|Year : 2015 | Volume
| Issue : 2 | Page : 64-71
Pediatric dermatoses in Benghazi, Libya
Safa Suleman Elfaituri
Department of Dermatology, Faculty of Medical, Benghazi University, Benghazi; Department of Dermatology, Jumhoria Hospital. Benghazi, Libya
|Date of Web Publication||9-Apr-2015|
Safa Suleman Elfaituri
Western Fwayhat Benghazi, P.O. Box 2602 Benghazi
Source of Support: None, Conflict of Interest: None
Introduction: Skin diseases in the pediatric population are common all over the world. They are important health problem affecting children in both developing and industrialized countries with variable prevalence and pattern.
Materials and Methods: Over 1-year, 954 pediatric patients attending Dermatology Department Outpatient Clinic in Jumhoria Hospital in Benghazi, Libya were studied to determine the spectrum and frequency of pediatric dermatoses in Libyan pediatric patients.
Results: Infections were the most frequent dermatoses (42%) followed by eczemas (32.4%), insect bite (9.6%), pilosebaceous disorder (4.5%), hair diseases (4%) papulosquamous diseases (2.3%) and genodermatoses (1%).
Conclusions: Dermatologic diseases in Libyan pediatric patients showed various features of pediatric dermatology in developing countries, such as high frequency of infections and infestations, and environmentally associated disorders; and to the best of our knowledge, this is the first study carried out on pediatric dermatoses in Libya.
Keywords: Children, Libyan, skin diseases
|How to cite this article:|
Elfaituri SS. Pediatric dermatoses in Benghazi, Libya. Indian J Paediatr Dermatol 2015;16:64-71
| Introduction|| |
The pediatric population is composed of persons <16 years of age. 
Skin diseases are an important and common health problem in children.
There are many risk factors for development of skin disease in the pediatric population; ecological and environmental including racial and genetic factors, nutritional status, climatic exposure, external environment, traditional taboos, and socioeconomic status; personal hygiene, large family size and over-crowding. There is a wide range of skin diseases presenting in different age groups. Most of the cutaneous diseases that result from intrinsic genetic abnormalities have onset in the pediatric age-group. , Numerous eczematous conditions can affect the pediatric population with atopic dermatitis being the most frequent; the majority of cases arise within the 1 st year of life. Cutaneous infections are common in children during school going years. Acne vulgaris is the most common skin disease of the adolescent population.
Pediatric dermatoses require a separate view from adult dermatoses as there are important differences in clinical presentation, management and prognosis. They can be transitory or chronic and recurrent, and although they are rarely lethal, they may associated with significant morbidity and psychological impact as well as an implication in their development. ,,
Although skin diseases are common in children, and pediatric dermatology is an established specialty all over the world with various epidemiological studies have been undertaken across the world to study the pattern of pediatric dermatoses, there are no epidemiologic data concerning pediatric dermatoses exist from Benghazi, Libya. Our aim was to study skin disease in children to determine the spectrum and frequency of pediatric dermatoses in Libyan pediatric patients, to correlate the prevalence with age, sex as well as seasonal variation and to compare our results with the similar international studies.
| Materials and methods|| |
A prospective study was performed over 1-year on the pediatric population with complaints of skin diseases attending dermatology department outpatient clinic in Jumhoria hospital in Benghazi, Libya. Nine hundred and fifty-four pediatric patients were studied. A detailed history was recorded, and skin examination carried out. In most instances, diagnosis of the diseases was based on clinical impression; relevant investigations including the skin biopsy were performed whenever they were indicated. Data were recorded according to the prepared performa. The diseases were sub-classified into nine categories; infectious (bacterial, fungal, viral and parasitic), eczematous, papulosqumous, hair and nail disorders, pilosebaceous disorders, insect bite, genodermatoses, and miscellaneous. The patients were grouped into five groups based on their age at first visit: Neonates (1 st month of life), infants (<2 years), preschool children (2-6 years), school children (7-12 years) and adolescents (13-16 years). The data were analyzed according to age, sex, and season. The statistical analysis of the data was done by Chi-square test, P < 0.01 was considered as statistically significant.
| Results|| |
A total of 954 patients were studied; all were < 16 years Libyan patients.
