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Mwageni N, van Wijk R, Daba F, Mamo E, Debelo K, Jansen B, Schoenmakers A, van Hees CLM, Kasang C, Mieras L, Mshana SE. The NLR SkinApp: Testing a Supporting mHealth Tool for Frontline Health Workers Performing Skin Screening in Ethiopia and Tanzania. Trop Med Infect Dis 2024; 9:18. [PMID: 38251215 PMCID: PMC10819267 DOI: 10.3390/tropicalmed9010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/14/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024] Open
Abstract
Background: The prevalence of skin diseases such as leprosy, and limited dermatological knowledge among frontline health workers (FHWs) in rural areas of Sub-Saharan Africa, led to the development of the NLR SkinApp: a mobile application (app) that supports FHWs to promptly diagnose and treat, or suspect and refer patients with skin diseases. The app includes common skin diseases, neglected tropical skin diseases (skin NTDs) such as leprosy, and HIV/AIDS-related skin conditions. This study aimed to test the supporting role of the NLR SkinApp by examining the diagnostic accuracy of its third edition. Methods: A cross-sectional study was conducted in East Hararghe, Ethiopia, as well as the Mwanza and Morogoro region, Tanzania, in 2018-2019. Diagnostic accuracy was measured against a diagnosis confirmed by two dermatologists/dermatological medical experts (reference standard) in terms of sensitivity, specificity, positive predictive value, and negative predictive value. The potential negative effect of an incorrect management recommendation was expressed on a scale of one to four. Results: A total of 443 patients with suspected skin conditions were included. The FHWs using the NLR SkinApp diagnosed 45% of the patients accurately. The values of the sensitivity of the FHWs using the NLR SkinApp in determining the correct diagnosis ranged from 23% for HIV/AIDS-related skin conditions to 76.9% for eczema, and the specificity from 69.6% for eczema to 99.3% for tinea capitis/corporis. The inter-rater reliability among the FHWs for the diagnoses made, expressed as the percent agreement, was 58% compared to 96% among the dermatologists. Of the management recommendations given on the basis of incorrect diagnoses, around one-third could have a potential negative effect. Conclusions: The results for diagnosing eczema are encouraging, demonstrating the potential contribution of the NLR SkinApp to dermatological and leprosy care by FHWs. Further studies with a bigger sample size and comparing FHWs with and without using the NLR SkinApp are needed to obtain a better understanding of the added value of the NLR SkinApp as a mobile health (mHealth) tool in supporting FHWs to diagnose and treat skin diseases.
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Affiliation(s)
- Nelly Mwageni
- Department of Microbiology, Catholic University of Health and Allied Sciences, Mwanza 33102, Tanzania; (N.M.)
| | - Robin van Wijk
- NLR/Leprastichting, 1097 DN Amsterdam, The Netherlands (A.S.); (L.M.)
- Department of Public Health, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Fufa Daba
- Deutsche Lepra-und Tuberkulosehilfe, Addis Ababa 1165, Ethiopia; (F.D.); (K.D.)
| | - Ephrem Mamo
- Armauer Hansen Research Institute, Addis Ababa 1005, Ethiopia;
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa 1176, Ethiopia
| | - Kitesa Debelo
- Deutsche Lepra-und Tuberkulosehilfe, Addis Ababa 1165, Ethiopia; (F.D.); (K.D.)
| | - Benita Jansen
- NLR/Leprastichting, 1097 DN Amsterdam, The Netherlands (A.S.); (L.M.)
| | - Anne Schoenmakers
- NLR/Leprastichting, 1097 DN Amsterdam, The Netherlands (A.S.); (L.M.)
- Department of Public Health, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Colette L. M. van Hees
- Department of Dermatology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Christa Kasang
- Deutsche Lepra-und Tuberkulosehilfe, 97080 Würzburg, Germany;
| | - Liesbeth Mieras
- NLR/Leprastichting, 1097 DN Amsterdam, The Netherlands (A.S.); (L.M.)
| | - Stephen E. Mshana
- Department of Microbiology, Catholic University of Health and Allied Sciences, Mwanza 33102, Tanzania; (N.M.)
