Epidemiology and Management of Common Skin Diseases

Associate Professor Dr Eman Al-Kamil

Associate Professor Dr Eman Al-Kamil

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While skin diseases are very common among the populations in many developing countries, they have not been regarded as a significant problem that could benefit from public health measures. This attitude is due to the assumption that : skin diseases are a benign, not life-threatening minor nuisance.

However, at least in some countries, there seems to be a high demand by patients and healthcare workers for more consideration to be given to skin diseases.
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The quality of life in this group of patients is compromised in different ways. Apart from the morbidity that is usually chronic, patients face a lot of agony from social stigma and low self-esteem due to deformities and disabilities of various degrees. For one or more of the reasons they become unproductive and live in poverty of a deeper degree. Skin diseases occur all over the world at significant levels. They have been identified as a public health problem in developing countries.
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They are dominated by: bacterial and superficial fungal infections. The eczemas. In some areas discoid lupus erythematosus is common lichen planus is seen far more frequently than in temperate countries. chronic infections: Leprosy, Leishmaniasis, scabies and onchocericiasis which affect the skin so distinctively; ulcers of the skin; and the serious effects on the skin of protein malnutrition.

Associate Professor Dr Eman Al-Kamil

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Skin diseases affect all segments of the population with out ethnic variability but are more prevalent among children and in low socioeconomic groups, essentially due to poor hygienic practices. Different studies also suggest that skin infections are more prevalent in extreme climatic conditions. Most skin infections transmit through contact with infected individuals or articles.

Associate Professor Dr Eman Al-Kamil

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Primary lesions Macular: flat lesion due to a localized color change only; the surface is normal (size <1cm) Patch: similar to a macule but the size (> 1cm) Nodule: any elevated lesion (> 1cm diameter) which has a round surface (i.e. the thickness is similar to the diameter): often due to dermal pathology Plaque: (size > 1cm) a raised lesion where the diameter is much greater than the thickness Vesicle: (size < 1cm) a fluid filled lesion (blister) Bullae: blister which is > 1cm in size Pustule when a vesicle contains pus and the size is < 1cm and if it is more than 1cm it is called abscess.
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Macular

Patch

Associate Professor Dr Eman Al-Kamil

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Nodule

Bullae

Associate Professor Dr Eman Al-Kamil

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Vesicles

Pustules

Associate Professor Dr Eman Al-Kamil

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Plaque

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Associate Professor Dr Eman Al-Kamil

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Secondary lesions Erosion: partial loss of epidermis, which will heal without scaring. Ulcer: full thickness loss of epidermis and some dermis, which will heal with scaring. Atrophy: depression of the surface due to thinning of the epidermis or dermis. There are often fine wrinkles and blood vessels easily seen under the skin. Fissure: linear split in the epidermis or dermis at an orifice (angle of the mouth or anus), over a joint or along a skin crease. Erythematous or non erythematous. Erythematous lesions are usually indicative of acute inflammation. Surface features Normal/ smooth: the surface is not different from the surrounding skin and feels smooth

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Associate Professor Dr Eman Al-Kamil

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Scaly: dry/flaky surface due to abnormal stratum corneum with accumulation of or increased shedding of keratinocytes. Exudate: serum, blood, or pus that has accumulated on the surface.

Friable: surface bleeds easily after minor trauma.

Crust: dried serum, pus or blood.

Excoriation: localized damage to the skin due to scratching.

Lichenification: thickening of the epidermis with increased skin markings due to persistent scratching. Umblicated; surface contains a round depression in the centre, characteristics of molluscum contagiosum or herpes simplex.
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1. Bacterial infection of the skin (pyodermas): Impetigo

Folliculitis
Cellulitis and Erysipelas Erythrasma leprosy

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Associate Professor Dr Eman Al-Kamil

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2. Superficial fungal infection of the skin Dermatophytes

Tinea Capitis Tinea corporis Tinea pedis Tinea versicolor (Pityriasis versicolor) Candidiasis Intertrigo Paronychia and onychomycosis Mucosal candidiasis Oropharyngeal candidiasis (OPC) Vulvovaginal candidiasis

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Associate Professor Dr Eman Al-Kamil

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Viral infections Warts genital warts Molluscum contagiosum Herpes simplex Infection Other infectious diseases with rash: Measles German measles Chicken pox Small pox Infectious mononucliosis
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Arthropod associated Skin Disease, Parasitic infections Scabies Leishmaniasis pediculosis Eczemas Atopic dermatitis Lichen Simplex Chronicus Acne vulgaris Psoriasis Exfoliative Dermatitis Erythroderma Syndrome Skin Failure Common skin manifestations of HIV/AIDS Prevention and control of common Skin infections Skin cancer Associate Professor Dr Eman Al-Kamil 16 12 81

Epidemiology: Skin disease was cited recently as one of the top 15 groups of medical conditions for which prevalence and health care spending increased. The burden of skin disease extends beyond the financial toll, estimated at $39.3 billion per year in medical services and lost productivity. There are more than 3,000 identified varieties of skin disease that can cause symptoms ranging from: simple burning and itch, to severe emotional and social effects, to physical disfigurement or death.
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Skin diseases are extraordinarily diverse in clinical presentation, severity, and epidemiology. These diseases are caused or exacerbated by such factors as genetic predisposition, environment, stress, and presence of comorbid conditions. Prevalence and incidence of skin conditions Previous studies suggest that around 2333% of individuals have a skin problem at any one time . This means that skin conditions in general, such as dermatitis, psoriasis, acne and skin infections are the commonest reason people consult their general practitioner with a new problem.
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52 % prevalence of skin disease in developed countries, just over half the cases required treatment. Studies from developing countries ,the prevalence of skin diseases range from 20 to 80 percent.

