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ORIGINAL ARTICLE
Year : 2016  |  Volume : 17  |  Issue : 4  |  Page : 267-272

Study of clinical spectrum of pediatric dermatoses in patients attending a Tertiary Care Center in North Kerala


Department of Dermatology, Pariyaram Medical College, Kannur, Kerala, India

Date of Web Publication7-Oct-2016

Correspondence Address:
Thyvalappil Anoop
B 2 Quarters, F3, Pariyaram Medical College, Kannur - 670 503, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.188424

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  Abstract 

Introduction: Skin diseases are a major health problem in the pediatric age group.
Aim: To determine the prevalence and clinical characteristics of different pediatric dermatoses in a tertiary care centre in Kerala.
Materials and Methods: Children with age 18 years and below with clinical evidence of cutaneous disorders were studied.
Results: 500 cases were studied which showed a female preponderance of 51.4%. The most common dermatoses was infections and infestations (33.8%) followed by eczemas (32.6%), disorders of sweat and sebaceous glands (7.4%), keratinisation and paulosquamous disorders (4%). Nutritional disorders were seen in 1% of children. 3.6% had photodermatoses, 2.6% had hair and nail disorders and 0.4 % had adverse cutaneous drug reactions.
Conclusions: Fungal infection was the most common infection noted in the study, followed by viral and bacterial infection. Allergic contact dermatitis was the commonest exogenous eczema and juvenile plantar dermatosis was the commonest endogenous eczemas. Acne, insect bite reaction and miliaria were the other common dermatoses.

Keywords: Allergic contact dermatitis, infections and infestations, insect bite reactions, juvenile plantar dermatosis, pediatric dermatoses


How to cite this article:
Reddy VS, Anoop T, Ajayakumar S, Bindurani S, Rajiv S, Bifi J. Study of clinical spectrum of pediatric dermatoses in patients attending a Tertiary Care Center in North Kerala. Indian J Paediatr Dermatol 2016;17:267-72

How to cite this URL:
Reddy VS, Anoop T, Ajayakumar S, Bindurani S, Rajiv S, Bifi J. Study of clinical spectrum of pediatric dermatoses in patients attending a Tertiary Care Center in North Kerala. Indian J Paediatr Dermatol [serial online] 2016 [cited 2020 Sep 20];17:267-72. Available from: http://www.ijpd.in/text.asp?2016/17/4/267/188424


  Introduction Top


Pediatric dermatology deals with diseases and skin care requirements in individuals from birth to adolescence, a relatively short period in lifetime when significant physiological, psychological, and maturity changes take place.[1] The pattern of skin diseases is known to differ in different countries of the world and in different regions of the same country.[2] Dermatological problems constitute at least 30% of all outpatient visits to a pediatrician and 30% of all visits to a dermatologist involve children.[3],[4] The prevalence of skin diseases among children in various parts of India ranges from 8.7% to 35%.[5]


  Materials and Methods Top


The study was conducted in the Department of Dermatology, in a Tertiary Care Center in Kerala, in 500 children attending the outpatient department. Children with age 18 years and below with clinical evidence of cutaneous disorders were included in this hospital-based descriptive study to determine the prevalence of various skin disorders and to determine clinical characteristics of different pediatric dermatoses.

All the patients were subjected to detailed history taking and meticulous examination as per the proforma after getting the informed consent. The clinical manifestations in relation to pediatric dermatoses were recorded. Detailed systemic evaluation was carried out in each case. Statistical test used was Chi-square test. The data obtained were subjected to descriptive analysis using SPSS software (Statistical software for social sciences, Version 20.0, Chicago, USA).


  Results Top


In this study, 500 pediatric patients of age 18 and below were included. Of them, 243 (48.6%) were males and 257 (51.4%) females. Adolescent group constituted highest percentage (48%) followed by school age group, which constitutes 27.6% of total pediatric patients [Figure 1].
Figure 1: Age-sex distribution of pediatric dermatoses (n = 500)

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Infections and infestations combined constituted highest proportion 33.8% (169), followed by eczematous dermatoses which constitute 32.6% (163) [Table 1].
Table 1: Distribution of patients according to their diagnosis of various etiological factors (n=500)

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Among the bacterial infections, furunculosis was the most common, amounting to 38% (8) cases followed by impetigo [Figure 2].
Figure 2: Distribution according to their diagnosis of bacterial infections (n = 21). SSSS: Staphylococcal scalded skin syndrome

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Dermatophytic infections constituted the maximum of the fungal infections involving the skin (48.5). Among dermatophytic infections, tinea corporis constituted the highest proportion, i.e., 53.12% (17), followed by tinea cruris 31.25% (10), tinea capitis 12.5% (4), and tinea faciei 3.1% (1) [Figure 3].
Figure 3: Distribution of fungal infections