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Li Q, Patrick MT, Sreeskandarajan S, Kang J, Kahlenberg JM, Gudjonsson JE, He Z, Tsoi LC. Large-scale epidemiological analysis of common skin diseases to identify shared and unique comorbidities and demographic factors. Front Immunol 2024; 14:1309549. [PMID: 38259463 PMCID: PMC10800546 DOI: 10.3389/fimmu.2023.1309549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Introduction The utilization of large-scale claims databases has greatly improved the management, accessibility, and integration of extensive medical data. However, its potential for systematically identifying comorbidities in the context of skin diseases remains unexplored. Methods This study aims to assess the capability of a comprehensive claims database in identifying comorbidities linked to 14 specific skin and skin-related conditions and examining temporal changes in their association patterns. This study employed a retrospective case-control cohort design utilizing 13 million skin/skin-related patients and 2 million randomly sampled controls from Optum's de-identified Clinformatics® Data Mart Database spanning the period from 2001 to 2018. A broad spectrum of comorbidities encompassing cancer, diabetes, respiratory, mental, immunity, gastrointestinal, and cardiovascular conditions were examined for each of the 14 skin and skin-related disorders in the study. Results Using the established type-2 diabetes (T2D) and psoriasis comorbidity as example, we demonstrated the association is significant (P-values<1x10-15) and stable across years (OR=1.15-1.31). Analysis of the 2014-2018 data reveals that celiac disease, Crohn's disease, and ulcerative colitis exhibit the strongest associations with the 14 skin/skin-related conditions. Systemic lupus erythematosus (SLE), leprosy, and hidradenitis suppurativa show the strongest associations with 30 different comorbidities. Particularly notable associations include Crohn's disease with leprosy (odds ratio [OR]=6.60, 95% confidence interval [CI]: 3.09-14.08), primary biliary cirrhosis with SLE (OR=6.07, 95% CI: 4.93-7.46), and celiac disease with SLE (OR=6.06, 95% CI: 5.49-6.69). In addition, changes in associations were observed over time. For instance, the association between atopic dermatitis and lung cancer demonstrates a marked decrease over the past decade, with the odds ratio decreasing from 1.75 (95% CI: 1.47-2.07) to 1.02 (95% CI: 0.97-1.07). The identification of skin-associated comorbidities contributes to individualized healthcare and improved clinical management, while also enhancing our understanding of shared pathophysiology. Moreover, tracking these associations over time aids in evaluating the progression of clinical diagnosis and treatment. Discussion The findings highlight the potential of utilizing comprehensive claims databases in advancing research and improving patient care in dermatology.
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Affiliation(s)
- Qinmengge Li
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - Matthew T Patrick
- Department of Dermatology, University of Michigan, Ann Arbor, MI, United States
| | - Sutharzan Sreeskandarajan
- The Center for Autoimmune Genomics and Etiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Jian Kang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - J Michelle Kahlenberg
- Department of Dermatology, University of Michigan, Ann Arbor, MI, United States
- Rheumatology, Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Johann E Gudjonsson
- Department of Dermatology, University of Michigan, Ann Arbor, MI, United States
| | - Zhi He
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
| | - Lam C Tsoi
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, United States
- Department of Dermatology, University of Michigan, Ann Arbor, MI, United States
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, United States
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Emanghe UE, Imalele EE, Ogban GI, Owai PA, Abraka BA. Awareness and knowledge of scabies and ringworm among parents of school-age children in Calabar, Cross River State, Nigeria: Implications for prevention of superficial skin infestations. Ann Afr Med 2024; 23:62-69. [PMID: 38358173 PMCID: PMC10922176 DOI: 10.4103/aam.aam_82_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/30/2023] [Accepted: 10/31/2023] [Indexed: 02/16/2024] Open
Abstract
Context Risk factors for the persistence of superficial skin infestations are prevalent in humid tropical environments, which are favorable for breeding of the causative vector mite Sarcoptes scabiei (ectoparasite) and dermatophyte fungi. Aim This study aimed at assessing the awareness and knowledge of childhood scabies and ringworm infestations among parents in Calabar, a highly humid rainforest tropical environment. Settings and Design Cross-sectional study design and systematic random sampling were used to recruit school-age children in selected primary schools in Calabar. Materials and Methods Researcher-driven administration of a structured questionnaire was conducted to obtain quantitative data from parents of recruited children. Statistical Analysis Used : Chi-square was used to assess factors associated with ever hearing or seeing scabies and ringworm infestations. Statistical significance was set at P < 0.05. Results One hundred and eighty-two (56.7%) and 218 (67.9%) of the respondents had heard of or seen scabies and ringworm infestation. Among respondents that were aware of scabies, 53.3% knew of the cause, 50.5% were aware of the risk factors while 68.1% and 78.0% knew their treatment and prevention, respectively; 98.6%, 60.6%, 76.6%, and 80.7% of respondents knew the cause, risk factors, treatment, and prevention of ringworm infestation, respectively. Fathers with at least secondary school literacy level and sharing beds were significantly associated with awareness of scabies. Conclusion There is a suboptimal level of awareness and knowledge of two of the most common superficial skin infestations among parents of primary school children in the study setting. There is a need to redouble our effort at sensitization of parents toward improved awareness of these common infestations.
