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EDITORIAL: PUBLIC HEALTH AND SKIN DISEASER J Hay DM FRCPInternational Foundation of

Dermatology

Professor of DermatologyFaculty of Medicine and Health SciencesQueens University, Belfast, UK

Most of the work of dermato-logists is concerned withthe treatment of individ-

ual patients to the highest standardsachievable with the facilities and skillsavailable. However, it is seldom possibleto apply this to large populations in

most parts of the developing world, par-ticularly where the lack of resources andsparse populations make the adoption ofthis model of health care unattainable.In assessing the needs for these groups adifferent approach is necessary.

Public Health and SkinDisease

Dermatological public health has sel-dom been prioritised as a key objec-

tive in the overall management ofskin diseases, although it has a strong

COMMUNITY DERMATOLOGY: 2005; 2: 116 Issue No. 2 1

EDITORIAL

Public Health andSkin Disease Rod Hay 1

REVIEW ARTICLES

Treatment of Leprosy Antoon Baar &Ben Naafs 3

How I Manage Eczemain the Community Najeeb Ahmad Safdar

& Jane Sterling 6

ESSENTIAL DRUGS IN DERMATOLOGY

1. Gentian Violet2. Whitfields Ointment Ramadhan Mawenzi 9

QUIZ

Are All White SpotsVitiligo? Claire Fuller 10

TEACHING AIDS

Teaching Aids atLow Cost (TALC) David Chandler 13

ABSTRACTS

Journal Extracts andRDTC Reports Neil Cox 15

An International Journal for Community Skin Health

At a Health Centre, Afgooye, SomaliaPhotos: Murray McGavin

record which is often unrecognised. Forinstance, in the early part of the twenti-eth century many countries had policies

for the control of scalp ringworm whichranged from school exclusion orders tospecial treatment facilities. It resulted inpartial control but, in the absence of aneffective remedy, elimination remaineda distant goal. With the discovery ofthe drug, griseofulvin, the potential toprovide a wider programme based onthe treatment of communities becamepossible and, in some areas, there was aconcerted effort to eliminate tinea capi-tis using control teams.

Yaws and leprosy are further exam-ples of diseases where control measures,backed by international collaboration,have focused on elimination of infectionby early identification of cases and con-tacts and mass drug treatment.

Skin Disease and the WesternWorld

In recent years, the focus of publichealth in 'western world' dermatology

has concentrated on the control of themodern epidemic of a non-infectious

Afghan refugee child

CONTENTS J Comm Dermatol 2005; 2: 116 Issue No. 2

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Editorial

condition skin cancer. The relationshipbetween skin cancer and sun exposureis well established although individualsusceptibility and sun avoidance practicesare all elements of the complex equationin the development of skin cancer. Schooland general public education, the identi-fication of risk and the development ofearly recognition programmes have allbeen brought forward in many countries with promising results in reducing theincidence of skin cancer and improvinglong term survival. There is, therefore,a well established basis for the develop-ment of a public health approach to skindisease.

Developing Countries and

Skin Disease

In the developing world, the major-ity of skin conditions are commoninfective diseases for which there isusually a simple remedy. The problemsthat arise in the effective managementof these cases are the result of a com-bination of poor disease recognition,generally because there are insufficientindividuals with appropriate skills atprimary care level, and poor treatment

regimens, due to unavailability or lackof knowledge. Treatment regimens arealso often inadequately explained. Thisresults in much misdiagnosis and, inconsequence, wasted funding. Largeamounts of scarce resources available tohealth centres, dependant on inadequatestate or personal funds, are wasted ontreating skin disease badly.

Training and Primary Care

A key strategic target has been to redressthis balance by providing highly focusedtraining for primary care staff, eitherthrough the development of diagnosticand therapeutic algorithms or through

focused training and practical instruc-tion. An example of the former is thedevelopment of a training programme fordoctors and nurses at primary care levelin Mali where the four commonest dis-eases, pyoderma, tinea capitis, scabies andeczema are targeted. A second example isthe work of Estrada and colleagues inMexico where the focus of education isthe primary care team doctors, nursesand health promoters through formalfocused training sessions using patient-

based education. A third approach hasbeen to teach future health care teachersand leaders. The Regional DermatologyTraining Centre in Moshi, Tanzania, wasset up to train the future dermatologi-cal leaders in this field amongst medicalofficers and, latterly, through a regionaldermatology residency programme, der-matologists. The key to the successfulimplementation of all these initiativeshas been to show, firstly, that the educa-tion provided has led to an improvement

in learning and, secondly, that it has hadan impact on local disease levels.

Good Management andSpecialist Centres

The second part of a public healthdelivery approach is to ensure that thosewith skin lesions that signal the develop-

ment of a more severe underlyingproblem are recognised and managedappropriately, if necessary by referral toa specialist centre. The skin is the mir-ror of many other events affecting thehuman body. A good example here isHIV/AIDS where the early recognitionof skin or mucosal signs may providethe earliest clues for investigation, coun-selling and treatment. The increasingavailability of anti-retrovirals in parts ofthe developing world, where previouslythese had been unavailable, makes thisapproach both justifiable and practica-ble. Similarly, leprosy and onchocerciasisare both examples of important diseaseswhere skin signs allow early recognitionand treatment.

Public Health, Education andCommunities

It is possible to develop programmes,based on practical education, which canreduce the prevalence of certain diseasesand bring prompt, effective treatment atprimary care level. It remains less clearwhether it will be possible to eliminatethese conditions from particular areas.In almost all cases these programmes

are best developed through adopting anapproach which targets communities.Such public health initiatives have muchto contribute to dermatology.

2 COMMUNITY DERMATOLOGY: 2005; 2: 116 Issue No. 2

Journals available FREE

Contact: Dr Murray McGavinICTHES World Care, PO Box 408

Bankhead Avenue, Edinburgh EH11 4HE, UK

Tel:+44 (0)131 442 5339

E-mail:[email protected]

Please state: Name, Full Postal Address, E-mail Address & Occupation

Developing Mental Health

Community Ear & Hearing Health

Community Dermatology

Repair & Reconstruction

EDITORIAL:COMMUNITY DERMATOLOGY WHAT IS IT?

CONTENTS

JComm Dermatol 2004; 1: 116 Issue No. 1

EDITORIALCommunity Dermatology Whatisit? Paul Buxton 1

BOOKREVIEWAn AtlasofAfrican Dermatology Sam Gibbs 2

Barbara Leppard

REVIEW ARTICLESEmollientsand Skin Care Terence Ryan 3Skin SignsofHIV/AIDS Barbara Leppard 6Skin Changesin Leprosy Antoon Baar and Ben Naafs 10

JOURNAL EXTRACTS Neil Cox 14

In mostof the world, health care isprovidednotbydoctors butbyotherhealth care workers, such as nurses,

the majorityof themin small rural com-munities. Usually,there is verylimitedaccess to hospitals andmedical specialistsfortheirpatients.

Knowledge and Training

Inaddition to medical supplies, healthcare workers also needopportunities fortraining andfurthereducation. is isalreadyprovidedfor Dermatologyinsome centres, such as the Regional Der-matologyTraining Centre at MoshiinTanzania. e vastmajority of thesehealth workers, however, do nothaveaccess to such centres andan alternativeis to sendinformation to the workersin theirown situations. is is alreadybeing done by Community Eye Health,publishedbythe International Centre forEye Health forthe last16 years.Current-ly, 16,000 copies are distributedto 178

countries, four times ayear (free todeveloping countries).e founderof this

Journal, Dr MurrayMcGavin, has said;

Everyday, in communities throughoutthe world, individuals urgentlyrequirehealth care, yetall too often ahealth

workersimplydoes notknow what todo. Sadly, patients mayeven be harmed simplythrough lack of knowledge.

