Skin diseases are common in school children. Epidemiologic studies of the general population, however, are still limited. Many previous studies have the following limitations: (a) a survey of the referred patients in hospital-based settings may not entirely reflect the real situation in the general population; (b) self-administered questionnaire studies or surveys conducted by nondermatologists make the validity of the diagnosis uncertain 1–3. Skin diseases such as acne and alopecia areata, although not life-threatening, may be particularly distressing for school-aged children. For some chronic refractory skin diseases such as atopic dermatitis, psoriasis, and vitiligo, the psychological impact, disease course, and complications, and the therapeutic decisions concerning long-term safety, may seriously concern the affected families 4. Sohag is an overcrowded city located in Upper Egypt. The Human Development Report ranks Sohag as the lowest governorate in the country. Socioeconomic indicators show it to be the poorest or the second poorest governorate in Egypt on the basis of the population pressure on land, illiteracy, and infrastructure. Also, it includes different urban and rural communities. Therefore, epidemiological studies are needed in this governorate to study the prevalent diseases in the area for the development of a targeted health plan. The aim of this study was to determine the pattern and the prevalence of skin disorders among primary school and preschool children from rural and urban communities in the Sohag governorate.
Patients and methods
The present study was carried out from March to the end of April 2009 using a randomized survey of school children from three primary schools in the Sohag Governorate: one urban community (Molhakat El-moalemin), located in the Sohag city, one rural community (Hamad abo El-senon), in El-hamadia village following Sohag city, and one in a slum area in Akhmim town (Arab El-atawla), which is one of the 11 towns in the Sohag Governorate. The sample size was calculated according to the equation N=2Z2Pq/d 2, where N=number (sample size), Z=the standard normal deviation (1.96), P=the prevalence of the disease, q=1.0−p, and d=the degree of accuracy desired (95%) 5.
On the day of the visit, the classes available for physical checkup were enlisted by school officials, and all the children in each class were individually examined in the nursing room. A total of 1804 school children (922 boys and 882 girls; age range 4–12 years) from preschool to grade six were examined. The children examined were divided into two age groups: the young age group from 4 years old to less than 8 years old and the older age group from 8 years old to 12 years old.
The assessment was conducted throughout the body, hair, nail, mouth, head, scalp, neck, and extremities. Feet were excluded, because it is labor-intensive and time-consuming for an average of 50 children per class to take off their shoes and socks for examination. Genital areas were also skipped because of privacy concerns. Diagnosis of warts, pityriasis versicolor, tinea corporis, and vitiligo was carried out by clinical examination without histopathological confirmation.
Overcrowding was assessed according to standards of the school health environment 6. Socioeconomic status was assessed according to the measurement of the socioeconomic status of the family by Abdel-tawab (1998; unpublished data).
The collected data were encoded, registered, and verified in a relevant database. Children who required further management were referred to the Sohag University Hospital.
Statistical analyses were performed using SPSS for data entry and analysis (PASW statistics 18, 2010; SPSS Inc., IBM company, Chicago, Illinois, USA). Results were recorded as frequencies, percentages, mean, and SD. χ2-test was performed to compare differences in the distribution of frequencies among various groups and distribution among different schools. A P-value of less than 0.05 was considered to be significant.
An approval of Sohag Faculty of the Medicine Research Ethics Committee was signed before the start of the study. A written consent from the children’s parents on the day before the planned clinical examination and a verbal approval from the children themselves were taken before the start of the study.
Of the 1804 children examined, 922 (51.1%) were boys and 882 (48.9%) were girls. There were 1202 (66.6%) students in the 4 to less than 8 years age group and 602 (33.4%) students in the 8–12 years age group. Of the children studied, 721 (40%) were from an urban area, 554 (30.7%) were from a rural area, and 529 (29.3%) were from a slum area. The socioeconomic status was high in 442 (24.5%), medium in 707 (39.2%), and low in 655 (36.3%) children. Overcrowding was recorded in 1355 (75.1%) cases. Of the children with diseases, 146 (19.5%) had sought medical advice and 602 (80.5%) did not seek medical advice before.
The relation between the sociodemographic factors and skin manifestations in school children is shown in Table 1. As many as 748 (42%) children had one or more skin disorders, whereas 1056 (58%) were clinically free from disease (Fig. 1). Pediculosis capitis, pityriasis alba, papular urticaria, and chicken pox (accidentally discovered or postchicken pox scars) were the most common diseases, accounting for 504 (67.4%) out of the 748 children with diseases, and representing 27.8% of the total children examined (Fig. 2).
