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Skin diseases in Nigeria: the Calabar experience Eshan B. Henshaw1, FWACP, and Olayinka A. Olasode2, FWACP, FACP
1 Dermatology Unit, Department of Medicine, University of Calabar, Calabar, Nigeria, and 2Department of Dermatology and Venereology, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
Abstract Background This paper reports on a 6-year study (April 2006 to April 2012) and a followup of a 9-month baseline survey of the pattern of dermatoses in Calabar, the capital of Cross River State in southern Nigeria. Prior to the time of this study, this region had not benefited from the services of a resident dermatologist for over a century. Methods Data on the age, gender, and diagnoses of 1307 consecutive new patients
Correspondence Eshan B. Henshaw, FWACP Department of Medicine Faculty of Medicine & Dentistry University of Calabar P.M.B. 1115 Calabar Cross River State Nigeria E-mail: [email protected]
attending the relatively new dermatology clinic at the University of Calabar Teaching Hospital during the study period were obtained and analyzed. Most diagnoses were based
Funding: none.
common group (30.4%), followed by infections/infestations (28.9%). A comparison of this study with others from various geopolitical zones of Nigeria revealed some similarities.
Conflicts of interest: none.
Dermatophytosis and acne were consistent reasons for visits to dermatologists in all
on clinical findings but were supported by relevant laboratory investigations and histopathologic examinations when necessary. Results The male : female ratio of patients was 1 : 1.5. The mean standard deviation age of the patients was 27.7 17.2 years (range: 4 weeks to 84 years). A total of 1459 diagnoses were recorded; 143 patients had more than one dermatosis. Diagnoses were broadly divided into 10 groups. Allergic/hypersensitivity diseases represented the most
zones. Conclusions Despite the wide spectrum of dermatoses observed, a small number of diseases account for a sizeable percentage of diagnoses. The pattern of dermatoses in Calabar is similar to that in other parts of the country. Climate and socioeconomic factors are synergistic in causing dermatoses that remain a major cause of morbidity in all age groups and both genders across Nigeria.
Introduction The University of Calabar Teaching Hospital (UCTH) is the only tertiary healthcare institution in Cross River State, one of the 36 states in Nigeria. It is an offshoot of St. Margaret’s Hospital, the first public hospital in Nigeria, built in 1897. It caters to the health needs of the approximately three million citizens of the state,1 as well as those of many others from neighboring states and as far away as Cameroon, a country with which the state shares an international boundary. To the best of the present authors’ knowledge, the hospital has never benefited from the services of a dermatologist, thus leaving the populace with unmet skin healthcare needs for more than a century. This is because a handful of dermatologists (approximately 602) are unevenly distributed across the country to serve a population of about 170 million people.3 The several military coups and the resulting unstable political climate that occurred thereafter had a great negative impact on the progress and distribution of medical subspecialties, including dermatology, in Nigeria.4 There ª 2014 The International Society of Dermatology
are therefore some states in the country without specialist dermatologists. Cross River State is a tropical paradise located in southeast Nigeria, in the Niger delta region (5°450 N, 8°300 E). Like the rest of the country, it has two seasons, which are, respectively, rainy (March–October) and dry (November–February). Its equatorial climate is marked by heavy rainfall, high temperatures, and high humidity. Burdens of skin diseases in some regions of the country have been cataloged and may or may not reflect that seen in this region. Several factors are known to affect the prevalence of skin diseases, including but not limited to genetic, cultural, climatic, and socioeconomic factors. Nigeria is a nation with a curious blend of states and is diverse in several of these factors. The climate in most of the northern part of the country is arid but is tropical or equatorial in the south; the predominant religions and cultures of these regions are also quite diverse. Many of Nigeria’s few dermatologists practice in tertiary institutions, which also deliver secondary-level dermatologic care, making hospital-based studies relevant.4 In addition, International Journal of Dermatology 2015, 54, 319–326
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hospital-based studies give an idea of the spectrum of dermatoses in a locality and may also provide an index against which the findings of community-based studies can be compared. Materials and methods This was a prospective study in which the biodata (including name, age, gender, and occupation) and diagnoses of consecutive new patients attending the dermatology outpatient clinic of UCTH between April 2006 and April 2012 were collected. History taking and physical examinations were conducted by specialist dermatologists. Diagnoses were often clinical but were sometimes supported by relevant laboratory investigations and histopathology. Diagnoses were divided into categories, some of which were further subcategorized for clarity. Data were entered into an Excel spreadsheet, transferred to StataSE 10 (StataCorp LP, College Station, TX, USA) for analysis, and reported with the aid of simple tables showing frequencies and percentages. The results were then compared with those from similar studies conducted in various parts of the country.
Results A total of 1307 patients were seen, among whom 1459 diagnoses were made. There were 143 patients with more than one diagnosis, including eight patients with three and one patient with four diagnoses. There was a female preponderance: the 775 female patients and 532 male patients gave a male : female ratio of 1 : 1.5. This female preponderance was evident to varying degrees in all but two of the various age groups (Table 1). The mean standard deviation age of the study population was 27.7 17.2 years (range: 4 weeks to 84 years). Over 64.3% of persons were in the highly economically active age group of 20–59 years. Table 1 Age and sex distribution of study subjects Sex frequency and ratio Age, years
Male, n
Female, n
M : F ratio
Total, n (%)
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 ≥80 Total
111 59 123 91 71 41 24 11 1 532
118 109 249 125 89 51 28 5 1 775
1 1 1 1 1 1 1 2.2 1 1
229 168 372 216 160 92 52 16 2 1307
: : : : : : : : : :
1.1 1.8 2 1.4 1.3 1.2 1.2 1 1 1.5
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(17.5) (12.9) (28.5) (16.5) (12.2) (7.0) (4.0) (1.2) (0.2) (100)
