SPECTRUM OF SKIN DISORDERS AT A SEMI-URBAN SETTING: THE KAKATA EXPERIENCE
Amadi ES1,2*
1Dermatology Unit, Internal Medicine, Rivers State University, Nkpolu-Oroworukwo, Port Harcourt, Nigeria
2Dermatology in Clinical Practice, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK
*Correspondence: Amadi, Ekechi Stella; ekechiamadi@yahoo.com
Abstract
Background: Skin diseases are diverse in various communities. They could be a major burden, affect the quality of life of individuals and cause increase in morbidity. Knowledge of the prevalent skin lesions will enable individuals and government to engage in health planning, prevention and allocation of resources.
Objective: To examine the spectrum of skin disorders in Kakata, Margibi County, Liberia.
Materials and Methods: This is a cross sectional descriptive study of persons with dermatological complains in Kakata, Margibi County, Liberia. A semi-structured interviewer-administered questionnaire was used for data collection. Data was analyzed using Microsoft Office Excel 2010. Results were summarized using frequencies and percentages and presented in tables and a figure.
Results: A total of 917 patients were seen in the general medical outpatient clinic during this period. Skin lesions were prevalent in 4.6% of the population. Fungal skin infections constituted the majority of skin diseases. Chronic stasis dermatitis was seen only in the elderly and scabies was predominant in school children.
Conclusion: A spectrum of skin diseases were seen amongst the different age groups residing in this semi-urban area. There is need for training of care workers on common prevalent skin disorders and their management.
Keywords: Kakata, Semi-urban, Skin, Spectrum
Cite this article: Amadi ES. Spectrum of skin disorders at a semi-urban setting: the Kakata experience. Yen Med J. 2023;5(2):61–70.
INTRODUCTION
Dermatological (skin) lesions are diverse in various communities; however, within the African population there are some skin lesions that have been noted to be more common. This could be as a result of genetic as well as environmental factors. Dermatological diseases are major health problems especially in resource poor countries. They hardly cause mortality; however, the morbidity associated with them can result in poor quality of life. This is probably due to poor funding and few dermatologists to manage the increasing number of cases.1 This study aims to present the spectrum of skin disorders that was seen in a general medical consultation clinic during a one-week medical outreach.
MATERIALS AND METHODS
Study design and period
This was a community based cross-sectional descriptive study which was conducted from the period 8th – 15th November 2022, amongst the members of the Kakata community in Margibi in Liberia during a medical outreach.
Study area
Kakata is the headquarters of Margibi County in Liberia. The county is subdivided into four health districts, with an estimated population of 269,570. The county has one government referral hospital located in the Kakata district which has the majority of the skilled and qualified public health workforce. 2, 3
Study Population
Persons with dermatological complains who consulted the general medical clinic within the medical outreach period.
Study Tool
This study utilized a semi-structured interviewer-administered questionnaire which included socio-demographics, presenting complains, vital signs, general and systemic examination; and management of the patient. Skin lesions were examined and clinical photographs were taken with the patients ‘consent.
Data analysis and management
Data entry and analysis was done using Microsoft Office Word Excel 2010. Simple arithmetic calculations were carried out using Tecno Camon 16 calculator application establishing the frequencies and proportions. Tables and charts were constructed for the presentation of the results.
