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Clinico-etiological study of pediatric dermatoses in tertiary health care hospital in East-coast Andhra Pradesh, India

Background: Pediatric dermatoses vary vastly from adult dermatoses in clinical presentation, treatment and prognosis and are more influenced by socioeconomic status, climatic exposure, dietary habits, external environment, thereby needing a special view in this field. The present study was carried to determine the clinico-epidemiological patterns of pediatric dermatoses. Methods: Consecutive 2581 children aged >1 month to 12 years with 2661 dermatoses attending dermatology OPD in tertiary care hospital, Kakinada (May 2018 to June 2019) with clinical evidence of cutaneous disorder were studied. Complete history and cutaneous examination with necessary investigations are recorded. Results: Infestations disorder in 39.68% followed by eczematous disorder 19.80%, infection in 13.71%, pigmentary disorder in 8.34%, papulosquamous disorder in 5.82%, appendageal disorder in 2.93%, nutritional disorder in 2.21% and drug reactions including toxic epidermal necrolysis in 1.12%, child abuse and sexually transmitted diseases in 0.37% was the pattern in the present study. Rare cases including aplasia cutis, cutis laxa, ectodermal dysplasia, monilethrix and griscelli syndrome, epidermolysis bullosa, ichthyosis, palmoplantar keratoderma and congenital syphilis were also observed. The most common cutaneous dermatoses are infection and infestations followed by eczemas and nutritional disorders. Surprisingly STD and child abuse contributed significantly which cannot be neglected. Genodermatosis were notable in the study probably due to the high incidences of consanguineous marriage Conclusions: The study reinforces features of tropical paediatric dermatology especially high prevalence of infections and infestations in school children (5-12 years) which highlights the need of proper counselling of caretaker regarding skin hygiene and establishment of specialized paediatric dermatology clinics.

immune system and increased exposure to sub clinical infectious carriers in school and family environment makes this age group population more susceptible to cutaneous dermatoses especially infections and infestations. 5 The present study was carried to determine the clinicoepidemiological patterns of common pediatric dermatoses presenting to a tertiary health care centre, coastal Southern India.

METHODS
This study was conducted in the dermatology, venereology, leprology (DVL) department of the tertiary health care centre in coastal South India after obtaining approval from institutional ethics committee.
This region is a typical tropical area with high temperature and humidity and is referred to as one of the green belts of South India.
All children ageing >1 month to 12 years, attending the DVL out-patient department (OPD) with any dermatoses between the period of May 2018 and June 2019 were enrolled in the study. The diagnosis was made by a dermatologist based on detailed history, cutaneous examination and appropriate hematological and biochemical investigations, VDRL test, KOH examination, Gram's stained smear, Tzanck test and skin biopsy etc. The diseases were tabulated based on the etiology and results were analyzed.

RESULTS
During the study period of one year, 27,854 new cases attended this study DVL OPD. Among them a total of 2581 children with 2661 cutaneous dermatoses were seen, thus constituting 9.5%.
Among these children, 80 (3%) had more than one dermatosis. Total boys were 1570 (60.83%) and girls were 1011 (39.17%) with boy to girl ratio 1 Among infestations scabies was the most common in all the age group contributing 51.89% (Table 1).  Among other infections, bacterial was the most common with impetigo the commonest contributing 27.94% in 102 children (Table 1).
Varicella (Figure 1) was most common among viral infection contributing to 6.8% in 25 children and dermatophyte infection was the most common among fungal infection contributing 22.19% in 81 children of the study.
Childhood leprosy and cutaneous tuberculosis were found to contribute 0.56% of the study and 4.11% among infectious disorder.
Genodermatoses such as ectodermal dysplasia (Figure 2), cutis laxa and neurofibromatosis were found in 0.49% of the total cutaneous dermatoses.
Authors also observed that seborrheic dermatitis, atopic dermatitis, cutaneous candidiasis, scabies and tinea capitis were more common in age group 1 month to 1 year. In pre-school age group (>1 to 6 years) scabies, impetigo, pyoderma, molluscum contagiosum and atopic dermatitis were common. While in school going children (7 to 14 years) scabies, molluscum contagiosum, phrynoderma, pyoderma and pityriasis alba were most common diseases in order of incidence.

