IJD FOCUS: DERMATOLOGY IN INDIA
|Year : 2015 | Volume
| Issue : 1 | Page : 21-27
|A study of desert dermatoses in the thar desert region
Manas Chatterjee1, Biju Vasudevan2
1 Department of Dermatology, Command Hospital, Kolkata, West Bengal, India
2 Department of Dermatology, Command Hospital, Pune, Maharashtra, India
|Date of Web Publication||26-Dec-2014|
Department of Dermatology, Command Hospital (Eastern Command), Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Desert dermatology describes the cutaneous changes and the diseases affecting those living in the desert. Diurnal variation in temperature is high and is characteristic of the deserts. The lack of water affects daily activities and impacts dermatological conditions. Adaptation to the desert is therefore important to survival. This original article focuses on dermatoses occurring in a population in the Thar desert of India, predominantly located in Rajasthan. Materials and Methods: This is a descriptive study involving various dermatoses seen in patients residing in the Thar desert region over a duration of 3 years. Results: Infections were the most common condition seen among this population and among them fungal infections were the most common. The high incidence of these infections would be accounted for by the poor hygienic conditions due to lack of bathing facilities due to scarcity of water and the consequent sweat retention and overgrowth of cutaneous infective organisms. Pigmentary disorders, photodermatoses, leishmaniasis and skin tumors were found to be more prevalent in this region. Desert sweat dermatitis was another specific condition found to have an increased incidence. Conclusion: The environment of the desert provides for a wide variety of dermatoses that can result in these regions with few of these dermatoses found in much higher incidence than in other regions. The concept of desert dermatology needs to be understood in more details to provide better care to those suffering from desert dermatoses and this article is a step forward in this regard.
Keywords: Climate, desert dermatoses, environment, infections, water
|How to cite this article:|
Chatterjee M, Vasudevan B. A study of desert dermatoses in the thar desert region. Indian J Dermatol 2015;60:21-7
What was known?
- People living in deserts have distinct dermatological problems
- This unique environment has not been studied in detail for the resultant dermatoses
| Introduction|| |
Deserts are of two types: The hot and cold deserts. The hot desert, though, is what the term connotes in common usage and this is the connotation that will be the subject of this original article. Deserts occupy about 47 × 10 km 2 of the Earth's surface. They are characterized by low humidity, dry weather and high temperatures, especially during the summer, and low temperatures during winter. Diurnal variation in temperature is high and is characteristic of the deserts. Sandstorms are common. The lack of water affects daily activities and impacts dermatological conditions seen in these areas. Adaptation to the desert is important to survival. The close relationship of humans and animals in the desert is essential but can contribute to diseases and infestations. The Thar Desert in India is predominantly located in Rajasthan and is geologically and strategically important as it separates India from its western neighbor.
Desert dermatology is a comparatively new concept.  It aims to describe the cutaneous changes and the diseases affecting those living in the desert. Desert dermatoses have not been reviewed comprehensively in India.  Patients seen in a hospital in Jodhpur, Rajasthan, with a catchment area of the whole of Western Rajasthan mainly including the Thar desert area were analyzed to find trends and provide much needed data for program managers for the allocation of resources for healthcare in this region. A total of 17,155 patients seen over a duration of 3 years were analyzed to arrive at the data described below.
| Materials and Methods|| |
This is a descriptive study of various dermatological conditions seen in the Thar desert region over a duration of 3 years with effect from 01 April 2005 to 31 March 2008. All patients of the region reporting to the outpatient department as well as those cases seen during door to door health activities during this period were included in the study.
| Results|| |
Infective conditions comprised 21.6% and non-infective conditions formed 78.4% of all patients seen.
Among infective conditions, fungal infections were the most common infections (8.3%), followed by viral (4.8%), bacterial (4.6%), and scabies (1.7%). Viral warts comprised ~ 66% of viral infections. Leprosy formed 0.4% of patients.
Among non-infective conditions, eczemas were the most common and comprised 28.3% of all cases and 36.1% of all non-infective conditions. Discoid eczemas were the most common single type of eczema seen (24.6% of all eczemas). Acne and rosacea comprised 10.9% of all and 13.9% of non-infective dermatoses.
