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ORIGINAL ARTICLE
Year : 2022 | Volume
: 23
| Issue : 3 | Page : 214-220
Pattern and distribution of pediatric dermatoses and their association with parental socioeconomic status: A single-center experience from India
Indrashis Podder1, Komal Agarwall2, Anubhav Anurag3
1 Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
2 Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
3 Intern, College of Medicine and Sagore Dutta Hospital, Kolkata, West Bengal, India
Correspondence Address:
Indrashis Podder
Department of Dermatology, College of Medicine and Sagore Dutta Hospital, Kolkata - 700 058, West Bengal
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijpd.ijpd_1_22
Background: In developing countries, pediatric dermatoses cause significant morbidity and are a major public health problem. Parental socioeconomic status (SES) is an important underlying factor. Aim: The aim of the study is to estimate the prevalence and disease characteristics of pediatric dermatoses at a tertiary care center in Eastern India. Materials and Methods: Patients aged 19 years and below, presenting with at least one skin disorder were included in this cross-sectional study. All patients were subjected to detailed history including parental SES and clinical examination. Results: We evaluated 525 subjects (mean age 9.9 ± 6.2 years; M:F 1:1.1), majority being adolescents (>12–19 years) (40.6%) and belonging to upper-lower socioeconomic class (69.3%). Infections and infestations were most frequent (56.6%), followed by skin appendageal disorders (22.7%), eczema and dermatitis (8.8%), miscellaneous disorders (6.9%), pigmentary and nevoid disorders (3.4%), and papulo-squamous disorders (1.7%). Among infections, dermatophytosis was most common, followed by scabies and impetigo; while acne vulgaris was the most frequent noninfectious disorder followed by seborrhoeic dermatitis. Skin disorders were significantly associated with parental SES (P = 0.04). Infections showed a significant inverse association with parental SES (P = 0.003) while eczematous disorders demonstrated a positive dose-response association (P = 0.005). Higher parental SES increased the risk of acne vulgaris but reduced the risk of impetigo. Conclusion: Infectious diseases occurred most frequently, followed by pilosebaceous disorders. Parental SES is a significant determinant of pediatric dermatoses. Increased awareness is needed to prevent and treat these disorders.
Keywords: Paediatric dermatoses, parental, socioeconomic status
Childhood dermatoses constitute about 30% of all dermatologic consultations.[1],[2] Infectious diseases are common in developing countries like India, compared to eczema in Western children.[2],[3] Recent pan-India school surveys have estimated the range of childhood dermatoses from 9% to 35%.[2] Childhood dermatoses cause significant physical and psychosocial morbidity, due to their visibility. Moreover, early detection of cutaneous manifestations may enable the diagnosis of latent genetic and systemic disorders.
Skin health evaluation is an essential component of primary health care as it indirectly reflects personal hygiene practices, health status, and dietary habits of the child along with his/her family.[2] Socioeconomic status (SES) is an important marker of health and nutritional status of a family. It also influences the accessibility and affordability to health care and basic hygiene. Thus, parental SES and childhood skin disorders are intertwined and interconnected. A recent systematic review has highlighted the association between SES and allergic disorders (allergic rhinitis and asthma); however, its link with skin disorders remains inconclusive.[4]
The current study aims to evaluate the clinicoepidemiologic profile of pediatric dermatoses and assess the association between pattern of pediatric dermatoses and parental SES. This would enable the identification of underlying predisposing factors and designing appropriate health policies. Dearth of similar literature in the present set-up has prompted this study.
Materials and MethodsStudy design
We conducted a cross-sectional study in a tertiary-care center across 12 months (February 2019 to January 2020) after obtaining requisite Ethics committee approval (CMSDH/IEC/227/03-2020).
Study participants
We included consecutive patients aged 0–19 years of either gender, presenting with at least one skin manifestation, by purposive sampling. Written informed consent and assent (>7 years) were obtained from the parents/guardians and participants.
Considering the prevalence of pediatric dermatoses to be 9.5%,[2] we calculated our sample size to be 132 patients, using the formula z2 pq/d2 (p is the prevalence of reference study [9.5%], q = 100-p, d = precision, margin of error = 5% and confidence interval [CI] = 95%). However, considering our patient footfall, we recruited 608 patients initially, but parents refused consent in 83 cases, so our final study sample was 525.
