INTRODUCTION

It has been reported that, on average, one in three patients seen at the outpatient clinic has a skin disease [1,2]. This is particularly true in pediatric clinics where skin conditions may represent 30% of all consultations [3]. Children and adolescents with skin conditions are less commonly seen by pediatricians and dermatologists [4]. Most patients are seen by general practitioners, who are the first contact for patients with skin conditions [5], or do not even seek care [6], making the epidemiology of skin diseases difficult to map out. This is especially true in a setting such as Cameroon where medical records are not digitalized.

Skin conditions may be highly confusing. A simple papular lesion may be many things, from a simple mosquito bite [7] to the more worrisome Buruli ulcer in its initial phases [8,9]. Pediatric patients are unable to describe their symptoms and, therefore, are more vulnerable to misdiagnosis, overprescription of antibiotics and rapid dissemination of diseases [10]. This is also fueled by inadequate dermatology training during conventional medical training [11], with only 25% of general practitioners considering themselves fully confident when faced with a skin disease [12]. The availability of only a few trained dermatologists in the workforce in Cameroon, and other sub-Saharan African countries, widens this knowledge gap [13] and further threatens the quality of dermatological care in these regions.

Understanding the pattern of common skin diseases in pediatric patients in resource-limited settings is crucial for accurate development of context-specific diagnostic and treatment guidelines, public health planning, prevention and control, and research [14]. Moreover, it will help healthcare professionals identify risk factors and develop appropriate educational materials [15]. All this will eventually improve the overall well-being and quality of life of these children and adolescents. Thus, we attempted to describe the pattern of common skin diseases encountered in pediatric patients.

METHODS

RESULTS

Recruitment Flow Chart

A total of 38,026 patients were consulted during the study period in both the pediatric and the dermatology unit during the study period. Follow-up visits, which represented 42.0% of the cases (n = 15976), were excluded. Pediatric skin diseases were diagnosed in 6.35% (850/13372) of pediatric consultations and 37.1% (3097/8338) of dermatology consultations. Incomplete data was recorded in 286 cases, illegible data in 54 cases, and follow-up visits in 15976 cases. From the eligible population, we excluded 7.93% (340/4287) of new cases and a total of 3947 patients were included (Fig. 1). Therefore, the overall proportion of skin diseases among children and adolescents was 23.97% (3497/16469).

Figure 1: Patient recruitment flowchart.

Age, Age Distribution, Sex, and Consultant Seen

The mean age in our sample was 6.19 ± 5.31 years with the minimum of 1 day of age to 17 years. The median age was 5 years (Q1-Q3: 1.5-10). Most patients were children (n = 2699, 68.38%) followed by adolescents (n = 697, 17.66%), infants (n = 423, 10.72%), and finally neonates (n = 128, 3.24%). Females constituted 53.89% (n = 2127) of the sample, giving a M/F sex ratio of 1/1.17. All age distributions had similar proportions of males and females except the adolescents who had a much higher proportion of females (n = 454, 65.14%) than males (n = 243, 34.86%) (Table 1). Most patients were seen by a dermatologist (n = 3097, 78.46%). Neonates and infants were most seen by the pediatrician, while up to 97.27% (n = 678) of adolescents were seen by the dermatologist. The year 2019 was the year with the highest proportion of consultations (n = 1078, 27.31%).

Table 1: Distribution of certain sociodemographic characteristics within specific age ranges.

Distribution of Commonly Diagnosed Skin Diseases within Different Age Groups

The three most common individual skin diseases encountered were eczema (n = 786, 19.91%), prurigo (n = 680, 17.23%), and scabies (n = 357, 9.04%) (Table 2). In neonates, eczema (n = 29, 22.86%) predominated, followed by scabies, dermatophyte infection, and impetigo/furuncles, which had a prevalence of 7.03% each. In infants, eczema (n = 108, 25.53%) and impetigo/furuncles (n = 50, 11.82%) predominated, followed by scabies and prurigo. In children, common individual skin diseases were similar to the overall sample. In adolescents, however, the most common pathology was acne (n = 157, 22.53%), followed by eczema, prurigo, and pityriasis versicolor (Table 3). All pathologies were most diagnosed in children except for acne which was most diagnosed in adolescents (n = 157, 82.20%).

	Table 2: Distribution of the top 10 skin diseases within specific age ranges.
	Table 3: Distribution of grouped skin diseases within specific age ranges.

Distribution of Commonly Diagnosed Skin Diseases with Climatic Season and Sex

Most consultations were in the dry season (n = 2003, 50.75%) and school period (n = 2901, 73.50%) (Table 1). Skin diseases did not vary much with climatic season except for prurigo, which had a higher prevalence in the rainy season (n = 361, 53.09%, p = 0.028) (Table 4). Moreover, skin diseases were more commonly diagnosed in females. Multivariable logistic regression revealed that acne [aOR = 1.66 (1.23-2.26), p = 0.001] and pityriasis rosea [aOR = 2.25 (1.47-3.45), p < 0.001) were more likely to be diagnosed in females while dermatophyte infections were more likely to be diagnosed in males [aOR = 1.42 (1.03-1.95), p = 0.031].

Table 4: Distribution of the top 10 skin diseases within climatic seasons and sex.

