TITLE OF THE TOPIC

An Observational Study On “THE PREVALENCE OF BARS(VITILIGO)”in Patients Attending Govt.Nizamia General Hospital,,Charminar,Hyderabad.

BRIEF RESUME OF THE INTENDED WORK

NEED OF THE STUDY :

Ø  The population prevalence of vitiligo ranges from 0.1%  to 2% and shows a wide variability among ethnic groups.The highest incidence of the condition has been recorded in Indians from Indian sub continent followed by mexico and japan

Ø  Vitiligo is reported more frequently in females than males , which may be the result of increased reporting rates in females due to greater social consequences in females affected by vitiligo.

Ø  However the majority of the vitiligo cases are reported during stages of active development .About 50% of cases presents before the age of 20 and nearly 70-80% before 30 years of age.Although no age is immune to vitiligo,the disease is very rarely observed at birth.

Ø  Accordingly,the worldwide prevalence of vitiligo ranges between 0.5 and 2%.The prevalence of vitiligo in India has been reported between 0.25% and 4% of dermatology outpatients across studies from India and upto 8.8% in Gujrat and Rajasthan¹⁶.

Ø   A number of studies have been conducted on the prevalence of vitiligo worldwide including india ,the prevalence of vitiligo is still the major public health problem in india.

Ø  In view of above facts I would like to conduct An Observational Study On “THE PREVALENCE OF BARS (VITILIGO)”in Patients Attending Govt. Nizamia General Hospital,,Charminar,Hyderabad.

INTRODUCTION :

Ø  Vitiligo is an autoimmune / acquired condition affecting 1% of the population world wide .Focal loss of melanocytes results in the development of patches of hypopigmentation.A positive family history  of vitiligo is relatively common in those with extensive disease and this type is also associated with other Autoimmune diseases,trauma and sunburn (through Kobner phenomenon) may precipitate the appearance of vitiligo .The pathogenesis is unclear and whilst melanocytes may be the target of cell mediated immune attack¹ 

REVIEW OF LITERATURE :-

UNANI  LITERATURE:

Ø  The Author of Makhzanul Hikmat” Hakeem Ghulam Jeelani Khan” stated that  Bars is a condition in which white spots arises on skin surface . These spots are primarily small in size and then increases gradually.Sometimes it may be due to

·       Neurogenic defect which leads to weakening of quwwate- e mughaiyara .

·       Idiopathic .

·       Hereditary.²

Ø  Abul Hasan Ahmed  Bin Tabri described in his book “Moalijat e Bukhratiya” that sometimes the lesion of Bars is smooth,shiny and soft to touch and it is because of Maddae raddiya (Morbid matter) that dearranged the Nutritional process of the effected site( zoof-e-quwwate jazeba).

In some cases the lesion of Bars is neither smooth nor shiny and soft . it is because of ghaleez rutobat (thick viscous matter)  at effected site

Sometimes the lesion is reddish because of the presence of blood in between the skin and the muscle .This condition is found before the blood is affected by Rutobat-e-Fasida3

Ø  Akbar Arzani distinguished  Bars from Beheq abyaz in his book “Tib e Akbar” that Behaq Abyaz doesn’t penetrate deep in the skin and it remains superficial .After pricking at the site of Beheq  abyaz  blood always comes out and hair at the site of beheq abyaz  never becomes white even after the disease becomes chronic . But in  Bars it penetrates deep in the skin and in most of the cases the hair at the site of Bars becomes white and the site of lesion doesn’t turn red on rubbing⁴.

Ø  Qamri described in his book “Ghina Muna “ quoting Yahya ibn Masuiyah that if the  white patches of bars turned red on rubbing it means lesion is new and can be treated easily and if the colour of the lesion remains unchanged it signifies that the disease is chronic and is difficult to treat⁵.

Ø  According to Raban Tabri in his famous book “Firdous ul Hikmat “  the causes of Bars are Fasad ud Dam ( Impairment of Blood) due to weakening of Quwwat-e-Hazima which leads to production of Fasid Blood ,

Burodat-e-Dam ( Coldness of blood) .If the causes of Fasad ud Dam are Burodat (Coldness) and Phlegm (Balgham) then it leads to bars(vitiligo)⁶.