The prevalence rates of infectious skin diseases (pediculosis capitis, chicken pox, impetigo, and scabies) and noninfectious skin diseases were 59.1 and 40.9%, respectively. With regard to the age group, the prevalences of infectious and noninfectious diseases among the 4–8 years age group were 57.2 and 41.4%, respectively, whereas those of the 8–12 years age group were 42.8 and 58.6%, respectively. Analysis of the association of both categories with age revealed that there was a nonsignificant (P=0.41) decline in the prevalence of infectious diseases with increasing age. Pediculosis capitis was more common in girls than in boys at all ages. The distribution of common skin diseases in school children according to age and sex is shown in Table 2. Rural residence was significantly associated with a higher prevalence of skin diseases, especially Pediculosis capitis (P-value=0.002) (Fig. 3).
Although skin diseases are very common among the population in many developing countries, they have not been regarded as a significant problem that could benefit from public health measures 7.
Many factors determine the results of epidemiologic studies on skin diseases, including ethnic background, geographic area, climate, season, socioeconomic status, living conditions, and medical resources 8. In this study, the pattern and the prevalence of skin diseases in three schools from different areas in the Sohag Governorate in Upper Egypt, and its relationship with socio-environmental factors, were studied. It revealed an overall prevalence of skin diseases among school children of 41.5%. These results are consistent with a study conducted in Iraq 8, in which the prevalence of skin diseases in primary school children was 40.9%, a study in rural Tanzania 9, in which 55% of the children had one or several skin disorders, and 54% in school children from Varanasi (India) 10. This is compared with a 22.8% prevalence of skin diseases in Romanian school children 11. It is more than twice that reported in Jordan (19.3%) 12 and slightly higher than in Mali (34.4%) 13 and Nigeria (35.2%) 14. The rate is lower than that reported in Turkey (49.3%) 15 and much lower than in Ethiopian school children (96.8%) 16.
Pediculosis capitis in this study was the most common skin disease (27.3%) compared with a study in Ghana 17 in which pediculosis capitis represented 50% of the dermatoses and 35% in Varanasi school children. 10 The prevalence of pityriasis alba in the current study was 11.6%, in agreement with another study 10 in which pityriasis alba was 12%. In a Romanian study 11, the most common diseases were infectious dermatoses such as viral warts (6.6%) and insect bites (6.3%), dermatitis/eczema (5.1%), pityriasis alba (5.1%), keratosis pilaris (4.0%), and urticaria (1.9%). Together, these five groups accounted for more than 84% of the cases.
In the current study, the prevalences of skin diseases were more common in older children (8–12 years, 52.2%) than in younger children (4–8 years, 36.1%). This significant increase in the prevalence of skin diseases with age may be due to the increased exposure to environmental pollutants, chemicals, and allergens, which is in agreement with a study in primary school children in Iraq 8.
The prevalence of infectious skin diseases in the present study was 59.1%, which is higher than that reported in Iraq (8.8%) 8 and Turkey (16.2%) 15. Similar rates varying between 50 and 60% were reported in Ethiopia 16 and Ghana 17. Rates of 28.8 and 20.3% were reported among blind and deaf pupils, respectively in Saudi Arabia 18. These differences may be attributed to variations in personal and environmental hygiene and degree of exposure.
The prevalence of noninfectious skin diseases in the current study was 40.9%, which is lower than that reported in Saudi Arabia (82.3%) and Turkey (57.5) 15,19. However, it is higher than that reported in Hong Kong (27%) 20. These variations may be due to differences in the way the clinical examination was carried out, whether it is only for the exposed parts of the body or the whole body. Also, variations in the prevalence of skin diseases may be related to genetic and racial differences, social and hygiene factors, nutrition status, climate, state of industrialization, age, structure of the study sample, and other socioeconomic factors 21.
In the present study, the prevalence of skin diseases in girls was significantly higher than that in boys (P=0.00), which may be due to the high incidence of pediculosis capitis in girls. These results were different from the results obtained in another study 11, which found no significant difference in the prevalence of skin diseases between school children according to age or sex.
In this study, there was a higher prevalence of pediculosis capitis and comorbidity in rural school children than in school children from urban and slum areas. This is in agreement with other studies 19,20. The overall prevalences of skin diseases in the present results are higher in rural school children. This may be attributed to the low socioeconomic status, low hygiene of these patients, and the scarcity of clean water; overcrowding may also act as a contributory factor in this regard. Although these factors are also found in slum areas, the current results showed similar values in slum and urban schools, which may be due to a seasonal increase of some diseases such as chicken pox and papular urticaria in spring time in both communities. The lack of medical intervention reported by symptomatic students in this study was unexpectedly high; only 19.5% of the children with skin diseases had sought medical advice.
Finally, we conclude that skin diseases are common in school children in the Sohag Governorate. Communicable diseases accounted for 59.1% of the detected skin diseases.
School health departments must be encouraged to further investigate the epidemiological determinants and risk factors among students, in particular the communicable diseases, in order to provide tools for implementing health education programs to control associated health problems among school children. Further community-based studies are needed to cover Upper Egypt to assess the scope and extent of skin problems in urban and rural areas.
