From time to time we like to share relevant articles written by our colleagues. In honor of World Vitiligo Day, we are pleased to share this article, in its entirety, originally published in the Vitiligo Support International’s Summer 2016 newsletter. VSI has generously granted permission for the reprinting of this article.
Have you ever heard or read about a community with a traffic intersection notorious for accidents, yet the authorities seem determined not to increase traffic safety measures until the history of collisions results in a fatal, or near fatal crash?
Your health should not have to parallel this analogy. The purpose of this article is to help you develop a proactive strategy to managing and controlling your health, before your health controls you. Being proactive gives you the time and flexibility to prepare and make decisions in advance of problems, rather than picking up the pieces after the crash.
How is Vitiligo Related to Thyroid Disease?
The simple answer is, by autoimmunity. By definition, an autoimmune disease is when your body’s own immune system mistakenly identifies specific cells in your own body as foreign and creates specific antibodies to attack them. In the case of vitiligo, your body’s immune system creates melanocyte-specific antibodies that attack your melanocytes, which are your pigment-making cells. With autoimmune thyroid disease (AITD), the body’s immune system creates thyroid-specific antibodies that attack the thyroid gland.
The development of most autoimmune (A/I) diseases includes a substantial hereditary component. So, if you have vitiligo, you inherited certain vitiligo risk genes from your parents. How does that correlate to A/I thyroid disease? Thanks in large part to an international team of researchers headed by Dr. Richard Spritz of the University of Colorado, autoimmune connections that were previously unknown have begun to surface and unravel the complex interrelationships between A/I diseases like vitiligo and autoimmune thyroid disease (AITD).
In some instances, the very same gene/s associated with the risk of developing one specific A/I disease (like vitiligo) have also been found to be associated with other autoimmune diseases. This shared association helps to explain why some people who have been diagnosed with one A/I disease may be more likely to develop certain other A/I diseases that share the same risk genes.
In the case of vitiligo and AITD, this shared gene association is a likely culprit for making AITD the most prevalent other A/I disease found among vitiligo patients and/or their family members.
What is the Thyroid?
The thyroid gland is a small butterfly-shaped organ located just below the “Adams apple,” or larynx. Its job is to take iodine from foods and convert it into two major thyroid hormones:
Triiodothyronine (T3): The active thyroid hormone
Thyroxine (T4): The thyroid storage hormone
These two hormones circulate throughout the body and regulate the metabolism of every cell in the body. If the level of the thyroid hormones (T3 & T4) drops too low, the pituitary gland produces thyroid stimulating hormone (TSH) to stimulate the thyroid gland to produce more hormones. If T3 and T4 levels are too high, the pituitary gland releases less TSH to slow production of these hormones.
There Are Two Types of Autoimmune Thyroid Disease:
- Hashimoto’s, a type of hypothyroidism (underactive thyroid) is the result of antibodies destroying the thyroid gland, causing decreased levels of the critically needed thyroid hormones (T3 and T4), which in turn causes the pituitary gland to release increased levels of the thyroid stimulating hormone (TSH).
- Graves’ disease, a type of hyperthyroidism (overactive thyroid) is the result of antibodies which stimulate the thyroid gland, causing increased levels of the thyroid hormones (T3 and T4), which in turn causes the pituitary gland to decrease the level of the thyroid stimulating hormone (TSH).
Be Prepared: Recognize the Signs and Symptoms
Hypo/Underactive Thyroid causes a decrease in metabolism, which will in time result in a decrease in many of the body’s functions. The symptoms listed below are a few of those typical of hypothyroidism. However, depending on a variety of factors, you may experience some, but not others. The longer the condition is left untreated, the more symptoms you are likely to experience, and the more severe they may become.
Hyper/Overactive Thyroid causes an increase in metabolism, resulting in symptoms associated with an increase in many of the body’s functions. As noted above, the symptoms listed below are a few of those typically associated with hyperthyroidism; however, each person’s experience is different. Also, as noted above, the earlier the condition is treated, the better.
Diagnosing Thyroid Disease
If your doctor suspects a thyroid dysfunction, he/she will most likely begin by asking you a few questions about things like any family history of autoimmune diseases, and what medications you are currently taking. Then he/she will order diagnostic tests to help evaluate thyroid function, and/or diagnose hypo, or hyper thyroidism.
There are a variety of thyroid tests and panels available and they can be ordered by your doctor individually, as a group, or as a panel. The tests listed below are used to evaluate thyroid function; however, the list is not intended to be suggestive or exclusive. Your doctor will order tests based on your specific health condition.
Diagnostic Tests for Autoimmune Thyroid Dysfunction
- Free T3: Measures blood level of T3 hormone that is unbound, meaning that it is available to be used by cells and tissues.
OR T3 (Total T3): When not preceded by the word “Free,” it is referring to the “Total” amount, which includes both bound (unavailable) and unbound (available) hormones.
- Free T4: Measures blood level of T4 hormone that is unbound, meaning that it is available to be used by cells and tissues.
- TPO test: Commonly used to detect autoimmune thyroid disease by identifying antibodies directed against TPO.
- TSH test: Measures the level of thyroid stimulating hormone (TSH) in the blood, ordered when signs or symptoms of an overactive or underactive thyroid condition is suspected or diagnosed, or to monitor for those conditions.