A total of 159 specific skin diseases were diagnosed and classified into main categories; some were further divided into subcategories. The main categories were allergic/hypersensitivity disorders, infections/infestations, disorders of skin appendages, papulosquamous disorders, pigmentary disorders, growths and tumors, disorders of keratinization, genodermatoses, connective tissue disorders, and miscellaneous disorders. Overall, the most common group of dermatoses were allergic/hypersensitivity disorders (30.4%), followed by infections/infestations (28.9%). Dermatitis accounted for the bulk of allergic/ hypersensitivity disorders, and fungal infections constituted the majority of infections/infestations. Acne vulgaris/acneiform eruptions (53.2%) represented the most common adnexal disorder, and pityriasis rosea accounted for 48.3% of papulosquamous disorders. Vitiligo accounted for the bulk of pigmentary disorders (49.5%), and Kaposi’s sarcoma represented the predominant diagnosis in the tumors/growths group (17.7%). Full details of categorizations, frequencies, and percentages are shown in Table 2. Male patients had higher frequencies of both allergic/ hypersensitivity disorders and infections/infestations, whereas all other categories of dermatoses showed a female preponderance. A total of 27 specific dermatoses occurred at frequencies of ≥1%. Seborrheic dermatitis (5.6%), acne/acneiform eruptions (5.1%), and pityriasis versicolor (5.0%) were the three most common. However, when data for tinea infection at all anatomic sites were pooled, tinea infection became the most common dermatosis, accounting for a total of 7.9% of diagnoses. Table 3 shows in descending order of frequency the most common specific dermatoses that accounted for ≥1% of all diagnoses. The study population included 42 persons with a positive laboratory diagnosis of human immunodeficiency virus (HIV) infection; these represented 3.2% of the study population. The most common HIV-related condition was Kaposi’s sarcoma (26.2%), followed by infection with human papillomavirus manifesting as viral warts, condyloma acuminata, and epidermodysplasia verruciformis, or sometimes all three in a single patient. Table 4 shows details of skin disease findings in subjects with HIV infection. Collation of the 10 most common dermatoses in this and each of six other studies5–10 under consideration revealed 20 specific dermatoses. For ease of comparison, all tinea infections were merged and considered as a single entity. Tinea and acne were universal in all studies, and urticaria and atopic dermatitis were seen in all but one of the studies. Table 5 lists these conditions in the various studies5–10 and in descending order of frequency of disease occurrence. ª 2014 The International Society of Dermatology
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Table 2 Frequencies and percentages of skin diseases
Disease Hypersensitivity disorders Dermatitis Seborrheic Atopic Contact Hand and/or foot Cosmetic Lichen simplex chronicus Stasis Pityriasis alba Exfoliative Pompholyx Others Urticaria/drug reaction/pruritus Urticaria/angioedema Papular urticaria Fixed drug eruption Pruritus sine materia Others Infections/infestations Fungal Dermatophytosis Pityriasis versicolor Candidal infections Viral Viral warts Herpes simplex Herpes zoster Epidermodysplasia verruciformis Condyloma acuminata Others Bacterial Pyoderma Furunculosis Hansen’s disease Impetigo Erythrasma Others Parasitic Scabies Onchodermatitis Cutaneous larva migrans Others Adnexal disorders Acne vulgaris/acneiform eruptions Folliculitis Alopecia Acne keloidalis nuchae Others Papulosquamous disorders Pityriasis rosea Psoriasis Lichen planus
Table 2 Continued
Diagnoses, n
Frequency in group (%)
Frequency in all diagnoses (%)
444
–
30.4
82 66 49 22 15 13 12 8 6 5 31
18.5 14.9 11.0 5.0 3.4 2.9 2.7 1.8 1.4 1.1 7.0
5.6 4.5 3.4 1.5 1.0 0.9 0.8 0.6 0.4 0.3 2.1
47 31 27 22 8 421
10.6 7.0 6.1 5.0 1.8 –
3.2 2.1 1.9 1.5 0.6 28.9
114 73 67
27.1 17.3 15.9
7.8 5.0 4.6
36 15 15 10 8 5
8.6 3.6 3.6 2.4 1.9 1.2
2.5 1.0 1.0 0.7 0.6 0.3
8 7 7 6 4 7
1.9 1.7 1.7 1.4 1.0 1.7
0.6 0.5 0.5 0.4 0.3 0.5
21 11 4 3 139 74
5.0 2.6 1.0 0.7 – 53.2
1.4 0.8 0.3 0.2 9.5 5.1
16 14 12 23 120 58 21 15
11.5 10.1 8.6 16.6 – 48.3 17.5 12.5
1.1 1.0 0.8 1.6 8.2 4.0 1.4 1.0
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Diagnoses, n
Disease Pityriasis lichenoides chronic Lichen nitidus Others Pigmentary disorders Vitiligo Post-inflammatory hyperpigmentation Post-inflammatory hypopigmentation Exogenous ochronosis Melasma Nevus Idiopathic guttate hypomelanosis Others Tumors/growths Benign Keloids/hypertrophic scars Dermatosis papulosa nigra Syringoma Seborrheic keratosis Lipoma Epidermal cyst Hemangioma Pyogenic granuloma Others Pre-malignant/malignant Kaposi’s sarcoma Actinic keratosis Non-melanoma skin cancer Cutaneous T cell lymphoma Melanoma Disorders of keratinization Keratoderma Keratosis pilaris Others Genodermatosis Icthyosis Neurofibromatosis Tuberous sclerosis Connective tissue diseases Scleroderma Morphea Systemic lupus erythematosus Discoid lupus erythematosus Others Miscellaneous disorders Granuloma annulare Papular pruritic eruptions Bullous dermatoses Lymphedema Xerosis Others
Frequency in group (%)
Frequency in all diagnoses (%)
12
10.0
0.8
5 9 107 53 11
4.2 7.5 – 49.5 10.3
0.3 0.6 7.3 3.6 0.8
11
10.3
0.8
10 7 7 5
9.4 6.5 6.5 4.7
0.7 0.5 0.5 0.3
3 79
2.8 –
0.2 5.4
10 9 6 5 5 4 4 3 6
12.7 11.4 7.6 6.3 6.3 5.1 5.1 3.8 7.6
0.7 0.6 0.4 0.3 0.3 0.3 0.3 0.2 0.4
14 5 4 2 2 38 15 11 12 22 11 10 1 12 4 2 2
17.7 6.3 5.1 2.5 2.5 – 39.5 28.0 31.6 50.0 45.5 4.5 – 33.3 16.7 16.7
1.0 0.3 0.3 0.1 0.1 2.6 1.0 0.8 0.8 1.5 0.8 0.7 0.1 0.8 0.3 0.1 0.1
2
16.7
0.1
2 77 16 9 7 4 4 37
16.7 – 20.8 11.7 9.1 5.2 5.2 48.1
0.1 5.3 1.1 0.6 0.5 0.3 0.3 2.5
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Table 3 Skin disorders with frequencies of ≥1% Skin disease
Diagnoses, n
Frequency (%)
Seborrheic dermatitis Acne/acneiform eruption Pityriasis versicolor Candidiasis Atopic dermatitis Pityriasis rosea Vitiligo Contact dermatitis Urticaria/angioedema Viral warts Papular urticaria Tinea corporis Tinea pedis Fixed drug eruption Pruritus Psoriasis Scabies Folliculitis Granuloma annulare Tinea capitis Cosmetic dermatoses Herpes simplex Herpes zoster Keratoderma Lichen planus Alopecia Kaposi’s sarcoma
82 74 73 67 66 58 53 49 37 36 31 31 31 27 22 21 21 16 16 16 15 15 15 15 15 14 14
5.6 5.1 5.0 4.6 4.5 4.0 3.6 3.4 2.5 2.5 2.1 2.1 2.1 1.9 1.5 1.4 1.4 1.1 1.1 1.1 1.0 1.0 1.0 1.0 1.0 1.0 1.0
Table 4 Dermatologic conditions in persons with human immunodeficiency virus (HIV) infection (n = 42) Skin disease
Diagnoses, na
Frequency (%)
Kaposi’s sarcoma Human papillomavirus infection Pruritic papular eruption Seborrheic dermatitis Herpes zoster Papular urticaria Tinea Psoriasis Stasis dermatitis Erythema multiforme major Exfoliative dermatitis Eruptive xanthoma Scabies Lichen planus Others
11 5 4 4 3 2 2 2 2 1 1 1 1 1 7
26.2 11.9 9.5 9.5 7.1 4.8 4.8 4.8 4.8 2.4 2.4 2.4 2.4 2.4 16.7
a
Some patients had more than one dermatosis.
