An International Journal for Community Skin Health

EDITORIAL: PUBLIC HEALTH AND SKIN DISEASE R J Hay DM FRCP record which is often unrecognised. For International Foundation of instance, in the early part of the twenti- Dermatology eth century many countries had policies Professor of Dermatology for the control of scalp ringworm which Faculty of Medicine and Health Sciences ranged from school exclusion orders to special treatment facilities. It resulted in Queen’s University, Belfast, UK partial control but, in the absence of an effective remedy, elimination remained ost of the work of dermato- a distant goal. With the discovery of logists is concerned with the drug, griseofulvin, the potential to the treatment of individ- provide a wider programme based on Mual patients to the highest standards the treatment of communities became achievable with the facilities and skills possible and, in some areas, there was a available. However, it is seldom possible concerted effort to eliminate tinea capi- to apply this to large populations in tis using control teams. Afghan refugee child most parts of the developing world, par- Yaws and leprosy are further exam- ticularly where the lack of resources and ples of diseases where control measures, sparse populations make the adoption of backed by international collaboration, this model of health care unattainable. have focused on elimination of infection In assessing the needs for these groups a by early identification of cases and con- different approach is necessary. tacts and mass drug treatment.

Public Health and Skin Skin Disease and the Western Disease World Dermatological public health has sel- In recent years, the focus of public dom been prioritised as a key objec- health in 'western world' dermatology tive in the overall management of has concentrated on the control of the At a Health Centre, Afgooye, Somalia skin diseases, although it has a strong modern epidemic of a non-infectious Photos: Murray McGavin CONTENTS J Comm Dermatol 2005; 2: 1–16 Issue No. 2 EDITORIAL QUIZ Public Health and Are All White Spots Skin Disease Rod Hay 1 Vitiligo? Claire Fuller 10 REVIEW ARTICLES Treatment of Leprosy Antoon Baar & TEACHING AIDS Ben Naafs 3 Teaching Aids at How I Manage Eczema Low Cost (TALC) David Chandler 13 in the Community Najeeb Ahmad Safdar & Jane Sterling 6 ABSTRACTS ESSENTIAL DRUGS IN DERMATOLOGY Journal Extracts and 1. Gentian Violet RDTC Reports Neil Cox 15 2. Whitfield’s Ointment Ramadhan Mawenzi 9

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 1 Editorial condition – skin cancer. The relationship Training and Primary Care ment of a more severe underlying between skin cancer and sun exposure problem are recognised and managed A key strategic target has been to redress is well established although individual appropriately, if necessary by referral to this balance by providing highly focused susceptibility and sun avoidance practices a specialist centre. The skin is the mir- training for primary care staff, either are all elements of the complex equation ror of many other events affecting the through the development of diagnostic in the development of skin cancer. School human body. A good example here is and therapeutic algorithms or through and general public education, the identi- HIV/AIDS where the early recognition focused training and practical instruc- fication of risk and the development of of skin or mucosal signs may provide tion. An example of the former is the early recognition programmes have all the earliest clues for investigation, coun- development of a training programme for been brought forward in many countries selling and treatment. The increasing doctors and nurses at primary care level – with promising results in reducing the availability of anti-retrovirals in parts of in Mali where the four commonest dis- incidence of skin cancer and improving the developing world, where previously eases, pyoderma, tinea capitis, scabies and long term survival. There is, therefore, these had been unavailable, makes this eczema are targeted. A second example is a well estab lished basis for the develop- approach both justifiable and practica- the work of Estrada and colleagues in ment of a public health approach to skin ble. Similarly, leprosy and onchocerciasis Mexico where the focus of education is disease. are both examples of important diseases the primary care team – doctors, nurses where skin signs allow early recognition and health promoters – through formal and treatment. Developing Countries and focused training sessions using patient- Skin Disease based education. A third approach has been to teach future health care teachers Public Health, Education and In the developing world, the major- and leaders. The Regional Dermatology Communities ity of skin conditions are common Training Centre in Moshi, Tanzania, was It is possible to develop programmes, infective diseases for which there is set up to train the future dermatologi- based on practical education, which can usually a simple remedy. The problems cal leaders in this field amongst medical reduce the prevalence of certain diseases that arise in the effective management officers and, latterly, through a regional and bring prompt, effective treatment at of these cases are the result of a com- dermatology residency programme, der- primary care level. It remains less clear bination of poor disease recognition, matologists. The key to the successful whether it will be possible to eliminate generally because there are insufficient implementation of all these initiatives these conditions from particular areas. individuals with appropriate skills at has been to show, firstly, that the educa- In almost all cases these programmes primary care level, and poor treatment tion provided has led to an improvement are best developed through adopting an regimens, due to unavailability or lack in learning and, secondly, that it has had approach which targets communities. of knowledge. Treatment regimens are an impact on local disease levels. also often inadequately explained. This Such public health initiatives have much results in much misdiagnosis and, in Good Management and to contribute to dermatology. consequence, wasted funding. Large Specialist Centres amounts of scarce resources available to health centres, depen dant on inadequate The second part of a public health state or personal funds, are wasted on delivery approach is to ensure that those treating skin disease badly. with skin lesions that signal the develop-

An International Journal for Community Skin Health DEVELOPING Journals available FREE MENTAL Vo lume 2 Issue No. 2 200 4 HEALTH An International Journal for Mental Health Care

EDITORIAL: COMMUNITY DERMATOLOGY – WHAT IS IT? Developing Mental Health: Issue No. 2 to Developing Countries Andrew Sims Diagnosis n most of the world, health care is MA MD FRCPsych FRCP Diagnosis is really provided not by doctors but by other Past President, only a technical term Ihealth care workers, such as nurses, Royal College of Psychiatrists, UK for what all profes- the majority of them in small rural com- Emeritus Professor, sional people do. The munities. Usually, there is very limited University of Leeds, UK medical model is, access to hospitals and medical specialists of course, not only for their patients. Developing Mental Health aims to support medical. If you consult those, either professionals or volunteers, a bank manager about Knowledge and Training who are caring for and treating mentally a debt, or a lawyer ill people. Effective treatment of the men- about buying a house, In addition to medical supplies, health tally ill has only been possible in the last they go through a care workers also need opportunities for 50 years, and so it is important now that similar process. The training and further education. This is anyone looking after them not only thinks first thing the profes- already provided for Dermatology in about their quality of life whilst ill, but also sional person has to • Community Dermatology some centres, such as the Regional Der- the possibility of appropriate treatment. do is work out what matology Training Centre at Moshi in But how do you start? the problem is, what In Mozambique Photo: Murray McGavin Tanzania. The vast majority of these general category it comes into, whether health workers, however, do not have Medical Model debt or house purchase. Then professional access to such centres and an alternative • What is this problem in terms of my Village young people in Tanzania This is where the so-called medical model problem solving is applied and, hope- professional expertise? is to send information to the workers is useful. Rational treatment can only begin fully, the professional comes up with the in their own situations. This is already Photo: Paul Buxton • In what way is it similar to the problems when the problem/diagnosis has been right procedure. However, they would not of some other people? being done by Community Eye Health, worked out quite precisely: then applying have done so had they not first decided • What was it that worked when we tried published by the International Centre for countries, four times a year (free to “Every day, in communities throughout the programme of treatment that is, in gen- what type of problem it was. Diagnosis to help them? Eye Health for the last 16 years. Current- developing countries). Thefounder of this the world, individuals urgently require eral, suitable for that specific diagnosis. is a similar process, but in the health No w, we will use the same, general ly, 16,000 copies are distributed to 178 Journal, Dr Murray McGavin, has said; health care, yet all too often a health field. • worker simply does not know what to programme for this individual. • Developing Mental Health do. Sadly, patients may even be harmed (2004), 2, 1–16 Issue No. 2 CONTENTS – simply through lack of knowledge”. Developing Mental Health Editorial: Issue No. 2 Andrew Sims 1 J Comm Dermatol 2004; 1: 1–16 Issue No. 1 Editorial Board; ICTHES World Management of an Acute Psychotic Episode Evelyn Sharpe 2 EDITORIAL Care Mental Health Care in Primary Health Care: Peter Ventevogel, Frank Kortmann 5 Community Dermatology – What is it? Paul Buxton 1 Experiences from Eastern Afghanistan This Journal is intended to provide guid- Cultural Factors in Mental Health and Illness: Joseph O’Neill Byrne, Cathy Myers 8 BOOK REVIEW ance for health care workers in the area ‘Normality and Abnormality’ of skin diseases and conditions such as An Atlas of African Dermatology Sam Gibbs 2 Abstracts 9, 15 Barbara Leppard leprosy, that manifest themselves by skin Is Religious Belief Bad for Your Health? (Book Review) Andrew Sims 10 changes. There is an Editorial Board that REVIEW ARTICLES plans the policy, content and manage- Mental Health Care in Primary and Community Settings: Shekhar Saxena, Pallab Maulik, 11 • Repair & Reconstruction Results from WHO’S Project Atlas (Courtesy of the Kathryn O’Connell, Benedetto Saraceno Emollients and Skin Care Terence Ryan 3 ment of the Journal. Publishing and dis- Skin Signs of HIV/AIDS Barbara Leppard 6 International Journal of Social Psychiatry) tribution is being carried out by ICTHES Skin Changes in Leprosy Antoon Baar Psychiatry in Nigeria (Courtesy of International Psychiatry) Oye Gureje 13 and Ben Naafs 10 World Care – a charity that also publishes similar journals in three other specialties. JOURNAL EXTRACTS Neil Cox 14 It is funded by voluntary contributions. An International Community Trust Publication for Health & Education • Community Ear & Hearing Health COMMUNITY DERMATOLOGY: 2004; 1: 1–16 Issue No. 1 1 1