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Molluscum contagiosum was the most common skin lesion caused by viral infection in this study and constituted 38.3% (23) followed by warts [Figure 4].
Figure 4: Distribution of patients according to their diagnosis of viral infections (n = 60)

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Among the infestations, scabies was the most common that constituted 85.7% (18) cases followed by pediculosis capitis [Figure 5].
Figure 5: Distribution of patients according to their diagnosis of infestations (n = 21)

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Endogenous eczemas were more common than exogenous eczemas during the study period. Juvenile plantar dermatosis (JPD) was the most common endogenous eczemas, which constituted 20.8% (34) cases of all eczemas. Among the exogenous eczemas, allergic contact dermatitis (ACD) was the most common which constituted 9.8% (16) cases. Irritant contact dermatitis (ICD) was seen in 3% (5), photo ACD in 2.45% (4), and infectious eczematoid dermatitis in 1.2% (2) of the total eczema cases [Figure 6].
Figure 6: Distribution of eczema. ICD: Irritant contact dermatitis, ACD: Allergic contact dermatitis, IED: Infectious eczematoid dermatitis, JPD: Juvenile plantar dermatoses, P. Alba: Pityriasis alba

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One percent of total pediatric dermatoses in this study were nutritional dermatoses, in which there were three cases of phrynoderma. Congenital melanocytic nevus was the most common among all the nevoid and developmental disorders seen in this study, which constituted 42.8% (3). Becker's nevus, nevus sebaceous, linear verrucous epidermal nevus, and achromic nevus were seen in one patient each.

The ichthyoses constituted 40% (4) cases of the keratinization disorders. Keratosis pilaris and palmoplantar keratoderma were seen in two patients each and lichen spinulosus and pityriasis rubra pilaris in one patient each. Plaque psoriasis constituted 30% (3) of papulosquamous disorders. Lichen planus was seen in 20% (2), lichen nitidus in 20% (2), and guttate psoriasis in 10% (1) of all papulo squamous disorders.

Among the disorders of sweat glands and sebaceous glands, acne was the most common to be seen. These cases constituted 75.6% (28) and 5.6% of total patients in this study. Miliaria cases constituted 16.2% (6) of sweat and sebaceous disorders and 1.2% of total patients, fordyce spots was seen in 2.7% (1), and sebaceous cysts in 5.4% (2) of sweat and sebaceous disorders.

Among the vesiculobullous disorders, there were 2 cases of epidermolysis bullosa simplex and one case of chronic bullous disease of childhood. Only two cases were seen in the category of connective tissue disorders which included one case of systemic lupus erythematosus and one case of morphea each. The disorder of skin color was seen in five patients during the study period. Vitiligo and freckles were 2 each, and postinflammatory hypo-pigmentation in one case.

Abnormal responses to light were seen in 18 cases during the period of study. Polymorphic light eruption was the most common abnormality as seen in 85.7%.

The disorders of hair and nails were seen in 20 cases during the study period. Telogen effluvium was the most common disorder belonging to this class, which constituted 30% (6), followed by alopecia areata in 20% (4). Paronychia was the most common nail disorder seen, which constituted 20% (4). The other disorders belonging to this category included premature canities in 10% (2) and trichotillomania 5% (1). Two patients developed adverse drug reactions, one patient had toxic epidermal necrolysis due to lamotrigine, and other patient had maculopapular rash due to amoxicillin.

Eighty-eight cases were included in the miscellaneous disorders category. It comprised 46.5% (41) cases of insect bite reaction, urticaria 18.2% (16), tuberous sclerosus 1.1% (1), erythema multiforme 1.1% (1), aphthous stomatitis 2.2% (2), corns and callosities 2.2% (2), pyogenic granuloma 2.2% (2), Henoch–Schonlein purpura 1.1% (1), prurigo nodularis 5.7% (5), acanthosis nigricans 3.4% (3), granuloma annulare 2.2% (2), mudi-chood 1.1% (1), fissure feet 6.8% (6), parapsoriasis 2.2% (2), angioedema 1.1% (1), juvenile xanthogranuloma 1.1% (1), and neurofibroma 1.1% (1) of the total miscellaneous disorders.


