NEWS
Growing awareness of skin disease starts flurry of initiatives
Sharon Kingman
London
More needs to be done to address skin diseases in developing countries.
Skin diseases in developing countries have a serious impact on people's quality of life, causing lost productivity at work and school, and discrimination due to disfigurement. Skin changes may also indicate the presence of more serious diseases that need treatment.
In the past, such conditions were ignored or given low priority by health authorities because they did not, on the whole, kill people, and they often did not present in tertiary care centres.
But now there is a big push at both national and international levels to train health workers in developing countries to improve diagnosis and treatment of dermatological conditions.
Professor Rod Hay, Head of the School of Medicine and Dentistry, Queen's University Belfast, said the change is very welcome. Hay is Chair of the International Foundation for Dermatology, a non-profit organization based in Chicago, the United States, linked to the International League of Dermatological Societies, that aims to improve dermatological care in developing countries. He said: "There is better recognition of the extent of the problem, helped by the fact that the first signs of certain diseases, including HIV/AIDS, leprosy and onchocerciasis, tend to appear as skin problems."
Dr José Figueroa-Munoz, who is currently a medical officer in WHO's Stop TB Department but was previously a fellow of the St John's Institute of Dermatology in London, United Kingdom, agreed that there is now better acknowledgement of skin diseases and the impact they have.
"Most of these diseases have always been there, and in many cases they are so common that they are part of the local culture," Figueroa-Munoz said. "But there is now more realization that even though many people do not see these diseases as a problem, they could still be having an important impact on general health."
For example, skin diseases that cause severe itching at night can reduce someone's productivity during the day at work, or their ability to pay attention in school. In many communities, people with visible skin disease suffer discrimination when applying for jobs, or, if a woman has a disfiguring skin disease, she may never marry.
"Factors such as these have an impact on people's quality of life," Figueroa-Munoz said, "and for this reason it is important to treat skin diseases and educate communities about how to prevent them".
There is plenty of evidence that skin diseases are much more common in developing countries than in the developed world. Surveys have shown that up to 60% of people in both rural and urban areas in developing countries suffer from skin diseases. By contrast, one study in the United Kingdom estimated that 28% of people had a treatable skin disease.
In contrast to the situation in developed countries, malignant melanoma and non-melanoma skin cancers are rare in the indigenous populations of most developing countries, and among those with pigmented skins in general. The exception is the very high risk of skin cancers in albinos.
The last few years have seen a flurry of new initiatives targeted at treatment of skin disorders in developing co untries, many of them fostered by the International Foundation for Dermatology. At the international level, recognition of the problem is continuing to grow: Hay points out that the Disease Control Priorities Project of the World Bank/WHO/Fogarty International Center is due to publish its second report this month, which includes a chapter on the priorities relating to skin diseases in developing countries.
At a workshop in September 2004 organized by the International Foundation for Dermatology, Hay made the case that it was time to strengthen community dermatology programmes for developing countries. Many skin conditions are due to infections, he concluded, and could be treated with simple remedies if these were used in the right way. Poor training is one factor contributing to the huge amount of time and resources being poured into treating skin disease badly, he said.
Delegates attending the workshop identified several areas for action. First, they called for more up-to-date evidence on common treatments for scabies that can be adopted by whole communities. Second, because antiretrovirals are now more commonly available in developing countries for the treatment of HIV/AIDS, they wanted a simple diagnostic scheme that would allow health-care staff to recognize people who were potentially infected with HIV from changes in their skin or mucosal surfaces.
Their third recommendation was for better training for health-care staff on treatment of common skin conditions, such as pyoderma, ringworm, tropical ulcer, infected sores and diabetic foot.
Finally, the delegates called for better promotion of existing examples of good practice that could be rolled out to other communities.
Hay said one example of good practice that could be usefully transferred to other settings is provided by the Regional Dermatology Training Centre (RDTC) in Moshi, the United Republic of Tanzania, which the International Foundation of Dermatology established, in collaboration with the Government of the United Republic of Tanzania, in 1997. The centre provides training for primary care doctors from across Africa, who can return to their own countries and train others.
The International Foundation of Dermatology, which will be based in London from January 2006, has helped with similar projects, based on a short-course educational model, in the state of Guerrero, Mexico, and in Mali (see article on pp. 935941).
Figueroa-Munoz also calls for better training and especially for evaluation of training projects in order to establish that these are having the desired impact on those people most in need. "There is a desperate need for operational research to evaluate interventions to find out what works best," he said.
One problem already identified, and which is not exclusive to dermatology, is the risk that doctors sent to Europe or the United States to undergo training will never return to their home countries. "It may be better for training to be undertaken locally," Figueroa-Munoz said. "This is particularly important in dermatology, as the trainer needs to understand the conditions under which people are going to work. Secondly, the presentation of dermatological conditions varies according to the type of skin. It can be very difficult to obtain photographs for training that feature these conditions on people with the same type of skin as occurs locally."
Some successful projects have focused on individual dermatological problems. For example, the RDTC in the United Republic of Tanzania has developed a treatment and prevention programme for skin cancer in albinos. A recent survey by the RDTC in the Kilimanjaro area, where about 1 million people live, showed that at least 15 000 are albinos and therefore at risk of dying from skin cancer in their teens.
In the Northern Territory of Australia, studies on the indigenous population have shown that children who caught scabies, and were therefore at risk of secondary bacterial infection, were more likely to show signs of kidney damage several years later the result of post-streptococcal glomerulonephritis. "There is now a well-organized public health programme to ensure that children with scabies are identified early and treated," Hay said.
Other issues that have the potential to be addressed locally through education or improved management include, he said, the problem of actinic dermatitis (a type of photosensitivity dermatitis) in rural indigenous populations in Mexico and Latin America; and the use of skin bleaching agents, which results in scarring. The latter, Hay said, is a "huge problem" in Africa, where women use such creams to lighten their skin.
According to the forthcoming chapter in the Disease Control Priorities Project report, the skin conditions that comprise most of the cases presenting in the community are: scabies, pyoderma, fungal infections, tropical ulcer, AIDS-related dermatoses and pigmentary disorders. Focusing on these conditions could significantly reduce the burden of skin disease in developing countries, the paper concludes.
Hay agreed. He said: "The core to tackling these problems is proper training at primary care level. Many of these conditions have comparatively simple treatments, and these are often not that expensive. Treatment will confer significant gains to both personal and public health." 