International Jotirnal of Dertnatolo^y, Vol. 35, No. 9, September f 996

REPORT

SKIN DISEASE IN RURAL TANZANIA

CATRIONA A. HENDERSON, M.R.C.P.

AbstractBackground. Skin disease is a common problem, account-ing for significant morbidity in developing countries. Knowl-edge about the prevalence of different skin conditionsallows appropriate planning for provision for these healthneeds. There are currently few data about the needs in ruralareas; therefore, this study was set up to investigate skin ab-normalities found in a village population in Tanzania.

Materials and Methods. A village with a population of2,876 was chosen and one-third of the population was ex-amined for cutaneous abnormalities.

Results. During the survey, 97.7% of the target populationwas examined. Signs of nutritional deficiency were commonwith koilonychia affecting 18.1% of the population examinedand signs of hypoproteinemia being present in 3.4% ofthem. Infections and infestations were also frequently seen.Scabies was observed in 6.0% and pediculosis capitis in5.3%. Dermatophyte infection was present in 5.1%. Thesewere all most common in prepubertal children. Leg soreswere seen in 5.1% and leg ulcers in 3.0% of the population.

Conclusions. The survey reveals that easily treatable skininfections and infestations are common in a rural Tanzianpopulation. Signs of nutritional deficiency are also fre-quently seen.

Int J Dermatol 1996; 35:640-642

Skin disease is a common problem in developing coun-tries and accounts for great morbidity and a large por-tion of the workload in outpatient clinics.' Knowledgeof the prevalence of the various skin diseases facilitatesplanning for provision for health needs; however, thereare few current data on the frequency of cutaneousproblems except in preschool children.^ This study wasset up to assess the prevalence of skin abnormalitiesseen in a rural area in central Tanzania.

Materials and MethodsA village, called Ndebwe was chosen, situated on the dry cen-tral plateau area of Tanzania at a height of 1,200 m. It is 60 kmfrom the commercial capital, Dodoma, and 10 km from the

From the Department of Dermatology, York District Hospital,York, England.

Address for correspondence: Catriona A. Henderson, M.R.C.P.,Department of Derinatology, York District Hospital, Wiggin-ton Road, York, England YO3 7HE.

local hospital at Mvumi. The population was 2,876 persons.The village is divided into six administrative units of similarsize; two of these were chosen at random for the survey. Thismade an estimated target population of 958. The majority ofthe population are subsistence farmers, with maize being themain crop. Water is available from a single borehole and nat-ural waterholes, although these were not reliable and, in thedry season, water was often only available from a few placesnecessitating long journeys to collect it.

The survey was conducted in February 1991 by the au-thor and a Tanzanian clinical assistant, who had beentrained to recognize skin disease. Each evening the surveyteam visited a different area of the village, accompanied bythe local area leader. Every household within the two areaswas visited and every member of the population was exam-ined from the waist upwards and from the knees down-wards. Any skin abnormality was noted. Every attempt wasmade to return to a particular house to examine peoplewho were missing at the time of the visit.

RESULTS

There were 936 people examined, this being 97.7% ofthe target population. Three-hundred-and-ninety (41%)were boys or men and 546 (59%) were girls or women.Figure 1 shows the age and sex distribution of thosesurveyed and Table 1, the abnormalities observed.These were categorized into signs of malnutrition,signs of infection, erosions and leg ulcers, tumors, orother disorders.

Signs of hypoproteinemia included dry hypopig-mented skin, hypopigmented, soft, dry hair, with ankle

Years

Figure 1. Age and sex distribution of the population surveyed.

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skin Disease in Rural TanzaniaHenderson

Table 1. Cutaneous Abnormalities Noted in theSurveyed Population of Ndebwe

Condition Number of Patients Percent

Signs of nutritional deficiencyKoilonychia 169 18.06Angular stomatitis 14 1.49Hypoproteiiiemia 32 3.42Phrynoderma 13 1.38

Infections and infestationsScabies 56 5.98Pediculosis capitis 50 5.34Dermatopliyte infection 48 5.13Bacterial infection 28 2.99Pityriasis versicolor 14 1.49Mollusca contagiosa 9 0.96Leprosy 2 0.21Pitted keratolysis 2 0.21Herpes simplex 1 0.11

Leg ulcers and soresSores on legs • 48 5.13Leg ulcers 28 2.99

TumorsKeloids 32 3.42Dcrmatofibroma 3 3.20Squamous cell carcinoma 2 0.21Sebaceous nevus (scalp) 1 0.11Solar keratosis 1 0.11Hemangioma 1 0.11

OthersAcne 54 5.77Folliculitis (legs) 18 1.92Icbtbyosis 13 1.39Cbloasma 3 3.20Marfan's syndrome 1 0.11Poliosis 1 0.11

edema and white nails either present or absent. Thesesigns were observed in 14.4% of children, 5 years oryounger. The average age of affected children was 2.0 .years and it affected boys more commonly than girls(M:F = 19:13). Pediculosis capitis tinea capitis and sca-bies infestations were not affected by the presence ofkoilonychia or signs of hypoproteinemia.

Scabies infestation was seen in 6% of the generalpopulation but was commoner in those 15 years or lesswith 8.5% of them affected. It was seen equally com-monly in boys/men and girls/women (M:F = 22:23).The average age of those affected was 11.9 years. Sec-ondary bacterial infection was judged to be present inall scabies cases.

The average age of those with pediculosis capitis was12.5 years, it being commoner in boys (M:F = 29:21).

