Spectrum of winter dermatoses in rural Yemen

Surveys that have been carried out to determine the prevalence of skin diseases in rural Yemen are scarce or not available.


Introduction
Skin diseases are a common problem in developing countries particularly in rural communities. 1 The World Bank Report 2002 estimated skin disease cases as more than 600 million in less developed countries. 2 Up to 21-87% of the population may be affected by some type of skin problem, depending on the locale. Dermatoses can have a profound effect on both the individual and the community. They are responsible for considerable disability. Therefore, the WHO has stressed the need to address skin disease in developing countries. [3][4][5][6] There are more than 3000 known diseases of the skin. 7 The pattern of skin diseases varies from one country to another and across different parts of the same country. 8 Many regional factors, such as socioeconomic status, personal habits, cultural differences, climate, and heredity, influence the prevalence of skin diseases. 9 Yemen is considered a rural community, with 74% of the population living in rural settlements, and many of them spread over a large territory with insufficient accessibility. Only 50% of the total population and 30% of the rural population has access to public health services. 3 The WHO estimates that 80% of the populations of most developing countries rely on traditional medicine as their primary source of healthcare. 10 Traditional medicine still plays an important role in Yemen, and in many rural areas, it is the only medical assistance available. 11 Surveys that have been carried out to determine the prevalence of skin diseases in rural populations in Yemen are scarce or not available. 12

Objective
To the author's knowledge, no study to date in the English language literature has investigated the seasonal prevalence of skin diseases in Yemen. This study was set up to investigate the spectrum and relative magnitude of common winter dermatoses in rural Yemeni communities. Patients attending our clinic were either by self-referral or referred from primary care units in remote villages. They were managed by the author, and diagnoses were based on history, examination, microscopy, dermoscopy, and Wood's light, but further laboratory investigations were used to confirm difficult diagnoses.
Study variables included age, sex, disease group, subgroup, and disease name. Patients were distributed into nine age groups, and skin conditions were classified into 13 principal groups according to the etiologic and morphological criteria (author's classification). Selected records were analyzed using a Microsoft Access database, and the frequency of each variable was calculated.

Results
Seven hundred patients with 730 diseases were reported in this study; some presented with more than one complaint.

