogenic mechanisms are still unknown, the autoimmune pathogenesis of vitiligo has been supported by some data from the literature: detection of circulating antibodies to melanocytes and circulating melanocyte specific cytotoxic T cells in vitiligo patients, the association with other autoimmune disorders and vitiligo. ^[4]

The second most probable mechanism is oxidative stress characterized by an increase in free radical production. Various antioxidants, alone or in combination with phototherapy, have been used for the treatment of vitiligo. ^[1] Although several reports suggested that vitamin B12 and folate levels are decreased in vitiligo patients, the study of Kim et al, did not show any difference in vitamin B12 and folate levels between vitiligo and control groups. ^[5] Our study showed that vitamin B12 and folate levels in vitiligo patients were not different than those of control similar to outcomes of Kim et al. Also, we did not detect pernicious anemia in vitiligo patients.

Iron is an essential element which can catalyze the formation of potentially toxic free radicals. The expression of ferritin is regulated by levels of iron, cytokines, hormones, and oxidative stress. Ferritin has been reported to exhibit different immunological activities including suppression of antibody production by lymphocytes, decreasing the phagocytosis of granulocytes and supression of delayed type of hypersensitivity. Ferritin levels are increased in inflammation, infections and malignancies. ^[2] Recently, ferritin has been accepted as a novel marker for autoimmunity and its level may increase in autoimmune disorders. Ferritin has been evaluated only once previously in vitiligo patients. In this study, Boisseau-Garsaud et al, reported that ferritin levels were not significant from the control group. ^[3] Our study supports these results.

According to the results of our study, we assume that iron, ferritin, vitamin B12, folate do not play a role in the etiopathogenesis of vitiligo and did not vary according to the duration of the disorder and activity of vitiligo. The lower levels of ferritin, iron and hemoglobin in females in the patient group may be related to the loss of iron via menstrual cycle, abortus or delivery or nutritional habitus in females.

1.	Dell'Anna ML, Mastrofrancesco A, Sala R, Venturini M, Ottaviani M, Vidolin AP, et al. Antioxidants and narrow band-UVB in treatment of vitiligo: A double-blind placebo controlled trial. Clin Exp Dermatol 2007;32:631-6. et al. Antioxidants and narrow band-UVB in treatment of vitiligo: A double-blind placebo controlled trial. Clin Exp Dermatol 2007;32:631-6.'>[Google Scholar]
2.	Zandman-Goddard G, Shoenfeld Y. Ferritin in autoimmune diseases. Autoimmun Rev 2007;6:457-63. [Google Scholar]
3.	Boisseau-Garsaud AM, Garsaud P, Lejoly-Boisseau H, Robert M, Quist D, Arveler B. Increase in total blood antioxidant status and selenium levels in black patients with active vitiligo. Int J Dermatol 2002;41:640-2. [Google Scholar]
4.	Ongenea K, Gell NV, Naeyaert J. Evidence for an autoimmune pathogenesis of vitiligo. Pigment Cell Res 2003;16:90-100. [Google Scholar]
5.	Kim SM, Kim YK, Hann SK. Serum levels of folic acid and vitamin B12 in Korean patients with vitiligo. Yonsei Med J 1999;40:195-8. [Google Scholar]