E • R HAB T IL C I U T R A T T S E Repair & Rec onstruc tion N Repair Rec onstruc tion O C E A JOURNAL FOR R

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Injury, Deformity & Disease R Volume 2 Issue No. 2 2001

m Contact: Dr Murray McGavin AN INTERNATIONAL COMMUNITY TRUST PUBLICATION FOR HEALTH AND EDUCATION c 2004; 1:1–16 Issue No. 1 Editorial: Burn Injury (2) TOMPOTOKAR FRCS(Ed), Specialist Registrar, Burns and Plastic Surgery EDITORIAL: A NEW JOURNAL Morriston Hospital, Swansea,Wales, UK Andrew W Smith in the better ear), and a fur- he second edition of Repair & Reconstruction is a this type of injury in the ther 340 million with mild natural follow on from the first and deals with future. specific types of burn injuries as well as the man- elcome to the first issue of Com- hearing loss. T Facial Burns and agement of the late consequences of burns. ICTHES World Care, PO Box 408 Wmunity Ear and Hearing Health. We Of these, 62 million per- Perineal Burns hope that this new international Journal Hand Burns sons have moderate or worse Facial and perineal burns Severe post-burn elbow contracture undergoing first will fill an urgent need in raising aware- Hand burns whilst often not involving a large surface area also have particular prob- stage release hearing loss that began in Photo: Tom Potokar ness, and providing knowledge and skills childhood and 104 million can have catastrophic consequences, especially if not man- lems, not just in terms of for ear and hearing health in developing such persons have mild hear- aged correctly in the first instance. For this reason there is function, but also in terms of resid- they are likely to cause a significant countries. a substantial chapter on the care of hand burns and it is ual deformity. Reconstructive options improvement. A failed procedure, or ing loss. Two thirds of the hoped that this will help to reduce the disability caused by in these cases can be limited and one that achieves nothing is discour- Hearing loss is one of the common- burden of hearing loss is in very difficult, thus appropriate initial aging for both the patient and the est disabilities in the world, and yet also developing countries, and the management is vital. team looking after him or her. one of the most neglected. Ear disease, Patients who have burns have number of people with hear- Testing for hearing impairment in Madagascar Thermal, Electrical and especially in children, is one of the most already suffered both physically and ing loss continues to increase. Photo: Andrew Smith Chemical Burns Bankhead Avenue, Edinburgh EH11 4HE, UK common reasons for needing health care, psychologically, and all those invol- Although thermal burns are the most ved in their care should endeavour yet there is much ignorance about it and Consequences of common type of burn, electrical and, to optimise their final outcome. Re- a huge shortage of skilled health workers Hearing Impairment hearing loss pr oduces a huge economic increasingly, chemical injuries are habilitation in these cases is often a in this field. Deafness and hearing loss have profound burden on society so that prevention of becoming more frequent. In particu- very long and slow process, however, These situations apply particularly in effects on individuals. Hearing loss dam- hearing loss is likely to be a very good lar, chemicals used in assaults pro- and careful follow up with well timed developing countries and are worst in the duce devastating injuries, and any interventions can maximise the ages development of speech and language investment. legislation aimed at reducing the functional, aesthetic and psychologi- poorest countries. in children especially, if commencing at At least 50% of the burden of hearing Elbow released to 90º incidence of this must be welcome. cal outcome. Photo: Tom Potokar birth or during infancy, and later slows loss in developing countries can be pre- Burns patients who present late, who Repair & Reconstruction Hearing Impairment progress in school. It also causes difficulty vented with current knowledge and many have taken a long time to heal, or BURN INJURY (2) who have been incorrectly treated The response to the first edition of Worldwide in obtaining, performing and keeping a more people with hearing loss can be BURN INJURY (2) Tel: +44 (0)131 442 5339 present with various problems such Repair & Reconstruction has been Editorial Tom Potokar 1 The World Health Organization estimates job and it produces social isolation and treated or given rehabilitation. as hypertrophic scars, contractures, encouraging, and although the that in 2000 there were 250 million people stigmatisation at all ages. These effects Hand Burns Stuart Watson 2 jointdeformities, pigmentary changes arrival of the second issue has taken in the world with disabling hearing loss are magnified in developing countries. Hearing Impairment: Head and Neck Burns Jimmy James 5 and unhealing ulcers. These chal- longer than expected, I hope the wait (moderate or worse hearing impairment In addition to the effects on individuals, Awareness, Prevention, Perineal Burns Peter Drew 6 lenging problems are difficult to treat, has been worthwhile. The next issue Management & Rehabilitation even in the best centres and therapy will be concerned with hand injuries. CONTENTS Chemical Burns Tom Potokar 8 must be aimed primarily towards Any submissions to the ‘clinical arti- A critical problem in dealing with this Chemical Eye Injuries Murray McGavin 9 restoration of function. It is impor- cles’ section should be addressed to Community Ear and Hearing Health 2004; 1: 1–16 Issue No. 1 problem is the lack of awareness about Electrical Burns Nithin Vaingankar, tant that patients have a realistic idea the Editor. � of the limitations of treatment, whilst EDITORIAL Andrew W Smith 1 hearing and hearing loss in all parts of Ian Grant & at the same time maintaining an REVIEW ARTICLES society. Most people are not aware of the Ankur Pandya 10 E-mail: optimistic environment to encourage [email protected] Congenital Deafness in Developing Countries Ian J Mackenzie 3 effects of hearing loss and ear disease on Principles of Early Detection of Hearing Impairment Valerie E Newton 4 patient participation in post-opera- individuals, and politicians and decision Treatment of Burn tive splinting and physiotherapy. Management of Otitis Media in a Developing Country Jose M Acuin 6 Contractures Ankur Pandya 12 Training for Primary and Advanced Ear and Hearing Care Piet van Hasselt 8 makers are not aware of the large num- Surgery and Rehabilitation bers with hearing loss and its high cost on Surgical Techniques: Providing Educational Services for Children with Chosen appropriately, skin grafting society. Programme planners and health i) The Y to V Plasty Tim Goodacre 13 Hearing Impairment Beatriz C Warth Raymann 10 and local flaps such as the Z-plasty ii) The Z-Plasty Alan McGregor 14 WORLD HEALTH ORGANIZATION: REPORT workers are not aware of the opportunities and the Y to V plasty can be benefi- WWHearing: World-Wide Hearing Care for for prevention, management and rehabil- Clinical Article: cial in the treatment of certain con- Developing Countries 12 Chemical Burns itation of hearing loss and ear disease. tractures. However, these procedures Post-operative POP splinting (hand not INTERNET RESOURCES 12 in Kaduna Malachy Asuku 14 should not be undertaken unless There is a critical lack of trained per- yet released) Photo: Tom Potokar ABSTRACTS 13 sonnel in the necessary health, rehabili- JOURNAL OF COMMUNITY EAR AND HEARING HEALTH: Please state: Name, Full Postal Address, E-mail Address & Occupation tation and education fields at all levels. Guidelines for Authors 15 Repair & Reconstructio n Vol. 2 No. 2 2001 1 COMMUNITY EAR AND HEARING HEALTH: 2004; 1: 1–16 Issue No. 1 1

