The characteristics of dermatology inpatients seen at the quaternary Inkosi Albert Luthuli Central Hospital in Durban, South Africa, over a 5-year period - 2015 - 2020

BACKGROUND

In recent years, dermatology has been offered as an outpatient service, with decreasing inpatient dermatology admissions. However, dermatology consultation services have remained active, offering care to patients admitted for non-cutaneous indications by other specialties.

OBJECTIVES

To describe the clinical spectrum and characteristics of inpatient dermatology diseases managed at a quaternary South African (SA) hospital.

METHODS

We retrospectively reviewed and analysed electronic records of all dermatology inpatients managed by dermatologists from 2015 to 2020 at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa. Demographic and clinical data on the International Classification of Diseases (ICD) 10 dermatology diagnosis and admitting specialty were collected and analysed.

RESULTS

A total of 4 867 patients were managed by the IALCH dermatology service during the study period. Females accounted for 2 527 (51.9%), while black African, coloured, Indian/Asian, white and unclassified patients constituted 3 146 (64.6%), 106 (2.2%), 1 129 (23.2%), 431 (8.9%) and 55 (1.1%), respectively. The median (interquartile range) age of the study population was 42.0 (28.0 - 58.0) years. Of 867 patients, 183 (3.8%) were dermatology inpatient admissions, whereas the remainder, 4 684 (96.2%), were seen as consults from other specialties. Most (1 010 (20.7%)) of the dermatology consults were received from plastic and reconstructive surgeons, while bacterial infections, decubitus ulcers and lower limb ulcers were the three most common referred diagnoses overall.

CONCLUSION

A broad range of diagnoses is managed through the dermatology inpatient service, particularly as consultations. These services remain essential in the holistic management of patients.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage

BACKGROUND

South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis.

OBJECTIVES

To develop and test an Ethics Framework for use in the SA context for health priority-setting.

METHODS

The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval.

RESULTS

This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs.

CONCLUSIONS

The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

Introducing the Global Health and Equity section in the British Journal of Dermatology

The Section Editor and Associate Editors for the new British Journal of Dermatology Section on Global Health & Equity outline their vision for the Section and suggest topics for submission.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/μL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.

An evaluation of the early effects of a combination antiretroviral therapy programme on the management of AIDS-associated Kaposi's sarcoma in KwaZulu-Natal, South Africa

Roll-out of combination antiretroviral therapy (cART) in South Africa should impact on AIDS-associated Kaposi's sarcoma (KS). Government provision began in 2003, with 23% coverage for World Health Organization (WHO) stage IV AIDS in 2006. To assess the effect of cART availability on KS management, we evaluated records from 701 KS patients seen at a tertiary oncology centre in KwaZulu-Natal, South Africa, from 1995 to 2006. Associations between cART use and measures of KS care were evaluated. cART availability was 0% prior to 2001, 9.6% (2001-2003) and 44% (2004-2006). Documentation of HIV status increased incrementally from 65% to 92%. cART was associated with chemotherapy administration: 56% on cART versus 17% not on cART (P < 0.001); and less loss to follow-up, 13% on cART versus 38% not on cART (P < 0.001). cART availability improves the care of AIDS-associated KS. Further increases in cART availability for this population are needed in South Africa.

Increasing incidence of Kaposi's sarcoma in black South Africans in KwaZulu-Natal, South Africa (1983-2006)

The aim of the study was to describe the temporal trends in the incidence of Kaposi's sarcoma (KS) in black South Africans in KwaZulu-Natal (KZN). The study was designed as a retrospective record review. The incidence of Kaposi's sarcoma was estimated using administrative records for patients receiving care for KS through public sector oncology clinics in KZN, 1983-2006. Annual age-standardized incidence rates were calculated using provincial census data for the denominator. Age-specific rates were calculated for the pre-AIDS (1983-1989) and for the generalized AIDS epidemic eras (2006). Age-standardized incidence of KS increased in KZN from <1:100,000 in 1990 to at least 15:100,000 in 2006; this increase was observed in both men and women. There was a shift in the peak age-specific incidence rates from the sixth decade of life in the pre-AIDS era to the fourth and fifth decades in the AIDS era. In conclusion, KS is a growing public health problem in KZN, South Africa. These data reinforce the need for comprehensive national access to and roll-out of antiretroviral drugs, given their success in prevention and treatment of KS in first-world settings.