  Discussion Top


The pattern of skin lesions in children is greatly influenced by climatic factors, dietary patterns, and socioeconomic status. In our study, age group of 11–18 years constituted the maximum (48%) number of pediatric patients. Sacchidanand et al.[2] observed 5–11 years is the common age group followed by adolescents with 33.21% and 29.81%, respectively. Sharma et al.[6] reported that pediatric dermatoses are more common in adolescent age group. Female patients outnumbered the male patients (51.4%) in our study, similar to that of Karthikeyan et al.[7] Flavia Regina Ferreira et al. also reported female predominance (57.2%).[8]

Infections and infestations were the most common dermatoses encountered, which were seen in 33.8% of the total cases. Our findings were similar to study by Sacchidanand et al. and Bisht et al. which showed 32.47% and 36.46%, respectively.[2],[9] Negi et al., Sharma and Mendiratta, and Bhatia and Ghosh et al. studies have reported them occurring in the range of 35.6–85%.[10],[11],[12],[13]

Scabies alone constituted the majority of infestation, making 3.6% of the total dermatoses. Sacchidanand et al.[2] in their study found that the incidence of scabies was 6.97%. The incidence of scabies had varied from 5.1% to 22.4% in studies done by Negi et al., Sharma and Mendiratta, and Bhatia.[10],[11],[12] Sarkar and Kanwar in their study pointed out that the prevalence of scabies in general population of rural communities in India is about 5%.[14] Pediculosis capitis was the next most common infestation.

Bacterial infections constituted 14.18% of the total infections and 4.2% of total pediatric dermatoses. Furunculosis was the most common bacterial infection with 38% of total bacterial infections, followed by impetigo with 28.5%, then secondary bacterial infections with 14.2% of bacterial infections. Pyodermas were the single most common dermatoses found out by Bhatia [12] and Ghosh et al.[13]

Fungal infections of the skin constituted 44.59% of the total infections and 13.2% of total dermatoses. Dermatophytic infections were the most common among these infections making up to 48.5%. Tinea corporis was found in a significant number of children forming 53.12% of dermatophytic infections and 3.4% of all dermatoses followed by tinea cruris. Tinea versicolor was seen in 39.4% of total fungal infections and 5.2% of the total dermatoses. The incidence varied from 3.3 to 8.5 in various other studies.[2],[7],[15] Among candidal infections, which constituted 12.1% of the fungal infections and 1.6% of total dermatoses, candidal intertrigo constituted 50% of all candidal infection and 0.8% of total dermatoses. Karthikeyan et al.'s study was similar to us which showed candidal infections constituted 2.1% of total dermatoses.[7]

The viral infections constituted 40.54% of the total infections and infestations and 12% of total dermatoses of our study. Molluscum contagiosum was the most common viral disease constituting 38.3% of these infections and 4.6% of total dermatoses. Karthikeyan et al. in their study observed that incidence of molluscum contagiosum was 2.5% in children aged 1 to 15.[7] Second most common viral infection in our study was warts, which constituted 20% of viral infections and 2.4% of total dermatoses. We observed that viral warts were more common in the adolescent group, similar to observations in previous studies.[16],[17] Pityriasis rosea was the next common viral infection with 16.6% of viral infections and 2% of total dermatoses in our study. Hand foot mouth disease constituted 10% of viral infections and 1.2% of total dermatoses. The incidence of Varicella was 0.4% in our study which is similar to that reported by Karthikeyan et al. (0.4%).[7] The incidence of herpes zoster was 0.6% in our study whereas in Karthikeyan et al.'s study, it was 0.37%.[7]

The present study recorded 1% of nutritional dermatoses which is very less as compared to other studies which reported incidence of 15.4% to 17.5%.[9],[10] Some studies have shown incidence from 0.45% to 2.8%.[7],[18] Phrynoderma was the most common among the nutritional deficiency disorders. Sacchidanand et al.'s study showed that incidence of nutritional dermatoses is 0.72%.[2] Karthikeyan et al.'s study showed 2.8%.[7] Awate et al. observed that the incidence of phrynoderma was 9.8%.[19]

Eczema was the second common group of dermatoses in our study constituting 32.6% of total cases. The incidence rate of eczema in the study by Sacchidanand et al. was 20.66%[2] whereas in Karthikeyan et al.'s study, it was 8.6%.[7] JPD was the most common endogenous eczema, followed by pityriasis alba, nummular eczema, atopic dermatitis, and seborrhoeic dermatitis. Exogenous eczema constituted 4.3% of total dermatoses. Sacchidanand et al. reported atopic dermatitis as the most common eczematous dermatitis which constituted 6.12%.[2] Other studies had same opinion as atopic dermatitis was the most common endogenous eczema which ranges from 3% to 28%.[20],[21] Pityriasis alba was second most common endogenous eczema in accordance with Saurabh Sharma et al.[6] with incidence rate of 4.9%. Nanda et al. reported an incidence of 5.2%.[22]