A male preponderance (52%) was observed [Figure 1], infants constituted the largest group within the patient population (33.8%) [Figure 2] and only 5% was black. The present study brings into focus the pattern of pediatric dermatoses encountered in Jumhoria Hospital as a referral center in Benghazi-Libya.
In the analysis of diagnoses by categories, the most frequent category was infections and infestations, it accounted for 42% of all cases followed by eczemas (32.4%), insect bite (9.6%), pilosebaceous disorder (4.5%), hair diseases (4%) papulosquamous diseases (2.3%) and genodermatoses (1%) [Figure 3].
The most common individual diagnoses were atopic dermatitis (11.7%), scabies (7.8%), warts (6.2%), impetigo (5.5%) and tinea capitis (4.8%) [Figure 4].
The frequency of various infectious and eczematous dermatoses is demonstrated in [Figure 5] and [Figure 6] respectively. Some other low frequencies dermatoses of various etiologies were grouped together into miscellaneous group (8.8%) [Figure 7].
The most common type of infections was viral infections, corresponding to 12.4% of diagnoses followed by bacterial (11.6%), fungal (9.5%) and parasitic infestations (8.5%) [Figure 8] [Figure 9] [Figure 10] [Figure 11] [Figure 12].
Among eczemas (32.4%), atopic dermatitis was the most common dermatitis reported in this study (11.7%), followed by contact dermatitis (4.5%), napkin dermatitis (4%), discoid eczema (2.7%) and seborrheic dermatitis (2%) [Figure 13] [Figure 14] [Figure 15]. Papulosquamous diseases were diagnosed in 2.3%, with the following frequencies; psoriasis (1.4%) [Figure 16], pityriasis rosea (0.4%), pityriasis rubra pilaris and lichen striatus each (0.2%) and lichen planus (0. 1%).
About 4% of our patients had hair diseases; alopecia areata (2.8%) [Figure 17], tractional alopecia (0.5%) hair fall (0.3%) and trichotillomania in 0.2%.
Beau's lines, trachynychia and pitting were the main reported nail changes (1.2%). One percent of our pediatric population had inherited skin diseases; ichthyosis was the most common (0.4%), whereas epidermolysis bullosa and palmoplanter keratoderma each was seen in 0.2%. Rare congenital conditions as aplasia cutis (0.2%) and naevoid conditions including vascular nevi (1%), melanocytic nevi (0.3%) [Figure 18] and epidermal nevi (0.4%) were recorded. Among nutritional deficiency diseases; zinc deficiency was observed in 3 cases and kwashiorkor in 1 case. Among the miscellaneous group, photodermatoses (2.4%), miliaria (2.5%), erythema multiforme (0.8%) and an interesting case of dermatitis artifacta were reported. Vitiligo was the most frequent pigment disorder (1%) [Figure 19]. The frequencies of some dermatoses were significantly (P < 0.01) related to age; eczema including atopic, seborrheic, discoid and napkin dermatitis was significantly related to age with most of the cases were infants. Acne vulgaris was the main diagnosis in the adolescent group [Figure 20] with 93% of our acne patients was adolescent. Viral warts were more prevalent in school-age children, and insect bites were more common in preschool-age children (P < 0.01). The frequencies of some diseases showed seasonal variations; bacterial infections were more common in summer whereas acne vulgaris patients were presented more in autumn and winter, and this was statistically significant. Although insect bite and atopic dermatitis were more commonly seen in spring, the relation between them and the season was statistically insignificant. In relation to race; atopic dermatitis and tinea capitis were the most frequently seen dermatoses in black children (P < 0.01).
