Strategic Approaches to Reducing the Burden of Atopic Dermatitis in the Middle East and Africa Region.

OBJECTIVES: Atopic dermatitis (AD) creates a significant burden on patients and society. This study proposes a set of health policy interventions that can reduce the burden of AD in the Middle East and Africa. METHODS: We conducted a scoping review to find relevant actions that have been implemented or recommended to decrease AD burden globally. An expert panel was conducted to discuss the review findings, then experts were surveyed to suggest the most efficient actions. Finally, survey results and recommendations were formulated into key actions to reduce the burden in the Middle East and Africa region. RESULTS: Recommended actions were related to 5 domains; capacity building, guidelines, research, public awareness, and patient support and education. Several actions related to each domain can help reduce the burden. One of the most advocated recommendations was investing in patient education through trained healthcare professionals. Understanding the disease and learning how to control it is a key cornerstone to treatment optimization and reducing the burden. Multidisciplinary care, publishing defined therapeutic guidelines, and investing in research were the most recommended actions based on the experts' discussion and survey results. CONCLUSIONS: Although the burden of AD is the highest among dermatological diseases, a well-grounded action plan has the potential to reduce the disease burden. Decision makers may develop a national AD action plan by selecting the most relevant items of this study based on their potential impact, feasibility, timeliness, and affordability.

The clinicopathological spectrum of preclinical folliculitis keloidalis with correlation to its dermoscopic features: a cross-sectional analytical study.

BACKGROUND: Folliculitis keloidalis (FK) is a chronic hair disorder commonly affecting males with afro-textured hair. It typically affects the nuchal area, but disease may also occur at extra-nuchal sites. Few studies have investigated the histopathological aspects of preclinical FK. In addition to the histopathology of preclinical FK, this article is the first to describe the dermoscopic features of preclinical FK at extra-nuchal sites. MATERIALS AND METHODS: This study was conducted in a tertiary dermatological clinic. Twenty-eight patients with a clinical diagnosis of FK were prospectively enrolled from 2014 to 2016. Dermoscopy was used to identify features that were not evident with the naked eye (preclinical). These sites were subsequently biopsied. The clinical, dermoscopic, and histopathological features of these preclinical areas are described and correlated. RESULTS: Most patients suffered a chronic disease course (mean: 7.6 years) with 57.1% (n = 16) displaying extra-nuchal involvement. Dermoscopy-guided biopsy of preclinical lesions displayed perivascular dermatitis (82.1%), folliculocentric inflammation (46.3%), and fibrosis (64.3%). Novel dermoscopic findings were perifollicular scale, perifollicular erythema and pink-white areas. The perifollicular scale was associated with fibrosis on histopathology (P < 0.05). CONCLUSIONS: This article lends further evidence for the existence of preclinical FK and describes its histological features. For the first time, it describes the dermoscopic features of preclinical FK. Dermoscopy may therefore be a useful tool to assess disease progression and treatment response.

Cross-sectional study of acral melanoma awareness in a group of South African final phase medical students.