Editorial Board;ICTHES WorldCare

is Journal is intendedto provide guid-ance forhealth care workers in the areaof skin diseases andconditions such asleprosy, thatmanifestthemselves byskinchanges. ere is an Editorial Boardthatplans the policy, contentandmanage-mentof the Journal. Publishing anddis-tribution is being carriedoutbyICTHES

WorldCare acharitythatalso publishessimilarjournals in three otherspecialties.Itis fundedbyvoluntarycontributions.

VillageyoungpeopleinTanzaniaPhoto:Paul Buxton

COMMUNITYDERMATOLOGY:2004;1:116 IssueNo. 1 1

An International Journal for Community Skin Health

DEVELOPING MENTALHEALTH

An International Journal for Mental Health Care

AndrewSimsMA MD FRCPsychFRCPPastPresident,RoyalCollege of Psychiatrists,UKEmeritus Professor,Universityof Leeds,UK

DevelopingMentalHealthaimstosupportthose,eitherprofessionals orvolunteers,who are caring forand treating mentallyill people.Effective treatmentof the men-tallyill has onlybeenpossible inthe last50 years,and so itis importantnow thatanyone looking afterthemnotonlythinksabouttheirqualityof life whilstill,butalsothe possibilityof appropriate treatment.Buthow doyou start?

Medical Model

This is where the so-called medicalmodelis useful.Rational treatmentcanonlybeginwhen the problem/diagnosis has beenworked outquite precisely:thenapplyingthe programme of treatmentthatis,ingen-eral,suitable forthat specificdiagnosis.

Diagnosis

Diagnosisis reallyonlyatechnical termforwhat all profes-sional people do.Themedical modelis,of course,notonlymedical.If you consultabankmanageraboutadebt,ora lawyeraboutbuyingahouse,theygothroughasimilarprocess.Thefirstthing the profes-sional personhas todois work outwhatthe problemis,whatgeneralcategoryitcomes into,whetherdebtorhouse purchase. Thenprofessionalproblemsolving is applied and,hope-fully,the professional comes up withtherightprocedure.However,theywould nothave doneso had theynotfirstdecidedwhattype of problemitwas. Diagnosisis asimilar process,but inthe healthfield.

Whatis this probleminterms of myprofessional expertise?

Inwhatwayis itsimilartotheproblemsof some otherpeople?

Whatwas itthatworked when we triedtohelpthem?

Now,wewill use the same,generalprogrammeforthis individual.

1

Volume 2Issue No. 22004

Developing Mental Health (2004),2,116 Issue No.2

Editorial:Issue No.2 Andrew Sims 1

Management of an Acute PsychoticEpisode EvelynSharpe 2

M ental H ealth C ar ei nPr i mar yH eal th C ar e: P eter V entevo gel ,Fr ank K o rtmann 5 Experiences fromEastern Afghanistan

C ul tur al Fac to rs i n M ental H ealth and I l l ness: Jo seph ONeil l Byrne,C athyM yers 8 Normalityand Abnormality

Abstracts 9,15

I s Rel i gi o us Bel i ef Bad f o r Yo ur H eal th? ( Bo ok Revi ew ) Andrew S i ms 1 0

M e nt a l He a lt h C a re i n Pr i ma r y an d C o mm u ni t y Se t ti n gs : S h ek h ar S ax e na , Pa l la b M au l ik , 1 1Results fromWHOSProjectAtlas (Courtesyof the Kathryn OConnell,BenedettoSaracenoInternationalJournalof SocialPsychiatry)

Psychiatryin Nigeria(Courtesyof InternationalPsychiatry) Oye Gureje 13

Developing Mental Health: Issue No. 2

An International Community Trust Publication for Health & Education

In MozambiquePhoto: Murray McGavin

Thesecondedition ofRepair & Reconstruction isa

natural followon fromthefirstand dealswithspecifictypesofburn injuriesaswell astheman-

agementofthelateconsequencesofburns.

Hand Burns

Handburnswhilstoften notinvolvingalargesurfaceareacan havecatastrophicconsequences,especiallyifnotman-

agedcorrectlyin thefirstinstance.For thisreason thereisasubstantial chapter on thecareofhandburnsandit ishopedthatthiswillhelptoreducethedisabilitycausedby

RReepapaiirr&& RRececoonnststrruuccttiiononInjury, Deformity & DiseaseInjury, Deformity & Disease

Volume 2 Issue No.2 2001

AN INTERNATIONALCOMMUNITYTRUST PUBLICATION FORHEALTH ANDEDUCATION

R EP A

IR

R EC

ONSTRU

CT REHABI LI T

AT

E

A JA JOOUURRNAL FNAL FOORR

Editorial:BurnInjury(2)TOMPOTOKARFRCS(Ed),SpecialistRegistrar,BurnsandPlasticSurgeryMorristonHospital,Swansea,Wales,UK

Repair & Reconstruction Vol.2No.22001

BURNBURNINJURYINJURY((2)2)Editorial T om Po to ka r 1

HandBurns S t ua r tW a ts o n 2

HeadandNeck Burns J im my J am es 5

PerinealBurns P et er Dr ew 6

ChemicalBurns T om Po to ka r 8

ChemicalEye Injuries M u rr a yM cG a vi n 9

ElectricalBurns NithinVaingankar,IanGrant&

A n ku r Pa n dy a 1 0

PrinciplesofTreatment of BurnContractures A n ku r Pa n dy a 1 2

SurgicalTechniques:i)The Y toVPlasty T i mG o od a cr e 1 3ii)The Z-Plasty A l an M cG r eg o r 1 4ClinicalArticle:ChemicalBurnsinKaduna M a la ch y As u ku 1 4

thistypeof injury in the

future.

FacialBurnsandPerinealBurns

Facial andperineal burnsalso haveparticular prob-lems,notjustin termsof

function,butalso in termsofresid-ualdeformity.Reconstructiveoptionsin thesecasescan belimitedand

verydifficult,thusappropriateinitialmanagementisvital.

Thermal, ElectricalandChemicalBurns

Although thermal burnsarethemostcommon typeofburn,electrical and,

increasingly, chemical injuries arebecomingmore frequent.In particu-lar, chemicals used in assaults pro-

duce devastating injuries, and anylegislation aimed at reducing theincidence of this must be welcome.Burnspatientswho presentlate,who

have taken a long time to heal, orwho have been incorrectly treatedpresentwithvariousproblemssuch

ashypertrophicscars,contractures,jointdeformities,pigmentarychangesand unhealing ulcers. These chal-

lengingproblemsaredifficulttotreat,eveninthebestcentresandtherapymust be aimed primarilytowardsrestorationoffunction. It is impor-

tantthatpatientshavearealisticideaofthelimitationsoftreatment,whilstat the same time maintaining an

optimisticenvironmentto encouragepatient participation in post-opera-tivesplintingandphysiotherapy.

Surgeryand Rehabilitation

Chosen appropriately,skin graftingandlocal flapssuchastheZ-plasty

andtheYto V plastycan bebenefi-cial in thetreatmentofcertain con-tractures.However,theseprocedures

shouldnot beundertaken unless

theyarelikelyto causeasignificantimprovement.A failedprocedure,oronethatachievesnothingisdiscour-

agingforboth thepatientandthet e a m looking a ft e rh im orh e r .Patientswho haveburns havealreadysufferedboth physicallyand

psychologically, andall thoseinvol-vedin their care should endeavourto optimisetheir final outcome.Re-

habilitation in thesecasesisoften averylongandslowprocess,however,andcarefulfollowupwithwelltimed

interventionscan maximise thefunctional,aestheticandpsychologi-cal outcome.

Repair & Reconstruction

Theresponsetothe firsteditionofRepair & Reconstruction hasbeen

e n c ou ra gin g ,a n d a lt h ou g h t h earrival ofthesecondissuehastakenlonger than expected,I hopethewait

hasbeen worthwhile.Thenextissuewill be concernedwithhandinjuries.Anysubmissionsto theclinical arti-cles section shouldbeaddressedto

theEditor.