Discussion The dermatologic health needs of a population can only be met when they have been identified. Standard tools for identification are epidemiologic surveys, which are often International Journal of Dermatology 2015, 54, 319–326
laborious, expensive, and tend to produce both clinically significant and trivial conditions, as observed in a study conducted in Lambeth,11 in which the point prevalence of all grades of skin disease was 55% but dropped to 22.5% when only skin diseases thought to require medical care were considered. By contrast, hospital-based surveys provide a guide to the spectrum of diseases in a given community. Other than the pilot study,12 of which this is a followup, there has been no attempt to chronicle the pattern of skin diseases in Calabar. The present data showed a female preponderance as observed in similar studies.5,13,14 This may corroborate the general belief that women are more concerned about their physical appearance and thus are more likely to seek intervention, as postulated by ElKhateeb et al.14 By contrast, Nnoruka6 and Onayemi et al.7 recorded a male preponderance, whereas a study by Yahya reported an equal sex ratio.8 It is probable that the reverse or equal sex ratio in studies from the northern part of Nigeria may be attributable to the predominance in the area of the Muslim religion, which encourages purdah (the seclusion of women from the sight of men or strangers, practiced by some Muslims and Hindus), a tradition with a considerable number of female adherents. As a result, fewer women seek medical intervention because there is a high likelihood that they will be examined by male physicians, who predominate in the profession. The most common category of skin diseases included allergic/hypersensitivity disorders, of which dermatitis formed the largest subgroup. This was also indicated in the study by Nnoruka.6 Dermatitis was also judged to account for the most common dermatoses in several other similar studies.8–10,13 By contrast, infections/infestations predominated in comparative studies in Nigeria,5,7 Egypt,14 Sierra Leone,15 Ghana,16 and Tunisia.17 This latter pattern was frequently seen in older studies18–21 and in relatively more recent studies22,23 of skin diseases in rural African populations. Reasons adduced for this include poor socioeconomic conditions, low levels of literacy, and overcrowding. Gibbs,22 working in rural Tanzania, found household density to be the only socioeconomic factor significantly associated with skin diseases, the most prevalent of which was scabies. Drawing from this, Hay and collaborators24 opined that household overcrowding was the most important risk factor for skin disease in developing countries. This may be a valid conclusion, particularly in regions in which scabies is prevalent. However, the most common transmissible skin conditions in many African studies, including both hospital-based5,7,9,13,14 and community-based23,25 studies, are fungal skin infections, among which tinea is often predominant. The warm and humid tropical climate ª 2014 The International Society of Dermatology
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Table 5 Comparison of studies on patterns of skin diseases in Nigeria Frequencies of 10 most common dermatoses in each study
Skin disease
This study (n = 1307) (%)
Nnoruka6 (n = 2871) (%)
Altraide et al.5 (n = 1333) (%)
Ogunbiyi et al.9 (n = 1091) (%)
Tinea Acne/acneiform eruption Urticaria Atopic dermatitis Pityriasis versicolor Contact dermatitis Seborrheic dermatitis Vitiligo Lichen planus Pityriasis rosea Candidiasis Viral warts Papular urticaria Lichen simplex chronicus Acne keloidalis nuchae Scabies Keloid Psoriasis Pseudofolliculitis Bacterial folliculitis
7.8 5.1 3.2 4.5 5.0 3.4 5.6 3.6 – 4.0 4.6 – – – – – – – – –
8.4 6.7 – 4.8 – 5.3 3.3 – 4.8 4.1 – – – – 3.6 – 3.7 – 3.5 –
9.0 4.6 6.5 6.0 5.4 3.0 – 5.3 4.6 3.6 – – 3.6 – – – – – – –
4.5 2.8 4.6 5.8 4.5 – 2.9 5.7 3.4 – – – – – 2.9 4.1 – – – –
constitutes a major predisposing factor to the acquisition of tinea. In hot and humid climates such as that found in Calabar, the rate of colonization by skin surface pathogens is raised, predisposing the subject to the development of infections, with a resultant increase in the prevalence of conditions such as fungal, bacterial, and parasitic skin diseases.26–28 In 1962, Clarke29 noted that ringworm was the most common complaint among Europeans living in the tropics, although this was not the case in Europe despite similarities in the standard of living of both groups. This, however, does not diminish the role played by suboptimal socioeconomic conditions; comparisons of past and recent studies of dermatoses reveal reductions in the frequencies of dermatophyte, pyoderma, and scabetic infections/infestations.6,8,9,18,19,30,31 These reductions are occurring despite the effects of climate change and global warming. Thus both factors are synergistic. The groups of diseases represented by tinea accounted for the most common reason for visits to the clinic, as observed in many other studies in the tropics.5–7,17 The reason for this has already been discussed. Seborrheic dermatitis was the most prevalent specific skin disease in this study, with a total frequency of 5.6%. This is slightly higher than frequencies found in similar studies in the country.6–9 It was, however, identified as the most ª 2014 The International Society of Dermatology
Ukonu & Eze10 (n = 755) (%)
Yahya8 (n = 5982) (%)
Onayemi et al.7 (n = 746) (%)
Frequency of listing
3.2 5.0 2.4 6.1 2.4 7.4 – 3.2 3.2 3.2 – 4.5 – – – – – 2.6 – –
6.0 7.1 3.6 13.8 – 5.8 2.5 – – – 2.8 2.9 3.6 3.0 – – – – – –
13.4 5.1 3.7 – 6.7 – 4.0 – – – 4.9 2.9 – 3.9 – 5.2 – – – 3.1
7/7 7/7 6/7 6/7 5/7 5/7 5/7 4/7 4/7 4/7 3/7 3/7 2/7 2/7 2/7 2/7 1/7 1/7 1/7 1/7
common type of dermatitis and the second most common skin condition in a study carried out by Hartshorne in South Africa,13 who recorded a higher frequency (10.2%). It was also reported among the five most common dermatologic disorders in Black patients in the USA.32 The high frequency of the condition might be assumed to be connected to the high prevalence of HIV in the state,33 but only 4.9% of patients with seborrheic dermatitis were positive for HIV. This frequency is similar to the finding obtained by Yahya in Kaduna8 and higher than that found by Ukonu and Eze,10 who appear to have found no single case of HIV-associated seborrheic dermatitis, but significantly lower than the 50% reported by Nnoruka in Enugu.6 Acne/acneiform eruption was the most common adnexal disorder and the second most common condition in the study, accounting for 5.1% of all diagnoses. It is believed to be the most common skin condition,34,35 and it is estimated that 80–95% of the population will have acne at some point during adolescence.36 The frequency obtained here is similar to that seen in many other studies,5,7,16,17,37 with the exception of one conducted in South Africa,13 where the percentage was higher (16.0%) among subjects of all races combined and more so among Black subjects (17.5%). In the study by Alexis et al.,32 acne was the most common reason for visiting a dermatologist among both Black (28.4%) and International Journal of Dermatology 2015, 54, 319–326