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Affiliation(s)
- Ubleni Ettah Emanghe
- Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Cross River State, Nigeria
| | - Edema Enogiomwan Imalele
- Department of Zoology and Environmental Biology, University of Calabar, Calabar, Cross River State, Nigeria
| | - Godwin Ibitham Ogban
- Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Cross River State, Nigeria
| | - Promise Akugom Owai
- Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Cross River State, Nigeria
| | - Bode Akashie Abraka
- Department of Medical Microbiology and Parasitology, University of Calabar, Calabar, Cross River State, Nigeria
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Yotsu RR, Fuller LC, Murdoch ME, van Brakel WH, Revankar C, Barogui MYT, Postigo JAR, Dagne DA, Asiedu K, Hay RJ. A global call for action to tackle skin-related neglected tropical diseases (skin NTDs) through integration: An ambitious step change. PLoS Negl Trop Dis 2023; 17:e0011357. [PMID: 37319139 PMCID: PMC10270348 DOI: 10.1371/journal.pntd.0011357] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
On 8 June 2022, the World Health Organization (WHO) released pivotal guidance, "Ending the neglect to attain the Sustainable Development Goals: A strategic framework for integrated control and management of skin-related neglected tropical diseases." Skin-related neglected tropical diseases, or skin NTDs, comprise a group of NTDs that produce signs and symptoms on the skin and include at least 9 diseases or disease groups. Moving away from disease-specific approaches, it is anticipated that synergies will be identified and integrated building on this shared feature, where possible, to achieve a greater health impact. This paper intends to draw attention to the prospects created by this scheme. The framework is a key basis for a proposal produced by WHO dedicated to skin NTD integration and describes the practical opportunities for this evolving strategy. It underlines the wider health benefits that will follow, thus working towards Universal Health Coverage and skin health for all.
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Affiliation(s)
- Rie R. Yotsu
- Tulane School of Public Health and Tropical Medicine, New Orleans, Louisiana, United States of America
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
- Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan
| | - L. Claire Fuller
- International Foundation for Dermatology, London, United Kingdom
- Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Michele E. Murdoch
- Department of Dermatology, West Herts Teaching Hospitals NHS Trust, Watford General Hospital, Watford, United Kingdom
| | | | - Chandrakant Revankar
- Elimination of NTDs (Independent), North Brunswick, New Jersey, United States of America
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Deng L, Fan Z, Chen B, Zhai H, He H, He C, Sun Y, Wang Y, Ma H. A Dual-Modality Imaging Method Based on Polarimetry and Second Harmonic Generation for Characterization and Evaluation of Skin Tissue Structures. Int J Mol Sci 2023; 24:ijms24044206. [PMID: 36835613 PMCID: PMC9966533 DOI: 10.3390/ijms24044206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
The characterization and evaluation of skin tissue structures are crucial for dermatological applications. Recently, Mueller matrix polarimetry and second harmonic generation microscopy have been widely used in skin tissue imaging due to their unique advantages. However, the features of layered skin tissue structures are too complicated to use a single imaging modality for achieving a comprehensive evaluation. In this study, we propose a dual-modality imaging method combining Mueller matrix polarimetry and second harmonic generation microscopy for quantitative characterization of skin tissue structures. It is demonstrated that the dual-modality method can well divide the mouse tail skin tissue specimens' images into three layers of stratum corneum, epidermis, and dermis. Then, to quantitatively analyze the structural features of different skin layers, the gray level co-occurrence matrix is adopted to provide various evaluating parameters after the image segmentations. Finally, to quantitatively measure the structural differences between damaged and normal skin areas, an index named Q-Health is defined based on cosine similarity and the gray-level co-occurrence matrix parameters of imaging results. The experiments confirm the effectiveness of the dual-modality imaging parameters for skin tissue structure discrimination and assessment. It shows the potential of the proposed method for dermatological practices and lays the foundation for further, in-depth evaluation of the health status of human skin.
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Affiliation(s)
- Liangyu Deng
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
| | - Zhipeng Fan
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
| | - Binguo Chen
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
- Department of Biomedical Engineering, Tsinghua University, Beijing 100084, China
| | - Haoyu Zhai
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
- Department of Biomedical Engineering, Tsinghua University, Beijing 100084, China
| | - Honghui He
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
- Correspondence: (H.H.); (C.H.)
| | - Chao He
- Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK
- Correspondence: (H.H.); (C.H.)
| | - Yanan Sun
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yi Wang
- Experimental Research Center, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Hui Ma
- Guangdong Research Center of Polarization Imaging and Measurement Engineering Technology, Shenzhen Key Laboratory for Minimal Invasive Medical Technologies, Institute of Biopharmaceutical and Health Engineering, Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen 518055, China
- Department of Physics, Tsinghua University, Beijing 100084, China
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Tiwari R, Amien A, Visser WI, Chikte U. Counting dermatologists in South Africa: number, distribution and requirement. Br J Dermatol 2022; 187:248-250. [PMID: 35084741 PMCID: PMC9543359 DOI: 10.1111/bjd.21036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/18/2022] [Accepted: 01/22/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Ritika Tiwari
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - Aqeelah Amien
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - Willem I Visser
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - Usuf Chikte
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town
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7
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Augustin M, Garbe C, Girbig G, Strömer K, Kirsten N. [Epidemiology of scabies in Germany: multisource analysis of primary and secondary data]. Hautarzt 2021; 73:61-66. [PMID: 34605943 PMCID: PMC8755673 DOI: 10.1007/s00105-021-04895-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Scabies is one of the most common and, in terms of burden of disease, one of the most significant skin diseases worldwide. In Germany, an increase in cases is currently being discussed, for which reliable data have been lacking until now. OBJECTIVES The goal is to clarify the prevalence and treatment of scabies in Germany. MATERIALS AND METHODS Multisource analyses of treatment data from a nationwide statutory health insurance company, the Federal Statistical Office and company skin screenings. RESULTS In Germany, the number of cases of scabies has been rising since 2009 and especially since 2014. In the outpatient setting, there was an increase of 52.8% to around 128,000 treatment cases between 2010 and 2015. Currently, more than 11,000 inpatient cases are documented annually in Germany with scabies as the main diagnosis (ICD-10 B86). The increase between 2010 and 2016 was about 306%. The main outpatient specialist groups providing care are dermatologists and general practitioners, while in the inpatient sector treatment is provided by departments of dermatology, paediatrics and internal medicine. CONCLUSION Due to the aforementioned development of prevalence and incidence, the need for care will remain at a high level in the future, which suggests an increased need for education and early detection.