Ø  Bars is caused by excessive accumulation of balgam e ghaleez in the blood and zoofe quwat-e-mughaiyara of skin⁷.

MODERN THEORY    

Ø  The word Vitiligo is derived from the greek word “vitilius”  meaning calf ( white patches of vitiligo resembles white patches of calf ) it is an acquired depigmentary disorders of skin which lacks melanocytes⁸.

Ø  It is an acquired sometimes familial condition,an auto immune disease in majority.Vitiligo is associated with other autoimmune diseases such as Thyroid disease ,Diabetes mellitus,Addisons disease and Pernicious anaemia .Pathogenesis of vitiligo is acomplex process involving  the melanocytes,epidermal keratinocytes,immune system and peripheral nervous system⁹.

Ø  Vitiligo usually begins since childhood or young adulthood with a peek onset between 10-30 years about half of the cases begins before the age of 20 .the prevalence ranges from 0.5 – 1%¹⁰.

Ø  This is a common skin disorder in which there is focal failure of pigmentation due to destruction of melanocytes that is thought to be mediated by immunological mechanism¹¹.

Ø  It presents in childhood or early adult life with well demarcated macules of complete pigment loss .there is no history of preceding inflammation .patients are very susceptible to sun burn .lesions are often symmetrical and frequently involve  the face ,hands and genitalia.the hair can also get depigmented .Trauma may induce new lesions.Spontaneous repigmentation  can occur and often starts around hair follicles,giving a specked appearance.However repigmentation is rare if a lesion persisted for more than 1 year.The psychological consequences can be devastating,especially in Asians and black African people¹².

ETIOLOGY:

 There are many theories of causation

1.Auto immune Theory (Immunological Theory). Vitiligo is associated with several circulating auto antibodies and other autoimmune disorders like Hashimoto’s thyroiditis,Dm etc.

2.Melanotoxic Theory: The autocytotoxic theory suggests that vitiligo may be form of cellular suicide in which intermediary metabolites of melanin selectively destroys pigment cells.

3.Neural theory: It is based on the observation that in some patients , vitiligo is confined to a portion of one side of the body i.e Segmental Vitiligo.

4.Melanocytorhagy: This theory proposes that vitiligo results from defective adhesion.

5.Convergance Theory: Available data suggests that vitiligo is multifactorial and may be the end result  of several different pathological  pathways8.

MORPHOLOGY:

Depigmented ,milky white  or hypopigmented (light colour) macules and patches that are sharply demarcated from the surrounding normal coloured skin typify the disease .The affected skin is otherwise normal except for a little erythema of patches on sun exposed regions  due to heightened sensitivity to sunlight .Hair within a patch may turn  white (Leukotrichia) margins of the patches may be hyper pigmented or hypopigmented or be normal in colour13.

TYPES :

Depending upon the number of lesions and site involved .it has been classified into

 1 .Localised Vitiligo :

(A) Focal Vitiligo : An isolated macule or a few macules limited in both size and number .it may be localized to skin or mucosa

(B) Segmental Vitiligo  :vitiligo macules are distributed along a dermatome.

2.Generalised Vitiligo :

(A)    Vitiligo vulgaris : the most common form of vitiligo in wich widespread macules are often     symmetrically placed over limbs and trunk.

    (B)Lip-Tip Vitiligo : Tips of fingers alone or with certain mucosal surfaces like lips,distal penis or nipples are involved.

(B)    Acrofacial Vitiligo : It involves face and distal digits.

(C)    Universal Vitiligo : Almost whole of the body is involved and only few small areas are spared8.

DIETARY RESTRICTIONS :

§  Milk and dairy products.

§  Aghziya Ghaliza.

