STUDY ON DERMATOLOGICAL MANIFESTATIONS IN SCHOOL AGED CHILDREN IN A
TERTIARY HEALTH CARE CENTRE
Dissertation
Submitted to
THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY In partial fulfilment of the requirements for
the award of the degree of
M.D.
DERMATOLOGY, VENEREOLOGY & LEPROLOGYB
RANCHXX
MAY 2020
This is to certify that this dissertation entitled Study on dermatological manifestations in school aged children in a Tertiary Health Care Centre is a bonafide
record of the work done by Dr. Neetha L under guidance and supervision of Dr. Murugan S in the Department of DVL during the period of her
postgraduate study for M.D. Dermatology, Venereology & Leprosy. [Branch- XX] from 2017-2020.
Dr. K.E .Elizabeth, MD., PhD.
[Co-Guide]
Professor and HOD
Department of Paediatrics,
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu - 629161
Dr. Rema V. Nair, M.D., D.G.O., Director
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu -629161
Dr. Murugan S, MD
[Guide]
Professor and HOD Department of DVL
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu - 629161
Dr. Padma Kumar, MS., Mch
Principal
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu -629161
Dr. M.K. Padma Prasad, MD
[Co-Guide]
Professor,
Department of DVL
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu - 629161
This is to certify that this dissertation work titled “Study on dermatological manifestations in school aged children in a Tertiary Health Care Centre” of the candidate Dr. Neetha L with Reg. No. 201730401 for the award of MD in the branch of Dermatology, Venereology & Leprosy. [Branch-XX]. I personally verified the website urkund.com for the purpose of plagiarism check. I found that the uploaded
thesis file contains from introduction to conclusion pages and result shows 5 percentage of plagiarism in the dissertation.
Guide & Supervisor sign with Seal.
In the following pages is presented a consolidated report of the study
“Study on dermatological manifestations in school aged children in a Tertiary Health Care Centre” on cases studied that I studied and followed up at Sree Mookambika Institute of Medical Sciences, Kulasekharam from 2017-2020.
This thesis is submitted to the Dr. M.G.R. Medical University, Chennai in partial fulfilment of the rules and regulations for the award of MD Degree examination in Dermatology, Venereology & Leprology.
Dr. Neetha L Junior Resident Department of DVL
Sree Mookambika Institute of Medical Sciences, [SMIMS]
Kulasekharam, K.K District, Tamil Nadu 629161.
Dr. Murugan S, MD
[Guide]
Professor and HOD Department of DVL
Sree Mookambika Institute of Medical Sciences [SMIMS]
Kulasekharam, K.K District, Tamil Nadu - 629161
First of all, I would like to thank God almighty for the immeasurable blessings that he has bestowed upon me.
It is indeed a very pleasant opportunity to express my cordial thanks to each and every one, who helped me in completing this thesis work; without their help support and guidance this work would have not come in existence.
I express my sincere gratitude to Dr. Velayudhan Nair, Chairman and Dr. Rema V Nair, Director, for providing facilities to accomplish my dissertation
work. I also extend my deep thanks to the Principal of the institution Dr. Padmakumar, for the great support that he lent me.
I would like to offer my sincere thanks to Dr. Mookambika, Vice Principal and Dr. Vinu Gopinath for their invaluable support.
I am fortunate to express my sincere, heartfelt thanks to my respected Research guide Dr. S Murugan, Head of Department, without whom this work would not be possible. I thank him for his constant guidance, suggestions and magnificent effort. His continuous encouragement helped me to overcome obstacles during the study.
I humbly thank my co-guide, Dr. M.K. Padma Prasad whose support, guidance, critical views and comments kept me in full swing throughout my study period. His suggestions were valuable at every stage of my dissertation work. I am indebted to him for his guidance and support throughout my post graduate days.
I extend my heartfelt gratitude to my Co-Guide Dr. Elizabeth K E, Head of Department of Paediatrics, for mentoring me and moulding my work to its present
It gives me immense pleasure to express my gratitude to Dr. S.Rajagopal, and Dr.Nivin Simon for their support and good wishes. I am indebted to them for their guidance and support throughout my postgraduate days.
My sincere thanks to my seniors Dr. Arishta Bala, Dr.Pinky Salim,
Dr.Siddhant Mahajan as well as my juniors Dr. M. Vijaya Bharathi and Dr. M.G. Varghese who have offered me their support and good wishes at the needed
time.
I also thank Sister Jacqueline for her unconditional support.
I would like to thank Leos Data Makers for their immense help in completing this dissertation.
Words are inadequate to express my sincere thanks to my parents, my brothers and my husband for their kind blessings, sacrifices, unconditional love and inspiration which were the driving force behind accomplishing my work.
Sl No. Content Page No.
1. Introduction 1
2. Aims & Objectives 5
3. Scientific Justification 6
4. Review Of Literature 7
5. Materials & Methods 39
6. Results 43
7. Discussion 78
8. Summary 90
9. Conclusion 93
10. Limitations & Recommendations 95
11. Bibliography i - xvi
12. Appendices
Sl. No. Tables Page no.
1 Distribution of children based on age 43
2 Distribution of children based on gender 44
3 Distribution of children based on socioeconomic status 45 4 Distribution of children based on location of residence 46 5 Distribution of children based on complaints 47 6 Distribution of children based on past history 48 7 Distribution of children based on family history 49 8 Distribution of children based on site of lesion 50
9 Distribution of children based on lesions 52
10 Distribution of children based on scaling 54 11 Distribution of children based on sharing personal
belongings 55
12 Distribution of children based on diagnosis 56 13 Distribution of patients based on the type of bacterial
infection 58
14 Distribution of patients based on the type of viral infection 59 15 Distribution of patients based on the type of fungal infection 60 16 Distribution of patients based on the type of parasitic
infection 61
17 Distribution of patients based on the type of inflammatory
disease 62
18 Distribution of patients based on the type of pigmentation 64 19 Distribution of dermatological manifestations based on age
groups 64
21 Association between upper middle class and dermatological
disorders 68
22 Association between lower middle class with dermatological
disorders 70
23 Association between upper lower class with dermatological
disorders 72
24 Association between lower class with dermatological
disorders 74
25 Association of socioeconomic status with dermatological
disorders 76
Sl. No. Figures Page No.