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Affiliation(s)
- Matthias Augustin
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Claudia Garbe
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland
| | - Gefion Girbig
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland
| | - Klaus Strömer
- Berufsverband der Deutschen Dermatologen e. V. (BVDD), Robert-Koch-Platz 7, 10115, Berlin, Deutschland
| | - Natalia Kirsten
- Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Hamburg-Eppendorf (UKE), Martinistr. 52, 20246, Hamburg, Deutschland
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8
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Natural Products and Skin Diseases. Molecules 2021; 26:molecules26154489. [PMID: 34361642 PMCID: PMC8348257 DOI: 10.3390/molecules26154489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 12/23/2022] Open
Abstract
The skin is the largest multifunctional organ in the human body, serving as an excellent barrier against chemical and biological hazards [...].
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9
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Abstract
This article analyzes various dermatology training programs in Africa by region and country. There is a paucity of dermatologists for the African population. West Africa has a harmonized curriculum, adopted by some anglophone and most francophone countries in the region. Algeria, Egypt, Ethiopia, Morocco, South Africa, Sudan, Tanzania, and Tunisia have national curricula. In the remaining countries for which information is available and programs exist, a university-specific curriculum is followed. Of the 55 countries in Africa, there is no opportunity for dermatology specialization in 30. Local and ethnic skin curricula content appropriate for Africa, developed through continent-wide collaborations, are recommended.
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Affiliation(s)
- Anisa Mosam
- Department of Dermatology, University of KwaZulu-Natal, Durban, South Africa Rm 327, 3rd Floor, Main Building, Durban, South Africa; Nelson R Mandela School of Medicine, 719 Umbilo Rd, 4013, Durban, South Africa.
| | - Gail Todd
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa
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10
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Himed S, Muddasani S, Fleischer A. Epidemiology of viral skin disease: An increased burden in childhood and a correlation with atopic dermatitis and gross domestic product. JOURNAL OF DERMATOLOGY & DERMATOLOGIC SURGERY 2021. [DOI: 10.4103/jdds.jdds_23_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Continuing Dermatology Education for Rural Physician Assistants in Ghana: An Assessment of Needs and Effectiveness. J Physician Assist Educ 2019; 29:19-24. [PMID: 29461452 DOI: 10.1097/jpa.0000000000000188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the effectiveness of lectures for continuing medical education (CME) in dermatology in a global health setting and to determine provider and patient demographics of physician assistants (PAs) practicing in rural Ghana. METHODS Physician assistants from Ghana who attended dermatology lectures at the International Seminar for Physician Assistants in 2011 or 2014 were included in this study. Surveys were administered to participants to determine dermatology resource availability, commonly encountered skin diseases, and management practices. Quizzes were administered before and after CME dermatology lectures to assess short-term retention of lecture material. RESULTS In all, 353 PAs participated in this study. Physician assistants reported seeing an average of 55 patients per day. The most commonly seen skin diseases were infections, with antifungals and antibiotics being the most commonly prescribed medications. Dermatology-related complaints represented 9.5% of total clinic visits. Among practicing PAs, 23.2% reported having internet access. A total of 332 PAs completed the quizzes, and a statistically significant increase in test scores was noted in postlecture quizzes. CONCLUSIONS This study reinforces the importance of dermatology education for PAs practicing in rural areas of Ghana and lends insight to critical topics for dermatology curriculum development. In addition, the increase in test scores after CME sessions suggests that lectures are an effective tool for short-term retention of dermatology-related topics. Our study indicates that as the need for health workers increases globally and a paradigm shift away from the traditional physician model of care occurs, dermatology training of PAs is not only important but also achievable.
