Atlas of Common Skin Diseases In Australia

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COMMON SKIN DISEASES I

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Robin Marks Anne Plunkett Kate Merlin Nicole Jenner Department of Dermatology St Vincent’s Hospital, Melbourne

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Published by the Department of Dermatology, St Vincent’s Hospital, Melbourne, Victoria Parade, Fitzroy, Victoria 3065 Australia. Telephone +61 3 9288 3293 Fax +61 3 9288 3292 © Department of Dermatology, St Vincent’s Hospital, 1999 No part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted in any form or by any means without the prior written permission of the copyright owner.

ISBN 1–875271–31–7

Foreword Professor Robin Marks and the Department of Dermatology at St Vincent’s Hospital in Melbourne are to be congratulated on producing this Atlas of Common Skin Diseases in Australia. Due to their fine efforts, we now have a clear idea of the prevalence and morbidity of common skin conditions in this country. Despite the significant prevalence of skin disease in Australia, as illustrated in this Atlas, this important healthcare issue has been given low priority in the community. Consequently and disappointingly, dermatology has received insufficient Government attention and inadequate funding for provision of clinical services, research and training. A key function of the Australasian College of Dermatologists is education. Through its range of educational activities, information concerning common skin conditions is circulated regularly amongst medical students, general practitioners, other medical practitioners and allied interest groups. This unique Atlas provides us with further important information and it should become an essential source of reference for anyone interested in Australian dermatology. Medical and allied health trainees, and others interested in ensuring the resources required for maintaining an appropriate profile and high standard of dermatological healthcare in Australia, would find the Atlas particularly valuable. The College is very pleased indeed to be associated with the launch of this Atlas and we wish it every success.

DUDLEY HILL President

STEPHEN LEE Honorary Secretary

THE AUSTRALASIAN COLLEGE OF DERMATOLOGISTS

—— Foreword ——

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—— Atlas Of Common Skin Diseases ——

Introduction Skin diseases are a bit like the common cold. Apart from some of the skin cancers, they are not recorded in any official registry. They vary enormously from mild conditions which may affect only the appearance of the skin to severe diseases which are totally incapacitating. The degree of treatment required, or even sought, varies accordingly. Nevertheless, every medical practitioner knows that there are plenty of people suffering with these conditions. A comprehensive survey of general practitioners’ workloads in Australia revealed that skin problems were the primary reason for at least 15% of consultations. On the other hand, community-based data collections show that medical practitioners are consulted about skin conditions by less than 50% of those who have them. People frequently seek advice from others in the community including pharmacists, family or friends and naturopaths, or they merely prescribe for themselves based on information from elsewhere.

This Atlas is only the beginning. It is not enough just to record that there are problems. The next step is to do something about them.

Like the common cold, everyone knows skin conditions are a problem, but until major community-based surveys are undertaken, no one realises the frequency and degree to which people suffer. In 1995, a new academic Department of Dermatology was formed at St Vincent’s Hospital in association with the University of Melbourne, the Australasian College of Dermatologists and the Skin and Cancer Foundation of Victoria. It was decided that the direction of research should be into the frequency and morbidity of common skin conditions in the community. After all, these conditions are the basis for the vast majority of dermatologists’ work. Their work includes not only providing care for patients with skin disease, but also teaching other medical professionals the approach to and management of these conditions.

This Atlas is a summary of the data that have been gathered over the last five years. Skin cancers are not included as they have been well reported elsewhere. The data presented here are startling. However, they do confirm an impression that most health professionals develop after some years of contact with the public. They show clearly that skin diseases are common, they cause considerable morbidity in the community, and people with them require better care. This Atlas is only the beginning. It is not enough just to record that there are problems. The next step is to do something about them. We now have data demonstrating quite clearly where there are problems and we look forward to using these data as the basis for taking steps to relieve them in the future.

Robin Marks Professor of Dermatology St Vincent’s Hospital, Melbourne November 1999

—— Introduction ——

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—— Atlas Of Common Skin Diseases ——

Contents

Methods..............................................................2 What Skin Diseases Do People Say They Have? .............................................4 What Skin Diseases Do People Really Have? Acne ..............................................................6 Nappy Rash (Napkin Dermatitis) ..................10 Atopic Dermatitis (Eczema) ..........................12 Seborrhoeic Dermatitis ................................16 Psoriasis ......................................................18 Warts...........................................................20 Tinea Pedis and Tinea Unguium ..................24 Birthmarks...................................................26 Campbell de Morgan Spots .........................29 Seborrhoeic Keratoses.................................30 Where Do People Seek Advice For Treatment Of Common Skin Diseases? ........................32 Recommendations ............................................36 Acknowledgements ...........................................39

—— Contents ——

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Methods The data presented in this Atlas are a compilation of a number of different studies undertaken by the Department of Dermatology over the last five years. They have been divided into different components and are presented as:- what skin diseases do people say they have when they are asked; what skin diseases do people really have when they are examined by dermatologists; the severity of the skin diseases that have been found on examination; where do people seek advice for treatment of common skin diseases; and is the treatment that people are currently using likely to be effective. The terms skin conditions and skin diseases are used, almost interchangeably at times, throughout the Atlas. This allows us to include conditions like Campbell de Morgan spots or some of the birthmarks which would not normally be classified as disease. Community-based surveys should be carefully designed to sample people who are representative of the whole population. Such surveys depend upon the ability to make contact with representative samples of people of all ages from birth to death. They seek self-report information on the presence of the skin diseases, the treatment and where they have received it. Respondents are then examined by a person experienced in skin disease, i.e. a dermatologist, to reveal whether or not they have a skin condition and what it is. There is no simple method of sampling the whole community at all ages in Australia. For that reason, the population-based surveys represented here have been performed in different ways. They vary according to the age groups of the people being surveyed and the ability to reach those people within age strata in a way which ensures that they are representative of the Australian population. They also vary according to what information is being sought. The data for the chapter on “what skin diseases do people say they have?” come from a communitybased telephone survey in which 416 people were asked if they suffered from skin disease and where they were seeking advice. These are self-reports of skin disease for which we have no clinical examination to confirm the diagnosis. The data for the section “what skin diseases do people really have?” where our dermatologists have examined people to determine the true frequency of skin disease in the community comprise three different studies. The first study “The Tiny Tots

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Survey” included 1,116 children aged from birth to 5 years. The children were examined from a random selection of kindergartens, child care centres and Maternal and Child Health Centres in urban and rural Victoria. In this survey the specific conditions sought in detail included napkin dermatitis (nappy rash), seborrhoeic dermatitis (cradle cap), birth marks, including haemangiomas and melanocytic naevi, and atopic eczema (dermatitis). The second survey “The School Skin Survey” was a school-based study of 2,491 children aged from 4-18 years. The schools were randomly selected from Government, Catholic and Independent schools in both urban and rural Victoria. In this survey, the specific conditions sought in detail included acne, warts, tinea pedis and atopic eczema. Although other conditions, including psoriasis and seborrhoeic dermatitis were recorded, the numbers and information are insufficient to be confident of the true prevalence in this age group. Therefore, they are not reported in this Atlas. The final community-based survey “The Maryborough Skin Health Survey” was of 1,457 adults aged 20 years and over who were randomly selected from the population of Maryborough in Central Victoria. In this survey specific conditions sought in detail included acne, warts, tinea pedis and tinea of the nail (unguium), psoriasis, atopic eczema, seborrhoeic keratosis and Campbell de Morgan spots (punctate haemangiomas). Although skin cancer was recorded, it is not reported here as that has been well covered in other publications. Each of the surveys required voluntary informed consent from the participants or their parents once the randomisation of who would be offered an examination was completed. The final chapter on “where do people seek advice for treatment of common skin diseases?” involved two pharmacy-based surveys in Maryborough seeking information from people who bought skinrelated products. It included information obtained in the three community-based skin examination surveys and the telephone survey of self-report data mentioned above. It can be seen that there are different methods used in each of the surveys that are being reported here and different methods of population sampling. Technically speaking, it is not possible to put them all together and come up with single curves derived from different studies. For that reason, the

—— Atlas Of Common Skin Diseases ——

frequency data are presented in three categories according to the age of the participants and the survey in which data were gathered. On several occasions, we have put the data from the three surveys together to give easy scanning, bearing in mind that they are not strictly compatible. Severity of the conditions was divided into minimal, mild, moderate and severe. These are clinical categories based on a classification of minimal: only a small area affected which may not even have been noticed by the person or their carer; mild: a small area affected, which responds to simple treatment available from a pharmacist, or very mild treatment from a medical practitioner; moderate: more widespread disease that would require treatment from a general practitioner with the use of medications available on prescription only; and severe: widespread active involvement which would require specialist advice. One of the other ways of determining the effect of these diseases, rather than just describing the severity, is to seek the morbidity associated with them. The morbidity is measured in regard to the direct and indirect effects of a skin disease on the individual’s work, home and social life. A Dermatology Life Quality Index (DLQI) has been used to include questions about the effect of these diseases in various aspects of a person’s life. These questions include symptoms related to the disease directly; whether or not it created embarrassment or interfered with such things as shopping or social activities; what effect it has had on relationships with other people; whether work or studying has been affected; and how much of a problem has been created by the treatment that has been necessary. The DLQI was used predominantly in the Adult Survey with some use in the School Survey. DLQI scores are reported in the Atlas where they are available, giving the responses categorised from “affected very much” to “not being affected at all” in each of the categories of the questionnaire. Full descriptions of the exact method for each of the surveys reported in this Atlas are given in the references at the end of this section. Further reading from this list is recommended for those who would like more detailed information on the epidemiological methods involved.