BACKGROUND: Acral melanoma refers to melanoma arising on the palms, soles and nail unit, which are sun-protected areas and ultraviolet exposure is not a risk factor. Acral melanoma is associated with a poorer prognosis than other melanoma subtypes most likely due to the high rates of delayed diagnosis. Acral melanoma affects all skin types equally. There is a misconception that people with more pigmented skin types (Fitzpatrick 4-6) do not develop melanoma, due to the protective effect of melanin. OBJECTIVES: The aim of the study was to determine acral melanoma knowledge and awareness of a group of South African, final phase medical students. METHODS: This was a quantitative and cross-sectional study. A questionnaire consisting of 20 clinical images of skin lesions requiring a diagnosis and management plan was distributed. Responses to six images of melanomas were analysed. Further questions to measure acral melanoma knowledge and related issues were included in the study. A biostatistician appropriately managed statistical analysis. RESULTS: Hundred and one final phase medical students' answers were gathered and analysed. Only 7.9% of the participants diagnosed all six melanomas correctly; 61.4% correctly diagnosed ≥50% of the melanomas. While 77.2% of the participants identified all non-acral cutaneous melanoma correctly, only 8.9% identified all acral melanomas. However, of all participants making the correct diagnosis, >90% selected the appropriate management plan (urgent referral). LIMITATIONS: This study examined a small sample of trainee healthcare workers. The results cannot be assumed to apply to all South African healthcare workers. Responses given in a questionnaire may not reflect actual behaviour. The dermatology division in question has made acral melanoma a research priority, thus acral melanoma knowledge in this group may in fact be better than in other institutions. CONCLUSION: The present study demonstrates that groups of imminent doctors have low rates of recognition of melanoma, particularly acral melanoma. This is consistent with high levels of primary misdiagnosis of acral melanoma reported in the literature. Fortunately, these participants managed the melanomas they diagnosed appropriately in >90% of cases. This confirms that the deficit in the participant group is awareness and knowledge. Those aware of the disease immediately acknowledged the need for urgent referral.

Exhaustive reanalysis of barcode sequences from public repositories highlights ongoing misidentifications and impacts taxa diversity and distribution.

Accurate species identification often relies on public repositories to compare the barcode sequences of the investigated individual(s) with taxonomically assigned sequences. However, the accuracy of identifications in public repositories is often questionable, and the names originally given are rarely updated. For instance, species of the Sea Lettuce (Ulva spp.; Ulvophyceae, Ulvales, Ulvaceae) are frequently misidentified in public repositories, including herbaria and gene banks, making species identification based on traditional barcoding unreliable. We DNA barcoded 295 individual distromatic foliose strains of Ulva from the North-East Atlantic for three loci (rbcL, tufA, ITS1). Seven distinct species were found, and we compared our results with all worldwide Ulva spp. sequences present in the NCBI database for the three barcodes rbcL, tufA and the ITS1. Our results demonstrate a large degree of species misidentification, where we estimate that 24%-32% of the entries pertaining to foliose species are misannotated and provide an exhaustive list of NCBI sequences reannotations. An analysis of the global distribution of registered samples from foliose species also indicates possible geographical isolation for some species, and the absence of U. lactuca from Northern Europe. We extended our analytical framework to three other genera, Fucus, Porphyra and Pyropia and also identified erroneously labelled accessions and possibly new synonymies, albeit less than for Ulva spp. Altogether, exhaustive taxonomic clarification by aggregation of a library of barcode sequences highlights misannotations and delivers an improved representation of species diversity and distribution.

Paediatric atopic eczema (atopic dermatitis) in South Africa: A practical algorithm for the management of mild-to-moderate disease in daily clinical practice.

BACKGROUND: Atopic eczema (AE) is a chronic, highly pruritic, inflammatory skin condition with increasing prevalence worldwide. Atopic eczema mostly affects children, impairing quality of life with poor disease control leading to progression of other atopic disorders. As most patients in South Africa have no access to specialist healthcare, a practical approach is needed for the management of mild-to-moderate AE in paediatric patients for daily clinical practice. METHODS: A panel of experts in AE convened to develop a practical algorithm for the management of AE for children and adolescents in South Africa. RESULTS: Regular moisturising with an oil-based emollient remains the mainstay of AE treatment. Severe AE flares should be managed with topical corticosteroids (TCSs). For mild-to-moderate AE flares in sensitive skin areas, a topical calcineurin inhibitor (TCI) should be applied twice daily from the first signs of AE until complete resolution. Topical corticosteroids may be used when TCIs are unavailable. In non-sensitive skin areas, TCSs should be used for mild-to-moderate AE, but TCIs twice daily may be considered. Proactive maintenance treatment with low-dose TCI or TCS 2-3 times weekly and the liberal use of emollients is recommended for patients with recurrent flares. CONCLUSIONS: This algorithm aims to simplify treatment of paediatric AE, optimising clinical outcomes and reducing disease burden. This approach excludes treatment of patients with severe AE, who should be referred to specialist care. Emphasis has been given to the importance of general skincare, patient education and the topical anti-inflammatory medications available in South Africa (TCSs and TCIs).

