## **Supplementary Online Content**

Bang CH, Park HE, Kim YH, et al. Risk of subsequent vitiligo in transplant recipients with comorbid graft-vs-host disease. *JAMA Dermatol.* Published online December 13, 2023. doi:10.1001/jamadermatol.2023.4933

**eTable 1.** Risks and Incidence Rates of Vitiligo in Transplant Patients According to a Health Check-Up Database

**eFigure 1.** Flowchart of Included Patients

**This supplementary material has been provided by the authors to give readers additional information about their work.** 

| | | Number | Vitiligo | Duration | IR* | Fully adjusted model |
|------------------------------------|------------------------------|--------|----------|------------|-------|----------------------|
| Transplantation | No | 74,231 | 204 | 367,806.60 | 0.55 | 1 (Ref.) |
| | Yes | 10,355 | 55 | 46,454.90 | 1.18 | 1.40 (0.96, 2.05) |
| Transplantation type | No | 74,231 | 204 | 367,806.60 | 0.55 | 1 (Ref.) |
| | KT | 5147 | 15 | 24,484.60 | 0.61 | 1.16 (0.67, 1.98) |
| | LT | 3586 | 12 | 16,207.00 | 0.74 | 1.33 (0.73, 2.40) |
| | HSCT | 1622 | 28 | 5763.3 | 4.86 | 10.32 (2.69, 39.60) |
| Transplantation method | No | 74,231 | 204 | 367,806.60 | 0.55 | 1 (Ref.) |
| | KT | 5147 | 15 | 24,484.60 | 0.61 | 1.16 (0.68, 1.98) |
| | LT | 3586 | 12 | 16,207.00 | 0.74 | 1.33 (0.73, 2.4) |
| | HSCT (allograft) | 875 | 27 | 2992.9 | 9.02 | 12.80 (3.10, 52.92) |
| | HSCT (autograft) | 747 | 1 | 2770.4 | 0.36 | 0.91 (0.03, 31.38) |
| Transplantation type and GvHD | No | 74,231 | 204 | 367,806.60 | 0.55 | 1 (Ref.) |
| | KT | 5147 | 15 | 24,484.60 | 0.61 | 1.16 (0.68, 1.98) |
| | LT | 3586 | 12 | 16207 | 0.74 | 1.32 (0.73, 2.39) |
| | HSCT without GvHD | 1183 | 6 | 4332.7 | 1.38 | 4.49 (0.96, 20.93) |
| | HSCT with GvHD | 439 | 22 | 1430.6 | 15.38 | 25.09 (6.08, 103.60) |
| Transplantation method and GvHD | No | 74,231 | 204 | 367,806.60 | 0.55 | 1 (Ref.) |
| | KT | 5147 | 15 | 24,484.60 | 0.61 | 1.16 (0.68, 1.98) |
| | LT | 3586 | 12 | 16,207.00 | 0.74 | 1.32 (0.73, 2.39) |
| | allograft without GvHD | 447 | 5 | 1592.8 | 3.14 | 5.44 (1.12, 26.45) |
| | allograft with GvHD | 428 | 22 | 1400.1 | 15.71 | 26.41 (6.26, 111.42) |
| | autograft without GvHD | 736 | 1 | 2739.9 | 0.37 | 0.75 (0.01, 47.27) |
| | autograft with GvHD | 11 | 0 | 30.5 | 0 | |

**eTable 1. Risks and incidence rates of vitiligo in patients with transplantation according to a health checkup database.**

Model data are expressed as hazard ratios and 95% confidence intervals.

KT, kidney transplantation; LT, liver transplantation; HSCT, hematopoietic stem cell transplantation; GvHD, graft versus host disease.

\*IR: Incidence rate per 1000.

Fully adjusted model was adjusted for age; sex; comorbidities of type 2 diabetes mellitus, hypertension, hyperlipidemia, leukemia, lymphoma, multiple myeloma, bone marrow failure disorders; alcohol consumption; physical activity; body mass index; fasting plasma glucose level; total cholesterol level; and systolic blood pressure

© 2023 American Medical Association. All rights reserved.

## **eFigure 1.** Flowchart of included patients

Abbreviations: KT, kidney transplantation; LT, liver transplantation; HSCT, hematopoietic stem cell transplantation

![](https://assets.reachrx.ai/images/10.1001%E2%98%8Djamadermatol.2023.4933/_page_2_Figure_2.jpeg)