Pigmentary disorders comprised 11.1% of all dermatoses and 14.2% of all non-infective disorders. Psoriasis accounted for 5.3% of the patients. Lichen planus constituted 2.1% of the total cases and 2.7% of non infective dermatoses. In addition to the classical presentation, actinic, mucosal and hypertrophic lichen planus were the most common variants seen. Drug reactions formed 0.4% of the dermatoses. Neoplastic disorders comprised 5.1% of patients.
Pigmentary disorders, photomelanosis, cutaneous tumors and actinic lichen planus were found to have more prevalence in these regions due to increased sun exposure. Leishmaniasis, mycetoma and psoriasis were also found to be more prevalent. Desert sweat dermatitis was a characteristic entity seen in this region. The common dermatoses seen in this study are summarized in [Table 1].
| Discussion|| |
The population living in this region, especially nomads such as Kalbelias, Gadaria Lohar, Gujar, Raika Merdh, Dewasi and others, have limited facilities compared with those who live in the cities. They have no source of continuous water supply; they must depend on wells and limited water storage capacity. They are always on the move; consequently, they do not have houses. Instead, they have tents, which are easy to dismantle and construct. The tents are made from camel skins/cloth and they have no electricity, no kitchens, and no bathrooms. The whole family lives in the same tent that is sometimes divided by a partition. Nomads depend mainly on camels that can live in the desert, usually called "desert ships." Sources of food are limited, and nomads depend on their cattle and gathering. There are very few types of edible plants in the desert. Clothing is usually helpful in providing protection from the sun and comfort in both cold and hot weather. They use elaborate clothing and various kinds of stone ornaments which not only have protective action, but also lend color to the monochrome of the desert [Figure 1].
The Thar Desert in Western Rajasthan is the most arid part of the State where the annual rainfall varies from 100 to 400 mm, quite often erratic, so much so, that the entire rainfall of the year may fall on a single day and the rest of the year may be dry. As an illustration, a certain area (Osian) has been used to depict the environmental aspects of desert life. The average humidity is low [Figure 2]. Average summer temperatures are always high [Figure 3] and the diurnal range exceeds even 20°C. Winters are of short duration, not exceeding 2 months-December and January.
|Figure 3: Mean monthly temperature in degrees centigrade throughout the year|
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Dermatological conditions having increased prevalence in this region
Infection and infestations
Bacterial and fungal infections
The high incidence of fungal and bacterial infections would be accounted for by the poor hygienic conditions due to lack of bathing facilities , scarcity of water and the consequent sweat retention and overgrowth of cutaneous infective organisms. Bacterial infections were exceed i ngly common and related to the poor hygiene conditions. Folliculitis, furunculosis and deeper infections were common, more so in the nomads. Occlusive clothing was associated with sweat retention, which further predisposed to bacterial infections. Fungal infections in dogs and cats are important sources of zoonotic infections in humans. As in humans, dermatophytosis affects the hair and the skin of animals.  Here again, occlusive clothing plays a part in leading to humid milieu, most suited to the growth of candida/dermatophytes. Women, especially in occlusive clothing face the prospect of chronic vulvovaginal candidiasis. High incidence of fungal infection in our study can also be attributed to these reasons.
This condition is known as Madura foot in the endemic areas of India. It occurs worldwide but with an uneven distribution. It is common in the thorny semi deserts of Central and South America, Africa, and India; and it has been reported from Saudi Arabia.  The environmental and living conditions help to produce a favorable condition for this disease, as seen in our study. More people walking barefoot is a major cause for this increased incidence. This results in a localized, chronic infection following trauma (like thorn prick), with various fungi or actinomycetes, resulting in severe damage to skin, subcutaneous tissues and bones of the feet, hands and other parts of the body. Eight such cases were seen in this study.
Human scan acquire wart infection from cattle, and they are common in the desert population, as seen in our study.
Scabies is an intensely pruritic, non-seasonal, contagious skin disease caused by the species-specific, Sarcoptes mite. The camel mite Sarcoptes scabiei var cameli was a common cause of skin infestation in camels, akin to that seen in Arabia.  Canine scabies, Sarcoptes scabiei var canis, was common, but feline scabies, Notoedres cati, was less common. The incidence of human infestation was high akin to those found in other desert regions. 