REFERENCES 1. The prevalence and morbidity of common skin diseases among adults in Maryborough, Victoria: The Maryborough Skin Health Survey; 1997-1998. Final Report. Dept of Dermatology, St Vincent’s Hospital, Melbourne. 2. The prevalence and morbidity of common skin diseases in Victorian school children. The School Skin Survey, 1996-1997. Final Report. Dept of Dermatology, St Vincent’s Hospital, Melbourne. 3. The prevalence and morbidity of common skin diseases amongst infants and preschool children. The Tiny Tots Survey, 1998-1999. Final Report. Dept of Dermatology, St Vincent’s Hospital, Melbourne. 4. Gill D, Merlin K, Plunkett A, Jolley D, Marks R. Population based surveys on the frequency of common skin diseases in adults - Is there a risk of response bias? Clin Exp Dermatol. 1999 (In Press). 5. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 3. Acne vulgaris. Brit J Dermatol. 1998; 139:840-845. 6. Kilkenny M, Merlin K, Young R, Marks R. The prevalence of common skin conditions in Australian school students: 1. Common, plane & plantar viral warts. Brit J Dermatol. 1998; 138:840-845. 7. Kilkenny M, Stathakis V, Jolley D, Marks R. Maryborough Skin Health Survey: Prevalence and sources of advice for skin conditions. Australas J Dermatol. 1998; 39:233-237. 8. Kilkenny M, Yeatman JM, Stewart K, Marks R. The role of pharmacists and general practitioners in the management of dermatological conditions. Int J Pharmacy Practice. 1997; 5:1115. 9. Mar A, Tam M, Jolley D, Marks R. The cumulative incidence of atopic dermatitis in the first 12 months amongst Chinese, Vietnamese and Caucasian infants born in Melbourne, Australia. J Am Acad Dermatol. 1999; 40:597-602. 10. Marks R, Kilkenny M, Plunkett A, Merlin K. The prevalence of common skin conditions in Australian school children: 2. Atopic Dermatitis. Brit J Dermatol. 1999; 140:468-473. 11. Merlin K, Kilkenny M, Plunkett A, Marks R. The prevalence of common skin conditions in Australian school students: 4. Tinea Pedis. Brit J Dermatol. 1999; 140:897-901. 12. Plunkett A, Merlin K, Gill D, Zuo Y, Jolley D, Marks R. The frequency of common non-malignant skin conditions in adults in central Victoria, Australia. Int J Dermatol. 1999 (In Press). 13. Yeatman JM, Kilkenny MF, Marks R. The prevalence of seborrhoeic keratoses in an Australian population: Does sunlight play a part in their frequency? Brit J Dermatol. 1997; 137:411-414. 14. Yeatman J, Kilkenny M, Stewart K, Marks R. Advice about management of skin conditions in the community: Who are the providers? Australas J Dermatol. 1996; 37 Suppl 1 S46-S47.

—— Methods ——

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What Skin Diseases Do People Say They Have? Everyone in the community will suffer from at least one skin condition during their lifetime. Conditions such as warts and acne are almost universal at certain ages. However, whether people recognise or report many of these common conditions as disease will vary according to the area affected and the severity of the problem. Memory for minor problems fades very rapidly so that recall of past skin conditions may be fraught with under-reporting. The nature of the questions seeking information on whether people have skin disease determines the frequency of response. Some conditions are more common or active at certain times of the year than others. Thus a questionnaire undertaken in winter may reveal a higher prevalence of dermatitis/eczema or acne than a questionnaire seeking the frequency of these conditions undertaken in summer. On the other hand, tinea of the feet (athlete’s foot) and skin cancer are often more frequently reported in the summer months than in the winter months. Thus what skin diseases people say they have may not necessarily be a true picture of what is really occurring in the community. The Australian Government through the Australian Bureau of Statistics undertakes national health surveys on a regular basis. In these surveys, relatively broad questions are used to determine the frequency of self-reported disease. In the 1989/90 survey, 12.7% of the population reported that they

had a disease of skin and subcutaneous tissue within the past two weeks. These are open-ended questions without prompting for specific diagnoses. People are more likely to remember a condition, particularly if it is not symptomatic, only when they are prompted specifically on whether or not they have had it. For example, a person when asked do they have skin disease may say no, even though they may have a wart on their finger. However, when asked specifically do they have a wart on their finger or elsewhere, they may then answer yes. We undertook a computer-assisted telephone interview survey in the city of Maryborough in which 416 adults agreed to answer questions not only on whether or not they had had skin disease recently, but also more specifically on what were the conditions (including prompting questions) that they had. The interviews took approximately 5-10 minutes to complete and were undertaken in midwinter in the months of July and August. Twenty seven percent of people reported having one or more skin conditions over the previous two weeks, with 25% of those reporting that they had more than one skin condition. There were slightly more women (51.4%) than men (48.6%) in the group who reported having a skin condition. Of those who had sought treatment for their problem, 65% reported that the condition was mild, 24% reported moderate and 13% reported that the condition was severe.

Table 1 — Prevalence of self reported skin diseases in adults Prevalence % (95% confidence interval) Past 2 weeks Acne/pimples Cold sores Dermatitis/eczema Psoriasis Skin cancer Thrush Tinea Urticaria/hives Warts

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16.2 15.1 25.5 4.5 0.5 2.5 11.2 1.1 16.1

(9.6-22.7) (7.3-18.9) (18.1-32.8) (1.0-7.9) (0.0-0.9) (0.2-4.8) (5.9-16.5) (0.0-2.7) (9.8-22-4)

Past 6 months (excluding last 2 weeks) 9.4 30.3 12.6 3.5 5.0 5.7 19.4 0.9 8.6

—— Atlas Of Common Skin Diseases ——

(5.4-12.5) (23.9-56.7) (7.9-17.3) (0.9-5.1) (2.3-7.7) (2.7-8.6) (15.8-24.9) (0.0-2.1) (4.9-12.4)

When asked about the past six months, 59% of people reported having at least one skin condition. Treatment was used for the majority of these conditions with the exception of acne and warts. Almost 70% of acne and 70% of warts were not treated by those people who said they had them. The majority of skin conditions reported within the last six months were regarded as mild (74%) with 18% considered by respondents to be moderate and the remaining 8% were classified as severe. A breakdown of the prevalence of the conditions reported by these adults (18 years and over) is shown in Table 1. As predicted, they show that the seasonal related conditions acne and dermatitis were more common at the time (winter) but less common in the last 12 months (including summer). The figures for tinea, skin cancer and cold sores are the other way around. In telephone surveys of this nature, the diagnosis suggested by the respondent is unable to be confirmed by clinical examination. In the Tiny Tots Survey and the School Skin Survey, the parents of the children and the adolescents themselves were asked before the examination whether they currently had a number of the common skin conditions (with prompting for specific conditions). Overall, 49% of pre-school children aged from birth to five years were reported to have some skin disease by their parents. Self-report of skin disease, or parental report, revealed that 54%

Table 2 — Skin diseases in preschool children reported by their parents* Prevalence % Overall Eczema/dermatitis Seborrhoeic dermatitis/ cradle cap Nappy rash/ diaper dermatitis Tinea/ringworm

of school children aged four to 18 years currently had at least one of the common skin conditions. A breakdown of these conditions can be seen in Tables 2 and 3. In both the Tiny Tots Survey and the School Survey, the self-report of skin disease was followed up with an examination by one of the dermatological team. This confirmed whether the condition that they had reported was present, and whether any other conditions were also present at the time of examination. Confirmation of the self-reported diagnoses revealed underestimates by self-report on some occasions and overestimate on others, with no clear trend. In other words, self-report is one of the ways of estimating morbidity, but there will be inaccuracies in both the diagnosis and the frequency with which people report that they have conditions. In summary, a substantial proportion of the community report that they are currently suffering from at least one skin disease. They also report that they have suffered from a variety of skin diseases in the past. Although crude, this estimate of frequency and morbidity related to skin conditions in the community begins to give an idea of the huge number of people who are affected. It also gives some measure of the morbidity that is related to these common cutaneous conditions.

