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Profile of Skin Diseases among Patients Attending a Dermatology Outpatient Clinic: A Record-based Cross-sectional Study from a Tertiary Care Centre in Northern Kerala, India
Correspondence Address :
Dr. Sandhya George,
Professor, Department of Dermatology, Government Medical College, Manjeri, Malappuram-676121, Kerala, India.
E-mail: drsandhyageorge@gmail.com
Introduction: Epidemiological studies to determine the pattern of skin diseases among patients attending a hospital are important for proper healthcare planning and management. They give insight to the epidemiology of diseases. Similar studies have not been conducted in Northern Kerala recently.
Aim: To identify the pattern of diseases among patients who attended the Outpatient (OP) section of the Department of Dermatology in our hospital.
Materials and Methods: The present study was retrospective, record-based cross-sectional study in which OP registers of the Department of Dermatology from December 2018 to November 2019 were analysed retrospectively. Skin diseases were grouped into different groups and the frequency of cases in each group was studied. These were also categorised according to different age groups, gender and month of their OP visit. Descriptive statistics were used to analyse the data. Data analysis was performed using Microsoft Excel and R software (R version 3.6.1 (2019-07-05)).
Results: Out of the 17,907 new patients, 42.7% of them had infections, of which fungal infections were the most common. Eczema (27.7%) was the common group. Significant difference in male: female ratio was seen in melasma (14:95), leprosy (13:2), drug reaction (1:28), connective tissue diseases (0:18) and Vesiculobullous (VB) (0:4). Monthly split-up of cases showed increased frequency of some groups of diseases during some months, these include Sexually Transmitted Infections (STI) in February-9/20 (45%), leprosy in May-4/15 (26.7%), drug reaction in December- 9/29 (31%), connective tissue diseases in April- 6/18 (33.3%) and VB diseases in February 4/4 (100%).
Conclusion: Infections and eczemas which could be managed in primary healthcare set-up contributed to majority of the OP attendance of our tertiary care centre. The peripheral institutions should be strengthened in manpower and the level of knowledge and skills. More focused and effective training of medical students, continuing medical education for general practitioners and the implementation of family physician system should gain more importance in our country. Increased frequency of some diseases was seen during some months these findings have to be confirmed by longer duration studies.
Connective tissue diseases, Eczema, Fungal infection, Leprosy, Vesiculobullous
Dermatological diseases form a large proportion of the OP department in any major hospital. Skin diseases are influenced by various factors like the environment, economic status, literacy, racial and social customs. The pattern of skin diseases varies from one country to another country and in various regions within the same country (1). It is more so in India, where the climate, socio-economic status, religions and customs are widely varied in different parts of the country (2),(3),(4).
Apart from environmental factors, the skin disease pattern varies depending on occupation, socio-economic status, age and sex of the patients. Patterns of skin diseases from tertiary care centres in Kerala have been studied earlier (2),(5),(6). In the study by Asokan N et al., the need to strengthen the primary healthcare system was highlighted and insisted on referral systems to focus on training of medical students and an effective tertiary care heath delivery system (5). Reports on the pattern of skin diseases pertaining to Northern Kerala, India are so far not available. The current retrospective study of the skin disease pattern was undertaken to fill this lacuna.
The record-based cross-sectional study was chosen because the number of patients coming to the OP clinic was high in the centre. Present study aimed to retrospectively analyse the pattern of skin diseases in the patients attending Dermatology OP for a period of one year and to determine the association of skin diseases, if any, in relation to different seasons, age groups and gender.
A retrospective, record-based cross-sectional study was conducted from December 2018 to November 2019. The OP registers of the department during this period were analysed. The registers were taken after getting permission from the Superintendent, Head of the Department and the Institutional Ethics Committee (IEC). The number of cases was on an average of 400 per day. So, as a representative sample, patients registered on Mondays and Saturdays were only analysed.
Inclusion criteria: The study included all new patients entered on the OP register on Mondays and Saturdays. Due to the selection of week and weekend days, this OP population included patients of all age, sex and social class like children, employed, unemployed and elderly. Diagnosis was primarily clinical, supported by relevant investigations and as per entry in the OP register. Data collected from the register was documented and analysed. For analysis, different skin diseases were broadly grouped into different groups and the frequency of cases in each group was studied. The groups were eczemas, psoriasis, lichen planus, pityriasis rosea, other papulosquamous diseases, pigmentation disorders, vitiligo, fungal, bacterial and viral infections, parasitic infestation, STIs, leprosy, malignancies, connective tissue diseases, VB diseases and drug reactions.
Exclusion criteria: Patients diagnosed with skin cancer, subungal, ocular, and visceral lesions and metastases were excluded from the study.
Statistical Analysis
Data were entered under different age, sex and the pattern of skin diseases groups. A monthly split-up of these demographic and clinical characteristics for this study sample was analysed using descriptive statistics. Descriptive statistics for quantitative variables were summarised as counts and percentages. Data analysis was performed using Microsoft Excel and R software (R version 3.6.1 (2019-07-05)).
There were a total of 17,907 cases who attended the skin OP clinic on the stipulated days during this period. There were 2655 (14.8%) children below 10 years. The maximum number of cases belonged to the age group of 11 to 20 (4071, 22.7%) and the minimum number belonged to more than 70 age groups. (224, 1.3%) (Table/Fig 1). Females showed mild preponderance, 9674 patients (54%) (Table/Fig 2). The distribution of cases in each month during the study period is shown in (Table/Fig 3).
Among different groups of diseases recorded, infections were the most common- 7640 patients (42.7%) out of 17907, this was followed by eczema, accounting for 4953 (27.7%), papulosquamous disorders 956 (5.3%) and acne vulgaris 622 (3.5%) (Table/Fig 4). Infections (excluding leprosy and sexually transmitted diseases) constituted the single largest group of diseases and were comprised of fungal (5393; 30.1%), bacterial (1510; 8.4%), parasitic (938; 5.2%) and viral (770; 4.3%) infections. Leprosy was the presenting disease in 15 patients (0.1%) and STIs in 20 (0.1%).
Gender predilection was seen in melasma (14 males and 95 females), leprosy (13 males and two females), drug reaction (one male and 28 females), connective tissue diseases (all 18 patients were females) and VB diseases (all four patients were females) (Table/Fig 5).
The total number of cases on a monthly basis ranged from 1420 (February) to 1576 (October). A monthly split-up of cases according to disease groups is shown in (Table/Fig 6). Out of the disease groups, increased frequency of some groups of diseases were observed in the following months-bacterial (199/1510) and fungal infection (600/5393) in June, viral infection (88/770) in March, scabies in December and March (98/938), papulosquamous (125/956) in December, vitiligo in May (20/113), melasma in April (17/109), urticaria in June (70/474), acne in January (77/622), STIs in February-9/20 (45%), leprosy in May-4/15 (26.7%), drug reaction in December- 9/29 (31%), connective tissue diseases in April- 6/18 (33.3%), VB diseases in February 4/4 (100%). This was more evident in diseases- STIs, leprosy, drug reaction, connective tissue diseases and VB diseases (Table/Fig 6).
Infections and eczemas contributed to the majority of the OP attendance, which was similar to many other studies (5),(6). Most of these cases could be managed by a primary healthcare doctor. This fact that common infections and eczemas account for such a large volume of OP attendance, points to the poorly developed referral system in our healthcare.
Fungal infection contributed to 30.1% while it was less in previous studies in Kerala. The prevalence was 18.74% in a study by Asokan N et al., 14.18% in a study by Nair PS et al., in 1999 and 17.19% in a study by Devi T and Zamzachin G in 2006 (5),(6),(7). It is an indisputable fact that there has been an increase in the prevalence of dermatophytosis over the past few years across the country (8). The recent prevalence of dermatophytosis in India ranges from 36.6-78.4% (9). Studies in the last five years have shown greater proportions of patients from urban areas (around 80% of patients) than in rural areas. Maximum cases were seen in young adults and adolescents in most of the recent studies (9),(10). In present study also, the 11-20 years age group was the most commonly affected group. Inadvertent use of topical steroids and illiteracy about the general measures to prevent and control the infection were noted as causes of uncontrolled tinea infection. Authors propose that Seasonal variation was demonstrated in some studies, with eczematous conditions and bacterial infection being higher during autumn and winter (11). In present study, some diseases showed clustering in some months. VB diseases were confirmed in four patients. All these patients had their first visit in February. No seasonal trend for VB diseases has been reported in previous studies. This observation might be due to chance as it is only a one-year observation. Autoimmune diseases result from the interaction between predisposing genetic factors and exogenous factors, the most common being drugs and food (1). So whether any food, drug or any unknown substances have provoked the development, this has to be confirmed by epidemiological studies of longer duration.
The month with the highest number of patients (nine out of 29) with drug reactions came was January. A relationship between viral infections and the simultaneous or subsequent development of drug rashes has been observed in a number of clinical situations (1). Most proven is the relation between Drug Hypersensitivity Syndrome (DHS) and Human Herpes Virus (HHV) (12). Although the type of drug reaction is not studied, authors consider this worth reporting because of the possible association with an infectious aetiology.
All 18 patients with connective tissue diseases were females and most patients (nine out of 18 patients) presented to OP in April and May. April and May are the summer seasons of Kerala and sunlight might have precipitated the symptoms. Similarly, melasma and vitiligo, which can be exacerbated by sunlight, were also common during these months. More cases of leprosy were presented in March, probably due to vigilant screening following observation of the leprosy in January.
Limitation(s)
The main limitation was that the study was only conducted for one year and patients coming on only two days in a week were selected. Hence, the relevance of month-wise distribution findings is difficult to assess. But authors believe that this is worth reporting because of the rarity of such studies. These findings have to be reassessed in more long-term studies.
Though present study was conducted in a tertiary centre, most of the cases were common dermatological conditions like infections and eczemas which should be ideally managed in the primary healthcare set-up. To achieve this, the peripheral institutions should be strengthened with manpower and the required level of knowledge in dermatology. More focused and effective training of medical students about management of common skin conditions at the undergraduate level, atleast two weeks’ compulsory posting in dermatology during an internship and continuing medical education for practitioners, are important in this regard. The role of family physician should gain more importance in our country. Clustering of diseases like VB diseases, connective tissue diseases and drug reactions during certain months was seen in present study which should be confirmed by studies involving longer duration.
DOI: 10.7860/JCDR/2023/63290.17776
Date of Submission: Feb 07, 2023
Date of Peer Review: Mar 11, 2023
Date of Acceptance: Mar 27, 2023
Date of Publishing: Apr 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No
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