|Year : 2013 | Volume
| Issue : 3 | Page : 67-72
Prevalence of various skin disorders in school going children of Kashmir valley of North India: A cross-sectional study
Umar Yaseen, Iffat Hassan
Department of Dermatology, Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||26-Nov-2013|
House No: 35, Mominabad, Hyderpora, Srinagar 190 014, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: Reports from different parts of the world have revealed wide variation in the prevalence of various skin disorders. Variations exist with respect to age, sex, dwelling and socio-economic status. Prevalence studies of skin disorders in children and adolescents are meager.
Aim: The aim of the present study was to determine the prevalence of various skin disorders in school going children of Kashmir valley of North India.
Materials and Methods: This cross-sectional study was designed to find the prevalence of skin disorders in the age group of 6-19 years. Kashmir valley of North India was stratified into North, Central and South Kashmir and among them one district was selected. Educational institutions were stratified as per levels of education, i.e. primary, middle, secondary, higher secondary and college. Each strata was sub-grouped sex-wise. From each educational institution, 10% of students were selected through the systematic random sampling. A specially designed questionnaire was framed and information regarding any of dermatological ailments was noted. A total of 5000 students were examined and prevalence of all types of skin disorders was noted.
Results: Eczemas formed the largest group followed by acne vulgaris. In the eczema group, pityriasis alba was most frequent type followed by hand eczema, irritant and allergic contact dermatitis taken together. Individually, acne vulgaris was the most prevalent skin disorder in the study group.
Conclusion: The study found that skin disorders were more common in males than females, in urban than in rural dwellers, in students from government schools than private schools and in students belonging to the low socioeconomic group.
Keywords: Prevalence, school children, skin disorders
|How to cite this article:|
Yaseen U, Hassan I. Prevalence of various skin disorders in school going children of Kashmir valley of North India: A cross-sectional study. Indian J Paediatr Dermatol 2013;14:67-72
|How to cite this URL:|
Yaseen U, Hassan I. Prevalence of various skin disorders in school going children of Kashmir valley of North India: A cross-sectional study. Indian J Paediatr Dermatol [serial online] 2013 [cited 2019 Aug 21];14:67-72. Available from: http://www.ijpd.in/text.asp?2013/14/3/67/122166
| Introduction|| |
Prevalence refers to the proportion of the population affected by a particular disorder.  Because most of the skin disorders are non-lethal yet chronic, prevalence is an important tool for research purposes. In children and adolescents the skin disorders vary markedly from those in adults. Low socio-economic status, malnutrition, overcrowding and poor standards of hygiene are important factors accounting for the distribution of skin diseases in developing countries. Reports from different parts of the world have revealed wide variation in the prevalence of various skin disorders. Variations exist with respect to age, sex, dwelling and socio-economic status. Prevalence studies of skin disorders in children and adolescents are meager.
Previous studies in students have shown enormous variation in prevalence of skin disorders. Shakkoury and Abu-Wandy from Amman Jordan found prevalence of 19.23% in a study of 2788 children from eight randomly selected schools.  In a study from Mexico by Estrada-Castanon in 1990, the overall prevalence noted was 50%.  However, their study was not limited to children and adolescents. A recent study done by Grills et al. in mountainous region of India (Uttarakhand) revealed that dermatological conditions were prevalent (45.3%) with 33% being of infectious etiology.  In this study, atopic dermatitis (9.2%), scabies (4.4%), tinea corporis (4.1%) and pityriasis alba (3.6%) were common.
| Materials and Methods|| |
The study was a cross-sectional study conducted on 5000 school going children and adolescents in the age group of 6-19 years in Kashmir valley of Jammu and Kashmir State of North India. Kashmir division, with a current population of 5.6 million, comprises of 10 districts namely Srinagar, Budgam, Baramulla, Kupwara, Pulwama, Anantnag, Ganderbal, Kulgam, Shopian and Bandipora. For the purpose of study, Kashmir valley was stratified into North, Central and South Kashmir and among them one district was selected. This study was approved by the ethical committee of the institution. Proper permission was taken from Director of school education Kashmir to visit the various schools. Schools were randomly selected from each district. From each selected school, students were studied clinically by a trained dermatologist. This was a clinical study and no laboratory investigation was performed to corroborate the diagnosis. Those students who had no skin disorder were also noted. A questionnaire was framed, which included the variables such as age, sex, education standard and address (rural/urban). Data hence obtained was compiled and the prevalence of various skin disorders was noted.
