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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 7  |  Page : 1076-1082

Spectrum of skin disorders among primary school children in Umuahia, South-East Nigeria


1 Department of Paediatrics, Federal Medical Centre (FMC) Umuahia, Abia State, Nigeria
2 Department of Internal Medicine, Alex Ekwueme Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
3 Department of Paediatrics, University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu State, Nigeria

Date of Submission02-Jun-2021
Date of Acceptance11-May-2022
Date of Web Publication20-Jul-2022

Correspondence Address:
Dr. C A Ibeneme
Department of Paediatrics, FMC, Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1573_21

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   Abstract 


Background: Skin disorders among primary school children are common in many countries, with a variable spectrum. They can constitute major health problems, resulting in considerable discomfort, parental anxiety, and embarrassment to the child. Aim: To determine the prevalence and pattern of skin diseases among primary school children in the Umuahia South local government area. Subjects and Methods: This was a descriptive cross-sectional study carried out over a 4-month period from December 2016 to March 2017 among school children consecutively recruited from their various primary schools. Result: A total of 1560 children aged 5 to 15 years with a mean age of 8.74 ± 2.079 years were studied. The overall prevalence of skin diseases was 40.2%. The prevalence in public schools was 46.0%, whereas the prevalence in private schools was 33.2% (P < 0.001). Skin eruptions and itchy skin were the most common presentations, whereas tinea capitis, pityriasis versicolor, and scabies were the most common skin diseases noted among the school children. Conclusion: The prevalence of skin diseases in the population studied is high, especially in public schools. The most common manifestation of skin disease is rash, and the most common type of skin disease is tinea capitis. It is recommended that standard hygienic practices should be maintained by primary school children and their parents/caregivers to prevent skin diseases.

Keywords: Child, Nigeria, prevalence, school, skin diseases


How to cite this article:
Ewurum O, Ibeneme C A, Nnaji T O, Ikefuna A N. Spectrum of skin disorders among primary school children in Umuahia, South-East Nigeria. Niger J Clin Pract 2022;25:1076-82

How to cite this URL:
Ewurum O, Ibeneme C A, Nnaji T O, Ikefuna A N. Spectrum of skin disorders among primary school children in Umuahia, South-East Nigeria. Niger J Clin Pract [serial online] 2022 [cited 2022 Aug 15];25:1076-82. Available from: https://www.njcponline.com/text.asp?2022/25/7/1076/351450




   Introduction Top


Among its myriad of biological functions such as thermoregulation, sensation, and excretion, the skin plays a key role in communication.[1] It is the boundary between self and the environment, serving as the point of contact with the external environment.[1] The skin serves as a critical barrier to infection and dehydration. It is therefore important to note that the impairment of the skin's normal function can lead to significant morbidity and mortality. The skin in children is thin and more delicate, with a greater ability of absorption because of its greater ratio of skin surface area to body volume. It however has a poor ability to regulate temperature, making them more prone to developing skin disorders.[2],[3] Skin diseases are a major source of health problems affecting a high proportion of the population and causing distress and disabilities.[4] Although very common in many developing countries, skin diseases are not often regarded as significant health problems even when serious diseases may be heralded by skin changes.[5],[6],[7],[8]

Skin diseases are frequently encountered in the tropics and constitute common causes of morbidity. For example, the disfigurement and distress of skin may result in loss of function, strained family relationships, poor self-image, psychiatric cormorbidities, stigmatization, and suicidal behavior.[9] They are particularly significant in children when they contribute to the risk of other life threatening illnesses such as glomerulonephritis, carditis, arthritis, and septicemia.[10] Skin diseases are public health problems in developing countries.[7],[9],[10] Skin diseases in the developing world have stimulated a lot of interest over the years because they are potentially preventable, can be controlled, and may also serve as an index of community development.[11] There are few data on the spectrum of skin diseases among primary school children in rural communities in South-eastern Nigeria. Most of the currently available studies on skin diseases in children are either hospital-based or deal with a single disease entity such as superficial fungal infection or were carried out among secondary school students.[12],[13],[14],[15],[16],[17],[18] There is a need to study the burden of skin diseases as they affect primary school children in our various communities. This is important because school-aged children have peculiarities which predispose them to bacterial skin infections, and they mix and crowd together, thus creating an avenue for easy transmission of infection and infestation from one person to another.[19]

This study was carried out to determine the spectrum of skin diseases among primary school children in Umuahia South local government area (LGA) of Abia state, in South-east Nigeria.