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Wlodek C, Va'a-Fuimaono H, Ekeroma A. Dermatological conditions encountered in The Independent State of Samoa and an exploration of possible strategies to manage dermatological health-care needs in this resource-poor setting. Australas J Dermatol 2019; 61:51-53. [PMID: 31319438 DOI: 10.1111/ajd.13118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 06/22/2019] [Indexed: 11/28/2022]
Abstract
This report adds to the limited existing literature concerning dermatoses in Samoa. Conditions encountered during a 4-day private clinic are reported. Amongst the 75 patients reviewed, eczema was the most frequent condition diagnosed. This was followed by infective dermatoses particularly pityriasis versicolor and tinea infections. Reassuringly, in 97% of cases, suitable medications were available locally.
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Affiliation(s)
- Christina Wlodek
- Department of Dermatology, Waikato Hospital, Hamilton, New Zealand
| | | | - Alec Ekeroma
- School of Medicine, National University of Samoa, Apia, Samoa
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13
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Dos Santos DS, Barreto RDSS, Serafini MR, Gouveia DN, Marques RS, Nascimento LDC, Nascimento JDC, Guimarães AG. Phytomedicines containing Matricaria species for the treatment of skin diseases: A biotechnological approach. Fitoterapia 2019; 138:104267. [PMID: 31319107 DOI: 10.1016/j.fitote.2019.104267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 01/09/2023]
Abstract
Skin diseases have a notable impact on the life of the affected and in their health conditions. In order to allow a more effective and economical treatment for such disorders, new therapeutic approaches have been continuously investigated. Due to its high therapeutic and phytochemical potential, Matricaria species emerges as a pleasant alternative, since it is an important source of bioactive secondary metabolites suitable for the treatment of varied skin diseases. Therefore, this review aimed to catalog inventions that have used Matricaria species as the active component for skin disease treatment in order to assess the status of the technological development of the fitomedicines. For this, a search of patents was performed in four specialized patent database, which have reported the discovery of pharmaceutical bioproducts that used Matricaria species in its composition for skin treatment. Therefore, it is possible to notice that the pharmaceutical industry has driven efforts and investment to produce medicines for the dermatopathies, using species of this genus as an active principle. Besides, a trend of growth has been identified for the last years, which is accompanied by the continuous publication of scientific articles on the subject. It is known that a long journey is traversed between the scientific findings and their applications in the pharmaceutical market, creating the perspective that new Matricaria-based medicines may reach the pharmaceutical market in the coming years.
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Affiliation(s)
- Damaris Silva Dos Santos
- Programa de Pós-graduação em Ciências Aplicadas à Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil
| | - Rosana de Souza Siqueira Barreto
- Programa de Pós-graduação em Ciências Aplicadas à Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil; Departmento de Educação em Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil
| | - Mairim Russo Serafini
- Departmento de Farmácia, Universidade Federal de Sergipe, São Cristóvão, Sergipe, Brazil
| | - Daniele Nascimento Gouveia
- Programa de Pós-graduação em Ciências Aplicadas à Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil
| | - Raquel Souza Marques
- Programa de Pós-graduação em Ciências Odontológicas, Universidade do Estado de São Paulo, Araraquara, São Paulo, Brazil
| | | | | | - Adriana Gibara Guimarães
- Programa de Pós-graduação em Ciências Aplicadas à Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil; Departmento de Educação em Saúde, Universidade Federal de Sergipe, Lagarto, Sergipe, Brazil.
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Mieras LF, Taal AT, Post EB, Ndeve AGZ, van Hees CLM. The Development of a Mobile Application to Support Peripheral Health Workers to Diagnose and Treat People with Skin Diseases in Resource-Poor Settings. Trop Med Infect Dis 2018; 3:E102. [PMID: 30274498 PMCID: PMC6160956 DOI: 10.3390/tropicalmed3030102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/16/2022] Open
Abstract
The high prevalence of skin diseases in resource-poor settings, where health workers with sufficient knowledge of skin diseases are scarce, calls for innovative measures. Timely diagnosis and treatment of skin diseases, especially neglected tropical diseases (NTDs) that manifest with skin lesions, such as leprosy, is crucial to prevent disabilities as well as psychological and socioeconomic problems. Innovative technological methods like telemedicine and mobile health (mHealth) can help to bridge the gap between the burden of skin diseases and the lack of capable staff in resource-poor settings by bringing essential health services from central level closer to peripheral levels. Netherlands Leprosy Relief (NLR) has developed a mobile phone application called the 'SkinApp', which aims to support peripheral health workers to recognize the early signs and symptoms of skin diseases, including skin NTDs, and to start treatment promptly or refer for more advanced diagnostic testing or disease management when needed. Further research is needed to determine how greatly mHealth in general and the SkinApp in particular can contribute to improved health outcomes, efficiency, and cost-effectiveness.
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Affiliation(s)
- Liesbeth F Mieras
- Technical Department, Netherlands Leprosy Relief, 1090 HA Amsterdam, The Netherlands.
| | - Anna T Taal
- Technical Department, Netherlands Leprosy Relief, 1090 HA Amsterdam, The Netherlands.
| | - Erik B Post
- Challenge TB, KNCV Tuberculosis Foundation, Jakarta 12870, Indonesia.
| | - Alcino G Z Ndeve
- Technical Department, Netherlands Leprosy Relief, Maputo, Mozambique.
| | - Colette L M van Hees
- Department of Dermatology, Erasmus Medical Centre, 3000 CA Rotterdam, The Netherlands.
