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REVIEW ARTICLE
Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 5-11

Evolution of pediatric dermatology in India: A medico-historical overview


Consultant Dermatologist, Asansol, West Bengal, India

Date of Web Publication14-Dec-2018

Correspondence Address:
Dr. Amiya Kumar Mukhopadhyay
“Pranab”, Ismile, Near Dharmaraj Mandir, Asansol - 713 301, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_46_18

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  Abstract 


Pediatric dermatology is a newly emerging branch of dermatology dealing with pediatric dermatoses. It was “officially” born in 1972 when the first International Symposium of Pediatric Dermatology was held in Mexico City. Historically, in India, a well-established branch of medicine, Kaumarabhritya (pediatrics) exists since ancient times. The Unani and the Western system were introduced in the country in later days and enriched the medical system of the country. They served pediatric patients with their own methods. The activity to establish modern pediatric dermatology began in recent years. In the year 1996, the Indian Society for Pediatric Dermatology was formed to establish a platform for the further advancement of the subject. The Indian Journal of Pediatric Dermatology has served the purpose of publishing modern research on pediatric dermatology in India and abroad since 1998. The present article is a review of history and evolution of pediatric dermatology in India since ancient time.

Keywords: Dermatology, history of dermatology, history of pediatrics, pediatric dermatology, pediatrics


How to cite this article:
Mukhopadhyay AK. Evolution of pediatric dermatology in India: A medico-historical overview. Indian J Paediatr Dermatol 2019;20:5-11

How to cite this URL:
Mukhopadhyay AK. Evolution of pediatric dermatology in India: A medico-historical overview. Indian J Paediatr Dermatol [serial online] 2019 [cited 2019 Jan 19];20:5-11. Available from: http://www.ijpd.in/text.asp?2019/20/1/5/247554



Yugānurūpasandarbho vibhagena karishyate.

……… classifying (the medical system in this treatise) in tune with the changing time.

Vagbhata (c. 6th Century AD).[1]


  Introduction Top


Medical science is an ever-changing subject that needs to keep pace with the need of civilization for alleviating the pain and agony of the diseased. The urge of learning the art and science of medicine started from the early days of human civilization. The knowledge gathered had ramifications, and one after another new branches of medical science evolved. Rapid advancement in science and technology has made the process faster. Some milestones mentioned below in the history of the evolution of pediatric dermatology, a recent subspecialty of dermatology will validate this fact:

  • 1827:First ever book on pediatric skin diseases: A treatise on the cutaneous diseases incidental to childhood, was written by Dendy[2]
  • 1930: Howard Fox in his book “Diseases of the skin in infancy and childhood” wrote…. It would be impossible in a volume of this size to describe them (pediatric dermatoses) in detail[3]
  • 1972: Pediatric dermatology – a fast emerging branch of dermatology was “officially” born[4]
  • 1827–1972 – not even one and a half century… and a new subspecialty of dermatology grew from a book to a branch at a fascinating pace…. A time frame not considered too long in the hourglass of historiography!


Indeed, pediatrics, including Pediatric Dermatology, emerged as a distinct branch in very recent times, but physicians from antiquity observed, analyzed myriad skin diseases of children, and managed them with then available knowledge and facilities. India occupies a special place in this regard. Although the first Western work The Children's Practice dates back to 12th Century AD,[5] a separate branch of medicine designated to the childhood disorders was practiced in ancient India under the realm of Kaumārbhritya long before the Christian era. The stream is flowing uninterruptedly…. The enthusiasm for the quest for knowledge is ever more palpable today. The evolution of pediatric dermatology in India is ample evidence of this. This present article is a brief overview on the history and advancement of pediatric dermatology in India.

