|Year : 2014 | Volume
| Issue : 2 | Page : 209
|Pattern of skin diseases in a tertiary institution in Kolkata
Chinmay Kar1, Sudip Das2, Alok Kumar Roy2
1 Department of Dermatology, Venereology and Leprosy, Malda Medical College and Hospital, Malda, India
2 Department of Dermatology, Venereology and Leprosy, NRS Medical College and Hospital, Kolkata, India
|Date of Web Publication||21-Feb-2014|
Department of Dermatology, Venereology and Leprosy, NRS Medical College and Hospital, Kolkata
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There are very little elaborative studies in India about various patterns of skin diseases and various factors those influence the diseases in a tertiary institution. Aims: To find out the various patterns of skin diseases in relation to age, sex, occupation, and socio-economic status. To find out the magnitude of skin diseases and compare with other similar studies . Materials and Methods: Collection of data of all new skin cases in a specified period of one year and put on proforma for diagnosis. Few investigations were done for correct diagnosis. Results: It was found that skin OPD patients (new) were 4.16% of total new OPD patients, and male female ratio was 1.1:1. Among all patients (12910), infection was commonest (39.54%), followed by allergic skin disorder (29.20%). 25.05% patients were housewives, followed by students (23.21%). Study showed that 33.28% patients had per capita income of ` 361-720/month, and 22.35% patients were educated and/or studied up to class V. Conclusion: Pattern of skin diseases are mostly depend not only on environmental factors but also on occupation, socio-economic status, literacy, and age of the patients.
Keywords: Pattern, skin diseases, tertiary institution
|How to cite this article:|
Kar C, Das S, Roy AK. Pattern of skin diseases in a tertiary institution in Kolkata. Indian J Dermatol 2014;59:209
| Introduction|| |
To comprehend the effect of ecology on the skin diseases in Kolkata, a mega city of India, it is imperative to know some facts about this city and its surrounding areas. It is situated by the side of river Ganges with extreme change of temperature and humidity. The temperature ranges from 10°C to 42°C, and humidity ranges from 25% to 95%. There is four fairly distinct seasons instead of six: A relatively cool winter, a hot humid summer, a rainy monsoon, and a post-monsoon season.
About demographic profile of Kolkata and its surrounding areas, we have found that it is hugely populated area with density about 25000/km 2 , and male female ratio is 1000:829. These figures are quite different in surrounding areas, i.e., density of population is 903/Km 2 , and male female ratio is 1000:934.
Though the study is based on tertiary institution of Kolkata, about 30-40% patients come from surrounding districts. Other 30-40% patients come from greater Kolkata and rest from main Kolkata.
| Aims and Objectives|| |
The aims and objectives are:
- To find out the various patterns of skin diseases in relation to age, sex, occupation, and socio-economic status that influence it.
- To determine the percentage of skin OPD attendance out of total OPD attendance (new cases only).
- To compare the study with other parts of India and also world.
| Materials and Methods|| |
This study was conducted amongst all new patients, attending at the Department of Dermatology, Venereology and Leprosy, N.R.S Medical College and Hospital, Kolkata, for a period of one year (from June `06 to May `07). We recorded 12910 new cases of both male and female of all age groups within this specified period. We tried our best to enroll all new patients. The study was based mainly on clinical basis of first visit, though difficult cases were diagnosed by some basic skin investigations like KOH preparation, slit skin smear for AFB, Tzank smear, wood's lamp examination, VDRL, skin biopsy, culture etc.
For this study, all particulars of the patients, history in details was taken, and thorough clinical examination was done. All information was put on proforma for clinical diagnosis and analysis.
| Results|| |
Out of 310393 new patients of all disciplines, skin patients were 12910 i.e., 4.16% of total. Here, male patients were 51.98%, and male female ratio was 1.1:1. For better visualization and understanding, the study results have been shown in [Table 1].
|Table 1: Study results disease no of patients (%) commonest age group in year (%)|
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In our study, one fourth (25.05%) of all patients were housewives, followed by students (23.21%), pre-school infants and children (11.80%), service holder (10.24%), business-man (9.86%), skilled worker (5.72%), unemployed group (4.02%), unskilled laborer (3.81%), cultivator (3.26%), retired person (1.15%), driver (0.74%), house-maid (0.60%), mason (0.50%), and commercial sex worker (0.04%).