Each participant was subjected to detailed history (demography, clinical, and family history), general, cutaneous, and systemic examination. Most of our diagnoses were clinical; however, bedside and laboratory investigations including skin scraping, smear, and staining (Grams, AFB, Tzanck), Wood's lamp examination, and skin biopsy were performed when needed. We categorized patients into four sub-groups, infants (0–1 year), preschool (1–6 years), school going (>6–12 years), and adolescents (>12–19 years) to compare diseases according to age groups. We classified skin disorders into 2 major groups – infectious and noninfectious. Infectious diseases were further subdivided into bacterial, fungal, parasitic, and viral. Noninfectious diseases were subgrouped as eczema and dermatitis, disorders of skin appendages, pigmentary and nevoid disorders, papulosquamous disorders, and miscellaneous disorders.
Socioeconomic determinant
Socioeconomic determinant was assessed by evaluating the parental SES. We used the validated modified Kuppuswamy's SES scale to determine the parental SES.[5] This scale has 3 basic parameters – (i) education, (ii) occupation of the head of family, and (iii) total monthly income of family. Each parameter is further classified into subgroups and scores are allotted to each subgroup ranging from 1 (minimum) to maximum scores of 7 (education of head of family), 10 (profession of the head of family) and 12 (total monthly income of the family). SES is determined by the cumulative score, which ranges from 3 to 29; higher scores indicating upper socioeconomic class. Based on total score, 5 socioeconomic classes are identified – (i) upper (26–29), (ii) upper middle (16–25), (iii) lower middle (11–15), (iv) upper lower (5–10), and (v) lower (1–4).[5]
Statistical analysis
Data were statistically analyzed using MedCalc® v12.5.0. Continuous variables have been represented by mean and standard deviation (parametric data) and median (inter-quartile range) (nonparametric data). We have used percentage/proportion from categorical variables. For statistical analysis, Chi-square test and analysis of variance were used for categorical and continuous variables, respectively. Multivariate logistic regression was performed to assess the effect of parental SES on skin disorders, adjusting for confounders (gender, age, and residence). The effect of parental SES was estimated by adjusted odds ratio (OR) and 95% CI, while the lowest SES group served as the reference group. A “P” value < 0.05 has been considered statistically significant.
ResultsOverall, we evaluated 525 consecutive patients aged 0–19 years with at least 1 dermatosis. In our center, pediatric dermatoses constituted 12.1% (525/4321) of all dermatologic consultations during the study period.
The mean age of our subjects (n = 525) was 9.9 ± 6.2 years (median 10, interquartile range 4–15), and females outnumbered males (273:252). Thirty-four subjects belonged to 0–1 year age group (20 boys, 14 girls), 140 were in the preschool (1–6 years) age-group (78 boys, 62 girls), 138 in the school (>6–12 years) age-group (79 girls, 59 boys) and 213 were adolescents (>12–19 years; 118 girls, 95 boys); this age distribution being statistically significant (P = 0.001, Chi-square) [Figure 1]. Based on parental SES, majority (69.3%, 364/525) belonged to upper-lower class, followed by 17.1% (90/525), 8.2% (43/525), 3% (16/525), and 2.3% (12/525) hailing from lower-middle, upper-middle, lower and upper classes, respectively [Table 1].
Table 1: Demography of participants and parental socioeconomic status (n=525)Infectious diseases (56.6%, 297/525) were more frequent than noninfectious diseases (43.4%, 228/525) [Table 2]. Overall (n = 525), we noted the following frequency of disease groups-infections and infestations (56.6%) > appendageal disorders (22.7%) > eczema and dermatitis (8.8%) >miscellaneous disorders (6.9%) > pigmentary and nevoid conditions (3.4%) >papulosquamous disorders (1.7%). Dermatophyte infections (17.8%), scabies (17.3%), impetigo and acne vulgaris (8.9% each), seborrhoeic dermatitis (8.6%), and folliculitis (6.3%) were our most common dermatoses.
Among infectious diseases, fungal infections were most common (19.8%, 104/525), followed by parasitic infestation (17.5%, 92/525), bacterial (16.8%, 88/525), and viral infections (2.5%, 13/525). Regarding individual diseases, dermatophytosis (17.8%, 93/525) was most frequent, followed by scabies (17.3%, 91/525), impetigo (8.9%, 47/525), and folliculitis (6.3%, 33/525). Molluscum contagiosum (0.9%, 5/525) was the most common viral infection [Table 2].