Table 3 — Skin diseases in school children reported by themselves or their parents*

(95% CI)

49.1 29.4

(46.1-52.1) (26.7-32.1)

19.5

(17.2-21.9)

15.0 0.9

(12.9-17.1) (0.5-1.7)

Prevalence % Overall Acne/pimples Eczema/dermatitis Tinea/ringworm Warts/papilloma

53.6 29.6 15.6 7.8 19.0

(95% CI) (51.6-55.6) (21.0-38.2) (13.9-17.3) (6.4-9.1) (17.0-21.0)

* A number of children had more than one condition.

—— What Skin Diseases Do People Say They Have? ——

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What Skin Diseases Do People Really Have? ACNE Clinical features Acne (pimples) is a common skin condition characterised by the presence of various spots called comedones (blackheads and whiteheads), papules, pustules, and, in severe cases, nodules and cysts. The development of acne coincides with the onset of puberty when androgen hormones, such as testosterone, are released. These hormones can cause the sebaceous glands to overproduce sebum (oil), which leads to blockage and the typical spots associated with acne. Even though many consider acne to be a normal part of growing up, it can have serious effects on a young person’s academic performance and their ability to interact socially. Prevalence of acne in school children 100

Overall Male Female

Prevalence (%)

80 60 40 20 0 4–6

7–9

10–12

13–15

Age (years) Prevalence of acne in school children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 4-6 7-9 10-12 13-15 16-18

2491 1174 1317 385 665 636 539 266

36.1 30.7 41.2 0.0 3.0 27.7 78.2 93.3

(24.7-47.5) (19.2-42.3) (29.1-53.3) (0.0-0.0) (1.5-4.6) (20.6-34.8) (73.8-82.6) (89.6-96.9)

Age (years)

Severity of acne in school children

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Overall Male Female 7-9 10-12 13-15 16-18

No. with acne

Minimal %

Mild %

Moderate–severe %

873 362 511 19 188 418 248

40.4 34.3 44.8 94.7 59.6 37.3 27.0

43.1 41.7 44.0 5.3 37.8 43.5 49.2

16.5 24.0 11.2 0.0 2.7 19.1 23.8

—— Atlas Of Common Skin Diseases ——

16–18

Prevalence of acne in adults 50 45 40

30 25 20 15 10 5 0 20–29

30-–39

40–49

50–49

Age (years) Prevalence of acne in adults

60–69

70+

Overall Male Female

Age (years)

No. examined Prevalence % (95% Cl) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

12.8 11.8 13.6 42.0 23.9 8.6 3.1 1.4 0.4

(11.0-14.5) (9.4-14.2) (11.2-16.1) (35.4-48.6) (18.6-29.3) (5.2-11.9) (1.6-6.0) (0.5-4.3) (0.1-2.8)

Severity of acne in adults No. with acne

Age (years)

Prevalence (%)

35

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

150 63 87 65 49 23 9 3 1

Mild % 81.2 81.2 81.1 72.5 90.8 88.9 75.2 100.0 100.0

Moderate %

Severe %

17.0 17.4 16.7 24.7 9.2 7.8 24.8 0.0 0.0

1.8 1.3 2.2 2.8 0.0 3.3 0.0 0.0 0.0

—— Acne ——

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Prevalence of acne in school children and adults 100

Overall Male Female

Prevalence (%)

80

60

40

20

0 5

11

17

25

35

45

55

65

75+

Age (years)

The Acne Disability Index (ADI) in school students with acne ADI question

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Answer

% (n=382)

1.

As a result of having acne/ pimples, during the last month have you been aggressive, frustrated or embarrassed ?

Very much indeed ......................... A lot................................................ A little............................................. Not at all ........................................

2.6 4.2 27.0 66.2

2.

Do you think that having acne/ pimples during the last month interfered with your daily social life, social events or relationships with members of the opposite sex ?

Severely, affecting all activities...... Moderately, in most activities ........ Occasionally or in only some activities.................................... Not at all ........................................

1.0 3.1

3.

During the last month have you avoided public changing facilities or wearing swimming costumes because of your acne/pimples ?

All of the time................................ Most of the time ............................ Occasionally ................................... Not at all ........................................

1.0 0.3 5.0 93.7

4.

How would you describe your feelings about the appearance of your skin over the last month ?

Very depressed and miserable....... Usually concerned .......................... Occasionally concerned.................. Not bothered ..................................

2.1 12.6 37.4 47.9

5.

Please indicate how bad you think your acne/pimples is now:

The worst it could possibly be ...... A major problem ............................ A minor problem ............................ Not a problem ................................

0.8 8.4 43.5 47.3

—— An Atlas of Common Skin Diseases ——

15.4 80.5

Frequency, severity and morbidity The data show that acne is most common in adolescence. It is more common in younger females due to early onset of puberty. It increases in frequency and severity in males in later adolescence. Even though it has traditionally been called a disease of adolescence, a substantial proportion of young adults in their twenties and thirties also suffer from acne to some degree. More than 15% of school children had acne that was classified as moderate to severe requiring medical care. Greater than 25% were in this category between 20-29 years. The acne disability index is a quality of life measure asking questions related specifically to the nature of acne. More than 30% of school students had felt aggressive, frustrated or embarrassed about the condition. A similar proportion was seen in adults using the DLQI. Twenty percent of school students stated that their social life or relationships with others had been affected and more than 50% of students had been concerned because of their skin in the last month. Over 40% of the adults affected had symptoms such as pain, stinging or soreness related to their acne within the last week.

The Dermatology Life Quality Index (DLQI) in adults with acne DLQI question

ANSWERS

Over the last week…

very much

a lot

% (n=122) a little not at all / not relevant

1.

how itchy, sore, painful or stinging has your skin been?

1.6

4.1

37.7

56.6

2.

how embarrassed or self-conscious have you been because of your skin?

2.5

4.1

30.3

63.1

3.

how much has your skin interfered with you going shopping or looking after your home or garden?

0.0

0.0

3.3

96.7

how much has your skin influenced the clothes you wear?

0.8

1.6

5.7

91.8

how much has your skin affected any social or leisure activities?

0.8

0.0

1.6

97.5

how much has your skin made it difficult for you to do any sport?

0.0

0.0

1.6

98.4

how much has your skin been a problem at work or studying?

0.0

0.8

3.3

95.9

how much has your skin created problems with your partner or any of your close friends or relatives?

0.0

0.0

4.1

95.9

how much has your skin caused any sexual difficulties?

0.0

0.0

3.3

96.7

0.0

0.0

5.7

94.3

4. 5. 6. 7. 8.

9.

10. how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time?

—— Acne ——

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NAPPY RASH

(NAPKIN DERMATITIS)

Clinical features Nappy rash is an inflammatory skin condition localised to the nappy area. It is usually red and can cause discomfort in the infant or toddler affected. It is caused by contact with urine and faeces which are irritating substances, and occurs on areas of the skin which are in contact with the nappy. The deep skin folds in the groin may therefore not be affected. Other types of eczema or dermatitis such as atopic dermatitis and seborrhoeic dermatitis, can occur in the nappy area and may be associated with an increased tendency to nappy rash.

Prevalence of nappy rash in infants 40 35

Prevalence (%)

30 25 20 15 10 5 0 <3

3–5

6–8

9–12

Age (months) Overall Male Female

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—— Atlas Of Common Skin Diseases ——

Prevalence of nappy rash in infants

Age (months)

No. examined Prevalence % (95% CI) Overall Male Female <3 3-5 6-8 9 - 11

182 96 86 46 60 38 38

25.8 25.0 26.7 19.6 20.0 34.2 34.2

(19.4-32.2) (16.2-33.8) (17.2-36.3) (7.7-31.5) (9.6-30.4) (18.4-50.0) (18.4-50.0)

Severity of nappy rash in infants

Age (months)

No. with nappy rash Overall Male Female <3 3-5 6-8 9 - 11

47 24 23 9 12 13 13

Minimal % 23.4 20.8 26.1 33.3 16.7 30.8 15.4

Mild %

Moderate %

Severe %

55.3 58.3 52.2 33.3 58.3 61.5 61.5

21.3 20.8 21.7 33.3 25.0 7.7 23.1

0.0 0.0 0.0 0.0 0.0 0.0 0.0

Frequency and severity The data show that napkin dermatitis occurs frequently in infants who are wearing nappies. There tends to be an increased frequency after the age of five months. Mothers often attribute this to teething when they describe the urine as smelling more concentrated. Very severe nappy rash is uncommon, with the majority being either minimal to mild requiring only conservative treatment. Nevertheless, at least 20% are classified as moderate which would require medical attention.