DISCUSSION
Cutaneous dermatoses are a major health problem in the pediatric population and are associated with significant morbidity. Skin diseases in pediatric age group can be transitory or chronic and recurrent.
The prevalence of pediatric dermatoses in the present study is 9.5%, whereas in various parts of India, it has ranged from 8.7% to 35% in school-based surveys. 4 In the study, majority of the patients were in school going age group 1202 (46.58%) followed by preschool children 989 (38.32%) and infants 390 (15.11%) respectively. Similar observation was made by Sacchidanand et al observed 5-11 years is the common age group followed by adolescents with 33.21% and 29.81%, respectively. 6 Dermatoses was found to be more in male children 1570 (60.83%) than in females 1011 (39.17%) in the present study with male to female ratio of 1 Of the infestations, scabies alone constituted the majority, making 24.23% of the total dermatoses which is higher than the previous studies done. Sacchidanand 8,9,12 The higher prevalence of scabies in the study might be because of lack of hygienic practices and congested environment.
Pediculosis capitis was the next most common infestation following scabies constituting 16.62 % in this study.
Fungal infections of the skin constituted 31.58% of the total infections and 4.32% of total dermatoses. Dermatophytic infections were the most common among these infections making up to 22.19% of the infections.
Bacterial infections constituted 48.73% of the total infections and 6.69% of total pediatric dermatoses.
Impetigo was the most common bacterial infection with 57.30% (102 children) of total bacterial infections (178 children) followed by pyoderma (60 children, 33.70%), cutaneous tuberculosis (9 children, 5.05%), Hansen's disease (6 children, 3.37%). A single case of proved congenital syphilis was observed in the study. Pyodermas were the single most common dermatoses found out by Bhatia and Ghosh et al. 9 The viral infections constituted 19.73% of the total infections and 2.70% of total dermatoses of this study. Varicella was the most common viral disease constituting 47% of these viral infections and 1.2% of total dermatoses followed by molluscum contagiosum constituting 25% of these viral infections and 0.6% of total dermatoses followed by viral warts which constituted 23.61% of viral infections and 0.6% of total dermatoses.
Sirisha et al, in their study observed that incidence of molluscum contagiosum was 1.16% in children aged 1 to 15. 13 The incidence of Varicella was 1.2% in this study whereas in the study done by Sirisha et al it is reported as he most common viral infection (1.83%).
Eczema was the second common group of dermatoses in the study constituting 39.68% of total dermatoses. The incidence rate of eczema in the study by Sacchidanand et al was 20.66%, whereas in Karthikeyan et al study, it was 8.6% and in Sirisha et al study it is 19.17%. 6,13,14 Of the eczema group, atopic dermatitis was the commonest and constituted 30.17% of eczematous disorders, followed by pityriasis alba (22.77%), contact dermatitis (22.39%), seborrheic dermatitis (13.66%), diaper dermatitis (6.26%), perianal dermatitis (4.74%).
Sacchidanand et al, reported atopic dermatitis as the most common eczematous dermatitis which constituted 6.12%. 6 Few other studies also showed atopic dermatitis as the most common endogenous eczema which ranges from 3% to 28%.
Hypersensitivity and drug reactions ( Figure 3)         Among 45 keratinization disorders observed, Icthyosis ( Figure 4) was seen in 32 children constituting 1.2 % of total dermatoses and keratoderma ( Figure 5) in children with 0.4 %. 13 Reddy et al observed the prevalence of Icthyosis in 0.8%. 15 Hair and scalp disorders constituted 3.00% of the total dermatoses. Alopecia areata (1.5%) was the most common hair and scalp disorder followed by diffuse hair loss (0.9%) congenital absence of hair or sparse hair (0.3%) ( Figure 2) and trichotillomania (0.2%). Vora  Vesiculobullous disorders constituted 0.11% of total dermatoses with 3 cases of different types epidermolysis bullosa ( Figure 6). According to Medasani et al, the prevalence rate of epidermolysis bullosa simplex was 0.46 %. 17 Connective tissue disorders (CTD) were noted in 3 children, 2 systemic lupus erythematosus and 1 systemic sclerosis (Figure 7) constituting 0.11% of total dermatoses. The prevalence of CTD is 0.37% in a study done by Pelkonan et al, and child abuse and sexually transmitted infections were observed in 10 female children constituting 0.37%. 18

CONCLUSION
The study reinforces features of tropical pediatric dermatology especially high prevalence of infections and infestations in school children (5-12 years) which highlights the need of proper counseling of caretaker regarding skin hygiene and establishment of specialized pediatric dermatology clinics.