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White (21.0%) patients. Davis et al.37 also found it to be the most common diagnosis for African-American patients in dermatology, whereas actinic keratosis was the most frequent diagnosis in White subjects. Pityriasis versicolor ranked as the third most common skin condition, with a frequency (5.0%) similar to those obtained by Altraide et al.5 (5.4%) and Ogunbiyi et al.9 (4.4%). It was found to be the most common fungal infection in Egypt,14 where a frequency of 7.7% was recorded, similar to the 6.7% obtained by Onayemi et al.7 This condition flourishes in hot and humid climates, such as those in which all of these studies were conducted, and is also purported to have a genetic basis.38–40 This may be confirmed by the fact that it ranked among the 12 most common skin diseases in Black subjects in Washington, USA,41 and in London, UK,42 despite their being resident in hugely temperate regions. Among the various disorders of pigmentation, vitiligo was the most prevalent. Its frequency of 3.6% in the present population is similar to that found in many other studies in Nigeria.5,9,10 Although it is mostly asymptomatic, vitiligo imposes a great deal of psychological stress on sufferers on account of its conspicuousness (especially when contrasted with Black skin) and because it is often erroneously considered to be leprosy by members of the public.43,44 Kaposi’s sarcoma was the most common tumor/growth in this study, accounting for 17.7% of this category of dermatoses and 63.3% of the total number of malignancies. It had an overall frequency of 1.0% but a frequency of 26.2% among those diagnosed with HIV infection and thus featured as the most common HIV-related dermatosis. Pruritic papular eruption, seborrheic dermatitis, and Kaposi’s sarcoma have been judged to be the most common HIV-related conditions in a number of studies in Nigeria.5,6,9,10 In a 10-year study of 162 patients with histologic diagnoses of dermatologic malignancies in UCTH, Asuquo and Ebughe45 reported Kaposi’s sarcoma as the second most common skin malignancy (after squamous cell carcinoma), with a frequency of 20.4%. This rising trend was also observed by Onunu et al.46 This increase may be explained by the growing number of HIV and acquired immunodeficiency syndrome (AIDS) infections in sub-Saharan Africa. However, it is important to note that prior to the increase in the prevalence of HIV and AIDS in sub-Saharan Africa, Kaposi’s sarcoma was already highly endemic in Cross River State,47 and thus the high frequency of this condition identified in this study in comparison with others5,6,14 may indeed reflect the combined effects of the endemicity of Kaposi’s sarcoma herpes virus (KSHV) and the HIV/AIDS virus epidemic. International Journal of Dermatology 2015, 54, 319–326
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Connective tissue diseases were relatively few and were found in only 12 (0.9%) patients. The most common was scleroderma, which accounted for half of these cases; within the spectrum of scleroderma, systemic sclerosis accounted for two-thirds of cases and morphea (localized) for one-third. This contrasts with the findings of most other studies in Nigeria,6,8,9 in which discoid lupus erythematosus is the most common connective tissue disorder reported. The reason for the relatively larger number of patients with scleroderma in this region is uncertain. A comparison of the findings of this study with the patterns demonstrated in six other studies carried out in various geopolitical zones of the country (south–south5,10 south–east,6 north–west,7 north–central,8 and south– west9) showed some similarities. Tinea and acne were among the 10 most common dermatoses in all studies. Based on the analysis of the frequency of disease occurrence, the 10 most common skin diseases in Nigeria would therefore include tinea, acne, urticaria, atopic dermatitis, pityriasis versicolor, contact dermatitis, seborrheic dermatitis, vitiligo, lichen planus, and pityriasis rosea. This is based on the listing of these conditions among the 10 most common dermatoses reported in no fewer than four of the seven studies considered (i.e. over half of the studies) as shown in Table 5. Conclusions Only a handful of dermatoses account for a sizeable percentage of diagnoses, most of which are treatable. The pattern of dermatoses in Calabar is similar to those in other parts of the country. The 10 most common skin conditions in Nigeria are dermatophytosis, acne, urticaria, atopic dermatitis, pityriasis versicolor, contact dermatitis, seborrheic dermatitis, vitiligo, lichen planus, and pityriasis rosea. Knowledge of the common dermatoses in our environment will facilitate interventions at various levels. Firstly, the training of general practitioners and community health workers will ameliorate the negative impact of the dearth of dermatologists; secondly, relevant government agencies can make drugs and other treatment modalities required for the management of these conditions accessible, and, thirdly, dermatologists can channel their energies into research to improve understanding of these indigenous dermatoses and spur the development of novel diagnostic and treatment modalities.
References 1 National Population Commission of Nigeria. Population Distribution by Sex, State, LGAs and Senatorial Districts. 2006 Census Priority Tables (Vol. 3). Abuja: National Population Commission, 2012; 58. ª 2014 The International Society of Dermatology
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2 National Association of Dermatologists. Profile of Nigerian Association of Dermatologists. 2013. www. dermatologyng.org/aboutus.php. [Accessed August 21, 2013.] 3 Index Mundi.Nigerian Demographics Profile 2013. www. indexmundi.com [Accessed August 21, 2013.] 4 George AO. Dermatology in Nigeria: evolution, establishment and current status. Int J Dermatol 2004; 43: 223–228. 5 Altraide DD, Akpa MR, George IO. The pattern of skin disorders in a Nigerian tertiary hospital. J Public Health Epidemiol 2011; 3: 177–181. 6 Nnoruka EN. Skin diseases in south-east Nigeria: a current perspective. Int J Dermatol 2005; 44: 29–33. 7 Onayemi O, Isezuo SA, Njoku CH. Prevalence of different skin conditions in an outpatients setting in north-western Nigeria. Int J Dermatol 2005; 44: 7–11. 8 Yahya H. Change in pattern of skin disease in Kaduna, north-central Nigeria. Int J Dermatol 2007; 46: 936–943. 9 Ogunbiyi AO, Daramola OOM, Alese OO. Prevalence of skin disease in Ibadan, Nigeria. Int J Dermatol 2004; 43: 31–36. 10 Ukonu BA, Eze EU. Pattern of skin diseases at University of Benin Teaching Hospital, Benin City, Edo State, South-South Nigeria: a 12-month prospective study. Glob J Health Sci 2012; 3: 148–156. 11 Rea JN, Newhouse ML, Halil T. Skin disease in Lambeth. A community study of prevalence and use of medical care. Br J Prev Soc Med 1976; 30: 107–114. 12 Olasode OA, Henshaw EB, Akpan NA, et al. The pattern of dermatoses in a skin clinic in Calabar, Nigeria: a baseline study. Dermatology 2011; 4: 1–6. 13 Hartshorne ST. Dermatological disorders in Johannesburg, South Africa. Clin Exp Dermatol 2003; 28: 661–665. 14 El-Khateeb EA, Imam AA, Sallam MA. Pattern of skin diseases in Cairo, Egypt. Int J Dermatol 2011; 50: 844–853. 15 Bari AU, Khan MB. Pattern of skin diseases in black Africans of Sierra Leone, West Africa. J Clin Diagn Res 2007; 5: 361–368. 16 Doe PT, Asiedu A, Acheampong JW, et al. Skin diseases in Ghana and the UK. Int J Dermatol 2001; 40: 323–326. 17 Souissi A, Zeglaoui F, Zouari B, et al. A study of skin diseases in Tunis. An analysis of 28,244 dermatological outpatient cases. Acta Dermatovenerol Alp Pannonica Adriat 2007; 16: 111–116. 18 Okoro AN. Skin diseases in Nigeria. Trans St Johns Hosp Dermatol Soc 1973; 59: 68–72. 19 Fekete E. The pattern of diseases of the skin in the Nigerian Guinea savanna. Int J Dermatol 1978; 17: 331–338. 20 Diogliotti M. Survey of skin disorders in the urban population of South Africa. Br J Dermatol 1973; 93: 259–270. 21 Ratnam AV, Jayaraju K. Skin diseases in Zambia. Br J Dermatol 1979; 101: 449–453. 22 Gibbs S. Skin disease and socioeconomic conditions in rural Tanzania. Int J Dermatol 1996; 35: 633–639.