Recalcitrant cutaneous sarcoidosis: an evidence-based sequential approach

BACKGROUND

Cutaneous sarcoidosis in black-skinned people is more severe and, in a subset, recalcitrant to therapy. Management of these patients is a challenge.

AIM

To document the clinical features of recalcitrant cutaneous sarcoidosis (RCS) and its response to sequential therapy. A treatment algorithm is suggested.

METHODS

A cross-sectional retrospective analysis was made of patients with RCS. Demographic data, clinical features, histology, blood parameters, radiology and management and response to therapy were recorded.

RESULTS

A total of 30 patients with cutaneous sarcoidosis were seen, of which six had recalcitrant lesions. All had black skin, with a male to female ratio of 1:5. The average age was 48.5 years (41-67) and the average duration of lesions was 11.3 years (2-29). Skin lesions were papules (three), plaques (four), annular (three), nodules (four), ulcers (one), alopecia (one) and lupus pernio (one). Extracutaneous involvement was noted in four of six patients as follows: pulmonary (three of six), dactylitis (two of six) and hepatosplenomegaly (one of six). Histopathology was undertaken in all confirmed non-caseating granulomas. None of the cases responded to systemic prednisone alone. Alternative therapies were: chloroquine (six of six), methotrexate (four of six), doxycycline (two of six), allopurinol (two of six) and isotretinoin (one of six), and azathioprine (one of six). All patients responded well to a stepwise approach to therapy using second-line agents with no relapses during the follow-up period.

CONCLUSION

Sequential therapy avoids the side effects of toxic drugs whilst controlling aggressive cutaneous lesions.

Characteristics of HIV-1-associated Kaposi's sarcoma among women and men in South Africa

Despite the increase of HIV-1-associated Kaposi's sarcoma (KS), little is known about HIV-associated KS in the African setting, particularly among women. A descriptive study of the demographic, clinical, immunological and virological features of AIDS-associated KS from KwaZulu-Natal, South Africa was undertaken. Consecutively, recruited patients were clinically staged; CD4/CD8 cell counts, HIV-1 viral loads and clinical parameters were evaluated. Of the 152 patients (77 male and 75 female) 99% were black. Females were significantly younger (P = 0.02) and had poorer disease prognosis (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.4-5.4, P = 0.003) and were more likely to have extensive cutaneous KS when compared with males (OR = 3.1, 95% CI = 1.4-6.7, P = 0.003). One-third of patients had coexisting HIV-related disease, most commonly tuberculosis, and these were more frequent in females (56.7 vs. 43.3%). In conclusion, HIV-associated KS in South Africans has an equal female-to-male ratio. Females are younger and have more severe disease than males.

Quality of life issues for South Africans with acne vulgaris

The adverse effects of acne on the psyche have been established in patients from 'first world' countries. There has been no in depth study in predominantly black patients from Africa addressing this issue. This was a prospective cross-sectional study of acne patients attending a dermatology unit in KwaZulu-Natal, South Africa. A questionnaire was completed and acne graded by the Global Acne Grading scale. Psychological morbidity and quality of life (QOL) were assessed by the General Health Questionnaire and Dermatology Specific Quality of Life Questionnaires, respectively. We found that clinical severity was not associated with patient perception or psychological distress. The QOL measures such as feelings, social activities, performance at work or school, activities of daily living and overall mental health were found to be associated with distress with associated P-values of 0.0002, 0.0168, 0.0032, 0.033 and < 0.0001, respectively. The severity of acne was not associated with psychological distress. Painful and bleeding lesions were associated with distress levels; P = 0.042 and P = 0.019, respectively. In conclusion, South African patients with acne vulgaris suffer significant psychological distress, which affects the quality of their lives.

