common skin diseases - department of dermatology, st. vincent's

A T L A S O F

COMMON SK IN D ISEASES

I N A U S T R A L I A

A U T H O R S

Robin Marks

Anne Plunkett

Kate Merlin

Nicole Jenner

Department of DermatologySt Vincent’s Hospital, Melbourne

Published by the Department of Dermatology,

St Vincent’s Hospital, Melbourne,

Victoria Parade, Fitzroy, Victoria 3065 Australia.

Telephone +61 3 9288 3293

Fax +61 3 9288 3292

© Department of Dermatology,

St Vincent’s Hospital, 1999

No part of this publication may be

reproduced, stored in or introduced into a

retrieval system, or transmitted in any form

or by any means without the prior written

permission of the copyright owner.

ISBN 1–875271–31–7

Professor Robin Marks and the Department ofDermatology at St Vincent’s Hospital in Melbourne are tobe congratulated on producing this Atlas of CommonSkin Diseases in Australia. Due to their fine efforts, wenow have a clear idea of the prevalence and morbidity ofcommon skin conditions in this country.

Despite the significant prevalence of skin disease inAustralia, as illustrated in this Atlas, this importanthealthcare issue has been given low priority in thecommunity. Consequently and disappointingly,dermatology has received insufficient Governmentattention and inadequate funding for provision of clinicalservices, research and training.

A key function of the Australasian College ofDermatologists is education. Through its range ofeducational activities, information concerning commonskin conditions is circulated regularly amongst medicalstudents, general practitioners, other medicalpractitioners and allied interest groups. This uniqueAtlas provides us with further important information andit should become an essential source of reference foranyone interested in Australian dermatology. Medicaland allied health trainees, and others interested inensuring the resources required for maintaining anappropriate profile and high standard of dermatologicalhealthcare in Australia, would find the Atlas particularlyvaluable.

The College is very pleased indeed to be associated withthe launch of this Atlas and we wish it every success.

DUDLEY HILL STEPHEN LEEPresident Honorary Secretary

THE AUSTRALASIAN COLLEGE OF DERMATOLOGISTS

—— Foreword —— i

Foreword

—— Atlas Of Common Skin Diseases ——ii

—— Introduction —— iii

Skin diseases are a bit like the common cold. Apart from some of the skincancers, they are not recorded in any official registry. They vary enormouslyfrom mild conditions which may affect only the appearance of the skin to severediseases which are totally incapacitating. The degree of treatment required, oreven sought, varies accordingly.

Nevertheless, every medical practitioner knows that there are plenty of peoplesuffering with these conditions. A comprehensive survey of general practitioners’workloads in Australia revealed that skin problems were the primary reason forat least 15% of consultations. On the other hand, community-based datacollections show that medical practitioners are consulted about skin conditionsby less than 50% of those who have them. People frequently seek advice from

others in the community including pharmacists, family or friends andnaturopaths, or they merely prescribe for themselves based oninformation from elsewhere.

Like the common cold, everyone knows skin conditions are a problem,but until major community-based surveys are undertaken, no one realisesthe frequency and degree to which people suffer.

In 1995, a new academic Department of Dermatology was formed at StVincent’s Hospital in association with the University of Melbourne, theAustralasian College of Dermatologists and the Skin and CancerFoundation of Victoria. It was decided that the direction of researchshould be into the frequency and morbidity of common skin conditionsin the community. After all, these conditions are the basis for the vastmajority of dermatologists’ work. Their work includes not only providingcare for patients with skin disease, but also teaching other medicalprofessionals the approach to and management of these conditions.

This Atlas is a summary of the data that have been gathered over the last fiveyears. Skin cancers are not included as they have been well reported elsewhere.The data presented here are startling. However, they do confirm an impressionthat most health professionals develop after some years of contact with thepublic. They show clearly that skin diseases are common, they cause considerablemorbidity in the community, and people with them require better care.

This Atlas is only the beginning. It is not enough just to record that there areproblems. The next step is to do something about them. We now have datademonstrating quite clearly where there are problems and we look forward tousing these data as the basis for taking steps to relieve them in the future.

Robin MarksProfessor of Dermatology

St Vincent’s Hospital, Melbourne

November 1999

Introduction

This Atlas is only

the beginning. It is

not enough just to

record that there

are problems.

The next step is to

do something

about them.

—— Atlas Of Common Skin Diseases ——iv

Methods..............................................................2

What Skin Diseases Do People Say They Have? .............................................4

What Skin Diseases Do People Really Have?

Acne ..............................................................6

Nappy Rash (Napkin Dermatitis) ..................10

Atopic Dermatitis (Eczema) ..........................12

Seborrhoeic Dermatitis ................................16

Psoriasis ......................................................18

Warts...........................................................20

Tinea Pedis and Tinea Unguium ..................24

Birthmarks...................................................26

Campbell de Morgan Spots .........................29

Seborrhoeic Keratoses.................................30

Where Do People Seek Advice For Treatment Of Common Skin Diseases? ........................32

Recommendations ............................................36

Acknowledgements ...........................................39

—— Contents —— 1

Contents

The data presented in this Atlas are a compilation ofa number of different studies undertaken by theDepartment of Dermatology over the last five years.They have been divided into different componentsand are presented as:- what skin diseases do peoplesay they have when they are asked; what skindiseases do people really have when they areexamined by dermatologists; the severity of the skindiseases that have been found on examination; wheredo people seek advice for treatment of common skindiseases; and is the treatment that people arecurrently using likely to be effective.

The terms skin conditions and skin diseases areused, almost interchangeably at times, throughoutthe Atlas. This allows us to include conditions likeCampbell de Morgan spots or some of the birthmarkswhich would not normally be classified as disease.

Community-based surveys should be carefullydesigned to sample people who are representativeof the whole population. Such surveys dependupon the ability to make contact with representativesamples of people of all ages from birth to death.They seek self-report information on the presence ofthe skin diseases, the treatment and where theyhave received it. Respondents are then examinedby a person experienced in skin disease, i.e. adermatologist, to reveal whether or not they have askin condition and what it is.

There is no simple method of sampling the wholecommunity at all ages in Australia. For that reason,the population-based surveys represented here havebeen performed in different ways. They varyaccording to the age groups of the people beingsurveyed and the ability to reach those peoplewithin age strata in a way which ensures that theyare representative of the Australian population.They also vary according to what information isbeing sought.

The data for the chapter on “what skin diseases dopeople say they have?” come from a community-based telephone survey in which 416 people wereasked if they suffered from skin disease and wherethey were seeking advice. These are self-reports ofskin disease for which we have no clinicalexamination to confirm the diagnosis.

The data for the section “what skin diseases dopeople really have?” where our dermatologists haveexamined people to determine the true frequency ofskin disease in the community comprise threedifferent studies. The first study “The Tiny Tots

Survey” included 1,116 children aged from birth to 5years. The children were examined from a randomselection of kindergartens, child care centres andMaternal and Child Health Centres in urban and ruralVictoria. In this survey the specific conditionssought in detail included napkin dermatitis (nappyrash), seborrhoeic dermatitis (cradle cap), birthmarks, including haemangiomas and melanocyticnaevi, and atopic eczema (dermatitis).

The second survey “The School Skin Survey” was aschool-based study of 2,491 children aged from 4-18years. The schools were randomly selected fromGovernment, Catholic and Independent schools inboth urban and rural Victoria. In this survey, thespecific conditions sought in detail included acne,warts, tinea pedis and atopic eczema. Althoughother conditions, including psoriasis and seborrhoeicdermatitis were recorded, the numbers andinformation are insufficient to be confident of thetrue prevalence in this age group. Therefore, theyare not reported in this Atlas.

The final community-based survey “TheMaryborough Skin Health Survey” was of 1,457adults aged 20 years and over who were randomlyselected from the population of Maryborough inCentral Victoria. In this survey specific conditionssought in detail included acne, warts, tinea pedisand tinea of the nail (unguium), psoriasis, atopiceczema, seborrhoeic keratosis and Campbell deMorgan spots (punctate haemangiomas). Althoughskin cancer was recorded, it is not reported here asthat has been well covered in other publications.Each of the surveys required voluntary informedconsent from the participants or their parents oncethe randomisation of who would be offered anexamination was completed.

The final chapter on “where do people seek advicefor treatment of common skin diseases?” involvedtwo pharmacy-based surveys in Maryboroughseeking information from people who bought skin-related products. It included information obtainedin the three community-based skin examinationsurveys and the telephone survey of self-report datamentioned above.