Skin appendageal (sweat and sebaceous glands) disorders were the most common noninfectious condition (22.7%, 119/525). Other noninfectious disorders, in order, included eczema and dermatitis, pigmentary and nevoid conditions, papulosquamous, and miscellaneous in 8.8%, 3.4%, 1.7%, and 6.9% cases, respectively. Overall, acne vulgaris (8.9%, 47/525) was the most common noninfectious disorder, followed by seborrhoeic dermatitis (8.6%, 45/525), miliaria (4.8%, 25/525), atopic dermatitis (3.4%, 18/525), and contact dermatitis (3.2%, 17/525). Lichenoid disorders (0.8%, 4/525) were the most frequent papulosquamous disorder. Keratinisation disorders were the most frequent (1.7%, 9/525) miscellaneous condition, followed by urticaria, generalized pruritus of unknown origin (7 [1.3%] cases each), and papular urticaria (1.1%, 6/525) [Table 2].
Overall, skin disorders were more common in females (P = 0.03, Chi-square). On regression analysis, infectious diseases showed a significant male predilection (OR 0.6, 95% CI 0.4–0.9, P = 0.007) while miscellaneous disorders showed female preponderance (OR 2.2, 95% CI 1.1–4.6, P = 0.03) [Figure 2].
In our study, skin disorders showed a significant association with patient age (P = 0.001). All noninfectious diseases were more common in adolescents (>12 years). However, among infectious diseases, bacterial infections and scabies predominated in childhood than adolescence, while fungal infections occurred more in adolescents. [Table 3] highlights the diseases according to age groups. Remarkably, infectious diseases were the most common in all age-groups.
Overall, the distribution of skin disorders was significantly associated with parental SES (P = 0.04, Chi-square) [Table 4]. Infectious diseases predominated across all socioeconomic classes, ranging from 37.2% in upper-middle class to 75% in upper and lower classes. Skin appendageal disorders were next in frequency in all socioeconomic classes, except in children hailing from upper middle class, 25.6% (11/43) of them presenting with eczema and dermatitis followed by 20.9% (9/43) with appendageal disorders [Table 3]. On regression analysis, infectious diseases showed a significant inverse association with parental SES (adjusted OR decreased from 5.4 to 0.8, compared with lowest SES group, P = 0.003), while eczema and dermatitis group was positively associated in a clear dose-response manner (adjusted OR increased from 0 to 6.8, with respect to lowest SES group, P = 0.005). None of the other disease groups showed a significant association with parental SES [Figure 3]. Regarding individual dermatoses, dermatophytosis, scabies, and miliaria showed no pattern of distribution, while impetigo showed an inverse trend (OR decreased from 3.9 to 0, compared with lowest SES), being marginally significant (P = 0.07). The prevalence of acne was directly proportional with parental SES (OR 0 at lowest SES to OR 1.4 at highest SES), but it was not statistically significant (P = 0.5).
Figure 3: Skin disorders and parental socioeconomic status, star marked, solid lines representing those with significant association
Table 4: Types of skin diseases with respect to parental socioeconomic status (n=525) Discussion Skin diseases occur frequently in children and adolescents hailing from underdeveloped and developing countries, leading to significant morbidity. Likewise, we noted a point prevalence of 12.1% for childhood and adolescent dermatoses, comparable to Asian and African studies (9.5% to 35.2%).[2],[6],[7] In our study, females outnumbered males with a mean age of 9.9 ± 6.2 years, consistent with studies from Nepal and Turkey;[6],[8] while an Indian study reported male predominance and an African study reported no gender predilection.[1],[3] Most (40.6%) of our patients were adolescents (>12–19 years), similar to that of Özçelik et al. (50.3%) and Saini et al.(51.6).[8],[9] In contrast, Bonthu et al. and Sacchidanand et al. observed 5–11 years as the commonest age group.[2],[10] Majority (69.3%) of our patients belonged to “upper-lower” socioeconomic class, while only 2.3% belonged to upper class. To our knowledge, this is the first Indian study to link common childhood skin diseases with parental SES.
