February 2005, Volume 55, Issue 2

Original Article

Spectrum of Common Childhood Skin Diseases: a single centreexperience

Nuzhat Yasmeen  ( Department of Dermatology, Jinnah Postgraduate Medical Centre, Karachi )
Mohammad Riaz Khan  ( Department of Dermatology Khyber )

Abstract

Objective: To assess the pattern of childhood skin diseases and to analyze the attitude towards consultation and self-treatment.

Methods: Children with complaints of skin diseases visiting outpatient department of Jinnah Postgraduate Medical Centre and National Institute of Child Health were enrolled in this study during the period of May 2002 to July 2003. A detail performa was filled in, for all the patients. 250 cases were finally analyzed in 15 months duration. The diseases were sub-classified on etiological basis e.g. infectious (bacterial, fungal, viral, parasitic) immune mediated, congenital, allergic and miscellaneous. The children's sex, race, age, duration, history of previous treatment and family and past history for skin or systemic diseases were noted.

Results: Of all the patients visiting the outpatient department (OPD), 31% were children with skin diseases. Infectious skin diseases were the commonest (60%). Among the infections, fungal were maximum (20.6%), followed by bacterial diseases (12%). Eczemas constituted 21% of skin diseases and 6.4% children had congenital skin conditions. Previous treatment history was present in 43.6% patients. Antibiotics (topical and/or systemic) were taken by 28.4% of patients; whereas history of steroids (topical and/or systemic) was present in 15.2% of patients. Most children (550) had a normal weight and 13.6% were severely malnourished.

Conclusion: Skin diseases are fairly common in children especially infectious skin diseases. Eczematous and allergic skin diseases are also frequently encountered in children. Self medication is a common practice. Topical steroids were the most commonly used medications (JPMA 55:60;2005).

Introduction

The role of a paediatrician is enormous as they treat a large range of diseases from common colds to most complex diseases like malignancies and collagen vascular disorders. The problem that a Paediatrician faces when encountered with skin diseases, is a difficult one. This is partly because of inexperience in the field of dermatology and partly because of atypical presentation of similar lesions.1

Children are in developing stage of life and can have a skin problem right from birth. There is a wide range of skin diseases presenting in different age groups. But there are certain factors which predisposes them to such diseases e.g. personal hygiene, family history, traditional taboos, nutritional status, large family size, over-crowding, child abuse and poverty.2 In such patients, contagious skin infections were more common.

Self-medication is fairly common in childhood skin diseases, as also in adults. They are usually administered by their care givers, which in most of instances are parents. This usually leads to delay in referral to the clinics and use of wrong medication which can cause complications or masking of original illnesses.

Patients and Methods

This study was conducted in OPD of JPMC and NICH, Karachi, from 10th May 2002 till 20th July 2003. As the aim of the study was to highlight skin diseases present in children, only children from birth to 12 years of age were included in this study, which is the age limit for paediatric patients in Pakistan. These children were either visiting the outpatient department directly or were referred by general practitioners or by primary and secondary health care centers.

A detailed performa was filled for all the patients stating age, sex, race, complaints, their duration, lesional site and description, past and family history of cutaneous or other illnesses and previous treatments.

Investigations were done in patients where they were required and included complete blood picture, Xray, biopsy of lesions, skin scraping and nail clippings.

The monthly income of the parents of patients was noted and divided into four broad groups. They were low income group (<3000 rupees per month), medium income group (3000-10,000 rupees per month), satisfactory or good income group (>10,000 rupees per month). The fourth group consisted of jobless, dead, divorced or missing in war fathers.

Results

A total of 273 patients were enrolled in this study at the end of 14 months of study period. During analysis, only 256 patients qualified for the study on the basis of complete data. Two hundred fifty patients were finally included in this study. The children comprised of 23.7% of total OPD visits in 14 months in a single OPD (total visits = 1092).

Maximum number of patients were between 5-12 years of age (46.4%), followed by children in the range of 1-5 years (36.4%). Among the patients, 54% were males and 45.6% were females. The male to female ratio was 1.2:1.

Majority of the patients belonged to different ethnic groups settled in Karachi, or in its outskirts; but 5.2% of patients were refugees from different countries (i.e. Afghanistan, Burma and Iran). Family history was positive for skin disease in 16% of patients e.g. impetigo, scabies, icthyosis, etc. however, in 12% of patients it was positive for systemic disease e.g. diabetes, allergic rhinitis and asthma.