It can be seen that there are different methods usedin each of the surveys that are being reported hereand different methods of population sampling.Technically speaking, it is not possible to put themall together and come up with single curves derivedfrom different studies. For that reason, the

—— Atlas Of Common Skin Diseases ——2

Methods

frequency data are presented in three categoriesaccording to the age of the participants and thesurvey in which data were gathered. On severaloccasions, we have put the data from the threesurveys together to give easy scanning, bearing inmind that they are not strictly compatible.

Severity of the conditions was divided into minimal,mild, moderate and severe. These are clinicalcategories based on a classification of minimal:only a small area affected which may not even havebeen noticed by the person or their carer; mild: asmall area affected, which responds to simpletreatment available from a pharmacist, or very mildtreatment from a medical practitioner; moderate:more widespread disease that would requiretreatment from a general practitioner with the use ofmedications available on prescription only; andsevere: widespread active involvement which wouldrequire specialist advice.

One of the other ways of determining the effect ofthese diseases, rather than just describing theseverity, is to seek the morbidity associated withthem. The morbidity is measured in regard to thedirect and indirect effects of a skin disease on theindividual’s work, home and social life.

A Dermatology Life Quality Index (DLQI) has beenused to include questions about the effect of thesediseases in various aspects of a person’s life. Thesequestions include symptoms related to the diseasedirectly; whether or not it created embarrassment orinterfered with such things as shopping or socialactivities; what effect it has had on relationshipswith other people; whether work or studying hasbeen affected; and how much of a problem hasbeen created by the treatment that has beennecessary.

The DLQI was used predominantly in the AdultSurvey with some use in the School Survey. DLQIscores are reported in the Atlas where they areavailable, giving the responses categorised from“affected very much” to “not being affected at all” ineach of the categories of the questionnaire.

Full descriptions of the exact method for each of thesurveys reported in this Atlas are given in thereferences at the end of this section. Furtherreading from this list is recommended for those whowould like more detailed information on theepidemiological methods involved.

—— Methods —— 3

REFERENCES1. The prevalence and morbidity of common skin diseases among

adults in Maryborough, Victoria: The Maryborough Skin Health

Survey; 1997-1998. Final Report. Dept of Dermatology, St

Vincent’s Hospital, Melbourne.

2. The prevalence and morbidity of common skin diseases in

Victorian school children. The School Skin Survey, 1996-1997.

Final Report. Dept of Dermatology, St Vincent’s Hospital,

Melbourne.

3. The prevalence and morbidity of common skin diseases

amongst infants and preschool children. The Tiny Tots Survey,

1998-1999. Final Report. Dept of Dermatology, St Vincent’s

Hospital, Melbourne.

4. Gill D, Merlin K, Plunkett A, Jolley D, Marks R. Population

based surveys on the frequency of common skin diseases in

adults - Is there a risk of response bias? Clin Exp Dermatol.

1999 (In Press).

5. Kilkenny M, Merlin K, Plunkett A, Marks R. The prevalence of

common skin conditions in Australian school students: 3. Acne

vulgaris. Brit J Dermatol. 1998; 139:840-845.

6. Kilkenny M, Merlin K, Young R, Marks R. The prevalence of

common skin conditions in Australian school students: 1.

Common, plane & plantar viral warts. Brit J Dermatol. 1998;

138:840-845.

7. Kilkenny M, Stathakis V, Jolley D, Marks R. Maryborough Skin

Health Survey: Prevalence and sources of advice for skin

conditions. Australas J Dermatol. 1998; 39:233-237.

8. Kilkenny M, Yeatman JM, Stewart K, Marks R. The role of

pharmacists and general practitioners in the management of

dermatological conditions. Int J Pharmacy Practice. 1997; 5:11-

15.

9. Mar A, Tam M, Jolley D, Marks R. The cumulative incidence of

atopic dermatitis in the first 12 months amongst Chinese,

Vietnamese and Caucasian infants born in Melbourne, Australia.

J Am Acad Dermatol. 1999; 40:597-602.

10. Marks R, Kilkenny M, Plunkett A, Merlin K. The prevalence of

common skin conditions in Australian school children: 2.

Atopic Dermatitis. Brit J Dermatol. 1999; 140:468-473.

11. Merlin K, Kilkenny M, Plunkett A, Marks R. The prevalence of

common skin conditions in Australian school students: 4.

Tinea Pedis. Brit J Dermatol. 1999; 140:897-901.

12. Plunkett A, Merlin K, Gill D, Zuo Y, Jolley D, Marks R. The

frequency of common non-malignant skin conditions in adults

in central Victoria, Australia. Int J Dermatol. 1999 (In Press).

13. Yeatman JM, Kilkenny MF, Marks R. The prevalence of

seborrhoeic keratoses in an Australian population: Does

sunlight play a part in their frequency? Brit J Dermatol. 1997;

137:411-414.

14. Yeatman J, Kilkenny M, Stewart K, Marks R. Advice about

management of skin conditions in the community: Who are the

providers? Australas J Dermatol. 1996; 37 Suppl 1 S46-S47.

Table 1 — Prevalence of self reported skin diseases in adults

Prevalence % (95% confidence interval)

Past 2 weeks Past 6 months(excluding last 2 weeks)

Acne/pimples 16.2 (9.6-22.7) 9.4 (5.4-12.5)

Cold sores 15.1 (7.3-18.9) 30.3 (23.9-56.7)

Dermatitis/eczema 25.5 (18.1-32.8) 12.6 (7.9-17.3)

Psoriasis 4.5 (1.0-7.9) 3.5 (0.9-5.1)

Skin cancer 0.5 (0.0-0.9) 5.0 (2.3-7.7)

Thrush 2.5 (0.2-4.8) 5.7 (2.7-8.6)

Tinea 11.2 (5.9-16.5) 19.4 (15.8-24.9)

Urticaria/hives 1.1 (0.0-2.7) 0.9 (0.0-2.1)

Warts 16.1 (9.8-22-4) 8.6 (4.9-12.4)

had a disease of skin and subcutaneous tissuewithin the past two weeks. These are open-endedquestions without prompting for specific diagnoses.People are more likely to remember a condition,particularly if it is not symptomatic, only when theyare prompted specifically on whether or not theyhave had it. For example, a person when asked dothey have skin disease may say no, even thoughthey may have a wart on their finger. However,when asked specifically do they have a wart on theirfinger or elsewhere, they may then answer yes.

We undertook a computer-assisted telephoneinterview survey in the city of Maryborough in which416 adults agreed to answer questions not only onwhether or not they had had skin disease recently,but also more specifically on what were theconditions (including prompting questions) that theyhad. The interviews took approximately 5-10minutes to complete and were undertaken in mid-winter in the months of July and August.

Twenty seven percent of people reported having oneor more skin conditions over the previous twoweeks, with 25% of those reporting that they hadmore than one skin condition. There were slightlymore women (51.4%) than men (48.6%) in thegroup who reported having a skin condition. Ofthose who had sought treatment for their problem,65% reported that the condition was mild, 24%reported moderate and 13% reported that thecondition was severe.


Everyone in the community will suffer from at leastone skin condition during their lifetime. Conditionssuch as warts and acne are almost universal atcertain ages. However, whether people recognise orreport many of these common conditions as diseasewill vary according to the area affected and theseverity of the problem.

Memory for minor problems fades very rapidly sothat recall of past skin conditions may be fraughtwith under-reporting. The nature of the questionsseeking information on whether people have skindisease determines the frequency of response.Some conditions are more common or active atcertain times of the year than others. Thus aquestionnaire undertaken in winter may reveal ahigher prevalence of dermatitis/eczema or acne thana questionnaire seeking the frequency of these

conditions undertaken in summer. On theother hand, tinea of the feet (athlete’sfoot) and skin cancer are often morefrequently reported in the summer monthsthan in the winter months. Thus whatskin diseases people say they have maynot necessarily be a true picture of whatis really occurring in the community.

The Australian Government through the AustralianBureau of Statistics undertakes national healthsurveys on a regular basis. In these surveys,relatively broad questions are used to determine thefrequency of self-reported disease. In the 1989/90survey, 12.7% of the population reported that they

What Skin Diseases Do People Say They Have?

When asked about the past six months, 59% ofpeople reported having at least one skin condition.Treatment was used for the majority of theseconditions with the exception of acne and warts.Almost 70% of acne and 70% of warts were nottreated by those people who said they had them.The majority of skin conditions reported within thelast six months were regarded as mild (74%) with18% considered by respondents to be moderate andthe remaining 8% were classified as severe.