Apart from female predominance in acne vulgaris and male predominance in pityriasis alba, there was no significant sex variations in the prevalence of skin diseases demonstrated in this study.
| Discussion|| |
Skin diseases in the pediatric population are common all over the world. They are an important health problem affecting children in both developing and industrialized developed countries.  Several epidemiological studies in pediatric age group have been undertaken across the world. Its prevalence and pattern vary depending on the regional and ethnic variation as well as the patients' clinical environment.
This study was carried out on 954 pediatric patients; the sample studied was adequate to study the skin diseases present in the community.
Infections and infestations were the most common pediatric dermatoses seen in our study (42%); this is consistent with other studies from developing countries ,,,,, but differ from developed countries where skin infections are rare. 
Our prevalence of infections and infestations was higher than that reported in Switzerland, Turkey (27%), and Spain (27.7%), ,, but lower than Egyptian, Ethiopian, Indian and Pakistani results (47-85%). ,,,,,,,
The high prevalence of infections and infestations can be attributed to poor hygienic and sanitary conditions, lack of awareness and poor health services.
Nutritional status, climate factors and other socioeconomic factors are additional contributing factors. 
Viral infections were the most common infections seen in our patients (12.4%); it was more than what is reported in other Indian and Pakistanian studies (3-10%). , Warts were the most frequent viral infection in our children (6.2%), our results was comparable to Switzerland, China and Turkey, ,, but lower than Spain and Kuwait results (13%). , Warts prevalence was related to age with statistical significance; though found in preschool and adolescent groups, they were more common in primary school children, this was consistent with Tawian and Kuwait study. , The contributing factors to wart infection may include an increase in outdoor and sports activities, eczema, and nail biting. Other risk factors include general nutrition and personal hygiene.
Bacterial infections are the major problem in children; they were seen in 11.6% of our pediatric patients, near to what was observed by pakistanian (12%) and Indian (15%) studies. ,, Bacterial infections were less common in developed countries as Switzerland (2.88%).  In concordance with Egyptian data, bacterial infections prevalence was increased significantly during the summer season, this could be due to swimming in sewage polluted sea water in addition to the hot, humid weather and poor hygienic standard. Impetigo was the main bacterial infection seen in this study; it was present in 5.5%, similar to Turkish data. 
Although fungal infections were high in our study (9.5%), Pakistanian, Indian and Nigerian studies showed a higher percentage (15-20%). ,,,, Tinea capitis was the most common fungal infection seen in this study (5%), which may be in part due to exposure to animals, poor hygiene, and sharing combs. Tinea capitis was significantly related to race, and this was consistent with Child et al. results in London.  Parasitic skin infections were seen in 8.5%; with Scabies was observed in 7.8%. Scabies was the commonest disease in other studies. ,, Our data is exceeded Nigerian (4.7%), and lower than Indian and Pakistanian literature (10-21.7%). ,,, Pediculosis capitis was observed to be the commonest problem by other authors from different studies. ,,, In contrast to these studies, our prevalence of pediculosis capitis was low (0.7%). This common public health problem could be underreported, as many patients are self-treated by antipediculus treatment given by pharmacists without dermatological consultation. Cutaneous leishmaniasis is rare parasitic disease of children; it was not seen in this study as there is no sand fly in Benghazi and its vicinity.
Different forms of endogenous or exogenous eczemas were seen in this study. Eczema was the second major presentations among our pediatric patients (32.4%), our study exceeded the reported ranges of eczema in other developing countries as Ethiopia, India, Pakistan, Turkey and Sultanate of Oman (8-27%), ,,,,,,, parallel to the situation in China (33%). 
In our study, we diagnosed 112 patients with atopic dermatitis (11.7%), it was the most common diagnosed dermatosis. In most studies done in developed countries, atopic dermatitis was the most frequent diagnosis in children. In the study published by Wenck and Itin in Switzerland in 2003, 25.9% of children referred to a pediatric dermatology clinic had atopic dermatitis.  These results are similar to those obtained in the study by Torrelo and Zambrano in a pediatric dermatology clinic in Madrid, Spain; 23.9% had atopic dermatitis. 