2 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Review Article Treatment of Leprosy

Antoon J M Baar MD DiplTM&H Resistance (cell mediated immunity) to M. leprae Consultant Dermatovenereologist +++ Regional Dermatology Training Centre i (RDTC), Moshi, Tanzania Correspondence to: De Zwette 54 ++ 9257RR Noordbergum The Netherlands E-mail: [email protected]

Ben Naafs MD PhD DiplTM&H Numbers of bacill + Consultant Dermatovenereologist Regional Dermatology Training Centre (RDTC), Moshi, Tanzania 0 Visiting Professor, Instituto Lauro de LL BL BB BT TT Souza Lima ( ILSL), Bauru, SP Brazil Clinical spectrum of disease Senior Lecturer, Ijsselmeerziekenhuizen Fig. 1: The leprosy spectrum of disease Emmeloord/Lelystad and Spectrum of clinical disease in leprosy: LL = lepromatous leprosy; Leiden University Medical Centre BL = borderline lepromatous leprosy; BB = borderline leprosy; (LUMC), Leiden, The Netherlands BT = borderline tuberculoid leprosy; TT = tuberculoid leprosy Gracht 15 8485KN Munnekeburen The Netherlands 2. To lower the incidence of the disease (Figure 1). The larger group of TT – BL E-mail: [email protected] in the hope of eradicating leprosy as patients should also be treated as soon as a communicable disease. possible in order to prevent them from Treatment of Leprosy has Two becoming disabled due to serious nerve Major Goals: From an epidemiological point of view damage (Figure 2). In practice, this it is important to treat the most infec- means that early diagnosis is very impor- 1. Treatment of the individual patient tious patients (BL and LL patients) tant for the treatment of both the indi- to prevent him or her from becoming with a form of treatment which renders vidual patient and for the community as disabled and a social outcast. them non-infectious as soon as possible a whole.1

Treatment Involves: 1. Antibacterial therapy. 2. Anti-inflammatory treatment of leprosy reactions. 3. Treatment and rehabilitation of disability due to nerve damage. 4. Prevention of spread of the disease in the community.

1. Antibacterial Therapy Monotherapy (treatment with a sin- gle drug) is no longer recommended because of widespread drug resistance. In 1982, the World Health Organiza- tion (WHO) recommended multi-drug therapy (MDT) for all patients.2 Treat- ment regimens are based on a simplified classification of leprosy (see box below). The tablets are provided to the patients free of charge and come in Fig. 2: Lagophthalmos after bilateral facial nerve damage blister packs (Figure 3). Each pack con- Photo: John DC Anderson tains enough tablets for 4 weeks. The

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 3 Leprosy tablets for the 1st day of each period reactions occur are swallowed under supervision in the after treatment clinic and patients have to report every is finished, so 4 weeks. At each visit they are examined the treatment of and told to attend in another 4 weeks. leprosy patients They are warned to attend immediately does not end if there is any problem. If the skin signs with the last are improving and the nerves are not blister pack of enlarged and/or tender the patient gets a MDT! new blister pack. • Type-2 leprosy Patients who miss an appointment reaction or ery- have to extend their treatment up to a thema nodosum maximum of 9 months for PB and 36 leprosum (ENL) months for MB leprosy. Patients who is an immune- have not used all their tablets in that complex reac- period will need to repeat the whole tion in patients Fig. 3: Blister packs provided by the government for the course of treatment. with LL leprosy. treatment of leprosy It is a general- 2. Anti-inflammatory Treatment ised inflamma- prednisolone 30–40mg/day (Figure 4). of Leprosy Reactions tory process not only of the skin Once the reaction is under control and peripheral nerves but of many continue with a reduced dose of pred- There are two types of reactions: organs of the body. The frequency of nisolone as follows: ENL has been halved since the intro- • Type-1 or reversal reactions in TT and duction of MDT, but again some • Patients with BT leprosy: 3–6 months borderline leprosy. In these patients, patients are developing ENL after • Patients with BB leprosy: 6–9 months acute inflammation develops. Affect- finishing their treatment. • Patients with BL leprosy: 6 months– ed nerves become tender or painful, 2 years. skin lesions become swollen and red. Treatment of type -1 reactions There may be rapid loss of nerve It is a mistake to stop treatment too function, if not treated. Some type-1 Start treatment immediately with soon. When a painful, very enlarged nerve WHO Classification of Leprosy does not respond to prednisolone, sur- Multibacillary (MB) Leprosy gical decompression of the involved nerve should be done as soon as pos- • patients with > 5 skin lesions • positive skin smear sible. Always check these patients for Paucibacillary (PB) Leprosy signs of other infections and infesta- • patients with 1–5 skin lesions • negative skin smear tions, especially for TB and intestinal worms (especially Strongyloides), and (1) MDT for multibacillary leprosy treat these diseases if found. One blister pack for 4 weeks Treatment of type-2 Day 1 reactions (ENL) • Rifampicin 600mg (2 capsules) } • Clofazimine 300mg (3 capsules) } given under supervision ENL is an episodic, self-limiting disease • Dapsone 100mg (1 tablet) } but it is a generalised disease with many organs of the body involved. Treat- Days 2–28 ment depends on the severity of the • Clofazimine 50mg (1 small capsule) symptoms: • Dapsone 100mg (1 tablet) • Mild forms of ENL with painful skin Duration of treatment 24 months = 24 blister packs nodules only will usually subside within 2–4 weeks. Treat with analge- (2) MDT for paucibacillary leprosy sics (aspirin 600mg qds, or a NSAID, Day 1 e.g., diclofenac 50mg tds). • Rifampicin 600mg (2 capsules) } given under supervision • For moderate forms of ENL, where • Dapsone 100mg (1 tablet) } patients have more extensive pain- ful skin nodules +/- ulceration, Days 2–28 together with fever, leucocytosis and • Dapsone 100mg (1 tablet) general malaise but no involvement Duration of treatment 6 months = 6 blister packs of joints, nerves, eyes or testes, treat