Pediatrics and pediatric dermatology: The beginning

To comprehend the evolution of pediatric dermatology, we should have a brief look at the progression of its mother branch, namely pediatric medicine. There was no special branch of medicine to take care of the sick children even two centuries back. Of course, one might cite examples of childhood ailments mentioned in the works of Hippocrates of Cos (BC 460-370), Celsus (1st Century AD), Oribasius (4th Century AD), Aetius (6th Century AD), and Avicenna (11th Century AD)……. but these were only a part of medicine in general. An early book on pediatrics came from the Arabic world. Rhazes (AD 865–925) wrote a book entitled Risala fi amraz al atfalwa 'I-'ianayabihim (The Diseases of Children). He described cradle cap, smallpox, and measles.[4] In the Western part of the globe, early work on pediatrics was done by an Italian, Paolo Bagellardo in 1472. In the coming two decades, another two books: one written in German by Metlinger in 1473 and the other in Belgian language by Roelans in 1483 marked the commencement of a new era. Thomas Phaer's The Boke of Chyldren (1544) was the first book on child disease in English language.[6] The London Foundling Hospital, established in 1745, was the first hospital devoted to diseases of children.[5] This trend continued for the next century, but Garrison observed that there was no “…. real existence (of pediatrics) before the middle of the 19th century.”[7] Thus, pediatric medicine was born on the later part of the 19th century and pediatric dermatology had to wait for another century.

Pediatric dermatology and its beginning: A brief overview

If the year 1972 is considered the “official” birth of pediatric dermatology, then the horizon of its history does extend beyond half a century back. However, a subject never appears de novo….it requires prolonged evolution. That the skin diseases of children received attention since the ancient times are evident in the writings of various authorities from Hippocrates (4th Century BC) to Avicenna (11th Century AD). After Avicenna, the next half of a millennium comprised of fruitless years of darkness. The 1472 book of Paolo Bagellardo described about tinea capitis, ear infections etc. and Leonellus Faventinus de Victriis in his book (1544) included chapters on aphthae, measles and small pox. In 1553, Giovanni P. Ingrassia wrote on rossalia (Scarlet fever) and measles. Hieronymus Mercurialis, in his Treatises on Diseases of Children (1583), mentioned about scrofuloderma. Dermatological disorders were mentioned by other authorities such as Sgambatus (1620), Baillou (1640), Bartholin (1646), and Savarinus (1652). These works were in languages other than English. In the year of 1653, Robert Pemell wrote a pediatric book, the second in English language, and it described skin diseases such as lice, scab and itch, sores on the head, measles, and pox.[6]

In the next 300 years, the world witnessed the havoc wreaked by smallpox, syphilis, scarlet fever and scrofula, plague (Black death) and porrigo (ringworms). This forced researchers to find out remedies that led to the accumulation of knowledge. Further, it was noted that up to 30% of pediatric patients used to present with skin problems.[8],[9],[10],[11],[12] These facts and figures necessitated the establishment of pediatric dermatology, a new division to meet the requirement. However, exactly when and where pediatric dermatology commenced its journey is not certain. If one considers the publication of a book or monograph on a particular topic determines the beginning, then A Treatise on the cutaneous diseases incidental to childhood by Dendy published in 1827 from London marks the occasion [Figure 1]. The first International Symposium of Pediatric Dermatology was held in Mexico City and the International Society of Pediatric Dermatology was formed in 1972 and as remarked by Harper, pediatric dermatology was “Officially born.”[4]
Figure 1: A treatise on the cutaneous diseases incidental to childhood, by Dendy. (1827) (Credit: https://creativecommons.org/public domain/1.0)

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Skin diseases of children: The Indian scenario

From antiquity to medieval period

It is remarkable that all the three oldest trio of Ayurveda, namely Charaka Samhita (Sutra sthanam 30:27), Susruta Samhita (Sutra sthanam1:7), and Vagbhata Samhita (Sutra sthanam1:5) included Kaumarabhritya (Pediatrics) as one of eight main organs of medical science. The mention of Kamarbhrityakushala (expert in pediatrics) physicians in ancient works such as Kalidasa's Raghuvamsham (3.12) and Kautilya's Arthashastra (1.16.10) is an indication of a well-developed practice of pediatrics in ancient India.[13] Before we elaborate further, it would be worthwhile taking a snapshot of skin diseases in children from the earliest period of the Indian medicine.