RESULTS
Those with complaints of skin disorders made up 4.6% (42 out of 917) of patients. The mean age in this study was 33.3±19.7 years. The male: female ratio is 1:1.5, see sociodemographic characteristics of the patients in Table 1. Table 2 show the nature of cutaneous complaints of patients. The duration of skin complaints was highly variable with a range of 1 day to 20 years. There were 32 classes of skin disorders identified in 53 diagnoses (Table 3). Eight patients had two diagnoses and 1 had three diagnoses. The infections seen in this study can be further classified. Fungal infections (24.5%) included onychomycosis, pityriasis versicolor, tinea corporis, tinea capitis and tinea glutei. Viral infections (5.7%) were herpes zoster and genital warts. Infestations (9.4%) included scabies and elephantiasis (lymphatic filariasis). Skin tumours (9.4%) included giant lipoma, post auricular cysts, dermatofibroma, neurofibromatosis and subcutaneous nodules. Diseases of skin appendages (3.8%) were miliaria and hidradenitis suppurativa. Allergic/pruritic lesions (9.4%) were acute allergic reaction, aquagenic pruritus, papular urticaria and prurigo nodularis. The hypertrophic /atrophic lesions (5.7%) included palmoplantar keratoderma, post burn scar and contractures and striae (post bleaching syndrome). Dermatitis (3.8%) included chronic stasis dermatitis and contact irritant dermatitis. Others include papulosquamous lesion (13.2%) which was mainly lichen planus, genodermatosis (1.9%) which was mainly lamellar ichthyosis. Body arts (5.7%) were scarification marks and tattoos. Table 4 shows how the skin disorders were distributed by age group. The use of soaps and oils or creams were highly variable with 71.4% (30 out of 42) having no specific soap or cream. Among those that specified, Kernel oil was the commonest oil used (n = 4; 9.5%) followed by cocoa butter (n = 3; 7.1%) and 1 patient (2.4%) used steroid containing cream with resultant complication of post bleaching syndrome manifesting as striae on the upper arm. One patient (2.4%) did not make use of any cream with resultant xerosis worsening the pruritus from lichen planus. Toilet soap was the commonest soap used (n = 8; 19.0%) amongst those with a specific soap, while 4 patients (9.5%) made use of locally made soap such as iron soap and caustic soda soap.
Table1: Socio-demographics of participants
| Socio-demographics | Frequency (%) |
AGE ≤5years 6-9 years 10-19years 20-39 years 40-59years ≥ 60years
Total |
1 (2.4) 3 (7.1) 6 (14.3) 17 (40.5) 8 (19.0) 7 (16.7) 42 (100) |
SEX Females Male
Total | 25 (59.5) 17 (40.5) 42 (100) |
MARITAL STATUS Married Single Widow
Total | 15 (35.7) 24 (57.1) 3 (7.2) 42 (100) |
OCCUPATION Business man/woman Civil engineer Clergy Cook Driver Housewife Hospital staff Infant Mason Primary school pupil Retired farmer Retired security personnel Secondary school student Trader Undergraduate student Unemployed
Total | 5 (11.9) 1 (2.4) 1 (2.4) 1 (2.4) 1 (2.4) 1 (2.4) 2 (4.8) 1 (2.4) 1 (2.4) 6 (14.3) 2 (4.8) 2 (4.8) 3 (7.1) 4 (9.5) 1 (2.4) 10 (23.8) 42 (100) |
ETHNIC GROUP Bassa Dan(Gio) Gbandi Kissi Kpelle Mandigo Mano Non-specified Others
Total | 3 (7.1) 2 (4.8) 2 (4.8) 3 (7.1) 21 (50.0) 1 (2.4) 1 (2.4) 7 (16.7) 2 (4.8) 42 (100) |
AREA OF RESIDENCE(COUNTY) Bong Grand Bassa Margibi Monterrado
Total | 1 (2.4) 1 (2.4) 38 (90.5) 2 (4.8) 42 (100) |
RELIGION Christian Muslim Others
Total | 37 (88.1) 5 (11.9) 0 (0) 42 (100) |
Table 2: Characteristics of cutaneous complaints
| Characteristics | Frequency% |
Cutaneous Complaints* Contractures & scars Itching Hair loss Nail dystrophy Joint pains Rashes Swelling Ulcers
Total |
1 (2.3) 6 (13.6) 3 (6.8) 1 (2.3) 1 (2.3) 24 (54.5) 6 (13.6) 2(4.5) 44 (100)
|
Duration of symptoms Days (< 7 days) Weeks (< 1 month) Months (< 1 year) 1-5 years 6-10 years >10years
Total | 3 (7.1) 3 (7.1.) 12 (28.6) 14 (33.3) 6 (14.3) 4 (9.5) 42 (100) |
Major Sites affected* Generalized Head and neck Lower limbs Upper limbs Both Upper and lower limbs Trunk
Total | 7 (15.2) 5 (10.9) 10 (21.7) 11 (23.9) 1 (2.2) 12 (26.1) 46 (100) |
* Includes multiple counts
