Managing skin disease in resource-poor environments - the role of community-oriented training and control programs

Towards enhanced control of mycetoma: a roadmap to achieve the UN's sustainable development goals by 2030

Mycetoma is a neglected tropical disease (NTD) with devastating morbidity and stigma. Despite increased awareness and international collaboration, the burden of mycetoma is largely unknown and diagnosis and treatment are difficult. Addressing mycetoma globally aligns with several United Nation's Sustainable Development Goals (SDGs). Little progress has been made since the WHO's NTD roadmap publication in 2020. The Global Mycetoma Working Group proposes an enhanced mycetoma-control roadmap to meet the SDGs, stimulate progress and improve the lives of patients experiencing mycetoma. By aligning mycetoma management with the goals and targets of this enhanced roadmap, it becomes possible to leverage existing resources, infrastructure and partnerships to improve the lives of affected individuals and communities. This updated assessment is designed for the benefit of health workers and providers in mycetoma-endemic areas, NTD government officials, civil society and funding and implementing agencies.

Community Dermatology: Current Status and the Way Forward

Community health interventions in dermatology have the potential to deliver healthcare to large populations. Such interventions can bridge the gap between increasing demands from vast populations and limited availability and asymmetric geographical distribution of specialist doctors. This narrative review aims to delineate various areas in which community dermatology initiatives are useful, the different approaches used, and the factors which could determine their effectiveness. We did a PubMed search using the search terms, "Community Health Services"[Mesh]) AND "Dermatology"[Mesh]. A further literature search was performed by cross-referencing these articles. In addition to its primary purpose of increasing access, community involvement can augment medical education, foster research, and help to develop more patient-centered clinical guidelines, understand disease trends and influences of the environment on various diseases, and formulate population-centered health policy. Task shifting, development of culture-sensitive and gender-sensitive community healthcare teams, disease-specific patient support groups, and use of advances in technology such as telemedicine are some of the important methods used in community dermatology. Task shifting may be performed at different levels - general practitioners, pharmacists, nurses, and community health workers. Community interventions harness volunteerism among health professionals as well as various stakeholders in the community. Partnering with non-governmental organizations, involving members of the community, and being a part of a long-term public health program help to sustain community interventions. The interventions should adapt to the ethical and cultural norms of the community. Continuity of care, fidelity, and evidence support are crucial for the success of community interventions in dermatology.

Effectiveness of self-care interventions for integrated morbidity management of skin neglected tropical diseases in Anambra State, Nigeria

Background

Lymphatic filariasis (LF), Buruli ulcer (BU) and leprosy are neglected tropical diseases (NTDs) of the skin co-endemic in some communities in Nigeria. Not enough is known about the effectiveness of integrated morbidity management and disability prevention in people with these conditions. An integrated self-care intervention was carried out for people with these skin NTDs in two endemic communities of Anambra state, Nigeria. The objective of the study was to assess the effectiveness of self-care practices on costs of care, disability status and health-related quality of life.

Methods

This study utilised a quasi-experimental pre-test/post-test design to assess the effectiveness of the self-care interventions for people affected by NTDs to care for these impairments at home. Data were collected using questionnaires administered at the beginning and at the end of the intervention on monthly cost of morbidity care, and on participants’ disability status and their quality of life (QoL). Focus group discussions (FGDs) were held with both the participants and healthcare workers at follow-up.

Results

Forty-eight participants were recruited. Thirty participants (62.5%) continued the self-care interventions until the end of the project. Of those, 25 (83%) demonstrated improvement from their baseline impairment status. The mean household costs of morbidity care per participant decreased by 66% after the intervention, falling from US$157.50 at baseline to US$53.24 after 6 months of self-care (p = 0.004). The mean disability score at baseline was 22.3; this decreased to 12.5 after 6 months of self-care (p < 0.001). Among the 30 participants who continued the interventions until the end of the project, 26 (86.7%) had severe disability score (i.e. a score of 10–46) at baseline, and the number with severe disability fell to 18 (60%) of the 30 after the intervention. The mean QoL score increased from 45.7 at baseline to 57.5 at the end of the intervention (p = 0.004).

Conclusions

The 6-month self-care intervention for participants affected by BU, leprosy, or LF led to lower costs of care (including out-of-pocket costs and lost earnings due to morbidity), improved QoL scores, and reduced disability status.