The prevalence and spectrum of mucocutaneous disease in South African people living with HIV and accessing care at a district-level hospital.

BACKGROUND: Although the association between human immunodeficiency virus (HIV) and mucocutaneous diseases has been well studied within South African specialist centres, there is limited data from district-level hospitals. Available data may, therefore, fail to reflect the prevalence and full spectrum of dermatoses seen in people living with HIV (PLWH). OBJECTIVES: To determine the prevalence and spectrum of dermatoses seen in PLWH. METHOD: We conducted a cross-sectional, descriptive study of 970 PLWH (men and women, ≥ 18 years old) accessing care at Karl Bremer Hospital, a district-level hospital located in the Western Cape province, South Africa, between 01 September 2016 and 28 February 2017. RESULTS: The prevalence of mucocutaneous disease in this sample was 12.7% (95% confidence interval [CI] 0.11-0.15). Non-infectious dermatoses comprised 71.0% of the disorders. Pruritic papular eruption (20.0%) and seborrheic dermatitis (6.0%) were the most common non-infectious dermatoses. Tinea corporis (8.0%) and oral candidiasis (6.0%) were the most prevalent infectious dermatoses. There was no significant association between skin disease category (infectious or non-infectious dermatoses) and patient demographics (gender and ethnicity) or HIV-disease characteristics (CD4+ cell count, viral load and duration of antiretroviral therapy [ART]). CONCLUSION: This study provides valuable scientific data on the prevalence and spectrum of mucocutaneous disease in PLWH attending a South African district-level hospital. Prospective studies conducted in other district-level centres across the country are required to determine the lifetime prevalence and spectrum of dermatoses in PLWH in the ART era.

An Analysis of Biopsies for Suspected Skin Cancer at a Tertiary Care Dermatology Clinic in the Western Cape Province of South Africa.

BACKGROUND: Skin cancer is a growing health concern worldwide. It is the most common malignancy in South Africa and places a large burden on the public healthcare sector. There is a paucity of published scientific data on skin cancer in South Africa. OBJECTIVES: To report the findings of biopsies performed in patients with suspected skin cancer attending the Tygerberg Academic Hospital (TAH) Dermatology outpatient department (OPD) in the Western Cape Province of South Africa. Methodology: A retrospective chart review identified all patients who underwent a biopsy for a suspected skin cancer diagnosis between September 2015 and August 2016 at the TAH dermatology OPD. RESULTS: A total number of 696 biopsies from 390 participants were identified, of which 460 were histologically confirmed as malignant lesions. The proportion of clinically suspected skin cancers that were histologically confirmed as cancer was 68%. The most commonly occurring malignancies were basal cell carcinoma (BCC) (54.8%), squamous cell carcinoma (SCC) (18.9%), squamous cell carcinoma in-situ (SCCI) (8.0%), Kaposi's sarcoma (KS) (6.7%), malignant melanoma (MM) (6.1%), and keratoacanthoma (KA) (4.6%). The number needed to treat (NTT) for all cancers diagnosed and for MM was 1.5 and 4 respectively. BCC (89.3%) and KS (67.7%) was the most common skin cancer in the white and black population respectively. The ratio of BCC to SCC was 2.03. CONCLUSION: This study provides valuable scientific data on the accuracy of skin cancer diagnosis, distribution and patient demographics in the Western Cape Province of South Africa, on which further research can be based. The study highlights the burden of skin cancer on this specific population group and calls for standardised reporting methods and increased surveillance of skin cancers.

The tumor genetics of acral melanoma: What should a dermatologist know?

