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Anthony D White and Ross StC Barnetson
MJA 1998; 169: 659-662
Introduction -
Diagnoses -
Teaching -
Problems -
Discussion -
Acknowledgements -
References -
Authors' details
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Introduction | |
In 1996 and 1997, we conducted a series of dermatology clinics in Samoa
and Vanuatu -- countries which lack resident dermatologists -- under
the aegis of the Pacific Islands Project. This three-year project was
an undertaking of the Australian Agency for International
Development (AusAID) to increase tertiary health service
capacities in Pacific Island countries with a shortage of trained
specialists. The project was implemented by the Royal Australasian
College of Surgeons and covered, in addition to dermatology,
anaesthesiology, general medicine, neurology/neurosurgery,
ophthalmology, orthopaedic surgery, otolaryngology, paediatric
surgery, plastic and reconstructive surgery and radiology. Major
aims were to educate local health workers and to use inexpensive
treatments which would be available long-term in the country. We
describe our experience during four separate two-week visits to
Samoa and Vanuatu in 1996 and 1997, and our resulting
recommendations.
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Diagnoses | |
We saw 1072 patients at clinics in local hospitals in Apia and Savaii in
Samoa (765 patients), and in Port Vila, Espiritu Santo and Tanna in
Vanuatu (307 patients). The clinics were advertised on local radio,
and there was prior liaison with hospital doctors. Patients were
therefore probably those with severe skin diseases, who were able to
travel to the clinics.
Diagnoses are shown in the Box. The vast majority of patients had
common skin conditions, often in severe or extensive forms, rather
than rare, exotic diseases.
Fungal infection: This was the most common
condition, affecting almost 40% of patients. Tinea (ringworm) was
found in a quarter of patients and was often extensive, involving up to
20% of the body surface (Figure 1). Tinea
(pityriasis) versicolor, caused by the yeast Malassezia furfur,
affected a further 13% of patients (Figure
2), while some patients had both types of infection (Figure 3).
The main contributing factors to the prevalence and extent of fungal
infections appeared to be the hot, humid climate, occlusive clothing
and inadequate treatment. There is a culturally determined tendency
to wear multiple layers of clothing, particularly in Samoa.
Antifungal drugs, even when available, were often out of patient
reach because of cost.
Dermatitis: 21% of patients had contact, atopic or
seborrhoeic dermatitis. A predisposing factor is the tendency,
despite the high ambient humidity, for Polynesian and Melanesian
skins to be dry. Among Samoans, this dryness is often aggravated by
overuse of soap and water and the practice of scrubbing the skin with a
ball of plant fibre. Photosensitivity dermatitis was seen in six
patients, all of whom had used a soap containing
trichlorocarbanilide, an antiseptic known to cause a
photosensitive rash.
Scabies: Each year all Samoans over the age of 12
months are treated with oral diethylcarbamazine as part of a national
filariasis eradication campaign. In 1997, ivermectin was added to
the regimen. This drug is also active against scabies, and during the
clinic visit a month after the campaign many patients were seen with
the stigmata of resolving scabies. The few patients with active
scabies were infants (who are excluded from the drug program) and an
adult who had refused treatment.
Pigmentary disorders: These included melasma,
vitiligo, postinflammatory hyperpigmentation and pityriasis
alba. Striking depigmentation was also the presenting symptom in two
patients with chronic discoid lupus erythematosus (Figure 4). Pigmentary disorders are a greater
cosmetic problem in dark-skinned than in white-skinned people,
because of the greater contrast between affected and unaffected
skin.
Other skin disorders: Acne was surprisingly infrequent
in both countries, while psoriasis was common (Figure 5). Other notable conditions which
affected small numbers of patients included epidermolytic
hyperkeratosis, leprosy, and lichen amyloidosis (Figures 6-8). One
skin cancer was seen, in a 60-year-old Vanuatu Melanesian man. It
presented as an eroded 8 cm plaque on the shoulder; biopsy showed it to
be basal cell carcinoma, a condition never previously encountered by
local physicians on black skin.
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Teaching | |
Every opportunity was taken to discuss diagnosis and management of
skin disease with interested local health workers, using clinic
patients as subjects. During one visit to Samoa, one of us (R StC B) was
accompanied by an indigenous physician, providing an opportunity to
discuss local dermatological problems and solutions. This was not
possible during other visits because of the shortage of available
medical personnel. Four lectures on skin diseases were given to
hospital staff.
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Problems | |
The main clinical difficulties we encountered were poor conditions
for examination, lack of diagnostic facilities and inadequate
pharmaceutical supplies. Skin specimens were returned to Australia
for histopathological examination or fungal culture, as neither
Samoa nor Vanuatu had facilities for these procedures.
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Discussion and recommendations | |
The spectrum of infectious skin diseases encountered in Samoa and
Vanuatu was similar to that seen in Australian clinics,3 although these
diseases tended to have a more severe and extensive course. In
contrast, skin cancer and precancer were virtually absent. Few
diseases were exotic or "tropical".