Trial registration

ISRCTN Registry: ISRCTN20317241; 27/08/2021, Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11729-1.

PEP4LEP study protocol: integrated skin screening and SDR-PEP administration for leprosy prevention: comparing the effectiveness and feasibility of a community-based intervention to a health centre-based intervention in Ethiopia, Mozambique and Tanzania

INTRODUCTION

Leprosy, or Hansen's disease, remains a cause of preventable disability. Early detection, treatment and prevention are key to reducing transmission. Post-exposure prophylaxis with single-dose rifampicin (SDR-PEP) reduces the risk of developing leprosy when administered to screened contacts of patients. This has been adopted in the WHO leprosy guidelines. The PEP4LEP study aims to determine the most effective and feasible method of screening people at risk of developing leprosy and administering chemoprophylaxis to contribute to interrupting transmission.

METHODS AND ANALYSIS

PEP4LEP is a cluster-randomised implementation trial comparing two interventions of integrated skin screening combined with SDR-PEP distribution to contacts of patients with leprosy in Ethiopia, Mozambique and Tanzania. One intervention is community-based, using skin camps to screen approximately 100 community contacts per leprosy patient, and to administer SDR-PEP when eligible. The other intervention is health centre-based, inviting household contacts of leprosy patients to be screened in a local health centre and subsequently receive SDR-PEP when eligible. The mobile health (mHealth) tool SkinApp will support health workers' capacity in integrated skin screening. The effectiveness of both interventions will be compared by assessing the rate of patients with leprosy detected and case detection delay in months, as well as feasibility in terms of cost-effectiveness and acceptability.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the national ethical committees of Ethiopia (MoSHE), Mozambique (CNBS) and Tanzania (NIMR/MoHCDEC). Study results will be published open access in peer-reviewed journals, providing evidence for the implementation of innovative leprosy screening methods and chemoprophylaxis to policymakers.

TRIAL REGISTRATION NUMBER

NL7294 (NTR7503).

Mycetoma and the Community Dermatology Program, Mexico

The Community Dermatology Program established in the state of Guerrero, Mexico for almost 30 y provides an adaptable method of detecting and monitoring skin neglected tropical diseases such as mycetoma, which is endemic in the state. The program utilises general and thematic teaching elements combined with distance learning through teledermatology, direct patient consultations and close collaboration with community teams. Using this approach, a picture of mycetoma in Guerrero has emerged, with a focal hot spot located in the southern part of the state in the Costa Chica region. Although in much of Mexico Nocardia infections dominate, in this area there are also substantial numbers of cases of eumycetoma. This combined approach provides a means of early case detection and long-term surveillance through targeted use of a small specialist team.

Dermatology Training in Africa: Successes and Challenges

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.

Community Dermatology in Argentina

All around the globe the population has limited access to dermatologic care, and there are too few dermatologists to accommodate the high demand for skin care. Education of the community and frontline health workers is key to obtaining long-term impact in the skin health of a population. Reaching a community as a whole is challenging for dermatologists coming from distant cities, because cross-cultural obstacles often arise. This article describes some simple and positive ways of addressing the community directly while training health care workers in the recognition of prevalent skin diseases and effective pathways of management of these conditions.

Protocol for a Case-Control Study to Investigate the Association of Pellagra With Isoniazid Exposure During Tuberculosis Preventive Treatment Scale-Up in Malawi