The information obtained may help to facilitate the effective implementation of relevant skin health education programs and appropriate preventive measures.


   Subjects and Methods Top


Study population

This study was conducted among public and private primary school children aged 5–15 years in Umuahia South LGA, Abia state, over a 4-month period from December 2016 to March 2017 when the schools were in session.

Study design

This was a descriptive cross-sectional study.

Subject selection

A list of all primary schools in the 44 communities in the LGA was obtained from the Abia State Ministry of Education. A multistage sampling technique was employed to select the schools to be studied, number of subjects to be selected from each of the schools, and the number of subjects to be recruited from each class of the schools studied.

Determination of the school sample size

The sample size was calculated using the following formula[20]



where n = the desired sample size (when the population is greater than 10,000)

z = the standard normal deviate usually set at 1.96 which corresponds to a 95% confidence level

P = the proportion of the population estimated to have skin disease. In the Ibadan study by Ogunbiyi,[21] the prevalence was 35.2% (0.352)

q = (1 − P) = proportion with no skin disease = 0.648

d = degree of accuracy required

= 0.025 = 2.5%

Therefore,



= 1402

A 10% non-response rate was added, giving a total of 1557.78, approximately 1560 pupils.

Ethical consideration

Ethical clearance was obtained from the Health Research Ethics Committee of the Federal Medical Centre, Umuahia. Permission was obtained from the State Ministry of Education.

Informed consent was obtained from the parents or guardians of the selected students before enrolling them into the study. The selected pupils were given a consent form to be signed by their parents/guardians and returned within 1 week before the dermatological screening phase began. Although the consent form signed by the parents sufficed for children aged 6 years and below included in the study, assent was also sought from children who were aged 7 years and above and could understand the explanations given to them. The parents and guardians of children were notified of any serious skin disease their children had and were referred to the Dermatology clinic of Federal Medical Center Umuahia for further management. For children with milder skin lesions, appropriate treatment was prescribed at the time of examination and communicated to the teacher.

Data collection

The study was conducted using a pre-tested, self-administered, and close-ended questionnaire designed by the researcher. The questionnaires were given to the selected pupils to be completed with the assistance of their parents or guardians at home for sociodemographic data.

In every school where the study was conducted, a complete head-to-foot examination of the entire skin was performed separately on each child in a well-lit office. Where indicated and where diagnosis was indeterminate, such as a condition like lichen planus, among others, confirmatory laboratory investigations were sought. Diagnosis of fungal infections was made both clinically and with microscopic examination of potassium hydroxide (KOH) preparation of the skin scrapings of the skin lesions. The species identified for tinea capitis were Trichophyton tonsurans and Microsporum canis; for tinea corporis, Trichophyton rubrum and Microsporum canis were identified, whereas Candida albicans was noted for candidiasis. Skin disorders were classified according to the second edition of the International Classification of Primary Care.[22]

Data analysis

Data was entered into a computer and analyzed using the Statistical Package for Social Sciences (SPSS) version 20, currently known as IBM SPSS statistics. Descriptive statistics including frequency, means, and proportions were calculated and the 95% confidence interval was calculated for proportions. The level of significance was set at a P value of ≤0.05.


   Results Top


General characteristics of the study participants

One thousand five hundred and sixty pupils were recruited into the study, 713 and 847 from private and public schools, respectively. The children were aged from 5 to 15 years with a mean age of 8.74 ± 2.079 years. Eight hundred and seventy-six (56.2%) were males, whereas 684 (43.8%) were females. [Table 1] shows the sociodemographic characteristics of the study population.
Table 1: Sociodemographic characteristics of the study population

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Prevalence of skin diseases in the study population

Skin diseases occurred in 627 out of the 1560 primary school pupils studied, giving a prevalence of 40.2%. Out the 713 private school pupils, 237 had skin diseases, giving a prevalence of 33.3%. In public schools, 390 out of 847 had skin diseases with a prevalence of 46%.

Common presentation of skin diseases among the primary school pupils

The commonest presentations of skin diseases among the primary school pupils were skin eruptions (44.1%) and itchy skin (13.2%). Others were loss of hair, hypopigmented lesion, scales, hyperpigmented lesions, swelling, and numbness. Eighty-eight (14.0%) of the patients had multiple presentations of skin diseases.