1 The Anatomy of Skin 9
2 Functions of skin 9
3 Lifecycle of Scabies mite, Lesions in web spaces 16
4 Pityriasis Alba over face 17
5 Scalp seborrhea 18
6 Warts over dorsum of foot 19
7 Impetigo over hand and buttocks 21
8 Pityriasis Versicolor over face 22
9 Chicken pox lesions over face 23
10 Tinea corporis over abdomen 25
11 Atopic dermatitis over leg and face 26
12 Contact dermatitis on axilla and leg 27
13 Nits on scalp 28
14 Interdigital Candidal Intertrigo 29
15 Miliaria Rubra over forearm 30
16 Polymorphous light eruption over dorsal aspect of forearm 31
17 Xerosis over leg 32
18 Vitiligo over hip 33
19 Papular urticaria over forearm 33
21 Insect bite reaction over thigh 35
22 Urticaria over trunk 36
23 Staphylococcal Scalded Skin Syndrome 37
24 Hand Foot Mouth Disease 38
25 Distribution of children based on age 43
26 Distribution of children based on gender 44
27 Distribution of children based on socioeconomic status 45 28 Distribution of children based on location 46 29 Distribution of children based on complaints 47 30 Distribution of children based on past history 48 31 Distribution of children based on family history 49 32 Distribution of children based on site of lesion 51 33 Distribution of children based on lesions 53 34 Distribution of children based on scaling 54 35 Distribution of children based on sharing 55 36 Distribution of children based on diagnosis 57 37 Distribution of patients based on the type of bacterial
infection 58
38 Distribution of patients based on the type of viral infection 59 39 Distribution of patients based on the type of fungal
infection 60
41 Distribution of patients based on the type of inflammatory 63 42 Distribution of dermatological manifestations based on
age groups 65
43 Comparison of dermatological manifestations based on
gender 67
44 Association between upper middle class with dermatological
disorders 69
45 Association between lower middle class with dermatological
disorders 71
46 Association between upper lower class with
dermatological disorders 73
47 Association between lower class with dermatological
disorders 75
48 Association of socioeconomic status with dermatological
disorders 77
P ALBA - Pityriasis Alba PV - Pityriasis Versicolor
PO - Per Orally
PLE - Polymorphic Light Eruption UVR - Ultraviolet Radiation
PUVA - Psoralen and Ultraviolet A NVUVB - Narrow Band Ultraviolet B AD - Atopic Dermatitis
ACD - Allergic Contact Dermatitis ICD - Irritant Contact Dermatitits VZ - Varicella Zoster
VZV - Varicella Zoster Virus MC - Molluscum Contagiosum MCV - Molluscum Contagiosum Virus HFMD - Hand Foot Mouth Disease
SSSS - Staphylococcal Scalded Skin Syndrome KOH - Potassium Hydroxide
TCA - Trichloroacetic Acid 5FU - 5 Fluoro Uracil
OPD - Out Patient Department
IV - Intravenous
SES - Socioeconomic Status
Abstract
BACKGROUND
Among the school going children dermatological problems are the most common problems that occur with respect to health. Dermatological problems cause a very bad impact on the emotional, psychological and bodily stress for both the child suffering and the child’s family. Dermatological diseases in children are very common, especially infections in school going children.
The various causes that have an influence in the prevalence of dermatological diseases are the socioeconomic status of the family, the environmental conditions the child lives in, the food and lifestyle habits, the climatic conditions that prevail, the hygienic practices that the child follows, cultural factors, genetic factors and education status of parents affects the presence of dermatological diseases in children. Factors such as playfulness, intimacy, overcrowding also contribute to the development of skin diseases in school-aged children. There exists very limited studies in South Tamil Nadu, in which the school children have been evaluated for skin disorders.
The State of Tamil Nadu, especially the area around this medical college has a huge number of children that belong to the school age group. In view of all this we at the medical college decided to study that was titled as “Study on dermatological manifestations in school aged children in a tertiary health care centre” with the aim to learn the clinical and the epidemiological pattern of skin manifestations in school going children.
MATERIALS AND METHODS
The study was a cross sectional study done at the Dermatology Venereology and Leprosy Department and Paediatrics Department at the Sree Mookambika
were chosen based on a pre-defined criteria. This study was initiated after approval of the study protocol by the institutional research and ethics committee. Assent was obtained from children above 8 years of age and informed consent was taken from the parents/guardians of children below 8 years of age. After getting clearance from ethics committee, the patients that fulfilled the inclusion criteria were enrolled.
RESULTS AND OBSERVATIONS
A total of 51 cases (63.75%) belonged to 5- 8 years age group and 29 cases (36.25%) belonged to 9-12 years age group. More skin diseases were seen among 5- 8 years age group (63.75%) in our study.
We got 47 male children and 33 female children. Skin diseases were found to be slightly more common in males with a ratio of 1.42: 1.
Using Modified Kuppuswamy Socioeconomic Status distribution we found that lower class formed most of the cases with 34 children (42.5 %), followed by Upper lower class with 26 cases accounting for 32.5 % of the study, followed by lower middle with 13 cases(16.25%). Infectious diseases were more common (19 cases) than inflammatory diseases (15 cases) in the lower class i.e. infectious diseases were more in lower class.
Rural patients comprised 64 cases (80 %) and the urban patients comprised 16 cases (20%). Dermatological lesions were more common in rural areas when compared to urban areas.
In 5 – 8 years old children, inflammatory skin conditions were the most common with 27 cases (52.9%) followed by infectious skin condition in 23 cases
followed by infectious diseases in 14 cases (48.2%).
Inflammatory skin conditions were highest in account with 42 cases (52.5%) in which Pityriasis alba was most common with 14 cases each (17.5 percent). This condition was more common in less than 9 years age group having 12 cases (44.44%).
Next to inflammatory conditions, infectious diseases were common with 37 cases(46.25%). Among this parasitic infestation was the commonest with 15 cases(40.5%), followed by bacterial infections which was seen in 14 cases (17.5 percent). Impetigo was the commonest bacterial infection seen in 5-8 years age group.
Association between socioeconomic status and dermatological conditions:
Infectious diseases were more common (19 cases) than inflammatory diseases (15 cases) in the lower class i.e. infectious diseases were more in lower class.
CONCLUSION
Dermatological conditions were more common in 5-8 years age group. Skin diseases were slightly more common in male children. Overall, Inflammatory diseases were higher in number than infectious diseases. According to Modified Kuppuswamy classification of Socioeconomic status, Infections were more common among lower socioeconomic class. Hence measures can be taken for overall improvement of education, job opportunities and socioeconomic status in rural areas so that there can be an improvement in the per capita income.