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23 Bissek AZ, Tabah EN, Kouotou E, et al. The spectrum of skin diseases in a rural setting in Cameroon (sub-Saharan Africa). BMC Dermatol 2012; 12: 7. 24 Hay R, Bendeck SE, Chen S, et al. Skin diseases. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease Control Priorities in Developing Countries, 2nd edn. Washington, DC: World Bank 2006; 707–721. 25 Satimia FT, McBride SR, Leppard B. Prevalence of skin disease in rural Tanzania and factors influencing the choice of health care, modern or traditional. Arch Dermatol 1996; 134: 1363–1366. 26 Taplin D, Lansdell I, Allen AM, et al. Prevalence of streptococcal pyoderma in relation to climate and hygiene. Lancet 1973; 1: 501–503. 27 Taplin D, Zaias N, Rebell G. Environmental influences on the microbiology of the skin. Arch Environ Health 1965; 11: 546–550. 28 Marples MJ. The normal flora of the human skin. Br J Dermatol 1969; 89: 2–13. 29 Clarke GHV. Skin diseases in a developing tropical country. Br J Dermatol 1962; 74: 123–126. 30 Alabi GO. Trends in the pattern of skin diseases in Nigeria. Niger Med J 1980; 10: 163–168. 31 Shrank AB, Harman RRM. The incidence of skin diseases in a Nigerian teaching hospital dermatology clinic. Br J Dermatol 1966; 78: 235. 32 Alexis AF, Sergay AB, Taylor SC. Common dermatologic disorders in skin of color: a comparative practice survey. Cutis 2007; 80: 387–394. 33 Federal Ministry of Health. National HIV Seroprevalence Sentinel Survey. Technical Report 2010. Abuja, Nigeria: Federal Ministry of Health, 2010. 34 Gelmett CC, Krowchuk DP, Lucky AW. Acne. In: Schachner LA, Katz SI, eds. Pediatric Dermatology, 3rd edn. Philadelphia, PA: Mosby, 2003: 589–609. 35 Kerkemeyer K. Acne vulgaris. Plast Surg Nurs 2005; 25: 31–35. 36 Mckinley Health Center. Acne. http://www.mckinley.uiuc. edu/handouts/acne/acne.html [Accessed 17 July 2012.] 37 Davis SA, Narahari S, Feldman SR, et al. Top dermatologic conditions in patients of color: an analysis of national representative data. J Drugs Dermatol 2012; 11: 466–473. 38 Hafez M, El-Shamy S. Genetic susceptibility in pityriasis versicolor. Dermatologica 1985; 17: 86–88. 39 He SM, Du WD, Yang S, et al. The genetic epidemiology of tinea versicolor in China. Mycoses 2008; 51: 55–62. 40 George AO, Daramola OOM. Pityriasis versicolor – possible genetic basis, probable transition from commensalism to parasitism and the implication on treatment approach. Afr J Clin Exp Microbiol 2004; 5: 139–147. 41 Halder RM, Grimes PE, McLaurin CI, et al. Incidence of common dermatoses in a predominantly black dermatological practice. Cutis 1983; 32: 388–390. 42 Child FJ, Fuller LC, Higgins EM, et al. A study of the spectrum of skin disease occurring in a black population
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in south-east London. Br J Dermatol 1999; 141: 512– 517. 43 Olasode OA, George AO. Psychosocial problems in patients with vitiligo in Nigeria. Sudan J Dermatol 2008; 5: 51–58. 44 Ayanlowo O, Olumide YM, Akinkugbe A, et al. Characteristics of vitiligo in Lagos, Nigeria. West Afr J Med 2009; 28: 118–121.
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45 Asuquo ME, Ebughe G. Major dermatological malignancies encountered in the University of Calabar Teaching Hospital, Calabar, southern Nigeria. Int J Dermatol 2012; 51(Suppl. 1): 32–36. 46 Onunu AN, Okoduwa C, Eze EU, et al. Kaposis sarcoma in Nigeria. Int J Dermatol 2007; 46: 264–267. 47 Otu AA. Kaposis sarcoma and HTLV-III: a study in Nigerian adult males. J R Soc Med 1986; 79: 510–514.
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This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material.
Skin diseases in Nigeria: the Calabar experience Eshan B. Henshaw1, FWACP, and Olayinka A. Olasode2, FWACP, FACP
1 Dermatology Unit, Department of Medicine, University of Calabar, Calabar, Nigeria, and 2Department of Dermatology and Venereology, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
Abstract Background This paper reports on a 6-year study (April 2006 to April 2012) and a followup of a 9-month baseline survey of the pattern of dermatoses in Calabar, the capital of Cross River State in southern Nigeria. Prior to the time of this study, this region had not benefited from the services of a resident dermatologist for over a century. Methods Data on the age, gender, and diagnoses of 1307 consecutive new patients
Correspondence Eshan B. Henshaw, FWACP Department of Medicine Faculty of Medicine & Dentistry University of Calabar P.M.B. 1115 Calabar Cross River State Nigeria E-mail: [email protected]
attending the relatively new dermatology clinic at the University of Calabar Teaching Hospital during the study period were obtained and analyzed. Most diagnoses were based
Funding: none.
common group (30.4%), followed by infections/infestations (28.9%). A comparison of this study with others from various geopolitical zones of Nigeria revealed some similarities.
Conflicts of interest: none.
Dermatophytosis and acne were consistent reasons for visits to dermatologists in all
on clinical findings but were supported by relevant laboratory investigations and histopathologic examinations when necessary. Results The male : female ratio of patients was 1 : 1.5. The mean standard deviation age of the patients was 27.7 17.2 years (range: 4 weeks to 84 years). A total of 1459 diagnoses were recorded; 143 patients had more than one dermatosis. Diagnoses were broadly divided into 10 groups. Allergic/hypersensitivity diseases represented the most
zones. Conclusions Despite the wide spectrum of dermatoses observed, a small number of diseases account for a sizeable percentage of diagnoses. The pattern of dermatoses in Calabar is similar to that in other parts of the country. Climate and socioeconomic factors are synergistic in causing dermatoses that remain a major cause of morbidity in all age groups and both genders across Nigeria.
Introduction The University of Calabar Teaching Hospital (UCTH) is the only tertiary healthcare institution in Cross River State, one of the 36 states in Nigeria. It is an offshoot of St. Margaret’s Hospital, the first public hospital in Nigeria, built in 1897. It caters to the health needs of the approximately three million citizens of the state,1 as well as those of many others from neighboring states and as far away as Cameroon, a country with which the state shares an international boundary. To the best of the present authors’ knowledge, the hospital has never benefited from the services of a dermatologist, thus leaving the populace with unmet skin healthcare needs for more than a century. This is because a handful of dermatologists (approximately 602) are unevenly distributed across the country to serve a population of about 170 million people.3 The several military coups and the resulting unstable political climate that occurred thereafter had a great negative impact on the progress and distribution of medical subspecialties, including dermatology, in Nigeria.4 There ª 2014 The International Society of Dermatology
are therefore some states in the country without specialist dermatologists. Cross River State is a tropical paradise located in southeast Nigeria, in the Niger delta region (5°450 N, 8°300 E). Like the rest of the country, it has two seasons, which are, respectively, rainy (March–October) and dry (November–February). Its equatorial climate is marked by heavy rainfall, high temperatures, and high humidity. Burdens of skin diseases in some regions of the country have been cataloged and may or may not reflect that seen in this region. Several factors are known to affect the prevalence of skin diseases, including but not limited to genetic, cultural, climatic, and socioeconomic factors. Nigeria is a nation with a curious blend of states and is diverse in several of these factors. The climate in most of the northern part of the country is arid but is tropical or equatorial in the south; the predominant religions and cultures of these regions are also quite diverse. Many of Nigeria’s few dermatologists practice in tertiary institutions, which also deliver secondary-level dermatologic care, making hospital-based studies relevant.4 In addition, International Journal of Dermatology 2015, 54, 319–326
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hospital-based studies give an idea of the spectrum of dermatoses in a locality and may also provide an index against which the findings of community-based studies can be compared. Materials and methods This was a prospective study in which the biodata (including name, age, gender, and occupation) and diagnoses of consecutive new patients attending the dermatology outpatient clinic of UCTH between April 2006 and April 2012 were collected. History taking and physical examinations were conducted by specialist dermatologists. Diagnoses were often clinical but were sometimes supported by relevant laboratory investigations and histopathology. Diagnoses were divided into categories, some of which were further subcategorized for clarity. Data were entered into an Excel spreadsheet, transferred to StataSE 10 (StataCorp LP, College Station, TX, USA) for analysis, and reported with the aid of simple tables showing frequencies and percentages. The results were then compared with those from similar studies conducted in various parts of the country.
Results A total of 1307 patients were seen, among whom 1459 diagnoses were made. There were 143 patients with more than one diagnosis, including eight patients with three and one patient with four diagnoses. There was a female preponderance: the 775 female patients and 532 male patients gave a male : female ratio of 1 : 1.5. This female preponderance was evident to varying degrees in all but two of the various age groups (Table 1). The mean standard deviation age of the study population was 27.7 17.2 years (range: 4 weeks to 84 years). Over 64.3% of persons were in the highly economically active age group of 20–59 years. Table 1 Age and sex distribution of study subjects Sex frequency and ratio Age, years
Male, n
Female, n
M : F ratio
Total, n (%)
0–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 ≥80 Total
111 59 123 91 71 41 24 11 1 532
118 109 249 125 89 51 28 5 1 775
1 1 1 1 1 1 1 2.2 1 1
229 168 372 216 160 92 52 16 2 1307
: : : : : : : : : :
1.1 1.8 2 1.4 1.3 1.2 1.2 1 1 1.5
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(17.5) (12.9) (28.5) (16.5) (12.2) (7.0) (4.0) (1.2) (0.2) (100)
A total of 159 specific skin diseases were diagnosed and classified into main categories; some were further divided into subcategories. The main categories were allergic/hypersensitivity disorders, infections/infestations, disorders of skin appendages, papulosquamous disorders, pigmentary disorders, growths and tumors, disorders of keratinization, genodermatoses, connective tissue disorders, and miscellaneous disorders. Overall, the most common group of dermatoses were allergic/hypersensitivity disorders (30.4%), followed by infections/infestations (28.9%). Dermatitis accounted for the bulk of allergic/ hypersensitivity disorders, and fungal infections constituted the majority of infections/infestations. Acne vulgaris/acneiform eruptions (53.2%) represented the most common adnexal disorder, and pityriasis rosea accounted for 48.3% of papulosquamous disorders. Vitiligo accounted for the bulk of pigmentary disorders (49.5%), and Kaposi’s sarcoma represented the predominant diagnosis in the tumors/growths group (17.7%). Full details of categorizations, frequencies, and percentages are shown in Table 2. Male patients had higher frequencies of both allergic/ hypersensitivity disorders and infections/infestations, whereas all other categories of dermatoses showed a female preponderance. A total of 27 specific dermatoses occurred at frequencies of ≥1%. Seborrheic dermatitis (5.6%), acne/acneiform eruptions (5.1%), and pityriasis versicolor (5.0%) were the three most common. However, when data for tinea infection at all anatomic sites were pooled, tinea infection became the most common dermatosis, accounting for a total of 7.9% of diagnoses. Table 3 shows in descending order of frequency the most common specific dermatoses that accounted for ≥1% of all diagnoses. The study population included 42 persons with a positive laboratory diagnosis of human immunodeficiency virus (HIV) infection; these represented 3.2% of the study population. The most common HIV-related condition was Kaposi’s sarcoma (26.2%), followed by infection with human papillomavirus manifesting as viral warts, condyloma acuminata, and epidermodysplasia verruciformis, or sometimes all three in a single patient. Table 4 shows details of skin disease findings in subjects with HIV infection. Collation of the 10 most common dermatoses in this and each of six other studies5–10 under consideration revealed 20 specific dermatoses. For ease of comparison, all tinea infections were merged and considered as a single entity. Tinea and acne were universal in all studies, and urticaria and atopic dermatitis were seen in all but one of the studies. Table 5 lists these conditions in the various studies5–10 and in descending order of frequency of disease occurrence. ª 2014 The International Society of Dermatology
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Table 2 Frequencies and percentages of skin diseases
Disease Hypersensitivity disorders Dermatitis Seborrheic Atopic Contact Hand and/or foot Cosmetic Lichen simplex chronicus Stasis Pityriasis alba Exfoliative Pompholyx Others Urticaria/drug reaction/pruritus Urticaria/angioedema Papular urticaria Fixed drug eruption Pruritus sine materia Others Infections/infestations Fungal Dermatophytosis Pityriasis versicolor Candidal infections Viral Viral warts Herpes simplex Herpes zoster Epidermodysplasia verruciformis Condyloma acuminata Others Bacterial Pyoderma Furunculosis Hansen’s disease Impetigo Erythrasma Others Parasitic Scabies Onchodermatitis Cutaneous larva migrans Others Adnexal disorders Acne vulgaris/acneiform eruptions Folliculitis Alopecia Acne keloidalis nuchae Others Papulosquamous disorders Pityriasis rosea Psoriasis Lichen planus
Table 2 Continued
Diagnoses, n
Frequency in group (%)
Frequency in all diagnoses (%)
444
–
30.4
82 66 49 22 15 13 12 8 6 5 31
18.5 14.9 11.0 5.0 3.4 2.9 2.7 1.8 1.4 1.1 7.0
5.6 4.5 3.4 1.5 1.0 0.9 0.8 0.6 0.4 0.3 2.1
47 31 27 22 8 421
10.6 7.0 6.1 5.0 1.8 –
3.2 2.1 1.9 1.5 0.6 28.9
114 73 67
27.1 17.3 15.9
7.8 5.0 4.6
36 15 15 10 8 5
8.6 3.6 3.6 2.4 1.9 1.2
2.5 1.0 1.0 0.7 0.6 0.3
8 7 7 6 4 7
1.9 1.7 1.7 1.4 1.0 1.7
0.6 0.5 0.5 0.4 0.3 0.5
21 11 4 3 139 74
5.0 2.6 1.0 0.7 – 53.2
1.4 0.8 0.3 0.2 9.5 5.1
16 14 12 23 120 58 21 15
11.5 10.1 8.6 16.6 – 48.3 17.5 12.5
1.1 1.0 0.8 1.6 8.2 4.0 1.4 1.0
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Diagnoses, n
Disease Pityriasis lichenoides chronic Lichen nitidus Others Pigmentary disorders Vitiligo Post-inflammatory hyperpigmentation Post-inflammatory hypopigmentation Exogenous ochronosis Melasma Nevus Idiopathic guttate hypomelanosis Others Tumors/growths Benign Keloids/hypertrophic scars Dermatosis papulosa nigra Syringoma Seborrheic keratosis Lipoma Epidermal cyst Hemangioma Pyogenic granuloma Others Pre-malignant/malignant Kaposi’s sarcoma Actinic keratosis Non-melanoma skin cancer Cutaneous T cell lymphoma Melanoma Disorders of keratinization Keratoderma Keratosis pilaris Others Genodermatosis Icthyosis Neurofibromatosis Tuberous sclerosis Connective tissue diseases Scleroderma Morphea Systemic lupus erythematosus Discoid lupus erythematosus Others Miscellaneous disorders Granuloma annulare Papular pruritic eruptions Bullous dermatoses Lymphedema Xerosis Others
Frequency in group (%)
Frequency in all diagnoses (%)
12
10.0
0.8
5 9 107 53 11
4.2 7.5 – 49.5 10.3
0.3 0.6 7.3 3.6 0.8
11
10.3
0.8
10 7 7 5
9.4 6.5 6.5 4.7
0.7 0.5 0.5 0.3
3 79
2.8 –
0.2 5.4
10 9 6 5 5 4 4 3 6
12.7 11.4 7.6 6.3 6.3 5.1 5.1 3.8 7.6
0.7 0.6 0.4 0.3 0.3 0.3 0.3 0.2 0.4
14 5 4 2 2 38 15 11 12 22 11 10 1 12 4 2 2
17.7 6.3 5.1 2.5 2.5 – 39.5 28.0 31.6 50.0 45.5 4.5 – 33.3 16.7 16.7
1.0 0.3 0.3 0.1 0.1 2.6 1.0 0.8 0.8 1.5 0.8 0.7 0.1 0.8 0.3 0.1 0.1
2
16.7
0.1
2 77 16 9 7 4 4 37
16.7 – 20.8 11.7 9.1 5.2 5.2 48.1
0.1 5.3 1.1 0.6 0.5 0.3 0.3 2.5