Sites of skin diseases among primary school children

Skin diseases were distributed on several parts of the bodies of the school children with the head and neck regions being the most affected parts in 43.3%. [Figure 1] shows the sites of skin diseases among the school children. Some children were affected in more than one site.
Figure 1: Sites of skin diseases among primary school children

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Types of skin diseases in the study population

Infective and non-infective skin diseases

Infective skin diseases occurred in 78.7% (307/390) of public school pupils with skin diseases and in 66.2% (157/237) of the 237 private-school pupils with skin diseases, making infective skin diseases more common in public schools (P < 0.001). Non-infective skin disease was more common among pupils of private schools compared to public schools (33.8% [80/237] vs 21.3% [83/307]; x2 = 12.58, P < 0.001).

Etiology of infective skin diseases

The most common etiologic cause of skin infections was fungal [Table 2]. Fungal infection was significantly more common in public than in private schools (P < 0.001). Other etiologic causes were bacterial, parasitic, and viral.
Table 2: Etiologic agents of infective skin diseases among the pupils

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Diagnosis of skin diseases among primary school children

Tinea capitis was the most common diagnosis and also the most common infective skin disease, whereas miliaria was the most common non-infective skin diseases noted in this study, as shown in [Table 3]. [Image 1], [Image 2], [Image 3], [Image 4], [Image 5] show the pictures of some of the skin diseases noted in the children.
Table 3: Diagnosis of skin diseases in the primary school children

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   Discussion Top


The spectrum of skin diseases in any community is influenced by genetic constitution, climatic condition, socioeconomic status, occupation, educational background, personal hygiene, customs, quality of medical care, family size, family history, and overcrowding in school or household.[23],[24] These factors give each community its unique pattern of skin diseases and accounts for the wide variation reported from different regions of the world and even in the same country.[23]

The 40.2% prevalence of skin diseases in this study is in support of the assertion by other researchers that skin diseases are common in primary school children.[25],[26],[27],[28],[29] This figure is comparable with the figures of 39.6, 40.9, and 42% documented among primary school children by Amoran et al. in Sagamu, South-west Nigeria[30] Khalifa et al. in Iraq,[27] and Hogewoing et al. in Ghana,[25] respectively. Lower prevalence figures of 35.2 and 26.7% were, respectively, documented in Ibadan[21] and Rwanda[25] among primary school children. Higher figures of 70.4, 77, and 80% were reported in Ethiopia,[31] Turkey,[28] and Brazil,[29] respectively. The reason for the variations in prevalence rates may be due to differences in social, nutritional, and hygienic factors of these children. Climatic factors as well as the level of industrialization may also play some roles.

The higher prevalence of skin diseases documented among children in public schools compared to private schools in this study is similar to the findings by Mohammed and colleagues in Sudan,[32] where prevalences of 45.5 and 25% were documented for public and private schools, respectively. Similarly, Laczynski and Cestari[29] in Brazil documented prevalence figures of 93 and 83%, respectively, for public and private schools. In this study, a majority of the public-school pupils were of low socioeconomic class and may explain why skin diseases were more common among them. Risk factors for skin diseases such as poor hygiene and overcrowding have been associated with low socioeconomic status.

The predominance of infectious skin diseases among the study population has been similarly reported by other authors within and outside Nigeria.[21],[25],[33] Ogunbiyi and co-workers in Ibadan,[21] Komba and Mgonda[33] in Dar es Salam, Tanzania, and Hogewoing et al.[25] in Ghana, Gabon, and Rwanda in their studies also documented the predominance of infectious skin diseases among primary school children. However, Fung and Lo[34] in Hong Kong, Laczynski and Cestari[29] in Brazil, and Sula et al.[35] in Turkey in their studies noted that non-infective skin diseases were more common. The reason for the difference in the types of skin diseases may be due to geographic characteristics of the region, socioeconomic status of the people, or developmental status of a country. The present study was carried out in a developing country, whereas Fung and Lo[34] and Laczinsky and Cestari[29] conducted their study in developed countries with temperate climate and better hygienic conditions.