Our top 3 disease groups were infections and infestations (56.6%), appendageal disorders (22.7%), and eczema and dermatitis (48.8%). Most Indian studies have reported highest frequency of infectious diseases, consistent with our findings.[2],[9],[11],[12] Bonthu et al.[2] and Saini et al.[9] reported somewhat similar patterns in which infections and infestations were the most common, followed by eczematous and appendageal disorders. Predominance of childhood infections has also been reported from similar underdeveloped or developing countries like Nepal (24.6%), Nigeria (57.6%), Turkey (24.6%), and Pakistan (45.1%).[6],[7],[8],[13] In contrast, eczematous and inflammatory disorders predominate in western children.[14],[15] The predominance of infections and infestations in countries like India may be attributed to poverty and resultant poor living conditions (overcrowding, poor sanitation facilities), debilitating co-morbidities like malnutrition and a favorable hot, humid tropical climate.
Among infectious conditions, fungal disorders (19.8%) predominated, followed by parasitic infestation, bacterial and viral infections. Our findings are consistent with Poudyal et al.(Nepal), Oninla et al.(Nigeria), and Mukhtar et al.(Pakistan) who also recorded maximum frequency of fungal infections in 18.5%, 17.1%, and 22% cases, respectively.[6],[7],[13] Interestingly, Indian studies have reported viral and bacterial infections to be more common than fungal infections,[9],[11],[12] while Bonthu et al. reported scabies to be most frequent.[2] Tinea cruris was our most common fungal infection, similar to Saini et al.,[9] while some authors have reported tinea capitis to be commonest in children.[7],[14] Scabies was our most common parasitic infestation in 17.3% cases, comparable to Bonthu et al.(20.6%),[2] but slightly lower than Mukhtar et al.(27.4%).[13] However, several authors have reported a much lower prevalence, ranging from 1.2% to 6.8%.[7],[9],[12] Our high prevalence of scabies may be explained by its contagious nature, congested and unhygienic living conditions. Bacterial infections occurred more frequently in our study compared to Bonthu et al.(6.7%), Saini et al.(5.7%), and Mukhtar et al.(8%), while impetigo was the most common pyoderma in all studies.[2],[9],[13] Özçelik et al.(Turkey), Saini et al.(India), and Mukhtar et al.(Pakistan) noted viral infections in 14.8%, 21.3% and 15.1% patients, respectively; in contrast, our frequency (2.5%) was much lower.[8],[9],[13] However, Bonthu et al. reported similar prevalence of viral infections (2.7%).[2] Molluscum contagiosum was our most common viral infection followed by warts, in agreement with Saini et al. and Balai et al.,[9],[11] however, other authors have reported a reverse order (warts > molluscum).[7],[9],[14] Varicella was our 2nd most common viral infection in 0.6% patients, while another Indian study recorded almost double prevalence (1.2%).[2] The variable frequency of infective disorders may be attributed to varying sample sizes, climatic conditions, socio-cultural habits, and heterogeneous hygienic and nutritional status of the study participants.
Skin appendageal disorders constituted the second commonest disease group, accounting for 22.7% cases, higher than other studies (6.5%–13.2%).[7],[9] In our study, acne was predominant, in contrast to other authors (seborrhoeic dermatitis >acne).[2],[9] The higher prevalence of these disorders in our study may be attributed to greater proportion of adolescents in our study population, as these disorders predominantly affect this age group.[7] Mukhtar et al. detected predominance of seborrhoeic dermatitis, as most of their patients aged <4 years, leading to higher proportion of infantile seborrhoeic dermatitis.[13] We observed miliaria (sweat gland obstruction disorder) in 4.8% cases, higher than most authors (1.5%–1.7%), probably explained by excessive hot and humid climate in the present set-up.[2],[9],[13]
Eczematous disorders constituted our 3rd most common disease group accounting for 8.8% cases, comparable to Karthikeyan et al.(8.6%),[16] but lower than other authors (19.2%–39.7%).[2],[11],[17] Among eczematous disorders, atopic dermatitis (3.4%) was most common, consistent with Bonthu et al.(5.9%), Ozcelic et al.(4.03%), Saini et al.(4.1%) and Mukhtar et al.(2.3%).[2],[8],[9],[13] In contrast, studies from developed countries have documented higher prevalence of atopic dermatitis (10%–20%), probably due to changing lifestyle, rigorous hygiene practices, and decreased breastfeeding.[8],[15] Contact dermatitis was our next frequent eczema (3.2%), similar to Mukhtar et al.(3.4%).[13] Incidence of eczematous conditions is dependent on environmental conditions and individual genetic predisposition, thus explaining the variable frequency.