According to monthly per capita income, patients were classified into five classes as per modified B.G. Prasad's criteria 2004.  Study showed that the commonest attendee was class IV - per capita income `Rs 361-720/month (33.28%), followed by class III - per capita income `720-1200/month (23.05%), class V - per capita income `<360/month (19.14%), class II - per capita income `1201-2400/month (18.64%), class I - per capita income `>2400/month. These patterns of socio-economic status of the patients are more or less similar with Indian socio-economic status.
As per education of our patients, maximum patients (22.35%) were educated and/or studied in class V, followed by 18.46% patients were educated and/or studied in class IX or X, 15% were educated and/or studied in class VI to VIII, 13.35% were illiterate (age > 6 years), 10.02% were educated and/or doing graduation, 8.1% were educated and/or studied in class XI or XII, 1.43% were postgraduate, and rest were children (age ≤ 6 years). It was also seen that the infective and allergic skin diseases were more common in illiterate and less-educated groups (46.15% and 42.20%, respectively) because of ignorance.
In our study, infection was the most common dermatological problem (39.54%), of which sexually transmitted disease (STD) cases were 0.945% (122 patients) and non-STD conditions were 38.59% (4983 patients). In non-STD patients, parasitic and protozoal infections were commonest (14.66% of total), followed by fungal infections (11.12%), bacterial infections (7.70%), viral infections (3.29%), and mixed infections (1.82%, 235 patients).
Among the parasitic and protozoal infection, scabies constituted the major number (1816 patients, 14.07% of total), of which 382 patients had associated secondary bacterial infection. Sixty-five patients (0.50%) had pediculosis, 9 patients (0.07%) had filariasis, 1 patient (0.008%) each had cutaneous larva migrans and PKDL in this group.
Fungal infections are tabulated in [Table 2].
|Table 2: Fungal infections disease no. of pts. (%) sub types sub-sub types no. of pts. (% in subtypes)|
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Among bacterial infection (995 patients, 7.70%), pyoderma was 6.19% of total (799 patients), Hansen's disease was 1.013% of total (131 patients), pitted keratolysis 0.19%, cutaneous tuberculosis 0.123%, bacterial balanoprothitis 0.062%, erythrasma 0.046%, trichomycosis axillaris 0.039%, SSSS and erysipeloid were 0.015% each, and lastly, actinomycosis was 0.008%. Among pyoderma patients, 308 patients (38.55%) had impetigo, followed by chronic folliculitis (16.65%), acute folliculitis (12.64%), ecthyma (10.01%), furanculosis (9.01%), cellulitis (4.38%), erysipelas (3.50%), acute paronychia (2.13%), carbuncle (1.63%), acute lymphangitis (1.13%), and whitlow (0.38%).
Among all Hansen's patients, 23 patients (17.56%) came for leprosy sequel. Rest of the patients (108 cases) were needed leprosy treatment, of which multi-bacillary adult patients were 60.185%, paucibacillary adult - 34.259%, multi-bacillary child -1.851%, and 3.704% cases had paucibacillary child leprosy. Our study revealed 5.56% cases were children, multi-bacillary leprosy cases were 62%, and approximately 10% cases had visible deformity. These data are quite deviated than national level (Child case - 10.1%, MB - 48%, visible deformity - 2.8%) due to greater pooling of complicated cases in tertiary institution.
In non-STD viral infection (425 cases), viral wart was highest (1.356% of total) followed by herpes zoster (0.875%), molluscum contagiosum (0.465%), herpes simplex (0.302%), chicken pox (0.225%), measles (0.046%), and other viral exanthems (0.023%).