Background: Pellagra is caused by niacin (vitamin B3) deficiency and manifested by a distinctive dermatitis. Isoniazid is critical for treating tuberculosis globally and is a component of most regimens to prevent tuberculosis. Isoniazid may contribute to pellagra by disrupting intracellular niacin synthesis. In 2017, Malawian clinicians recognized a high incidence of pellagra-like rashes after scale-up of isoniazid preventive treatment (IPT) to people living with HIV (PLHIV). This increase in pellagra incidence among PLHIV coincided with a seasonal period of sustained food insecurity in the region, which obscured epidemiological interpretations. Although isoniazid has been implicated as a secondary cause of pellagra for decades, no hypothesis-driven epidemiological study has assessed this relationship in a population exposed to isoniazid. We developed this case-control protocol to assess the association between large-scale isoniazid distribution and pellagra in Malawi. Methods: We measure the relative odds of having pellagra among isoniazid-exposed people compared to those without exposure while controlling for other pellagra risk factors. Secondary aims include measuring time from isoniazid initiation to onset of dermatitis, comparing niacin metabolites 1-methylnicotinamide (1-MN), and l-methyl-2-pyridone-5-carboxamide (2-PYR) in urine as a proxy for total body niacin status among subpopulations, and describing clinical outcomes after 30-days multi-B vitamin (containing 300 mg nicotinamide daily) therapy and isoniazid cessation (if exposed). We aim to enroll 197 participants with pellagra and 788 age- and sex-matched controls (1:4 ratio) presenting at three dermatology clinics. Four randomly selected community clinics within 3-25 km of designated dermatology clinics will refer persons with pellagra-like symptoms to one of the study enrollment sites for diagnosis. Trained study dermatologists will conduct a detailed exposure questionnaire and perform anthropometric measurements. A subset of enrollees will provide a casual urine specimen for niacin metabolites quantification and/or point-of-care isoniazid detection to confirm whether participants recently ingested isoniazid. We will use conditional logistic regression, matching age and sex, to estimate odds ratios for the primary study aim. Discussion: The results of this study will inform the programmatic scale-up of isoniazid-containing regimens to prevent tuberculosis.

Patterns of Skin Disease in the Context of a High Prevalence HIV Population in Botswana

The authors reviewed outpatients in a tertiary dermatology clinic in Botswana to expand knowledge on patterns of skin disease in this population with a high prevalence of human immunodeficiency virus (HIV). Approximately one-third of new and follow-up patients were HIV positive. Common dermatologic conditions included eczematous eruptions, viral and fungal infections, malignant neoplasms, vascular disorders, disorders of pigmentation, and mechanical/physical injury-related disorders. HIV has impacted patterns of dermatologic disease in Botswana, with Kaposi sarcoma being the most frequently biopsied condition. Given the shortage of dermatology specialists, resources should be allocated toward education and management of these most prevalent skin conditions.

Continuing Dermatology Education for Rural Physician Assistants in Ghana: An Assessment of Needs and Effectiveness

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.

Diagnosis and Management of Fungal Neglected Tropical Diseases In Community Settings-Mycetoma and Sporotrichosis

BACKGROUND

This is a retrospective, analytic observational study where we describe cases of sporotrichosis and mycetoma from Acapulco General Hospital and Community Dermatology Mexico C.A. over 25 years. Analysis of environmental features that favour the development of such diseases has been made, as well as the limitations in the study and treatment of such diseases in resource poor settings.

METHODS

We reviewed the information on 76 sporotrichosis and 113 mycetoma patients out of a total of 14,000 consultations at Acapulco General Hospital and from Community Dermatology clinics. We analysed the epidemiological and mycological characteristics and the investigations used for diagnosis such as direct examination, culture, intradermal test reactions, and biopsy.

RESULTS

In total 91 confirmed cases of actinomycetoma, 22 of eumycetoma and 76 of sporotrichosis have been identified including diagnostic studies for both diseases and their treatment.

DISCUSSION

The results obtained have been analysed and interpreted in patients with mycetoma and sporotrichosis in the state of Guerrero, México, along with limitations in their management in areas with limited economic and logistical resources. The prevalence of mycetoma in our setting is compared with other centres where patients from all over the country are seen. The possible causes for variations in prevalence in specific areas has been looked for, in one of the poorest states of the Mexican Republic.

Integrated Management of Skin NTDs-Lessons Learned from Existing Practice and Field Research

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. Because a number of these diseases share not only the geographical distribution, but also a common feature which is skin involvement, bringing together a sub-group of 'skin NTDs' is one way forward to promote further integration among NTDs. With these diseases, which include leprosy, Buruli ulcer, yaws, mycetoma, lymphatic filariasis, and leishmaniasis, patients may be left with life-long deformities and disabilities when diagnosis and treatment are delayed. Stigma is another serious consequence of skin NTDs as it places a large barrier on the economic activities and social life of a patient. As a result, this creates a vicious cycle and obstructs a key goal of society, the elimination of poverty. Enhancement in surveillance systems as well as the further development of diagnostic methods, improvement in treatment and management, and identification of preventative measures for skin NTDs are therefore urgently needed. This article summarizes the existing practices and field research on skin NTDs and identifies potential synergies that could be achieved by adopting this integrated approach.