Vedas are the oldest religious texts of the Indo-Iranian races compiled before 1500 BC.[14] The Atharva Veda, one of the four Vedas, mentioned about worm infestation in children and an incantation for its treatment (AV5:23).[15]

The Purana s (1000 BC-700 AD) comprise literature that mainly dealt with history and genealogy.[16] The Garuda Purana described about congenital hemorrhoid of a child, dental caries due to krimi (infecting organism), inflammation of the palate, erysipelas, diseases causing ulcerations and blebs on the skin caused by Shakunigraha, Revatigraha. These balagraha s stood for some infecting invisible agents.[17] The Agni Purana contains a full chapter on childhood ailments, and description of diseases enumerated chronologically starting from the very 1st day of life up to 16 years. An example is a case of a monster (a putative infecting agent) called Urdhavagrahi possessing a child, following which it develops cyanosis on the 9th day of age. The diagnostic importance of body odor in various childhood diseases has been described in detail.[18] There is a plethora of literature such as Satapath Brahmana, Upanishad s, and Tantra s that contain knowledge on skin diseases of children.

In the later Vedic era, Ayurveda evolved as a science of life. Only a handful of Ayurvedic treatises are extant today, either in incomplete form or a redacted version. Among the various existing samhita s, Charaka, Sushruta, and Vagbhata are the main Ayurvedic texts worthy of mention.

The Charaka Samhita (c. BC 4th and 2nd century) described pediatric disorders in Sharirasthan (4, 8), Vimanasthan (8), and Chikitsasthan (30). It has discussed different issues like taking care of the skin including oral mucosa immediate postpartum, resection and aftercare of the umbilicus, with reference to infective and inflammatory conditions including umbilical hernia. The features of a normal healthy baby have been elaborated in detail.[19]

The Sushruta Samhita (c. 10 BC – 6th century) like Charak Samhita described not only the childhood diseases of skin but also about care to be taken soon after a bath. This extended from topics like how to tie, sever, and take care of the umbilical cord of the newborn to cleaning of the tongue and bathing of the newborn. Umbilical hernia, phimosis, paraphimosis, anal stricture, rectal prolapse, pruritus scrotii, and birthmarks among other various other diseases were discussed. The description and management of smallpox (masurika), scrofuloderma, and napkin rash (ahiputana) are fascinating. It has cautioned against misuse of thermal and chemical cautery in childhood.[20]

The third classic, AstangaHridaya of Vagbhata (c. AD 600) also dealt with various skin conditions of children such as ulvaparimarjana (cleaning of vernix caseosa), bathing soon after birth, and management of caput succedaneum, cleft lip and Rajika (miliaria with secondary infection) were also discussed.[21] Various balagraha s described in Ayurveda have been interpreted as microbes in modern times, and their affliction was associated with various skin diseases.[22]

Navanitakam (3rd or 4th century AD) known in the world of medical history as Bower Manuscript is an invaluable source of Indian medicine. The chapter XIV of this manuscript is fully devoted to pediatric diseases including those of the skin. It described the treatment for anemia, jaundice (2.14.21), oral and palatal infection including Rohini roga (Possibly Diphtheria) (2.14.22), ringworm, leprosy (may not be the leprosy of modern-day connotation), and vitiligo (2.14.24) in pediatric age group.[15],[23]

There were some specialized treatises of Kaumarbhritya, namely Hiranyaksha Tantra, Parvataka Samhita, Jivaka Samhita, BandhakaSamhita, Kumara Tantra of Ravana, and VriddhaJivakiya Tantra (Kashyap Samhita).[24] Of these, only Kashyapa Samhita and Kumara Tantra of Ravana are in existence today in incomplete form but occupy a special place as these are the first ever books in the field of pediatric medicine.