Post-operativePOPsplinting(hand notyetreleased)

Photo: Tom Potokar

Elbow released to90Photo: Tom Potokar

Severe post-burn elbow contractureundergoingfirststagerelease

Photo: Tom Potokar

1

cm

COMMUNITYEARAND HEARINGHEALTH:2004;1:116 IssueNo.1 1

EDITORIAL: A NEWJOURNALAndrew WSmith

Wel cometothef i r s t i s s ueof Com-munityEarandHearingHealth.Wehopethat thisnew internationalJournalwillfillan urgentneed in raisingaware-ness,andprovidingknowledgeand skillsforearand hearinghealthin developingcountries.

Hearing loss is one of the common-estdisabilities in the world,and yet alsoone of the most neglected. Ear disease,especially in children, isoneofthe mostcommon reasons forneedinghealthcare,yet thereismuchignoranceabout itand

a hugeshortageofskilled healthworkersin thisfield.

Thesesituationsapply particularlyindevelopingcountriesand areworst in thepoorestcountries.

HearingImpairmentWorldwide

TheWorldHealthOrganization estimatesthatin 2000there were250million peoplein the worldwith disablinghearingloss(moderateorworsehe aringimpairment

in the better ear), anda fur-ther 340 million with mild

hearingloss.Of these, 62 million per-

sonshavemoderateor worsehearing loss that began inchildhood and104 millionsuchpersonshavemildhear-ing loss. Two thirds of the

burden of hearing loss is indevelopingcountries, andthenumberofpeople with hear-inglosscontinuestoincrease.

Consequencesof

HearingImpairmentDeafness and hearinglosshaveprofoundeffectsonindividuals. Hearinglossdam-

agesdevelopmentofspeech andlanguagein children especially, ifcommencing atbirth or duringinfancy,and later slowsprogressin school.Italso causesdifficultyin obtaining,performingand keepingajob andit produces social isolation andstigmatisation at all ages. These effectsare magnified in developing countries.

Inaddition tothe effects on individuals,

hearingloss produces a hugeeconomicburden on societyso thatprevention ofhearingloss is likely to be a very goodinvestment.

At least50% of theburden ofhearinglossindevelopingcountries can bepre-

ventedwith current knowledgeandmanymore people with hearing loss can betreated or givenrehabilitation.

HearingImpairment:Awareness,Prevention,Management& Rehabilitation

A critical problem in dealing with thisproblem is the lack of awarenessabout

hearingand hearinglossin all parts ofsociety.Mostpeoplearenot awareoftheeffects ofhearinglossandeardisease onindividuals, andpoliticiansanddecisionmakers arenot awareofthe largenum-berswith hearinglossanditshighcost onsociety.Programme plannersandhealth

workersarenotawareoftheopportunitiesforprevention, management andrehabil-itation of hearing lossandeardisease.

Thereisa critical lack oftrained per-sonnelin the necessary health, rehabili-tation and education fieldsat all levels.

Testingforhearingimpairment in Madagascar

Photo:Andrew Smith

CONTENTS

CommunityEarandHearingHealth2004;1:116 I ssue No.1

EDITORIAL AndrewW Smith 1REVIEWARTICLESConge n i ta l De afnes s in De ve lopingCountrie s I an J M ackenz ie 3Early De tect ion o f He aring Impa irme nt Va lerie E Newton 4

Managementof OtitisMedia in a DevelopingCountry JoseMAcuin 6TrainingforPrimaryandAdvancedEarandHearingCare Pietvan Hasselt 8ProvidingEducational ServicesforChildren withH ea ri ng Im pa ir me nt B ea tr iz C Wa rt hR ay ma nn 1 0WORLDHEALTHORGANIZATION:REPORTWWHearing:World-WideHearingCareforDevelopingCountries 12INTERNET RESOURCES 12

ABSTRACTS 13JOURNALOF COMMUNITYEARANDHEARINGHEALTH:GuidelinesforAuthors 15

2004;1:116 IssueNo.1

to Developing Countries

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Treatment of Leprosy

Antoon J M BaarMD DiplTM&H

Consultant DermatovenereologistRegional Dermatology Training Centre(RDTC), Moshi, TanzaniaCorrespondence to: De Zwette 549257RR NoordbergumThe NetherlandsE-mail:[email protected]

Ben Naafs MD PhD DiplTM&H

Consultant DermatovenereologistRegional Dermatology Training Centre(RDTC), Moshi, Tanzania

Visiting Professor, Instituto Lauro deSouza Lima ( ILSL), Bauru, SP BrazilSenior Lecturer, IjsselmeerziekenhuizenEmmeloord/Lelystad andLeiden University Medical Centre(LUMC), Leiden, The NetherlandsGracht 15 8485KN MunnekeburenThe NetherlandsE-mail:[email protected]

Treatment of Leprosy has TwoMajor Goals:

1. Treatment of the individual patientto prevent him or her from becomingdisabled and a social outcast.

2. To lower the incidence of the diseasein the hope of eradicating leprosy asa communicable disease.

From an epidemiological point of view

it is important to treat the most infec-tious patients (BL and LL patients)with a form of treatment which rendersthem non-infectious as soon as possible

(Figure 1). The larger group of TT BLpatients should also be treated as soon aspossible in order to prevent them frombecoming disabled due to serious nervedamage (Figure 2). In practice, this

means that early diagnosis is very impor-tant for the treatment of both the indi-vidual patient and for the community asa whole.1

Treatment Involves:

1. Antibacterial therapy.2. Anti-inflammatory treatment of

leprosy reactions.3. Treatment and rehabilitation of

disability due to nerve damage.

4. Prevention of spread of the diseasein the community.

1. Antibacterial Therapy

Monotherapy (treatment with a sin-gle drug) is no longer recommendedbecause of widespread drug resistance.In 1982, the World Health Organiza-tion (WHO) recommended multi-drugtherapy (MDT) for all patients.2 Treat-ment regimens are based on a simplified

classification of leprosy (see box below).The tablets are provided to the

patients free of charge and come inblister packs (Figure 3). Each pack con-tains enough tablets for 4 weeks. The

Review Article


LL BL BB BT TT0

+

++

+++

Numbersofbacilli

Clinical spectrum of disease

Resistance (cell mediated immunity) to M. leprae

Spectrum of clinical disease in leprosy: LL = lepromatous leprosy;BL = borderline lepromatous leprosy; BB = borderline leprosy;

BT = borderline tuberculoid leprosy; TT = tuberculoid leprosy

Fig. 1: The leprosy spectrum of disease

Fig. 2: Lagophthalmos after bilateral facial nerve damagePhoto: John DC Anderson

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Leprosy

tablets for the 1st day of each periodare swallowed under supervision in theclinic and patients have to report every4 weeks. At each visit they are examinedand told to attend in another 4 weeks.They are warned to attend immediatelyif there is any problem. If the skin signsare improving and the nerves are notenlarged and/or tender the patient gets anew blister pack.

Patients who miss an appointmenthave to extend their treatment up to amaximum of 9 months for PB and 36months for MB leprosy. Patients whohave not used all their tablets in thatperiod will need to repeat the wholecourse of treatment.

2. Anti-inflammatory Treatmentof Leprosy Reactions

There are two types of reactions:

Type-1 or reversal reactionsin TT andborderline leprosy. In these patients,acute inflammation develops. Affect-ed nerves become tender or painful,skin lesions become swollen and red.There may be rapid loss of nervefunction, if not treated. Some type-1

reactions occurafter treatmentis finished, sothe treatment ofleprosy patientsdoes not endwith the lastblister pack ofMDT!

Type-2 leprosyreaction or ery-thema nodosumleprosum (ENL)is an immune-complex reac-tion in patientswith LL leprosy.It is a general-

ised inflamma-tory process not only of the skinand peripheral nerves but of manyorgans of the body. The frequency ofENL has been halved since the intro-duction of MDT, but again somepatients are developing ENL afterfinishing their treatment.