Control Strategies for Scabies

Scabies is a neglected tropical disease of the skin, causing severe itching and stigmatizing skin lesions. Further, scabies leads to impetigo, severe bacterial infections, and post-infectious complications. Around 200 million people are affected, particularly among disadvantaged populations living in crowded conditions in tropical areas. After almost 50 years, research into scabies control has shown great promise, particularly in highly-endemic island settings, but these findings have not been widely adopted. Newer approaches, utilizing ivermectin-based mass drug administration, appear feasible and highly effective. Inclusion of scabies in the WHO portfolio of neglected tropical diseases in 2017 may facilitate renewed opportunities and momentum toward global control. However, further operational research is needed to develop evidence-based strategies for control in a range of settings, and monitor their impact. Several enabling factors are required for successful implementation, including availability of affordable drug supply. Integration with existing health programs may provide a cost-effective approach to control.

Skin disease prevalence study in schoolchildren in rural Côte d'Ivoire: Implications for integration of neglected skin diseases (skin NTDs)

Background

Early detection of several skin-related neglected tropical diseases (skin NTDs)–including leprosy, Buruli ulcer, yaws, and scabies- may be achieved through school surveys, but such an approach has seldom been tested systematically on a large scale in endemic countries. Additionally, a better understanding of the spectrum of skin diseases and the at-risk populations to be encountered during such surveys is necessary to facilitate the process.

Methods

We performed a school skin survey for selected NTDs and the spectrum of skin diseases, among primary schoolchildren aged 5 to 15 in Côte d’Ivoire, West Africa. This 2-phase survey took place in 49 schools from 16 villages in the Adzopé health district from November 2015 to January 2016. The first phase involved a rapid visual examination of the skin by local community healthcare workers (village nurses) to identify any skin abnormality. In a second phase, a specialized medical team including dermatologists performed a total skin examination of all screened students with any skin lesion and provided treatment where necessary.

Results

Of a total of 13,019 children, 3,504 screened positive for skin lesions and were listed for the next stage examination. The medical team examined 1,138 of these children. The overall prevalence of skin diseases was 25.6% (95% CI: 24.3–26.9%). The predominant diagnoses were fungal infections (n = 858, prevalence: 22.3%), followed by inflammatory skin diseases (n = 265, prevalence: 6.9%). Skin diseases were more common in boys and in children living along the main road with heavy traffic. One case of multi-bacillary type leprosy was detected early, along with 36 cases of scabies. Our survey was met with very good community acceptance.

Conclusion

We carried out the first large-scale integrated, two-phase pediatric multi-skin NTD survey in rural Côte d’Ivoire, effectively reaching a large population. We found a high prevalence of skin diseases in children, but only limited number of skin NTDs. With the lessons learned, we plan to expand the project to a wider area to further explore its potential to better integrate skin NTD screening in the public health agenda.

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. A common feature shared by several NTDs is skin involvement. Conditions within this group of NTDs have now been classified as skin NTDs to promote wider NTD integration. Several skin NTDs including leprosy, Buruli ulcer, yaws, and scabies are co-endemic in Côte d’Ivoire, West Africa. As children are vulnerable to these diseases, we carried out the first large-scale integrated, multi-skin NTD school survey in a rural district of this country. Our strategy of involving community healthcare workers and dermatologists effectively reached a large population. However, the detection of skin NTDs may have been limited because of the low schooling and attendance rate. We found a high prevalence of skin diseases among schoolchildren (26%), possibly due to poor socio-economic status and air pollution, which requires more attention. This high prevalence of skin diseases posed a challenge for our project as the need for medications and those with dermatological skills exceeded our capacity to reach our initial target population. Our study provides important lessons that will aid the framing of future school skin surveys in sub-Saharan Africa.

Task Shifting in Dermatology: A Call to Action

Clinical Question

Can task shifting be used to improve the delivery of dermatologic care in resource-poor settings worldwide?

Bottom Line

Task shifting is a means of redistributing available resources, whereby highly trained individuals train an available workforce to provide necessary care in low-resource settings. Limited evidence exists for task shifting in dermatology; however, studies from psychiatry demonstrate its efficacy. In the field of dermatology there is a need for high-quality evidence including randomized clinical trials to validate the implementation of task shifting in low-resource settings globally.