Most of the patients hailed from lower middle class i.e. income of 3000-10,000 rupees per month (63.6%) or, to poor / labour class (24.4%). Both these classes had mainly communicable skin diseases. The nutrition status of patients was not important statistically, as skin diseases were equally common in both normal and under nourished children (52.8% vs 47.2%).

Diseases were neglected for variable length of time. Some (19.2%) presented to OPD within a week of illness. Majority were brought after a month of illness (42.4%). In 17.6%, illness had lasted for more than one year, before the child was brought for consultation. Infectious diseases were the most common skin diseases (60%) and fungal infections were also common (20.6%). Parasitic skin infections were seen in 17.5% and bacterial in 12% patients. Viral infections were seen in 9.7% and eczemas in 21% of patients along

with atopic dermatitis in 8.5%. Congenital cutaneous lesions were encountered in 6.4% of O.P.D visits. Some other illnesses of various etiologies were grouped together into miscellaneous group (5.7%) (Figure 2).

History of previous treatment was present in 43.6% of patients. Among these 28.4% had received antibiotics whereas 15.2% received steroids (Figure 3).

Discussion

Skin diseases often pose a diagnostic dilemma for Paediatrician and hence they are referred to dermatologists for expert opinion where children make a significant percentage of OPD visits. Unfortunately in Pakistan (as in many other countries of the world), paediatric dermatology concept is not yet established and there are no separate paediatric skin clinics even in the best skin centers. Due to this, sometimes patients are tossed between paediatrician and dermatologist, which enhance anxiety of patients which is more in chronic cases.
This study was more widely aimed hence encompassed all types of childhood skin diseases attending the outpatient department. The sample studied was adequate to determine the pattern and related factors of skin diseases present in the community. Although this is not a true reflection of the disease pattern (as this is a single centre experience and setting is in a tertiary care), but it points towards the varied spectrum of infectious and communicable diseases that are still prevalent in the society. Infectious diseases comprised the major form. These include fungal, bacterial, viral and parasitic.
Fungal infections especially of scalp were predominant. Among them, two major types of Tinea capitus, black dot and grey patch were most common. Seborrhoeic dermatitis was mainly seen is infants. Cutaneous parasitic diseases especially with positive family history like scabies and pediculosis were second common infections. These all indicated poor personnel hygiene and low socio-economic status. Rare parasitic diseases of children (e.g. cutaneous leishmaniasis) presented as infected nodular lesions.
The pattern of skin diseases differ from developed countries where contagious skin infections like scabies, pediculosis and tineal infections are rare.3 This indicates the poor personal hygiene and low socioeconomic status of children living in developing countries like Pakistan.
Bacterial skin infections like impetigo and folliculitis, which are more common, were not seen in large number (12%); the probable reason being that they were treated by local doctors or pediatricians and thus not qualifying for referrals. However severe forms, of bacterial infections especially in the new-born e.g., Bullous Impetigo or Scalded Skin Syndrome, were usually referred to dermatologist.1 But lesions due to atypical bacteria like cutaneous tuberculosis are almost always treated by dermatologists.
Cutaneous TB, although rare in children, can present in any age group. A case-report from Vietnam reported localized erythematous lesions in five months old baby.5 A similar experience of 63 patients being reported from India by Ramesh et al.6 In this study, the tuberculous lesions found were either of lupus vulgaris or scrofuloderma. Contagious viral exanthum like molluscum contigiosum, warts, or more severe illnesses as varicella, present to the clinic usually with a positive family history. Zoster though a disease of adults, was also seen in children all being immuno-compromised as those with nephrotic syndrome on steroid therapy or with systemic malignancies. Varicella and Zoster is 5-times more common in leukemias and Hodgkin\'s disease.7,8
Different forms of endogenous or exogenous eczemas were also seen in children. A large study from Sultanate of Oman reported that eczemas were prevalent in 14.4% of children between 13-14 years and 7.5% in younger children.9 Some children with Atopic dermatitis or P. Alba had positive personal or family history of asthma, allergic rhinitis or other form of eczemas. This association of eczema with rhinitis and or wheeze, is also reported by Harty et al in 6-7 years old Irish school children. Its prevalence was 11.2% whereas 2.4% children were suffering from all three conditions.10
Congenital form of icthyosis was the commonest congenital skin condition encountered in this study. Icthyosis is a congenital disorder of keretinization ranging from collodion to vulgaris, to non-bullous icthyosiform erythroderma.11,12 Other rare congenital disorders13-15 presenting were epidermolysis bullosa, aplesia cutis, hyperhydrosis of whole body and naevoid conditions like OTA and ITA were referred for consultation.
Cutaneous immunlogical diseases usually present in school age children and only 3.3% children in this study had vitiligo and alopecia areata. They also had positive family history for similar or other immune mediated diseases like diabetes mellitus and hypothyroidism.
Among vesico-bullous disease two cases of erythema multiforme and one patient with Steven Johnson Syndrome with extensive muco-cutaneous involvement were seen.
Rarer diseases especially presenting a diagnostic challenge, e.g. trichotillomania, keloids in zoster scars, dermatomal lentigenosis and syndromes like Shabbir syndrome, Papillion le fever syndrome were additions to the spectrum.
The duration of illness before being taken to a specialist clinic was very variable. Some of the chronic cases had been running to all sorts of quacks, homeopathic clinics or taking other cultural/home remedies before embarking upon specialist advices.
Self-medication in children were uncommon and mostly present in adolescents. Those with a history were given medications by their care-takers. These self-cure remedies were either bought over the counter or on advice of neighbors, family-friends or an elderly, thus leading to wrong treatment e.g. 46% of fungal infections received systemic or topical antibiotics. Steroids especially potent topical ones like betamethasone were used by patients for weeks for acute conditions like impetigo (on face), scabies, chicken pox, aplasia cutis, leishmaniasis and fungal scalp infections.
It can be concluded from this study that skin diseases are fairly common in children especially infectious diseases. Among infections, fungal and parasitic skin and scalp disease out number other types of illnesses reflecting low social standards of the country. The children are usually treated by their parents or care givers at home, leading to wrong self medication and delayed referrals. Therefore the need for separate-paediatric dermatological clinics, either in children\'s hospital, or in dermatology OPD in general hospital cannot be over emphasized, because pediatric dermatology is a highly specialized field.