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Cushing Syndrome due to Inappropriate Corticosteroid Topical Treatment of Undiagnosed Scabies. Trop Med Infect Dis 2018; 3:tropicalmed3030082. [PMID: 30274478 PMCID: PMC6161154 DOI: 10.3390/tropicalmed3030082] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/23/2018] [Accepted: 07/24/2018] [Indexed: 11/17/2022] Open
Abstract
The uncontrolled sale of topical corticosteroids has become an important risk factor for the development of iatrogenic Cushing syndrome in children, especially in countries where medications are sold over the counter. This is exacerbated by the lack of information for both the patients and pharmacists. This report documents a series of eight cases of iatrogenic Cushing syndrome secondary to an inappropriate use of topical steroids, due to a misdiagnosis of scabies.
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Seth D, Cheldize K, Brown D, Freeman EF. Global Burden of Skin Disease: Inequities and Innovations. CURRENT DERMATOLOGY REPORTS 2017; 6:204-210. [PMID: 29226027 PMCID: PMC5718374 DOI: 10.1007/s13671-017-0192-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW We review the current understanding of the burden of dermatological disease through the lens of the Global Burden of Disease project, evaluate the impact of skin disease on quality of life in a global context, explore socioeconomic implications, and finally summarize interventions towards improving quality of dermatologic care in resource-poor settings. RECENT FINDINGS The Global Burden of Disease project has shown that skin diseases continue to be the 4th leading cause of nonfatal disease burden world-wide. However, research efforts and funding do not match with the relative disability of skin diseases. International and national efforts, such as the WHO List of Essential Medicines, are critical towards reducing the socioeconomic burden of skin diseases and increasing access to care. Recent innovations such as teledermatology, point-of-care diagnostic tools, and task-shifting help to provide dermatological care to underserved regions in a cost-effective manner. SUMMARY Skin diseases cause significant non-fatal disability worldwide, especially in resource-poor regions. Greater impetus to study the burden of skin disease in low resource settings and policy efforts towards delivering high quality care are essential in improving the burden of skin diseases.
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Affiliation(s)
- Divya Seth
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Khatiya Cheldize
- Weill Cornell Medical College, New York, New York
- Massachusetts General Hospital Department of Dermatology, Boston, MA
| | - Danielle Brown
- Massachusetts General Hospital Department of Pediatrics, Boston, MA
| | - Esther F Freeman
- Massachusetts General Hospital Department of Dermatology, Boston, MA
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Bini S, Clavenna A, Rigamonti AE, Sartorio A, Marazzi N, Fiorini G, Cella SG. Drugs Delivery by Charities: A Possible Epidemiologic Indicator in Children of Undocumented Migrants. J Immigr Minor Health 2016; 19:1379-1385. [PMID: 27460254 DOI: 10.1007/s10903-016-0471-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Describing the health status of a population is difficult, especially in the case of irregular migrants who are now a growing population in western Countries. Data for children of these families are almost inexistent. In the absence of databases on this peculiar pediatric population, we analyzed drugs dispensation by a major Charity to have an insight into their health needs. This observational retrospective study was carried out during the entire 2015 and enrolled 628 undocumented children. A cohort of 8438 adult patients belonging to the same ethnic groups was used for comparison. Respiratory drugs were those most commonly prescribed, followed by those for skin and ocular diseases and by those for gastrointestinal disorders. Also in adults respiratory medications were the most dispensed, but almost in equal measure than cardiovascular drugs.To our knowledge this is the first study on the health needs of undocumented children residing in a western Country. The method we used seems to be a useful method for epidemiological analysis. As could be expected, respiratory and skin diseases ranked first, possibly owing to environmental factors.
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Affiliation(s)
- S Bini
- Department of Clinical Sciences and Community Health, University of Milan, Via Vanvitelli, 32, 20129, Milan, Italy
| | - A Clavenna
- IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - A E Rigamonti
- Department of Clinical Sciences and Community Health, University of Milan, Via Vanvitelli, 32, 20129, Milan, Italy
| | - A Sartorio
- Experimental Laboratory for Auxo-endocrinological Research, IRCCS-Istituto Auxologico Italiano, Milan and Verbania, Italy
| | - N Marazzi
- Experimental Laboratory for Auxo-endocrinological Research, IRCCS-Istituto Auxologico Italiano, Milan and Verbania, Italy
| | - G Fiorini
- Department of Clinical Sciences and Community Health, University of Milan, Via Vanvitelli, 32, 20129, Milan, Italy.,Istituti Clinici Zucchi, Carate, Italy
| | - S G Cella
- Department of Clinical Sciences and Community Health, University of Milan, Via Vanvitelli, 32, 20129, Milan, Italy.