Treatment of type -1 reactions

Start treatment immediately with

prednisolone 3040mg/day (Figure 4).Once the reaction is under controlcontinue with a reduced dose of pred-nisolone as follows:

Patients with BT leprosy: 36 months Patients with BB leprosy: 69 months Patients with BL leprosy: 6 months

2 years.

It is a mistake to stop treatment toosoon.

When a painful, very enlarged nervedoes not respond to prednisolone, sur-gical decompression of the involvednerve should be done as soon as pos-sible. Always check these patients forsigns of other infections and infesta-tions, especially for TB and intestinalworms (especially Strongyloides), andtreat these diseases if found.

Treatment of type-2reactions (ENL)

ENL is an episodic, self-limiting diseasebut it is a generalised disease with manyorgans of the body involved. Treat-ment depends on the severity of thesymptoms:

Mild forms of ENL with painful skinnodules only will usually subsidewithin 24 weeks. Treat with analge-sics (aspirin 600mg qds, or a NSAID,e.g., diclofenac 50mg tds).

For moderate forms of ENL, where

patients have more extensive pain-ful skin nodules +/- ulceration,together with fever, leucocytosis andgeneral malaise but no involvementof joints, nerves, eyes or testes, treat


Fig. 3: Blister packs provided by the government for thetreatment of leprosy

WHO Classification of Leprosy

Multibacillary (MB) Leprosy

patients with > 5 skin lesions positive skin smear

Paucibacillary (PB) Leprosy

patients with 15 skin lesions negative skin smear

(1) MDT for multibacillary leprosy

One blister pack for 4 weeks

Day 1

Rifampicin 600mg (2 capsules) } Clofazimine 300mg (3 capsules) } given under supervision Dapsone 100mg (1 tablet) }

Days 228

Clofazimine 50mg (1 small capsule) Dapsone 100mg (1 tablet)

Duration of treatment 24 months = 24 blister packs

(2) MDT for paucibacillary leprosy

Day 1

Rifampicin 600mg (2 capsules) } given under supervision

Dapsone 100mg (1 tablet) }Days 228

Dapsone 100mg (1 tablet)

Duration of treatment 6 months = 6 blister packs

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Leprosy

with analgesics (as above) and addstibophen (Fouadin) 23 ml dailyfor 3 days.

In the more severe forms of ENLwith signs of arthritis and/or nerveinvolvement give analgesics (as above)plus chloroquine 300 mg/day.

In very severe ENL, patients have asevere generalised disease with orchi-tis, iridocyclitis, neuritis and arthri-tis. Start treatment with high dosesof prednisolone (120 mg daily) fora short period, diminishing to zerowithin 23 weeks. Avoid maintenancedoses of steroids. If there is a flare-upduring the period of drug reduction,double the dose of prednisolonebeing used at that time and then try

again to reduce the dose quickly.When the episodes of severe ENL arefrequent and short courses of highdose prednisolone are not stoppingit, add thalidomide as a maintenancedrug between prednisolone pulses.Start with 300mg at night. When thereaction has subsided continue with150 mg nocte. Remember that tha-lidomide is teratogenic, so do not giveit to pregnant women. Patients withsevere, frequently relapsing forms of

ENL should be referred to an experi-enced leprologist.

3. Treatment andRehabilitation of Disabilities

The curse of leprosy has always been thesevere disabilities of hands, feet, face andeyes due to peripheral neuropathy and/or iridocyclitis. Such disabilities lead tosocial isolation and poverty. Preventionof disability depends on early diagnosis

and treatment, especially the early treat-ment of leprosy reactions.

Unfortunately, there are still patientswho come late for treatment and whoalready have irreparable nerve damagewhen they are first seen. With healtheducation, timely wound care, specialshoes and various aids to help replacethe loss of function in the hands andfeet, further damage can be prevented.Orthopaedic and plastic surgery is some-times needed to correct anatomical and

functional abnormalities. Correctionof lagophthalmos, corneal transplanta-tion and other specialised ophthalmicprocedures can restore vision in somepatients.

4. Preventionof Spreadin theCommunity

The goal of healthprogrammes is

eradication of lep-rosy worldwide.Although the preva-lence (total numberof patients in apopulation) of lep-rosy has decreaseddramatically in thelast 25 years, theincidence (numberof new patients/year in a population) remains the same.

This means that leprosy, although treat-ed at an early stage (and the patientscured), remains as infectious as before.For a realistic strategy to eradicate lep-rosy the following facts have to be keptin mind:

In most countries with a high inci-dence of leprosy, the socio-economicsituation is poor and so funds and agood infrastructure for eradicationcampaigns are low

Case finding of early leprosy cases isdifficult in integrated primary healthcare schemes

The incubation period of leprosy isvery long up to 15 years

Vaccination with an antigen specificforM. lepraeis not yet available

The influence of the HIV-epidemicon the transmission ofM. leprae isnot known but there are indicationsthat HIV-patients, who also haveasymptomatic multibacillary leprosy,

are a serious source of infection tothe population at large

Care of disabled patients with burnt-out leprosy who no longer needspecific anti-leprosy drugs, remainsimportant. Otherwise the generalpublic will not believe that leprosy,is curable.

With these facts in mind, the followingare possible ways of dealing with leprosyas a public health problem:

MDT treatment for all leprosypatients as early as possible

Health education and BCG vaccina-tion to the general public (see box)

Rapid access to health facilities with

expert staff for patients with leprosyreactions or other complications ofthe disease

Good aftercare for leprosy patientswith disabilities

Research into the influence of theHIV-epidemic on the spread of lep-rosy.

BCG Vaccination in Leprosy

Gives better protection against M.lepraethan againstM. tuberculosis

Protection against M. leprae variesfrom 80% in Uganda to < 30% inAsia

Estimated time to lower the inci-dence of leprosy by 50% is:

8 years with BCG vaccination 43 years without BCG vaccina-tion.

References

1. Baar AJM, Naafs B. Skin changes inLeprosy. Comm Dermatol2004; 1:1016.

2. WHO Chemotherapy of leprosy for con-trol programmes. WHO Tech Rep Ser1982;675.

3. WHO Expert committee on leprosy. 6threport. WHO Tech Rep Ser1988; 768.

4. Naafs B. Treatment duration of reversalreaction: a reappraisal. Back to the past.Lepr Rev2003; 74: 328336.

5. Naafs B. Reactions: The body as battlefield.III: Treatment. Memisa Medisch 2003; 69:343346.


Fig. 4: Type 1 reversal reaction (left) and the same patient after48 hours of prednisolone treatment (right)

Photos: Margreet Hogeweg

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Najeeb Ahmad SafdarMBBS MRCP(UK)Consultant Dermatologist

Department of DermatologySeremban Hospital, Jalan Rasah

70300 Seremban, Negeri Sembilan,

Malaysia

Honorary Senior Lecturer, International

Medical University, Seremban, Malaysia

Jane Sterling FRCP PhDHonorary Consultant

DermatologistAddenbrooke's Hospital

Cambridge CB2 2QQ

UK

Eczema is a group of skin disorderscharacterized clinically by red-ness, itching, oozing, scaling and

thickening and occasionally blistering ofthe skin. It is probably the most com-mon skin condition seen in the commu-nity. The terms eczema and dermatitisare generally used interchangeably todescribe the same condition.

The clinical picture depends on the

stage of the eczema which can be dividedinto:

Acute Eczema

Characterised by intensely itchy andoccasionally painful erythema, oedema,papules, vesicles, occasionally bullae,exudation (weeping) and crusting.

Chronic Eczema

Characterised by dry, scaly, thickened orlichenified lesions with occasional fis-sures, which may be very painful, andpigmentary changes.

Subacute Eczema

Features of both acute and chroniceczema. Frequently redness, minimaloedema, dried-up vesicles and crusting.

There are many different types ofeczema (Table1), all of which can vary

from mild to severe. They can usuallybe classified into Exogenous/ContactEczema (due to external factors) andEndogenous Eczema (due to internal orconstitutional factors).