—— Nappy Rash ——

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ATOPIC DERMATITIS (ECZEMA) Clinical features Atopic dermatitis is an inflammatory skin condition which manifests as a red, scaly rash that is normally very itchy. It tends to be an inherited condition which runs in families along with asthma and hayfever. In general, it occurs first on the face in infants and then on the front of the elbows and behind the knees (the flexures) with increasing age. It can occur on any part of the skin at some stage, depending on age and exposure to environmental irritants. For example, in mothers with young babies, or hairdressers, it may occur on the hands. Prevalence of atopic dermatitis in preschool children 60

Overall Male Female

Prevalence (%)

50 40 30 20 10 0 <3

4–6

7–9

10–12

2

3

months

4

5

years

Age Prevalence of atopic dermatitis in preschool children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female <1 1 2 3 4 5

1116 567 549 182 176 184 224 184 166

30.8 31.3 30.2 27.4 40.6 28.6 34.4 31.2 22.9

(28.0-33.5) (27.5-35.1) (26.3-34.1) (20.7-34.0) (33.4-47.9) (22.1-35.0) (27.6-41.3) (24.4-37.7) (16.9-28.9)

Severity of atopic dermatitis in preschool children

Age (years)

No. with Minimal atopic dermatitis %

12

Overall Male Female <1 1 2 3 4 5

346 178 168 50 71 52 77 58 38

4.9 5.6 4.9 2.1 4.1 10.9 6.1 5.1 0.0

Mild %

Moderate %

Severe %

58.8 57.0 60.4 45.8 60.3 61.8 62.1 57.6 63.6

34.5 36.3 32.3 47.9 35.6 25.5 28.8 35.6 36.4

1.7 1.1 2.4 4.2 0.0 1.8 3.0 1.7 0.0

—— Atlas Of Common Skin Diseases ——

Prevalence of atopic dermatitis in school children 25

15 10 5 0 4–6

7–9

10–12

13–15

Age (years)

16–18

Overall Male Female

Prevalence of atopic dermatitis in school children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 4-6 7-9 10-12 13-15 16-18

2491 1174 1317 385 665 636 539 266

16.3 14.8 17.7 18.7 18.7 15.6 15.4 11.6

(14.1-18.5) (11.8-17.8) (15.0-20.4) (13.0-24.3) (15.0-22.5) (12.1-19.0) (12.1-18.7) (8.5-14.6)

Severity of atopic dermatitis in school children No. with Minimal atopic dermatitis %

Age (years)

Prevalence (%)

20

Overall Male Female 4-6 7-9 10-12 13-15 16-18

414 180 234 70 129 99 84 32

32.1 28.9 34.6 38.6 31.8 33.3 29.8 21.9

Mild %

Moderate %

Severe %

54.1 55.6 53.0 50.0 51.2 52.5 59.5 65.6

12.6 13.9 11.5 10.0 16.3 12.1 9.5 12.5

1.2 1.7 0.9 1.4 0.8 2.0 1.2 0.0

—— Atopic Dermatitis ——

13

Prevalence of atopic dermatitis in adults 25

Overall Male Female

Prevalence (%)

20

15

10

5

0 20–29

30-–39

40–49

50–49

60–69

70+

Age (years) Prevalence of atopic dermatitis in adults

Severity of atopic dermatitis in adults No. with atopic dermatitis

No. examined Prevalence % (95% CI) Overall Male Female Age (years) 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787

6.9 5.7 8.1

(5.6-8.3) (4.0-7.4) (6.2-10.1)

156 211 272 267 268 283

15.6 10.4 6.8 5.1 1.9 2.6

(10.7-20.4) (6.6-14.2) (3.8-9.7) (2.2-7.9) (0.8-4.6) (1.2-5.5)

Overall Male Female Age (years) 20-29 30-39 40-49 50-59 60-69 70+

Mild %

93 37 56

82.8 79.0 85.3

14.6 18.6 11.9

2.6 2.5 2.7

26 23 19 13 5 7

70.3 92.4 95.9 76.5 79.3 85.8

24.8 7.6 4.1 23.5 20.7 0.0

4.9 0.0 0.0 0.0 0.0 14.2

Frequency, severity and morbidity These data show that the condition commences at around two to three months of age and increases in frequency after that. The prevalence peaks at about 12 months of age and then slowly decreases. It is uncommon after the fifth decade. The severity tends to vary with age. Although the proportion of those affected with disease classified as severe is around 2% in all ages, infants and children have a higher proportion with moderate disease than older people. The proportion with mild disease tends to increase with increasing age and decreasing prevalence. The morbidity index (DLQI) completed by adults indicates that people with atopic dermatitis can have many aspects of their work, home and social life affected. There is not always a clear correlation with severity. For example, those with disease classified as mild may have relatively high DLQI scores on occasion.

14

—— Atlas Of Common Skin Diseases ——

Moderate Severe % %

Prevalence of atopic dermatitis over all ages 60

Overall Male Female

50

Prevalence (%)

40

30

20

10

0 <3

6

9

12

2

3

4

5

11

months

17

25

35

45

55

65

75+

years

Age (

The Dermatology Life Quality Index (DLQI) in adults with atopic dermatitis DLQI question

ANSWERS

Over the last week…

very much

a lot

% (n=78) a little not at all / not relevant

1.

how itchy, sore, painful or stinging has your skin been?

3.8

10.3

62.8

23.1

2.

how embarrassed or self-conscious have you been because of your skin?

1.3

1.3

28.2

69.2

3.

how much has your skin interfered with you going shopping or looking after your home or garden?

0.0

2.6

5.1

92.3

how much has your skin influenced the clothes you wear?

0.0

3.8

19.2

76.9

how much has your skin affected any social or leisure activities?

0.0

0.0

6.4

93.6

how much has your skin made it difficult for you to do any sport?

0.0

0.0

1.3

98.7

7.

how much has your skin been a problem at work or studying?

0.0

2.6

14.1

83.3

8.

how much has your skin created problems with your partner or any of your close friends or relatives?

0.0

0.0

1.3

98.7

how much has your skin caused any sexual difficulties?

0.0

0.0

2.6

97.4

0.0

1.3

14.1

84.6

4. 5. 6.

9.

10. how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time?

—— Atopic Dermatitis ——

15

SEBORRHOEIC DERMATITIS Clinical features Seborrhoeic dermatitis is an inflammatory skin condition which usually occurs in hair bearing areas, such as the scalp, chest or beard, and in the flexures, particularly under the arms, submammary region and in the groin or perianal region. It manifests as a red, scaly rash, which may appear shiny or greasy looking. In newborns, it is a cause of cradle cap and can occur in the face, nappy area, and other flexures. The cause of the condition is unknown, although it can be precipitated by cold, dry weather, contact with irritating substances such as soap, scratching and periods of worry and anxiety. Prevalence of seborrhoeic dermatitis in preschool children 50 45

Prevalence (%)

40 35 30 25 20 15 10 5 0 <1

1

2

3

4

5

Age (years)

Overall Male Female

Prevalence of seborrhoeic dermatitis in preschool children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female <1 1 2 3 4 5

1116 567 549 182 176 184 224 184 166

10.0 10.4 9.5 44.6 7.3 7.3 1.1 0.5 1.6

(8.2-11.7) (7.9-12.9) (7.0-12.0) (37.1-52.0) (3.6-11.3) (3.7-11.1) (0.3-4.4) (0.1-3.5) (0.5-5.0)

Severity of seborrhoeic dermatitis in preschool children

Age (years)

No. with seborr- Minimal hoeic dermatitis %

16

Overall Male Female <1 1 2 3 4 5

114 62 52 81 13 14 2 1 3

3.4 4.7 1.8 3.8 7.7 0.0 0.0 0.0 0.0

Mild % 69.2 63.8 75.3 60.3 84.6 85.7 100.0 100.0 100.0

—— Atlas Of Common Skin Diseases ——

Moderate %

Severe %

26.6 29.9 22.8 34.6 7.7 14.3 0.0 0.0 0.0

0.8 1.6 0.0 1.3 0.0 0.0 0.0 0.0 0.0

Prevalence of seborrhoeic dermatitis in adults 18

Overall Male Female

16

12 10 8 6 4 2 0 20–29

30–39

40–49

50–59

60–69

70+

Age (years)

Frequency and severity

Prevalence of seborrhoeic dermatitis in adults

The data show that seborrhoeic dermatitis commences soon after birth, peaking early in the first year and reducing in prevalence after that.

Very few people have severe seborrhoeic dermatitis with the vast majority being either mild or moderate. Nevertheless, this condition can be itchy, particularly when it occurs in the scalp or in the perianal region and can cause considerable discomfort.

Age (years)

There were insufficient numbers with seborrhoeic dermatitis in the School Survey to present data in this Atlas with any confidence. However in adults, there is a relatively steady prevalence of around 10% at all ages.