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Jahan-Tigh RR, Chinn GM, Rapini RP. A Comparative Study Between Smartphone-Based Microscopy and Conventional Light Microscopy in 1021 Dermatopathology Specimens. Arch Pathol Lab Med 2016; 140:86-90. [PMID: 26717060 DOI: 10.5858/arpa.2014-0593-oa.s1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The incorporation of high-resolution cameras into smartphones has allowed for a variety of medical applications including the use of lens attachments that provide telescopic, macroscopic, and dermatoscopic data, but the feasibility and performance characteristics of such a platform for use in dermatopathology have not been described. OBJECTIVE To determine the diagnostic performance of a smartphone microscope compared to traditional light microscopy in dermatopathology specimens. DESIGN A simple smartphone microscope constructed with a 3-mm ball lens was used to prospectively evaluate 1021 consecutive dermatopathology cases in a blinded fashion. Referred, consecutive specimens from the community were evaluated at a single university hospital. The performance characteristics of the smartphone platform were calculated by using conventional light microscopy as the gold standard. The sensitivity and specificity for the diagnosis of melanoma, nonmelanoma skin cancers, and other miscellaneous conditions by the phone microscopy platform, as compared with traditional light microscopy, were calculated. RESULTS For basal cell carcinoma (n = 136), the sensitivity and specificity of smartphone microscopy were 95.6% and 98.1%, respectively. The sensitivity and specificity for squamous cell carcinoma (n = 94) were 89.4% and 97.3%, respectively. The lowest sensitivity was found in melanoma (n = 15) at 60%, although the specificity was high at 99.1%. The accuracy of diagnosis of inflammatory conditions and other neoplasms was variable. CONCLUSIONS Mobile phone-based microscopy has excellent performance characteristics for the inexpensive diagnosis of nonmelanoma skin cancers in a setting where a traditional microscope is not available.
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Affiliation(s)
- Richard R Jahan-Tigh
- From the Departments of Dermatology and Pathology, University of Texas Houston Health Science Center, Houston (Drs Jahan-Tigh and Rapini);,and the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (Dr Chinn)
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Jahan-Tigh RR, Chinn GM, Rapini RP. A Comparative Study Between Smartphone-Based Microscopy and Conventional Light Microscopy in 1021 Dermatopathology Specimens. Arch Pathol Lab Med 2016. [DOI: 10.5858/arpa.2014-0593-oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
The incorporation of high-resolution cameras into smartphones has allowed for a variety of medical applications including the use of lens attachments that provide telescopic, macroscopic, and dermatoscopic data, but the feasibility and performance characteristics of such a platform for use in dermatopathology have not been described.
Objective
To determine the diagnostic performance of a smartphone microscope compared to traditional light microscopy in dermatopathology specimens.
Design
A simple smartphone microscope constructed with a 3-mm ball lens was used to prospectively evaluate 1021 consecutive dermatopathology cases in a blinded fashion. Referred, consecutive specimens from the community were evaluated at a single university hospital. The performance characteristics of the smartphone platform were calculated by using conventional light microscopy as the gold standard. The sensitivity and specificity for the diagnosis of melanoma, nonmelanoma skin cancers, and other miscellaneous conditions by the phone microscopy platform, as compared with traditional light microscopy, were calculated.
Results
For basal cell carcinoma (n = 136), the sensitivity and specificity of smartphone microscopy were 95.6% and 98.1%, respectively. The sensitivity and specificity for squamous cell carcinoma (n = 94) were 89.4% and 97.3%, respectively. The lowest sensitivity was found in melanoma (n = 15) at 60%, although the specificity was high at 99.1%. The accuracy of diagnosis of inflammatory conditions and other neoplasms was variable.
Conclusions
Mobile phone–based microscopy has excellent performance characteristics for the inexpensive diagnosis of nonmelanoma skin cancers in a setting where a traditional microscope is not available.