4 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Leprosy

with analgesics (as above) and add 4. Prevention stibophen (Fouadin) 2–3 ml daily of Spread for 3 days. in the • In the more severe forms of ENL Community with signs of arthritis and/or nerve involvement give analgesics (as above) The goal of health plus chloroquine 300 mg/day. programmes is • In very severe ENL, patients have a eradication of lep- severe generalised disease with orchi- rosy worldwide. tis, iridocyclitis, neuritis and arthri- Although the preva- tis. Start treatment with high doses lence (total number of prednisolone (120 mg daily) for of patients in a a short period, diminishing to zero population) of lep- within 2–3 weeks. Avoid maintenance rosy has decreased doses of steroids. If there is a flare-up dramatically in the Fig. 4: Type 1 reversal reaction (left) and the same patient after during the period of drug reduction, last 25 years, the 48 hours of prednisolone treatment (right) double the dose of prednisolone incidence (number Photos: Margreet Hogeweg being used at that time and then try of new patients/ again to reduce the dose quickly. year in a population) remains the same. • Rapid access to health facilities with When the episodes of severe ENL are This means that leprosy, although treat- expert staff for patients with leprosy frequent and short courses of high ed at an early stage (and the patients reactions or other complications of dose prednisolone are not stopping cured), remains as infectious as before. the disease it, add thalidomide as a maintenance For a realistic strategy to eradicate lep- • Good aftercare for leprosy patients drug between prednisolone ‘pulses’. rosy the following facts have to be kept with disabilities Start with 300mg at night. When the in mind: • Research into the influence of the HIV-epidemic on the spread of lep- reaction has subsided continue with • In most countries with a high inci- rosy. 150 mg nocte. Remember that tha- dence of leprosy, the socio-economic lidomide is teratogenic, so do not give situation is poor and so funds and a it to pregnant women. Patients with good infrastructure for eradication BCG Vaccination in Leprosy severe, frequently relapsing forms of campaigns are low • Gives better protection against M. ENL should be referred to an experi- • Case finding of early leprosy cases is leprae than against M. tuberculosis enced leprologist. difficult in integrated primary health • Protection against M. leprae varies care schemes from 80% in Uganda to < 30% in • The incubation period of leprosy is 3. Treatment and Asia very long – up to 15 years Rehabilitation of Disabilities • Estimated time to lower the inci- • Vaccination with an antigen specific dence of leprosy by 50% is: The curse of leprosy has always been the for M. leprae is not yet available severe disabilities of hands, feet, face and • The influence of the HIV-epidemic – 8 years with BCG vaccination eyes due to peripheral neuropathy and/ on the transmission of M. leprae is – 43 years without BCG vaccina- or iridocyclitis. Such disabilities lead to not known but there are indications tion. social isolation and poverty. Prevention that HIV-patients, who also have of disability depends on early diagnosis asymptomatic multibacillary leprosy, References and treatment, especially the early treat- are a serious source of infection to ment of leprosy reactions. the population at large 1. Baar AJM, Naafs B. Skin changes in Unfortunately, there are still patients • Care of disabled patients with burnt- Leprosy. Comm Dermatol 2004; 1:10–16. 2. WHO Chemotherapy of leprosy for con- who come late for treatment and who out leprosy who no longer need trol programmes. WHO Tech Rep Ser 1982; already have irreparable nerve damage specific anti-leprosy drugs, remains 675. when they are first seen. With health important. Otherwise the general 3. WHO Expert committee on leprosy. 6th education, timely wound care, special public will not believe that leprosy, report. WHO Tech Rep Ser 1988; 768. 4. Naafs B. Treatment duration of reversal shoes and various aids to help replace is curable. reaction: a reappraisal. Back to the past. the loss of function in the hands and With these facts in mind, the following Lepr Rev 2003; 74: 328–336. feet, further damage can be prevented. 5. Naafs B. Reactions: The body as battlefield. are possible ways of dealing with leprosy Orthopaedic and plastic surgery is some- III: Treatment. Memisa Medisch 2003; 69: as a public health problem: 343–346. times needed to correct anatomical and functional abnormalities. Correction • MDT treatment for all leprosy of lagophthalmos, corneal transplanta- patients as early as possible tion and other specialised ophthalmic • Health education and BCG vaccina- procedures can restore vision in some tion to the general public (see box) patients.

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 5 Review Article How I Manage Eczema in the Community

Najeeb Ahmad Safdar Table 1: Types of Eczema MBBS MRCP(UK) Endogenous Exogenous Consultant Dermatologist Department of Dermatology 1. Atopic eczema 1. Irritant contact dermatitis Seremban Hospital, Jalan Rasah 2. Seborrhoeic eczema • Acute irritant 70300 Seremban, Negeri Sembilan, 3. Discoid eczema • Cumulative insult Malaysia 4. Juvenile plantar dermatosis Honorary Senior Lecturer, International 5. Pompholyx / dyshidrotic eczema 2. Allergic contact dermatitis Medical University, Seremban, Malaysia 6. Stasis eczema 7. Lichen simplex Jane Sterling FRCP PhD 8. Asteatotic eczema Honorary Consultant Dermatologist Addenbrooke's Hospital Management • Avoidance of any precipitating or exacerbating factors Cambridge CB2 2QQ A management strategy (Table 2) is UK • Reduction in skin inflammation by essential. It is often helpful to consider the use of topical steroids. Occasion- treatment in two phases – management czema is a group of skin disorders ally may be necessary for more per- of the acute disease and then longer- characterized clinically by red- sistent, severe and uncontrolled skin term measures to maintain control and ness, itching, oozing, scaling and inflammation minimise the risk of ‘flares’. The first Ethickening and occasionally blistering of • Reduction of skin damage caused by important step is to diagnose correctly the skin. It is probably the most com- scratching by means of itch reduc- the type of eczema, as this can influence mon skin condition seen in the commu- tion using antihistamines the management. nity. The terms ‘eczema’ and ‘dermatitis’ • If skin is oozing and exudative, are generally used interchangeably to astringent preparations can reduce describe the same condition. Diagnosis blistering and weeping from skin The clinical picture depends on the • Eradication by anti-bacterial, anti- The diagnosis of the different types of viral or anti-fungal therapy of sec- stage of the eczema which can be divided eczema depends upon the history, char- into: ondary skin infection, if present acteristic clinical features occurring at • Counselling and education to allow typical distribution sites of the body and patients to maintain their own Acute Eczema the age of onset. The severity of eczema longer term treatment and to recog- depends upon the extent of body surface Characterised by intensely itchy and nise acute flares and their need for area involvement and intensity of red- occasionally painful erythema, oedema, altered therapy. ness, swelling, oozing, dryness, excoria- papules, vesicles, occasionally bullae, tion and lichenification. Emollients have a pivotal role and should exudation (weeping) and crusting. be used liberally in all patients. Skin Treatment affected by eczema is frequently dry and Chronic Eczema as inflammation settles, the skin usually Most eczema patients can be managed peels. These effects reduce the barrier Characterised by dry, scaly, thickened or in the community. Care and treatment function of the skin and so increase the lichenified lesions with occasional fis- includes: irritant effects of water and detergents, sures, which may be very painful, and leading to further inflammation and pigmentary changes. • General measures for all types of itch. This cycle can be broken by regular eczema targeted towards control of use of emollients. skin inflammation, dryness, oozing, Subacute Eczema Aqueous cream is the most commonly itchiness and occasionally secondary used. It is cheap and suits most people. Features of both acute and chronic infection Patients are advised to use the cream in eczema. Frequently redness, minimal • Specific treatment for particular two ways: oedema, dried-up vesicles and crusting. states or types of eczema There are many different types of • Provision of education and counsel- a) As a soap substitute, i.e., applied eczema (Table1), all of which can vary ling. directly onto wet skin, massaged from mild to severe. They can usually gently on the affected skin and then The aims of general treatment are: be classified into Exogenous/Contact washed off with water, and Eczema (due to external factors) and • Cleansing and soothing of the skin b) Gently rubbed into skin as a mois- Endogenous Eczema (due to internal or plus improvement in skin barrier turiser 4–5 times a day. constitutional factors). function by the use of emollients

6 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Eczema

Table 2: Management Strategy Table 3: Strengths of Topical Steroids • Diagnosis Potency Example • Exclude/avoid contact irritants/ Mild 1% hydrocortisone (e.g., Efcortelan) sensitizers • Emollients – soap substitution. Moderate 0.05% clobetasone butyrate (e.g., Eumovate) Moisturise frequently and use 1 in 4 dilutions of potent topical steroids emollient bath oils Potent 0.1% betamethasone valerate (e.g., Betnovate) • Anti-inflammatory agents – topical 0.1% hydrocortisone butyrate (e.g., Locoid) steroids 0.025% beclometasone dipropionate (e.g., Propaderm) • Antihistamines to relieve itch 0.05% betamethasone dipropionate (e.g., Diprosone) • Treatment of secondary infection 0.05% clobetasol propionate (e.g., Dermovate) • Education – reassurance, Very potent 0.3% diflucortolone valerate (e.g., Nerisone Forte) explanation, prognosis • Psychosocial support Amount to be used: The sedative antihistamines are there- fore helpful in reducing pruritus and in Emulsifying ointment can also be used The amount of very potent steroid used but is more difficult to apply as it is allowing everyone in the family to sleep. should be less than 50g per week for an Examples of sedative antihistamines firmer and more greasy. It can be mixed adult. into twice its volume of very hot water to are hydroxyzine, alimemazine (trime- A rough guide to estimate the amount prazine), promethazine and chlorphenir- create a milky emulsion to be added into of topical application required is: bath water. amine maleate. There are many other commercially • 1% of total body surface area requires Secondary bacterial infection is com- available emollients which are usually 0.25g each application mon and may cause acute exacerbations more expensive and not necessarily of • Use rule of 9 to estimate amount of eczema. Staphylococcus aureus is almost greater benefit. However, some cannot required for large areas always responsible. Swabs for bacterial cul- tolerate aqueous cream or emulsifying • The fingertip unit (F.T.U.) is a con- ture and sensitivity should be sent. Topi- ointment. Children in particular often venient way of indicating to patients cal antibiotics should be used in small find that heavier, greasier products make how much of a topical steroid should areas of localised infection, e.g., Fucidin their skin feel more itchy and young be applied to skin at any one site. or mupirocin, but more severe or wide- children may complain of stinging after One finger tip unit is the amount spread infection requires a concomitant application of aqueous cream. Some of steroid expressed from the tube systemic antibiotic, eg., cloxacillin, patients may develop a contact allergy to to cover the length of the flexor aspect erythromycin and cephalosporins. a particular preservative used in a cream. of the terminal phalanx of the index In these situations other emollients finger (1 F.T.U.= 0.5g = to cover Counselling and education is essential in should be tried until one is found that 1 hand/foot/face) any disease especially in chronic condi- can be tolerated. tions such as eczema. Patients and par- ents are often anxious when the diagnosis Topical steroids are the mainstay in the Choice of formulations: treatment of inflammation in eczema is made and need to be reassured that but many patients and parents are con- i. Lotions for exudative lesions. the condition is not contagious. Care- cerned about their potential side effects. ii. Creams for dry lesions. ful explanation of the disease, the main In general, use the lowest strength topical iii. Ointments for very dry lesions. causes of exacerbation and its manage- steroid that will keep the eczema under iv. Lotion or gel for scalp. ment, especially with regard to the cor- control (Table 3). Another approach is rect use of emollients and topical steroids Astringents are used to dry up lesions to use potent topical steroids for short is required. Patients and parents will not during vesicular or exudative stages. duration (1–2 weeks) to bring eczema understand how to use their treatments Examples are potassium permanga- under control quickly, then reduce the until they are shown. Such demonstra- nate, 1:10,000 dilution (deep pink in potency. Potent topical steroids should tions are central to teaching them how to colour) or normal saline. The affected not be used in children without care- care for their skin disease. parts are soaked in the selected solution ful supervision and the same applies to for 10 to 15 minutes each time, once or Systemic therapy is needed only rarely for adults for large areas, face and flexures. twice a day, depending on the severity a very small proportion of people with The very potent topical steroids should and response. The solutions can also be eczema. Oral corticosteroids or injec- only be used in adults for rare localised applied as cool compresses for a similar tions should be avoided, if possible, but severe/resistant cases and on palmar/ length of time. occasionally may be prescribed for short plantar skin, sometimes with occlusion. periods (oral prednisolone, 0.5mg/kg/ Most topical steroids should be applied Oral antihistamines can relieve itch. day for 1–2 weeks) and intermittently not more than twice a day. They may Most patients find some symptomatic (triamcinolone injections 0.5–1mg/kg) be combined with topical antibiotics to relief but the main benefit may be large- when other measures have failed or to control bacterial secondary infection. ly due to their central sedative effect. treat a severe, acute flare.

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 7 Eczema

Specific Treatments for Lichen simplex (Figure 5) is a chronic Various Types of Eczema eczema, maintained by the habit of scratching or rubbing a specific area of Atopic eczema (Figure 1) can be exac- skin. The effects of moisturisers and erbated by various air-borne allergens short-term use of potent topical steroids such as house-dust mite, animal fur and can be augmented by occlusion with pollens. If possible, contact with known paste-impregnated bandaging or zinc allergens should be minimised. Regular, paste applied over the steroid at night. life-long use of emollients will reduce The paste preparation is lifted off with a exacerbations and pruritus. Cool cloth- cream wash the following morning. ing and bedding will reduce skin irrita- tion and hence reduce scratching.

Fig. 3: Discoid eczema

need short periods of treatment with a potent or very potent steroid.

Juvenile plantar dermatosis affects the sole, especially the forefoot, usually in children and young teenagers. It may be exacerbated by occlusive footware and Fig. 5: Lichen simplex often clears after puberty. Regular use of emollients is essential to control the dry- Asteatotic eczema is most common Fig. 1: Atopic eczema; most commonly ness and fissuring of the skin. starts in infancy on the face and scalp on the lower legs and may be a sign of hypothyroidism or malnutrition. It can Pompholyx / dyshidrotic eczema also be caused by repeated washing with Seborrhoeic eczema (Figure 2) occurs on (Figure 4) affects the palms and / or soles, soaps or detergents. Plentiful and regu- the greasy areas of the face and upper producing itchy and uncomfortable blis- lar application of emollients may be the body. Reduction in the skin yeasts by ters. Astringent preparations and potent only treatment needed. application of an imidazole cream, topical steroids are often necessary. combined with a mild topical steroid Exogenous eczema should be treated by will usually keep this condition under avoidance of the causative contact agent control. as well as general measures. If a contact allergy is suspected, the cause may be identified by allergy patch testing or an open usage test. Ideally, any patient with a diagnosis of eczema should have adequate educa- tion about their condition and available therapy to maintain their skin in a good or moderate condition. In addition, they Fig. 4: Pompholyx require ready access to a health profes- sional with knowledge of skin disease management for help with acute flares, Stasis eczema results from venous hyper- when extra therapy will often be needed. tension. Control of the underlying prob- lem with elevation, elastic support and, where possible, exercise will all help to Fig. 2: Seborrhoeic eczema reduce the eczema, but occasional mild Discoid eczema (Figure 3) frequently topical steroid, in combination with does not respond to mild or moderate regular emollients will minimise the skin strength topical steroids and may often inflammation.

8 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Essential Drugs Essential Drugs in Dermatology

Ramadhan L Mawenzi it is very contagious and can easily DipMed ADDV be passed on from child to child. Chief Dermatology Officer Egerton University Herpes Zoster Kenya It has no effect on the virus causing the herpes zoster itself, but painted 1. Gentian Violet on any broken blisters, twice a day, Gentian Violet (Crystal Violet) was it will prevent secondary bacterial discovered by Churchman in 1912. infection. It is a methylrosaniline chloride dye Oral candida which is effective against Gram positive Small Burns and Photo: Ramadhan Mawenzi cocci, especially Staphylococcus aureus, Lacerations and some pathogenic yeasts, especially Candida albicans. It is much less active Apply twice a day as an antisep- against Gram negative bacteria and has tic to prevent secondary bacterial no effect against acid-fast bacilli (TB infection. and leprosy). It is a dark green powder or greenish Oral, Vaginal and glistening pieces with a metallic lustre, Cutaneous Candidiasis and is sparingly soluble in water. It has • For oral candida use 5ml (1 to be stored in a dark bottle and kept in teaspoonful) as a mouthwash. a cool dark place to maintain its potency. Get the patient to swish it It is very cheap and is available over the around the mouth for as long counter. It is used as a 0.5% aqueous as he can bear it and then spit solution (0.5 gram Gentian Violet in it out. It is in fact safe to swal- 100ml water) to treat the following: Gentian Violet staining of the tongue low, and this can be done if Photo: Ramadhan Mawenzi the thrush is extensive and Impetigo put up with this because it is so effec- goes down into the oesophagus. Use tive in treating oral candidiasis it 3 times daily after food. The can- First remove the crusts with soap and • It can be caustic if the concentration didiasis will be better in 2-3 days. water. Then apply Gentian Violet paint. exceeds 1% (if the water evaporates). For babies, get the mother to paint it Do this twice a day for 2–3 days until Storage technique is therefore of onto the affected areas of the mouth it is healed. Keep the child away from crucial importance (see above). other children until it is healed because with a piece of clean cloth rolled on the index finger • For vaginal candidiasis thoroughly 2. Whitfield’s Ointment paint on the vaginal walls using (Benzoic acid compound Chittle forceps and gauze twice daily ointment) • For cutaneous candidiasis, including balanitis, paint it onto the affected Whitfield’s Ointment consists of 3% skin twice daily using a cotton wool salicylic acid and 6% benzoic acid in tipped applicator or a feather, until it emulsifying ointment. It is very cheap is better (3–4 days). and available over the counter. Salicylic acid and benzoic acids are Problems with using it keratolytic agents (they remove surface keratin from the skin). Whitfield’s • It is very messy to use, staining Ointment is mainly used for treating everything it comes in contact with dermatophyte fungal infections, i.e., a purple colour. On the skin and ringworm. It works by removing the mucous membranes this is unsightly keratin on which the fungus lives rather for a while but soon disappears. On than by killing the fungus itself. Apply it clothes, furniture and floors the twice a day until the ringworm is gone staining may be permanent and for a further 2 weeks to make sure Impetigo • It tastes absolutely foul when applied it does not come back. It can be used in Photo: Ramadhan Mawenzi in the mouth, but most patients will this way for treating:

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 9 Essential Drugs

Tinea Corporis It can also be used:

Ringworm on the face or body. • To increase the percutaneous Tinea Pedis absorption of other topical drugs e.g., steroids through its action of Ringworm on the feet. softening and loosening keratin. Tinea Cruris Apply the Whitfield’s Ointment at night and the topical steroid in the Ringworm in the groin. It may sting at morning. This is useful for patients this site. with hyperkeratotic eczema on the It does not work for infections of the palms and/or soles scalp and nails (tinea capitis or tinea • To prepare the skin for debridement. unguium), or for candida or pityriasis It is applied twice a day on any hard versicolor. tenacious crust, to soften it up and loosen it, so that it can be removed. It can also be used as a mild keratolytic agent for treating: Unwanted effects of Plane Warts and Small Whitfield’s Ointment Common Warts Ringworm on the face • May sting especially when applied in Photo: Ramadhan Mawenzi Ichthyosis the flexures Dry scaly skin, especially on the extrem- • Applied over large areas it can but some may find it cosmetically ities. cause 'salicylism' especially in small children unacceptable. Heavy Dandruff • Because it is an ointment it can make Rub it into the scalp once a week. the skin shine. Most people like this, Quiz: Questions Are All White Spots Vitiligo? Case 1: What Is It?

L Claire Fuller MA FRCP Visiting Senior Lecturer Regional Dermatology Training Centre Kilimanjaro Christian Medical Centre Moshi, Tanzania

All illustrations are copyright of the Regional Dermatology Training Centre, Moshi, Tanzania

Fig. 1: Scaly oval lesions scattered over the trunk and tops of limbs atients often present to the Dermatology Department complaining of some problem with the pigmentation in the skin. After any sort of skin problem the dark • This patient may be itchy or not Pskinned patient may develop changes in pigmentation. • The rash has been present for a few weeks Often they assume they have vitiligo but there are several other conditions that can produce reduction in pigmenta- • It does not occur on the face tion. The following cases are common problems that we • What is the diagnosis? see frequently here in Tanzania. We present them in quiz form . . . Have a go! • What is the differential diagnosis? • How will you treat it?

10 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Quiz: Questions

Case 2: What Is This?

Fig. 2: Hypopigmented scaly macules Fig. 3: Macules scattered over upper back and upper chest

• What is the diagnosis? • How would you diagnose it? • What is the cause? • What treatment would you use? • What is the differential diagnosis?

Case 3: What Is This?

Fig. 4: De-pigmented macular areas in symmetrical Fig. 5: De-pigmented areas may extend over areas of trauma distribution like backs of hands

• Complaint: white spots on the skin

Summary of Descriptions/Questions

1: Scaly oval lesions scattered over the trunk and tops of limbs (Figure 1). 2. Hypopigmented scaly macules (Figure 2). 3. Macules scattered over upper back and upper chest (Figure 3). 4. De-pigmented macular areas in symmetrical distribution (Figure 4). 5. De-pigmented areas may extend over areas of trauma like backs of hands (Figure 5). See Next Page for Answers

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 11 Quiz: Answers

Case 1: Answer – Pityriasis Rosea • Differential diagnosis: ♦ Why is this not leprosy? There are too many lesions and sensation would be intact over them. Also, they are slightly scaly (leprosy lesions are smooth) ♦ Why not pityriasis alba? This is usually on the face and is a variant of eczema. The distribution of pit- yriasis versicolor is so typical ♦ Why not vitiligo? The slight scale would be against vitiligo which is absolutely macular (i.e., flat and smooth). • Pityriasis rosea: rash mainly over the torso • Treatment: topical sodium thiosulphate solution 20% • Why is it not psoriasis? in 1% cetrimide solution daily for 2 weeks will settle it. ♦ Distribution and morphology are wrong: 5mm Alternatives include topical clotrimazole cream, topical scattered oval slightly scaly macules over the trunk, terbinafine cream or, if very extensive, an oral azole anti- extending onto the tops of arms and tops of thighs fungal such as ketoconazole or itraconazole 200mg once (area that is covered by wearing shorts and a T- daily for 1–2 weeks. shirt) • Tips: it tends to recur, so maintenance treatment is ♦ There may be a single bigger lesion that was noted recommended with selenium sulphide shampoo as a 2 weeks before the widespread rash arrived; this is scalp and body wash once per month. called the ‘Herald Patch’ Case 3: Answer – Vitiligo ♦ There is no thickened, silvery scale, no nail changes and no involvement of scalp. • Why is it not eczema? Scaly oval lesions with a charac- teristic fine scale around the rim of each lesion (like a collar) is very typical of pityriasis rosea. The distribution along the lines of the ribs is also very classical . Discoid eczema is not often confined to the trunk. It would be expected to affect the limbs too. • What treatment? Treatment is not necessary unless it is very itchy. Then a topical steroid, such as betamethasone • Examination: symmetrical macules (flat lesions) of 0.1% ointment can be used. hypo- or depigmented skin. Often over knuckles of hand • How long does it last? About 6 weeks and then sponta- and elbows and knees. May occur anywhere on the body. neously settles and may leave behind some post-inflam- The skin itself is of normal texture. matory pigmentary changes (either hyper-pigmentation • Cause: assumed to be an autoimmune condition or hypo-pigmentation). although no antibody has been identified. • Tips: if the patient suffers also from atopic dermatitis, • Diagnosis: clinical picture is typical. pityriasis rosea may be more widespread. • Differential Diagnosis: Case 2: Answer – Pityriasis Versicolor ♦ Why is this not leprosy? Symmetry is very typical of vitiligo ♦ There is no loss of sensation over the lesions ♦ Some of the lesions are occurring over areas of trauma (koebnerization). • Treatment: this is difficult. Some patients do well with a short course of potent topical steroid applied to the white area for 6 weeks. It is best to avoid steroids for longer periods as there is a risk of skin thinning • Complaint: rash of white spots over top of chest. (atrophy) if 6 weeks is exceeded. • Examination: pale (hypo-pigmented) oval macules, • Course: can spontaneously remit and recur but, especially slightly scaly overlying the upper chest and upper back. when it affects the extremities, it can be very persistent. • Cause: pityrosporum yeast (also known as Malassezia • Tips: patients are often very distressed about this furfur). condition and so a great deal of empathy and • Diagnosis: classical clinical picture, but also a scraping understanding is useful at the start. from the surface of the skin viewed in 10% potassium ❖ ❖ ❖ hydroxide and a drop of ink shows spores and hyphae together which are said to look like ‘meat balls and spaghetti’.

12 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Teaching Aids at Low Cost (TALC) TALC: Images for Development

David Chandler General Manager, TALC David Chandler has been in post as General Manager of Teaching-aids At Low St Albans, UK Cost (TALC) since 1999. His previous work included the role of Coordinator of the Skin Care Campaign whilst at the National Eczema Society in London. He or many people who work in also acted as General Manager for the Psoriatic Arthropathy Alliance, a charitable development the names of Teach- organisation he co-founded with his wife following his diagnosis with psoriasis and ing–aids At Low Cost (TALC) psoriatic arthritis in the early 1990s. Fand Professor David Morley are always linked. The work of Professor Morley and TALC has always been the desire TALC is a registered charity based in the UK. Main activity is the distribution of to introduce innovative methods of low-cost health education materials accessories to developing countries, including teaching, training and healthcare moni- books, slides, bench aids, charts, videos, CD-ROMs and growth monitoring. toring. TALC also commissions and publishes material. In the early 1960s, when David Mor- ley returned from West Africa to take up TALC, PO Box 49, St Albans, Herts AL1 5TX, UK a post at the London School of Hygiene Tel: 44 (0) 1727 853869 Fax: 44 (0) 1727 846852 and Tropical Medicine, he could not E-mail: [email protected] Website: www.talcuk.org have imagined that the next few years would be an epic journey to change and introduce new methods and ideas. There are many diseases which are 2002 slide sales dropped from 11,696 firstly, of Picture Cards (printed copies mainly diagnosed by visual inspection. sets per annum to 1,120 sets per annum, of slide images), and then Bench Aids. This is particularly relevant for skin whilst book sales fell from 52,564 to These methods of education would not disease and conditions which have skin 27,912. rely on the availability of electricity, a involvement, even more so in develop- Why have these changes happened? slide projector or, most importantly, a ing countries. David Morley has always In the case of slides, it could be due to working bulb. believed the power of a picture is much the lack of equipment or a change of The Bench Aids provide an ideal greater than the use of words, particu- study and teaching methods. opportunity for quick reference and identification of a disease with simple larly for people living in Africa. In 1965, The importance of demonstrating the guidelines on appropriate treatments. he introduced 24–image slide and scripts difference between different diagnoses Made from durable coated material, this sets on Measles, Growth Monitoring, is clear when the untrained eye views low cost item can be used over and over Smallpox and Management of Diarrhoea similar looking diseases, but is unable to again. The current series, developed by at the low cost of six shillings (£0.30). make a clear distinction. Dr Barbara Leppard, contains cards on These sets were produced because of the TALC is aware that it is also impor- atopic eczema, common bacterial infec- demand from students and fellow teach- tant to show diseases in the relevant set- tions, herpes zoster, ringworm, scabies ers who felt that David Morley’s meth- ting and skin colour. In Africa, to show and tinea capitis. The sets are available od and approach to teaching should be Caucasian skin in many instances would in English and Swahili. given greater exposure. be inappropriate and could possibly The development of other areas of Since the early days of TALC, the imply that certain diseases do not affect disease or step-by-step treatment guides majority of distribution and sales have those who do not have white skin. could also be useful as Bench Aids. been either slides or books. Although Given the changing learning and TALC is currently exploring other poten- a very successful process in the past, in teaching environment, TALC took the recent years the demand has shown a view that a low-tech solution could be tial sources of information for future dramatic change. Between 1992 and used. This included the introduction, development. Bench Aids for Dermatology A set of 4 full colour laminated bench aids, which include the following common skin diseases – atopic eczema, common bacterial infections, herpes zoster, ringworm, scabies and tinea capitis. Ideal for quick reference and identification of diseases with useful information on diagnosis, clinical features and treatment. Ideal for healthworkers, students and teachers (available either in English or Swahili). Designed and written by Dr Barbara Leppard. Cost £4.00 + p&p per set Available from: Teaching-aids At Low Cost (TALC) PO Box 49 St Albans Herts AL1 5TX UK www.talcuk.org

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 13 Teaching Aids at Low Cost (TALC) ATOPICECZEMA start at any age). start the cheeks &/or scalp (but can months with an itchy rash on Most age 3–12 commonly starts oral cloxacillin for 1 week. For infection give secondary • for 10 minutes twice a day. diluted to a pale pink colour soak in potassium permanganate If the eczema is weeping • child sleeps through the night). until the increase as necessary with a dose of 12.5mg and at night (start promethazine syrup because of scratching, give keeping the family awake at night If the child is not sleeping, or • young children. Do not use stronger steroids in (not cream) applied twice a day. 1% hydrocortisone ointment • TREATMENT CLINICAL FEATURES the itchy skin. Shiny nails occur from rubbing may localise in the flexures. As the child gets older rash rest of the body. The rash may then spread to the

Designed by Barbara Leppard and Alfred Naburi, Regional Dermatology Training Centre, KCMC, Moshi, Tanzania TALC Very itchy rash. Symmetrical,skin. poorly defined scaly plaques often associated with dry leave hypo-or hyperpigmentation. As the rash gets better it may No burrows • Other family members also itching Runs in families together with asthma and • • May be secondarily infected • Not contagious – other family members not • May be secondarily infected • Rash begins on face &/or scalp; later often • Rash symmetrical • Very itchy rash – itches day & night • Usually begins age 3–12 months • Atopic eczema differences are shown below. disease to be differentiatedThe most important from atopic eczema is scabies. The most important DIFFERENTIAL DIAGNOSIS itching involves flexures hay fever is associated with asthma and hay fever. Commonest kind of eczema affecting about 10% of the population. Runs in families and infection. Scratching can lead to secondary Rash all over the body but spares face & • Very itchy especially at night • Occurs at any age • Burrows along present in fingerwebs, • Contagious between close contacts – • (palms & soles in infants) those sharing a bed sides of fingers & on front of wrists scalp Scabies increased skin markings. – thickening of the skin and leads to lichenification of the skin Constant rubbing TALC

14 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 Abstracts

Journal Extracts and Reports from Extensive pityriasis alba in a child the Regional Dermatology Training with atopic dermatitis Sandhu K, Handa S, Kanwar AJ. Centre, Moshi, Tanzania Pediatr Dermatol 2004; 21: 275–276 Neil H Cox BSc(Hons) FRCP his case report, the subject of which is evident from the Dermatology Department Ttitle, is probably not that unusual – the mechanism is Cumberland Infirmary probably that of post-inflammatory phenomenon. However, it Carlisle, CA2 7HY, UK reminded me of two important issues that the authors do not discuss. One of these is that, for those who have not seen it Immune reconstitution inflammatory before (and especially if associated atopy is subtle), it might be syndrome associated with HIV and leprosy confused with leprosy. The other issue is that the pigment loss Couppié P, Abel S, Voinchet H, et al. may not be apparent when the skin is inflamed, so patients may Arch Dermatol 2004; 140: 997–1000 blame the development of pale areas on their treatment and the physician who administered it. any HIV-associated skin conditions improve when Mthe HIV infection is treated – for example, psoriasis, Vaccines and immunotherapies for the seborrhoeic dermatitis, candida infection, and drug eruptions. prevention of infectious diseases having However, others may worsen or become apparent during treat- cutaneous manifestations ment. Examples include viral infections such as herpes zoster or Wu JJ, Huang DB, Pang KR, Tyring SK molluscum contagiosum. This report adds leprosy to the list of . 2004; 50: 495–528 conditions that may present in an atypical ulcerative pattern as J Am Acad Dermatol the immune system reactivates. his article raises hope for prevention of some diseases of Tworld-wide importance. Most relevant to this journal is Transmission of cutaneous leishmaniasis the potential for vaccines to HIV/AIDS, leishmaniasis and den- by sand flies is enhanced by gue fever. In the case of leishmaniasis, genetic advances have regurgitation of fPPG identified at least 100 gene targets that are being investigated as vaccine candidates. However, the major work is on HIV – Rogers ME, Ilg T, Nikolaev AV, Ferguson MA, Bates PA. since trials started in 1987, 34 vaccines have started preliminary Nature 2004; 430: 463–467 (Phase I) trials, a few have progressed to Phase II, and ‘at least 74 are in some stage of development’. n sand flies with mature Leishmania infections the anterior Imidgut is blocked by a gel of parasite origin, the promas- tigote secretory gel, which contains a filamentous proteophos- Regional Dermatology Training phoglycan (fPPG) that is inoculated with the parasites when Centre Research Reports the fly bites. This gel not only adds to the virulence of the leish- mania parasite but its presence seems to make the fly bite more Tungiasis in Kenya often, therefore increasing the risk of disease transmission. The Amino S Fora proposed explanation is that the sticky gel prevents the sandfly his study demonstrated a 31% prevalence of tungiasis in from getting an adequate blood meal, so it becomes frustrated Ta sample of 250 subjects from the Marasmit community and bites repeatedly. fPPG may be another target for vaccines in Kenya, the peak prevalence being in the first decade of life or prophylactic treatment. (41% in those aged 1–9 years). A questionnaire showed that having tungiasis was positively linked with poor knowledge of Blue cellulitis: a rare entity in the era of the condition, temporary housing, poor foot hygiene and low Hib conjugate vaccine socio-economic status. Many of these risk factors are inter-relat- ed, so targeted education may be helpful. Inamadar AC, Palit A. Pediatr Dermatol 2004; 21: 90–91 Drug Eruptions From hese authors describe a 6–month old child with unilateral Anti-tuberculous Therapy Tfacial swelling of bruise-like colour, associated with fever and upper respiratory tract infection. It is easy for those of us in Elizabeth Q Mvila more affluent countries to forget that the commonest cause of n this questionnaire study of 300 patients who had received Haemophilus influ- facial cellulitis in a young child used to be IDirect Observed Treatment Short-course (DOTS) for TB, enzae. I suspect the blue colour in part reflects the dark skin 34% had experienced a drug eruption, mainly early in treat- of the patient, as a red colour was more typical in Caucasian ment. The anticipated higher frequency of eruptions in those skin, but the message is important – the lesions may initially be with concurrent HIV infection was confirmed – a higher preva- quite minor and mistaken for minor trauma. In older children, lence of drug eruption in males and in the 20–50 year age pneumococcal infection should be suspected – and I would group was not explained but this reviewer suspects that it may include haemorrhagic oedema of childhood in the differential reflect the higher frequency of HIV in men of this age. A larger diagnosis. analysis of the DOTS database might confirm this view.

COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2 15 Community Dermatology An International Journal for Community Skin Health Community Dermatology Guidelines For Authors The Editorial Board of Community Dermatology will be pleased to receive original articles, reports and letters from our readers – and will Editorial Board then consider publication in the Published by Journal. Dr Beverley Adriaans ICTHES World Care Original articles should not exceed Dr Paul Buxton (Chair) 1200 words. Dr Neil Cox Executive Director Short reports and letters should not exceed 500 words. Dr Claire Fuller Dr Murray McGavin Dr Sam Gibbs A more comprehensive document, International Development ‘Guidelines for Authors’, will be Dr Richard Goodwin Director e-mailed or sent by post, on request. Dr Barbara Leppard Mr Andrew McGavin Editorial Board Dr Chris Lovell Community Dermatology Administration/Distribution Dr Murray McGavin c/o Murray and Andrew McGavin Mrs Sally Collier ICTHES World Care Mr Andrew McGavin Mrs Ruth McGavin PO BOX 408, Bankhead Avenue Dr Michele Murdoch Ms Heather Wright Edinburgh EH11 4HE Scotland, UK Ms Rebecca Penzer Ms Caroline McGavin Dr Margaret Price E-mail: [email protected] Dr Michael Waugh Supported by The following points are emphasised International Editors in submitting material for Ethicon Scotland Professor Henning Grossman publication: Words and phrases used should (Tanzania) International Community Trust • be understood by people for Professor Rod Hay (UK) for Health and Educational whom English is not their first Dr Don Lookingbill (USA) Services (ICTHES World Care) language Professor Robin Marks • Content should be clear to Typeset by (Australia) those without specialist health professional training Regent Typesetting, London Professor Aldo Morrone (Italy) • A glossary should be provided Professor Ben Naafs for technical terms (The Netherlands) Printed by • Sections and subsections with headings are preferred Professor Terence Ryan (UK) The Heyford Press Ltd • Good-quality photographs, Professor Gail Todd ISSN 1743 – 9906 tables and summary boxes are (South Africa) encouraged • References are the responsibility of the author(s) and should follow the presentation used in © Community Dermatology Correspondence/Enquiries to: this Journal • Material is preferred in Word Articles may be photocopied, repro- Dr Paul K Buxton format and sent by e-mail, or on duced or translated provided these are British Association of Dermatologists disk or CD-Rom not used for commercial or personal 4 Fitzroy Square profit. Acknowledgements should London W1T 5HQ We look forward to receiving your be made to the author(s) and to articles, reports and letters! Email: [email protected] Community Dermatology Editorial Board [email protected] Community Dermatology

16 COMMUNITY DERMATOLOGY: 2005; 2: 1–16 Issue No. 2