No. examined Prevalence % (95% CI) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

9.7 12.3 7.3 11.1 10.0 8.4 11.7 7.8 9.6

(8.2-11.2) (9.9-14.8) (5.4-9.2) (6.9-15.3) (6.3-13.8) (5.1-11.7) (7.5-15.9) (4.2-11.4) (6.0-13.1)

Severity of seborrhoeic dermatitis in adults No. with seborrhoeic dermatitis

Age (years)

Prevalence (%)

14

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

—— Seborrhoeic Dermatitis ——

136 79 57 16 21 22 31 22 24

Mild % 75.3 74.4 76.4 79.2 84.0 52.2 74.1 70.6 88.0

Moderate Severe % % 23.6 23.3 23.6 20.8 16.0 47.8 22.2 23.5 12.0

1.1 2.3 0.0 0.0 0.0 0.0 3.7 5.9 0.0

17

PSORIASIS Clinical features Psoriasis is inflammatory skin disease characterised by a red, scaly rash, which can be itchy. A typical lesion is a well-defined raised plaque with a silvery scale. It occurs classically on the elbows, knees and in the scalp, but can occur on any part of the body on occasion, including the flexures. It can cause the nails to become pitted, discoloured and fragile. While the cause of psoriasis is essentially unknown, it appears to be more common in some families. It has also been associated with various factors in those people who are predisposed to psoriasis, such as trauma to the skin, streptococcal upper respiratory infections, stress, some medications, heavy alcohol intake and smoking. Prevalence of psoriasis in adults 12

Overall Male Female

Prevalence (%)

10 8 6 4 2 0 20–29

30–39

40–49

50–59

60–69

70+

Age (years) Prevalence of psoriasis in adults

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

6.6 8.9 4.5 7.4 5.8 8.3 6.3 7.6 4.6

(5.4-7.9) (6.8-11.0) (3.2-6.3) (3.9-10.9) (2.9-8.7) (5.0-11.6) (3.2-9.5) (4.1-11.2) (2.7-7.8)

Severity of psoriasis in adults

Age (years)

No. with psoriasis

18

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

99 65 34 12 12 21 19 21 14

Mild %

Moderate %

Severe %

81.1 77.6 87.5 75.1 66.6 94.2 77.3 80.8 86.5

16.1 18.1 12.5 16.6 33.4 0.0 22.7 19.2 13.5

2.8 4.3 0.0 8.3 0.0 5.8 0.0 0.0 0.0

—— Atlas Of Common Skin Diseases ——

Frequency, severity and morbidity The data show that psoriasis is predominantly an adult disease. The numbers and classification in the childhood surveys were insufficient to give figures with confidence. Nevertheless, a frequency of almost 7% in adults is high. The majority of disease is mild. Psoriasis can be a difficult condition to treat, particularly when it is moderate to severe. Although the proportions in these categories are less than 20% in adults, they still represent a substantial number of people in the community requiring treatment. The DLQI reveals that more than 50% of people said their skin had been itchy in the last week and more than 25% had been embarrassed by it. Over 20% had some problem created by the treatment making their home messy or by it taking up time.

The Dermatology Life Quality Index (DLQI) by adults with psoriasis DLQI question

ANSWERS

% (n=90) a little not at all / not relevant

very much

a lot

how itchy, sore, painful or stinging has your skin been?

2.2

6.7

46.7

44.4

how embarrassed or self-conscious have you been because of your skin?

1.1

5.6

20.0

73.3

how much has your skin interfered with you going shopping or looking after your home or garden?

0.0

3.3

5.6

91.1

how much has your skin influenced the clothes you wear?

0.0

0.0

13.3

86.7

how much has your skin affected any social or leisure activities?

0.0

2.2

3.3

94.4

how much has your skin made it difficult for you to do any sport?

0.0

1.1

2.2

96.7

how much has your skin been a problem at work or studying?

0.0

2.2

6.7

91.1

8

how much has your skin created problems with your partner or any of your close friends or relatives?

0.0

0.0

6.7

93.3

9

how much has your skin caused any sexual difficulties?

1.1

1.1

3.3

94.4

1.1

3.3

17.8

77.8

Over the last week… 1 2 3

4 5 6 7

10 how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time?

—— Psoriasis ——

19

WARTS Clinical features Warts are a viral infection of the skin caused by the Human Papilloma Virus (HPV). There are several different types, two of which will be reported in this chapter: common warts (verruca vulgaris) and plantar warts (verruca plantaris). Common warts are flesh-coloured lesions occurring most frequently on the hands, fingers and knees. They can also grow at a site where an injury has occurred. They are not usually painful, although they may cause pain if they develop at a site where pressure occurs, e.g. knuckle or the knee. Plantar warts (also called papillomas) are flesh-coloured and are found on the sole of the foot. They are flat as the person’s body weight forces them to grow inwards. This can be very painful. Prevalence of common warts in school children 25

Overall Male Female

Prevalence (%)

20 15 10 5 0 4–6

7–9

10–12

13–15

16–18

Age (years) Prevalence of common warts in school children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 4-6 7-9 10-12 13-15 16-18

2491 1174 1317 385 665 636 539 266

16.2 17.0 15.5 7.8 15.1 17.9 18.9 17.2

(14.4-18.1) (14.5-19.5) (12.9-18.1) (4.5-11.0) (12.8-17.4) (14.2-21.6) (14.9-22.9) (11.2-23.1)

Number of common warts in school children

Age (years)

No. with common warts

20

Overall Male Female 4-6 7-9 10-12 13-15 16-18

383 190 193 29 96 114 99 45

1–2 %

Number of Warts 3–5 6 or more % %

72.6 70.5 74.6 69.0 78.1 67.5 69.7 82.2

19.8 22.6 17.1 20.7 16.7 21.1 23.2 15.6

7.6 6.8 8.3 10.3 5.2 11.4 7.1 2.2

—— Atlas Of Common Skin Diseases ——

Prevalence of plantar warts in school children 10

Overall Male Female

8 7 6 5 4 3 2 1 0 4–6

7–9

10–12

13–15

16–18

Age (years)

Prevalence of plantar warts in school children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 4-6 7-9 10-12 13-15 16-18

2491 1174 1317 385 665 636 539 266

6.3 5.9 6.6 5.1 6.9 5.9 6.2 6.6

(5.2-7.3) (4.7-7.1) (5.0-8.2) (3.0-7.2) (4.8-9.0) (3.9-7.8) (4.3-8.2) (4.1-9.0)

Number of plantar warts in school children No. with plantar warts

Age (years)

Prevalence (%)

9

Overall Male Female 4-6 7-9 10-12 13-15 16-18

155 69 86 19 46 40 33 17

1–2 % 80.6 79.7 81.4 94.7 78.3 85.0 81.8 58.8

Number of Warts 3–5 6 or more % % 11.6 13.0 10.5 0.0 15.2 12.5 6.1 23.5

—— Warts ——

3.2 2.9 3.5 0.0 4.3 2.5 6.1 0.0

Mosaic % 4.5 4.3 4.7 5.3 2.2 0.0 6.1 17.6

21

Prevalence of common warts in adults 14

Overall Male Female

Prevalence (%)

12 10 8 6 4 2 0 20–29

30–39

40–49

50–59

60–69

70+

Age (years) Prevalence of common warts in adults

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

5.6 6.0 5.2 11.7 7.8 4.0 5.0 3.1 2.5

(4.4-6.7) (4.2-7.7) (3.6-6.8) (7.4-16.0) (4.5-11.2) (2.2-7.4) (2.2-7.9) (1.6-6.2) (1.3-5.0)

Number of common warts in adults

Age (years)

No. with common warts Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

81 40 41 24 18 10 13 8 8

Number of Warts 1-2 3 - 5 6 or more % % % 80.0 78.0 82.1 73.1 94.7 90.9 75.0 71.4 57.1

15.0 17.1 12.8 15.4 5.3 9.1 25.0 28.6 28.6

5.0 4.9 5.1 11.5 0.0 0.0 0.0 0.0 14.3

Frequency and number of warts The data show that warts, although starting in young children, become most frequent in adolescence and then they decrease in frequency with increasing age. This is the case for both common and plantar warts. It is consistent with these infections being spread amongst people with frequent contact, i.e., at school. The data show that the lesions are not only frequent, but also they are multiple in both common and plantar warts. At least 20% of those affected with common warts had more than two. Plantar warts are often painful and 20% of those with them in childhood and 10% of those with them in adulthood had more than two. 22

—— Atlas Of Common Skin Diseases ——

Prevalence of plantar warts in adults 4.5

Overall Male Female

Prevalence (%)

4 3.5 3 2.5 2 1.5 1 0.5 0 20–29

30–39

40–49

50–59

60–69

Age (years)

70+

Prevalence of plantar warts in adults

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

1.3 1.4 1.2 3.6 1.6 1.7 1.2 0.0 0.0

(0.8-2.1) (0.7-2.8) (0.6-2.3) (1.6-8.0) (0.5-5.0) (0.7-4.1) (0.4-3.7) (0.0) (0.0)

Number of plantar warts in adults

Age (years)

