Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
Users online: 3330  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page

Table of Contents 
Year : 2021  |  Volume : 66  |  Issue : 1  |  Page : 49-54
Prevalences of allergic disorders in children with terra firma-forme dermatosis

1 Department of Pediatrics, Pamukkale University Faculty of Medicine, Denizli, (The work was carried out at Denizli MediKlinik Hospital), Mugla, Turkey
2 Department of Pediatrics, Mugla Sitki Koçman University Faculty of Medicine, Mugla, Turkey
3 Department of Dermatology, Servergazi State Hospital, Denizli, Turkey

Date of Web Publication1-Feb-2021

Correspondence Address:
Gurbuz Akcay
Department of Pediatric, Pamukkale University Faculty of Medicine, Pamukkale, Denizli
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.IJD_324_19

Rights and Permissions


Background: Terra firma-forme dermatosis (TFFD) is a clinical condition that may be defined as a dirty appearance of skin. Although it has been defined for many years, its clinical value is not well known. Objective: We aimed to determine the prevalence of allergic disorders (asthma, allergic rhinitis, and eczema) to investigate if this clinical condition is associated with allergic disorders in children with TFFD. Materials and Methods: A questionnaire descriptive of allergic disorders [International Study of Asthma and Allergies in Children (ISAAC)] was applied to all children diagnosed with TFFD at the pediatric clinics during a 6-month period specified for the study. The results were compared with the two ISAAC studies that have been previously conducted in our region. Results: The prevalence of TFFD among 1695 children examined at our outpatient clinic was found to be 3.18% (n = 54). The youngest of the children was 6 months old and the oldest 13 years, with an average age of 6.08 ± 2.69 years. Our study group had significantly greater rates and intensities of lifetime wheezing, wheezing in the last 12 months (current wheezing), lifetime allergic rhinitis, allergic rhinitis in the last 12 months; and the rate of physician-diagnosed allergic rhinitis compared to the comparator groups (P < 0.005). Conclusions: The results support the view that TFFD may be a sign of associated asthma and allergic rhinitis.

Keywords: Allergic rhinitis, asthma, eczema, ISAAC, prevalence, terra firma-forme dermatosis

How to cite this article:
Akcay G, Topal Y, Aydın O. Prevalences of allergic disorders in children with terra firma-forme dermatosis. Indian J Dermatol 2021;66:49-54

How to cite this URL:
Akcay G, Topal Y, Aydın O. Prevalences of allergic disorders in children with terra firma-forme dermatosis. Indian J Dermatol [serial online] 2021 [cited 2023 Mar 22];66:49-54. Available from:

   Introduction Top

Terra firma-forme dermatosis (TFFD) is a clinical condition that may be defined as a dirty appearance of skin. It was first described by Duncan in 1987.[1] It is characterized by dirty, brownish asymptomatic plaques that develop secondary to idiopathic hyperkeratosis. It is distinguished from dermatitis neglecta by normal hygiene of patients. Affected patients describe that their lesions persist despite scrubbing them with soap.[2] Lesions fading upon scrubbing with 70% ethyl alcohol are required for confirmation of the diagnosis and for administering therapy [Figure 1] and [Figure 2].[1] Acanthosis nigricans should be considered in the differential diagnosis if it persists despite rubbing with alcohol.[3]
Figure 1: The arm lesion considered to be a TFFD lesion

Click here to view
Figure 2: The lesion disappears by the application of 70% alcohol and the skin returns to its normal appearance

Click here to view

Lesions may occur in trunk, neck, arms, legs, chest, or abdomen. Lesions may be solitary or multiple and distributed symmetrically over arms and legs or in more than one region. In children, they are usually detected during systemic examination.

The lesions disappearing upon scrubbing with 70% alcohol are sufficient for making the diagnosis.[1] Dermoscopy may also be used for supporting the diagnosis. Using dermoscopy technique, a brown, tile-like appearance resembling a multigonal plaque intersected by lines can be observed.[4] These appearances disappear when scrubbed 30 with alcohol [Figure 3] and [Figure 4]; images were acquired with 31 DermLite DL1, 3Gen Inc-USA].
Figure 3: Dermoscopy-Before alcohol

Click here to view
Figure 4: Dermoscopy-After alcohol

Click here to view

A biopsy is not necessary for making the diagnosis; biopsy sampling has demonstrated hyperkeratotic stratum corneum.[5]

Prior studies on TFFD have reported that it was accompanied by allergic rhinitis.[6] Berk et al. reported the presence of atopic dermatitis in 12 patients.[2] Another study linked it to emollients and urea-containing preparations and reported that one of the cases was using these preparations for xerosis and the other for atopic dermatitis.[1] To date, no epidemiological or prevalence study of TFFD exists.

