Epidemiological Study of Skin Disorders in Andaman and Nicobar Islands.

BACKGROUND: The study pertaining to the prevalence of diseases plays a valuable tool in the planning and implementation of health care facilities. The prevalence of skin diseases in Andaman and Nicobar islands, which is rightly called "Little India" considering the heterogeneity of the people living here, will serve as an indispensable tool.
METHODOLOGY: The data from the outpatient records of the Dermatology Department of 2 consecutive years were collected retrospectively, the study duration being January 2017 to December 2018. The diagnoses were classified as per the International Classification of Diseases (ICD 10). The quantitative variables are expressed as numbers and percentages.
RESULTS: Cutaneous infections namely dermatophyte infection, tinea versicolor, impetigo, scabies, molluscum, and warts were the most commonly encountered disorders. Hansen's disease was witnessed in 42 patients. Among the tribals, scabies, dermatophytosis, and pyoderma were the commonly encountered cutaneous disorders.
CONCLUSION: Thus, the data presented in the present study can be extrapolated on the mainland considering the diversity of the population in the Andaman and Nicobar (A and N) Islands. Copyright:

Introduction

The prevalence studies play a vital role in understanding the disease burden in a given population thus leading to effective implementation of health care facilities and preventive measures.[1] The Andaman and Nicobar (A and N) is a group of pristine islands located to the east of the Indian mainland amidst the Bay of Bengal. It includes 572 islands of which 38 are permanently inhabited. It can be proudly called “Little India” because of its diverse population which includes people from almost all the states of India who live in harmony. The total population of A and N is approximately 5 lakhs including the migrant population. Thus, a prevalence study of skin disorders in A and N will be a great boon and can be roughly extrapolated upon the Indian population.

The Dermatology OPD, where the current study was done, is the only functioning dermatology center in A and N. Thus, almost all the patients from the other Community Health Centers (CHCs), Primary Health Centers (PHCs), and subcenters are referred to our department revealing the importance of the prevalence study done in our center.

Methodology

The data from the outpatient records of the Dermatology Department were collected retrospectively. The study duration being January 2017 to December 2018. The diagnoses were made based on the clinical findings and necessary laboratory investigations.

For calculating the actual prevalence of the skin diseases, the diagnoses made at the initial visit of the patients were considered. When the patients had a new skin disease at the time of the follow-up visit, they were considered as separate disease entities and the entry of the new disease in those patients was made into the master chart whereas the previously diagnosed disease was not entered. Some of the patients had multiple skin disorders which were considered separately while entering the data in the master chart. For example, if patient X has acne vulgaris and seborrheic dermatitis, each disease was counted separately while tabulating the disease frequency. The entry for each disease in a particular patient was made only once in the master chart to facilitate accuracy in calculating the prevalence of the dermatoses.

The diagnoses were classified as per the International Classification of Diseases (ICD 10) and tabulated in Microsoft Excel. The quantitative variables are expressed as numbers and percentages.

Results

The Dermatology Outpatient Department is visited by 152–233 patients daily. The total number of patients who visited the skin department during the study period was 100,360 who constitute around 10.6% of the total outpatients visiting the GB Pant Hospital, Port Blair. Of these patients, 46.4% were males and 53.6% were females. Children of 14 years and below are constituted upon by 14.3% of the total patients visiting the skin department. Senior citizens who include patients of age more than 60 are constituted upon by 10.6% of the total patients. The total number of indigenous tribal people who visited the skin OPD during the study period included 2,533 (2.52%) patients, the distribution of which is mentioned in Table 1.

Table 1

Distribution of the tribal people who visited the skin OPD during the study period

Name of the tribal community	Numbers	Percentage
Nicobarese	2,486	98.14%
Jarawas	30	1.18%
Great Andamanese	10	0.4%
Onge	4	0.16%
Shompens	3	0.12%
Total	2,533	100%

The diseases that were encountered among the patients who visited the skin OPD are mentioned in the master chart [Table 2]. In total, 59,317 entries were made. Cutaneous infections were the most common category of skin disorders that were encountered in the present study. Among the skin infections, dermatophytoses (26.57%) was the most commonly encountered problem followed by tinea versicolor (10.73%). Among the bacterial infections, impetigo (4.31%) was commonly encountered, more so in children (less than 10 years of age). Among the viral disorders, warts (2.17%) and molluscum contagiosum (1.08%) were most commonly seen. Scabies is highly prevalent in the Islands evidenced by the fact that 5.12% of the patients had the infestation. Leprosy was encountered in 42 patients.