DISCUSSION

This study aimed to determine the pattern of common skin diseases encountered in children and adolescents and their variations with sex, age, and climatic season in Cameroon.

Overall, pediatric skin diseases were noted in 23.97% of children and adolescents: 6.35% at the pediatric outpatient unit and 37.14% at the dermatology outpatient unit. Several authors have reported varied information [3,13,19]. The low proportion of skin diseases at the pediatric outpatient unit may be explained by the high amount (15%) of systematic newborn consultations at Laquintinie. Despite these, we understand that these proportions are more likely underestimated, since many patients with skin conditions do not seek medical care for skin diseases [6,20] or do so at the level of their primary care physician [5].

Females constituted 53.89% of the sample. The female predominance in outpatient consultations has been recorded by several authors [13,21,22]. Skin diseases usually pose cosmetic concerns, and therefore, women are more likely to initiate consultation for these issues [23]. In the younger age groups (< 13 years), as it is believed that consultations are initiated by parents or guardians, we noted a similar proportion between males and females. However, in adolescents, who generally initiate consultations, the proportion of females was much higher. This correlates with the high proportion of acne in this age group. Puberty leads to a rise in the level of circulating androgens, which boosts the pilosebaceous unit’s production of sebum [24]. Acne has been recognized as one of the skin diseases that significantly impairs self-esteem and quality of life [25,26]. The importance of appearance in determining one’s value and self-esteem has proven to be more important for women, as such, they will seek care more often than men [27].

Immunoallergic skin diseases have been reported by several authors [13,28,29] as the most common skin diseases in urban settings such as in our study and may be explained by the industrialization in cities and the constant exposure to allergens [30]. In rural settings, however, infectious skin diseases have been reported to predominate and this may be attributed to the degree of poverty, promiscuity and poor hygiene, which are favorable factors for the transmission of infections [31]. In concordance, eczema, which includes atopic dermatitis, has been reported as the most diagnosed skin disease in our sample. Acute and subacute forms are frequently marked by excruciatingly itchy, erythematous papules and vesicles with excoriations and a serous discharge, while plaques and papules with lichenification and excoriations are typical of chronic forms [32]. It is frequently misdiagnosed due to the variety of clinical features, severity levels, and clinical courses [33,34]. Physicians have reported low confidence when faced with eczema [35,36]. However, this could be improved through CME courses [37].

Prurigo was the second most common diagnosis in our study and its prevalence was higher in the rainy season. The term prurigo refers to a reactive cutaneous condition marked by papules or nodules [38]. The main form seen in pediatrics is called prurigo strophulus and has been linked to atopy [39]. It is characterized by pruritic, papular, or papulovesicular erythematous skin lesions mainly on the exposed areas of the body and is caused by cellular hypersensitivity to environmental arthropods [40]. The high prevalence of prurigo in the rainy season has been reported before and it has been attributed to the fact that rainy conditions favor the breeding and growth of arthropods [39].

Scabies (n = 357, 9.04%) was the third most diagnosed skin disease especially in patients aged < 13 years. The prevalence of scabies varies with settings and has been reported to be as low as 1% in primary schools in Cote d’Ivoire [20], 17.8% in Cameroonian boarding secondary schools [41], and 19.25% in Ethiopian communities [42]. The predominance of scabies in the younger age groups [43,44] relates to the close personal contact children have with each other as they play and sleep together in the same bed [45].

Scabies and impetigo/furuncles were the second commonly diagnosed skin disease in neonates in conjunction with dermatophyte infections. Diagnosing the latter fungal zoonotic infections in neonates is unexpected [46]. Since this age group was most commonly seen by pediatricians, these results may reflect misdiagnosis as infantile seborrheic dermatitis/cradle cap, a highly common fungal infection caused by Malassezia in first months of life, may be mistaken for tinea capitis, a dermatophyte infection of the scalp [47].

Impetigo is a superficial infection of the skin caused by Gram-positive bacteria. A furuncle/boil is a bacterial infection of the hair follicle. These infections affected 7.85% of children and adolescents in our study. A much higher prevalence value (19.4%) has been reported before among children living in remote communities [48]. Its prevalence in infants may reflect immaturity of the immune system yet also, the change from relatively sterile environment of the neonate’s crib to the non-sterile environment encountered by infants when learning how to crawl, walk, eat, etc. Conditions that permit the infant to explore its environment in a more hygienic manner may be helpful in limiting these pathologies.

This study was a monocentric hospital-based study in a single urban city setting in Cameroon, and therefore, results cannot be generalized. Moreover, since diagnoses were not independently confirmed by a team of pediatric dermatologists, the risk for misdiagnoses cannot be overemphasized. Nonetheless, this study is one of the few in Cameroon, if not the first, that gives us insight on the most common pediatric skin diseases encountered in both dermatology and pediatric outpatient units and their variation with age, sex, and climatic season. These skin diseases may be linked to genetic predispositions, hygienic habits, auto-immunity, and/or environmental factors. This study paves the way for further research geared toward the development of public health interventions and educational activities.

CONCLUSION

Overall, 23.97% of children and adolescents seen at Laquintinie had a skin disease. The top three skin diseases diagnosed among children and adolescents were eczema, prurigo, and scabies.