Asthma, allergic rhinitis, and eczema are common allergic disorders among children.[7] They are more prevalent, especially in developed countries.[8] As they lead to important morbidity, population-based prevalence studies have been done.[9] Standard tools have been developed for these prevalence studies. One of them is the International Study of Asthma and Allergies in Children (ISAAC) questionnaire.[7] The prevalence of allergic disorders among children belonging to the age groups of 6–7 years and 13–14 years in Denizli was determined using the ISAAC questionnaire.[10],[11],[12]

The aim of our study was to determine the prevalence of allergic disorders (asthma, allergic rhinitis, and eczema) using the ISAAC questionnaire among children with TFFD, and to compare it with the results of prevalence studies formerly conducted in a pediatric group in our province.

   Materials and Methods Top

This study was approved by the Ethics Committee of Pamukkale University. We enrolled all children aged under 14 years (because of the highest age in the comparison group was 14 years) who presented to our pediatric clinics for any reason in the first 6 months of the calendar year 2017. The parents of the children who were diagnosed with TFFD during the examination by the physician were called for completing a questionnaire in July and August. Informed consent was obtained from the parents. The families were applied a phase 1 questionnaire translated into Turkish language that was in compliance with the ISAAC questionnaire at an outpatient clinic setting. The phase 1 questionnaire was designed to assess the prevalence and severity of allergic disorders in defined populations. The question titles were coded between A1 and A8 for asthma, R1 and R6 for allergic rhinitis, and E1 and E7 for eczema. Children/parents that were unwilling for participating in the study were excluded.

Statistical analysis

The prevalence was calculated by dividing the positively responded questions by a total number of questions. The study data were analyzed using IBM Statistical Package for Social Sciences (SPSS) for MacOS software package. The comparison of the questionnaire responses with the results of former studies was performed with the sample proportion test. A P value of less than 0.05 was considered statistically significant for all comparisons. The questionnaire results were compared with those obtained by the results of the ISAAC studies conducted in our province in 2006[11] and 2007.[12]

   Results Top

A total of 4722 examinations were performed during the study period. The total number of children examined was 1695. Of these, 52% (n = 883) were male and 48% (n = 812) were female. The prevalence of TFFD was found to be 3.18% (n = 54). All 54 children/families enrolled in the study and participated in the questionnaire. All questionnaires were completed by his/her family. The youngest child was 6 month old and the oldest was 13 years old, with a mean age of 6.08 ± 2.69 years. The sex distribution of the study group was as 52% (n = 28) male and 48% (n = 26) female. The distribution percentage of the responses to questionnaire questions and the comparison with previous studies performed in our province are presented in [Table 1].
Table 1: ISAAC questionnaire and its comparison with other studies from our province

Click here to view

As seen from [Table 1], the study group had significantly higher scores for lifetime wheezing (A1), wheezing in the last 12 months (current wheezing) (A2), 1–3 and 4–12 wheezing attacks in the last 12 months (A3), sleep disturbance due to wheezing for more than one or more nights in the last 12 months (A4), lifetime allergic rhinitis (R1), allergic rhinitis in the last 12 months (R2), rhinoconjunctivitis in the last 12 months (R3), slight impaired daily activity due to allergic rhinitis (R5), and physician-diagnosed allergic rhinitis (R6) compared to the comparator groups (P < 0.005). In the Physician-diagnosed asthma (A6) questionnaire, on the other hand, only the comparison with the 13–14 year age group was found statistically significant (P < 0.005). The question in which of the last 12 months did this nose problem occur? (R4) could not be compared with previous studies since it was absent in them, with only numerical values being reported. Signs of allergic rhinitis were most prevalent in November and May. Both lifetime wheezing (A1) and lifetime allergic rhinitis (R1) had a prevalence of 53.70% (n = 29).