Discussion
This study is the first describing the spectrum of winter skin disorders in Yemen and the second in the country that discusses the spectrum of skin dermatoses in Yemen as a whole; the first study was conducted by Khatri 12 at the Dermatology Clinic of Saudi Hospital at Hajjah and discussed the spectrum of skin diseases in Hajjah and the adjacent region (published in 2004).
The current study was conducted at the dermatology clinic of the Al-Helal Specialized Hospital, Radaa, which has served the referral dermatology unit in Al Bayda because it was difficult to analyze and computerize a larger number of those patients' records. Summer dermatoses will be studied in a future study.
This study has documented the current spectrum and relative magnitude of winter dermatoses in a rural community of central Yemen but also reflects the pattern of common skin disorders in the Yemeni rural population as a whole.
The Al Bayda Governorate (11,193 km 2 area and 695,000 inhabitants 13 ) is located within the central region of Yemen, topping the inner (central) highlands, which are more like a plateau of about 2000-3200 m, the mean temperatures range from below 15°C in winter to 25°C in summer. The number of days and nights that are considered hot under current climate conditions is projected to increase, and the projected rate of warming is more rapid in these areas more than in areas close to the coast. 14 As in many other studies from developing countries such as Saudi Arabia, 15 Pakistan, 16 Nepal, 17 Kenya, 18 and India, 19 females were more vulnerable than males, and the current study indicated that females attended the dermatology clinic more frequently than males; this was considerably higher than that reported from Hajjah, 10 and adults >18-40 years of age (46.57%) than other age groups. The age-related finding is also endorsed by a study in Hajjah 10 (approximately 54% of the patients were in the 11-30 year age group) and Pakistan (the most commonly affected age group was between 21 and 30 years). 20 The author refers that to excess of women in   Al-Kamel Winter dermatoses in Yemen Report villages compared to men, in addition to social, occupational, habitual, psychological, and environmental factors related to the central Yemen rural population. Higher than proportions reported by other studies conducted in Hajjah (northern Yemen), 11 neighboring Saudi Arabia, 21,22 Qatar, 23 and Iraq, 24 the spectrum of winter dermatoses in the current study revealed that the dermatitis, eczematous, and allergic disorders group alone comprised more than one-third (38.49%) of the 730 skin diseases diagnosed in this study, and contact dermatitis was the most commonly encountered condition in the dermatitis, eczematous, and allergic disorders group (27.76%), ranked as the first in the top 10 most prevalent disorders (10.68%). In comparison, Khatri, reported that the dermatitis and eczematous disorders group comprised the largest number of patients (27.2%), and contact dermatitis was the second common subgroup with an overall prevalence of 6.4% in the above-mentioned study in north-west Yemen. 12 The largest number of cases of occupational skin diseases was among construction workers, although the highest incidence has been reported in agriculture workers. 25 In contrast, the author considers contact dermatitis (irritant and allergic) as the most common occupational dermatoses in the Al Bayda Governorate, referring to the intense use of illegal agricultural pesticides particularly in khat shrub cultivation (the gross domestic product of the agricultural sector), 26 the cold climate, prolonged contact of housewives to water, soap powder detergents, and rubber products (e.g., gloves and footwear), commonly used dyes particularly in hair coloring products and henna, cheap cosmetics, widely-used popular treatment regimens, cement, and electric generator fuel.
Atopic dermatitis was the second most commonly encountered in the dermatitis, eczematous, and allergic disorders subgroup (14.60%) in this study and ranked as fifth in the top 10 most prevalent disorders (5.62%); considerably higher than that reported from Hajjah (2.6%). 10 There has been a threefold increase in patients with atopic dermatitis in the past 30 years, but the reason for this is not clear, and the hygiene hypothesis seems to be the best explanation. 27 Photodermatitis (which is either allergic or toxic) was the third most commonly encountered condition in the dermatitis, eczematous, and allergic disorders group (11.03%), ranked as ninth in the top 10 most prevalent skin disorders (4.25%), and children (>2-12 years) were more vulnerable to photodermatitis and sunburns; which was also considerably higher than that reported from Hajjah (1.5%). 10 The skin infections and infestations group (20%) was the second most common group; comparable findings were reported from northern Yemen, 11 where skin infec-tions were the second most common group (24.2%) and the fungal infections subgroup was the first most common skin infection with an overall prevalence rate of 5.75%, while in the current study viral infections were the most common skin infections (28.77%) and ranked as the fourth in the top 10 most prevalent disorders (5.75%). A comparable study conducted at the dermatology clinic at King Khaled Hospital in Al-Majmaah (Saudi Arabia) 14 has reported that viral infection was the most prevalent infectious disorder, as found in the current study.
The current study revealed that leishmaniasis was the most common parasitic infestation (76.92%), the first most prevalent infectious disease (20.55%), with an overall prevalence of 4.11% among all detected skin diseases, with an expected higher occurrence in summer and autumn; an interesting finding, which was higher than that reported from Hajjah of northern Yemen (0.9%), 10 and nearby Saudi Arabia. 14 The author has previously reported 152 cases of leishmaniasis from central Yemen, detected within the five months of spring and summer 2013, 28 which reflect the magnitude of leishmaniasis disease in that region. Climate change and rising temperature may explain the high incidence of leishmaniasis in a cold season, as in our study. The magnitude of leishmaniasis disease is alarming in central Yemen and the country as a whole.
The current study revealed that the pigmentary disorders group was the third most common winter disorders group (13.70%), and comparative data have been reported from Qassim of Saudi Arabia. Hyperpigmentations were the most common in the pigmentary disorder subgroup (64%), ranked as second in the top 10 most prevalent disorders (8.77%), and chloasma and melasma were the commonest hyperpigmentary dermatoses, which is higher than that reported from comparable regions and countries. 10,15 The author suggests that occupational, psychological, and environmental factors are responsible. Although hyperpigmentations were very common during the winter season in rural Yemen, as in this study, higher rates are expected during the summer season.

Conclusion
This survey has documented spectrum and relative magnitude of winter dermatoses in a rural community of central Yemen but also reflects the pattern of common skin disorders in the rural Yemeni population and the country as a whole.
Females and adults are predominantly the most affected groups. Dermatitis, eczematous, and allergic disorders, followed by skin infections and infestations, and pigmentary disorders are the commonest skin disorder groups. Contact dermatitis (allergic and irritant), followed by hyperpigmentations, acne, viral infections, atopic dermatitis, and parasitic infestations topped the list of the most prevalent skin disorders. Leishmaniasis is the most prevalent skin infectious disease, and climate, occupational, social, cultural, psychological, and environmental factors contribute greatly to that situation. It is likely that this survey underestimates the burden of skin disease among rural communities, and such statistics can form an important basis for community-based health policies.