Nevoid and developmental disorders constituted 1.4% of total dermatoses in this study. Thappa [3] in their study observed a prevalence of 0.5%. Dogra and Kumar observed a prevalence of 1.1%.[23] Congenital melanocytic nevus was the most common nevoid and developmental disorder in our study. Among keratinization disorders, ichthyosis was seen in 0.8%, followed by palmoplantar keratoderma and keratosis pilaris each with 0.4% prevalence and pityriasis rubra pilaris and lichen spinulosus each with 0.2% prevalence. Thappa observed the prevalence of ichthyoses and palmoplantar keratoderma in 2.1% of cases,[3] which is similar to our study. In contrast, Ghosh et al.[13] did not encounter any of these disorders in their studies. In the study conducted by Dogra and Kumar,[23] the prevalence was 1.3%.

Papulosquamous disorders were noted in 2% of the cases during this study period. Prevalence of papulosquamous disorders in the study of Sacchidanand et al. was 6.08%.[2] In accordance with Sacchidanand et al., among the papulosquamous disorders, psoriasis was the most common dermatoses and constituted about 4.28% of the total dermatoses. Karthikeyan et al. reported prevalence of psoriasis as 1.4%.[7] In a prospective study from Kuwait, psoriasis was seen in 4%.[24]

Sweat and sebaceous gland disorders constituted 7.4% of dermatoses during this study period. Acne was the most common among them with prevalence rate of 5.6%, followed by miliaria with 1.2%. In the study done by Karthikeyan et al.,[7] the prevalence of miliaria was 4.1%. Tamer et al.[25] showed 12.4% prevalence while Rajar et al.[26] reported a prevalence of 26% in the age group of 11–15 years.

Vesiculobullous disorders constituted 0.6% of total dermatoses with two cases of epidermolysis bullosa simplex and one case of chronic bullous dermatoses of childhood. According to Sarkar et al., the prevalence rate of epidermolysis bullosa simplex was 4.65%.[27] Connective tissue disorders constituted 0.6% of dermatoses in this study. Dogra and Kumar reported an incidence of 0.09% in their study among schoolchildren in Northern India.[23] Karthikeyan et al. reported that 0.5% of dermatoses were connective tissue disorders.[7]

Pigmentary disorders constituted 1% of total dermatoses in our study. Vitiligo and freckles were 0.4% each and postinflammatory hyperpigmentation in 0.2%. Sacchidanand et al.[2] reported that pigmentary disorders constituted 5.81% and Karthikeyan et al.[7] reported 5.7%. Abnormal response to light was seen in 4.2% of total cases in our study. Polymorphic light eruption was the most common among them with 3.6%, followed by porphyrias in 0.4% and xeroderma pigmentosum was seen in 0.2%.

Hair and nail disorders constituted 4% of cases in this study. Telogen effluvium was the most common hair disorder noted in this study, followed by alopecia areata, premature canities, and trichotillomania. Paronychia was the most common nail disorder. Thappa reported 5.2% prevalence of hair and nail disorders in their study.[3] Vora et al. observed alopecia in 0.07%, premature canities in 0.02%, nail changes in 0.07%, and paronychia in 0.02%.[28]

Toxic epidermal necrolysis due to lamotrigine and 1 patient had maculopapular rash due to amoxicillin constituted 0.2%. Sacchidanand et al. reported adverse drug reactions in 0.72% of patients.[2] Miscellaneous conditions constituted 17.6% of study population. Insect bite reaction contributed to 46.5% of these disorders.

Our study had few limitations. It was conducted in a single center and sample size was small. No laboratory tests were done for conformation. A large, prospective multicentric study needs to be conducted to know more about pediatric dermatoses.


  Conclusions Top


The present study was undertaken to determine the characteristic clinical pattern and prevalence of pediatric dermatoses. The majority of the study population (48%) belonged to adolescent age group. Of them, females outnumbered males. Fungal infections were the most common infection noted in the study, followed by viral and bacterial infections. ACD was the most common exogenous eczema and JPD was the most common endogenous eczema. Plaque psoriasis was the most common papulosquamous disorder, followed by lichen planus. Acne was the most common sweat and sebaceous gland disorder with female preponderance. Telogen effluvium was the most common hair disorder, followed by alopecia areata. Paronychia was the most common nail disorder.