Kashyapa Samhita was a compilation and codification of knowledge by VriddhaJivaka (Jivaka the Elder) learned from the sage Kashyapa. Its probable date is on or before 600 BC. Only 78 out of 200 chapters are available.[25] This text, unlike other classics of Ayurveda, places Kaumarabhritya (Pediatrics) in the first place and deals mainly with the problems of childhood including issues about the wet nurses. It mentioned leprosy, vicharchika (possibly some blistering disorder), pruritus, boils, visarpa (Erysipelas), urticaria, hyperhidrosis, seborrhiasis capitis (Chikitsa), and charmadala (dermatitis). It has a separate chapter on the method of ear piercing (karnavedana) and process to increase the size of ear lobules.[26],[27]

From medieval era till the beginning of 20th century

The most significant feature of the medieval period (from post-Vagbhata period to the beginning of the colonial era) is the introduction of Unani and Tibb to the Indian soil that accompanied and patronized by the Islamic invaders. As this system was based on the Galenic principles and reinforced by scholars such as Rhazes (854–925), Haly Abbas (949–994), Avicenna (980–1037), Al Khoarizmi, and others, an altogether new concept changed the prevailing Indian scenario.

Rhazes was the first to describe the difference between measles and smallpox in his book Kitab fi al-Jadariwa al-hasbah.[28],[29] He in his Kitab al-Hawi fi al-Tibb wrote about the bathing of a newborn and advised avoiding ointments to evade the entrapment of dirt on the skin. His Practicapuerorum contains chapters on the skin lesions of children and scabies. Another towering personality of Arabic medicine, HalyAbbas wrote about the care of the newborn with salt and rose petals immediately after birth to strengthen the skin in his Kitab Kamil al-sina ah al-tibbiyia. The most celebrated master of Unani medicine is Avicenna. He in his Kitab al-Qanun fi al-tibb (the Canon of Medicine) described the care of the newborn, aphthous stomatitis, oral thrush, furunculoses, intertrigo, etc.[30] These works formed the foundation of the Unani system and are still followed by Unani physicians in India while treating childhood ailments.

From the invasion of the Europeans to the beginning of the pediatric dermatology

It was the 27th of May, in the year 1498. Vasco da Gama reached Calicut. This event marked the beginning of a new era, and many Western nations started trying their luck to occupy this land for trade, economic, political, and other gains. They added new flavor to the medical system of the country. The early medical education started in Goa under the Portuguese administration at the Royal College under Cipriano Valadares as early as 1703. Surprisingly, a course on gynecology, midwifery and child disease was added to the syllabus only in 1881. The same state of affairs continued with the British. The early medical curriculum did not contain any special book on sick children. A practice of smallpox vaccination was in vogue since antiquity, but children used to die of various diseases including skin diseases such as smallpox and plagues.[31]

The situation did not change much till the middle of the last century. In 1940s, there were around 12–15 pediatricians in the country and pediatric dermatology was a distant possibility![32],[33] A study from India showed that about 15.5% of the total dermatological referral was constituted by neonatal dermatological emergencies.[34],[35] Hence, the demand for a separate branch was on the rise.

Progress of the skin diseases of children: The “pediatric dermatology” way

As already discussed, pediatric medicine was at its nascent stage at the turn of the last century, but there are some great thinkers who could foresee the future. It was Dr. K. C Sahu, who in 1936 wrote an article in the Indian Journal of Venereal Disease and Dermatology entitled “Application of Pediatric Dermatology,” highlighting the importance and need of dermatology for pediatric patients. This was a beginning, but we had to wait for almost another half a century. An idea was gradually developing and was getting nurtured by the torchbearers of Indian Pediatric Dermatology like Dr. Deepak A. Parikh, Dr. Rui Fernanadez, and others in Mumbai, as early as 1986. In 1995, at the National Conference of the Indian Association of Dermatologists, Venereologists and Leprologists at Ahmedabad, base work was done with great endeavor of pioneers such as Drs. Deepak A. Parikh, Rui Fernandez, D. A. Satish, and H. Hanumanthappa to promote pediatric dermatology in an organized manner. A draft was crafted to establish the Indian Society for Pediatric Dermatology (ISPD). Dr. Rui Fernandez was the first President of the society with Dr. Deepak Parikh as Honorary General Secretary and Dr. Manish Shah as treasurer. The 1st National conference of the association was held in November 1996, with the notable presence of Dr. C. T. C. Kennedy, the then Chairman of the British Society for Pediatric Dermatology. The subject dealing with the skin diseases of children started its journey in a “pediatric dermatology” way.[36]