A breakdown of the prevalence of the conditionsreported by these adults (18 years and over) isshown in Table 1. As predicted, they show that theseasonal related conditions acne and dermatitiswere more common at the time (winter) but lesscommon in the last 12 months (including summer).The figures for tinea, skin cancer and cold sores arethe other way around. In telephone surveys of thisnature, the diagnosis suggested by the respondentis unable to be confirmed by clinical examination.

In the Tiny Tots Survey and the School Skin Survey,the parents of the children and the adolescentsthemselves were asked before the examinationwhether they currently had a number of the commonskin conditions (with prompting for specificconditions). Overall, 49% of pre-school childrenaged from birth to five years were reported to havesome skin disease by their parents. Self-report ofskin disease, or parental report, revealed that 54%

of school children aged four to 18 years currentlyhad at least one of the common skin conditions. Abreakdown of these conditions can be seen inTables 2 and 3.

In both the Tiny Tots Survey and the School Survey,the self-report of skin disease was followed up withan examination by one of the dermatological team.This confirmed whether the condition that they hadreported was present, and whether any otherconditions were also present at the time ofexamination. Confirmation of the self-reporteddiagnoses revealed underestimates by self-report onsome occasions and overestimate on others, with noclear trend. In other words, self-report is one of theways of estimating morbidity, but there will beinaccuracies in both the diagnosis and the frequencywith which people report that they have conditions.

In summary, a substantial proportion of thecommunity report that they are currently sufferingfrom at least one skin disease. They also reportthat they have suffered from a variety of skindiseases in the past. Although crude, this estimateof frequency and morbidity related to skinconditions in the community begins to give an ideaof the huge number of people who are affected. Italso gives some measure of the morbidity that isrelated to these common cutaneous conditions.

—— What Skin Diseases Do People Say They Have? —— 5

Table 2 — Skin diseases in preschool childrenreported by their parents*

Prevalence % (95% CI)

Overall 49.1 (46.1-52.1)

Eczema/dermatitis 29.4 (26.7-32.1)

Seborrhoeic dermatitis/ cradle cap 19.5 (17.2-21.9)

Nappy rash/ diaper dermatitis 15.0 (12.9-17.1)

Tinea/ringworm 0.9 (0.5-1.7)

Table 3 — Skin diseases in school childrenreported by themselves or their parents*

Prevalence % (95% CI)

Overall 53.6 (51.6-55.6)

Acne/pimples 29.6 (21.0-38.2)

Eczema/dermatitis 15.6 (13.9-17.3)

Tinea/ringworm 7.8 (6.4-9.1)

Warts/papilloma 19.0 (17.0-21.0)

* A number of children had more than one condition.

Age

(yea

rs)

Age

(ye

ars)


ACNEClinical features

Acne (pimples) is a common skin condition characterised by the presence of various spots calledcomedones (blackheads and whiteheads), papules, pustules, and, in severe cases, nodules and cysts.

The development of acne coincides with the onset of puberty when androgen hormones, such astestosterone, are released. These hormones can cause the sebaceous glands to overproducesebum (oil), which leads to blockage and the typical spots associated with acne.

Even though many consider acne to be a normal part of growing up, it can have serious effects on a young person’s academic performance and their ability to interact socially.

Prevalence of acne in school children

No. examined Prevalence % (95% CI)

Overall 2491 36.1 (24.7-47.5)Male 1174 30.7 (19.2-42.3)Female 1317 41.2 (29.1-53.3)4-6 385 0.0 (0.0-0.0)7-9 665 3.0 (1.5-4.6)10-12 636 27.7 (20.6-34.8)13-15 539 78.2 (73.8-82.6)16-18 266 93.3 (89.6-96.9)

Severity of acne in school children

No.with Minimal Mild Moderate–severeacne % % %

Overall 873 40.4 43.1 16.5Male 362 34.3 41.7 24.0Female 511 44.8 44.0 11.27-9 19 94.7 5.3 0.010-12 188 59.6 37.8 2.713-15 418 37.3 43.5 19.116-18 248 27.0 49.2 23.8

What Skin Diseases Do People Really Have?

Prevalence of acne in school children

Pre

vale

nce

(%)

Age (years)

100

80

60

40

20

04–6 7–9 10–12 13–15 16–18

OverallMaleFemale

Age

(ye

ars)

Age

(ye

ars)

—— Acne —— 7

Prevalence of acne in adults

No. examined Prevalence % (95% Cl)

Overall 1,457 12.8 (11.0-14.5)Male 670 11.8 (9.4-14.2)Female 787 13.6 (11.2-16.1)20-29 156 42.0 (35.4-48.6)30-39 211 23.9 (18.6-29.3)40-49 272 8.6 (5.2-11.9)50-59 267 3.1 (1.6-6.0)60-69 268 1.4 (0.5-4.3)70+ 283 0.4 (0.1-2.8)

Severity of acne in adults

No. with Mild Moderate Severeacne % % %

Overall 150 81.2 17.0 1.8Male 63 81.2 17.4 1.3Female 87 81.1 16.7 2.220-29 65 72.5 24.7 2.830-39 49 90.8 9.2 0.040-49 23 88.9 7.8 3.350-59 9 75.2 24.8 0.060-69 3 100.0 0.0 0.070+ 1 100.0 0.0 0.0

Prevalence of acne in adults

Pre

vale

nce

(%)

Age (years)

50

45

40

35

30

25

20

15

10

5

0

20–29 30-–39 40–49 50–49 60–69 70+

OverallMaleFemale

8 —— An Atlas of Common Skin Diseases ——

1. As a result of having acne/pimples, during the last monthhave you been aggressive,frustrated or embarrassed ?

2. Do you think that having acne/pimples during the last monthinterfered with your daily sociallife, social events or relationshipswith members of the opposite sex ?

3. During the last month have youavoided public changing facilitiesor wearing swimming costumesbecause of your acne/pimples ?

4. How would you describe yourfeelings about the appearance ofyour skin over the last month ?

5. Please indicate how bad you thinkyour acne/pimples is now:

Very much indeed .........................A lot................................................A little.............................................Not at all ........................................

Severely, affecting all activities......Moderately, in most activities ........Occasionally or in only some

activities....................................Not at all ........................................

All of the time................................Most of the time ............................Occasionally ...................................Not at all ........................................

Very depressed and miserable.......Usually concerned ..........................Occasionally concerned..................Not bothered ..................................

The worst it could possibly be ......A major problem ............................A minor problem ............................Not a problem................................

2.64.227.066.2

1.03.1

15.480.5

1.00.35.093.7

2.112.637.447.9

0.88.443.547.3

ADI question Answer % (n=382)

The Acne Disability Index (ADI) in school students with acne

Prevalence of acne in school children and adults

Pre

vale

nce

(%)

Age (years)

100

80

60

40

20

0

5 11 17 25 35 45 55 65 75+

OverallMaleFemale

9

The Dermatology Life Quality Index (DLQI) in adults with acne

DLQI question ANSWERS % (n=122)

Over the last week… very a lot a little not at all /much not relevant

1. how itchy, sore, painful or stinging has your skin been? 1.6 4.1 37.7 56.6

2. how embarrassed or self-conscious have you been because of your skin? 2.5 4.1 30.3 63.1

3. how much has your skin interfered with you going shopping or lookingafter your home or garden? 0.0 0.0 3.3 96.7

4. how much has your skin influenced the clothes you wear? 0.8 1.6 5.7 91.8

5. how much has your skin affected any social or leisure activities? 0.8 0.0 1.6 97.5

6. how much has your skin made it difficult for you to do any sport? 0.0 0.0 1.6 98.4

7. how much has your skin been a problem at work or studying? 0.0 0.8 3.3 95.9

8. how much has your skin created problems with your partner or any of your close friends or relatives? 0.0 0.0 4.1 95.9

9. how much has your skin caused any sexual difficulties? 0.0 0.0 3.3 96.7

10. how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time? 0.0 0.0 5.7 94.3

—— Acne ——

Frequency, severity and morbidity

The data show that acne is most common in adolescence. It is morecommon in younger females due to early onset of puberty. It increases infrequency and severity in males in later adolescence.

Even though it has traditionally been called a disease of adolescence, asubstantial proportion of young adults in their twenties and thirties alsosuffer from acne to some degree. More than 15% of school children hadacne that was classified as moderate to severe requiring medical care.Greater than 25% were in this category between 20-29 years.