Lice are species-specific parasites that spread by direct contact. Cattle, horses, and goats can be affected. Transmission to humans is less likely but can occur by direct contact. There was evidence for correlation between home density and pediculosis infestation in this population, akin to various other studies. 
Zoonotic cutaneous leishmaniasis is endemic in many arid countries extending from North Africa to Afghanistan as well as some parts of Rajasthan. Cases have been documented from patients living in the desert for long periods. The cause of the disease is Leishmaniasis major, which infects desert rodents (e.g. Psammomys and Rhombomys). Chenopod desert plants provide the rodents with the food and water they need for survival in this harsh environment. The disease is maintained in colonies of those rodents, and it is transmitted by the sand fly, Phlebotomus papatasi. The inhabitants and, nomads passing through endemic areas are at high risk of acquiring the infection. Twelve such cases were also seen in our study.
Control of the disease involves destruction of burrows of the animal reservoirs around villages. This is often carried out by plowing the area within a few-kilometer radius. The use of repellents and pesticide-impregnated bed nets is also helpful in protecting people at risk.
Sexually transmitted infections
A total of 79 sexually transmitted infection cases were concurrently seen during this period. Chancroid was the most common sexually transmitted disease (STD) in our patients accounting for 28.2% of cases. Condylomata acuminata was the second in frequency accounting for 16.8% of cases. The incidence of non-gonococcal urethritis (NGU) was 13.9%, which was third in frequency. This was more in comparison to other studies in India. ,,,,,,, Syphilis was the next most common condition seen, accounting for 10.5% of patients over the study period. Most cases were of early syphilis, accounting for 8.4% of cases while late syphilis accounted for 2.1% of cases. Gonorrhea was the next common STD accounting for 8.6% of cases. It accounted for 38.3% of all genital discharges. Genital herpes was found to have an incidence of 8.1%. Genital molluscum contagiosum accounted for 1.4% of cases. Other conditions which are sexually transmitted like infective balanitis, scabies and pediculosis accounted for 5.7% of cases. The proportion of viral STDs had been on the increase from 28% in 2002 to 36.4% in 2003 and 33.3% in 2004. This is the harbinger of a trend which is being seen all over the world including India, where conditions such as genital herpes are being seen more often, in the recent past. 
The overall rate of HIV seropositivity in this group of patients was 1.2%. The rate has shown an increasing trend over the period from 12% in 1995 to 19.2% in 1996 and thereafter fluctuated to a high of 20% in 2001. It is probable that after the initial spurt of increase in HIV infection among STD cases, education and control measures in the form of condom promotion and other activities have been helpful in the control of this condition as evidenced by the total overall trend toward reduction in STD incidence as well.
Nomads are usually dark skinned (Type III to Type VI); this partially protects them from the carcinogenic effect of the sun. They protect their skin by wearing long-sleeved clothes, and they cover their heads with 'safas' (turban) and even faces are covered in women. Because of the nature of the sunny desert all year round, they are prone to develop skin tumors and even malignant ones such as basal cell carcinoma, squamous cell carcinoma, and melanoma. There are no community based statistical data to show the incidence and prevalence of these tumors in desert dwellers. There were nine malignant tumors, six of which were basal cell carcinomas [Figure 4], two squamous cell carcinomas and one melanoma in our study.
Out of a total of 17,155 patients, atopic dermatitis diagnosed as per standard (UK Working Party) criteria was seen in 689 (14.2%) cases of eczemas.  However, clinically, the condition was seen in a form more severe as compared to that in the rest of the country and similar to that seen in the West. Extensor distribution of lesions was seen very frequently among older children and adults as well. Unusual morphological forms were seen in addition to the usual pattern of lesions. A strong association with autosomal dominant ichthyosis was found as expected. An association with other elements of the atopic diathesis in the patient or his family was seen in only 12% cases. It therefore appears that environmental factors seem to be important in manifestations of atopic dermatitis in this group of patients.