Various types of STDs are tabulated in [Table 3]. Various cutaneous allergic manifestations have been summarized in [Table 4].
|Table 3: STD patients types no. of pts (%) subtypes no. of pts (% in subtypes)|
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|Table 4: Allergic skin disease no. of patients (%) subtypes no. of pts (% in subtypes)|
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Among non-malignant papulosquamous disorder, psoriasis was the commonest (2.35% of total), followed by lichen planus (1.92%), pityriasis rosea (0.84%), sebopsoriasis (0.085%) and so on.
Study revealed, 564 patients (4.37%) were suffering from acne vulgaris and 29 patients (0.22%) from other forms of acne. Twenty-four patients (0.19%) had perioral dermatitis, and 15 patients (0.12%) had rosecea.
Amongst pigmentary disorders, 202 patients (1.56%) had melasma and 189 patients (1.46%) had vitiligo.
If we go through the keratinization disorder, we found icthyosis - 0.387% of total, folliculocentric keratotic disorders - 0.279%, congenital keratoderma - 0.209%, keratolysis exfoliata and Pityriasis rubra pilaris - 0.07% each, porokeratosis - 0.039%, and Darier's disease, perforating disorder, and erythrokeratoderma - 0.008% each.
About cutaneous toxicity to drugs, fixed drug eruption (FDE) became commonest (0.31% of total), followed by maculosquamous drug rash (0.155%), erythema multiforme (0.07%), lichenoid drug eruption (0.046%), Steven Johnson Syndrome (SJS) (0.039%), bullous drug eruption (0.023%), erythema nodosum (0.015%), toxic epidermal necrolysis (TEN), and urticarial drug rash (0.008% each). About causative agents, 16.09% patients could not recognize any offending drugs. Among the recognized drugs, most common was sulfonamides and its congeners (13.79% of total drug reaction), followed by combination of anti-amebic, quinolones and NSAIDs (12.64%), only anti-amebic drugs (11.49%), combination of anti-amebic and quinolones (10.34%), NSAIDs (6.90%), anti-convulsant (6.90%), chloroquin (5.75%), doxycycline, amoxycilline, quinolones, homoeopathic medicine (each 3.45%), allopurinol (2.30%).
Most common drug causing FDE was anti-amebic or combination from described above. Maculopapular rash was mainly due to combination drugs described above. SJS was usually due to sulfonamide group of drugs, and surprisingly, single patient of TEN was due to homeopathic medicines.
Among connective tissue disorder, discoid lupus erythematosus ranked first (0.178% of total), followed by lichen sclerosus et atrophicus (0.124%), morphea (0.07%), systemic sclerosis and systemic lupus erythematosus (0.062% each), sub-acute cutaneous lupus erythematosus (0.023%), dermatomyositis and rheumatic fever (0.008% each). It is also seen that 30% patients of this group are male, which is quite high.
In vesiculo-bullous disorder, there were pemphigus vulgaris (0.062% of total), pemphigus foliaceus (0.046%), bullous pemphigoid and dermatitis herpitiformis (0.031% each), epidermolysis bullosa aquisita and Heiley Heiley disease (0.023% each), sub-corneal pustular dermatosis, chronic bullous disease of childhood, inherited epidermolysis bullosa and paraneoplastic pemphigus (0.015% each) and lastly, erythema multiforme not due to drug (0.116%).
In malignant disorders of skin, squamous cell carcinoma (SCC) ranked first (0.062% of total), followed by basal cell carcinoma, malignant melanoma (0.023% each), and acute lymphatic leukemia, metastatic deposits (0.015% each) . About miscellaneous group, patients with scar of various types were 0.589% of total, generalized pruritus were 0.426%, fissuring sole were 0.395%, observation - 0.341%, multi-vitamin deficiencies - 0.263%, amyloidosis - 0.256%, pigmented purpuric dermatoses - 0.186%, vasculitis - 0.163%, non-healing ulcer, cheilitis (0.147% each), xerosis, corn (0.139% each), granuloma pyogenicum (0.132%) and so on. The list was so long that it was not possible to cover all. A large number of patients were under the group of observation, which had diagnostic dilemma.
| Discussion|| |
Apart from environmental factors, skin diseases are mostly depending on occupation, socio-economic status, and age of the patients. For example, maid-servants usually presented with candidiasis, paronychia, and hand eczemas; people from low socio-economic group came for infective and allergic disorders. Similarly, adolescent group usually came for acne-related disorders.