The acne disability index is a quality of life measure asking questionsrelated specifically to the nature of acne. More than 30% of schoolstudents had felt aggressive, frustrated or embarrassed about the condition.A similar proportion was seen in adults using the DLQI. Twenty percent ofschool students stated that their social life or relationships with others hadbeen affected and more than 50% of students had been concerned becauseof their skin in the last month. Over 40% of the adults affected hadsymptoms such as pain, stinging or soreness related to their acne withinthe last week.


NAPPY RASH (NAPKIN DERMATITIS)

Clinical features

Nappy rash is an inflammatory skin condition localised to the nappy area.It is usually red and can cause discomfort in the infant or toddler affected.It is caused by contact with urine and faeces which are irritatingsubstances, and occurs on areas of the skin which are in contact with thenappy. The deep skin folds in the groin may therefore not be affected.

Other types of eczema or dermatitis such as atopic dermatitis andseborrhoeic dermatitis, can occur in the nappy area and may be associatedwith an increased tendency to nappy rash.

Prevalence of nappy rash in infants

Pre

vale

nce

(%)

Age (months)

40

35

30

25

20

15

10

5

0

<3 3–5 6–8 9–12

OverallMaleFemale

Age

(mon

ths)

Age

(mon

ths)

—— Nappy Rash —— 11

Frequency and severity

The data show that napkin dermatitis occurs frequently in infantswho are wearing nappies. There tends to be an increased frequencyafter the age of five months. Mothers often attribute this to teethingwhen they describe the urine as smelling more concentrated.

Very severe nappy rash is uncommon, with the majority being eitherminimal to mild requiring only conservative treatment. Nevertheless,at least 20% are classified as moderate which would require medicalattention.

Prevalence of nappy rash in infants


Overall 182 25.8 (19.4-32.2)

Male 96 25.0 (16.2-33.8)

Female 86 26.7 (17.2-36.3)

< 3 46 19.6 (7.7-31.5)

3 - 5 60 20.0 (9.6-30.4)

6 - 8 38 34.2 (18.4-50.0)

9 - 11 38 34.2 (18.4-50.0)

Severity of nappy rash in infants

No. with Minimal Mild Moderate Severenappy rash % % % %

Overall 47 23.4 55.3 21.3 0.0

Male 24 20.8 58.3 20.8 0.0

Female 23 26.1 52.2 21.7 0.0

< 3 9 33.3 33.3 33.3 0.0

3 - 5 12 16.7 58.3 25.0 0.0

6 - 8 13 30.8 61.5 7.7 0.0

9 - 11 13 15.4 61.5 23.1 0.0

Age

(ye

ars)

Age

(ye

ars)


ATOPIC DERMATITIS (ECZEMA)Clinical features

Atopic dermatitis is an inflammatory skin condition which manifests as a red, scaly rash thatis normally very itchy. It tends to be an inherited condition which runs in families alongwith asthma and hayfever.

In general, it occurs first on the face in infants and then on the front of the elbows andbehind the knees (the flexures) with increasing age. It can occur on any part of the skin atsome stage, depending on age and exposure to environmental irritants. For example, inmothers with young babies, or hairdressers, it may occur on the hands.

Prevalence of atopic dermatitis in preschool children


Overall 1116 30.8 (28.0-33.5)Male 567 31.3 (27.5-35.1)Female 549 30.2 (26.3-34.1)< 1 182 27.4 (20.7-34.0)1 176 40.6 (33.4-47.9)2 184 28.6 (22.1-35.0)3 224 34.4 (27.6-41.3)4 184 31.2 (24.4-37.7)5 166 22.9 (16.9-28.9)

Severity of atopic dermatitis in preschool children

No. with Minimal Mild Moderate Severeatopic dermatitis % % % %

Overall 346 4.9 58.8 34.5 1.7Male 178 5.6 57.0 36.3 1.1Female 168 4.9 60.4 32.3 2.4< 1 50 2.1 45.8 47.9 4.21 71 4.1 60.3 35.6 0.02 52 10.9 61.8 25.5 1.83 77 6.1 62.1 28.8 3.04 58 5.1 57.6 35.6 1.75 38 0.0 63.6 36.4 0.0

Prevalence of atopic dermatitis in preschool children

Pre

vale

nce

(%)

Age

60

50

40

30

20

10

0

OverallMaleFemale

months years<3 4–6 7–9 10–12 2 3 4 5

Age

(ye

ars)

Age

(ye

ars)

—— Atopic Dermatitis —— 13

Prevalence of atopic dermatitis in school children


Overall 2491 16.3 (14.1-18.5)Male 1174 14.8 (11.8-17.8)Female 1317 17.7 (15.0-20.4)4-6 385 18.7 (13.0-24.3)7-9 665 18.7 (15.0-22.5)

10-12 636 15.6 (12.1-19.0)

13-15 539 15.4 (12.1-18.7)

16-18 266 11.6 (8.5-14.6)

Severity of atopic dermatitis in school children

No. with Minimal Mild Moderate Severeatopic dermatitis % % % %

Overall 414 32.1 54.1 12.6 1.2

Male 180 28.9 55.6 13.9 1.7

Female 234 34.6 53.0 11.5 0.9

4-6 70 38.6 50.0 10.0 1.4

7-9 129 31.8 51.2 16.3 0.8

10-12 99 33.3 52.5 12.1 2.0

13-15 84 29.8 59.5 9.5 1.2

16-18 32 21.9 65.6 12.5 0.0

Prevalence of atopic dermatitis in school children

Pre

vale

nce

(%)

Age (years)

25

20

15

10

5

0

4–6 7–9 10–12 13–15 16–18

OverallMaleFemale



These data show that the condition commences at around two tothree months of age and increases in frequency after that. Theprevalence peaks at about 12 months of age and then slowlydecreases. It is uncommon after the fifth decade.

The severity tends to vary with age. Although the proportion ofthose affected with disease classified as severe is around 2% in allages, infants and children have a higher proportion with moderatedisease than older people. The proportion with mild disease tendsto increase with increasing age and decreasing prevalence.

The morbidity index (DLQI) completed by adults indicates thatpeople with atopic dermatitis can have many aspects of their work,home and social life affected. There is not always a clearcorrelation with severity. For example, those with disease classifiedas mild may have relatively high DLQI scores on occasion.

Prevalence of atopic dermatitis in adults


Overall 1,457 6.9 (5.6-8.3)Male 670 5.7 (4.0-7.4)Female 787 8.1 (6.2-10.1)

Age (years)20-29 156 15.6 (10.7-20.4)30-39 211 10.4 (6.6-14.2)40-49 272 6.8 (3.8-9.7)50-59 267 5.1 (2.2-7.9)60-69 268 1.9 (0.8-4.6)70+ 283 2.6 (1.2-5.5)

Severity of atopic dermatitis in adults

No. with Mild Moderate Severeatopic dermatitis % % %

Overall 93 82.8 14.6 2.6Male 37 79.0 18.6 2.5Female 56 85.3 11.9 2.7

Age (years)20-29 26 70.3 24.8 4.930-39 23 92.4 7.6 0.040-49 19 95.9 4.1 0.050-59 13 76.5 23.5 0.060-69 5 79.3 20.7 0.070+ 7 85.8 0.0 14.2

OverallMaleFemale

Prevalence of atopic dermatitis in adultsPre

vale

nce

(%)

Age (years)

25

20

15

10

5

020–29 30-–39 40–49 50–49 60–69 70+

months years

Prevalence of atopic dermatitis over all ages

Pre

vale

nce

(%)

Age (

60

50

40

30

20

10

0

<3 6 9 12 2 3 4 5 11 17 25 35 45 55 65 75+

—— Atopic Dermatitis —— 15

The Dermatology Life Quality Index (DLQI) in adults with atopic dermatitis



1. how itchy, sore, painful or stinging has your skin been? 3.8 10.3 62.8 23.1

2. how embarrassed or self-conscious have you been because of your skin? 1.3 1.3 28.2 69.2

3. how much has your skin interfered with you going shopping or looking after your home or garden? 0.0 2.6 5.1 92.3

4. how much has your skin influenced the clothes you wear? 0.0 3.8 19.2 76.9

5. how much has your skin affected any social or leisure activities? 0.0 0.0 6.4 93.6

6. how much has your skin made it difficult for you to do any sport? 0.0 0.0 1.3 98.7

7. how much has your skin been a problem at work or studying? 0.0 2.6 14.1 83.3

8. how much has your skin created problems with your partner or any of your close friends or relatives? 0.0 0.0 1.3 98.7

9. how much has your skin caused any sexual difficulties? 0.0 0.0 2.6 97.4

10. how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time? 0.0 1.3 14.1 84.6

OverallMaleFemale

Age

(ye

ars)

Age

(ye

ars)


SEBORRHOEIC DERMATITISClinical features

Seborrhoeic dermatitis is an inflammatory skin condition which usually occurs in hair bearingareas, such as the scalp, chest or beard, and in the flexures, particularly under the arms,submammary region and in the groin or perianal region. It manifests as a red, scaly rash,which may appear shiny or greasy looking. In newborns, it is a cause of cradle cap and canoccur in the face, nappy area, and other flexures.