   Discussion Top

Our study is the first to assess the prevalence of allergic conditions in TFFD using the ISAAC questionnaire. It is already known that the prevalence of allergic conditions shows regional variability. Genetic factors rather than environmental factors have been implicated in this occurrence.[11] Our main advantage was to have access to previously performed studies on the prevalence of pediatric allergic disorders in our region.[11],[12] The presence of lifetime wheezing (A1) was higher compared to those reported in the other two previously conducted studies. In a study involving 14 countries from the Asia-Pacific region, the mean lifetime wheezing prevalence was 12.6% in the 13–14 year age group and 11.4% in the 6–7 year age group.[13]

The positive responses to the question related to the presence of wheezing in the last 12 months (A2) were higher compared to that in the two other studies from our province.

Previous studies have reported the lowest pediatric wheezing prevalence in the last 12 months in the 6–7 year age group in Lithuania (4.3%) and the highest in Costa Rica (32.1%).[14] In the 13–14 year age group, on the other hand, the lowest prevalence was in Albania (2.6%) and the highest in Great Britain (32.0%).[14] In a study from the Asia-Pacific region, the prevalence of wheezing in the last 12 months was 8.8% in 13–14 year age group and 8.9% in the 6–7 year age group.[13] As one can see, our prevalence for wheezing in the last 12 months was two times higher than those reported from the other two studies in our province, as well as it was higher than those obtained from population-based ISAAC studies worldwide.

There is a correlation between increased asthma prevalence and severity of symptoms and increased mortality.[14] In our study, a higher weekly number of attacks compared to the control groups suggests that mortality and morbidity rates may also be higher due to attacks in patients with TFFD.

Allergic rhinitis is among the most prevalent conditions worldwide, and it persists for life. It is reported that the prevalence of self-reported allergic rhinitis was 2%–25% in children and 1% and 40% in adults.[15] In an ISAAC study reported from England, the lifetime prevalence of getting allergic rhinitis (question no = R1) was 34.9% while the prevalence of signs of rhinitis was 37.9%.[16] The study from 14 countries in the Asia-Pacific region reported a mean prevalence of allergic rhinitis (question number R1) of 15.1% in the 13–14 year age group and 10.6% in the 6–7 year age group.[13] In addition to reporting higher figures compared to previously reported prevalence from our province, our study also reported higher prevalence figures than studies reported from other countries (72.22%). This may be explained by TFFD patients having an atopic body habitus.

It has been reported that asthma co-occurs with allergic rhinitis at a rate of 15% and 38% while symptoms of allergic rhinitis accompany asthma at a rate of 6% to 85%.[15] Our results are in accordance with the literature data in showing lifetime wheezing and allergic rhinitis occurring together in more than half of the patients.

Physician-diagnosed eczema is considered a major criterion by asthma prediction indexes.[17] Among children younger than 3 years who were on asthma treatment, the prevalence of physician-diagnosed eczema was reported to be 12%.[17] According to ISAAC questionnaire data obtained from 56 countries, the prevalence of eczema was 1% to 17% in the 13–14 year age group and 2% to 16% in the 6–7 year age group.[18] In our study, the prevalence of physician-diagnosed eczema was found similar in TFFD patients and the comparator groups. In order not to miss TFFD, we recommend that a patient should be undressed and examined under adequate light. After observing a dirty appearance of skin, it would be appropriate to use a flow chart to facilitate making the diagnosis [Figure 5].
Figure 5: Terra Firma-forme Dermatosis diagnosis flow chart

