Skin diseases in the pediatric population are common worldwide, including rural and urban areas. There are variations in the pattern of dermatoses, with eczemas being the most common skin disorder in developed countries, whereas infections and infestations are the most common skin disorders in the developing countries 1. Although it is believed that the prevalence of dermatoses among children of developing countries is very high, there have been few epidemiologic reports on this subject, which makes the planning of health program a difficult task 2.
Thus, this study was carried out across the four seasons to detect the pattern of skin diseases among preschool and primary school-aged children receiving dermatological care in Dermatology Damietta Hospital, the only specialized hospital for Dermatology and Venereology in Damietta. It serves all villages and towns of the Damietta governorate.
Patients and methods
The Damietta governorate overlooks the Mediterranean Sea coast in the North Delta region of Egypt. The governorate covers an area of 910.3 km2, representing 0.1% of the Republic’s area, and encompasses 10 cities, 47 rural units, and 85 villages. According to the preliminary results of the 2006 census, the population is about 1.1 million people, 38.4% of whom live in urban areas and 61.6% in rural areas. The natural growth rate of the population is 21.6/1000 3.
A descriptive cross-sectional study was carried out on preschool and primary school-aged children attending the outpatient clinic of the Damietta Hospital for Dermatology and Venereology. A nonprobability purposive (convenience) sample was obtained, which included 4000 children out of 4658 children attending the outpatient clinic of the Damietta Hospital of Dermatology and Venereology in the period from January 2010 to December 2010. We included in this study those children aged from 0 to 12 years, with any dermatological disorders, excluding only those who refused to be involved in the study (658 children). The diagnoses were made on the basis of clinical dermatological examination, laboratory investigations, and biopsy specimen when needed. Infectious and noninfectious skin diseases were categorized according to Bolognia et al.4.
Data collection was carried out using a field pretested interviewing questionnaire including the sociodemographic status of children and their families: age of the child, sex, residence, and social class. The social score includes social variables used to calculate the social class including fathers’ education (score 2–10), mothers’ education and work (scores 1–10), and crowding index (scores 1–5). The total scores were as follows: 19–25, high social class; 12–18, middle social class; and below 12, low social class 5. All the participants included were treated according to the Helsinki Declaration of biomedical ethics 6; verbal consent was obtained after a proper explanation of the objectives of the study was provided to the participants.
Data obtained from the study were coded and entered using the statistical package for the social science (SPSS, version 15.0, SPSS Inc., Chicago, Illinois, USA) software. Data were summarized as mean, SD, and range for quantitative variables, and number and percentage for qualitative variables. Comparison between groups was carried out using the χ2-test for qualitative variables. A P value of 0.05 was considered a cut-off level for statistical significance. Cases were distributed according to the diseases diagnosed; this was followed by the distribution of common diagnoses (those with frequency of ≥1%) according to age, sex, residence, social class, and season.
Four thousand children with dermatological diseases were included in this study; 2095 (52.4%) females and 1905 (47.6%) males. Their ages ranged from newborn to 12 years with mean±SD=4.6±2.5 years. Patients were classified into three age groups; group 1: from birth to 2 years [1358 (34%) patients]; group 2: from 2.1 to 6 years [1454 (36.4%) patients]; group 3: from 6.1 to 12 years [1118 (29.7%) patients]. In total, 1602 (40.1%) lived in urban areas, whereas 2398 (59.9%) lived in rural areas. Of 4000 patients, 963 (24.1%) presented in winter, 1195 (29.9%) in spring, 1117 (27.9%) in summer, and 725 (18.1%) in autumn. A total of 1156 (28.9%) of the children studied had a low social score, 2113 (52.8%) had an intermediate score, and 731 (18.3%) had a high score.
Distribution of skin diseases according to their percentage of frequency
A total of 92 dermatoses were recorded. Papular urticaria was the most frequent dermatosis (16.62%), followed by impetigo (13.37%), chicken pox (9.15%), tinea capitis (7.47%), and furunculosis (6.2%) (Table 1 and Fig. 1).
Distribution of infectious and noninfectious skin diseases according to their percentage of frequency
The study found that eczematous dermatoses (19.77%), followed by papular urticaria (16.62%) were the most common noninfectious skin diseases. Infections and infestations included 860 (21.5%) bacterial, 614 (15.35%) fungal, and 540 (13.5%) viral infections and 238 (5.95%) parasitic infestations (Figs 2 and 3).
Distribution of the most common skin diseases according to age, sex, residence, social class, and season
The most common dermatoses can be categorized according to Bolognia et al.4 into infectious and noninfectious skin diseases. Infectious skin diseases included bacterial diseases such as impetigo (13.37%) and furunculosis (6.2%); fungal diseases such as tinea capitis (7.47%), tinea corporis (4.55%), pityriasis versicolor (1.95%), and candidiasis (1.37%); viral diseases such as chicken pox (9.15%) and warts (2.75%); and infestations such as pediculosis capitis (3.57%) and scabies (2.37%). Noninfectious skin diseases included eczematous dermatoses such as atopic dermatitis (5.17%), napkin dermatitis (3.85%), contact dermatitis (3.45%), pityriasis alba (2.65%), and cradle cap (1.72%), bites and stings in the form of papular urticaria (16.62%), adnexal diseases such as miliaria rubra (4.4%); papulosquamous dermatoses such as pityriasis rosea (1.6%); hair disorders such as alopecia areata (1.22%); and urticarias, erythemas, and purpura in the form of urticaria (1.07%).
The most common dermatoses in the first 2 years of life (group 1) were papular urticaria, followed by impetigo, napkin dermatitis, miliaria rubra, and furunculosis. Among children from 2.1 to 6 years of age (group 2), the most frequent diagnoses were papular urticaria, followed by impetigo, chicken pox, tinea capitis, and furunculosis. In primary school-aged children (group 3), chicken pox was the most common presentation, followed by tinea capitis, impetigo, pediculosis capitis, and warts (Table 2).
The male group had a higher frequency of papular urticaria, tinea capitis, atopic dermatitis, and pityriasis alba. The female group had a higher frequency of impetigo, pediculosis capitis, and pityriasis versicolor. The frequency of some dermatoses was almost equal in both sexes, for example, chicken pox, tinea corporis, and warts (Table 2 and Fig. 4).
In terms of the distribution of the most common dermatoses according to residence and social score, papular urticaria, contact dermatitis, napkin dermatitis, and warts were significantly higher among urban children, whereas impetigo, tinea capitis, and tinea corporis were significantly higher among rural children. Impetigo, tinea capitis, and pediculosis were significantly higher among children from a low social class, whereas papular urticaria, cradle cap, and candidiasis were significantly higher among children from a higher social class (Table 3).
The most common skin diseases detected in winter were papular urticaria, followed by impetigo and chicken pox, whereas the most prevalent ones in summer were impetigo, followed by furunculosis and miliaria rubra. However, in spring, the most common dermatoses were papular urticaria, followed by chicken pox and atopic dermatitis, whereas the most frequent dermatoses in autumn were impetigo, followed by papular urticaria, tinea capitis, pityriasis versicolor, and pityriasis rosea (Table 4).
In 1974, the first large epidemiologic survey of skin diseases in children was conducted in South Africa, with an analysis of 10 000 patients 7. A few similar studies were carried out later in other regions as Kuwait 8, India 9,10, Turkey 11,12, and Saudi Arabia 13.
In our study, bacterial infections were the most frequent (21.5%) in the category of infections and infestations. These results were similar to the findings of previous investigators 10,14. In the current study, among the bacterial infections, impetigo (13.37%) and furunculosis (6.2%) were the most common. Impetigo was common in rural areas with lower hygiene than urban areas and was also common in children with a low social score. Further, impetigo affected females more than males, which may be attributed to the highly significant concomitant infestation with pediculosis capitis.
Fungal infections were the second most common infection, constituting 15.35% of the cases. Among the fungal infections, tinea capitis (7.47%) and tinea corporis (4.55%) were common. A lower frequency was reported in previous studies 8,11,14. In the current study, tinea capitis affected males more than females, those in rural areas more than those in urban areas, children more than 6–12 years more than others as well as those from a low social class more than those from a high social class. These results are similar to those obtained by Al Samarai 15. The high rate of tinea capitis in males may be attributed to the easy implantation of spores because of short hair 16.
In the current study, viral infections constituted 13.5% of the cases. The most common presentation was chicken pox (9.15%), followed by warts (2.75%). A similar frequency had been observed in previous studies 8,11,13. As regards chicken pox, we reported an equal sex affection but with higher age predisposition (>6–12 years). These results are in agreement with those of other investigators who reported that viral infection was more frequent in school children, which could be related to frequent close contact among them and an increase in outdoor and sports activities 13. Also, in this study, there was a significant statistical relation between chicken pox and season (spring followed by winter), and this is in agreement with Deguen et al.17, who reported that transmission rates increased during school terms.
In the current study, parasitic skin infestations constituted 5.95% of the cases, among which pediculosis capitis (3.57%) and scabies (2.37%) were the most common presentations. A similar frequency was observed by Nanda et al.8. However, lower frequency was observed by others 10,12. In the present study, pediculosis capitis affected females more than males, with a ratio of 16 : 1. This can be attributed to longer hair among females and is in agreement with the results of other investigators 18,19. Also, children of school age more than 6–12 years were more affected and this is in agreement with the result of Aydemir et al.20. Moreover, children were more affected in autumn and winter, which emphasizes that transmission rates increase during school terms. Also, patients with a low social score were more affected and this is in agreement with previous studies 19,21.
The present study showed that eczematous dermatoses were common presentations and were found in 19.77% of the cases. Among eczematous dermatoses, atopic dermatitis (5.17%), napkin dermatitis (3.85%), contact dermatitis (3.45%), and pityriasis alba (2.65%) were common. A similar frequency was reported by Gul et al.11, whereas other studies reported higher frequencies 8,10,13,22,23. The discrepancy between the low figures in developing countries and the high figures in developed countries can be attributed to the difference in industrialization, the ‘hygiene-hypothesis’, and climate 9,24.
Papular urticaria was found in 16.62% of the cases, thus being the most common dermatologic disease reported in the current study. A lower frequency was reported by other investigators 9,10. This discrepancy between the different values of frequency of papular urticaria in different studies may be attributed to the difference in climate and biting habits of the insects 25. In our study, papular urticaria was more common in spring and this is in agreement with the results of other investigators 26,27, whereas Banerjee et al.28 reported higher frequency in the rainy season.
Miliaria rubra was found in 4.4% of the cases. It was more common in summer and in a younger age group (0–2 years) and this is in agreement with the result of Banerjee et al.28, who reported that the decrease in the prevalence of miliaria as children reach preschool age may be because of the development of some degree of tolerance to environmental factors.
Papulosquamous dermatoses were found in 2.52% of the cases including mainly pityriasis rosea (1.6%) and psoriasis (0.75%). A higher frequency was reported by other investigators 11,13,29. Similar to other studies, pityriasis rosea was more common in females 7, in older age groups (>6–12) 30, and in autumn 12.
Alopecia areata was found in 1.22% of the cases whereas a higher frequency was reported in other studies 8,11.
Urticaria was found in 1.07% of the cases. A similar frequency was reported by Nanda et al.8, whereas higher frequencies were reported by others 9,10,12,13.
In conclusion, the present study sheds light on the most frequent dermatoses encountered in Damietta Hospital, and provides the basis for better health services in this hospital. Infectious skin diseases represented a large proportion of the cases analyzed. Community-based studies need to be carried out to confirm and explore our findings to determine the magnitude and pattern of different types of dermatoses in Damietta affecting that age group, which could be a basis for future health plans.
Conflicts of interest
There are no conflicts of interest.
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