Desert sweat dermatitis
327 patients had an unusual scaly dermatosis involving the area covered by clothes and were assessed clinically and by patch testing in a prospective manner [Figure 5] and [Figure 6]. Lesions were present exclusively in the hot dry summers. Males outnumbered females 4:1 and all were between 16 and 40 years of age. All patients spent a considerable amount of time outdoors in work involving significant physical activity. Patch test to patients' own sweat showed an irritant reaction in all patients. 
A chronic cumulative irritant contact dermatitis to sweat solutes in individuals who consumed less fluid and those who wore the traditional porous undergarments was observed. The type of garment involved which allows this condition to develop is made of porous material, allowing the fluid component of the sweat to evaporate easily, leaving the sweat solutes which are in a higher concentration in these patients, to cause the irritant reaction. The reason for reporting this typical finding was that it is not consistent with the described forms of miliaria. The term "sweat dermatitis" has been used for this observed unique dermatologic condition, which has been observed once before in a report from Bikaner, Rajasthan, India,  but has not been assessed to be able to hypothesize the cause, as has been done in the quoted study.
This is similar to some studies, , but higher than most others. , In one of these studies, it was second in frequency among non-infective conditions.
Photodermatoses accounted for 11.4% of all skin conditions seen in this study. The sunny weather which persists for most parts of the year in this area may be an important factor in development of photodermatoses. Solar energies with as high a mean as 6.5 kWh/m 2 /d found in deserts are responsible for the drastic increase in incidence of photodermatoses.  Such a high incidence of photodermatoses has not been seen in any of the quoted studies in India and indicates that photodermatoses is the highest in the desert areas and measures towards photodermatoses are important in preventive desert dermatology. Actinic lichen planus can again be explained by the sunnier climates of the desert [Figure 7]. Solar elastotic degeneration is common among desert dwellers. These individuals spend long hours under the open sun and this leads to early appearance of wrinkles and features of skin ageing, as seen in our study [Figure 8].
Fissured heels and dystrophic toenails
Although the sand dunes are hot during the day, nomads walk almost barefoot. This results in hyperkeratotic thick feet. Fissured heels are frequently seen. Repeated trauma to toenails results in their abnormality, ending in dystrophy.
Strangely acne and rosacea also had higher incidences, though no reason could be attributed. ,
Desert skin care
How can one combat environmental pollutants, the effect of solar radiation, and the noteworthy drying effects of the arid desert winds? How can one be sure that one is using the correct products on the skin- so one can be healthy inside and out? Here are tips to assist in this process:
- One must drink plenty of water! Really, plenty of water-extra water. Water hydrates skin and hair as well as flushes toxins out of the body.
- Proper hygiene to mainly prevent infections and infestations
- Not to sleep in the open: To prevent vector-borne diseases
- To find products with Proteo-C and Proflavonol-T. These two vitamins can protect the skin from premature aging caused by the sun, pollution and other environmental factors. They also provide advanced nutrition to the skin to keep it appearing smooth and firm
- Sunscreens used must protect from UVB as well as UVA. Physical sunscreens such as calamine and zinc oxide are more effective in this situation, especially as the former helps to keep the skin cool
- Physical sun protective measures to prevent development of photodermatoses and malignancies
- Keep skin moisturized.
| Conclusion|| |
Though the concept of desert dermatology is new and considered to be in the realms of future research, we are already in the midst of re-assessing the common conditions that dermatologists are faced with in these areas. In rural areas (Osian), sun related disorders such as polymorphic light eruptions are common, as are miliaria and fungal and bacterial infections due to the poor hygiene of the population due to scarcity of water. Dry discoid eczemas are also common, again due to the low humidity. However, in the urban areas, melasma and acne are the most common disorders. Psoriasis is also common, understandably, due to the low humidity. Data gleaned from conduct of more studies in the rural areas and their correlation with conditions faced with in urban areas will further help to elicit these conditions and their relationship to the desert ecology.
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What is new?
- This is a very unique study of desert dermatoses
- Infections, especially fungal are the commonest dermatoses seen in this region
- Disorders aggravated by sun exposure like pigmentary conditions, actinic lichen planus, photodermatoses and basal cell carcinoma are more common than in general population
- Leishmaniasis, mycetoma, psoriasis and atopic dermatitis are more common in this region due to the unique environment
- Desert sweat dermatosis is a unique dermatoses seen in this region
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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