Vitiligo was our most common pigmentary disorder (1.3%). Our finding is consistent with other authors (0.7% to 2.2%).[5],[11] However, a Nigerian study recorded higher prevalence of vitiligo (5.3%),[7] as it dealt with only referred cases.
Lichenoid disorders (LN > LP) were our most common papulo-squamous dermatoses (0.8%), similar to Bonthu et al. (LN > LP)[2] and Oninla et al.(LP > LN),[7] while Ozcelic et al.[8] and Saini et al.[9] noted psoriasis to be most frequent in their cohorts. Our study corroborates the fact psoriasis is less common in the tropics and dark-skinned individuals.[7]
Urticaria (1.3%) and papular urticaria (1.1%) were our most common hypersensitivity disorders, included under miscellaneous section. This finding is consistent with Saini et al.,[9] who reported urticaria and papular urticaria in 1.8% and 1.1% children, respectively. Karthikeyan et al. (India)[16] and Xiao et al. (China)[18] noted slightly higher frequency of urticaria in their patients, 2.5% and 2.7%, respectively. Notably, the Chinese study included adolescent patients exclusively. Other notable diagnoses in our study included keratinization disorders and pityriasis alba in 1.7% and 0.8% cases, respectively. In comparison, Saini et al. noted keratoderma in 1.7% children, while Bonthu et al. reported pityriasis alba in 4.5% patients.[2],[9]
In our study, skin disorders were significantly more common in females contradicting the findings of Oninla et al.,[7] who observed no gender predilection. However, on individual level, only infectious diseases and miscellaneous disorders showed significant predilection for male and female genders, respectively. Predominance of infectious diseases in males may be attributed to increased contact during play and sharing of fomites, in agreement with Oninla et al.[7] Along with miscellaneous disorders, appendageal and pigmentary disorders were also more common in females, which may be attributed to their increased aesthetic concern.
We detected a significant association between skin disorders and patient age (P = 0.001), contradicting the findings of Saini et al. (P = 0.07).[9] All noninfectious diseases were more common in adolescents (>12 years). Oninla et al.[7] and Sacchidanand et al.[10] reported fungal infections to be more frequent in childhood than adolescence, however, we found them to be more frequent in adolescents.
To our knowledge, this is the first study to link common childhood skin disorders with parental SES in India. Overall, we detected a significant association between childhood skin disorders and parental SES (P = 0.04, Chi-square). Among disease groups, only infectious disorders showed a significant inverse relation with parental SES, while eczematous disorders showed a directly proportional relationship [Figure 3]. This finding is consistent with Xiao et al.[18] We failed to find any significant association between 5 most common diseases in our study (tinea, scabies, impetigo, acne, and seborrhoeic dermatitis) and parental SES, except impetigo showing a marginally significant inverse relationship (P = 0.07). In contrast, Xiao et al.[18] demonstrated positive significant association with parental SES for atopic dermatitis and chronic spontaneous urticaria, while tinea showed an inverse association. In our study, the prevalence of acne vulgaris was directly proportional to parental SES in a clear dose-response manner, consistent with Xiao et al., none being statistically significant. Notably, Xiao et al. included only adolescent patients in their cohort.[18]
Limitations
Our major limitations were small sample size and selection bias. Besides, we could not assess the effect of seasonal variation on childhood dermatoses.
ConclusionOur study reported infections and infestations to be the most common pediatric dermatoses, followed by pilosebaceous and eczematous disorders, while papulosquamous disorders were least frequent. Among infections, dermatophytosis predominated, followed by scabies and bacterial infections. This pattern reflects the current Indian epidemic of superficial fungal infections. Adolescents (>12–19 years) were affected most commonly, followed by 1–6 years age group, while infants (<1 year) were least affected. Our study also demonstrated a significant association between infectious and eczematous disorders, and parental SES; the possible links being accessibility and affordability of health-care and hygienic life-style.
The predominant skin conditions in our study, i.e., infections and infestations may be minimized by proper patient education and appropriate community health programs. Thus, treating physicians must become aware of the epidemiology of childhood skin disorders in their region and underlying factors; for better management of these conditions. Our study is a small attempt in this regard, as there is dearth of similar literature in the present set-up. These authors recommend further large-scale, multicenter, population-based studies to evaluate the clinico-epidemiology of paediatric dermatoses and assess their contributory factors. This would enable designing more effective preventive health policies and education programs in the near future.
Declaration of consent
The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Institutional.
Conflicts of interest
There are no conflicts of interest.
References
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