Management

A management strategy (Table 2) is

essential. It is often helpful to considertreatment in two phases managementof the acute disease and then longer-term measures to maintain control andminimise the risk of flares. The firstimportant step is to diagnose correctlythe type of eczema, as this can influencethe management.

Diagnosis

The diagnosis of the different types of

eczema depends upon the history, char-acteristic clinical features occurring attypical distribution sites of the body andthe age of onset. The severity of eczemadepends upon the extent of body surfacearea involvement and intensity of red-ness, swelling, oozing, dryness, excoria-tion and lichenification.

Treatment

Most eczema patients can be managed

in the community. Care and treatmentincludes:

General measures for all types ofeczema targeted towards control ofskin inflammation, dryness, oozing,itchiness and occasionally secondaryinfection

Specific treatment for particularstates or types of eczema

Provision of education and counsel-ling.

The aims of general treatment are:

Cleansing and soothing of the skinplus improvement in skin barrierfunction by the use ofemollients

Avoidance of any precipitating orexacerbating factors

Reduction in skin inflammation bythe use oftopical steroids. Occasion-ally may be necessary for more per-sistent, severe and uncontrolled skininflammation

Reduction of skin damage caused byscratching by means of itch reduc-tion usingantihistamines

If skin is oozing and exudative,astringent preparations can reduceblistering and weeping from skin

Eradication by anti-bacterial, anti-

viral or anti-fungal therapy of sec-ondary skin infection, if present Counselling and education to allow

patients to maintain their ownlonger term treatment and to recog-nise acute flares and their need foraltered therapy.

Emollientshave a pivotal role and shouldbe used liberally in all patients. Skinaffected by eczema is frequently dry andas inflammation settles, the skin usuallypeels. These effects reduce the barrier

function of the skin and so increase theirritant effects of water and detergents,leading to further inflammation anditch. This cycle can be broken by regularuse of emollients.

Aqueous cream is the most commonlyused. It is cheap and suits most people.Patients are advised to use the cream intwo ways:

a) As a soap substitute, i.e., applieddirectly onto wet skin, massaged

gently on the affected skin and thenwashed off with water, and

b) Gently rubbed into skin as a mois-turiser 45 times a day.

Review Article


How I Manage Eczema in the Community

Endogenous Exogenous

1. Atopic eczema 1. Irritant contact dermatitis2. Seborrhoeic eczema Acute irritant3. Discoid eczema Cumulative insult4. Juvenile plantar dermatosis5. Pompholyx / dyshidrotic eczema 2. Allergic contact dermatitis6. Stasis eczema7. Lichen simplex8. Asteatotic eczema

Table 1: Types of Eczema

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Eczema

Emulsifying ointment can also be usedbut is more difficult to apply as it isfirmer and more greasy. It can be mixedinto twice its volume of very hot water tocreate a milky emulsion to be added intobath water.

There are many other commerciallyavailable emollients which are usuallymore expensive and not necessarily ofgreater benefit. However, some cannottolerate aqueous cream or emulsifyingointment. Children in particular oftenfind that heavier, greasier products maketheir skin feel more itchy and youngchildren may complain of stinging afterapplication of aqueous cream. Somepatients may develop a contact allergy toa particular preservative used in a cream.In these situations other emollientsshould be tried until one is found thatcan be tolerated.Topical steroidsare the mainstay in thetreatment of inflammation in eczemabut many patients and parents are con-cerned about their potential side effects.In general, use the lowest strength topical

steroid that will keep the eczema undercontrol (Table 3). Another approach isto use potent topical steroids for shortduration (12 weeks) to bring eczemaunder control quickly, then reduce thepotency. Potent topical steroids shouldnot be used in children without care-ful supervision and the same applies toadults for large areas, face and flexures.The very potent topical steroids shouldonly be used in adults for rare localisedsevere/resistant cases and on palmar/

plantar skin, sometimes with occlusion.Most topical steroids should be appliednot more than twice a day. They maybe combined with topical antibiotics tocontrol bacterial secondary infection.

Amount to be used:

The amount of very potent steroid usedshould be less than 50g per week for an

adult.A rough guide to estimate the amount

of topical application required is:

1% of total body surface area requires0.25g each application

Use rule of 9 to estimate amountrequired for large areas

The fingertip unit (F.T.U.) is a con-venient way of indicating to patientshow much of a topical steroid shouldbe applied to skin at any one site.One finger tip unit is the amountof steroid expressed from the tubeto cover the length of the flexor aspectof the terminal phalanx of the indexfinger (1 F.T.U.= 0.5g = to cover1 hand/foot/face)

Choice of formulations:

i. Lotions for exudative lesions.ii. Creams for dry lesions.iii. Ointments for very dry lesions.

iv. Lotion or gel for scalp.Astringents are used to dry up lesionsduring vesicular or exudative stages.Examples are potassium permanga-nate, 1:10,000 dilution (deep pink incolour) or normal saline. The affectedparts are soaked in the selected solutionfor 10 to 15 minutes each time, once ortwice a day, depending on the severityand response. The solutions can also beapplied as cool compresses for a similarlength of time.

Oral antihistamines can relieve itch.Most patients find some symptomaticrelief but the main benefit may be large-ly due to their central sedative effect.

The sedative antihistamines are there-fore helpful in reducing pruritus and inallowing everyone in the family to sleep.

Examples of sedative antihistamines

are hydroxyzine, alimemazine (trime-prazine), promethazine and chlorphenir-amine maleate.

Secondary bacterial infection is com-mon and may cause acute exacerbationsof eczema. Staphylococcus aureusis almostalways responsible. Swabs for bacterial cul-ture and sensitivity should be sent. Topi-cal antibiotics should be used in smallareas of localised infection, e.g., Fucidinor mupirocin, but more severe or wide-

spread infection requires a concomitantsystemic antibiotic, eg., cloxacillin,erythromycin and cephalosporins.

Counselling and educationis essential inany disease especially in chronic condi-tions such as eczema. Patients and par-ents are often anxious when the diagnosisis made and need to be reassured thatthe condition is not contagious. Care-ful explanation of the disease, the maincauses of exacerbation and its manage-ment, especially with regard to the cor-rect use of emollients and topical steroidsis required. Patients and parents will notunderstand how to use their treatmentsuntil they are shown. Such demonstra-tions are central to teaching them how tocare for their skin disease.

Systemic therapyis needed only rarely fora very small proportion of people witheczema. Oral corticosteroids or injec-tions should be avoided, if possible, butoccasionally may be prescribed for short

periods (oral prednisolone, 0.5mg/kg/day for 12 weeks) and intermittently(triamcinolone injections 0.51mg/kg)when other measures have failed or totreat a severe, acute flare.


Diagnosis Exclude/avoid contact irritants/

sensitizers Emollients soap substitution.

Moisturise frequently and use

emollient bath oils Anti-inflammatory agents topical

steroids Antihistamines to relieve itch Treatment of secondary infection Education reassurance,

explanation, prognosis Psychosocial support

Table 2: Management Strategy

Potency Example

Mild 1% hydrocortisone (e.g., Efcortelan)

Moderate 0.05% clobetasone butyrate (e.g., Eumovate)1 in 4 dilutions of potent topical steroids

Potent 0.1% betamethasone valerate (e.g., Betnovate)0.1% hydrocortisone butyrate (e.g., Locoid)0.025% beclometasone dipropionate (e.g., Propaderm)0.05% betamethasone dipropionate (e.g., Diprosone)

Very potent 0.05% clobetasol propionate (e.g., Dermovate)0.3% diflucortolone valerate (e.g., Nerisone Forte)

Table 3: Strengths of Topical Steroids

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Eczema

Specific Treatments forVarious Types of Eczema

Atopic eczema (Figure 1) can be exac-erbated by various air-borne allergenssuch as house-dust mite, animal fur andpollens. If possible, contact with known

allergens should be minimised. Regular,life-long use of emollients will reduceexacerbations and pruritus. Cool cloth-ing and bedding will reduce skin irrita-tion and hence reduce scratching.

Seborrhoeic eczema(Figure 2) occurs onthe greasy areas of the face and upperbody. Reduction in the skin yeasts byapplication of an imidazole cream,combined with a mild topical steroidwill usually keep this condition undercontrol.

Discoid eczema (Figure 3) frequentlydoes not respond to mild or moderatestrength topical steroids and may often

need short periods of treatment with apotent or very potent steroid.

Juvenile plantar dermatosis affects thesole, especially the forefoot, usually inchildren and young teenagers. It may beexacerbated by occlusive footware andoften clears after puberty. Regular use ofemollients is essential to control the dry-ness and fissuring of the skin.

Pompholyx / dyshidrotic eczema(Figure 4) affects the palms and / or soles,producing itchy and uncomfortable blis-ters. Astringent preparations and potenttopical steroids are often necessary.

Stasis eczemaresults from venous hyper-tension. Control of the underlying prob-lem with elevation, elastic support and,

where possible, exercise will all help toreduce the eczema, but occasional mildtopical steroid, in combination withregular emollients will minimise the skininflammation.

Lichen simplex (Figure 5) is a chroniceczema, maintained by the habit ofscratching or rubbing a specific area ofskin. The effects of moisturisers andshort-term use of potent topical steroidscan be augmented by occlusion withpaste-impregnated bandaging or zincpaste applied over the steroid at night.The paste preparation is lifted off with acream wash the following morning.

Asteatotic eczema is most common

on the lower legs and may be a sign ofhypothyroidism or malnutrition. It canalso be caused by repeated washing withsoaps or detergents. Plentiful and regu-lar application of emollients may be theonly treatment needed.

Exogenous eczemashould be treated byavoidance of the causative contact agentas well as general measures. If a contactallergy is suspected, the cause may beidentified by allergy patch testing or an

open usage test.Ideally, any patient with a diagnosis

of eczema should have adequate educa-tion about their condition and availabletherapy to maintain their skin in a goodor moderate condition. In addition, theyrequire ready access to a health profes-sional with knowledge of skin diseasemanagement for help with acute flares,when extra therapy will often be needed.


Fig. 2: Seborrhoeic eczema

Fig. 5: Lichen simplex

Fig. 4: Pompholyx

Fig. 1: Atopic eczema; most commonly

starts in infancy on the face and scalp

Fig. 3: Discoid eczema

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Ramadhan L MawenziDipMed ADDV

Chief Dermatology Officer

Egerton UniversityKenya

1. Gentian Violet

Gentian Violet (Crystal Violet) wasdiscovered by Churchman in 1912.It is a methylrosaniline chloride dyewhich is effective against Gram positivecocci, especially Staphylococcus aureus,and some pathogenic yeasts, especiallyCandida albicans. It is much less active

against Gram negative bacteria and hasno effect against acid-fast bacilli (TBand leprosy).

It is a dark green powder or greenishglistening pieces with a metallic lustre,and is sparingly soluble in water. It hasto be stored in a dark bottle and kept ina cool dark place to maintain its potency.It is very cheap and is available over thecounter. It is used as a 0.5% aqueoussolution (0.5 gram Gentian Violet in100ml water) to treat the following:

Impetigo

First remove the crusts with soap andwater. Then apply Gentian Violet paint.Do this twice a day for 23 days untilit is healed. Keep the child away fromother children until it is healed because

it is very contagious and can easilybe passed on from child to child.

Herpes Zoster

It has no effect on the virus causingthe herpes zoster itself, but paintedon any broken blisters, twice a day,it will prevent secondary bacterialinfection.

Small Burns andLacerations

Apply twice a day as an antisep-

tic to prevent secondary bacterialinfection.

Oral, Vaginal andCutaneous Candidiasis

For oral candida use 5ml (1teaspoonful) as a mouthwash.Get the patient to swish itaround the mouth for as longas he can bear it and then spitit out. It is in fact safe to swal-

low, and this can be done ifthe thrush is extensive andgoes down into the oesophagus. Useit 3 times daily after food. The can-didiasis will be better in 2-3 days.For babies, get the mother to paint itonto the affected areas of the mouthwith a piece of clean cloth rolled onthe index finger

For vaginal candidiasis thoroughlypaint on the vaginal walls usingChittle forceps and gauze twice daily

For cutaneous candidiasis, includingbalanitis, paint it onto the affectedskin twice daily using a cotton wooltipped applicator or a feather, until itis better (34 days).

Problems with using it

It is very messy to use, stainingeverything it comes in contact witha purple colour. On the skin andmucous membranes this is unsightly

for a while but soon disappears. Onclothes, furniture and floors thestaining may be permanent

It tastes absolutely foul when appliedin the mouth, but most patients will

put up with this because it is so effec-tive in treating oral candidiasis

It can be caustic if the concentrationexceeds 1% (if the water evaporates).Storage technique is therefore ofcrucial importance (see above).

2. Whitfields Ointment(Benzoic acid compoundointment)

Whitfields Ointment consists of 3%salicylic acid and 6% benzoic acid inemulsifying ointment. It is very cheapand available over the counter.

Salicylic acid and benzoic acids arekeratolytic agents (they remove surfacekeratin from the skin). WhitfieldsOintment is mainly used for treatingdermatophyte fungal infections, i.e.,ringworm. It works by removing thekeratin on which the fungus lives rather

than by killing the fungus itself. Apply ittwice a day until the ringworm is goneand for a further 2 weeks to make sureit does not come back. It can be used inthis way for treating:

Essential Drugs


Essential Drugs in Dermatology

ImpetigoPhoto: Ramadhan Mawenzi

Oral candidaPhoto: Ramadhan Mawenzi

Gentian Violet staining of the tongue

Photo: Ramadhan Mawenzi

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Tinea Corporis

Ringworm on the face or body.

Tinea Pedis

Ringworm on the feet.

Tinea CrurisRingworm in the groin. It may sting atthis site.

It does not work for infections of thescalp and nails (tinea capitis or tineaunguium), or for candida or pityriasisversicolor.

It can also be used as a mild keratolyticagent for treating:

Plane Warts and Small

Common WartsIchthyosis

Dry scaly skin, especially on the extrem-ities.

Heavy Dandruff

Rub it into the scalp once a week.

It can also be used:

To increase the percutaneousabsorption of other topical drugse.g., steroids through its action ofsoftening and loosening keratin.Apply the Whitfields Ointment at

night and the topical steroid in themorning. This is useful for patientswith hyperkeratotic eczema on thepalms and/or soles

To prepare the skin for debridement.It is applied twice a day on any hardtenacious crust, to soften it up andloosen it, so that it can be removed.

Unwanted effects ofWhitfields Ointment

May sting especially when applied inthe flexures

Applied over large areas it cancause 'salicylism' especially in smallchildren

Because it is an ointment it can makethe skin shine. Most people like this,

but some may find it cosmeticallyunacceptable.


Essential Drugs

Ringworm on the face

Photo: Ramadhan Mawenzi

Quiz: Questions

Are All White Spots Vitiligo?

L Claire Fuller MA FRCP

Visiting Senior Lecturer

Regional Dermatology Training CentreKilimanjaro Christian Medical Centre

Moshi, Tanzania

All illustrations are copyright of theRegional Dermatology Training Centre, Moshi, Tanzania

Patients often present to the Dermatology Departmentcomplaining of some problem with the pigmentationin the skin. After any sort of skin problem the dark

skinned patient may develop changes in pigmentation.Often they assume they have vitiligo but there are several

other conditions that can produce reduction in pigmenta-tion. The following cases are common problems that wesee frequently here in Tanzania. We present them in quizform . . . Have a go!

Case 1: What Is It?

Fig. 1: Scaly oval lesions scattered over the trunk and tops oflimbs

This patient may be itchy or not

The rash has been present for a few weeks

It does not occur on the face

What is the diagnosis?