Table 2

Prevalence of skin diseases in A&N

Diseases	Number of patients (n)	Percentage
Infectious and parasitic diseases
Mycoses
Dermatophytosis	15,763	26.57
Pityriasis versicolor	6,363	10.73
Candidiasis	1,591	2.68
Bacterial Infections
Folliculitis	1,109	1.87
Furuncle(s)	1,350	2.28
Cutaneous abscess(es)	15	0.025
Impetigo	2,555	4.31
Ecthyma	10	0.02
Cellulitis	84	0.14
Erythrasma	12	0.02
Acute paronychia	64	0.11
Botryomycosis*	2	0.003
Other Pyodermas	641	1.08
Viral infections
Viral warts	1,287	2.17
Varicella	386	0.65
Herpes zoster	337	0.57
Herpes simplex	241	0.41
Molluscum contagiosum	641	1.08
Parasitic diseases
Scabies	3,037	5.12
Pediculosis	641	1.08
Cutaneous larva migrans*	4	0.007
Mycobacterial diseases*
Leprosy	42	0.07
Lupus vulgaris	6	0.01
Neoplasms
Malignant neoplasms	8	0.01
Premalignant neoplasms*	5	0.008
Benign neoplasms
Melanocytic naevi	248	0.42
Other benign neoplasms of skin	84	0.14
Diseases of the oral cavity, salivary glands, and jaws
Recurrent oral aphthae	12	0.02
Cheilitis	62	0.10
Diseases of the skin and subcutaneous tissue
Bullous disorders
Pemphigus	8	0.01
Dermatitis herpetiformis	3	0.005
Bullous pemphigoid	6	0.01
Dermatitis and eczema
Contact dermatitis	964	1.63
Lichen simplex chronicus	1,287	2.17
Atopic dermatitis	3,856	6.50
Seborrheic dermatitis	2,555	4.31
Nummular eczema	641	1.08
Nodular prurigo	318	0.54
Pruritus	641	1.08
Papulosquamous disorders
Psoriasis	1,204	2.03
Lichen planus	241	0.41
Pityriasis rosea	323	0.54
Parapsoriasis	6	0.01
pityriasis rubra pilaris*	4	0.007
Urticaria and erythema
Urticaria	964	1.63
Erythema nodosum	14	0.02
Erythema multiforme	12	0.02
Radiation-related disorders of the skin and subcutaneous tissue
Polymorphous light eruption	1928	3.25
Sunburn	106	0.18
Skin disorders of the appendages
Acne	3,215	5.42
Alopecia areata	641	1.08
Rosacea	964	1.63
Androgenic alopecia	641	1.08
Hirsutism	48	0.08
Miliaria rubra	331	0.56
Other disorders of pigmentation
Melasma	723	1.22
Vitiligo	641	1.08
Seborrheic keratosis	362	0.61
Lupus erythematosus	18	0.03
Congenital malformations, deformations, and chromosomal abnormalities
Neurofibromatosis	8	0.013
Ichthyosis vulgaris	38	0.064
BIE, X-linked ichthyosis, EBS, Pachyonychia congenita, OCA, AED	6 (1 each)	0.010

*Is attached to the diseases which are not mentioned in the ICD 10. BIE – Bullous ichthyosis erythroderma, EBS – Epidermolysis bullosa simplex, OCA – Oculocutaneous albinism, AED – Anhidrotic ectodermal dysplasia

Among the allergic contact dermatitis (ACDs), cement and hair dye ACDs were the most commonly encountered ones. Of the endogenous eczemas, seborrheic and atopic dermatitis were most commonly witnessed. Polymorphic light eruption (PMLE) was the commonest radiation-induced skin disorder encountered. Ichthyosis vulgaris and neurofibromatosis were the most commonly encountered genodermatosis.

Dermatophytosis followed by scabies and pyoderma constitute the major skin disorders among the Nicobarese. Scabies, dermatophytosis, and pyoderma were the common skin disorders encountered in the Jarawas, Great Andamanese, Somphens, and Onges.

