Association of vitiligo with Sjögren's syndrome.

Sir, Many years after publication of the last comprehensive treatise on vitiligo (1), two recent books (2, 3) provide a thorough review of the literature on this common autoimmune disorder. Interestingly, while vitiligo may be associated with one or several of many systemic abnormalities (2), to our knowledge there have been no reports of its association with Sjögren’s syndrome, another autoimmune condition. In our Vitiligo Unit we observed two women (32 and 35 years old) first affected by Sjögren’s syndrome followed 2 – 3 years later by generalized vitiligo. Onset of the two conditions took place after implantation of a copper intrauterine device (IUD), a frequent, although still unexplained finding among our vitiligo patients. Lymphocytic infiltration and destruction of the lacrimal gland epithelium is a main histologic feature of Sjögren’s syndrome (4). Lymphocytic infiltration of the dermis and destruction of melanocytes is a hallmark of vitiligo. In Sjögren’s syndrome, 30% of patients have moderate leucopenia (5). The leucocyte counts in our two patients were also diminished (3400 and 5400/mm). Both disorders are associated with an increased incidence of autoantibodies (2, 6). Among the various pathogenetic mechanisms for these two entities, nutritional deficiencies have been shown to play a role. Vitiligo may be accompanied by deficiency of vitamin B12, folic acid, vitamin C, vitamin B6, vitamin E, iron or copper (2). Sjögren’s syndrome can develop as a unique characteristic of scurvy (7), or as a manifestation of vitamin A deficiency (8). In patient 1, there were diminished serum levels of folic acid and vitamin B6. In patient 2, the serum levels of folic acid and vitamin B6 were near the low limit of the normal range (3.9 and 6 ng/ml, respectively). Immunological abnormalities may result from nutritional deficiencies in general or from deficiencies of single elements such as minerals and vitamins (9); they might thus have played a role in the autoimmune disorders of these two patients. After the most commonly associated abnormalities have been ruled out when evaluating vitiligo patients, a search to determine the presence of Sjögren’s syndrome seems warranted. Likewise, the skin of patients with Sjögren’s syndrome should be carefully examined both by direct clinical inspection and under Wood’s light to detect areas of depigmentation, which are always discernable in vitiligo.