Age-Associated Skin Conditions and Diseases: Current Perspectives and Future Options

The International League of Dermatological Societies (ILDS), a global, not-for-profit organization representing 157 dermatological societies worldwide, has identified the consequences of skin aging as one of the most important grand challenges in global skin health. Reduced functional capacity and increased susceptibility of the skin with development of dermatoses such as dry skin, itching, ulcers, dyspigmentation, wrinkles, fungal infections, as well as benign and malignant tumors are the most common skin conditions in aged populations worldwide. Environmental (e.g., pollution) and lifestyle factors (e.g., smoking, sunbed use) negatively affect skin health. In turn altered appearance, dry skin, chronic wounds, and other conditions decrease general health and reduce the likelihood for healthy and active aging. Preventive skin care includes primary, secondary, and tertiary interventions. Continuous sun protection from early childhood onward is most important, to avoid extrinsic skin damage and skin cancer. Exposure to irritants, allergens, or other molecules damaging the skin must be avoided or reduced to a minimum. Public health approaches are needed to implement preventive and basic skin care worldwide to reach high numbers of dermatological patients and care receivers. Education of primary caregivers and implementation of community dermatology are successful strategies in resource-poor countries. Besides specialist physicians, nurses and other health care professionals play important roles in preventing and managing age-related skin conditions in developing as well as in developed countries. Healthy skin across the life course leads to better mental and emotional health, positive impact on social engagement, and healthier, more active, and productive lives.

Opportunities for Integrated Control of Neglected Tropical Diseases That Affect the Skin

Many neglected tropical diseases (NTDs) affect the skin, causing considerable disability, stigma, and exacerbation of poverty. However, there has been relatively little investment into laboratory research, epidemiology, diagnostic tools or management strategies to control tropical skin disease. Integration may advance the control of skin disease across a range of domains, including mapping, diagnosis, clinical management, and community control measures such as mass drug administration. Examples of successful integration strategies include programs targeting scabies, impetigo, yaws, and diseases causing lymphoedema. Future strategies should build on these experiences and the experience of integration of other NTDs, strengthen existing health systems, and contribute toward the attainment of Universal Health Coverage. Strong partnerships and political support and will be necessary to achieve these goals.

Building a global teledermatology collaboration

Skin disease is common in low-resource countries and is associated with significant morbidity. The disease burden is often heightened by lack of access to adequate diagnosis and treatment. Teledermatology is a growing healthcare delivery modality that allows access to subspecialty care at a distance. This article describes how a low-cost teledermatology program was launched through collaboration between the Medical College of Wisconsin and Hillside Healthcare International. Several factors are required for a teledermatology program to be successful, beginning with a partnership between two entities that targets a locally identified need and is mutually beneficial to invested partners. The program should utilize the expertise of each partner, be based on an agreed upon process with clearly defined objectives, and protect patient privacy. After a program is implemented, adaptation to address challenges and best meet the needs of all parties involved will allow for continued success and sustainability. This process can serve as a model for other programs desiring to establish similar teledermatology partnerships in an academic setting.

The wow factor as a determinant of funding for disorders of the skin

As people live beyond 100 years, there is an extended period of impaired quality of life for the increasing numbers of individuals with skin disorders. There is also a growing work force of fit elderly individuals who are able to provide low technology skin care and who can teach self-help if well instructed. The International Society of Dermatology's sub-committee Skin Care for All: Community Dermatology seeks to bring together those who care for skin diseases and those who manage wounds, burns, lymphoedema and neglected tropical diseases affecting the skin for the purpose of skin care. Their focus is the repair of four functions: barrier, thermoregulation, sensory perception and communication. The curriculum includes low cost self-help and the restoration of absent skin. The care expectation is one of technical proficiency integrated with kindness and altruism. The concept is attracting wide attention but needs to develop compelling and persuasive arguments ("wow factors") regarding why it should be funded. There is probably no greater wow factor than tracing the path of a severely injured patient from the battlefield through the course of immediate first aid by paramedics to the surgeon in the frontline tent who can almost guarantee survival. Seeing these disfigured persons winning trophies at the Olympic Games has garnered the admiration of millions of viewers.