Molecular characteristics of human immunodeficiency virus type 1 subtype C viruses from KwaZulu-Natal, South Africa: implications for vaccine and antiretroviral control strategies

The KwaZulu-Natal region of South Africa is experiencing an explosive outbreak of human immunodeficiency virus type 1 (HIV-1) subtype C infections. Understanding the genetic diversity of C viruses and the biological consequences of this diversity is important for the design of effective control strategies. We analyzed the protease gene, the first 935 nucleotides of reverse transcriptase, and the C2V5 envelope region of a representative set of 72 treatment-naïve patients from KwaZulu-Natal and correlated the results with amino acid signature and resistance patterns. Phylogenetic analysis revealed multiple clusters or "lineages" of HIV-1 subtype C that segregated with other C viruses from southern Africa. The same pattern was observed for both black and Indian subgroups and for retrospective specimens collected prior to 1990, indicating that multiple sublineages of HIV-1 C have been present in KwaZulu-Natal since the early stages of the epidemic. With the exception of three nonnucleoside reverse transcriptase inhibitor mutations, no primary resistance mutations were identified. Numerous accessory polymorphisms were present in the protease, but none were located at drug-binding or active sites of the enzyme. One frequent polymorphism, I93L, was located near the protease/reverse transcriptase cleavage site. In the envelope, disruption of the glycosylation motif at the beginning of V3 was associated with the presence of an extra protein kinase C phosphorylation site at codon 11. Many polymorphisms were embedded within cytotoxic T lymphocyte or overlapping cytotoxic T-lymphocyte/T-helper epitopes, as defined for subtype B. This work forms a baseline for future studies aimed at understanding the impact of genetic diversity on vaccine efficacy and on natural susceptibility to antiretroviral drugs.

Childhood Lichen scrofulosorum revisited

Lichen scrofulosorum (LS), an uncommon cutaneous tuberculous reaction, has been described in children and young adults. In the last three decades, there has been a dearth of literature on the entity in children, despite a global increase in tuberculosis. It is usually associated with localized cervical, hilar, or mediastinal lymphadenopathy or with osseous tuberculosis. The occurrence of LS in association with pulmonary tuberculosis is rare and its occurrence with generalized lymphadenopathy is unrecognized. We report LS in two children and highlight its occurrence with pulmonary tuberculosis and generalized lymphadenopathy.

Papulonecrotic tuberculid in a 2-year-old girl: with emphasis on extent of disease and presence of leucocytoclastic vasculitis

The clinicopathologic features of childhood papular necrotic tuberculid (PNT) have been detailed in 10 patients. PNT is characterized by symmetric, acral papular lesions that undergo necrosis. Despite widespread cutaneous involvement, the number of lesions is usually sparse. The extensor aspects of the limbs are usually involved and trunk involvement is uncommon. Vasculitis, an integral component of PNT, has been documented only once in childhood PNT. We describe PNT in a 2-year-old girl in whom a multitude of lesions were present all over the body, including unusual involvement of flexor surfaces of the limbs, trunk, perineum, and vulva. Biopsied tissue revealed the characteristic features of PNT, including leucocytoclastic vasculitis. There was prompt response to antituberculous therapy. Based on the findings in this patient, we believe that the clinical spectrum of this eminently treatable disease in children must be expanded in terms of distribution and number of lesions to include extensive limb and trunk, perineal, and vulval involvement; the histopathologic spectrum of childhood PNT must include leucocytoclastic vasculitis; and adult and childhood PNT share common histopathologic features, including a common cellular immunohistochemical profile, thereby suggesting a common pathogenesis.