The formation of ISPD was the single most important landmark in the history of pediatric dermatology in India [Figure 2]. Founded by Dr. Deepak Parikh and Dr. Rui Fernandez, the society progressed to great heights under the proficient guidance of subsequent presidents such as Drs. D. A. Satish, H. Hanumanthappa, Deepak Parikh, Rajeev Sharma and Sandipan Dhar who provided a strong platform for the progress and reinforcement of pediatric dermatology in India. With further contributions from distinguished authorities on the subject like Dr. Manish Shah, Dr. Raghubir Banerjee, Dr. RajibMalakar, Dr. Rajesh Jadhav, Dr. Arun Inamadar, Dr. S. Criton, Dr. Rashmi Sarkar, Dr. Vibhu Mendiratta, Dr. Renu George and others, pediatric dermatology has become a strong pillar of dermatology in India within a very short period. Indian Pediatric Dermatology has also been enriched by a number of dedicated dermatologists like Late Dr. A K Dutta, Drs. A J Kanwar, Jayakar Thomas and a few more. ISPD was born with a motto of promoting the science of pediatric dermatology to excellence and to materialize this aim, it started various grants, awards, and support to dermatologists, especially the young generation working in this field, and arranged workshops to update dermatologists about the most recent developments in this specialty. The society has started an award for the best article published in the Indian Journal of Pediatric Dermatology (IJPD) in 2002. Under the leadership of Dr. Deepak Parikh, Chairman and Dr. Sandipan Dhar, President, ISPD has made a paradigm shift in its academic focus both in terms of quantity and quality and has achieved significant prestige not only among dermatologists but among the entire medical fraternity. While Dr. Deepak Parikh with his tremendous administrative and organizational experience and expertise has been nurturing the society for more than two decades, Dr. Sandipan Dhar has provided necessary succour to him in terms of scientific quality and credentials to the organisation and the journal. While Dr. Parikh is being supported by his two able and dedicated colleagues, Dr. Manish Shah and Dr. Rajesh Jadhav, Dr. Sandipan Dhar gets necessary help and support from his sincere and hardworking colleagues Dr. Raghubir Banerjee and Dr. Rajib malakar for regular activities of ISPD and the journal. These 'Six Masketeers' of the organisation form the skeleton of ISPD today. The annual national conferences of ISPD are now considered to be an epitome of science and academics in India. The ISPD has taken up the mission of guiding the management strategy of various diseases with an Indian perspective. One such task carried out by the ISPD is “Treatment guidelines for the atopic dermatitis by ISPD task force 2016.”[37]
Figure 2: Logo of the Indian Society for Pediatric Dermatology

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A cluster of young and energetic Dermatologists such as Dr. Sahana Srinivas, Dr. RamkumarRamamoorthy, Dr. Manjyot Gautam, Dr. ReshamVasani, Dr. Tarang Goyal, and a few more have joined ISPD and have been contributing to its growth by infusing newer ideas and concepts. There are many more much younger dermatologists who have been working for ISPD. Mr. Haridas Moule has been doing the office work of the association with great devotion. The future of ISPD appears to be quite bright.

Books and periodicals on pediatric dermatology: The Indian state of affairs

Once Prof. Karl Holubar commented:….medals, appointments, attempts at listing efflorescences, concepts of the organic nature of skin are all ephemeral. A book is tangible---something to get your hands on.[38] Truly the publication of books and periodicals mark the “physical” beginning of a subject.