Our prevalence of atopic dermatitis (11.7%) was in agreement with Turkish (12%), and Chinese (11.5%) results but higher than Indian (5.27%). ,,
This relatively high frequency of atopic dermatitis in our children may be related to the dietary habits and environmental factors including allergens in addition to the role of the genetic factor. Although atopic dermatitis was seen in all age groups except neonates, its frequency was statistically significant more in infancy as many atopic patients experience improvement with age. In Turkey, atopic dermatitis was the most frequently seen dermatosis in both infants and preschool-age children  whereas it was the most frequent skin disorder seen in all age groups in Switzerland and Kuwait. , The variation in the pattern of dermatoses with atopic dermatitis being the most common skin disorder in developed industrialized countries can explained by temperate cold climate and the increased exposure to environmental pollutants, chemicals, and allergens. ,,,,, Atopic dermatitis was the most frequent dermatoses seen in the dark race children, a similar result was previously reported.  Infantile seborrhoeic dermatitis is a common inflammatory disease with spontaneous improvement with age. It contributed to 2% of our study population, all cases were infants, similar results recorded in Spain.  Sardana et al.  and Tamer et al.  observed a higher frequency (4.3% and 10.5%) in their studies.
Acne vulgaris is chronic disease of pilosebaceous unit that generally starts at puberty and in concordance with literature, most of our acne patients were adolescents. It was seen in 4.5% of our patients, in Spain it constituted 7%,  and it was the most prevalent dermatosis in some Turkish studies (12.4%), , which could be related to the age structure of the study. Female patients presented with acne significantly more than males, similar to what was observed in Kuwait and Egypt. , For unknown reason, our acne patients were presented more in autumn and winter.
Genodermatoses are rare inherited skin disorder, 1% of our patients had genetic disorders that could be due to relatively high incidence of consanguineous marriages in our society. Our data was less than Indian (2.1%).  The prevalence of inherited skin disorder may be underreported, because of referring cases to the genetic clinic directly from different polyclinics in Benghazi without passing through the outpatient clinic of the dermatology department.
As it is in other studies; congenital ichthyosis was the most common congenital skin condition encountered in this study (0.4%). ,,
Insect bites were the third most common dermatoses (9.6%) in our study, it exceeded the reported ranges from 1% to 5.2% in other studies. ,, Such high frequency is probably due to the fact that many of these bites were during spring; picnic time. In addition; poor sanitary measures in our country favor multiplication of mosquito and other insects.
Cutaneous immunlogical diseases with genetic basis as vitiligo, alopecia areata, psoriasis were diagnosed in 1%, 2.8% and 1.4% respectively, their prevalence was going with some but far from another reports, which may related to genetic and racial differences. ,,,,
Prevalence of melanocytic nevi as a presenting complaint constituting 0.3%, a higher percentage was reported in Spain (10.5-19.5%) and Switzerland (9%), ,, this may be due to concern about melanoma among the Europeans population.
| Conclusions|| |
This study provides important data on the frequency of dermatologic diseases in Libyan pediatric patients; it shows various features of pediatric dermatology in a developing country, such as high frequency of infectious diseases, and environmentally associated disorders as insect bites and eczematous dermatoses. There is a great lack of epidemiological studies on pediatric dermatoses in Arabic countries and to the best of our knowledge this is the first study carried out on pediatric dermatoses in Benghazi, Libya.
| Recommendations|| |
Infections out-numbered other pediatric dermatoses and were potentially controllable and therefore strategies that target infections may represent a key to an efficient child health care program. There is an obvious need for diagnostic and therapeutic training for dermatologists, general practitioners and pediatricians in this group of disorders. Because pediatric dermatology is a highly specialized field, the need for separate-pediatric dermatological clinics, either in children's hospital or in dermatology department in the general hospital should be emphasized.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]