No. with plantar warts Overall Male Female 20-29 30-39 40-49 50-59

1–2 %

17 8 9 6 3 5 3

Number of Warts 3–5 6 or more % %

90.0 90.0 88.9 87.5 100.0 80.0 100.0

5.0 10.0 0.0 12.5 0.0 0.0 0.0

5.0 0.0 11.1 0.0 0.0 20.0 0.0

Prevalence of warts in school children and adults 20

Common Plantar

18

Prevalence (%)

16 14 12 10 8 6 4 2 0 5

11

17

25

35

—— Warts ——

45

55

65

75+

Age (years) 23

TINEA PEDIS

AND

TINEA UNGUIUM

Clinical features Tinea (also called ringworm) is an infection of the skin, nails or hair caused by dermatophyte fungi. Dermatophytes are grouped into three classes: Trichophyton, Epidermophyton and Microsporum. Each of these classes of fungi can infect the skin, but Microsporum tends not to involve the nails and Epidermophyton seldom invades hair. Tinea is also classified clinically based on what area is infected. Two types of tinea will be reported in this chapter: tinea pedis (tinea of the foot) and tinea unguium (tinea of the nail). Tinea pedis manifests as a red, scaly, rash on the foot which can be itchy on occasion. It commonly occurs between the toes, particularly between the 4th and 5th toes, but can occur anywhere on the foot. Tinea unguium (also called dermatophyte onychomycosis) manifests as discolouration of the nail plate and there may be a build-up of infectious material and cells under the nail plate. The nail plate may occasionally partially lift away from the nail bed. This condition is usually accompanied by tinea pedis. Prevalence of tinea pedis in school children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female 4-6 7-9 10-12 13-15 16-18

2491 1174 1317 385 665 636 539 266

5.2 6.0 4.3 2.1 2.5 4.6 5.8 9.7

(3.6-6.8) (3.8-8.3) (2.6-6.1) (1.0-3.3) (1.1-3.9) (2.3-6.9) (3.5-8.2) (5.2-14.3)

Prevalence of tinea pedis in adults

Age (years)

No. examined Prevalence % (95% Cl) Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

9.2 13.3 5.4 11.1 5.3 8.3 9.5 12.7 9.4

(7.8-10.7) (10.8-15.9) (3.8-7.1) (6.9-15.3) (2.5-8.1) (5.0-11.5) (5.7-13.4) (8.2-17.1) (5.9-13.0)

Prevalence of tinea unguium in adults

Age (years)

No. examined Prevalence % (95% CI)

24

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

5.1 8.2 2.3 3.0 1.4 4.9 3.2 8.3 9.6

(4.0-6.3) (6.1-10.2) (1.5-3.6) (1.1-8.0) (0.5-4.3) (2.9-8.3) (1.7-5.9) (4.6-12.0) (6.1-13.2)

—— Atlas Of Common Skin Diseases ——

Dermatophytes causing tinea pedis in school children Type of dermatophyte

% (no. cases)

Trichophyton mentagrophytes

61.2 (82)

Trichophyton rubrum

33.6 (45)

Epidermophyton floccosum

1.5 (2)

Other dermatophyte*

3.7 (5)

* Includes Trichophyton terrestre,Trichophyton tonsurans, Microsporum gypseum

Dermatophytes causing tinea pedis in adults Type of dermatophyte

% (no. cases)

Trichophyton mentagrophytes var interdigitale

53.1 (69)

Trichophyton mentagrophytes var mentagrophytes

19.2 (25)

Trichophyton rubrum

18.5 (24)

Epidermophyton floccosum

9.2 (12)

Dermatophytes causing tinea unguium in adults Type of dermatophyte

% (no. cases)

Trichophyton mentagrophytes var interdigitale

57.0 (45)

Trichophyton rubrum

22.8 (18)

Trichophyton mentagrophytes var mentagrophytes

13.9 (11)

Epidermophyton floccosum

6.3 (5)

Frequency

Prevalence (%)

Prevalence of tinea pedis in school children and adults 20 18 16 14 12 10 8 6 4 2 0

Overall Male Female

5

11

17

25

35

45

55

65

Tinea affecting the nail is uncommon in children but there is an increasing frequency with increasing age. Both tinea pedis and tinea unguium tend to be more common in men than in women.

75+

Age (years)

14

Prevalence of tinea pedis in school children

Overall Male Female

12 10 8 6 4 2 0 4–6

7–9

10–12

13–15

16–18

Age (years)

Prevalence of tinea pedis in adults

20 18 16 14 12 10 8 6 4 2 0 20–29

Overall Male Female

30–39

Prevalence (%)

Prevalence (%)

Prevalence (%)

Although tinea pedis is said to be rare amongst children, these data show that it occurs in four to six year olds with increasing frequency during adolescence. It slowly increases in frequency in adulthood.

20 18 16 14 12 10 8 6 4 2 0

40–49

59–59

60–69

70+

Age (years)

Prevalence of tinea unguium in adults

20–29

Overall Male Female

30–39

40–49

59–59

60–69

70+

—— Tinea Pedis and Tinea Unguium ——

Age (years) 25

BIRTHMARKS Clinical features There are several different types of birthmarks, which, as the name suggests, are often present at birth or in early infancy. They are areas of abnormal skin cell development, in which a particular type of cell may have a higher proportion than other types. Four types of birthmark will be reported in this chapter: Salmon patch, haemangiomas, congenital melanocytic naevi and Mongolian spot. A salmon patch is a vascular lesion due to large numbers of small blood vessels which are very close to the surface of the skin. They are harmless and are normally found on the neck, forehead and eyelids. Haemangiomas (also called strawberry naevi) are red vascular lesions. They are made up of large numbers of capillaries. They are commonly found on the head and neck. Congenital melanocytic naevi (moles) are due to a problem with the movement of melanocytes during an infant’s development. This leads to an accumulation of a large number of cells and hence the dark appearance of the mole. Mongolian spots are grey or brown areas found on the buttocks or the sacrum. They are due to increased melanin production, particularly among children born to Asian parents.

Salmon Patch Prevalence of salmon patch in preschool children 70

Overall Male Female

Prevalence (%)

60 50 40 30 20 10 0 <1

1

2

3

Age (years) Prevalence of salmon patch in preschool children

Age (years)

No. examined Prevalence % (95% CI)

26

Overall Male Female <1 1 2 3 4 5

1116 567 549 182 176 184 224 184 166

34.8 30.6 39.3 55.7 40.8 33.0 21.7 28.6 31.3

(32.1-37.7) (26.8-34.4) (35.2-43.5) (48.2-63.1) (33.5-48.1) (26.3-39.8) (15.9-27.8) (22.1-35.1) (24.5-37.7)

—— Atlas Of Common Skin Diseases ——

4

5

Haemangioma Prevalence of haemangioma in preschool children 16

Overall Male Female

Prevalence (%)

14 12 10 8 6 4 2 0 <1

1

2

3

4

5

Age (years)

Prevalence of haemangioma in preschool children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female <1 1 2 3< 4 5

1116 567 549 182 176 184 224 184 166

7.2 5.1 9.3 10.9 7.8 8.4 5.3 5.3 5.7

(5.7-8.7) (3.3-6.9) (6.9-11.8) (6.4-15.8) (3.9-11.7) (4.5-12.5) (2.1-8.5) (1.9-8.2) (2.4-9.0)

Congenital Melanocytic Naevus Prevalence of congenital melanocytic naevus in preschool children 16

Overall Male Female

12 10 8 6 4 2 0 <1

1

2

3

4

5

Age (years)

Prevalence of congenital melanocytic naevus in preschool children No. examined

Age (years)

Prevalence (%)

14

Overall Male Female <1 1 2 3 4 5

1116 567 549 182 176 184 224 184 166

Prevalence % 10.2 10.0 10.4 5.1 12.8 10.5 11.6 9.5 11.5 —— Birthmarks ——

(95% CI) (8.4-12.0) (7.5-12.5) (7.9-13.0) (1.7-8.2) (8.0-17.9) (6.1-14.9) (7.0-16.2) (5.5-14.0) (6.7-15.8) 27

Mongolian Spot Prevalence of Mongolian spot in preschool children 25

Overall Male Female

Prevalence (%)

20 15 10 5 0 <1

1

2

3

4

5

Age (years)

Prevalence of Mongolian spot in preschool children

Age (years)

No. examined Prevalence % (95% CI) Overall Male Female <1 1 2 3 4 5

1116 567 549 182 176 184 224 184 166

10.9 11.2 10.6 16.6 10.6 9.4 13.2 9.5 6.8

(9.1-12.8) (8.6-13.8) (8.0-13.2) (10.8-21.9) (6.2-15.4) (5.3-13.7) (8.2-17.8) (5.5-14.0) (3.1-10.2)

Mother’s country of birth

Prevalence of Mongolian spot in preschool children by mother’s country of birth Australia and New Zealand Asia United Kingdom and Ireland Europe Middle East and Africa Other

0

10

20

30

40

50

60

70

80

Prevalence (%)

“Europe” includes all European countries apart from United Kingdom and Ireland “Other” includes United States, Central and South America, and the Pacific Islands

Frequency The data show that birthmarks are very common in young children. Mongolian spots are extremely common in children of parents who have increased pigmentation in their skin, occurring in almost 80% of children of Asian parents. They are less common in children of white Anglo-Saxon parents. Salmon patches and other vascular abnormalities (haemangiomas) tend to occur within the first year of life and slowly disappear with increasing age. Congenital melocytic naevi tend to occur within the first year of life and then remain stable and present for many years after that.