Data obtained was transferred to Statistical Packages for Social Sciences (SPSS) software version 11.0 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered to be significant.
| Results|| |
A total of 5000 students in the age group of 6-19 years were selected and studied clinically to assess the prevalence of skin disorders in this age group. In our study, there were 3730 males and 1270 female students. A total number of 3987 students were rural dwellers and 1013 were from urban areas. We found an almost equal distribution of age, 9 years onward. Only 6% of the students were in the age group of 6-8 years. Nearly 29.8% were in the age group of 9-11 year, 24.4% in 12-14 year, 23.6% in 12-14 year and 23.6% in 15-17 year and16.2% in 18-19 years. Around 79.7% of the students were rural dwellers, 65.5% were from private schools and 74.6% were males. Regarding the parental occupation, 43.1% were from the business class, 33.9% were from employee class and rest 23% belonged to farmer/laborer class. Among the studied 5000 students, 3469 students were found to have a skin disorder and 1531 (30.62%) students had no skin disorder. Overall prevalence of all skin disorders was found to be 69.38%.
We observed prevalence of 19.2% [Table 1] for acne disorders, which include acne vulgaris, truncal acne and post-acne scarring. Acne vulgaris by far, was most common (17.2%). We observed that 63.5% of total students with acne vulgaris were in the age group of 15-17 years, reflecting the peak age for acne vulgaris is mid-adolescence. Acne vulgaris was found more commonly in males (69.6%) than in females (30.4%). Post-acne scarring was seen in 1.2% of the studied subjects. It was found more commonly in 15-17 year age group with P value = 0.00 meaning a statistically significant correlation. This correlates well with high prevalence of acne vulgaris in this particular age group. Truncal acne was found in 0.8% of the students. Only males were found to have truncal acne. It was not found in any of the female students.
Eczema was found more commonly among males (26.1%) [Table 1] with a P = 0.00 meaning statistically significant correlation. It was more prevalent in urban dwellers (41.6%) than in rural dwellers (18.8%) with a P value of 0.000 meaning a significant correlation. We found that in students who belong to < 10,000 income group most frequent diagnoses was eczema (24.2%). In the other income group, 10,000-20,000 and > 20,000 the prevalence of eczema was 21.7% and 25% respectively. Among the eczematous disorders pityriasis alba was most common (15.8%), followed by irritant, allergic and hand eczema (4.6%). Pityriasis alba predominated in 9-14 year age group (68.7%). Its prevalence decreased after 17 years. It was found more commonly in males (82.6%) living in urban areas. Atopic dermatitis was prevalent in 2.5% of the population studied. It appeared more commonly (44.1%) in 9-11 year age group. It was found to be more prevalent (55.1%) in middle class community. Its prevalence was noted more in students from government schools. Students from the rural areas were affected more often than urban dwellers and atopic dermatitis was more prevalent in the male students (68.5%). Hand eczema, irritant and allergic contact dermatitis occurred most often in the age group of 15-17 years (41.3%). Males (91.3%) were affected more often. These disorders were in lesser frequency in students from urban areas. Seborrheic dermatitis was prevalent in 0.4% of the studied subjects seborrhoeic dermatitis was found in 18-19 year age group. It was found in both males and females with equal frequency.
Infectious dermatoses were found in students of rural dwellers only; prevalence of 5.3% was noted [Table 2]. Verrucae vulgaris was most prevalent (2.0%) among the infectious dermatoses followed by tinea capitis (0.8%) and onychomycosis (0.6%), kerion, tinea faciei and tinea corporis were found in equal proportions, each 0.4%. Herpes simplex was found in 0.3%of the students studied. Furunculosis (0.2%) and varicella (0.2%) were less prevalent. Prevalence of herpes simplex was noted to be 0.34%. It was more common in students in the age group 6-12 years (52.9%) than in 13-19 years (47.1%) [Table 3]. It was more common in females (52.9%) than in males (47.1%). Scabies was found more commonly in children below the age of 12 years with prevalence of 0.7%. It was predominantly found in males (83.5%) from rural areas [Table 4]. Students belonging to lower economical classes were affected more commonly (41.7%). Nearly 33% students were in 12-14 year age group and the rest in 15-17 year group.
|Table 3: Correlation of skin disorders with age of studied subjects (P=0.00)|
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|Table 4: Correlation of skin disorders with the gender of studied subjects (P=0.00)|
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Prevalence of psoriasis was 0.8% in the studied age group, i.e., 6-19 years. We found two peaks of Psoriasis, first in the age group of 9-11 years and later in 18 and 19 years. Prevalence was more in students aged 18-19 year (74.4%). It was found more in males (74.4%) dwelling in rural areas. Polymorphic light eruptions occurred in all ages starting from 9 years of age. Students falling in the age group 9-11 years most often had polymorphous light eruption. It was found more in males (76.0%) from rural areas. Systemic lupus erythematosus was noted in 0.1% of students. All students belonged to age group of 15-17 years. 3 (75%) students were female and one was male.