A detailed knowledge about the pattern of pediatric dermatoses in each geographic area will help us in implementing essential changes in health education, disease control, and preventive strategies in the area concerned.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

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Hamm H, John R, Evans SE, Martin AH. Principles of diagnoses in pediatric dermatology. In: Schachner LA, Hansen RC, editors. Pediatric Dermatology. 4th ed. London: Mosby Elsevier; 2011. p. 69-114.  Back to cited text no. 1
    
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Sacchidanand S, Sahana MS, Asha GS, Shilpa K. Pattern of pediatric dermatoses at a referral centre. Indian J Pediatr 2014;81:375-80.  Back to cited text no. 2
    
3.
Thappa DM. Common skin problems. Indian J Pediatr 2002;69:701-6.  Back to cited text no. 3
    
4.
Federman DG, Reid M, Feldman SR, Greenhoe J, Kirsner RS. The primary care provider and the care of skin disease: The patient's perspective. Arch Dermatol 2001;137:25-9.  Back to cited text no. 4
    
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Sharma NK, Garg BK, Goel M. Pattern of skin diseases in urban school children Indian J Dermatol Venereol Leprol 1986;52:330-1.  Back to cited text no. 5
    
6.
Sharma S, Bassi R, Sodhi MK. Epidemiology of dermatoses in children and adolescents in Punjab, India. J Pak Assoc Dermatol 2012;22:224-30.  Back to cited text no. 6
    
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Karthikeyan K, Thappa DM, Jeevankumar B. Pattern of pediatric dermatoses in a referral center in South India. Indian Pediatr 2004;41:373-7.  Back to cited text no. 7
    
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Ferreira FR, Nascimento LF, Cirvidiu DC. Prevalence of pediatric dermatoses in a university hospital in southeastern Brazil. An Bras Dermatol 2011;86:477-82.  Back to cited text no. 8
    
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Bisht JS, Rana SK, Kumari N, Aggarwal B, Mehta A, Singh R. Pattern of dermatoses in preschool children in a teaching hospital in Uttarakhand, India. Indian J Paediatr Dermatol 2015;16:198-202.  Back to cited text no. 9
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12.
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Sarkar R, Kanwar AJ. Three common dermatological disorders in children (scabies, pediculosis and dermatophytoses). Indian Pediatrics 2001;38:995-1008.  Back to cited text no. 14
    
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Saurabh S, Sahu SK, Sadishkumar A, Kakkanattu JC, Prapath I, Ralte IL, et al. Screening for skin diseases among primary school children in a rural area of Puducherry. Indian J Dermatol Venereol Leprol 2013;79:268.  Back to cited text no. 15
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Patel JK, Vyas AP, Berman B, Vierra M. Incidence of childhood dermatosis in India. Skinmed 2010;8:136-42.  Back to cited text no. 16
    
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Sterling JC, Kurtz JB. Viral infections. In: Champion RH, Burton JL, Burns DA, Breathnach SM, editors. Textbook of Dermatology. 6th ed., Vol. 4. New York: Blackwell Science; 1998. p. 995-1095.  Back to cited text no. 17
    
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Sardana K, Mahajan S, Sarkar R, Mendiratta V, Bhushan P, Koranne RV, et al. The spectrum of skin disease among Indian children. Pediatr Dermatol 2009;26:6-13.  Back to cited text no. 18
    
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Awate RV, Ketkar YA, Somaiya PA. Prevalence of nutritional deficiency disorders among rural primary school children (5-15 years). J Indian Med Assoc 1997;95:410-1, 415.  Back to cited text no. 19
    
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Sladden MJ, Dure-Smith B, Berth-Jones J, Graham-Brown RA. Ethnic differences in the pattern of skin disease seen in a dermatology department – Atopic dermatitis is more common among Asian referrals in Leicestershire. Clin Exp Dermatol 1991;16:348-9.  Back to cited text no. 20
    
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Larsen FS, Holm NV, Henningsen K. Atopic dermatitis. A genetic-epidemiologic study in a population-based twin sample. J Am Acad Dermatol 1986;15:487-94.  Back to cited text no. 21
    
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Nanda A, Al-Hasawi F, Alsaleh QA. A prospective survey of pediatric dermatology clinic patients in Kuwait: An analysis of 10,000 cases. Pediatr Dermatol 1999;16:6-11.  Back to cited text no. 22
    
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Dogra S, Kumar B. Epidemiology of skin diseases in school children: A study from northern India. Pediatr Dermatol 2003;20:470-3.  Back to cited text no. 23
    
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al-Fouzan AS, Nanda A. A survey of childhood psoriasis in Kuwait. Pediatr Dermatol 1994;11:116-9.  Back to cited text no. 24
    
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Tamer E, Ilhan MN, Polat M, Lenk N, Alli N. Prevalence of skin diseases among pediatric patients in Turkey. J Dermatol 2008;35:413-8.  Back to cited text no. 25
    
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