The cause of the condition is unknown, although it can be precipitated by cold, dry weather,contact with irritating substances such as soap, scratching and periods of worry and anxiety.



Severity of seborrhoeic dermatitis in preschool children

No. with seborr- Minimal Mild Moderate Severehoeic dermatitis % % % %

Overall 114 3.4 69.2 26.6 0.8Male 62 4.7 63.8 29.9 1.6Female 52 1.8 75.3 22.8 0.0< 1 81 3.8 60.3 34.6 1.31 13 7.7 84.6 7.7 0.02 14 0.0 85.7 14.3 0.03 2 0.0 100.0 0.0 0.04 1 0.0 100.0 0.0 0.0

5 3 0.0 100.0 0.0 0.0

Prevalence of seborrhoeic dermatitis in preschool children

Prevalence of seborrhoeic dermatitis in preschool children

Pre

vale

nce

(%)

Age (years)

50

45

40

35

30

25

20

15

10

5

0<1 1 2 3 4 5

OverallMaleFemale

Age

(ye

ars)

Age

(ye

ars)

—— Seborrhoeic Dermatitis —— 17

Prevalence of seborrhoeic dermatitis in adults



Severity of seborrhoeic dermatitis in adults

No. with seborr- Mild Moderate Severehoeic dermatitis % % %

Overall 136 75.3 23.6 1.1Male 79 74.4 23.3 2.3Female 57 76.4 23.6 0.020-29 16 79.2 20.8 0.030-39 21 84.0 16.0 0.040-49 22 52.2 47.8 0.050-59 31 74.1 22.2 3.760-69 22 70.6 23.5 5.9

70+ 24 88.0 12.0 0.0

Frequency and severity

The data show that seborrhoeicdermatitis commences soonafter birth, peaking early in thefirst year and reducing inprevalence after that.

There were insufficientnumbers with seborrhoeicdermatitis in the School Surveyto present data in this Atlaswith any confidence. Howeverin adults, there is a relativelysteady prevalence of around10% at all ages.

Very few people have severeseborrhoeic dermatitis with thevast majority being either mildor moderate. Nevertheless,this condition can be itchy,particularly when it occurs inthe scalp or in the perianalregion and can causeconsiderable discomfort.

Prevalence of seborrhoeic dermatitis in adults

Pre

vale

nce

(%)

Age (years)

18

16

14

12

10

8

6

4

2

020–29 30–39 40–49 50–59 60–69 70+

OverallMaleFemale


PSORIASISClinical features

Psoriasis is inflammatory skin disease characterised by a red, scaly rash, whichcan be itchy. A typical lesion is a well-defined raised plaque with a silvery scale.

It occurs classically on the elbows, knees and in the scalp, but can occur on anypart of the body on occasion, including the flexures. It can cause the nails tobecome pitted, discoloured and fragile.

While the cause of psoriasis is essentially unknown, it appears to be morecommon in some families. It has also been associated with various factors inthose people who are predisposed to psoriasis, such as trauma to the skin,streptococcal upper respiratory infections, stress, some medications, heavyalcohol intake and smoking.

Age

(ye

ars)

Prevalence of psoriasis in adults



Age

(ye

ars)

Severity of psoriasis in adults

No. with Mild Moderate Severepsoriasis % % %

Overall 99 81.1 16.1 2.8Male 65 77.6 18.1 4.3Female 34 87.5 12.5 0.020-29 12 75.1 16.6 8.330-39 12 66.6 33.4 0.040-49 21 94.2 0.0 5.850-59 19 77.3 22.7 0.060-69 21 80.8 19.2 0.070+ 14 86.5 13.5 0.0

Prevalence of psoriasis in adults

Pre

vale

nce

(%)

Age (years)

12

10

8

6

4

2

0

OverallMaleFemale

20–29 30–39 40–49 50–59 60–69 70+

19—— Psoriasis ——

The Dermatology Life Quality Index (DLQI) by adults with psoriasis



1 how itchy, sore, painful or stinging has your skin been? 2.2 6.7 46.7 44.4

2 how embarrassed or self-conscious have you been because of your skin? 1.1 5.6 20.0 73.3

3 how much has your skin interfered with you going shopping or looking after yourhome or garden? 0.0 3.3 5.6 91.1

4 how much has your skin influenced the clothes you wear? 0.0 0.0 13.3 86.7

5 how much has your skin affected any social or leisure activities? 0.0 2.2 3.3 94.4

6 how much has your skin made it difficult for you to do any sport? 0.0 1.1 2.2 96.7

7 how much has your skin been a problem at work or studying? 0.0 2.2 6.7 91.1

8 how much has your skin created problems with your partner or any of your close friends or relatives? 0.0 0.0 6.7 93.3

9 how much has your skin caused any sexual difficulties? 1.1 1.1 3.3 94.4

10 how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time? 1.1 3.3 17.8 77.8


The data show that psoriasis is predominantly an adult disease. Thenumbers and classification in the childhood surveys were insufficient togive figures with confidence. Nevertheless, a frequency of almost 7% inadults is high.

The majority of disease is mild. Psoriasis can be a difficult condition totreat, particularly when it is moderate to severe. Although the proportionsin these categories are less than 20% in adults, they still represent asubstantial number of people in the community requiring treatment.

The DLQI reveals that more than 50% of people said their skin had beenitchy in the last week and more than 25% had been embarrassed by it.Over 20% had some problem created by the treatment making their homemessy or by it taking up time.

Age

(ye

ars)

Age

(ye

ars)


WARTSClinical features

Warts are a viral infection of the skin caused by the Human Papilloma Virus (HPV).There are several different types, two of which will be reported in this chapter:common warts (verruca vulgaris) and plantar warts (verruca plantaris).

Common warts are flesh-coloured lesions occurring most frequently on the hands, fingers and knees.They can also grow at a site where an injury has occurred. They are not usually painful, althoughthey may cause pain if they develop at a site where pressure occurs, e.g. knuckle or the knee.

Plantar warts (also called papillomas) are flesh-coloured and are found on the sole of the foot. They are flat as the person’s body weight forces them to grow inwards. This can be very painful.

Prevalence of common warts in school children



Number of common warts in school children

No.with Number of Wartscommon warts 1–2 3–5 6 or more

% % %Overall 383 72.6 19.8 7.6

Male 190 70.5 22.6 6.8

Female 193 74.6 17.1 8.3

4-6 29 69.0 20.7 10.3

7-9 96 78.1 16.7 5.2

10-12 114 67.5 21.1 11.4

13-15 99 69.7 23.2 7.1

16-18 45 82.2 15.6 2.2

Prevalence of common warts in school children

Pre

vale

nce

(%)

Age (years)

25

20

15

10

5

0

OverallMaleFemale

4–6 7–9 10–12 13–15 16–18

—— Warts —— 21

Age

(ye

ars)

Age

(ye

ars)

Prevalence of plantar warts in school children



Number of plantar warts in school children

No. with Number of Wartsplantar warts 1–2 3–5 6 or more Mosaic

% % % %Overall 155 80.6 11.6 3.2 4.5Male 69 79.7 13.0 2.9 4.3Female 86 81.4 10.5 3.5 4.74-6 19 94.7 0.0 0.0 5.37-9 46 78.3 15.2 4.3 2.210-12 40 85.0 12.5 2.5 0.013-15 33 81.8 6.1 6.1 6.116-18 17 58.8 23.5 0.0 17.6

Prevalence of plantar warts in school children

Pre

vale

nce

(%)

Age (years)

10

9

8

7

6

5

4

3

2

1

0

OverallMaleFemale

4–6 7–9 10–12 13–15 16–18


Frequency and number of warts

The data show that warts, although starting in young children, become most frequentin adolescence and then they decrease in frequency with increasing age. This is thecase for both common and plantar warts. It is consistent with these infections beingspread amongst people with frequent contact, i.e., at school.