With the formation of the ISPD, the need for an organ to discuss and communicate the activity of the society and academics was immensely perceived. Hence, a bulletin was started in 1996 under the editorship of Dr. D. A. Satish, the then Vice-President of the ISPD. In 1998, a resolution was taken in the Annual meeting of the society in Chandigarh to publish a complete journal that would replace the bulletin. The journal was entitled IJPD, and its editorial reins were deftly held by the Founder Editor Dr. Deepak Parikh since its inception in 1998 [Figure 3]. In no time, it became a place for publication of various interesting researches on the subject and was contributed by authors from far and near. With the effort of the subsequent editors such as Dr. D. M. Thappa and Dr. S. Criton, the journal continued its journey. The past issues of the journal have been archived, and back issues are available from volume 13(1), 2012. Dr. Sandipan Dhar, the present President and Editor took charge in July 2013 and with his immense experience in authorship and editorship, he steered the course of the journal by getting it indexed with various indexing bodies such as DOAJ, Baidu Scholar, CNKI (China National Knowledge Infrastructure), EBSCO Publishing's Electronic Databases, Exlibris – Primo Central, Google Scholar, Hinari, Infotrieve, National Science Library, ProQuest, and TdNet, and also scaling new heights.[39]
Figure 3: Cover page of the very first issue of the Indian Journal of Pediatric Dermatology (Courtesy of Dr. Manish Shah, MD, Mumbai, Maharashtra, India)

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Dermatology in India and Indian dermatology are not synonymous. Every country and region has a special effect on the disease process, and hence strategy for treatment is formulated depending on the social, economic, and demographic nature.[40] To guide the same, a treatise focusing on the clinical aspects of pediatric dermatology in India was the need of the hour. This task was met by the Color  Atlas More Details and Synopsis of Pediatric Dermatology authored by Dr. Sandipan Dhar in 2003, the first ever reference book on the specialty in India.[41],[42],[43] In recent years, many more books have been published by various Indian authors which depict the immense activity and advancement of the subject in the country.[44],[45],[46],[47],[48]

Epilogue

When the country is in dire need of dermatologists who could deal with all sorts of dermatological problem, can we really afford to have a sub- or super-specialty in dermatology? In answering a similar question, the editor of IJPD once wrote: It has now become difficult for one individual to know all facets of dermatology, which necessitates its bifurcation into a different subspecialty. This will help study diseases in greater depth and improve patient care, which is an ultimate goal of medicine.[49] How right it is! Unless, we cope with the rapidly changing global scenario we will lag, and this, in turn, deprive patients of their opportunity to get an updated answer to their ailments. Hence, the establishment of a subspecialty is highly justified. Pediatric dermatology as a new branch in India has established a precedence of attaining excellence in a very short period, keeping an eye on the development in a modern direction with an Indian perspective. It evolved much later but has matured fast to keep pace with global developments. The journal IJPD is only one of the 4–5 journals dedicated to the subject of Pediatric Dermatology in the world, although there are as many as 32 pediatric dermatology societies in the world. The best part of IJPD is that unlike other top-ranking medical journals (not only Dermatology) many in India the “International Advisory Board” in IJPD is not just an “ornamental body” of the journal. Each and every member of the body has been contributing some of the finest articles in the field regularly which add great value to the journal and its readers. This has of course been possible due to tireless efforts of all contributors and the painstaking efforts put in by the editorial team. For this full credit to the current Editor-in-Chief, Dr. Sandipan Dhar and his entire Editorial team for their hard work and dedication and continuous efforts to raise the bar of the journal. The journal, in fact, has taken the scenario of Indian Pediatric Dermatology to the Global readers and has been able to make its presence felt to the Global Pediatric Dermatology leaders in a slow, humble but substantial way! A special mention must be registered about by Mr. Tapas Kayal for his dedicated work as Editorial Assistant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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