Discussion

Considering the high humidity in the A and N islands, the incidence of dermatophyte infection is highly rampant in this population. The rate of recurrences and recalcitrance is high as observed in the other parts of India.[2345] Combination creams containing topical steroids are widely abused in the islands for which the author is taking utmost efforts to spread the awareness for curtailing its usage by delivering TV, radio programs, and through local newspaper articles.

Steroid abuse is highly rampant in the islands. Several patients with tinea incognito were witnessed in the islands. The usage of topical steroids for acne, facial pigmentation, and as a fairness cream is highly rampant here as a result of which steroid-induced dermatoses were frequently witnessed and several awareness programs through the media are conducted to curtail it. Anthralin-induced irritant dermatitis was seen in 44 patients due to over-the-counter usage of anthralin ointment for cutaneous dermatophyte infection which is another area of concern in the A and N.

Pityriasis alba, scabies, pyoderma, papular urticaria, and molluscum contagiosum were the dermatoses commonly encountered in children mentioned in the order of decreasing frequency. In the study by Jose et al.,[6] pediculosis, scabies, and pyodermas were the commonly encountered dermatoses in children. Infections and infestations were the common dermatoses encountered in children in the other studies from India as well.[789] Scabies was more prevalent among those in crowded houses, among the hostel inmates, and those living in barracks.

Hansen's disease witnessed in 42 patients is an alarming issue in the islands [Table 3]. This is more so due to migrant laborers from the leprosy endemic areas such as Bihar, Chhattisgarh, Jharkhand, etc. Among the 42 patients with Hansen's disease, 18 patients (42.9%) are migrants from the mainland. As per the observation of Chhabra et al.,[10] a majority of the leprosy cases were immigrants from leprosy endemic areas. Among those with deformities, trophic ulcer was seen in three patients and clawing of hand was seen in one patient.

Table 3

Classification of the patients with Hansen’s disease who visited skin OPD

Type of Hansen’s disease	Number of patients (n)	Percentage
Tuberculoid (TT)	6	14.2
Borderline tuberculoid (BT)	22	52.4
Borderline lepromatous (BL)	6	14.3
Lepromatous (LL)	2	4.8
Histoid Hansen	2	4.8
Deformities - Grade 2	4	9.5

Seasonal clustering of cases was observed in certain diseases. The incidence of varicella, pyodermas, cutaneous dermatophyte infection, miliaria, polymorphic light eruption, and sunburn were more during the hotter months (March to May). The incidence of scabies, papular urticaria, and hand, foot and mouth disease (HFMD) was more during the rainy seasons. This was similar to the observation by Banerjee et al.[11] except for the fact that scabies was more commonly witnessed during the winter months in their study.

ACD was commonly witnessed due to cement followed by hair dye, nickel, and fragrance. This high prevalence of ACD induced by cement is due to the increased rate of construction activities going on in the islands. Cement is one of the commonest allergens implicated in occupational contact dermatitis.[12]

Apart from the primary cutaneous malignancies (Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC), and melanoma) in eight cases, metastatic cutaneous nodule (from carcinoma lung) and subcutaneous panniculitis-like T-cell lymphoma (SPTCL) were observed in one patient each.

Some of the dermatoses unique to this region are jellyfish sting (two cases) and cutaneous larva migrans (four cases). Papular urticaria was commonly seen involving the legs, forearm, and neck following a visit to the seashore in the evening time in hypersensitive individuals. Some uncommon cutaneous infections such as botryomycosis (two cases) and bacillary angiomatosis (one case) were also encountered.

Nicobarese, who were horticulturists primarily, have their living standards similar to the general population nowadays. Thus, their dermatoses are similar to the general population. Among the particularly vulnerable tribal groups (PGVT) such as Jarawas, Great Andamanese, Onges, and Somphens, the common dermatoses encountered were scabies, dermatophyte infection, and pyoderma. Surprisingly, papular urticaria and photodermatosis were rarely encountered among the native tribals. The Sentinelese are the most isolated of all the tribes and have no contact with outsiders, hence, the prevalence of skin diseases among them could not found.

Conclusion

This study provides detailed information regarding the epidemiology of skin diseases prevailing in the A and N Islands. The data can serve as a valuable tool since it can be implied on the mainland population considering the heterogeneity of the people in this group of islands.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.