The data show that the lesions are not only frequent, but also they are multiple inboth common and plantar warts. At least 20% of those affected with common wartshad more than two. Plantar warts are often painful and 20% of those with them inchildhood and 10% of those with them in adulthood had more than two.

Age

(ye

ars)

Age

(ye

ars)

Prevalence of common warts in adults



Number of common warts in adults

No. with Number of Wartscommon warts 1 - 2 3 - 5 6 or more

% % %Overall 81 80.0 15.0 5.0Male 40 78.0 17.1 4.9Female 41 82.1 12.8 5.120-29 24 73.1 15.4 11.530-39 18 94.7 5.3 0.040-49 10 90.9 9.1 0.050-59 13 75.0 25.0 0.060-69 8 71.4 28.6 0.070+ 8 57.1 28.6 14.3

Prevalence of common warts in adultsPre

vale

nce

(%)

Age (years)

14

12

10

8

6

4

2

0

OverallMaleFemale

20–29 30–39 40–49 50–59 60–69 70+

—— Warts —— 23

Age

(yea

rs)

Number of plantar warts in adults

No. with Number of Wartsplantar warts 1–2 3–5 6 or more

% % %Overall 17 90.0 5.0 5.0Male 8 90.0 10.0 0.0Female 9 88.9 0.0 11.120-29 6 87.5 12.5 0.030-39 3 100.0 0.0 0.040-49 5 80.0 0.0 20.050-59 3 100.0 0.0 0.0

Age

(ye

ars)

Prevalence of plantar warts in adults


Overall 1,457 1.3 (0.8-2.1)Male 670 1.4 (0.7-2.8)Female 787 1.2 (0.6-2.3)20-29 156 3.6 (1.6-8.0)30-39 211 1.6 (0.5-5.0)40-49 272 1.7 (0.7-4.1)50-59 267 1.2 (0.4-3.7)60-69 268 0.0 (0.0)70+ 283 0.0 (0.0)

Prevalence of plantar warts in adults

Pre

vale

nce

(%)

Age (years)

4.5

4

3.5

3

2.5

2

1.5

1

0.5

0

OverallMaleFemale

20–29 30–39 40–49 50–59 60–69 70+

Prevalence of warts in school children and adults

Pre

vale

nce

(%)

Age (years)

20

18

16

14

12

10

8

6

4

2

0

CommonPlantar

5 11 17 25 35 45 55 65 75+

Age

(ye

ars)

Age

(ye

ars)


Age

(ye

ars)

Prevalence of tinea pedis in school children



Prevalence of tinea pedis in adults

No. examined Prevalence % (95% Cl)


Dermatophytes causing tinea pedis inschool children

Type of dermatophyte % (no. cases)

Trichophyton mentagrophytes 61.2 (82)

Trichophyton rubrum 33.6 (45)

Epidermophyton floccosum 1.5 (2)

Other dermatophyte* 3.7 (5)

* Includes Trichophyton terrestre,Trichophytontonsurans, Microsporum gypseum

Dermatophytes causing tinea pedis in adults


Trichophyton mentagrophytes var interdigitale 53.1 (69)

Trichophyton mentagrophytes var mentagrophytes 19.2 (25)



Prevalence of tinea unguium in adults



Dermatophytes causing tinea unguium in adults


Trichophyton mentagrophytes var interdigitale 57.0 (45)


Trichophyton mentagrophytes var mentagrophytes 13.9 (11)


TINEA PEDIS AND TINEA UNGUIUMClinical features

Tinea (also called ringworm) is an infection of the skin, nails or hair caused by dermatophytefungi. Dermatophytes are grouped into three classes: Trichophyton, Epidermophyton andMicrosporum. Each of these classes of fungi can infect the skin, but Microsporum tends notto involve the nails and Epidermophyton seldom invades hair.

Tinea is also classified clinically based on what area is infected. Two types of tinea will bereported in this chapter: tinea pedis (tinea of the foot) and tinea unguium (tinea of the nail).

Tinea pedis manifests as a red, scaly, rash on the foot which can be itchy on occasion. Itcommonly occurs between the toes, particularly between the 4th and 5th toes, but can occuranywhere on the foot.

Tinea unguium (also called dermatophyte onychomycosis) manifests as discolouration of thenail plate and there may be a build-up of infectious material and cells under the nail plate.The nail plate may occasionally partially lift away from the nail bed. This condition is usuallyaccompanied by tinea pedis.

—— Tinea Pedis and Tinea Unguium —— 25

Frequency

Although tinea pedis is said tobe rare amongst children, thesedata show that it occurs in fourto six year olds with increasingfrequency during adolescence. It slowly increases in frequencyin adulthood.

Tinea affecting the nail isuncommon in children but thereis an increasing frequency withincreasing age. Both tinea pedisand tinea unguium tend to bemore common in men than inwomen.

Prevalence of tinea pedis in school children and adults

Pre

vale

nce

(%)

Age (years)

20

18

16

14

12

10

8

6

4

2

0

OverallMaleFemale

5 11 17 25 35 45 55 65 75+

Prevalence of tinea pedis in school children

Pre

vale

nce

(%)

Age (years)

14

12

10

8

6

4

2

0

OverallMaleFemale

4–6 7–9 10–12 13–15 16–18

Prevalence of tinea pedis in adults

Pre

vale

nce

(%)

Age (years)

20181614121086420

OverallMaleFemale

20–29 30–39 40–49 59–59 60–69 70+

Prevalence of tinea unguium in adults

Pre

vale

nce

(%)

Age (years)

20181614121086420

OverallMaleFemale

20–29 30–39 40–49 59–59 60–69 70+


Age

(ye

ars)

BIRTHMARKSClinical features

There are several different types of birthmarks, which, as the name suggests, are oftenpresent at birth or in early infancy. They are areas of abnormal skin cell development, inwhich a particular type of cell may have a higher proportion than other types. Four types of

birthmark will be reported in this chapter: Salmon patch, haemangiomas,congenital melanocytic naevi and Mongolian spot.

A salmon patch is a vascular lesion due to large numbers of small blood vesselswhich are very close to the surface of the skin. They are harmless and arenormally found on the neck, forehead and eyelids.

Haemangiomas (also called strawberry naevi) are red vascular lesions. They aremade up of large numbers of capillaries. They are commonly found on the headand neck.

Congenital melanocytic naevi (moles) are due to a problem with the movement ofmelanocytes during an infant’s development. This leads to an accumulation of alarge number of cells and hence the dark appearance of the mole.

Mongolian spots are grey or brown areas found on the buttocks or the sacrum.They are due to increased melanin production, particularly among children born toAsian parents.

Prevalence of salmon patch in preschool children



Prevalence of salmon patch in preschool children

Salmon Patch

Pre

vale

nce

(%)

Age (years)

70

60

50

40

30

20

10

0

OverallMaleFemale

<1 1 2 3 4 5

—— Birthmarks —— 27

Age

(ye

ars)

Age

(ye

ars)

Prevalence of haemangioma in preschool children


Overall 1116 7.2 (5.7-8.7)Male 567 5.1 (3.3-6.9)Female 549 9.3 (6.9-11.8)< 1 182 10.9 (6.4-15.8)1 176 7.8 (3.9-11.7)2 184 8.4 (4.5-12.5)3< 224 5.3 (2.1-8.5)4 184 5.3 (1.9-8.2)5 166 5.7 (2.4-9.0)



Prevalence of congenital melanocytic naevus in preschool children

Haemangioma

Congenital Melanocytic Naevus

Prevalence of haemangioma in preschool children

Pre

vale

nce

(%)

Age (years)

16

14

12

10

8

6

4

2

0

OverallMaleFemale

<1 1 2 3 4 5

Prevalence of congenital melanocytic naevus in preschool children

Pre

vale

nce

(%)

Age (years)

16

14

12

10

8

6

4

2

0

OverallMaleFemale

<1 1 2 3 4 5


Age

(ye

ars)

Prevalence of Mongolian spot in preschool children



Prevalence of Mongolian spot in preschool children by mother’s country of birth

Australia andNew Zealand

Asia

United Kingdom and Ireland

Europe

Middle Eastand Africa

OtherMot

her’s

cou

ntry

of bi

rth

“Europe” includes all European countries apart from United Kingdom and Ireland

“Other” includes United States, Central and South America, and the Pacific Islands

Frequency

The data show that birthmarks are very common in young children.Mongolian spots are extremely common in children of parents who haveincreased pigmentation in their skin, occurring in almost 80% of children ofAsian parents. They are less common in children of white Anglo-Saxonparents. Salmon patches and other vascular abnormalities (haemangiomas)tend to occur within the first year of life and slowly disappear with increasingage. Congenital melocytic naevi tend to occur within the first year of life andthen remain stable and present for many years after that.