28

—— Atlas Of Common Skin Diseases ——

CAMPBELL DE MORGAN SPOTS Clinical features Campbell de Morgan spots (also called cherry angiomas) are small, cherry red, smooth spots which are found on the trunk of middle aged or elderly people. They do not bleed and they have no symptoms. The cause is unknown. While they appear to be very common in the community, the prevalence has not been previously reported.

Prevalence of Cambell de Morgan spots in adults 90

Overall Male Female

80

60 50 40 30 20 10 0 20–29

30–39

40–49

50–59

60–69

70+

Age (years)

Prevalence of Campbell de Morgan spots in adults No. examined Prevalence % (95% CI)

Age (years)

Prevalence (%)

70

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

54.4 50.2 58.4 22.0 43.5 51.8 61.2 66.9 78.0

(51.9-57.0) (46.5-53.9) (54.9-61.9) (16.4-27.5) (37.3-49.7) (45.8-57.7) (54.9-67.6) (60.6-73.2) (73.0-83.0)

Frequency These tiny red vascular spots start to occur in young adulthood and become increasingly common with age. Although not reported in detail here, the average number of these lesions also increases with age from 1-2 lesions in early adulthood to 50 or more Campbell de Morgan spots in people aged 60 years and over. The significance of these lesions is unknown.

—— Campbell de Morgan Spots ——

29

SEBORRHOEIC KERATOSES Clinical features Seborrhoeic keratoses (also called seborrhoeic warts) are very common benign growths. They are usually round, dark brown or almost black warty growths which occur on the face and trunk. On the back of the hands and forearms, they are often dark and flat, described as “liver spots”. On the lower legs they may be pale scaling spots in large numbers described as “stucco keratoses”. They have been described as “senile warts” in the past because of a belief that they were a condition of older people.

Prevalence of seborrhoeic keratoses in adults 100 90 80

Prevalence (%)

70 60 50 40 30 20 10 0 20–29

30–39

40–49

50–59

60–69

70+

Age (years) Overall Male Female Prevalence of seborrhoeic keratoses in adults

Age (years)

No. examined Prevalence % (95% CI)

30

Overall Male Female 20-29 30-39 40-49 50-59 60-69 70+

1,457 670 787 156 211 272 267 268 283

58.2 55.8 60.4 9.4 30.1 54.9 76.3 84.6 90.4

(55.6-60.7) (52.1-59.5) (56.9-63.9) (5.5-13.3) (24.4-35.9) (49.0-60.8) (70.8-81.9) (79.8-89.4) (86.9-94.0)

—— Atlas Of Common Skin Diseases ——

Frequency The data show that these conditions start to occur at a relatively young age so that by young adulthood 10% of people are affected. They occur with increasing frequency with increasing age so that a large proportion of the population have at least one by the age of 60. Although the numbers of seborrhoeic keratoses per person are not reported here, the number of people with them not only increases with age, but also the number that individuals have increases at the same time. By the age of 60 it is common to have at least 10 seborrhoeic keratoses.

—— Seborrhoeic Keratoses ——

31

Where Do People Seek Advice For Treatment Of Common Skin Diseases?

Because the skin conditions occur on the surface of the body where they are easily seen, they are often noticed first when they might be considered to be relatively mild. Under such circumstances, a person with a mild condition may decide that they don’t want to bother a doctor about something that might be considered trivial. Likewise they may think it is too expensive to seek professional advice for a mild condition. Consequently, they may show it to their family or friends initially.

sources with the pharmacist being high on the list. Almost 20% said that they had diagnosed the condition themselves and prescribed the treatment that was necessary. Of course, this may have been on the basis of past experience or from something that they had seen or read in the media. The first table (page 31) is a breakdown of where adults said they received their advice according to the diagnosis that they reported. It can be seen

They may attend a pharmacist where many efficacious products for mild skin conditions are available over the counter without prescription. Other persons they may turn to include naturopaths, osteopaths, chiropractors, beauticians, hairdressers, or a variety of other people who may be seen as a source of advice about minor skin conditions in the community. Thus surveys of medical practitioners on the frequency with which people seek advice for skin problems may grossly underestimate the true extent of the problem in the community.

Source of advice for treatment in adults 60 50

Prevalence (%)

There is a tendency amongst the medical profession to believe that they are the major source of advice for medical problems in the community. This is not always the case, particularly for diseases affecting the skin.

40 30 20 10 0 Eczema/ Dermatitis

Acne

Tinea

Skin Condition

In the Maryborough telephone survey of adults in Central Victoria, less than 50% of people who had sought advice for a condition they had in the last two weeks had gone to a medical practitioner. Over 50% had sought it from a variety of other

Other Family/friend Pharmacist General practitioner Dermatologist

Source of advice for self-reported skin conditions in adults

All conditions Acne/pimples Cold sores Dermatitis/eczema Psoriasis Skin cancer Thrush Tinea Urticaria/hives Warts

Medical practitioner (%)

Pharmacist (%)

Family/ friends (%)

49 8 11 71 92 92 84 30 100 60

19 17 35 9 35 10

6 25 14 2 10

No of conditions treated = 242 32

Warts

—— Atlas Of Common Skin Diseases ——

SelfOther prescribed (%) (%) 19 8 34 16 8 8 23 20

7 42 6 4 8 8 10 -

that the more active or difficult the condition, the more likely they were to seek advice from a medical practitioner. This is particularly the case in dermatitis, psoriasis and, of course, skin cancer. Urticaria can be an extremely itchy and distressing condition and hence the use of medical practitioners frequently.

of advice for cradle cap. In Victoria, there is an outstanding community-based Maternal and Child Health Service. It is free and has been used by all new mothers and babies in the State for decades. These nurses are very well trained to give advice about minor skin conditions such as cradle cap.

Finally, in this series, there was a relatively high proportion of people with warts who attended a medical practitioner. In this case, the use of physical therapy such as liquid nitrogen or burning or cutting off a wart may be seen as a skill in the domain of a medical practitioner.

For nappy rash, there is a spread of advice between the medical practitioners, pharmacists, family, friends and with nurses giving advice in a relatively small proportion.

None of the diagnoses of the conditions reported in the telephone survey are able to be verified. On the other hand, in the three community-based surveys where dermatologists verified the diagnosis, it is possible to link the specific conditions with where advice was received and whether or not it was of value. In the conditions common in preschool children, it can be seen that a very large proportion of children with eczema (dermatitis) receive their advice from a medical practitioner. On the other hand, a nurse (a maternal and child health nurse) is the major source

Source of advice for treatment in school children

Looking at the source of advice for school children whose diagnosis was confirmed, the same use of medical practitioners as the preschool children is seen for eczema (dermatitis). Medical practitioners also give a substantial proportion of advice for the treatment of warts, including the physical treatments such as the use of liquid nitrogen. Pharmacists also provide advice for treatment of warts and there are many efficacious products available over the counter at pharmacists without the need for a medical prescription. Pharmacists are the most common source of advice for tinea of the feet in children with medical practitioners being used slightly less frequently.

Source of advice for treatment in preschool children

80

60

70

50

Prevalence (%)

Prevalence (%)

60 50 40 30

40 30 20

20 10

10

0

0 Eczema/ Dermatitis

Acne

Tinea

Warts

Skin Condition

Eczema/ Dermatitis

Nappy Rash

Seborrhoeic dermatitis/ cradle cap

Skin Condition

Other Family/friend Pharmacist General practitioner Dermatologist

—— Where Do People Seek Advice For Treatment Of Common Skin Diseases? ——

Other Family/friend Pharmacist General practitioner Dermatologist Other specialist Nurse

33

On the other hand, in the treatment of acne, advice from family and friends is sought most frequently with others, including the beauticians and naturopaths being the second most common source of advice. Pharmacists and medical practitioners are relatively low down in the scale. In adults, once again, medical practitioners are the major source of advice for treatment of eczema (dermatitis). Like school children, adults frequently seek advice for acne from family or friends, with pharmacists and medical practitioners being a far less common group to whom adults would turn with this condition. In summary, these data show that a large proportion of people with minor skin conditions do not seek advice from a medical practitioner but seek it out from a variety of other people who may be seen as a source of information. The likelihood of doing that depends very much on the nature and extent of the condition and perceived severity by the individual affected.