Introduction
Page 1
INTRODUCTION
The skin is the largest organ of the human body and is a prime pointer of the general health. Among the school going children dermatological problems are the most common problems that occur with respect to health. Dermatological problems cause a very bad impact on the emotional, psychological and bodily stress for both the child suffering and the child’s family.
Dermatological diseases in children are very common, especially infections in school going children.1 The prevalence of dermatological diseases among the Indian children is said to be ranging anywhere between 8.7 percent to 35 percent.2-4 Golfy José et al stated the prevalence to range from 4.3 percent to 49.1 percent.4
The various causes that have an influence in the prevalence of dermatological diseases are the socioeconomic status of the family, the environmental conditions the child lives in, the food and lifestyle habits, the climatic conditions that prevail, the hygienic practices that the child follows, cultural factors, genetic factors and education status of parents affects the presence of dermatological diseases in children.5-9 Factors such as playfulness, intimacy, overcrowding also contribute to the development of skin diseases in school-aged children.
The dermatological diseases that can be seen in children can be broadly divided into physiological dermatoses and pathological dermatoses. As the age advances physiological manifestations becomes less prevalent and prevalence of pathological manifestations is increased.10 The pattern of dermatological diseases in paediatric age group differs between different countries and also within the same
Page 2 country between the different states as an influence of various climatic, cultural, socio-economic factorsthus reflecting the health, hygiene and personal cleanliness of the community.5
In a developing country like ours where the living conditions are poor, the following factors contribute to the various skin problems. The pattern of dermatological diseases is an outcome of poverty, malnutrition, congestion, unhygienic practices, illiteracy, and communal backwardness prevailing in these countries.11-13
Over one fifth of our population comprises of children aged 6-14years which is the age group covering primary and secondary education. Among these only about 80 percent of children are enrolled and about 65 percent are regularly attending school on an average for 200 days in a year. Children between 5-14 years of age spend most of their time in school. The school is an ideal place for learning and growing up.14
The health of children and the youth is very essential. The health services for school going children are a necessity for constructing a healthy young nation.15 If schools are to develop into a power house of health education, we require to go for a transformation in the syllabus.
The World Health Organization considers school as a health promoting one when it is constantly strengthening its capacity as a healthy setting for living, learning and working. Health education, health services, and healthy school environment are components of such educational setups. “Schools can do more than any other institution in society to help young people live healthier, longer and more productive lives”.16
Page 3 School children are a vulnerable section of the population by virtue of their physical, mental, emotional and social growth during this period. It is in this age that their personality develops.5-9
Also they are exposed to various environmental factors which might cause problems and require health, guidance and care.5-9 Children in school age are susceptible to get specific skin problems. In school-based surveys the prevalence of pediatric dermatoses in different parts of India ranges between 8.7 percent to 35 percent.17-19
A variety of acute and chronic conditions which can be seen during school period anywhere in the world include Scabies, Eczema, warts, Impetigo, Dermatitis, Acne, chickenpox.17-18
Skin diseases are neglected in health care. Probably due to the fact that majority of them are not life threatening. However, morbidity caused by these problems are either not realized fully or not taken much seriously even by the heath care administrators, who have other competing priorities in the public health front.
Since majority of skin diseases do not present any acute problems, serious public health interventions are also not evolving.20,21
Many studies have been done on school going children, but very few studies have been conducted to find out the correlation between socioeconomic status and dermatological manifestations among school going children in south Tamil Nadu.
The state of Tamilnadu, especially the area around this medical college has a huge number of children that belong to the school age group.
In view of all these things we in our institution decided to do a study that was titled as “Study on dermatological manifestations in school aged children in a
Page 4 tertiary health care centre” with the aim to learn the prevalence of skin manifestations as well as association of socioeconomic status with skin disease in school going children.
In this study, the correlation of low socio economic status and there by poor personal hygiene with dermatological manifestations among the school aged children was studied. The need for proper personal hygiene, life style modification and proper treatment was emphasized. Early detection of diseases can avoid later complications. For example, early detection of impetigo can prevent chronic kidney disease which is a known complication of the disease. A guideline was set up for parents to prevent skin manifestations among children and to take adequate care and precautionary measures so that the major impact of the disease could be prevented.
Aims & Objectives
Page 5
AIMS & OBJECTIVES
To study the prevalence of dermatological manifestations in school aged children in a tertiary health care centre.
To study the association of socioeconomic status with dermatological manifestation.
Scientific Justification
Page 6
SCIENTIFIC JUSTIFICATION
Most of the skin diseases in pediatric age group differ based on socio economic and cultural patterns. There are intercontinental, intercountry and interstate variations. My study was conducted in the southern most district of Tamil Nadu which share many socioeconomic and cultural patterns with neighbouring districts of the state of Kerala.
Only a handful of studies have been conducted in South Tamil Nadu where school going children have been evaluated for dermatological manifestations.
Review of Literature
Page 7
REVIEW OF LITERATURE
The skin occupies a large part of the human body and is susceptible to various diseases.22 the skin is immature in childhood and hence is prone for various diseases and these are rather different from those seen in adulthood.23
The factors that differentiate the occurrence of skin diseases in children from adults are:
The immunity status of the children:
As a result of first time exposure of a child to various environmental or sociological factors like pollutants, contaminants, allergens, they are more prone to diseases than adults because a child’s skin differs from an adult’s skin in many ways.
Exposure to Contact allergens:
As children start going to school, they are exposed to dust and other contact allergens when they indulge in sports and other co-curricular activities
Unhealthy food habits and the ingestion of non-nutritional foods can be harmful to children. Contact with paint of toys and contaminated soil can also have adverse effects on the skin like fungal infections, contact dermatitis.
Exposure to unhygienic conditions:-
From around 3-4 years of age, children become more socially mobile and tend to spend more time at the play areas, amusement parks as well as playing with pets. Such characteristics and mannerisms along with the presence of unhygienic environmental conditions make them more prone to various skin like tinea corporis, scabies, etc. as well as systemic diseases.
Page 8 Exposure to social areas prone to communicable diseases
Many public areas and schools tend to lack hygienic norms and regulations;
as they are frequently visited by various socio-demographic groups. This makes those children who spend a lot of time in these areas more susceptible to the environment related adverse effects and contagious diseases.
Physically and mentally handicapped children:
These children maybe neglected often and this along with a combination of their habitual actions makes them more prone to communicable diseases.
Low socio-economic status of the parents of some of these children may also contribute to the etiology of the disease, as they fail to seek medical help in the early stage of disease due to financial problems.
Parents of those children especially with intellectual disabilities maybe unaware of the disease condition.
Skin manifestations of systemic disease in children:-
Systemic diseases in children may be associated with cutaneous manifestations such as in viral exanthems, collagen vascular disorders and drug reactions.
In children, the Stratum corneum layer is thinner than that of the adult skin, and the rest of the epidermal layers are immature. Maturity of these layers maybe attained only by puberty.
At times paediatric diseases especially those that present with an emergency may constitute a part of a much widespread systemic disease, drug allergy or infection.25
Page 9 Fig 1: The Anatomy of Skin
Functions of the Skin
They are as follows:22,23,26-28
1. To protect the underlying structures.
2. To help in maintaining and regulating the body temperature.
3. To help in the immunity of the body.
4. To help in regulating the water loss by acting as a barrier.
5. To help in the secretion of waste substances in the form of sweat.
6. To help prevent physical injuries by its sensory perception.
Fig 2: Functions of skin
Page 10 Human skin consists of a stratified, cellular epidermis and an underlying dermis of connective tissue, separated by a dermal epidermal basement membrane.
Beneath the dermis is a layer of subcutaneous fat, which is separated from the rest of the body by a vestigial layer of striated muscle. The epidermis is mainly composed of keratinocytes and, for the living cell layers, is typically 0.05–0.1 mm in thickness.
It is formed by the division of cells in the basal layer, which gives rise to the spinous layer. This layer contains cells that move outwards and progressively differentiate, forming the granular layer and the stratum corneum. The cellular progression from the basal layer to the skin surface takes about 30 days but is accelerated in diseases such as psoriasis. The ‘brick‐like’ shape of keratinocytes is provided by a cytoskeleton made of keratin intermediate filaments. As the epidermis differentiates, the keratinocytes become flattened. This process involves the filament aggregating protein, filaggrin, a protein component of keratohyalin granules. Indeed, keratin and filaggrin comprise 80–90% of the mass of the epidermis.
The outermost layer of the epidermis is the stratum corneum, where cells (now called corneocytes) have lost the nuclei and cytoplasmic organelles. The corneocyte has a highly insoluble, cornified envelope within the plasma membrane, formed by crosslinking of soluble protein precursors, including involucrin and loricrin, the latter contributing 70- 85% to the mass of the cornified cell envelope. It also contains several lipids (fatty acids, sterols and ceramides) released from lamellar bodies within the upper, living epidermis.
The stratum corneum can be divided into three distinct biochemical and functional zones - an outer absorber of solutes, a middle absorber of water for hydration, and an inner mechanical defense barrier. Melanocytes, Langerhans cells, Merkel cells, Keratinocytes together form the epidermis. Melanocytes are dendritic cells that distribute packages of
Page 11 melanin pigment in melanosomes to the surrounding keratinocytes to give skin its colour.
The number of melanocytes does not differ much between skin types. Rather it is the nature of the melanin and the size of the melanosomes that account for the different appearances. The Langerhans cells are also dendritic in nature, although these are of mesenchymal origin and originate from bone marrow. Langerhans cells are antigen‐presenting cells and process antigens encountered by the skin to local lymph nodes and thus have a key role in adaptive immune responses in the skin.
Skin and Childhood
Physiological Skin Changes
During childhood, skin progressively acquires the structural and functional characteristics of the adult before the sexual development at puberty and the transition to adulthood. Sebaceous activity starts to increase again toward the end of childhood before other signs of approaching puberty. Significant changes occur between the ages of 8 and 9. They may be related to an increase in the output of adrenal androgens.28 Cutaneous Disorders
In the school-going age, there is an increased risk of infections and contagions, such as impetigo, furunculosis, measles, chicken pox, verruca, molluscum contagiosum, tinea capitis, scabies, and pediculosis. Miliaria is a common skin problem in tropical countries during summer months. It is due to eccrine sweat retention and may be associated with secondary bacterial infections and eczema.
Childhood eczema is due to endogenous and exogenous causes. The exogenous eczemas are mainly due to contact and irritant dermatitis. Endogenous eczemas in childhood are mainly atopic dermatitis and seborrhoeic dermatitis.
Page 12 Pityriasis alba, a nonspecific dermatitis in childhood, can be easily mistaken for early vitiligo, tinea versicolor, nummular eczema, or leprosy. Seborrheic dermatitis of the exfoliative type in a child can be mistaken for psoriasis, ichthyosiform erythroderma, and Langerhans cell histiocytosis.29
There is an increased incidence of nut allergy in children in recent years. It is important to be aware of this fact as rarely anaphylaxis can occur. Children allergic to one kind of nut are likely to be allergic to other kinds like peanuts, almonds, cashew nuts, walnuts, and pistachio. In few children, coconut, sesame seed, poppy seed, sunflower seed, green beans, and pine kernels can also induce allergy. It is equally important to avoid prescriptions containing nut or nut products (e.g., aracus oil) in patients with nut allergy. Dermatitis may also be due to immune deficiency and metabolic disorders in certain genodermatoses.
Childhood skin diseases may also be due to nutritional and endocrinal disorders. In addition, there is an increasing awareness that both boys and girls may present to the dermatologist with signs and symptoms of sexual abuse.30
THE PREVALENCE OF SKIN DISEASES IN SCHOOL GOING CHILDREN The prevalence of dermatological manifestation in school going children globally
Dermatological disorders affect about one third of the overall population globally. Aysegul Uludag et al, in a study done in 2016 in Canakkale, Turkey, found that 79.9 percent of the 2660 students evaluated had at least one type of skin manifestation7.
Abdel-Hafez et al31 in their study done in Egypt stated that 86.9 percent had dermatoses. Another study by Ogunbiyi et al in 20055 in Nigeria found that 35.0
Page 13 percent had dermatological problems. In a study that was done in the city of Hong Kong by Fung et al32 31.3 percent had dermatological problems.
The prevalence of dermatological manifestations in the school going children in India In a study that was done in India by Grill et al 45.3 % of the population above 5 years in India had at least one skin finding.33
Yasha Upendra et al3 in a study that was done in India on tribal school children 72.1 % of the child population had skin disease.
Bhatia et al stated that 51.95 percent of children had one or more dermatoses.6
The prevalence of dermatological manifestations in the school going children in Tamil Nadu
Bharatesh Devendra Basti et al3 in a study that was done in Tamil Nadu on tribal school children 64.6 percent manifested skin disease.