Prevalence of Mongolian spot in preschool children

Pre

vale

nce

(%)

Prevalence (%)

Age (years)

25

20

15

10

5

0

OverallMaleFemale

<1 1 2 3 4 5

0 10 20 30 40 50 60 70 80

Mongolian Spot

—— Campbell de Morgan Spots —— 29

CAMPBELL DE MORGAN SPOTSClinical features

Campbell de Morgan spots (also called cherry angiomas) are small, cherry red, smoothspots which are found on the trunk of middle aged or elderly people. They do notbleed and they have no symptoms. The cause is unknown. While they appear to bevery common in the community, the prevalence has not been previously reported.

Age

(ye

ars)

Prevalence of Campbell de Morgan spots in adults



Frequency

These tiny red vascular spots start to occur in young adulthood and becomeincreasingly common with age. Although not reported in detail here, theaverage number of these lesions also increases with age from 1-2 lesions inearly adulthood to 50 or more Campbell de Morgan spots in people aged 60years and over. The significance of these lesions is unknown.

Prevalence of Cambell de Morgan spots in adults

Pre

vale

nce

(%)

Age (years)

90

80

70

60

50

40

30

20

10

0

OverallMaleFemale

20–29 30–39 40–49 50–59 60–69 70+


SEBORRHOEIC KERATOSESClinical features

Seborrhoeic keratoses (also called seborrhoeic warts) are very commonbenign growths. They are usually round, dark brown or almost black wartygrowths which occur on the face and trunk. On the back of the hands andforearms, they are often dark and flat, described as “liver spots”. On thelower legs they may be pale scaling spots in large numbers described as“stucco keratoses”. They have been described as “senile warts” in the pastbecause of a belief that they were a condition of older people.

Age

(ye

ars)

Prevalence of seborrhoeic keratoses in adults



Prevalence of seborrhoeic keratoses in adults

Pre

vale

nce

(%)

Age (years)

100

90

80

70

60

50

40

30

20

10

0

OverallMaleFemale

20–29 30–39 40–49 50–59 60–69 70+

—— Seborrhoeic Keratoses —— 31

Frequency

The data show that these conditions start to occur at arelatively young age so that by young adulthood 10% ofpeople are affected. They occur with increasing frequencywith increasing age so that a large proportion of thepopulation have at least one by the age of 60.

Although the numbers of seborrhoeic keratoses per person arenot reported here, the number of people with them not onlyincreases with age, but also the number that individuals haveincreases at the same time. By the age of 60 it is common tohave at least 10 seborrhoeic keratoses.

There is a tendency amongst the medical professionto believe that they are the major source of advicefor medical problems in the community. This is notalways the case, particularly for diseases affectingthe skin.

Because the skin conditions occur on the surface ofthe body where they are easily seen, they are oftennoticed first when they might be considered to berelatively mild. Under such circumstances, a personwith a mild condition may decide that they don’twant to bother a doctor about something that mightbe considered trivial. Likewise they may think it istoo expensive to seek professional advice for a mildcondition. Consequently, they may show it to theirfamily or friends initially.

They may attend a pharmacist where manyefficacious products for mild skin conditions areavailable over the counter without prescription.Other persons they may turn to include naturopaths,osteopaths, chiropractors, beauticians, hairdressers,or a variety of other people who may be seen as asource of advice about minor skin conditions in thecommunity. Thus surveys of medical practitionerson the frequency with which people seek advice forskin problems may grossly underestimate the trueextent of the problem in the community.

In the Maryborough telephone survey of adults inCentral Victoria, less than 50% of people who hadsought advice for a condition they had in the lasttwo weeks had gone to a medical practitioner. Over 50% had sought it from a variety of other

sources with the pharmacist being high on the list.Almost 20% said that they had diagnosed thecondition themselves and prescribed the treatmentthat was necessary. Of course, this may have beenon the basis of past experience or from somethingthat they had seen or read in the media.

The first table (page 31) is a breakdown of whereadults said they received their advice according tothe diagnosis that they reported. It can be seen


Where Do People Seek Advice For TreatmentOf Common Skin Diseases?

Source of advice for self-reported skin conditions in adults

Medical Pharmacist Family/ Self- Otherpractitioner (%) (%) friends (%) prescribed(%) (%)

All conditions 49 19 6 19 7Acne/pimples 8 17 25 8 42Cold sores 11 35 14 34 6Dermatitis/eczema 71 9 - 16 4Psoriasis 92 - - 8 -Skin cancer 92 - - - 8Thrush 84 - - 8 8Tinea 30 35 2 23 10Urticaria/hives 100 - - - -Warts 60 10 10 20 -

No of conditions treated = 242

Source of advice for treatment in adults

Pre

vale

nce

(%)

60

50

40

30

20

10

0

OtherFamily/friendPharmacistGeneral practitionerDermatologist

Eczema/ Acne Tinea WartsDermatitis

Skin Condition

that the more active or difficult the condition, themore likely they were to seek advice from a medicalpractitioner. This is particularly the case in dermatitis,psoriasis and, of course, skin cancer. Urticaria canbe an extremely itchy and distressing condition andhence the use of medical practitioners frequently.

Finally, in this series, there was a relatively highproportion of people with warts who attended amedical practitioner. In this case, the use ofphysical therapy such as liquid nitrogen or burningor cutting off a wart may be seen as a skill in thedomain of a medical practitioner.

None of the diagnoses of the conditions reported in the telephone survey are able to be verified. On the other hand, in the three community-basedsurveys where dermatologists verified the diagnosis,it is possible to link the specific conditions withwhere advice was received and whether or not itwas of value.

In the conditions common in preschool children, itcan be seen that a very large proportion of childrenwith eczema (dermatitis) receive their advice from amedical practitioner. On the other hand, a nurse (amaternal and child health nurse) is the major source

of advice for cradle cap. In Victoria, there is anoutstanding community-based Maternal and ChildHealth Service. It is free and has been used by allnew mothers and babies in the State for decades.These nurses are very well trained to give adviceabout minor skin conditions such as cradle cap.

For nappy rash, there is a spread of advice betweenthe medical practitioners, pharmacists, family,friends and with nurses giving advice in a relativelysmall proportion.

Looking at the source of advice for school childrenwhose diagnosis was confirmed, the same use ofmedical practitioners as the preschool children isseen for eczema (dermatitis). Medical practitionersalso give a substantial proportion of advice for thetreatment of warts, including the physical treatmentssuch as the use of liquid nitrogen. Pharmacists alsoprovide advice for treatment of warts and there aremany efficacious products available over the counterat pharmacists without the need for a medicalprescription. Pharmacists are the most commonsource of advice for tinea of the feet in childrenwith medical practitioners being used slightly lessfrequently.

—— Where Do People Seek Advice For Treatment Of Common Skin Diseases? —— 33

Source of advice for treatment in preschool children

Pre

vale

nce

(%)

60

50

40

30

20

10

0

General practitionerDermatologistOther specialist

Pharmacist

Nurse

Family/friend

Other

Eczema/ Nappy Rash Seborrhoeic dermatitis/Dermatitis cradle cap

Skin Condition

Source of advice for treatment in school children

Pre

vale

nce

(%)

80

70

60

50

40

30

20

10

0

OtherFamily/friendPharmacistGeneral practitionerDermatologist

Eczema/ Acne Tinea WartsDermatitis

Skin Condition

On the other hand, in the treatment of acne, advicefrom family and friends is sought most frequentlywith others, including the beauticians andnaturopaths being the second most common sourceof advice. Pharmacists and medical practitioners arerelatively low down in the scale.

In adults, once again, medical practitioners are themajor source of advice for treatment of eczema(dermatitis). Like school children, adults frequentlyseek advice for acne from family or friends, withpharmacists and medical practitioners being a farless common group to whom adults would turn withthis condition.

In summary, these data show that a large proportionof people with minor skin conditions do not seekadvice from a medical practitioner but seek it outfrom a variety of other people who may be seen asa source of information. The likelihood of doingthat depends very much on the nature and extent ofthe condition and perceived severity by theindividual affected.