In the pigmentary disorders [Table 5], melasma was found in 1.5% of the students. Vitiligo was seen in 1.2% of the subjects followed by post-inflammatory hyperpigmentation (1.1%). Vitiligo was found more (85.2%) in the age group of 13-19 years than 6-12 years (14.8%). Its prevalence was noted more in males (67.2%) as compared with females (32.8%).
|Table 5: Prevalence of pigmentary disorders and photosensitive dermatosis in the studied subjects|
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Among the hair disorders, androgenetic alopecia was most prevalent (1.4%) followed by telogen effluvium (1.2%) [Table 6]. Prevalence of canities was found to be (0.4%) Its frequency increased up to 14 years and again showed a peak in 18 and 19 years. All patients were females. Alopecia areata occurred in 0.2% of the population studied. Androgenetic alopecia was found only in 68 male students. Of this, 57.4% occurred in the age group of 15-17 years. Telogen effluvium occurred in both males and females. However, males (66.1%) were affected commonly than females. It occurred more often in students in the age group 18-19 years.
Lichen planus was noted in 0.8% of the students. Exactly 52.4% were in the age group of 12-14 years. Pterygium of nails was noted in 0.2% of the students and was seen only in 12-14 year age group. Urticaria occurred in 0.8% of the studied students [Table 7]. It was found in 9-11 year age group only. Palmoplantar keratoderma was seen in 0.4% of the selected patients. Keloids were seen in 0.4% of the students in age groups 9-11 years and 15-17 years [Table 3]. Perinosis was noted in 0.7% of the students. It was found in the age group of 9-11 years more commonly. Male students (64.71%) from the rural areas (100.0%) were affected more often [Table 4]. Perioral dermatitis was noted in 0.4% of the examined students.
| Discussion|| |
In order to study the prevalence of skin disorders in detail and to determine, which group of students is particularly affected by that particular disorder and also we divided the study group in sub groups according to age, gender, dwelling and parental occupation. In our study, the prevalence of skin disorders in school going children and adolescents was much higher than the previous studies. In the study from northern India by Dogra and Kumar  the age group was 6-14 years only, whereas in our study, the age group was 6-19 years. In the age group of 14-19 years, there is the excess of skin disorders in the form of acne.
In our study, eczema was the most common skin disorder in the 6-12 year age group. 808 (35.3%) out of 2288 students in 6-12 year age group were suffering from eczema. In the age group of 13-19 years, the prevalence of eczema was 13.3%. Overall, a total of 1170 students had eczema. Overall prevalence of all forms of eczema was 23.3%. This prevalence is higher than in the previous studies. In the study from northern India, the prevalence of eczemas was found only in 5.2% of the school children. This reflects that in Kashmir valley, the eczema is extremely common. This high prevalence was observed due to pityriasis alba being extremely common and may be linked to genetic factors. However, further causal studies need to be done. Eczema was more common in males (83.07%). A study conducted by Zamanian and Mahjub  in Hamedan, Iran showed eczematous disorders to be most common of all disorders.
Among the eczematous disorders pityriasis alba was the most common. Prevalence of pityriasis alba was noted to be 15.8%. Students in the age range of 9-14 years (64.7%) were most frequently affected. It was found more in males (82.6%) than in females (17.4%).
We observed that atopic dermatitis was prevalent in 2.5% of total examined students. This is in contrast to the data from the west where in McNally and Phillips noted a cross-sectional prevalence of 19.7%.  In England, the point prevalence in one study was 11.5%-14% in 3-11-years-old children. This therefore suggests that atopic dermatitis is more prevalent in western countries than in developing countries like India implicating thereby a strong environmental factor in causation of this disorder.
We observed the prevalence of seborrheic dermatitis as 0.4%. It was found only in the age group of 18-19 years reflecting that peak of seborrheic dermatitis occurs after puberty. It was found equally in both sexes.