Free T4 vs T4: The total T4 test can be affected by the amount of protein in the blood that is available to bind to the hormone, as opposed to the free T4, which is not affected by the protein levels. The free T4 test is considered to be a more accurate reflection of thyroid hormone function and in most cases, its use has replaced the total T4 test.
Additional Tests That May Be Helpful, and Why…
- Antithyroglobulin antibody (ATA) test
- Antinuclear antibody (ANA) test
- 25-Hydroxy Vitamin D
- Reverse T3 (RT3)
Antithyroglobulin antibody (ATA) test: Even though symptoms of thyroid disease can go unnoticed for many years, blood tests can detect two primary anti-thyroid antibodies (thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TGAb) decades before a change in the TSH levels. Therefore, ATA (as well as TPO) screening is a very effective diagnostic tool that can be used to screen for thyroid problems in advance of symptoms.
Antinuclear antibody (ANA) test: This test detects autoantibodies which may indicate the presence of an autoimmune disease; however, this is not a disease-specific test. If the test is positive, your doctor will then run more specific tests.
Folate/B12: B12 and other B vitamins play an important role in managing thyroid hormones. B12 deficiency is quite often found among those with hypothyroidism. Because research has found that many vitiligo patients are deficient in B12 and Folate, it’s wise to monitor your B vitamin levels.
Reverse T3 (rT3): (associated with hypothyroidism) is an inactive form of T3 that is produced in the body particularly during periods of stress. Under normal conditions, T4 will convert to both T3 and rT3 continually, and the body eliminates the rT3. Under certain conditions, the body conserves energy by converting T4 into RT3, an inactive form of T3 incapable of delivering oxygen and energy to the cells. The RT3 test must be done at the same time as free T3. The Free T3 should be 20 times higher than the RT3 to be within a healthy range.
25-Hydroxy-Vitamin D – also known as 25(OH)D: Vitamin D is another area of deficiency for many vitiligo patients, and has also been found to be associated with impaired thyroid function and autoimmune thyroiditis.
Thyroid Dysfunction and Cholesterol Levels
Your body depends on thyroid hormones to regulate cholesterol, as well as to break down and rid the body of low-density lipoprotein (LDL), known as the “bad” cholesterol. A high level of LDL is one of the major risks of cardiovascular disease and can lead to a number of serious health problems.
Underactive (hypo) thyroid function causes the body’s metabolism to slow down, which has a direct effect on the body’s ability to clear cholesterol from the bloodstream, resulting in an increase in LDL and triglyceride levels. It has also been noted that even slightly low thyroid hormone levels, known as subclinical hypothyroidism, can raise LDL cholesterol.
Overactive (hyper) thyroid function results in an increase in metabolism, which can cause your body to burn cholesterol more quickly, resulting in a drop in the LDL and triglyceride levels.
Recommendations from thyroid dysfunction research indicates that patients with abnormal levels of LDL, whether too high or too low, as well as patients with unexpected improvement or worsening of their lipids (cholesterol and triglycerides), should receive thyroid screening, specifically including TSH testing, as elevated TSH levels can raise LDL cholesterol before thyroid hormone levels reach abnormal levels.
Research, Facts, and Recommendations
The risk for those with vitiligo of developing AITD disease has been found to be 2.5 times higher than in the normal population.
The risk of developing elevated thyroid antibodies has been found to be greater than 5 times higher than in the normal population.
It’s possible that “thyroid autoimmunity might play an important role in triggering and maintaining the depigmentation process of vitiligo.”
Source: 2015 review of vitiligo and thyroid diseases conducted in Florence, Italy
Review recommendation: Vitiligo patients should be screened for AITD
The following symptoms may indicate an increased probability of developing AITD:
- Higher body surface area of involvement (widespread vitiligo)
- Experienced stress as an onset factor
- Family history of AITD
- Duration of disease: The risk of developing AITD doubles every 5 years after a vitiligo diagnosis.
Source: 2013 Belgian study of 700, and French study of 626 of non-segmental vitiligo (NSV) patients
Recommendations from both groups: NSV patients with any of these symptoms should be regularly monitored for thyroid function and thyroid antibodies.
There is an increased incidence of AITD among pediatric and adolescent vitiligo patients
Source: 2013 study performed in the Netherlands on 260 pediatric and adolescent vitiligo patients
Study Recommendation: Screen for thyroid function and antibody levels in all pediatric patients with non-segmental vitiligo.
Even for the professional, understanding thyroid disease can be very complex and challenging. However, research is clear on the topic of increased incidence of autoimmune thyroid disease among those with vitiligo. Research also confirms that the earlier the diagnosis and treatment, the better the outcome.
As noted in the opening of the article, the most effective health strategy is a proactive approach, which requires being informed. Being aware of your health, signs and symptoms to be aware of, and most importantly, what to report to your doctor to help him/her make the best diagnosis, will help you maintain control of your health.
VSI regularly receives patient requests for help locating a doctor that prescribes vitiligo treatments.
If you treat vitiligo patients and would like to be listed on VSI’s physician referral, click here to send the name of the doctor, and VSI will contact you for additional information.
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Editor’s note: The information in this article is for the purpose of information and is not meant to be a substitute for medical advice, diagnosis or treatment. Please consult your own physician or healthcare provider for personal recommendations with respect to your own symptoms.
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