PRODUCTS USED BY SCHOOL CHILDREN

Efficacy of the products used by school children for acne

Source of advice Efficacious (%) Non efficacious (%)

Medical practitioner 81.5 18.5

Pharmacist 51.5 48.5

Family/friend 25.7 74.3

Other 31.3 68.8

(Please note: ‘Other’ includes alternative practitioner and

beautician)

Efficacy of the products used by school children for warts





Other 25.0 75.0

PRODUCTS USED BY ADULTS

Efficacy of the products used by adults for acne


Dermatologist 100.0 0.0

General practitioner 71.4 28.6



Other 25.0 75.0

Efficacy of the products used by adults for warts





Are People Receiving the Correct Advice?Part of the work undertaken in the studies reported inthis Atlas was to obtain details of all the products thatpeople were using for their various skin conditionsand then classify them according to whether or notthey were likely to be effective (efficacious). Theresults reported show that there is considerablevariation in the value of the products being usedaccording to both the condition being treated and itsseverity, and who prescribed the product.

There is a relatively high proportion of efficaciousproducts being used by the infants with seborrhoeicdermatitis. This includes advice from family andfriends and other sources. Other sources in thisinstance includes the use of books and pamphletsthat the parents report they use to select a product.Examination of the value of the products used bypreschool children for both eczema and seborrhoeicdermatitis or cradle cap shows increasingly effectiveproducts being used with increasing severity of thedisease. This correlates well with the finding thatas the diseases become more severe, parents aremore likely to seek advice for their children frommedical practitioners who are qualified to give it.


In school children with acne and warts there is quitea lot of variation in the value of the products theyuse according to where they receive their advice. It is ironic that the data show that the mostfrequent source of advice used by school children isfamily or friends from whom, the data show, theyare least likely to be recommended something thatis effective. When examining the value of productsaccording to the severity of the acne in schoolchildren, it can be seen that almost 50% of theadolescents with moderate acne and a substantialproportion with severe acne are using products thatare of no therapeutic value at all. That is incontrast to the products used by school children foreczema in which the majority were classified aslikely to have some satisfactory effect.

In adults, the efficacy of products used for acne andwarts varies once again according to the source ofadvice. However it was fairly uniform that advicereceived from unqualified persons was likely to leadto a high chance of purchase and use of productswhich were of no value at all for the conditions forwhich they had been recommended.

—— Where Do People Seek Advice For Treatment Of Common Skin Diseases? —— 35

PRODUCTS USED BY PRESCHOOL CHILDREN

Efficacy of the products used by preschool childrenfor seborrhoeic dermatitis


General practitioner 91.7 8.3

Dermatologist 100.0 0.0



Nurse 80.4 19.6

Other 100.0 0.0

(Please note: ‘Other’ includes books and pamphlets)

Efficacy of products used by preschool childrenaccording to severity

Condition Efficacious (%) Non efficacious (%)

Eczema/dermatitis

Minimal 87.5 12.5

Mild 95.3 4.7

Moderate 94.4 5.6

Severe 100.0 0.0

Seborrhoeic dermatitis/cradle cap

Minimal 57.1 42.9

Mild 92.3 7.7

Moderate 76.3 23.7

Severe 100.0 0.0

Efficacy of products used by school childrenaccording to severity

Condition Efficacious (%) Non efficacious (%)

Eczema/dermatitis

Minimal 96.4 3.6

Mild 86.2 8.7

Moderate 83.3 7.6

Severe 88.9 11.1

Acne

Minimal 37.6 62.4

Mild 38.1 61.9

Moderate 51.9 48.1

Severe 85.7 14.3

Efficacy of the products used by school children for tinea





Other 0.0 100.0

SummaryIt can be seen that people with skin diseases in thecommunity are seeking advice from many quarters.The quality of advice that they receive is variableaccording to not only from whom they seek it, butalso according to what condition they have and howsevere it is.

Looking at the proportions of people with skindisease who are seeking advice from those who areunqualified to give it, a large proportion of thecommunity are receiving advice and using productsfor which there is no medical or scientific basis andwhich are unlikely to be of any value for thecondition.

Overall these data show that although in manyinstances people are receiving adequate care fromthose who are qualified to give it, there are stilllarge gaps. There are many people who havecommon skin problems turning for advice to othersin the community who may not be qualified to giveit and, on the basis of such advice, are usingproducts that either make no difference to the skincondition or potentially may make it worse.


Recommendations

The data reported in this Atlas show that skinconditions are common in the Australian community.Everyone will have now or will have had in the pastone or more of the conditions reported. Manypeople have several of them at the same time.When asked, almost 50% of the communitydepending on age, will have at least one skincondition for which they may be seeking treatmentright now.

The data also show that people in the communityare not always receiving advice that is likely to lead

to satisfactory treatment of their condition. This isof considerable concern as there is very satisfactorymanagement available for virtually all of theconditions reported It is distressing to learn thatso many people, including infants and children whoare dependent on others, are not receiving the helpthat they require.

It is clear from the data reported in this Atlas thatmore work needs to be done. On the basis of thesedata, we make the following recommendations:-

� Research should be undertaken on cohorts of peoplewith common skin diseases following them over time.This will determine the morbidity, the effect on quality oflife, the cost of having these diseases and will enablequantification of the effect on both the individual andthe community.

� Education programs need to be developed for allprofessionals or organisations to whom people in thecommunity turn when they are affected by a skindisease. These programs should include undergraduatemedical students, general practitioners, pharmacists, andallied health professionals who are in an appropriateposition to provide advice to people with skin diseases.

� Within the general practice training programs thereshould be specific units on dermatology. These shouldhighlight the frequency and nature of these commondiseases and the relatively simple approaches tomanagement that are available.

� There should be an increase in the number of grants fortraining dermatologists in Australia. Dermatologists haveresponsibility not only for providing care for therelatively small proportion of people in the communitywho require specialist attention, but also for providingfurther training and teaching for others in the communityto whom people with skin diseases turn.

� Government and other agents responsible for taking thelong-term view of maintaining the health of thecommunity should put more resources into research onthe frequency, cause, management and prevention ofcommon skin conditions affecting the community.

� Education programs for the general community need tobe developed giving information on the nature ofcommon skin diseases, the treatments that are available,and where they can turn for advice which is likely to beof value. They should include education programs inmaternal and child health centres, child care centres,kindergartens, schools, work places and other areas ofadult activity. Each of these should be designed anddelivered on the basis of research and developmentappropriate to the area and groups being targeted.

� Finally, there should be regular studies on the frequencyof common skin diseases in Australia that have beenreported in this Atlas. They should monitor not only thefrequency and severity of the disease over time, but alsomonitor whether there is an increase in the proportion ofpeople who receive care which is appropriate to theirneeds.

—— Recommendations —— 37


Acknowledgements

We would like to acknowledge all the help we received fromteachers, parents and students at schools throughout urban andrural Victoria; Directorate of School Education, Victoria; Youthand Family Services, Human Services Victoria; Catholic EducationOffice; Rotary, Maryborough District Health Services,Maryborough pharmacies, Maryborough general practitioners andthe population of Maryborough, Victoria; the parents, childrenand staff of the maternal and child health centres, preschoolchild care centres and kindergartens throughout urban and ruralVictoria; all the dermatologists and dermatology registrars whoparticipated as examiners in the surveys over the five yearperiod; the nurses; Dorevitch Tresize Pathology and St Vincent’sHospital Pathology Service.

It is not possible to name everyone. However there are anumber of special people who we would particularly like tothank, including Val Bennett, Jan Campbell, Jean Ebejer, RebeccaEdwards, Peter Foley, David Gill, Damien Jolley, Monique Kilkenny,Adrian Mar, Marlene Rennie, Malcolm Rosier, Voula Stathakis,Kay Stewart, Josie Yeatman, Richard Young, and Yeqin Zuo. Wethank Andrew Finlay for permission to use the DLQI and ADI, andDavid Weedon for use of his photomicrographs.

This Atlas would not have been possible without the support,encouragement, unfailing enthusiasm and devotion to thecommon aim of helping people in the community with skinproblems by all those people and organisations involved.

Funding for these studies came from:

• Australasian College of Dermatologists, Victorian Faculty,Chair of Dermatology Fund

• Skin and Cancer Foundation (Victoria)

• St Vincent’s Hospital (Melbourne) Ltd

• Jack Brockhoff Foundation

• Australian Dermatology Research and Education Foundation

• F. Bauer Foundation

• William Angliss Trust

common skin diseases - department of dermatology, st. vincent's

Documents