We observed prevalence of 19.2% for acne disorders, which include acne vulgaris, truncal acne and post-acne scarring. Acne vulgaris, by far, was the most common (17.2%). We observed that 63.5% of total students with acne vulgaris were in the age group of 15-17 years. In this age group, a total of 1180 patients were examined and 547 students were found to have acne vulgaris. It means 46.3% of the students in the age group 15-17 year were found to have acne vulgaris, which is in contrast with the study by Stern in USA where they found the prevalence of 100% in 13-17 year age group.  Acne vulgaris was found more commonly in males (69.6%) than in females (30.4%).
We observed prevalence of 5.3% for infectious disorders. Verrucae vulgaris was most frequently found among infectious disorders. Its prevalence was noted to be 2%. We noted peak prevalence in 15-17 years (40%). We observed the prevalence of fungal infections to be 2.6%. Tinea faciei, tinea corporis, tinea capitis, kerion and onychomycosis were most frequent of the fungal infections. Herpes simplex was found in 0.3% of the students. We however, noted only facial infections and genital infections were absent. In our study, there were two peaks. Nearly 52.9% of total infected patients were in the age group of 6-8 years and another peak was at the age group of 12-14 years (47.1%). The prevalence rate of 5.3% for infectious dermatoses is in sharp contrast to the study by Dogra and Kumar who found infections in 11.4% of patients. The difference may be due to cold climate and low humidity. This also contrasts with the study conducted by Grover et al. over the patients attending a medical camp in rural Allahabad India, which revealed a high prevalence (59.1%) of infective disorders.
We noted that pigmentary disorders were prevalent in 7.3% of the studied students. Ephelides were most frequent of the pigmentary disorders (3.5%). Melasma was seen in 1.5%. The prevalence rate of vitiligo was 1.2% and 1.1% for post-inflammatory hyperpigmentation. Ephelides were noted to be most prevalent in the age group of 9-11 years (42.9%). 65.5% of students with ephelides were females and the rest were males. The high prevalence of ephelides in this study implicates a high ultraviolet content in sunlight in our valley.
Melasma was more prevalent in 12-14 year age group (38.9%). We also noted melasma in the age group of 6-8 years in 11 patients, which is a very interesting observation as melasma is very rare in this age group. 61.1% of total melasma patients were males and only 38.9% were females.
Vitiligo was found to be prevalent in 1.2% of the study group. 52.5% of vitiligo patients were in the age group of 18-19 years. Vitiligo has been classically found to be more common in females, which is in contrast to our observation. In our study, 67.2% of vitiligo patients were males and 32.8% were females.
Hair disorders, which we found in the study group, were Androgenetic alopecia, Telogen effluvium, Canities and alopecia areata [Table 6]. Androgenetic alopecia was the prevalent (1.4%). Its prevalence noted was 1.4%. We found that all these students were males. 57.4% were in the age group of 15-17 years. Interestingly, 11 students (16.2%) were in the age group of 9-11 years. The prevalence rates for Telogen effluvium, canities and alopecia areata were 1.2%, 0.4% and 0.2% respectively.
In our study group, prevalence of scabies was 2.3%. 62.6% were in the age group of 6-12 years. 83.5% were males and 16.5% females, which may be due to more person to person contact in case of males. 73.9%, were rural dwellers.
We noted a point prevalence of 0.78% for psoriasis, which is less than the prevalence of 1.5% and 3% from Europe and Scandinavia. , 74.4% of psoriatics were in the age group of 13-19 years, which matches with previous studies where a peak of onset of psoriasis was noted to be 16 years. Most of the psoriatics were males (74.4%) in contrast to the earlier studies where an equal prevalence in both sexes was noted. Male predominance has been seen in previous studies like the study done by Sardana et al.  where they had found a high male to female ratio of 1.07:1.
Four students were noted to have symptoms suggestive of systemic lupus erythematosus implying a prevalence rate of 0.1%. All these students were in the age group of 15-17 years. Three (75%) of these students were females and only one (25%) was male.
We hereby summarize that skin disorders are extremely common in Kashmir valley with eczemas forming the largest group followed by acne vulgaris. In the eczema group, pityriasis alba was most frequent followed by hand eczema, irritant and allergic contact dermatitis taken together. In our study, we found that skin disorders were more common:
- In males than females
- In urban dwellers than in rural dwellers
- In students from government schools in comparison with those from private schools
- In the students belonging to income group international normalized ratio (INR) 10000-20000 than those in INR < 10000 or INR > 20000 sub group.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]