The head region included the face (1), neck (1), peri-orbital (1) post auricular region(1) and scalp(1). The lower limbs included the thigh(2), soles(1) and legs(7).The upper limbs included arms(3) axillae(1), cubital fossae(1), elbow(1), forearms(3) inter-digital cleft(2), fingernails (1) and palms (1). The trunk included the abdomen (5), buttocks (4) chest (1), scrotum (1) and vagina (1)
Table 3: Spectrum of Skin Disorders
Skin Disorders N = 53 | ||||||
| Diagnosis | Frequency (%) | Diagnosis | Frequency (%) | Diagnosis | Frequency (%) | |
| Acute allergic reaction | 1 (1.9) | Aquagenic pruritus | 2 (3.8) | Autoimmune diseases likely SLE and RA | 2 (3.8) | |
| Chronic stasis dermatitis | 3 (5.7) | Contact irritant dermatitis | 1 (1.9) | Dermatofibroma | 1 (1.9) | |
| Elephantiasis | 1 (1.9) | Fungal nail infection | 2 (3.8) | Genital warts | 1 (1.9) | |
| Giant Lipoma | 1 (1.9) | Herpes Zoster | 2 (3.8) | Hidradenitis suppurativa | 1 (1.9) | |
| Lamellar Ichthyosis | 1 (1.9) | Lichen planus | 7 (13.2) | Miliaria | 1 (1.9) | |
Neuro- fibromatosis | 1 (1.9) | Palmoplantar keratoderma | 1 (1.9) | Papular urticaria | 1 (1.9) | |
| Pityriasis versicolor | 2 (3.8) | Post bleaching Syndrome | 1 (1.9) | Post burn scar & contractures | 1 (1.9) | |
| Posterior auricular cyst | 1 (1.9) | Prurigo Nodularis | 1 (1.9) | Scabies | 4 (7.5) | |
| Scarification marks | 1 (1.9) | Seborrheic dermatitis | 1 (1.9) | Sporotrichosis | 1 (1.9) | |
| Subcutaneous nodules | 1 (1.9) | Tattoos | 2 (3.8) | Tinea capitis | 2 (3.8) | |
| Tinea corporis | 3 (5.7) | Tinea glutei | 2 (3.8) | |||
Table 4: Distribution of skin disorders by age group
| Age group | Number of diagnoses N = 53 | Skin Disorders Diagnosed |
| Under-fives ≤5years | 1 | Milaria (1) |
| Children 6-9 years | 4 | Scabies (2), Tinea capitis (1), Tinea glutei (1) |
| Adolescence 10-19years | 7 | Autoimmune disease likely RA (1), Lamellar ichthyosis (1), Papular urticaria (1), Pityriasis versicolor (1), Tinea capitis (1), Tinea corporis (1), Scabies (1) |
| Young adults 20-39 years | 23 | Acute allergic reaction (1), Aquagenic pruritus (1), Autoimmune disease likely SLE (1), Genital warts (1), Herpes zoster (2), Hidradenitis suppurativa (1), Lichen planus (4), Neurofibromatosis (1), Pityriasis versicolor (1), Posterior auricular cyst (1), Post bleaching Syndrome (1), Post burn scar & contracture (1), Seborrheic dermatitis (1), subcutaneous nodules (1), Tattoos (2), Tinea glutei (1), Tinea corporis (1), Scabies (1) |
| Middle aged 40-59years | 11 | Aquagenic pruritus (1), Contact irritant dermatitis (1), Elephantiasis (1), Fungal nail infection (1), giant lipoma (1), Lichen planus (2), Multiple dermatofibroma (1), Palmoplantar keratoderma (1), Scarification marks (1), Sporotrichosis (1) |
| Elderly ≥ 60years | 7 | Chronic stasis dermatitis (3), Fungal nail infections (onychomycosis) (1), Lichen planus (1), Prurigo nodularis (1), Tinea Corporis (1) |
The autoimmune cases were suspected to be Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). The two patients affected were both females. The case with SLE had malar rash with hypopigmented macules and patches on extremities. She also had hypertension, severe proteinuria and anemia. The patient with rheumatoid arthritis had musculoskeletal abnormalities involving the small joints of the hands and knee joint deformities. It is noted that those with chronic stasis dermatitis all had hypertension. Some of the patients with skin diseases had other chronic medical conditions, with 31% (n = 13) being hypertensive, 4.8% (n = 2) being diabetic and one patient each (2.3%) being retroviral positive and hepatitis B positive. Out of the patients that presented to see the dermatologist 59.5% (n = 25) had to be referred for further care which included surgical interventions and skin biopsies to confirm diagnosis and exclude other possible causes. Treatments were available for common lesions such as skin infections and dermatitis and included Whitfield ointment and other topical antifungals, topical corticosteroids, antihistamines, emollients and soaps. Some patients were able to testify to actual improvement within the short period of the medical outreach particularly about relieve of pruritus. Figure 1 shows the photographs of the spectrum of skin disorders and scars seen during the study.