References

1. Taplin D, Lansdell I, Allen AM, et al. Prevalence of streptococcal pyoderma in relation to climate and hygiene. Lancet 1973;1:501-3.
2. Burton JL. The logic of dermatological diagnosis: Dowling oration. Clin Exp Dermatol 1980. 1981;6:1-21.
3. Ibarra J, Hall DM. Head lice in school children. Arch Dis Child 1998;78:288-9.
4. Coskey RJ, Coskey LA. Diagnosis and treatment of impetigo. J Am Acad Dermatol 1987;17:62-3.
5. Paul MA, Williford PM. Cutaneous tuberculosis in a child: case report and review. Pediatr Dermatol 1996;13:386-8.
6. Ramesh V, Misra RS, Beena KR, Mukherjee A. A study of cutaneous tuberculosis in children. Pediatr Dermatol 1999;16:264-9.
7. Baba K, Yabuuchi H, Takanashi M, et al. Increased incidence of herpes zoster in normal children, infected with varicella zoster virus in infancy. J Pediatr 1986;108:372-7.
8. Tarlow MJ, Walters S. Chicken pox in childhood. J Infect Dis 1998;36 (Suppl):39-47.
9. Al-Riyami BM, Al-Rawas OA, Al-Riyami AA, et al. A relatively high prevalence and severity of asthma, allergic rhinitus and atopic eczema in school children in Sultanate of Oman. Pediatr Dermatol 2003;20:207-10.
10. Harty SB, Sheridan A, Howell F, et al. Wheeze eczema and rhinitis in 6-7 years old Irish school children. Ir Med J 2003;96:102-4.
11. Crowe MA, Jarmes WD. X-linked icthyosis. JAMA 1993;270:2265-6.
12. Shwayder T, Ott F. All about icthyosis. Pediatr Clin North Am 1991;38:835-57.
13. Leung AK, Kao CP, Cho HY, et al. Scleral melanocytosis and oculodermal melanocytosis(naevus of Ota) in Chinese children. J Pediatr 2000;137:581-4.
14. Frieden IJ. Aplasia cutis congenita: a clinical review and proposal for classification. J Am Acad Dermatol 1986;14:646-60.
15. Giannetti A, Malmusi M, Girolomoni G. Vesiculo-bullous drug eruption in children. Clin Dermatol 1993;11:551-5.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: