A Cross Sectional Survey for Dermatoses in Children and Adolescents Residing in Orphanages in Urban Tirunelveli, Tamil Nadu, India.

CONTEXT: Skin diseases are a major cause of public concern among underprivileged people residing in orphanages. There is a need for community-based study for dermatoses in orphanages as the literature is scarce at the national and international levels. AIMS: For profiling of various dermatoses to generate information on general health, nutritional status, and sanitation, and to educate about personal skin hygiene and care to inmates in urban child orphanages. SETTINGS AND
DESIGN: A cross-sectional study was conducted at 18 urban child orphanages in Tirunelveli city for 1 month. METHODS AND MATERIAL: A predesigned proforma was prepared and the demographic details regarding the inmates were obtained and they were screened under natural light for skin, hair, nail, and oral disorders as well as their built, nourishment, height, and weight were measured and recorded in tabulations. STATISTICAL ANALYSIS USED: Descriptive statistical analysis was followed for describing the prevalence of dermatoses and the age group affected which are explained in percentages and ratios.
RESULTS: Out of a total of 850 inmates, 93 (11%) were of 5-9 years and 757 (89%) were of 10-19 years. Among them, 330 (39%) were males and 520 (61%) were females. Overall, the inmates affected with dermatoses were 360 (42.4%) and infectious dermatoses were seen in 218 inmates (60.5%) and non-infectious dermatoses were seen in 142 inmates (39.5%). Adolescent females were more commonly affected and the commonest dermatoses observed were pediculosis capitis (13.6%) followed by acne vulgaris (8.1%) and in adolescent males, scabies (7.1%) was the commonest. No psychocutaneous disorders were encountered.
CONCLUSIONS: Infections and infestations are common in orphanages due to a lack of awareness of personal hygiene and self-care practices. They should be given health education in order to reduce the disease burden in children living in orphanages which in turn decreases the disease burden at the community level. Copyright:

Introduction

An orphanage is an institution dedicated to the care and upbringing of children who have lost their parents. Orphan children have been increasing in numbers at national as well as global levels due to social, political, and economic factors. The number of orphans in India was 20 million in 2011 and has been expected to rise to 24 million by 2021. Children who have lost either or both parents are frequently sent to orphanages where they are deprived of sufficient parental care, adequate food, education, and medical care.[1] They also face high dropouts from formal school, social downfall, child labor, child abuse, drug abuse, and immunization problems.[2] The Government of India is also responsible for caring for the destitute children in the country.

Many studies have been done regarding the nutritional status, quality of life, and skin diseases of children with selected diseases like scabies and dermatophytoses but exclusive descriptive or analytical study regarding dermatoses in orphanages and factors promoting them at both national and international levels are scarce. Hence, we conducted this survey to screen for various dermatoses in children and adolescents residing in urban orphanages and to plan and advise them to seek the needed medical services and create awareness about skin health and hygiene in the city of Tirunelveli located in the south of Tamil Nadu state.

Methodology

This is a cross-sectional study done in all orphanages in urban Tirunelveli over a period of 1 month (July 2018). After obtaining written permission from the Institutional Ethical Committee (IEC) as well as the Head of the Tirunelveli Medical College, District Child Protection Officer (DCPO), and administrative head of the orphanages in urban Tirunelveli, this study was carried out by the Department of Dermatology. All orphanages in Tirunelveli city were listed out and all resident children and adolescents of age group of 5–19 years were included in the study. The purpose of the study was to profile various dermatoses, to generate information on general health, nutritional status, and sanitation, and to educate about personal skin hygiene and care and these were explained to the head of the institution of orphanages, and written consent was obtained for clinical examination and taking relevant photographs wherever necessary. Assent was obtained from children of age group 8–19 years. A predesigned proforma was prepared which was prevalidated by faculties of Dermatology. The demographic details regarding the inmates were obtained and they were screened for dermatoses. All inmates were examined under natural light for skin, hair, nail, and oral disorders, as well as their built, nourishment, height and weight were measured and recorded. Also, general information regarding personal hygiene, cleanliness, and environmental hygiene was noted. Locally treatable conditions were treated accordingly and disorders which required further workup and follow-up were advised to attend outpatient Department of Dermatology, Tirunelveli Medical College Hospital. Health education regarding personal hygiene and care like cleanliness, frequent bathing, hair bath, washing of clothes, and hand washing techniques were taught to all inmates including housekeepers and caretakers since these can prevent many dermatoses. Pamphlets regarding health care and hygiene were also given to all orphanages. Descriptive statistical analysis was followed for describing the prevalence of dermatoses and the age group affected which are explained in percentages and ratios.

Results

A total of 18 orphanages in urban Tirunelveli with a total of 850 inmates were screened. Among the total inmates, age-wise distribution included 5–9 years (n = 93, 11%, M = 41, F = 52) and 10–19 years (n = 757, 89%, M = 289, F = 468) in the ratio of 1:8. The Sex-wise distribution included 330 males (39%) and 520 females (61%) with a ratio of 1:1.5. Dermatoses were classified into infectious and non-infectious dermatoses. Infections were further classified into bacterial, viral, fungal, parasitic infections, and arthropod infestations. Non-infectious diseases include acne, pigmentary, nutritional deficiency, all forms of dermatitis, and miscellaneous conditions based on their causes and presentations. Infections were encountered in 218 inmates (25.6%), non-infectious dermatoses in 142 inmates (16.7%), and no dermatoses were noted in 490 (57.6%) [Table 1].

Table 1

Classification and prevalence of dermatoses in urban child orphanages of Tirunelveli

Classification	Male (n=330)	Female (n=520)	Total (n=850)
Infections and infestations	63 (7.4%)	155 (18.2%)	218 (25.6%)
Non-infectious	40 (4.7%)	102 (12%)	142 (16.7%)
No dermatoses	227 (26.7%)	263 (30.9%)	490 (57.6%)
Total	330 (38.8%)	520 (61.2%)	850 (100%)

Age and sex-wise distribution of dermatoses

Prevalence of dermatoses in inmates of urban orphanages were 360 (42.4%); among 5–9 years (n = 23, 24.7%) and 10–19 years (n = 337,44.5%) in the ratio of 1:15 and among males 103 (12.1%) and females 257 (30.3%) with ratio of 1:2.5.

5–9 years

Among 41 males of 5–9 years, only 7 (17%) had dermatoses and among 52 females of the same age group, 16 (30.8%) had dermatoses in the ratio of 1:2.3. Age-wise prevalence of infectious dermatoses and non-infectious dermatoses showed 15 (16.1%, M = 4, F = 11) and 8 (8.6%, M = 3, F = 5) inmates of 5–9 years of age, respectively.

10–19 years

Out of 289 and 468 adolescent males and females, 96 (33.2%) and 241 (51.5%) were diagnosed with specific dermatoses respectively in the ratio of 1:2.5. Age-wise prevalence of infectious dermatoses and non-infectious dermatoses showed 203 (26.8%, M = 59, F = 144) and 134 (17.7%, M = 37, F = 97) inmates of 10–19 years of age, respectively [Table 2] [Chart 1].

Table 2

Age and sex-wise prevalence of dermatoses

Classification	5-9 years				10-19 years				Total (850)
	Male (41)	Female (52)	Total (n=93)	Total (n=93)	Male (289)	Female (468)	Total (n=757)	Total (n=757)
DERMATOSES	1	2	15 (16.1%)	23 (24.7%)	18	20	203 (26.8%)	337 (44.5%)	360 (42.4%)
INFECTIONS B. INFESTATIONS	3	9			41	124
B. NON-INFECTIOUS	3	5	8 (8.6%)		37	97	134 (17.7%)
NO DERMATOSES	34	36	70 (75.3%)		193	227	420 (55.5%)		490 (57.6%)
TOTAL	41	52	93 (100%)		289	468	757 (100%)		850 (100%)

Chart 1

Age and sex-wise analysis of dermatoses prevalence

Morbidity profile of dermatoses

The ratio of infectious and non-infectious dermatoses among inmates was 1.5:1 (218 vs. 142). Among the infections that were diagnosed (n = 218, 60.5%), infestations were seen in 177 inmates (81.2%), fungal infections in 25 (11.5%), bacterial infections in 10 inmates (4.6%) and to end with viral infections in 6 (2.8%). In non-infectious group (n = 142, 39.5%), inmates affected with acne were 69 (48.6%), dermatitis 19 (13.4%), nutritional deficiency disorders 10 (7%), pigmentary disorders 3 (2.1%), and miscellaneous conditions 41 (28.9%). The details are depicted in Table 3. The total prevalence of significant dermatoses among the inmates (n = 850) when arranged in descending order showed the highest prevalence of pediculosis capitis (n = 116;13.6%) followed by acne vulgaris (n = 69; 8.1%), scabies (n = 61; 7.1%), pityriasis versicolor (n = 20; 2.4%), and mosquito bite allergy (n = 15; 1.8%) [Chart 2].

Table 3

Morbidity analysis of observed dermatoses

Dermatoses	5-9 years (n=93)			10-19 years (n=757)			Total (850)
	Male (n=41)	Female (n=52)	Total (n=93)	Male (n=289)	Female (n=468)	Total (n=757)
Infections and infestations							218 (25.6%)
Pediculosis capitis	-	8	8	-	108	108	116 (13.6%)
Scabies	3	1	4	41	16	57	61 (7.2%)
Pityriasis versicolor	-	-	-	7	13	20	20 (2.4%)
Verruca vulgaris	-	-	-	5	1	6	6 (0.7%)
Furuncle	-	-	-	2	3	5	5 (0.6%)
Dermatophytoses	1	-	1	2	2	4	5 (0.6%)
Impetigo	-	2	2	2	1	3	5 (0.6%)
Non-infectious							142 (16.7%)
Acne vulgaris	-	-	-	14	55	69	69 (8.1%)
Mosquito bite allergy	2	2	4	3	8	11	15 (1.8%)
Miliaria rubra	-	1	1	7	3	10	11 (1.3%)
Pityriasis alba	1	1	2	4	3	7	9 (1.1%)
Seborrheic dermatitis	-	1	1	2	6	8	9 (1.1%)
Acanthosis nigricans	-	-	-	1	7	8	8 (0.9%)
Chronic urticaria	-	-	-	1	2	3	3 (0.4%)
PMLE	-	-	-	-	2	2	2 (0.2%)
Oral lichen planus	-	-	-	1	1	2	2 (0.2%)
Atopic dermatitis	-	-	-	1	-	1	1 (0.1%)
Vitiligo	-	-	-	2	1	3	3 (0.4%)
Nutritional dermatoses
Premature graying of hair	-	-	-	-	8	8	8 (0.9%)
Phrynoderma	-	-	-	1	1	2	2 (0.2%)
Total dermatoses	7 (17.1%)	16 (30.8%)	23 (24.7%)	96 (33.2%)	241 (51.5%)	337 (44.5%)	360 (42.4%)
No dermatoses	34	36	70 (75.3%)	193	227	420 (55.5%)	490 (57.6%)
Total	41	52	93 (100%)	289	468	757 (100%)	850 (100%)

Chart 2

Proportion of various dermatoses observed

Discussion

Each city in India owns around 60–100 orphanages including both governmental and non-governmental organizations. India has a very large number of orphans and is in the top 10 in the world. There is not much information regarding environmental sanitation, cleanliness, nutrition, and hygiene practices in scientific studies or newsletters except for psychosocial issues, rare incidence of sexual abuse, and a few political matters. Children in orphanages tend to lead fairly structured lives on a scheduled basis due to the disproportion in the number of orphans and caregivers. They get up, get cleaned, eat, learn, and recreate in a regimented way by themselves. Despite being surrounded by people at all hours of the day, orphanage life can be lonely and they will learn a lot of coping mechanisms for building up survival skills in life.[3] There are 84 registered orphanages in the Tirunelveli district out of which 18 are urban orphanages—1 is run by the government, 3 are government aided and the remaining 14 are private orphanages. These orphanages apparently have good living conditions, environmental sanitation, and nutrition which reflects good physical and mental development probably from enough funding by the missionaries and trusts.

Morbidity profiling of various diseases in orphanages has been done in various parts of India and at the world level but a scientific structured study regarding the pattern and prevalence of dermatoses in child orphanages has never been done before in India.[14567] All the above-mentioned studies have been done by the department of community medicine, pediatrics, and nursing health and none has been done by dermatologists which is required to make a specific diagnosis about dermatological problems. Also, they described diseases in general terms like skin rashes without any specifications. One study has been done by microbiologists regarding the screening of dermatophytoses and other fungal infections in Kalaburgi (Karnataka) in five orphanages but not with other dermatoses.[8] Hence, we could not compare our statistics that well with the other studies. Yet, we have made an attempt to compare the prevalence and pattern of dermatoses in orphanages in various parts of India and worldwide with the available literature. The above-mentioned studies included a maximum study population of 100–420, which is also comparatively less when compared to ours with a huge study population of 850. Various studies that have been used for comparison are tabulated in Table 4.

Table 4

Study comparison[4579101112]

Study	Total dermatoses	Infections and infestations	Non-infectious	Nutritional dermatoses
Our study	42.4%	60.6%	36.7%	2.7%
Mayuri et al.,[4] Chitradurga, KA	48.4%	35.5% skin infections	12.9% scalp infections	23% malnutrition
Amiri et al.,[7] Tanzania	57.4%	64.9%	35.1%	-
Serarslan et al.,[5] Turkey	71.9%	60.8%	39.2%	-
Shukla et al.,[6] Salem, TN	-	38.5%	83% dandruff	57% malnutrition
Vaida et al.,[11] Jammu and Kashmir (exclusively for nutrition)	-	-	-	53% malnutrition
Dogra et al.,[9] Chandigarh (suburban school children, 6-14 years)	38.8%	42.3%	57.7%	-
Shameena et al.,[10] Mangalore, KA (school children, 5-16 years)	63%	63%	-	-

Description of the Dermatoses

Among the study group, one-fourth of the residents of 5–9 years and almost half of the adolescents were affected. This difference is because of separate accommodation between the age groups and more congestion was seen among the adolescents. Overall, 42.4% revealed cutaneous manifestations, and in both age groups, females were more affected than males (M: F = 1:2.3 vs. 1:2.5). The prevalence of dermatoses in our study is almost the same in all Indian studies but studies done abroad in Tanzania and Turkey showed an increased percentage of dermatoses. Also, the prevalence of dermatoses in our study is almost similar to the prevalence in school children study done by Dogra et al.[9] in Chandigarh (6–14 years) indicating an equal burden of skin disorders among children in the general population and orphanage centers. In our study, the percentage of infections and infestations were higher than non-infectious dermatoses (60.6% vs. 39.4%) which is similar to a school study done by Shameena et al.[10] in the coastal areas of Karnataka showing 63% of infectious dermatoses. This observation is in contrast to the school study done by Dogra et al.[9] in Chandigarh where non-infectious dermatoses are prevalent.

Many studies in orphanages have been studied on various behavioral, emotional, and psychosocial problems of those children as they are mentally deprived of a family's love and care.[13] Some could have been affected with psychocutaneous disorders like neurotic excoriations, trichotillomania, and dermatitis artefacta, but we could not discover such disorders in our study.

Infections and infestations

Three-fifth of dermatoses were contributed by infections and infestations, the latter one being more common than the former. Among them, pediculosis capitis (53.2%) was the most common infestation affecting mainly the adolescent females which could be due to long hair and lack of proper grooming and none of the males were found affected with pediculosis as they kept short hair [Figure 1]. Scabies was the second most common infestation which was comparatively more common in adolescent males than females (20.2% vs. 7.8%) [Figure 2]. This is different from a study done by Kumar et al.[8] at Kalaburgi which showed increased incidence among children of 5–10 years. Overcrowding and sharing of clothing and bedding could be the factors behind the high prevalence of infestations among adolescents when compared to the younger age group in our study. Pityriasis versicolor was detected among 9.2% of adolescents and none in 5–9 years of age as it is naturally expected to occur after puberty [Figure 3]. Other infections encountered were a few cases of verruca vulgaris [Figure 4], dermatophytoses [Figure 5], furuncle, and impetigo. Most of the studies done in orphanages globally and all over India frequently have reported superficial fungal and bacterial infections like dermatophytoses and pyodermas implicating poor level of hygiene and low socioeconomic status.[7] Similarly, a school study done by Dogra et al.[9] in Chandigarh (urban) also showed 64.4% of pyodermas and 25.4% of fungal infections which is in contrast to our study. The difference could be due to better hygiene practices, better living environment, good nutrition, and sufficient funding received by missionaries and trusts as orphanages we studied were mostly private.

Figure 1

Pediculosis capitis

Figure 2

Scabies - —papules and excoriations involving penile skin and inner thighs

Figure 3

Pityriasis versicolor

Figure 4

Verruca vulgaris

Figure 5

Tinea corporis

Non-infectious dermatoses

Two-fifth of dermatoses were contributed by non-infectious dermatoses [Figure 6]. Among them, acne vulgaris (19.1%) was found to be the commonest followed by mosquito bite allergy or papular urticaria (10.5%) and miliaria rubra (7.7%). The increased prevalence of acne among adolescent females can be explained by hormonal and climatic factors affecting this age group. Acne predominantly involved the face and the grading we observed was predominantly grades 1 and 2 and we did not encounter any severe grades of acne. Seborrheic dermatitis was seen in 6.3% and it was also common among the adolescent age group and it is in contrast to the study done by Shukla et al.[6] in southern Tamil Nadu. Pityriasis alba accounts for 6.3% and was less compared to the Turkey study where it accounted for 12.4% and the reason implicated was because of low socioeconomic status.[5] Pigmentary disorders were not many as vitiligo alone was seen in three patients (2.1%) and there were no other disorders of hypo- and hyperpigmentation [Figure 8].

Figure 6

Acne vulgaris—grade 2

Figure 8

Segmental vitiligo

Nutritional dermatoses

We could not find major nutritional deficiency disorders like marasmus and kwashiorkor except for phrynoderma [Figure 7] and premature graying of hair affecting 1.1% of the inmates which could be attributed to micronutritional deficiencies if at all. A study in Karnataka, Jammu and Kashmir, and Salem showed 23, 53, and 57% of malnutrition among children residing in orphanages but our study did not show any signs of malnutrition attributing to a healthy and nutritious diet in orphanages in recent years in our state.[4611] A study had been done exclusively to assess the nutritional status of children living in orphanages in Jammu and Kashmir showing 53% nutritionally deficient children and presented with various dermatoses like depigmentation of hair, conjunctival xerosis, bleeding gums, and so on.[11] Most of our study inmates are adequately provided with a well-balanced diet as their height to weight ratio and mid-arm circumference were found to be normal and clinical examination also did not reveal signs of malnourishment. Anthropometric measurements were checked periodically and recorded in their health records.

Figure 7

Phrynoderma

In general, various dermatoses may affect the well-being and quality of life of such individuals.[14] Even though infectious dermatoses are common in other studies, we could not encounter such problems in our orphanages, as our orphanages nowadays are not as bad as in the minds of common people. Environmental sanitation and health and hygiene practices have been changed to a brighter side in the last few years because of increased funding, Furthermore, awareness has to be improved to decrease the proportion of infestations like pediculosis and scabies and so pamphlets and lectures regarding health and hygiene awareness were given to all inmates and caregivers for proper utilization of health services that are available in our state of Tamil Nadu.[12]

Conclusion

Our study is the first of its kind in our country to study the pattern and prevalence of dermatoses among orphanages. Most studies in India and the world were done on nutrition and general morbidity profile of inmates of orphanages by non-dermatologists. Community-based studies regarding the profiling of various dermatoses in India are scarce. In our study, infestations were common than infections in contrast to many other studies, and adolescent females were more commonly affected. Multiple factors may attribute to these dermatoses which include lack of parental care, overcrowding, lack of awareness of personal hygiene among inmates, and lack of utilization of government medical services by the administrative person. There is a need that these orphans are to be screened regularly as they are the less privileged in our country. Thus, all stakeholders including the residents, keepers of orphanages, and the administrative head must be given health education regarding awareness on proper self-hygiene and self-care practices and modify their health-seeking behavior for management and prevention of various diseases and complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.