Click here to view

   Conclusions Top

Our study showed that both the prevalence and the severity of signs and symptoms of asthma and allergic rhinitis were higher in children with TFFD. These findings support the idea that TFFD may be a condition with a possible link with asthma and allergic rhinitis and that it may have a common etiopathogenesis with these conditions. Future multicenter clinical and laboratory studies with a larger sample size would enable us to better understand the TFFD and its relationship with other clinical conditions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Duncan WC, Tschen JA, Knox JM. Terra firma-forme dermatosis. Arch Dermatol 1987;123:567-9.  Back to cited text no. 1
Berk DR. Terra firma-forme dermatosis: A retrospective review of 31 patients. Pediatr Dermatol 2012;29:297-300.  Back to cited text no. 2
Guarneri C, Cannavo SP. Is this skin diseased, or is it just dirty? JAAPA 2009;22:17.  Back to cited text no. 3
Abdel-Razek MM, Fathy H. Terra firma-forme dermatosis: Case Series and dermoscopic features. Dermatol Online J 2015;21. pii: 13030/qt4rq5×48c.  Back to cited text no. 4
Chun SW, Lee SY, Kim JB, Choi HM, Ro BI, Cho HK. A Case of terra firma-forme dermatosis treated with salicylic acid alcohol peeling. Ann Dermatol 2017;29:83-5.  Back to cited text no. 5
Aslan NÇ, Güler Ş, Demirci K, Isiyel E. Features of terra firma-forme dermatosis. Ann Fam Med 2018;16:52-4.  Back to cited text no. 6
Asher MI, Weiland SK. The international study of asthma and allergies in childhood (ISAAC). ISAAC steering committee. Clin Exp Allergy 1998;28(Suppl 5):52-66; discussion 90-1. Available from: [Last access date: 2020 Mar 14].  Back to cited text no. 7
Hopkin JM. Mechanisms of enhanced prevalence of asthma and atopy in developed countries. Curr Opin Immunol 1997;9:788-92.  Back to cited text no. 8
Mitchell EA, Stewart AW, Rea HH, McNaughton S, Taylor G, Smith LT, et al. Measuring morbidity from asthma in children. N Z Med J 1997;110:3-6.  Back to cited text no. 9
İnce T. Denizli il merkezinde 13-14 yaş arası okul çocuklarında astım semptomlarının prevelansının yazılı ve video anketle saptanması ve risk faktörlerinin değerlendirilmesi (Determination of the prevalence of asthma symptoms with written and video questionnaire and evaluation of potential risk factors among 13-14 years-old school children in Denizli) [Uzmanlık Tezi (master's thesis)]: Pamukkale Üniversitesi; 2009. Turkish. Available from:ülay%20%20İnce%20.pdf?sequence=1&isAllowed=y. [Last accessed on 2020 Mar 14].  Back to cited text no. 10
Akcay A, Tamay Z, Inan M, Gürses D, Zencir M, Ones U. The prevalence of symptoms related to allergic diseases in 13-14-yr-old school children in Denizli. Turk Arch Ped 2006;41:81-6. Available from: [Last accessed on 2020 Mar 14].  Back to cited text no. 11
Akcay A, Tamay Z, Dagdeviren E, Zencir M, Ones U, Guler N. The prevalences of allergic diseases symptoms among 6-7-yr-old school children in Denizli. Ege J Med 2007;46:145-50. Available from: [Last accessed on 2020 Mar 14].  Back to cited text no. 12
Wong GW, Leung TF, Ko FW. Changing prevalence of allergic diseases in the Asia-pacific region. Allergy Asthma Immunol Res 2013;5:251-7.  Back to cited text no. 13
Anderson H, Gupta R, Kapetanakis V, Asher M, Clayton T, Robertson C, et al. International correlations between indicators of prevalence, hospital admissions and mortality for asthma in children. Int J Epidemiol 2008;37:573-82.  Back to cited text no. 14
Brozek JL, Bousquet J, Agache I, Agarwal A, Bachert C, Bosnic-Anticevich S, et al. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines-2016 revision. J Allergy Clin Immunol 2017;140:950-8.  Back to cited text no. 15
Austin JB, Kaur B, Anderson HR, Burr M, Harkins LS, Strachan DP, et al. Hay fever, eczema, and wheeze: A nationwide UK study (ISAAC, international study of asthma and allergies in childhood). Arch Dis Child 1999;81:225-30.  Back to cited text no. 16
Castro-Rodriguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med 2000;162:1403-6.  Back to cited text no. 17
Williams H, Robertson C, Stewart A, Aït-Khaled N, Anabwani G, Anderson R, et al. Worldwide variations in the prevalence of symptoms of atopic eczema in the International Study of Asthma and Allergies in Childhood. J Allergy Clin Immunol 1999;103:125-38. Available from: [Last accessed on 2020 Mar 14].  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1]

This article has been cited by
1 Cobblestone-like rashes on the penis
Li-Wen Zhang, Wen-Ju Wang, Tao Chen
BMJ. 2022; : e070996
[Pubmed] | [DOI]


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,170 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded65    
    Comments [Add]    
    Cited by others 1    

Recommend this journal