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Associate Professor Dr Eman Al-Kamil

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However, skin problems are generally among the most common diseases seen in primary care settings in tropical areas, and in some regions where transmissible diseases are endemic, they become the dominant presentation. World Health Organizations 2001 report on the global burden of disease indicated that skin diseases were associated with mortality rates of 20,000 in Sub-Saharan Africa in 2001. This burden was comparable to mortality rates attributed to meningitis, hepatitis B, obstructed labor, and rheumatic heart disease in the same region.
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Skin diseases have a significant impact on quality of life. Although mortality rates are generally lower than for other conditions, peoples needs for effective remedies for skin conditions should be met for a number of important reasons: First, skin diseases are so common and patients present in such large numbers in primary care settings that ignoring them is not a viable option. Children, in particular, tend to be affected, adding to the burden of disease among an already vulnerable group.

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Associate Professor Dr Eman Al-Kamil

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Second, morbidity is significant through disfigurement, disability, or symptoms such as intractable itch, as is the reduction in quality of life. For instance, the morbidity from secondary cellulitis in lymphatic filariasis, which may lead to progressive limb enlargement, is severe, and subsequent immobility contributes to social isolation.

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Associate Professor Dr Eman Al-Kamil

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Third, the relative economic cost to families of treating even trivial skin complaints limits the uptake of therapies. Generally, families must meet such costs from an overstretched household budget, and such expenses in turn reduce the capacity to purchase such items as essential foods. Fourth, screening the skin for signs of disease is an important strategy for a wide range of illnesses, such as leprosy, yet a basic knowledge of the simple features of disease whose presenting signs occur in the skin is often lacking at the primary care level

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Associate Professor Dr Eman Al-Kamil

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Associate Professor Dr Eman Al-Kamil

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A shortage of elementary skills in the management of skin diseases is a further confounding problem. A number of success in the management of skin diseases in primary care settings in the developing world find that treatment failure rates of more than 80 percent are common . An additional point, often overlooked, is that skin diseases in the developing world are often transmissible and contagious but are treatable.

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Associate Professor Dr Eman Al-Kamil

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A number of common diseases account for the vast majority of the skin disease burden; therefore implementing effective treatments targeted at those conditions results in significant gains for both personal and public health. Even where eradication is impossible, control measures may be important in reducing the burden of illness.

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Associate Professor Dr Eman Al-Kamil

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Risk factors the main risk factors associated with skin disease in developing countries: -household overcrowding. In primary schools in some countries more than 80 % of randomly examined schoolchildren had at least one skin disease, which was usually caused by one of four conditions: scabies, pediculosis capitis, tinea capitis, or pyoderma . - Hot and humid climatic conditions may also predispose populations to pyoderma, superficial mycoses, while scabies is higher incidence in colder months -Age , higher among children
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Poor hygiene Role of water the prevalence of pyoderma was higher in children with a low level of hygiene. More recently, in the same geographical area, a programme of intensive education combined with the distribution of free soap, in an area with easy access to water, resulted in a significant decrease in pyoderma incidence Low level of knowledge about hygiene practices has been found to be associated with a higher prevalence of scabies, Interpersonal transmission Medical problems 28
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Risk factors for skin infections include: HIV infection/ AIDS Treatment with corticosteroid medications Diabetes Eczema Elderly Exposure to animals Insect bites or stings Peripheral vascular disease Psoriasis Skin cancer Skin injury Skin ulcers Surgical wound
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PATTERNS OF SKIN DISEASES AT THE COMMUNITY LEVEL The following were the main skin conditions at community level: Scabies: Although scabies was often the commonest skin disease, it was completely absent in some regions. Superficial mycoses: This group of infections was usually reported as one of the three commonest diseases. Pyoderma. This disease was often, but not invariably, associated with scabies. Pediculosis: This disease was the subject of much variation but is often overlooked in surveys. At communitylevel data on the prevalence of pediculosis are deficient. 18 Associate Professor Dr Eman Al-Kamil 30 12

Eczema or dermatitis: Although this disease was usually unclassified, irritant dermatitis and chronic lichen simplex were often cited. . HIV-related skin disease :This disease was reported mainly in Africa. The pruritic papular dermatitis of AIDS is a specific Problem , Kaposi sarcoma. Pigmentary anomalies: Three different problems were cited: hypopigmentation, often diagnosed as pityriasis alba, a form of eczema; melasma; and dermatitis caused by cosmetic bleaching agents Acne: This disease was reported as an emerging and common problem. Associate Professor Dr Eman Al-Kamil 31 12 81

Tropical ulcer: The incidence was highly variable, but tropical ulcer can account for a huge workload in primary care centers in endemic areas.
Nonfilarial lymphoedema: This condition was mainly confined to Africa.

Onchodermatitis, filarial lymphoedema, endemic treponematoses, Buruli ulcers, and leprosy..

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Associate Professor Dr Eman Al-Kamil

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Prevention and control of common Skin infections Treatment of individual cases Community measures i .e. Community-Based Treatments for Scabies Without a community approach to therapy in many developing countries, the successful management of scabies in areas where it affects more than5 to 6 percent of the population is exposed to failure. Health education Improvement of personal hygiene
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