Hypopigmented macules of patient with AUID likely SLE |
Chronic stasis dermatitis |
Dermatofibroma |
Elephantiasis (lymphatic filariasis) | Fungal nail infection (onychomycosis) | Herpes zoster |
Hidradenitis suppurativa | Lamellar ichthyosis |
Lichen planus |
Palmoplantar keratoderma | Papular urticaria Prurigo nodularis | Pityriasis versicolor |
Posterior Post bleaching auricular cyst syndrome |
Post burn scar and Subcutaneous contracture nodules | Scabies |
Scarification Sporotrichosis marks |
Tattoos |
T. capitis T. corporis T. glutei |
Figure 1: Photographs of spectrum of skin disorders and scars in Kakata community, Margibi County, Liberia
AUID – Autoimmune disease
DISCUSSION
This study showed that persons with dermatological complaints made a small proportion of those who attended the medical outreach. The proportion was even smaller compared to medical outreaches done in other semi-urban and rural areas within the same tropical region. Akinkugbe et al1 in Nigeria reported 21.7% of the total population of their study had a skin complaint while Bissek et al4 in Cameroun reported 62% in their study from four villages. Gibbs5 reported from Tanzania a 26% of persons in two villages had significant skin diseases and Kibar Öztürk6 reported 92.6% in an orphanage and refugee camps in a rural area in Sudan. The small proportion in this study is understandable because the other studies were focused mainly on screening for skin disorders regardless of the sufferers seeing this as a concern warranting dermatology consultations. Young adults were the commonest age group with skin complaints in this study with the mean age similar to that seen in other studies done within the same sub region. Akinboro et al7 reported 31.1 ± 19.1 years, Olanrewaju et al8 reported 33.88 ± 20.57 years, Akinkugbe et al1 reported 38.04 ±13.04, while Bissek et al4 reported a lower mean age (21 ± 8.13 years) but had young adults being the age group with the most skin disorders. Gibbs, Kibar Öztürk and Satimia et al all reported skin disorders found in the younger age group as well.5, 6, 9 The young demographics of this area can account for the predominance of this young age group, however all age groups were represented in this study which buttress the fact that skin diseases are universal regardless of age.2, 3 There was female preponderance in this study which is similar to that reported by Akinkugbe et al and Olarenwaju et al.1,8 Other studies such as that done by Satima et al who had 37% of the participants with skin disorders and Bissek et al showed equal M:F ratio.4, 9 Majority of the participants were unemployed followed by students at different levels. This implies that there might be limited income to take care of healthcare needs including skin care as seen in other rural communities in Tanzania and South Florida from the studies by Gibbs and Asbeck et al respectively.5, 10 The predominant religious beliefs was Christianity which is similar to the study done by Bissek et al in Cameroun. This is understandable since it has been established that Christianity is the dominant religion in Liberia.3
This study showed a variety of dermal disorders in this semi-urban population. Infections were the highest category seen in this study. This finding is similar to other studies done within the same region. Similar studies done in a similar setting showed infections as major causes of skin disorders. Bissek et al had fungal infections causing about one quarter of all the skin disorders.4 Akinkugbe et al also had fungal infections as the major cause of skin complaints but with a lesser proportion.1 Kibar Öztürk reported one third with fungal infections in the study done in Sudan.6 Satima et al also had different fungal skin infections making the top two causes of skin disorders in the rural population that they studied.9 The major categories seen in this study was also seen in other studies done by Akinkugbe et al, Bissek et