Inadequate treatment because of the lack of availability or high cost
of antifungal drugs was probably a contributing factor to the
severity of fungal infections. Topical antifungal creams were
available in impracticably small volumes. For example,
clotrimazole must be applied for four weeks, but the standard 20 g tube
is sufficient to treat extensive disease for only a day. The standard
oral fungistatic drug, griseofulvin, needs to be taken for four
weeks, but is usually prescribed in Samoa and Vanuatu for only seven
days. An alternative treatment, oral terbinafine, is fungicidal and
may be adequate in a seven-day course.4 The manufacturer of
terbinafine, Novartis, has been approached officially to provide
this drug as a humanitarian service to these countries.
Inadequate treatment probably also contributed to the prevalence
and extent of dermatitis. Topical steroids were available, in both
countries, but only in 15 g tubes (30 g of cream/ointment is needed for
one total body application).
Scabies was common. It requires community-based rather than
individual treatment, as repeated re-infestation occurs from
untreated individuals. In Samoa, it should now be possible to
capitalise on the fortuitous scabicidal effect of ivermectin (used
in the filariasis eradication campaign), which is an ideal treatment
in populations with high endemic rates of infestation.5 However, this
needs to be backed up by topical antiscabetic treatment for those who
are ineligible for ivermectin or who become re-infested.
Unfortunately, no topical antiscabetic agents were available in
Samoa at the time of the 1997 campaign, and an opportunity to eradicate
scabies was lost.
Although leprosy is endemic in Samoa and Vanuatu, only one new case was
seen. This condition is well managed by the World Health
Organization, which undertakes treatment, contact tracing and
follow-up.
Public education about preventing skin disease could be
beneficial. It should define simple hygiene but explain that
excessive washing, scrubbing of the skin and use of germicidal soaps,
although customary, are unnecessary and often injurious. In
addition, occlusive clothing is inappropriate for a hot, humid
climate and encourages skin disease, particularly fungal
infection. Effort is also needed to overcome the enormous stigma
attached to skin disease, which delays or prevents presentation and
increases individual suffering and the prevalence of infectious
disease in the community.
With adequate resources, most of the conditions we saw are treatable
and many are preventable. Because half a dozen diseases account for
two-thirds of patients presenting, it should be possible to educate
primary carers to diagnose and treat most cases. We are currently
preparing an illustrated booklet describing the clinical features,
prevention and treatment of the main diseases. However, the need for
affordable, effective treatments remains.
The dermatological contribution to the Pacific Islands Project was
valuable in defining the main problems, formulating solutions,
educating local health workers and providing treatment in two of
Australia's less-developed neighbours. We hope that the program
will continue and expand to assist other countries in the area.
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Acknowledgements | |
We are very grateful to Associate Professor Steven Kossard (Skin
Cancer Foundation, Sydney, NSW) and Dr Andrew Gal (Sydney, NSW) for
histopathological examinations, to pharmaceutical companies for
generous donation of drugs, and to the Department of Microbiology,
Royal Prince Alfred Hospital, for fungal cultures. We also thank our
patients for allowing publication of their photographs.
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References | |
- Manzano-Gayosso P, Mendez-Tovar LJ, Hernandez-Hernandez F, et
al. Dermatophytoses in Mexico City. Mycoses 1994; 37: 49-52.
-
Khosravi AR, Aghamirian MR, Mahmoudi M. Dermatophytoses in Iran.
Mycoses 1994; 37: 43-48.
-
Kilkenny MF, Marks R. The frequency and nature of skin conditions
seen in a private dermatology practice in central Victoria. Aust J
Dermatol 1996; 37: S50-S53.
-
Barnetson R StC, Marley J, Bullen M, et al. Comparison of one week of
oral terbinafine (250 mg/day) with four weeks of treatment with
clotrimazole 1% cream in interdigital tinea pedis. Br J
Dermatol 1998; 139: 675-678.
-
Meinking TL, Taplin D, Hermida JL, et al. The treatment of scabies
with ivermectin. N Engl J Med 1995; 333: 26-30.
(Received 22 Jul, accepted 7 Oct, 1998)
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Authors' details | |
Department of Dermatology, Royal Prince Alfred Hospital, Sydney,
NSW.
Anthony D White, FRACP, FACD, Consultant Dermatologist;
Ross StC Barnetson, MD, FRACP, FACD, Head of Department, and
Professor of Dermatology, Sydney University, Sydney, NSW.
Reprints will not be available from the authors.
Correspondence:
Professor R StC Barnetson, Department of Dermatology, Royal Prince
Alfred Hospital, Missenden Road, Camperdown, NSW 2050.
Email: rossATcanc.rpa.cs.nsw.gov.au
©MJA 1998
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