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Table 3 Skin disorders with frequencies of ≥1% Skin disease
Diagnoses, n
Frequency (%)
Seborrheic dermatitis Acne/acneiform eruption Pityriasis versicolor Candidiasis Atopic dermatitis Pityriasis rosea Vitiligo Contact dermatitis Urticaria/angioedema Viral warts Papular urticaria Tinea corporis Tinea pedis Fixed drug eruption Pruritus Psoriasis Scabies Folliculitis Granuloma annulare Tinea capitis Cosmetic dermatoses Herpes simplex Herpes zoster Keratoderma Lichen planus Alopecia Kaposi’s sarcoma
82 74 73 67 66 58 53 49 37 36 31 31 31 27 22 21 21 16 16 16 15 15 15 15 15 14 14
5.6 5.1 5.0 4.6 4.5 4.0 3.6 3.4 2.5 2.5 2.1 2.1 2.1 1.9 1.5 1.4 1.4 1.1 1.1 1.1 1.0 1.0 1.0 1.0 1.0 1.0 1.0
Table 4 Dermatologic conditions in persons with human immunodeficiency virus (HIV) infection (n = 42) Skin disease
Diagnoses, na
Frequency (%)
Kaposi’s sarcoma Human papillomavirus infection Pruritic papular eruption Seborrheic dermatitis Herpes zoster Papular urticaria Tinea Psoriasis Stasis dermatitis Erythema multiforme major Exfoliative dermatitis Eruptive xanthoma Scabies Lichen planus Others
11 5 4 4 3 2 2 2 2 1 1 1 1 1 7
26.2 11.9 9.5 9.5 7.1 4.8 4.8 4.8 4.8 2.4 2.4 2.4 2.4 2.4 16.7
a
Some patients had more than one dermatosis.
Discussion The dermatologic health needs of a population can only be met when they have been identified. Standard tools for identification are epidemiologic surveys, which are often International Journal of Dermatology 2015, 54, 319–326
laborious, expensive, and tend to produce both clinically significant and trivial conditions, as observed in a study conducted in Lambeth,11 in which the point prevalence of all grades of skin disease was 55% but dropped to 22.5% when only skin diseases thought to require medical care were considered. By contrast, hospital-based surveys provide a guide to the spectrum of diseases in a given community. Other than the pilot study,12 of which this is a followup, there has been no attempt to chronicle the pattern of skin diseases in Calabar. The present data showed a female preponderance as observed in similar studies.5,13,14 This may corroborate the general belief that women are more concerned about their physical appearance and thus are more likely to seek intervention, as postulated by ElKhateeb et al.14 By contrast, Nnoruka6 and Onayemi et al.7 recorded a male preponderance, whereas a study by Yahya reported an equal sex ratio.8 It is probable that the reverse or equal sex ratio in studies from the northern part of Nigeria may be attributable to the predominance in the area of the Muslim religion, which encourages purdah (the seclusion of women from the sight of men or strangers, practiced by some Muslims and Hindus), a tradition with a considerable number of female adherents. As a result, fewer women seek medical intervention because there is a high likelihood that they will be examined by male physicians, who predominate in the profession. The most common category of skin diseases included allergic/hypersensitivity disorders, of which dermatitis formed the largest subgroup. This was also indicated in the study by Nnoruka.6 Dermatitis was also judged to account for the most common dermatoses in several other similar studies.8–10,13 By contrast, infections/infestations predominated in comparative studies in Nigeria,5,7 Egypt,14 Sierra Leone,15 Ghana,16 and Tunisia.17 This latter pattern was frequently seen in older studies18–21 and in relatively more recent studies22,23 of skin diseases in rural African populations. Reasons adduced for this include poor socioeconomic conditions, low levels of literacy, and overcrowding. Gibbs,22 working in rural Tanzania, found household density to be the only socioeconomic factor significantly associated with skin diseases, the most prevalent of which was scabies. Drawing from this, Hay and collaborators24 opined that household overcrowding was the most important risk factor for skin disease in developing countries. This may be a valid conclusion, particularly in regions in which scabies is prevalent. However, the most common transmissible skin conditions in many African studies, including both hospital-based5,7,9,13,14 and community-based23,25 studies, are fungal skin infections, among which tinea is often predominant. The warm and humid tropical climate ª 2014 The International Society of Dermatology
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Table 5 Comparison of studies on patterns of skin diseases in Nigeria Frequencies of 10 most common dermatoses in each study
Skin disease
This study (n = 1307) (%)
Nnoruka6 (n = 2871) (%)
Altraide et al.5 (n = 1333) (%)
Ogunbiyi et al.9 (n = 1091) (%)
Tinea Acne/acneiform eruption Urticaria Atopic dermatitis Pityriasis versicolor Contact dermatitis Seborrheic dermatitis Vitiligo Lichen planus Pityriasis rosea Candidiasis Viral warts Papular urticaria Lichen simplex chronicus Acne keloidalis nuchae Scabies Keloid Psoriasis Pseudofolliculitis Bacterial folliculitis
7.8 5.1 3.2 4.5 5.0 3.4 5.6 3.6 – 4.0 4.6 – – – – – – – – –
8.4 6.7 – 4.8 – 5.3 3.3 – 4.8 4.1 – – – – 3.6 – 3.7 – 3.5 –
9.0 4.6 6.5 6.0 5.4 3.0 – 5.3 4.6 3.6 – – 3.6 – – – – – – –
4.5 2.8 4.6 5.8 4.5 – 2.9 5.7 3.4 – – – – – 2.9 4.1 – – – –
constitutes a major predisposing factor to the acquisition of tinea. In hot and humid climates such as that found in Calabar, the rate of colonization by skin surface pathogens is raised, predisposing the subject to the development of infections, with a resultant increase in the prevalence of conditions such as fungal, bacterial, and parasitic skin diseases.26–28 In 1962, Clarke29 noted that ringworm was the most common complaint among Europeans living in the tropics, although this was not the case in Europe despite similarities in the standard of living of both groups. This, however, does not diminish the role played by suboptimal socioeconomic conditions; comparisons of past and recent studies of dermatoses reveal reductions in the frequencies of dermatophyte, pyoderma, and scabetic infections/infestations.6,8,9,18,19,30,31 These reductions are occurring despite the effects of climate change and global warming. Thus both factors are synergistic. The groups of diseases represented by tinea accounted for the most common reason for visits to the clinic, as observed in many other studies in the tropics.5–7,17 The reason for this has already been discussed. Seborrheic dermatitis was the most prevalent specific skin disease in this study, with a total frequency of 5.6%. This is slightly higher than frequencies found in similar studies in the country.6–9 It was, however, identified as the most ª 2014 The International Society of Dermatology
Ukonu & Eze10 (n = 755) (%)
Yahya8 (n = 5982) (%)
Onayemi et al.7 (n = 746) (%)
Frequency of listing
3.2 5.0 2.4 6.1 2.4 7.4 – 3.2 3.2 3.2 – 4.5 – – – – – 2.6 – –
6.0 7.1 3.6 13.8 – 5.8 2.5 – – – 2.8 2.9 3.6 3.0 – – – – – –
13.4 5.1 3.7 – 6.7 – 4.0 – – – 4.9 2.9 – 3.9 – 5.2 – – – 3.1
7/7 7/7 6/7 6/7 5/7 5/7 5/7 4/7 4/7 4/7 3/7 3/7 2/7 2/7 2/7 2/7 1/7 1/7 1/7 1/7
common type of dermatitis and the second most common skin condition in a study carried out by Hartshorne in South Africa,13 who recorded a higher frequency (10.2%). It was also reported among the five most common dermatologic disorders in Black patients in the USA.32 The high frequency of the condition might be assumed to be connected to the high prevalence of HIV in the state,33 but only 4.9% of patients with seborrheic dermatitis were positive for HIV. This frequency is similar to the finding obtained by Yahya in Kaduna8 and higher than that found by Ukonu and Eze,10 who appear to have found no single case of HIV-associated seborrheic dermatitis, but significantly lower than the 50% reported by Nnoruka in Enugu.6 Acne/acneiform eruption was the most common adnexal disorder and the second most common condition in the study, accounting for 5.1% of all diagnoses. It is believed to be the most common skin condition,34,35 and it is estimated that 80–95% of the population will have acne at some point during adolescence.36 The frequency obtained here is similar to that seen in many other studies,5,7,16,17,37 with the exception of one conducted in South Africa,13 where the percentage was higher (16.0%) among subjects of all races combined and more so among Black subjects (17.5%). In the study by Alexis et al.,32 acne was the most common reason for visiting a dermatologist among both Black (28.4%) and International Journal of Dermatology 2015, 54, 319–326
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White (21.0%) patients. Davis et al.37 also found it to be the most common diagnosis for African-American patients in dermatology, whereas actinic keratosis was the most frequent diagnosis in White subjects. Pityriasis versicolor ranked as the third most common skin condition, with a frequency (5.0%) similar to those obtained by Altraide et al.5 (5.4%) and Ogunbiyi et al.9 (4.4%). It was found to be the most common fungal infection in Egypt,14 where a frequency of 7.7% was recorded, similar to the 6.7% obtained by Onayemi et al.7 This condition flourishes in hot and humid climates, such as those in which all of these studies were conducted, and is also purported to have a genetic basis.38–40 This may be confirmed by the fact that it ranked among the 12 most common skin diseases in Black subjects in Washington, USA,41 and in London, UK,42 despite their being resident in hugely temperate regions. Among the various disorders of pigmentation, vitiligo was the most prevalent. Its frequency of 3.6% in the present population is similar to that found in many other studies in Nigeria.5,9,10 Although it is mostly asymptomatic, vitiligo imposes a great deal of psychological stress on sufferers on account of its conspicuousness (especially when contrasted with Black skin) and because it is often erroneously considered to be leprosy by members of the public.43,44 Kaposi’s sarcoma was the most common tumor/growth in this study, accounting for 17.7% of this category of dermatoses and 63.3% of the total number of malignancies. It had an overall frequency of 1.0% but a frequency of 26.2% among those diagnosed with HIV infection and thus featured as the most common HIV-related dermatosis. Pruritic papular eruption, seborrheic dermatitis, and Kaposi’s sarcoma have been judged to be the most common HIV-related conditions in a number of studies in Nigeria.5,6,9,10 In a 10-year study of 162 patients with histologic diagnoses of dermatologic malignancies in UCTH, Asuquo and Ebughe45 reported Kaposi’s sarcoma as the second most common skin malignancy (after squamous cell carcinoma), with a frequency of 20.4%. This rising trend was also observed by Onunu et al.46 This increase may be explained by the growing number of HIV and acquired immunodeficiency syndrome (AIDS) infections in sub-Saharan Africa. However, it is important to note that prior to the increase in the prevalence of HIV and AIDS in sub-Saharan Africa, Kaposi’s sarcoma was already highly endemic in Cross River State,47 and thus the high frequency of this condition identified in this study in comparison with others5,6,14 may indeed reflect the combined effects of the endemicity of Kaposi’s sarcoma herpes virus (KSHV) and the HIV/AIDS virus epidemic. International Journal of Dermatology 2015, 54, 319–326
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Connective tissue diseases were relatively few and were found in only 12 (0.9%) patients. The most common was scleroderma, which accounted for half of these cases; within the spectrum of scleroderma, systemic sclerosis accounted for two-thirds of cases and morphea (localized) for one-third. This contrasts with the findings of most other studies in Nigeria,6,8,9 in which discoid lupus erythematosus is the most common connective tissue disorder reported. The reason for the relatively larger number of patients with scleroderma in this region is uncertain. A comparison of the findings of this study with the patterns demonstrated in six other studies carried out in various geopolitical zones of the country (south–south5,10 south–east,6 north–west,7 north–central,8 and south– west9) showed some similarities. Tinea and acne were among the 10 most common dermatoses in all studies. Based on the analysis of the frequency of disease occurrence, the 10 most common skin diseases in Nigeria would therefore include tinea, acne, urticaria, atopic dermatitis, pityriasis versicolor, contact dermatitis, seborrheic dermatitis, vitiligo, lichen planus, and pityriasis rosea. This is based on the listing of these conditions among the 10 most common dermatoses reported in no fewer than four of the seven studies considered (i.e. over half of the studies) as shown in Table 5. Conclusions Only a handful of dermatoses account for a sizeable percentage of diagnoses, most of which are treatable. The pattern of dermatoses in Calabar is similar to those in other parts of the country. The 10 most common skin conditions in Nigeria are dermatophytosis, acne, urticaria, atopic dermatitis, pityriasis versicolor, contact dermatitis, seborrheic dermatitis, vitiligo, lichen planus, and pityriasis rosea. Knowledge of the common dermatoses in our environment will facilitate interventions at various levels. Firstly, the training of general practitioners and community health workers will ameliorate the negative impact of the dearth of dermatologists; secondly, relevant government agencies can make drugs and other treatment modalities required for the management of these conditions accessible, and, thirdly, dermatologists can channel their energies into research to improve understanding of these indigenous dermatoses and spur the development of novel diagnostic and treatment modalities.
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