Part of the work undertaken in the studies reported in this Atlas was to obtain details of all the products that people were using for their various skin conditions and then classify them according to whether or not they were likely to be effective (efficacious). The results reported show that there is considerable variation in the value of the products being used according to both the condition being treated and its severity, and who prescribed the product. There is a relatively high proportion of efficacious products being used by the infants with seborrhoeic dermatitis. This includes advice from family and friends and other sources. Other sources in this instance includes the use of books and pamphlets that the parents report they use to select a product. Examination of the value of the products used by preschool children for both eczema and seborrhoeic dermatitis or cradle cap shows increasingly effective products being used with increasing severity of the disease. This correlates well with the finding that as the diseases become more severe, parents are more likely to seek advice for their children from medical practitioners who are qualified to give it.

PRODUCTS USED BY ADULTS

PRODUCTS USED BY SCHOOL CHILDREN

Efficacy of the products used by adults for acne

Efficacy of the products used by school children for acne

Source of advice Dermatologist General practitioner Pharmacist Family/friend Other

Efficacious (%) Non efficacious (%) 100.0 71.4 50.0 31.8 25.0

0.0 28.6 50.0 68.2 75.0

Efficacy of the products used by adults for warts Source of advice Medical practitioner Pharmacist Family/friend

34

Are People Receiving the Correct Advice?

Efficacious (%) Non efficacious (%) 100.0 100.0 33.3

0.0 0.0 66.7

Source of advice Medical practitioner Pharmacist Family/friend Other

Efficacious (%) Non efficacious (%) 81.5 51.5 25.7 31.3

18.5 48.5 74.3 68.8

(Please note: ‘Other’ includes alternative practitioner and beautician)

Efficacy of the products used by school children for warts Source of advice Medical practitioner Pharmacist Family/friend Other

—— Atlas Of Common Skin Diseases ——

Efficacious (%) Non efficacious (%) 100.0 100.0 83.3 25.0

0.0 0.0 16.7 75.0

In school children with acne and warts there is quite a lot of variation in the value of the products they use according to where they receive their advice. It is ironic that the data show that the most frequent source of advice used by school children is family or friends from whom, the data show, they are least likely to be recommended something that is effective. When examining the value of products according to the severity of the acne in school children, it can be seen that almost 50% of the adolescents with moderate acne and a substantial proportion with severe acne are using products that are of no therapeutic value at all. That is in contrast to the products used by school children for eczema in which the majority were classified as likely to have some satisfactory effect. In adults, the efficacy of products used for acne and warts varies once again according to the source of advice. However it was fairly uniform that advice received from unqualified persons was likely to lead to a high chance of purchase and use of products which were of no value at all for the conditions for which they had been recommended.

Summary It can be seen that people with skin diseases in the community are seeking advice from many quarters. The quality of advice that they receive is variable according to not only from whom they seek it, but also according to what condition they have and how severe it is. Looking at the proportions of people with skin disease who are seeking advice from those who are unqualified to give it, a large proportion of the community are receiving advice and using products for which there is no medical or scientific basis and which are unlikely to be of any value for the condition. Overall these data show that although in many instances people are receiving adequate care from those who are qualified to give it, there are still large gaps. There are many people who have common skin problems turning for advice to others in the community who may not be qualified to give it and, on the basis of such advice, are using products that either make no difference to the skin condition or potentially may make it worse.

PRODUCTS USED BY PRESCHOOL CHILDREN Efficacy of the products used by school children for tinea Source of advice Medical practitioner Pharmacist Family/friend Other

Efficacious (%) Non efficacious (%) 73.3 78.6 66.7 0.0

26.7 21.4 33.3 100.0

Efficacy of the products used by preschool children for seborrhoeic dermatitis Source of advice General practitioner Dermatologist Family/friend Pharmacist Nurse Other

Efficacious (%) Non efficacious (%) 91.7 100.0 94.4 69.2 80.4 100.0

8.3 0.0 5.6 30.8 19.6 0.0

(Please note: ‘Other’ includes books and pamphlets)

Efficacy of products used by school children according to severity Condition Eczema/dermatitis Minimal Mild Moderate Severe Acne Minimal Mild Moderate Severe

Efficacious (%) Non efficacious (%) 96.4 86.2 83.3 88.9 37.6 38.1 51.9 85.7

Efficacy of products used by preschool children according to severity Condition

Efficacious (%) Non efficacious (%)

3.6 8.7 7.6 11.1

Eczema/dermatitis Minimal Mild Moderate Severe

62.4 61.9 48.1 14.3

Seborrhoeic dermatitis/cradle cap Minimal 57.1 Mild 92.3 Moderate 76.3 Severe 100.0

87.5 95.3 94.4 100.0

—— Where Do People Seek Advice For Treatment Of Common Skin Diseases? ——

12.5 4.7 5.6 0.0 42.9 7.7 23.7 0.0

35

Recommendations The data reported in this Atlas show that skin conditions are common in the Australian community. Everyone will have now or will have had in the past one or more of the conditions reported. Many people have several of them at the same time. When asked, almost 50% of the community depending on age, will have at least one skin condition for which they may be seeking treatment right now. The data also show that people in the community are not always receiving advice that is likely to lead









36

to satisfactory treatment of their condition. This is of considerable concern as there is very satisfactory management available for virtually all of the conditions reported It is distressing to learn that so many people, including infants and children who are dependent on others, are not receiving the help that they require. It is clear from the data reported in this Atlas that more work needs to be done. On the basis of these data, we make the following recommendations:-

Research should be undertaken on cohorts of people with common skin diseases following them over time. This will determine the morbidity, the effect on quality of life, the cost of having these diseases and will enable quantification of the effect on both the individual and the community. Education programs need to be developed for all professionals or organisations to whom people in the community turn when they are affected by a skin disease. These programs should include undergraduate medical students, general practitioners, pharmacists, and allied health professionals who are in an appropriate position to provide advice to people with skin diseases. Within the general practice training programs there should be specific units on dermatology. These should highlight the frequency and nature of these common diseases and the relatively simple approaches to management that are available. There should be an increase in the number of grants for training dermatologists in Australia. Dermatologists have responsibility not only for providing care for the relatively small proportion of people in the community who require specialist attention, but also for providing further training and teaching for others in the community to whom people with skin diseases turn.

—— Atlas Of Common Skin Diseases ——







Government and other agents responsible for taking the long-term view of maintaining the health of the community should put more resources into research on the frequency, cause, management and prevention of common skin conditions affecting the community. Education programs for the general community need to be developed giving information on the nature of common skin diseases, the treatments that are available, and where they can turn for advice which is likely to be of value. They should include education programs in maternal and child health centres, child care centres, kindergartens, schools, work places and other areas of adult activity. Each of these should be designed and delivered on the basis of research and development appropriate to the area and groups being targeted. Finally, there should be regular studies on the frequency of common skin diseases in Australia that have been reported in this Atlas. They should monitor not only the frequency and severity of the disease over time, but also monitor whether there is an increase in the proportion of people who receive care which is appropriate to their needs.

—— Recommendations ——

37

Acknowledgements We would like to acknowledge all the help we received from teachers, parents and students at schools throughout urban and rural Victoria; Directorate of School Education, Victoria; Youth and Family Services, Human Services Victoria; Catholic Education Office; Rotary, Maryborough District Health Services, Maryborough pharmacies, Maryborough general practitioners and the population of Maryborough, Victoria; the parents, children and staff of the maternal and child health centres, preschool child care centres and kindergartens throughout urban and rural Victoria; all the dermatologists and dermatology registrars who participated as examiners in the surveys over the five year period; the nurses; Dorevitch Tresize Pathology and St Vincent’s Hospital Pathology Service. It is not possible to name everyone. However there are a number of special people who we would particularly like to thank, including Val Bennett, Jan Campbell, Jean Ebejer, Rebecca Edwards, Peter Foley, David Gill, Damien Jolley, Monique Kilkenny, Adrian Mar, Marlene Rennie, Malcolm Rosier, Voula Stathakis, Kay Stewart, Josie Yeatman, Richard Young, and Yeqin Zuo. We thank Andrew Finlay for permission to use the DLQI and ADI, and David Weedon for use of his photomicrographs. This Atlas would not have been possible without the support, encouragement, unfailing enthusiasm and devotion to the common aim of helping people in the community with skin problems by all those people and organisations involved.

Funding for these studies came from:

• Australasian College of Dermatologists, Victorian Faculty, Chair of Dermatology Fund

• Skin and Cancer Foundation (Victoria) • St Vincent’s Hospital (Melbourne) Ltd • Jack Brockhoff Foundation • Australian Dermatology Research and Education Foundation

• F. Bauer Foundation • William Angliss Trust

38

—— Atlas Of Common Skin Diseases ——