Golfy José et al stated the prevalence of skin diseases was 68.2 percent in Salem.4
SKIN DISEASES IN SCHOOL GOING CHILDREN
The commonest dermatological problems of school children include scabies, tinea-versicolor, pityriasis alba, seborrheic dermatitis, urticaria, warts, tinea corporis, papular urticaria, pediculosis, contact dermatitis, atopic dermatitis, miliaria, xerosis, insect bite allergy, candidal intertrigo, varicella zoster, polymorphic light eruption, hand foot mouth disease, staphylococcal scalded dermatological syndrome.34-36
Page 14 The variation in gender in the incidence of dermatological disorders
There happens to be a gender difference in the dermatological diseases among school children as shown in studies by Sharma et al (34), Patel JK (35), Sacchidanand Shrestha R et al ( 36-37 ), Jawade (38), who state that male are affected more than females .
The incidence of overall infections
In the year 1999, a study by Sharma et al found that fungal Infections constituted 8.42 percent of the study population, viral Infections constituted 3.85 percent of the study population and parasitic infestations constituted 53.66 percent of the study population.34
In a study that was done in the year 1998 by Sayal SK et al39 found that infections constituted 31 percent of the study population.
A study by Sardana K et al40 in the year 2009 found that infections constituted 31 percent of the study population.
Sacchidanand et al36 did a study in the year 2014 and found that infections constituted 32.47 percent of the study population.
In the year 2010, a study by Patel JK et al35 found that infections constituted 38.43 percent of the study population.
In a study that was done in the year 1999 by Sharma et al they found that insect bite reaction constituted 8.42 percent of the study population, viral Infections constituted 3.85 percent of the study population.34
Page 15 Shrestha R et al in his study in the year 2012 found that fungal Infections constituted 7.3 percent of the study population, viral Infections constituted 14.12 percent of the study population.37
A study by Manisha Balai13 in the year 2012 et al found that fungal Infections formed 6.52 % of the study population, viral infections formed 14.12 % of the study population. Another study that was done in the year 2011 by Flávia Regina Ferreira et al41 they found that infections 14.4 % of the study population.
Dadapeer et al, in the year 2018, did a study in which 8.1 percent42 formed infections and 56.4 percent formed infestations.
In the year 2017, Krishnendra Varma et al43 conducted a study and found that infections comprised 48.8 percent of the study population.
In a study in the year 2017 by Kodandapani et al44 on HIV paediatric patients found that non-infectious lesions constituted 51 % of the study population. .
SCABIES
Scabies affects about 300 million people worldwide yearly. Scabies is a highly pruritic disease.45 It can occur in all age groups but most commonly occurs in children.46-48 Poverty and overcrowding are the main contributing factors of the condition.49
Sarcoptesscabiei var. hominis, the human itch mite, is the causative organism of scabies.
Scabies is highly contagious and transmission occurs primarily by the transfer of the impregnated females from person-to-person, including sexual
Page 16 transmission, skin-to-skin contact. Transmission may occur via fomites (e.g., bedding or clothing).
Symptoms usually appear two to four weeks after infection, people who have previously been infected may develop symptoms within two days. Clinically children may present with papules, pustules, vesicles, or nodules.
The characteristic feature of scabies is the burrow. A practical approach for the diagnosis of scabies includes the presence of papules, vesicles, pustules, itching (especially at night), and a positive family history as proposed by Heukelbach and colleagues is an acceptable method for the diagnosis of a case.50 5% permethrin cream is probably the most effective and safest treatment for scabies in children beyond two months of age.51
Fig 3: Lifecycle of Scabies mite, Lesions in web spaces PITYRIASIS ALBA
Pityriasis alba is a common skin condition first characterized by red, scaly patches. Pityriasis Alba is a very common dermatological problem of children of unknown etiology,52-55 although it has been regarded as a manifestation of another skin disorder called atopic dermatitis.56
Page 17 Pityriasis alba is usually asymptomatic and often incidentally detected. It most often occurs on the face, particularly the forehead and malar ridges, but it also may occur on the extremities.
Diagnosis is based on clinical signs and symptoms. Pityriasis alba may resolve spontaneously and does not always require treatment. A moisturizer cream may be recommended to retain moisture in the skin. A low potency topical corticosteroid may also be prescribed to decrease inflammation and reduce symptoms.57
Fig 4: Pityriasis Alba over face SEBORRHEIC DERMATITIS
Seborrheic dermatitis is a type of papulosquamous disorder affecting the regions of the scalp, face, chest, back and flexular areas presenting as reddish and greasy looking scales, caused by Malassezia fur fur.58-60 The main role in triggering the inflammation is played by this organism.55 Corona seborrheica refers to Seborrheic dermatitis involving the hairline and extending onto the forehead. When lesions of psoriasis occur along with seborrheic dermatitis it is called as sebopsoriasis.61
Treatment - Responds to topical antifungals and regular shampooing.
Topical steroids are used only in acute flare ups.
Systemic antifungals used only in severe recalcitrant SD.
Page 18 Fig 5: Scalp seborrhea
VIRAL WARTS
Cutaneous viral warts are discrete benign epithelial proliferations caused by the human papillomavirus. Warts are caused by virus that appear as a flat growth especially on the areas of pressure but they can occur in any part of the body, and they have a tendency to spontaneously disappear, but recurrence is a rule.62
Types occur:
Previous studies shows common wart was the most common type of warts among students followed by plantar and plane warts while genital wart was the least frequent.63
Types of viral warts Common warts
Common warts begin as smooth flesh coloured papules that enlarge and develop a characteristic hyperkeratotic surface of grossly thickened keratin. They can occur at sites of injury (Koebner phenomenon)
Plantar warts (verrucae)
Plantar warts occur on the soles of the feet and can be painful. They protrude only slightly from the surface of the skin and often have a surrounding collar of keratin.
Page 19 Plane warts
Plane warts are flat topped papules, typically scattered over the face and arms. Warts may be widespread and persistent in patients who are immunocompromised. The clinical appearance of warts depends on their location.
The hands are most commonly affected.
Treatment
Although most warts resolve spontaneously within two years, some persist and become large.
Main treatment options include:
Topical Salicylic acid (12%–26%) ,Topical TCA 50%, once or twice weekly, Tretinoin cream 0.05% once daily, Podophyllotoxin 0.5% in ethanol for anogenital warts, Topical 5-Fluorouracil (5-FU) 5% ointment for 4 hours twice daily for 3 weeks, Electrosurgery.