§  Muwallid-i-Balgham Aghziya.¹⁵

DIFFERENTIAL DIAGNOSIS:-

Acquired :   

                1.Chemical Induced

                2.Halo Nevus

                3.Pityriasis Alba

                4.Idiopathic Gutate Hypomelanois

                5.Tinea Versicolor

Congenital:

                1.Albinism

                2.Piebaldism

                3.Nevus Depigmentosus

                4.Tuberous Sclerosis

                5.Nevus Anemicus8

 OBJECTIVES OF THE STUDY

1.     The Aim of this Study is to Measure the prevalence of BARS (Vitiligo) in GNGH ,Charminar,Hyderabad.

2.     To Educate the patient Regarding the Disease Spreading through family predisposing and dietary factors.

MATERIAL AND METHODS

v  Source of Data:-

·       Patients Attending at OP Dept of Skin & Cosmetology ,Govt. Nizamia General Hospital, Charminar, Hyderabad, Telangana.

v  Method of Collection of Data:-

·       Data will be Collected by using a predesigned structured Questionnaire which contains open ended Questions.

v  Inclusion Criteria:-

·       Age Group : All

·       Sex: Both

v  Exclusion Criteria:-  

·       Patient who are not giving informed consent.

v  Parameters of Study:-  

                                Subjective Parameters:

·       Patients complaining of hypo-pigmentation and white patches.

                                Objective Parameters:

·       The diagnosis will be based on the Inspection ,history,clinical examination

·       Interaction by using predesign structured questionnaire.

·       Basic investigations if required.

v  Study Design:-

·       observational study

v  Sample Size:-

·       All Available Patients attending at OP Dept of Skin & Cosmetology, Govt Nizamia General Hospital during the period of study.

v  Duration of Protocol:-

·       12 months

v  Procedure of Study:

·       It will be based on History taking and clinical features and Interaction with patient

v  Evaluation:-

·       Data will be Analyzed statistically

Does the study require any investigations to be conducted on patients or Human Being or Animals

No

Has Ethical clearance been obtained from your institution in case of 7.3

List of references

1.     Walker BR , Colledge NR,Ralston SH,Penman ID,Davidson’s principles and practice of medicine,22^nd Edition,Edinburgh;Newyork;Churchill Livingstone/Elsevier;2014,page:1295.

2.       Jeelani H Ghulam,Makhzanul Hikmat,New Delhi,Aijaz publication,page :1021.

3.     Tabri A , Moalijat-e-Bukhratiyah,Vol-2,CCRIUM,New Delhi,page :199.

4.      Arzani M Akbar ,Tib-e-Akbar ,translated by Hakeem Mohd Hasan ,Idara Kitabul Shifa, page:735

5.      Qamri A,Ghina Muna ,New Delhi,CCRIUM,2008,page:458.

6        Tabri R, ,Firdous ul Hikmat,page :294.

7       Jurjani A Hassan ,Zakheere Khwarzim Shahi,translated  by Hakeem Hadi hussain khan,New Delhi ,Idare Kitabul Shifa ,page:18.

8       Thappa DM ,Textbook of Dermatology,venerology and Leprology,3^rd edition, London ;Elsevier Health sciences APAC;2013,page :196,197,198.

9      Golwalla Shahrukh A Nadkar Milind Y Golwalla Aspi F,Golwalla medicine for students,21^st edition,Jaypee brothers  medical publisher(P)Ltd;2014,page:942.

10    James WD,Berger TG,Elston DM,Andrews diseases of skin clinical dermatology,11^th edition,Elsevier Health sciences;2011,page:855,856.

11   Marks R,Roxburgh’s common skin diseases,17^th edition,CRC press 2003,page:297.

12    Kumar PJ and Clark ML,Kumar and Clark’s clinical medicine,7^th edition,Edenburgh;Elsevier,page:1264.

13   Khopkar U,An illustrated handbook of skin diseases and  sexually transmitted 

infections,page:141.

14   Ferri FF, Studdiford JS,Tully AS,Ferri’sFast Facts in Dermatology,Elsiever Health Sciences;2010 ,page:392,393.

15   Standard Unani Treatment Guidelines For Common Diseases,Vol-I ,CCRUM-2014, Pg 181.

16   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6362747/#:~:text=The%20prevalence%20of%20vitiligo%20in,8.8%25%20in%20Gujarat%20and%20Rajasthan.