What is the differential diagnosis?

How will you treat it?

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Quiz: Questions


Case 2: What Is This?

Fig. 2: Hypopigmented scaly macules

What is the diagnosis?

What is the cause?

What is the differential diagnosis?

Case 3: What Is This?

Fig. 4: De-pigmented macular areas in symmetricaldistribution

Complaint:white spots on the skin

Fig. 3: Macules scattered over upper back and upper chest

How would you diagnose it?

What treatment would you use?

Fig. 5: De-pigmented areas may extend over areas of traumalike backs of hands

1: Scaly oval lesions scattered over the trunk and tops of limbs (Figure 1).

2. Hypopigmented scaly macules (Figure 2).

3. Macules scattered over upper back and upper chest (Figure 3).

4. De-pigmented macular areas in symmetrical distribution (Figure 4).

5. De-pigmented areas may extend over areas of trauma like backs of hands (Figure 5).

See Next Page for Answers

Summary of Descriptions/Questions

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Quiz: Answers


Case 1: Answer Pityriasis Rosea

Pityriasis rosea: rash mainly over the torso Why is it not psoriasis?

Distribution and morphology are wrong: 5mmscattered oval slightly scaly macules over the trunk,extending onto the tops of arms and tops of thighs(area that is covered by wearing shorts and a T-shirt)

There may be a single bigger lesion that was noted

2 weeks before the widespread rash arrived; this iscalled the Herald Patch

There is no thickened, silvery scale, no nail changesand no involvement of scalp.

Why is it not eczema? Scaly oval lesions with a charac-teristic fine scale around the rim of each lesion (like acollar) is very typical of pityriasis rosea. The distributionalong the lines of the ribs is also very classical . Discoideczema is not often confined to the trunk. It would beexpected to affect the limbs too.

What treatment? Treatment is not necessary unless it isvery itchy. Then a topical steroid, such as betamethasone

0.1% ointment can be used. How long does it last?About 6 weeks and then sponta-

neously settles and may leave behind some post-inflam-matory pigmentary changes (either hyper-pigmentationor hypo-pigmentation).

Tips: if the patient suffers also from atopic dermatitis,pityriasis rosea may be more widespread.

Case 2: Answer Pityriasis Versicolor

Complaint: rash of white spots over top of chest. Examination: pale (hypo-pigmented) oval macules,

slightly scaly overlying the upper chest and upper back. Cause: pityrosporum yeast (also known as Malassezia

furfur). Diagnosis: classical clinical picture, but also a scraping

from the surface of the skin viewed in 10% potassium

hydroxide and a drop of ink shows spores and hyphaetogether which are said to look like meat balls andspaghetti.

Differential diagnosis:

Why is this not leprosy? There are too many lesionsand sensation would be intact over them. Also, theyare slightly scaly (leprosy lesions are smooth)

Why not pityriasis alba? This is usually on the faceand is a variant of eczema. The distribution of pit-

yriasis versicolor is so typical Why not vitiligo? The slight scale would be againstvitiligo which is absolutely macular (i.e., flat andsmooth).

Treatment: topical sodium thiosulphate solution 20%in 1% cetrimide solution daily for 2 weeks will settle it.Alternatives include topical clotrimazole cream, topicalterbinafine cream or, if very extensive, an oral azole anti-fungal such as ketoconazole or itraconazole 200mg oncedaily for 12 weeks.

Tips: it tends to recur, so maintenance treatment isrecommended with selenium sulphide shampoo as a

scalp and body wash once per month.

Case 3: Answer Vitiligo

Examination: symmetrical macules (flat lesions) ofhypo- or depigmented skin. Often over knuckles of handand elbows and knees. May occur anywhere on the body.The skin itself is of normal texture.

Cause: assumed to be an autoimmune conditionalthough no antibody has been identified.

Diagnosis: clinical picture is typical. Differential Diagnosis: Why is this not leprosy? Symmetry is very typical

of vitiligo There is no loss of sensation over the lesions Some of the lesions are occurring over areas of

trauma (koebnerization). Treatment: this is difficult. Some patients do wellwith a short course of potent topical steroid applied tothe white area for 6 weeks. It is best to avoid steroidsfor longer periods as there is a risk of skin thinning(atrophy) if 6 weeks is exceeded.

Course:can spontaneously remit and recur but, especiallywhen it affects the extremities, it can be very persistent.

Tips: patients are often very distressed about thiscondition and so a great deal of empathy andunderstanding is useful at the start.

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Teaching Aids at Low Cost (TALC)


Bench Aids for DermatologyA set of 4 full colour laminated bench aids, which include the following common skin diseases atopic eczema, common

bacterial infections, herpes zoster, ringworm, scabies and tinea capitis. Ideal for quick reference and identification ofdiseases with useful information on diagnosis, clinical features and treatment. Ideal for healthworkers, students and teachers

(available either in English or Swahili).Designed and written by Dr Barbara Leppard. Cost 4.00 + p&p per set

Available from: Teaching-aids At Low Cost (TALC) PO Box 49 St Albans Herts AL1 5TX UKwww.talcuk.org

David Chandler

General Manager, TALCSt Albans, UK

For many people who work indevelopment the names of Teach-ingaids At Low Cost (TALC)

and Professor David Morley are alwayslinked. The work of Professor Morleyand TALC has always been the desireto introduce innovative methods ofteaching, training and healthcare moni-toring.

In the early 1960s, when David Mor-

ley returned from West Africa to take upa post at the London School of Hygieneand Tropical Medicine, he could nothave imagined that the next few yearswould be an epic journey to change andintroduce new methods and ideas.

There are many diseases which aremainly diagnosed by visual inspection.This is particularly relevant for skindisease and conditions which have skininvolvement, even more so in develop-ing countries. David Morley has always

believed the power of a picture is muchgreater than the use of words, particu-larly for people living in Africa. In 1965,he introduced 24image slide and scriptssets on Measles, Growth Monitoring,Smallpox and Management of Diarrhoeaat the low cost of six shillings (0.30).These sets were produced because of thedemand from students and fellow teach-ers who felt that David Morleys meth-od and approach to teaching should begiven greater exposure.

Since the early days of TALC, themajority of distribution and sales havebeen either slides or books. Althougha very successful process in the past, inrecent years the demand has shown adramatic change. Between 1992 and

2002 slide sales dropped from 11,696sets per annum to 1,120 sets per annum,whilst book sales fell from 52,564 to27,912.

Why have these changes happened?In the case of slides, it could be due tothe lack of equipment or a change ofstudy and teaching methods.

The importance of demonstrating thedifference between different diagnosesis clear when the untrained eye viewssimilar looking diseases, but is unable tomake a clear distinction.

TALC is aware that it is also impor-tant to show diseases in the relevant set-ting and skin colour. In Africa, to showCaucasian skin in many instances wouldbe inappropriate and could possibly

imply that certain diseases do not affectthose who do not have white skin.

Given the changing learning andteaching environment, TALC took theview that a low-tech solution could beused. This included the introduction,

firstly, of Picture Cards (printed copiesof slide images), and then Bench Aids.These methods of education would notrely on the availability of electricity, aslide projector or, most importantly, aworking bulb.

The Bench Aids provide an idealopportunity for quick reference andidentification of a disease with simpleguidelines on appropriate treatments.Made from durable coated material, thislow cost item can be used over and overagain. The current series, developed byDr Barbara Leppard, contains cards onatopic eczema, common bacterial infec-tions, herpes zoster, ringworm, scabiesand tinea capitis. The sets are availablein English and Swahili.

The development of other areas ofdisease or step-by-step treatment guidescould also be useful as Bench Aids.TALC is currently exploring other poten-tial sources of information for futuredevelopment.