Fig 6: Warts over dorsum of foot IMPETIGO
Impetigo is considered a highly communicable skin disease and has a higher prevalence in school aged children.64-65
Page 20 Impetigo is a superficial skin infection characterised by golden crusts. It is caused by Staphylococcus aureus or Streptococcus pyogenes. Lesions are highly contagious and can spread rapidly by direct contact, through a family, nursery, or class. The condition is more common in children living in tropical climates, and in conditions of overcrowding and poor hygiene.
Impetigo can occur either as a primary infection or secondary to another condition, such as atopic dermatitis or scabies. It can be classified clinically as impetigo contagiosa (non-bullous impetigo) or bullous impetigo.
Impetigo contagiosa
Impetigo contagiosa is the most common form (about 70%) of impetigo and the organism causing the disease is Staphylococcus aureus or Streptococcus pyogenes.66 Lesions begin as vesicles or pustules that rapidly evolve into gold-crusted plaques. They usually affect the face and extremities and heal without scarring.
Bullous impetigo
Bullous impetigo is characterised by flaccid, fluid filled vesicles and blisters (bullae). It is caused by toxin-producing S aureus. These are painful, spread rapidly, and produce systemic symptoms. Childhood impetigo predominantly affects the lower limbs.67 Lesions are often multiple, particularly around the oronasal orifices, and grouped in body folds.
Treatment
Topical mupirocin or fusidic acid for 7 days is used in clinically mild impetigo.68 Oral antibiotics may be better than topical preparations for more serious or extensive disease. Flucloxacillin is considered the treatment of choice for impetigo.
Page 21
Fig 7: Impetigo over hand and buttocks PITYRIASIS VERSICOLOR
It is a superficial, but chronic fungal infection of the stratum corneum characterized by hypopigmentation and scaling of the skin. It is one of the most common pigmentary disorders worldwide
Malassezia furfur or Pityrosporum, a yeast-like lipophilic fungus is the causative organism of Pityriasis Versicolor.
The disease is most prevalent in early adulthood and small children are rarely affected. PV is common in the pubertal and post-pubertal age where sebaceous glands are active and in individuals who sweat more.69 There is often a positive family history of the disease.
The risk factors are humid environment leading to hyperhidrosis, malnutrition, diabetes mellitus, and use of oral contraceptive pills, Cushing’s disease, corticosteroids, immunosuppression, and hereditary predisposition.
Pityriasis versicolor is benign, superficial fungal infection and occurs from using infected clothes, towels and bed sheets.70
It is usually asymptomatic. The chief lesion is a macule that may be hypopigmented or hyperpigmented and covered with branny scales .As the name
Page 22 versicolor suggest, the color of the lesion may be varied, which includes pink to tan to dark brown and even black. The typical eruption shows large confluent areas and scattered patches with satellite lesions.
The upper trunk is most commonly involved, but the infection usually extends to the upper arms, neck, and abdomen. Facial involvement is more typical on the forehead, usually evident as achromic or hypopigmented macules, scaly and smaller than patches on the trunk.71 Wood’s lamp shows pale yellow fluorescence.
Topical antifungals like Clotrimazole, Miconazole, Econazole, are used to treat pityriasis versicolor
Systemic Therapy
Ketoconazole and Itraconazole are very effective in the treatment of pityriasis versicolor. Ketoconazole is usually given at the dosage of 200 mg daily for 5–25 days. A single dose (400 mg) also works well in some cases.72
Fig 8: Pityriasis Versicolor over face VARICELLA ZOSTER VIRUS
Varicella zoster virus (VZV) is a double stranded DNA virus and causes two clinically distinct forms of disease: varicella (chicken pox) and herpes zoster (shingles).
Page 23 Chickenpox is a self-limiting infection characterized by fever, malaise and generalized pruritic rash.73,74
The primary infection of varicella includes viremia and a widespread vesicular eruption, after which the virus persists in sensory nerve ganglion cells and produces Herpes Zoster on reactivation.
Chickenpox is extremely contagious and over 80% of people would have been infected by the age of 20-30 years.75 The incubation period ranges from 10-21 days. It spreads mainly by respiratory droplets but infection through direct contact may also occur.
Vesicles can also be present on the mucous membranes mostly on the palate, and rarely, nose, larynx, pharynx, and conjunctiva can also be involved where they rupture easily and leave behind shallow ulcer.
The Indian Academy of Paediatrics ‑.Committee on Immunisation recommends the administration of varicella vaccine in children aged 15 months or older.76
Treatment is Oral acyclovir 20 mg/kg PO (up to 800 mg per dose) five times daily for 5 days.
Fig 9: Chicken pox lesions over face
Page 24 TINEA CORPORIS
It is defined as dermatophytosis of the glabrous skin.
Epidemiology
Tinea corporis may be transmitted by direct contact with other infected individuals or by infected animals.
Predisposing factors are poor personal hygiene, poor nutrition, and systemic diseases like diabetes, leukemia, and other endocrine disorders. The age predilection in younger children is believed to result from the biological and behavioral patterns in children which include lack of fungistatic properties of fatty acids of short and medium chains that is found in postpubertal sebum.77
Etiology and Pathogenesis
All species of dermatophytes belonging to the genera Trichophyton, Microsporum, or Epidermophyton can cause tinea corporis. The three most common causative organisms are Trichophyton rubrum, Trichophyton mentagrophytes, and M. canis. In India, Trichophyton rubrum accounts for the majority of cases.
Clinical Features
The typical lesion of tinea corporis is usually annular or polycyclic. Its borders are erythematous and vesicular or scaly, but the center is clear. Infection due to a zoophilic organism, occurs commonly on exposed skin (the head, neck, face, and arms). Tinea corporis due to an anthropophilic organism occurs in occluded areas or in areas of trauma, such as, perifolliculitis in the legs of women associated with leg shaving. Tinea corporis on or below the waistline is commonly seen in Indian women.
Page 25 Treatment
Topical antifungals are effective in isolated lesions, but for widespread or more inflammatory lesions, systemic antifungals are indicated
Topical
Miconazole cream 2% twice daily, Ketoconazole cream 2% twice daily, Clotrimazole cream1% twice daily, Terbinafine cream 1% twice daily.78 Continue topicals for 7–14 days after complete resolution of symptoms.
Oral
Fluconazole 150-300 mg once weekly for 4-6 weeks, Itraconazole 200-400 mg once daily for 1 week , Terbinafine 250 mg once daily for 14 days, Griseofulvin 500 mg once daily for 4-8 weeks
Fig 10: Tinea corporis over abdomen ATOPIC DERMATITIS
Atopic dermatitis is a chronic, recurring, inflammatory skin disease that mostly affects young children79.