al, Akinboro et al and Olanrewaju et al.1, 4, 7, 8 A variety of skin diseases were seen within the different age groups. Chronic stasis dermatitis and fungal nail infection was exclusively seen in older adults. This is similar to the finding by Amadi et al who noted eczema (dermatitis) and fungal skin infections were the commonest set of skin disorders in the elderly.11 Fungal skin infections have also been noted to be seen among the elderly in the rural areas as described in the study by Ikpae et al.12 Scabies was seen more in school age children although it affected other age groups as well. Scabies has been noted to be a common skin infestation in Liberia as seen in a previous study by Collison et al.13 Amongst school children scabies was one of the most common skin disorders however tinea infections which are a group of fungal infections were more prevalent. This is similar to studies done by Yotsu et al who discovered scabies as the prevalent skin neglected tropical diseases but fungal infections were more overall.14 In a study by Komba et al in Salaam, Tanzania, superficial fungal infections like dermatophytes and pityriasis vesicolor were the commonest skin disorders while scabies constituted only 1.4%.15 A similar study by Figueroa conducted twenty five years ago in Ethiopia revealed that infestations were more predominant than fungal infections.16 This change may be attributed to an increase in awareness to maintain good hygiene and avoid overcrowding. It could also be that this study only looked at those who had a skin complaint since skin infestations like scabies may also be asymptomatic. There was no significant association of skin diseases with any chronic disease in this study similar to the study done by Pepple et al.17 It was also noted that on skin examination, body art was found such as scarification marks and tattoos which may reflect traditional practices for healing or for identification. Tattoos seen in this study was seen amongst the young adults and was done more for pleasure from peer influence. Scarification mark seen in a woman was for healing purposes. These reasons were similar to those found in the study done by Otike-Odibi et al.18 A great majority needed a referral to the dermatologist for further care which definitely emphasizes the need for dermatologists’ services even in the rural area.10
CONCLUSION
A spectrum of skin diseases were seen amongst the different age groups residing in this semi-urban area with fungal infections being the most prevalent in all age groups; chronic stasis dermatitis in older adults and scabies more amongst school children. There was no significant disease associated with the skin lesions. A great majority needed further care by the dermatologists hence were referred. There is need for training of care workers on common skin disorders and their management prevalent in an area.
CONFLICT OF INTEREST
The author declare that there is no conflict of interest.
FUNDING
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
ETHICAL CONSIDERATIONS
Oral consent was sought and obtained from each participant with ethical principles for the guidance of physicians in medical research which was as follows: confidentiality of data, beneficence of participants, non-maleficence to the participants and right to decline/withdraw from the study without loss of benefits.
ACKNOWLEDGEMENTS
I acknowledge the Christian Medical and Dental Association, Nigeria, International Christian Medical and Dental Association, Chapel Hill Church, USA, Hands of Hope Foundation and Pro Health International organizers of the medical outreach. Appreciation goes to all the staff of Waterfield Primary Healthcare center. My appreciation also goes to the Liberian Medical and Dental Council for granting me license to practice during the medical outreach. I also appreciate my colleagues for their various inputs, Professors Kenneth Shelu Ordu, Emmanuel Agba, Drs. Mary Amaewhule, Godwin Ewu, Elkanah Kabilis, Anuye Jude, Oderinde Babatunde, Mfon Inyang, Folahan Sholeye, Alioke Ikechukwuka and Awajimoror Isotu.
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