TALC: Images for Development

David Chandlerhas been in post as General Manager of Teaching-aids At Low

Cost (TALC) since 1999. His previous work included the role of Coordinator of

the Skin Care Campaign whilst at the National Eczema Society in London. He

also acted as General Manager for the Psoriatic Arthropathy Alliance, a charitable

organisation he co-founded with his wife following his diagnosis with psoriasis and

psoriatic arthritis in the early 1990s.

TALC is a registered charity based in the UK. Main activity is the distribution of

low-cost health education materials accessories to developing countries, including

books, slides, bench aids, charts, videos, CD-ROMs and growth monitoring.

TALC also commissions and publishes material.

TALC, PO Box 49, St Albans, Herts AL1 5TX, UKTel: 44 (0) 1727 853869 Fax: 44 (0) 1727 846852

E-mail: [email protected] Website: www.talcuk.org

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Teaching Aids at Low Cost (TALC)


ATOPICEC

ZEMA

Commonestk

indofeczemaaffectingabout10%o

fthepopulation.Runsinfamiliesan

d

isassociatedw

ithasthmaandhayfever.

CLINICAL

FEATURES

Veryitchy

rash.Symmetrical,poorlydefinedscalyplaquesoftenassociatedwithd

ryskin.

Mostcommonlystartsage312

monthswithanitchyrashon

thecheeks&/orsc

alp(butcan

startatanyage).

TREATMENT

1%hydrocortison

eointment

(notcream)applied

twiceaday.

Donotusestronger

steroidsin

youngchildren.

Ifthechildisnot

sleeping,or

keepingthefamilya

wakeatnight

becauseofscratching,give

promethazinesyrup

atnight(start

withadoseof12.5m

gand

increaseasnecessary

untilthe

childsleepsthrough

thenight).

Iftheeczemaisweeping

soakinpotassiumpermanganate

dilutedtoapalepin

kcolour

for10minutestwiceaday.

Forsecondaryinfectiongive

oralcloxacillinfor1

week.

erashmaythenspreadtothe

restofthebody.

Astherashgetsbetter

itmay

leavehypo-orhyperpigmentation.

Scratchingcanleadtosecondary

infection.

Constantrubbingoftheskin

leadstolichenification

thickeningoftheskin

and

increasedskinmarkings

.

DIFFERENTIALDIAGNOSIS

emostimportant

diseasetobedifferentiatedfromatopiceczemaisscabies.emostimportant

differencesareshownbelow.

Atopiceczema

Scabies

Usuallybeginsage312months

Occursatanyage

Veryitchyrash

itchesday&night

Veryitchyespeciallyatnight

Rashsymmetrica

l

Rashalloverthebodybutsparesface&

scalp

Rashbeginsonface&/orscalp;lateroften

Maybesecondarilyinfected

involvesflexures

Contagiousbetweenclosecontacts

Maybesecondar

ilyinfected

thosesharingabed

Notcontagious

otherfamilymembersnot

Otherfamilymembersalsoitching

itching

Burrowspresentinfingerwebs,along

sidesoffingers&onfrontofwrists

Runsinfamilies

togetherwithasthmaand

(palms&solesininfants)

hayfever

Noburrows

Asthechildgetsoldertherash

maylocaliseintheflexures.

Shinynailsoccurfromrubbing

theitchyskin.

DesignedbyBarbaraLeppardandAlfredNaburi,RegionalDermatologyTrainingCentre,KCMC,Moshi,TanzaniaT

ALC

TAL

C

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Abstracts


Journal Extracts and Reports fromthe Regional Dermatology TrainingCentre, Moshi, Tanzania

Immune reconstitution inflammatorysyndrome associated with HIV and leprosy

Blue cellulitis: a rare entity in the era ofHib conjugate vaccine

Inamadar AC, Palit A. Pediatr Dermatol2004; 21: 9091

These authors describe a 6month old child with unilateralfacial swelling of bruise-like colour, associated with feverand upper respiratory tract infection. It is easy for those of us inmore affluent countries to forget that the commonest cause offacial cellulitis in a young child used to be Haemophilus influ-enzae. I suspect the blue colour in part reflects the dark skinof the patient, as a red colour was more typical in Caucasian

skin, but the message is important the lesions may initially bequite minor and mistaken for minor trauma. In older children,pneumococcal infection should be suspected and I wouldinclude haemorrhagic oedema of childhood in the differentialdiagnosis.

Couppi P, Abel S, Voinchet H, et al.Arch Dermatol2004; 140: 9971000

Many HIV-associated skin conditions improve whenthe HIV infection is treated for example, psoriasis,seborrhoeic dermatitis, candida infection, and drug eruptions.However, others may worsen or become apparent during treat-

ment. Examples include viral infections such as herpes zoster ormolluscum contagiosum. This report adds leprosy to the list ofconditions that may present in an atypical ulcerative pattern asthe immune system reactivates.

Transmission of cutaneous leishmaniasisby sand flies is enhanced by

regurgitation of fPPG

Rogers ME, Ilg T, Nikolaev AV, Ferguson MA, Bates PA.Nature2004; 430: 463467

In sand flies with mature Leishmania infections the anteriormidgut is blocked by a gel of parasite origin, the promas-tigote secretory gel, which contains a filamentous proteophos-phoglycan (fPPG) that is inoculated with the parasites whenthe fly bites. This gel not only adds to the virulence of the leish-mania parasite but its presence seems to make the fly bite moreoften, therefore increasing the risk of disease transmission. Theproposed explanation is that the sticky gel prevents the sandflyfrom getting an adequate blood meal, so it becomes frustratedand bites repeatedly. fPPG may be another target for vaccinesor prophylactic treatment.

Extensive pityriasis alba in a childwith atopic dermatitisSandhu K, Handa S, Kanwar AJ.

Pediatr Dermatol2004; 21: 275276

T

his case report, the subject of which is evident from thetitle, is probably not that unusual the mechanism is

probably that of post-inflammatory phenomenon. However, itreminded me of two important issues that the authors do notdiscuss. One of these is that, for those who have not seen itbefore (and especially if associated atopy is subtle), it might beconfused with leprosy. The other issue is that the pigment lossmay not be apparent when the skin is inflamed, so patients mayblame the development of pale areas on their treatment and thephysician who administered it.

Vaccines and immunotherapies for theprevention of infectious diseases having

cutaneous manifestationsWu JJ, Huang DB, Pang KR, Tyring SK.J Am Acad Dermatol2004; 50: 495528

This article raises hope for prevention of some diseases ofworld-wide importance. Most relevant to this journal isthe potential for vaccines to HIV/AIDS, leishmaniasis and den-gue fever. In the case of leishmaniasis, genetic advances haveidentified at least 100 gene targets that are being investigatedas vaccine candidates. However, the major work is on HIV since trials started in 1987, 34 vaccines have started preliminary(Phase I) trials, a few have progressed to Phase II, and at least74 are in some stage of development.

Regional Dermatology TrainingCentre Research Reports

Tungiasis in KenyaAmino S Fora

This study demonstrated a 31% prevalence of tungiasis ina sample of 250 subjects from the Marasmit communityin Kenya, the peak prevalence being in the first decade of life(41% in those aged 19 years). A questionnaire showed thathaving tungiasis was positively linked with poor knowledge of

the condition, temporary housing, poor foot hygiene and lowsocio-economic status. Many of these risk factors are inter-relat-ed, so targeted education may be helpful.

Drug Eruptions FromAnti-tuberculous Therapy

Elizabeth Q Mvila

In this questionnaire study of 300 patients who had receivedDirect Observed Treatment Short-course (DOTS) for TB,34% had experienced a drug eruption, mainly early in treat-ment. The anticipated higher frequency of eruptions in those

with concurrent HIV infection was confirmed a higher preva-lence of drug eruption in males and in the 2050 year agegroup was not explained but this reviewer suspects that it mayreflect the higher frequency of HIV in men of this age. A largeranalysis of the DOTS database might confirm this view.

Neil H Cox BSc(Hons) FRCPDermatology DepartmentCumberland Infirmary

Carlisle, CA2 7HY, UK

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