JAMA Dermatology

<jats:sec id="ab-dbr230020-4"><jats:title>Importance</jats:title><jats:p>Vitiligo is a multifactorial, depigmenting skin disorder characterized by selective loss of melanocytes. Large-scale studies are lacking to determine the risk of vitiligo in transplant recipients with graft-vs-host disease (GVHD).</jats:p></jats:sec><jats:sec id="ab-dbr230020-5"><jats:title>Objective</jats:title><jats:p>To investigate the incidence rates and risk of vitiligo in patients who had received solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT) overall and by HSCT graft type and concomitant GVHD.</jats:p></jats:sec><jats:sec id="ab-dbr230020-6"><jats:title>Design, Setting, and Participants</jats:title><jats:p>This population-based cohort study included data from the National Health Insurance Service database of Korea for patients aged 20 years or older who had received a transplant (SOT or HSCT) between January 2010 and December 2017, with follow-up until December 2019. A cohort of age- and sex-matched (1:5) control individuals who did not receive a transplant was included for comparison. Data were analyzed from July 2021 to December 2021.</jats:p></jats:sec><jats:sec id="ab-dbr230020-7"><jats:title>Exposure</jats:title><jats:p>Transplant (SOT or HSCT) and GVHD.</jats:p></jats:sec><jats:sec id="ab-dbr230020-8"><jats:title>Main Outcomes and Measures</jats:title><jats:p>The main outcome was risk of vitiligo, assessed using multivariable Cox proportional hazards regression analyses adjusting for potential confounding factors.</jats:p></jats:sec><jats:sec id="ab-dbr230020-9"><jats:title>Results</jats:title><jats:p>The study included 23 829 patients who had undergone SOT or HSCT (62.78% male; mean [SD] age, 49.58 [11.59] years) and 119 145 age- and sex-matched controls. Patients who had undergone transplant had a significantly higher risk of vitiligo compared with controls (adjusted hazard ratio [AHR], 1.73; 95% CI, 1.35-2.22). Risk of vitiligo was also slightly higher in kidney transplant recipients and liver transplant recipients compared with the controls but was highest in HSCT recipients (AHR, 12.69; 95% CI, 5.11-31.50). Patients who had received allogeneic grafts (AHR, 14.43; 95% CI, 5.61-37.15), those who had received autologous grafts (AHR, 5.71; 95% CI, 1.20-3.18), those with comorbid GVHD (AHR, 24.09; 95% CI, 9.16-63.35), and those without GVHD (AHR, 8.21; 95% CI, 3.08-21.87) had a higher risk of vitiligo compared with controls.</jats:p></jats:sec><jats:sec id="ab-dbr230020-10"><jats:title>Conclusion and Relevance</jats:title><jats:p>In this study, risk of vitiligo was significantly higher in transplant recipients, especially in HSCT recipients and those with allogeneic grafts or comorbid GVHD. These findings provide new insights into the association between the risk of vitiligo and transplant and GVHD. Clinicians should be aware of these risks, implementing a multidisciplinary approach for monitoring.</jats:p></jats:sec>

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Vitiligo is a multifactorial, depigmenting skin disorder characterized by selective loss of melanocytes. Large-scale studies are lacking to determine the risk of vitiligo in transplant recipients with graft-vs-host disease (GVHD).
To investigate the incidence rates and risk of vitiligo in patients who had received solid organ transplant (SOT) or hematopoietic stem cell transplant (HSCT) overall and by HSCT graft type and concomitant GVHD.
This population-based cohort study included data from the National Health Insurance Service database of Korea for patients aged 20 years or older who had received a transplant (SOT or HSCT) between January 2010 and December 2017, with follow-up until December 2019. A cohort of age- and sex-matched (1:5) control individuals who did not receive a transplant was included for comparison. Data were analyzed from July 2021 to December 2021.
Transplant (SOT or HSCT) and GVHD.
The main outcome was risk of vitiligo, assessed using multivariable Cox proportional hazards regression analyses adjusting for potential confounding factors.
The study included 23 829 patients who had undergone SOT or HSCT (62.78% male; mean [SD] age, 49.58 [11.59] years) and 119 145 age- and sex-matched controls. Patients who had undergone transplant had a significantly higher risk of vitiligo compared with controls (adjusted hazard ratio [AHR], 1.73; 95% CI, 1.35-2.22). Risk of vitiligo was also slightly higher in kidney transplant recipients and liver transplant recipients compared with the controls but was highest in HSCT recipients (AHR, 12.69; 95% CI, 5.11-31.50). Patients who had received allogeneic grafts (AHR, 14.43; 95% CI, 5.61-37.15), those who had received autologous grafts (AHR, 5.71; 95% CI, 1.20-3.18), those with comorbid GVHD (AHR, 24.09; 95% CI, 9.16-63.35), and those without GVHD (AHR, 8.21; 95% CI, 3.08-21.87) had a higher risk of vitiligo compared with controls.
In this study, risk of vitiligo was significantly higher in transplant recipients, especially in HSCT recipients and those with allogeneic grafts or comorbid GVHD. These findings provide new insights into the association between the risk of vitiligo and transplant and GVHD. Clinicians should be aware of these risks, implementing a multidisciplinary approach for monitoring.

Risk of Subsequent Vitiligo in Transplant Recipients With Comorbid Graft-vs-Host Disease.

Risk of Subsequent Vitiligo in Transplant Recipients With Comorbid Graft-vs-Host Disease

Risk of Subsequent Vitiligo in Transplant Recipients With Comorbid Graft-vs-Host Disease

Clinical Summary

What was studied

Key findings

Study limitations

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