The most common etiologic agent of skin diseases in the present study is fungus, followed by parasites, bacteria, and viruses. The high preponderance of skin diseases of fungal etiology is comparable to the findings by Odueko and colleagues[7] in Ile-Ife, Ogunbiyi and co-workers[21] in Ibadan, Komba and colleagues in Tanzania,[33] Amoran et al.[29] in Sagamu, and Hogewoing et al.[25] in Ghana, Gabon, and Rwanda, who noted fungal infections to be the most common aetiology of skin infections in their series. In Ethiopia, Tolesa, and colleagues[36] documented fungal infections to be the second most predominant skin infections after parasitic infection in their series. The reason for the preponderance of fungal infections in both the private and public primary schools in the present study may be explained by the tropical climate which predisposes to excessive sweating (as fungi thrive in warm, moist and sweaty conditions), poor hygiene and overcrowding predominant in low-income countries which are risk factors for fungal skin infections.[7],[37]

Tinea capitis and pityriasis versicolor were the most common fungal skin lesions noted in the study. Tinea capitis was the most common skin disease documented in this study and is in tandem with the reports from the studies by Odueko et al.[7] in Ile-Ife, Kalu et al.[38] in Ohafia, and Hogewoing et al. in Gabon,[25] who noted tinea capitis to be the most predominant skin disease among primary school children. The predominance of tinea capitis could be attributed to the exposed nature of the head/scalp compared to other body areas. Poor haircare practices such as sharing of hair clippers and combs, contamination from the place of barbing, and poor personal hygiene enhance the ease of transmission and acquisition of this infection. Pityriasis versicolor may be explained by the inclusion of older children up to 15 years of age in this study. The stimulation of sex hormones such as androgen stimulation that occurs in adolescents results in a greater development of the sebaceous gland with more secretion of sebum and skin lipids, which favors the growth of Malassezia, the etiologic agent of pityriasis versicolor.[39],[40]

Non-infective skin lesions such as papular urticaria, atopic dermatitis, seborrheic dermatitis, and lichen planus among others were also noted in this study. Papular urticaria results from exaggerated response to insect bites and stings. It may be worsened by poor environmental sanitation and inadequate drainages prevalent in developing countries as Nigeria, which provide breeding areas for biting insects such as fleas and mosquitoes.

The parasitic skin disease noted in this study was scabies with a prevalence rate of 8.9%, which is lower than the rates of 16.5% reported by Odueko et al.[7] in Ile-Ife and 13.5% documented by Emodi et al.[12] in Enugu, whose studies were carried out in referral centers where these cases may be referred. Scabies is a highly contagious and itchy parasitic infection that can be seen at any age. Overcrowding which promotes body contact may be a significant contributor to the spread of scabies. Its incidence may also be a reflection of poor health and personal hygienic practices in the community and environment. Differences in socioeconomic standards even within countries have been mentioned as some of the factors responsible for variations in prevalence.[41]

Carbuncles or furuncles and bullous impetigo were the bacterial skin lesions noted in the study. Bullous impetigo with a prevalence of 1.3% was another skin infection documented in this study although with a rate lower than the 15.7% documented by Odueko and colleagues[7] in a hospital-based study in Nigerian children. The increased availability of over-the-counter antibiotics and use of antiseptic and germicidal soaps in the community could be responsible for the decreased prevalence of this skin disorder.

The most common presenting symptom of skin diseases recorded in this study was skin eruptions. This may be due to the fact that skin diseases of various etiologies such as fungal, bacterial, viral, parasitic, and non-infective diseases can present with skin eruptions. The head and neck were the most affected region of the body in the present study similar to the report by Oyedeji et al.[19] in Ijesha who noted that the most affected body site in their study was the head. This finding may be due to the fact that tinea capitis which was the most common skin disease noted in the study usually occurs on the scalp. The head and neck region are usually more exposed than other parts of the body.


   Conclusions Top


The prevalence of skin diseases among primary school children in Umuahia South LGA is high, especially among children in public schools. The most common forms of presentation are skin eruptions and itchy skin. Infectious skin diseases are predominant with tinea capitis being the most common disease.

Recommendation

Standard hygienic practices should be maintained by primary school children and their parents/caregivers to prevent skin diseases. Public awareness of the importance of skin health should be created to enable primary school teachers become more mindful about skin disorders and, if recognized in school children, refer such pupils to relevant medical experts.

Limitations of the study

Due to the one-point examination of the skin for diseases in this study, children with infectious skin diseases of short duration may be missed, thereby underestimating the true burden of skin diseases in these children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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