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Affiliation(s)
- Richard R. Jahan-Tigh
- From the Departments of Dermatology and Pathology, University of Texas Houston Health Science Center, Houston (Drs Jahan-Tigh and Rapini)
- and the Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (Dr Chinn)
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Beltraminelli H, Kiprono S, Zuriel D, Swai B, Giabbani E, Grossmann H, Masenga J. Dermatopathology in sub-Saharan Africa: a systematic 5-year analysis of all histopathological diagnoses from the Regional Dermatology Training Centre (RDTC) in Moshi, Tanzania. J Eur Acad Dermatol Venereol 2014; 29:1370-5. [DOI: 10.1111/jdv.12877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 10/22/2014] [Indexed: 12/31/2022]
Affiliation(s)
- H. Beltraminelli
- University Clinic for Dermatology; Inselspital - Bern University Hospital; Bern Switzerland
- Regional Dermatology Training Centre at Kilimanjaro Christian Medical University College; Moshi Tanzania
| | - S. Kiprono
- Regional Dermatology Training Centre at Kilimanjaro Christian Medical University College; Moshi Tanzania
- Department of Dermatology; Provincial General Hospital; Kakamega Kenya
| | - D. Zuriel
- Pathology Department; University of Nairobi; Nairobi Kenya
| | - B. Swai
- Pathology Department at the Kilimanjaro Christian Medical University College; Moshi Tanzania
| | - E. Giabbani
- University Clinic for Dermatology; Inselspital - Bern University Hospital; Bern Switzerland
- Regional Dermatology Training Centre at Kilimanjaro Christian Medical University College; Moshi Tanzania
| | - H. Grossmann
- Regional Dermatology Training Centre at Kilimanjaro Christian Medical University College; Moshi Tanzania
| | - J.E. Masenga
- Regional Dermatology Training Centre at Kilimanjaro Christian Medical University College; Moshi Tanzania
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The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol 2013; 134:1527-1534. [PMID: 24166134 DOI: 10.1038/jid.2013.446] [Citation(s) in RCA: 800] [Impact Index Per Article: 72.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/01/2013] [Accepted: 09/09/2013] [Indexed: 02/06/2023]
Abstract
The Global Burden of Disease (GBD) Study 2010 estimated the GBD attributable to 15 categories of skin disease from 1990 to 2010 for 187 countries. For each of the following diseases, we performed systematic literature reviews and analyzed resulting data: eczema, psoriasis, acne vulgaris, pruritus, alopecia areata, decubitus ulcer, urticaria, scabies, fungal skin diseases, impetigo, abscess, and other bacterial skin diseases, cellulitis, viral warts, molluscum contagiosum, and non-melanoma skin cancer. We used disability estimates to determine nonfatal burden. Three skin conditions, fungal skin diseases, other skin and subcutaneous diseases, and acne were in the top 10 most prevalent diseases worldwide in 2010, and eight fell into the top 50; these additional five skin problems were pruritus, eczema, impetigo, scabies, and molluscum contagiosum. Collectively, skin conditions ranged from the 2nd to 11th leading cause of years lived with disability at the country level. At the global level, skin conditions were the fourth leading cause of nonfatal disease burden. Using more data than has been used previously, the burden due to these diseases is enormous in both high- and low-income countries. These results argue strongly to include skin disease prevention and treatment in future global health strategies as a matter of urgency.
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McKoy K, Rehmus W. American Academy of Dermatology and Health Volunteers Overseas: A decade of partnership. J Am Acad Dermatol 2013; 69:162-3. [DOI: 10.1016/j.jaad.2013.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Revised: 02/06/2013] [Accepted: 02/21/2013] [Indexed: 11/27/2022]
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Nkondjo Minkoumou S, Fabrizi V, Papini M. Onychomycosis in Cameroon: a clinical and epidemiological study among dermatological patients. Int J Dermatol 2013; 51:1474-7. [PMID: 23171013 DOI: 10.1111/j.1365-4632.2012.05509.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are currently no studies on epidemiology and clinical aspects of nail fungal infections in the general population of Cameroon. PATIENTS AND METHODS Two series of patients observed at a hospital dermatological service of Yaoundé and in a volunteer service of Douala were evaluated. All the patients, regardless of the reason for the consultation, were examined by an expert dermatologist to discover signs of onychomycosis. Patients with suspected nail lesions underwent mycological examination according to the standard techniques. RESULTS Among 590 subjects (317 males and 273 females), aged 16-83 years, onychomycosis was mycologically confirmed in 52 cases (8.8%). The infection was most common in the fifth decade. Fingernails were affected in 12 cases, toenails in 30 cases, and both fingernails and toenails in 10 cases. Dermatophytes were isolated in 57.7% of cases, the most common species being Trichophyton rubrum (16 cases) and Trichophyton violaceum (eight cases). Non-dermatophytic mould, including Aspergillus spp., Fusarium spp., and Neoscytalidium dimidiatum, was found in 10 cases. Onychomycosis was more common in patients from low social-economic classes. CONCLUSIONS This is the first investigation dealing with onychomycosis in Cameroon. These data may be useful for future research and in the development of preventive and educational strategies.
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Developing and Investigating Skin and Wound Cleaning Approaches Within Rural Africa. JOURNAL OF THE DERMATOLOGY NURSES’ ASSOCIATION 2012. [DOI: 10.1097/jdn.0b013e3182617a78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
To translate scientific discovery into improved health, we must study health care itself: ie, how people access health care, costs or other barriers to the provision of good care, and what happens to patients as a result of this care. Health services research (HSR) is the interdisciplinary field that studies health care and its effects. This paper reviews different types of HSR and highlights some dermatologic examples that have resulted in improved health care systems or have helped us understand access to existing systems. The paper also addresses some of the political and systematic challenges for health services research overall, and for individual investigators and program leaders.
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Affiliation(s)
- Mary-Margaret Chren
- Department of Dermatology, University of California, San Francisco, San Francisco, California 94143-0808, USA.
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