About incidence of new patients attending skin OPD, two studies , showed higher incidence (5.17%, 6.16%, respectively) than our study, and male female ratio showed very much similar to one Indian study  and very little deviation from foreign studies, , but moderate deviation from another Indian study. 
According to study reports conducted in India, rather West Bengal,  infective dermatoses, allergic skin disease, papulosquamous (non-malignant) disorders, connective tissue disorder, drug rashes are very much similar to our study. There is good similarity between our study and a report from neighouring state of Assam  about infective dermatoses, eczema, non-malignant papulosquamous disorder, acne, melanodermatoses, hair disorders, vesiculo-bullous disorder, skin and appendegeal tumors, and also very close to another Indian study  in infective and acne disorders but wide deviation from other Indian study  about infective diseases. This indicates geographic position of study center.
By review various reports, we find that almost all studies mentioned here ,,,,,,, are compatible with our reports i.e., the commonest skin disease is of infective origin, followed by allergic diseases except two reports, , which show the reverse situation. But, the reports of two developed countries , show opposite reports of one another. The reasons for high number of infective dermatoses are large family size, hot and humid condition, low socio-economic status of few urban slams.
For infective dermatoses, by reviewing different studies, ,,,,,,,, it is clear that the fungal or bacterial infections are the commonest infective skin disorder, instead of parasitic and protozoal infestations of our study. It is probably due to large number of urban slam populations around this tertiary institution. Apart from parasitic and protozoal infestations, the incidence of fungal,  bacterial, , and also viral infections  of few studies are very close to our study. Leprosy incidence of few Indian studies show wide variation (0.41-5.68%), ,,,,, and our study result lies in between.
In fungal infection, superficial fungal infection is compatible with few Indian studies. ,,, But, the deep fungal infections of our study is far low than above-described studies, ,, because it is not common in Bengal.
About STD cases, our study reveals quiet low incidence than other reports (2.26-5.4%) ,, but lies within another two Indian reports (0.63-1.345%). , STD reports are quite low because of lack of privacy.
About allergic skin disorders, endogenous eczema and photodermatitis of our study are very similar to one study  but extremely dissimilar to another study,  and urticaria is very close to another two Indian studies. , Our study is based on mainly urban populations who are inhabited in highly polluted indoor and outdoor, used to take food additives and unwilling in breast feeding, and ultimately higher number of endogenous eczema occurs.
It is obvious that the incidence of lichen planus is compatible with other studies (1.50-2.54%), ,,,,, but it is quite low in psoriasis (3.4-7.75%), ,,,,, due to hot, humid environment.
Though incidence of vitiligo is low, incidence of melasma lies in between other studies (1.50-4.75%). ,,,, The cause of this discrepancy is not explainable.
Keratinization disorder in total is quite low than one study,  but ichthyosis is almost same with other study.  Incidence of hair disorder was quite low from other report (2.8-3.72%). , Cause is poorly understood.
There is no dissimilarity between studies about total percentage of connective tissue diseases (0.41-0.8%) ,,, but no similarity between subclasses. For comparison, large numbers of patients are required.
About drug rashes, our one year study is not matched with Indian studies, , which were carried out over few years. But, the commonest form of drug eruptions and the offending drug are similar to our study and study in Ghana. 
In vesiculo-bullous disorder, incidence is very close to two Indian studies (0.33-0.42%) , but slightly lower than other Indian studies (0.68-0.78%). , Our study showed 27% pemphigus patients, 8% bullous pemphigoid patients, which had wide variation from other studies. ,,
Our study provides lot of information about the factors those influence the skin diseases and details of percentage of subclasses.
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[Table 1], [Table 2], [Table 3], [Table 4]