The male preponderance seen in hospital‑based Indian epidemiological studies could be due to more treatment‑seeking behavior for boys compared to girls.80
Page 26 The major symptom of AD is pruritus. During childhood, the typical flexural distribution of AD begins, with involvement of the elbow and knee creases, wrists, and ankles. There may be flexural oozing and crusting, which is usually followed by lichenification.
Fig 11: Atopic dermatitis over leg and face Patch testing is the gold standard diagnostic test81
The use of immuno suppressive therapy may help to improve the quality of life of children with atopy.
CONTACT DERMATITIS
Contact dermatitis refers to skin inflammation induced by contact with substances in the environment that leads to the development of lesions in the skin and mucosa through allergic and irritant reactions.82,83
Around 7% of the general population is affected by ACD.84
It is classified into allergic contact dermatitis and irritant contact dermatitis.85 Patch testing is by far the commonly used method of identification of the causative allergen.86
Children with atopic dermatitis (AD) are very often affected by contact dermatitis.87
Page 27
Fig 12: Contact dermatitis on axilla and leg Treatment of Irritant Dermatitis
Antibacterial cream or topical corticosteroids. Application of bland emollients may be encouraged to facilitate skin barrier repair.81
PEDICULOSIS
It is an infestation with ectoparasites, that is, lice.
It is a worldwide community health problem that affects children in both developed and developing countries.88,89
Pediculushumanus var. corporis (body louse), Pediculushumanus var. capitis (head louse) and Pthirus pubis (pubic or crab louse) are the three important types.
Pediculosis capitis is the lice infestation of the scalp presenting with itching and secondary pyoderma in the scalp.
Infestation with lice is called pediculosis. Lice infestation of the scalp is most common in children, especially girls with long hairs.90 Head lice are generally spread through direct transmission via head-to-head contact with an infected person or indirect transmission by sharing clothing, hairbrushes, hats, towels or other
Page 28 personal items of a person already having lice.91 Itching and secondary bacterial infection of the skin resulting from scratching can occur with any lice infestation.
The diagnosis is made by seeing the lice in the scalp or more often, nits glued to the hair shaft in the retroauricular and occipital region of the scalp.
Treatment Options for Pediculosis.
1% permethrin rinse
Gamma benzene hexachloride lotion/shampoo
Malathion, crotamiton, and lindane
Combing with a metal or plastic comb after conditioner (8% formic acid solution).
Oral cotrimoxazole
Oral ivermectin (400 µg/kg)
Fig 13: Nits on scalp CANDIDAL INTERTRIGO
Candidal intertrigo is characteristically a disorder of the folds of the skin that is initiated by warmth, humidity, maceration and friction. The disease has seasonal variation, being more frequent in summer and monsoons. This disease tends to be more frequent in the obese; suffer from diabetics, those affected by hyperhidrosis and those who have a poor hygiene individuals, infants are also more likely to
Page 29 develop intertrigo due to drooling and short neck structure with prominent skin folds and a flexed position.92 Sites mainly affected are inter digital spaces, abdominal folds, the inframammary area, axilla and perineal region. Bodily secretions, including perspiration, urine, and feces, often exacerbate skin inflammation.93
Fig 14: Interdigital Candidal Intertrigo
MILIARIA RUBRA
This disease is also known as sweat rash, heat boils or rash, or prickly heat disease. It is more common in hot and humid climates. It commonly occurs on the face, neck, infra mammary areas, scrotum, and in between skin folds.
The varieties of miliara are known to occur, based on sweat duct involvement.94
The miliaria crystallina
The miliaria rubra
The pustular miliaria or pustulosa
The miliara Profunda
Miliaria cystallina presents as clear pinpoint superficial vesicles without any inflammatory infiltrate.
Page 30 Miliaria rubra occurs when there is increased sweating; which leads to occlusion of the sweat ducts. The clinical features are erythematous papules, vesicles, pruritus, pins and needles sensation.95,96 Miliaria pustulosa presents as papulovesicular lesions that become sterile pustules.
Miliaria profunda when lesions progress to form plaques.
Treatments are light weight cotton clothing, avoidance of excessive heat, cool baths.
Systemic antihistamine for severe itching.
Fig 15: Miliaria Rubra over forearm
POLYMORPHIC LIGHT ERUPTION
Polymorphic Light Eruption (PLE) is mostly induced by bright summer sunlight but can be seen at any time of the year in India. Polymorphic light eruption is a highly prevalent photosensitivity disorder, estimated to affect 11–21% people in temperate countries.97 Photosensitive disorders in children are idiopathic, or related to nutritional, genetic, metabolic or connective tissue diseases. Most photosensitive disorders begin in infancy or childhood and persist during adulthood. However, their severity decreases with age.98
Page 31 PLE is characterized by a chronic and recurrent eruption on the photoexposed sites, though some light exposed parts may be spared. Typical sites affected are the bridge of the nose, cheeks, and chin; the back, sides and “V” area of the neck, dorsal aspect of hands, dorsolateral aspect of the arms, and sometimes the dorsal aspect of the feet. The primary lesions are itchy, grouped, small or large erythematous or skin-colored papules, plaques or papulovesicles.
Treatment measures:
1. Restriction of UVR exposure plus antihistamines, 2. Covering up with appropriate protective clothing.
3. Application of high protection broad spectrum sunscreens.
4. Patients with fully developed disease require topical corticosteroids, in some cases in the form of wet dressings, for several days.99
Fig 16: Polymorphous light eruption over dorsal aspect of forearm XEROSIS
Xerosis, or xeroderma refers to a dermatological disorder characterized by dry skin, and is manifested as a mosaic pattern with dull scales and mild erythema.100 This dermatological condition also tends to itch and flake, which may be distracting and distressful for some patients. 101
Page 32 Environmental factors may influence the composition of natural moisturizing factor. For example, a decrease in ambient humidity has been shown to reduce the generation of free amino acids in the stratum corneum and increase skin dryness.102
Fig 17: Xerosis over leg VITILIGO
Vitiligo is an acquired, chronic, maybe autoimmune, pigmentary disorder characterised by white macules and patches, due to the progressive loss of cutaneous melanocytes and to an abnormality in their normal function.103
Leukotrichia is a common presentation in vitiligo with various studies reporting an incidence rate varying from 3.7% to 32.5%, being most commonly associated with vitiligo vulgaris.104 Vitiligo rarely causes physical discomfort, but patients may develop inferiority complexes, fear, anxiety, depression, social communication difficulties, embarrassment, irritability, and fear of stigmatization.105 Treatment options include: Topical tacrolimus, calcipotriol, and corticosteroids, Systemic corticosteroids and Phototherapy-PUVA, NBUVB.103
Page 33 Fig 18: Vitiligo over hip
PAPULAR URTICARIA
Papular urticaria is a common disorder occurring due to a hypersensitivity reaction secondary to bites of insects such as mosquitoes, bed bugs, fleas and ticks.