Table 2 shows the localization of cutaneous fungalinfections that affected the sexes equally (M:F = 24:23).The average age of those affected was 10.7 years (ex-cluding the cases of tinea pedis and onychomycosis thatwere only seen in those adults wearing closed shoes).

The type of cutaneous bacterial infection (not in-cluding those with scabies) is shown on Table 3 (M:F =16:12), with the average age of the affected person

being 19.0 years. Pitted keratolysis was only seen inthose wearing closed shoes.

Leg sores were commoner in boys/men (M:F = 29:19),with the average age of affected men being 22.8 yearsand women being 26.9 years. Leg ulcers were commonerin men (M:F = 19:9) and affected them at an earlier age(average age 15.8 years) compared to women (averageage 32.2 years). Only two cases showed signs of venoushypertension and both were women.

Acne was commoner in men (M:F = 33:21) with theaverage age of those affected being 21.2 in men and20.0 in women.

DISCUSSION

It is estimated that 97.7% of those recorded as villagemembers in the study area were examined during a 3-week-period. There may have been several reasons forfailure to see each member of the target population.There are always individuals who are absent and, be-cause transport is poorly developed in Tanzania, jour-neys often took people out of the village for weeks ormonths at a time. Some villagers may have avoided theexamination purposely, although the survey was con-ducted with the support of the village committee, whocommanded fairly strong authority, making it unlikelythat this was a common factor. The survey was conduct-ed in the late afternoon of each day, when the villagershad returned from their fields and were awaiting orpreparing the evening meal. This is the time when mostmembers of a family are at home and, therefore, it is lesslikely that individuals would be missed accidentally.

The excess of women in the village is a well-recog-nized phenomenon in developing countries, reflectedby an excess of men in the towns and cities.

People were examined outside because the houseswere small and dark, with few windows. It was not pos-sible to examine the villagers below the waist or abovethe knees because this would not have been acceptablein public. Thus there was not a full examination of theskin and some skin lesions may have been missed.

The diagnoses made here were all clinical and couldbe subject to errors; however, other studies suggestthat infectious diseases, particularly scabies, are easily

Table 2. Types of Superficial Fungal Infection Notedin tbe Surveyed Population of Ndebwe

Site of Derntatophyte Infection Number

Head: tinea capitis

Trunk: tinea corporis

Feet: tinea pedis

Face: tinea facieii

Nails: onychomycosis

Total

374421

48

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International journal of DermatologyVol. 35, No. 9, Sfptcmber 1996

Table 3. Types of Cutaneous Bacterial tnfectionin the Surveyed Population of Ndehwe

Type of Bacterial Infection Number

Secondarily infected folliculitis

tnfected cuts

Impetigo

Ecthyma

Other

Total

6

5

3

1

13

28

Secondarily infected scabies infestation not included.

recognizable.^ Most cases of scabies looked as if therewas secondary bacterial infection and Masawe's studywould support this.-̂ One of those conducting the sur-vey had qualified and worked in Tanzania all his lifeand the other person had worked there for 9 months.Thus both had extensive experience of diagnosis andtreatment in this setting.

Examination of the skin revealed frequent signs ofnutritional deficiency, particularly in children less than5 years old. It is important to note that the koilonychiamay have been partly traumatic in origin, although itwas clear that iron deficiency anemia was a commonproblem among those attending the local hospital.(The regular diet is maize porridge, made from recon-stituting dried maize flour, with the addition of occa-sional protein in the form of peanuts. Fruit and vegeta-bles are rarely taken).

Infection and infestation were common, particularlyin the young, although the majority could be easily rec-ognized and treated; however, tinea versicolor wasrare in this dry arid area.

The average age of those with acne, the early twen-ties, reflects the later onset of puberty in the popula-tion where most people experience periods of undernu-trition during their childhood.

Leg ulcers and sores were more commoti in rnenthan women; this may reflect the role of trauma inyoung men. The older group of women affected wouldhave the responsibility for feeding a large family andwould spend long hours in the fields. Most would haveundergone recurrent pregnancies and breastfeeding,while receiving a poor diet; they were more nutrition-ally stressed than men of the same age. Signs of venoushypertension were uncommon in this populationwhere obesity is rare and women have little bedrestafter giving birth, making deep venous thrombosis arare problem.

CONCLUSIONS

This survey has shown that skin disease is comtnon inrural Tanzania and affects predominantly the prepu-bertal population. This agrees with Canizares' findingsof community-based skin disease.' The prevalence rateof scabies recorded here is sirnilar to that estimated inrural Malawi,^ although lower than that in anotherarea of Tanzania.^ Season and geographic location areknown to affect infection rates. Most of the diseasesidentified are easily treatable. Examination of the skinalso shows that signs of nutritional deficiency are fre-quent and easily recognizable.

REFERENCES

1. Canizares O. Dermatological priorities in developingcountries. Trop Doct 1986; 16:50-53.

2. Masawe AEJ, Nsanzutnuhire H. Scabies and other skindiseases in preschool children in Ujarnaa villages inTanzania. Trop Geogr Med 1975; 27:288-294.

3. Kristensen JK. Scabies and pyoderma in Lilongwe,Malawi, hit J Dermatol 1991; 30:699-702.

From the 23rd Annual American Academy of DermatologyArt Exhibit, February 11-14, 1996. Washington, District ofColumbia. Twelve and under, Betsy Sheretz, Winston-Salem,North Carolina, "Carousel Dog," Honorable Mention.

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