Conflicts of interest
There are no conflicts of interest.
1. Mohammed Amin RS, van der Wouden JC, Koning S, van der Linden MW, Schellevis FG, van Suijlekom-Smit LW, et al. Increasing incidence of skin disorders in children? A comparison between 1987 and 2001. BMC Dermatol. 2006;21:4–10
2. Walker N, Lewis-Jones MS. Quality of life and acne in Scottish adolescent schoolchildren: use of the Children’s Dermatology Life Quality Index (CDLQI) and the Cardiff Acne Disability Index (CADI). J Eur Acad Dermatol Venereol. 2006;20:45–50
3. Yang YC, Cheng YW, Lai CS, Chen W. Prevalence of childhood acne, ephelides, warts, atopic dermatitis, psoriasis, alopecia areata and keloid in Kaohsiung County, Taiwan: a community-based clinical survey. J Eur Acad Dermatol Venereol. 2007;21:643–649
4. Chen GY, Cheng YW, Wang CY, Hsu TJ, Hsu MM, Yang PT, et al. Prevalence of skin diseases
among schoolchildren in Magong, Penghu, Taiwan: a community-based clinical survey. J Formos Med Assoc. 2008;107:21–29
5. Briggs AH, Gray AM. Power and sample size calculation for stochastic cost effectivness analysis. Med Decis Making. 1998;18:S81–S92
6. Anderson CL, William H School health practice. 19766th ed Saint Louis Mosby:324–327
7. Wu YH, Su HY, Hsieh YJ. Survey of infectious skin diseases
and skin infestations among primary school students of Taitung County, eastern Taiwan. J Formos Med Assoc. 2000;99:128–134
8. Khalifa KA, Al-Hadithi TS, Al-Lami FH, Al-Diwan JK. Prevalence of skin disorders among primary-school children
in Baghdad governorate, Iraq. East Mediterr Health J. 2010;16:209–213
9. Ferie J, Dinkela A, Mbata M, Idindili B. Schmid-Grendelmeier Pand Hatz C. Skin disorders among school children
in rural Tanzania and assessment of therapeutic needs. Trop Doct. 2006;36:219–221
10. Valia RA, Pandey SS, Kaur P, Singh G. Prevalence of skin diseases
in Varanasi school children
. Indian J Dermatol Venereol Leprol. 1991;57:141–143
11. Popescu R, Popescu CM, Williams HC, Foresa D. The prevalence of skin conditions in Romanian school children
. Br J Dermatol. 1999;140:891–896
12. Shakkoury WA, Abu-Wandy E. Prevalence of skin disorders among male school children
in Amman, Jordan. East Mediterr Health J. 1999;5:955–959
13. Mahé A, Prual A, Konaté M, Bobin P. Skin diseases
of children in Mali: a public health problem. Trans R Soc Trop Med Hyg. 1995;89:467–470
14. Ogunbiyi AO, Daramola OO, Alese OO. Prevalence of skin diseases
in Ibadan, Nigeria. Int J Dermatol. 2004;43:31–36
15. Inanir I, Sahin MT, Gündüz K, Dinç G, Türel A, Oztürkcan S. Prevalence of skin conditions in primary school children
in Turkey: Differences based on socioeconomic factors. Pediatr Dermatol. 2002;19:307–311
16. Figueroa JI, Fuller LC, Abraha A, Hay RJ. The prevalence of skin disease among school children
in rural Ethiopia – a preliminary assessment of dermatologic needs. Pediatr Dermatol. 1996;13:378–381
17. Acheampong JW, Whittle HC, Obasi EO, Harman RR, Addy HA, Parry EH, et al. Scabies and streptococcal skin infection in Ghana. Trop Doct. 1988;18:151–152
18. Parthasaradhi A, Al Gufai AF. The pattern of skin diseases
in Hail Region, Saudi Arabia. Ann Saudi Med. 1998;18:558–561
19. Abolfotouh MA, Bahamdan K. Skin disorders among blind and deaf male students in Southwestern Saudi Arabia. Ann Saudi Med. 2000;20:161–164
20. Fung WK, Lo KK. Prevalence of skin disease among school children
and adolescents in a Student Health Service Center in Hong Kong. Pediatr Dermatol. 2000;17:440–446
21. Bechelli LM, Haddad N, Pimenta WP, Pagnano PM, Melchior E Jr, Fregnan RC, et al. Epidemiological survey of skin diseases
in school children
living in the Purus Valley (Acre State, Amazonia, Brazil). Dermatologica. 1981;163:78–93
Keywords:© 2012 Egyptian Women's Dermatologic Society
infectious; noninfectious; pediculosis capitis; pityriasis alba; school children; skin diseases