Other aetiological hypotheses which have at one time or another found supporters are Food allergy, nervous factors, infection and parasites.106
It usually presents as pruritic recurrent papules or vesicles with surrounding edema and a central punctum.107 Treatment is usually symptomatic and includes antihistamines and corticosteroids. The reappearance of the symptoms can be prevented by successful control of the parasite.108
Fig 19: Papular urticaria over forearm
Page 34 Molluscum Contagiosum
Molluscum contagiosum is caused by Molluscum contagiosum virus (MCV) which belongs to Poxviridae family. MC is more common in children but can also affect adolescents and adults. It typically affects children between 2-5 years old, being rare under the age of 1 year. There are no gender differences.109
MC is transmitted by direct contact with the skin of affected individual.
Autoinoculation can occur from the manipulation of lesions by the patient. Fomites may also play a role in acquiring the infection. MCV produces single or multiple, umbillicated, skin-colored, opalescent, discrete, smooth, dome-shaped waxy papules.
The size of papules may be 2–6 mm, but it may be as large as 1 cm. They can occur anywhere on the body, but mostly seen on face, axillae, antecubital and popliteal fossae, and perineal area. Lesions are usually asymptomatic. The lesions may become red and swollen sometimes forming pus-filled pimples. This is usually a good sign that the immune system is fighting the virus and starting to clear the infection.110
Treatment of Molluscum Contagiosum
Some authors suggest watchful waiting of the lesions and to await spontaneous resolution.111 Topical Tretinoin, Needling, oral Cimetidine etc. are the treatment modalities.
Fig 20: Molluscum contagiosum over chin
Page 35 Insect bite reactions
Insect bite reactions are common, but information about their prevalence is limited. Children <14 years of age in dermatology outpatient clinic in Pondicherry had a prevalence of 5.3%.112
Of the 30 or so orders of insects, only a few have significance for dermatologists like Anoplura (lice), Diptera (flies, mosquitoes), Cleoptera (beetles), Hemiptera (bedbugs, kissing bugs), Siphonaptera (fleas), Hymenoptera (ants, bees, wasps), and Lepidoptera (butterflies and moths).113 Although insect bite reactions are mostly transient, papules and nodules occasionally persist for long periods, sometimes as a result of unrestrained scratching. Most cases of insect bite occur at night when patients are asleep. The usual sites of insect bite are the exposed areas of the skin, more so in the case of flying insects like mosquitoes and flies, and the lesions tend to be unilateral in majority of the cases. On the contrary, trunk may be involved in case of bedbugs or blister beetle bites, which may be unilateral or bilateral. The morphology of lesions is usually discrete rather than being grouped.
The response to insect bites depends on the amount and intensity of previous exposure to biting by similar insects. People sensitized to one insect species may not respond to another species.114
Fig 21: Insect bite reaction over thigh
Page 36 URTICARIA
Urticaria is one of the most common skin diseases, characterized by the development of wheals (hives), angioedema, or both and it is classified as acute or chronic form based on the duration of illness. Urticaria of longer than 6 weeks duration is classified as chronic urticaria, which is further classified into chronic spontaneous or inducible urticaria.115
Although the relationship between acute urticaria and food is known, however, the relation between chronic urticaria and food remains unclear. In a report of 3-17 years old children, 75% of the causes of urticaria severity were due to food additives such as coloring agents, preservatives, monosodium glutamate.116
The mainstay of treatment is avoidance of triggers, if identified. H1- antihistamines like Chlorpheniramine, Hydroxyzine, Promethazine are first-line pharmacotherapy. Second-generation H1 antihistamines such as loratadine, desloratadine, fexofenadine, cetirizine, and levocetirizine are relatively nonsedating at standard dosages and are dosed once per day.
Second-generation H1 antihistamines are first-line medication for the treatment of acute urticaria because of lesser side effects.117
Fig 22: Urticaria over trunk
Page 37 STAPHYLOCOCCAL SCALDED SKIN SYNDROME
Staphylococcal scalded skin syndrome (SSSS) is the medical term used to define a skin condition induced by the exfoliative toxins produced by Staphylococcus aureus.
The symptoms of this disease varies from a few watery blisters on some part of skin to a severe exfoliation affecting the entire body surface.118
The mortality rate caused by Staphylococcal Scalded Skin Syndrome in children is very low (1-5%), and is much lower in children than in adults unless associated sepsis or an underlying serious medical condition exists.119
Hospitalization, IV fluids and electrolytes, and antibiotics are required to treat Staphylococcal Scalded Skin Syndrome.
Fig 23: Staphylococcal Scalded Skin Syndrome HFMD
Hand, foot and mouth disease (HFMD) is a common childhood infectious disease that is mainly caused by enterovirus A71 (EV-A71), coxsackievirus A16 (CV-A16), and CV-A6.120
Page 38 The patient may be presented with common cold, sore throat and characteristic rashes on the palms, soles, inside the mouth, tongue, gums and cheek, known as hand-foot-mouth disease (HFMD), more common in children under 10 years.121
It is a self-limiting disease and may lead to peeling of skin and nails.122
Fig 24: Hand Foot Mouth Disease
Materials & Methods
Page 39
MATERIALS AND METHODS
Study Design: Cross sectional study
Study Settings: Dermatology Venereology and Leprosy Department and Paediatrics Department, Sree Mookambika Institute of Medical Sciences, Kulasekharam
Study group: In this study school aged children are included that is in between age group 5 – 12 years of age.
Study period: 18 months
Sampling Population: 80 Sample Size Calculation:
𝑵 = 4𝑝𝑞
𝑑2 N = 4x68.20x31.8
10.23x10.23 = 8328
104.6 = 79.61 = 80 p = Percentage of dermatoses = 68.20 q = 100-p
= 100 – 68.20 = 31.8 d = 15% of p = 10.23(4)
Sampling technique used: Purposive sampling.
Inclusion Criteria:
Children in between age group 5-12 years.
Exclusion criteria:
Critically ill children