Dermatologists stand at the gateway of individualization of classification, treatment, and outcomes of acral melanoma patients. The acral melanoma genetic landscape differs in vital ways from that of other cutaneous melanomas. These differences have important implications in understanding pathogenesis, treatment, and prognosis. The selection of molecularly targeted therapy must be adapted for acral melanoma. It is also critical to recognize that tumor development is far more complex than an isolated event, reliably treated by a medication acting on a single target. Tumors exhibit intratumor genetic heterogeneity, metastasis may have different genetic or epigenetic features than primary tumors, and tumor resistance may develop because of the activation of alternative genetic pathways. Microenvironmental, immune, and epigenetic events contribute and sustain tumors in complex ways. Treatment strategies with multiple targets are required to effectively disrupt the tumor ecosystem. This review attempts to translate the current molecular understanding of acral melanoma into digestible concepts relevant to the practice of dermatology. The focus is tumor genetics defining potentially treatable cancer pathways, contextualized within the relevant pathologic and molecular features.

Report of 2 Novel Presentations of Subcutaneous Fat Necrosis of the Newborn.

Subcutaneous fat necrosis of the newborn (SCFNN) is a rare form of panniculitis classically affecting healthy full-term infants. There are a number of predisposing factors including perinatal asphyxia. The condition generally has a benign course with spontaneous resolution, but monitoring for metabolic complications, in particular the potentially life-threatening complication of hypercalcaemia, is critical. The authors report 2 cases of preterm infants with perinatal asphyxia with atypical presentations of SCFNN: the first with bony involvement resembling Langerhans cell histiocytosis and with follicular pseudocarcinomatous hyperplasia on histology; and the second presenting with a huge haematoma requiring surgical debridement. Both cases were initially erroneously diagnosed as pyogenic infections.

Dowling-Degos Disease Presenting Primarily with Comedones and Atrophic Scarring.

Dowling-Degos disease (DDD) is a rare genodermatosis primarily presenting with reticulated pigmentation of the flexures. Secondary features include comedones and atrophic scarring. We present a patient with histologically confirmed DDD whose predominant clinical finding was of comedones and scarring, with less prominent pigmentation, thus expanding the clinical spectrum of DDD.

Growing Azolla to produce sustainable protein feed: the effect of differing species and CO2 concentrations on biomass productivity and chemical composition.

BACKGROUND: Since available arable land is limited and nitrogen fertilizers pollute the environment, cropping systems ought to be developed that do not rely on them. Here we investigate the rapidly growing, N2 -fixing Azolla/Nostoc symbiosis for its potential productivity and chemical composition to determine its potential as protein feed. RESULTS: In a small production system, cultures of Azolla pinnata and Azolla filiculoides were continuously harvested for over 100 days, yielding an average productivity of 90.0-97.2 kg dry weight (DW) ha-1 d-1 . Under ambient CO2 levels, N2 fixation by the fern's cyanobacterial symbionts accounted for all nitrogen in the biomass. Proteins made up 176-208 g kg-1 DW (4.9 × total nitrogen), depending on species and CO2 treatment, and contained more essential amino acids than protein from soybean. Elevated atmospheric CO2 concentrations (800 ppm) significantly boosted biomass production by 36-47%, without decreasing protein content. Choice of species and CO2 concentrations further affected the biomass content of lipids (79-100 g kg-1 DW) and (poly)phenols (21-69 g kg-1 DW). CONCLUSIONS: By continuous harvesting, high protein yields can be obtained from Azolla cultures, without the need for nitrogen fertilization. High levels of (poly)phenols likely contribute to limitations in the inclusion rate of Azolla in animal diets and need further investigation. © 2018 The Authors. Journal of the Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Skin conditions in a South African tuberculosis hospital: Prevalence, description, and possible associations.

BACKGROUND: The current pandemic of tuberculosis (TB) and human immunodeficiency virus (HIV) co-infection, the modern era of antiretroviral therapy, and the rising incidence of multidrug-resistant TB have led to a broader spectrum of skin conditions in patients hospitalized with TB. These factors also influence investigations into possible causal relationships with TB. OBJECTIVES: The aim of this study was to describe mucocutaneous conditions found in patients hospitalized with TB and to report associated factors. METHODS: A cross-sectional observational study examining the spectrum of skin manifestations found in 105 patients hospitalized with TB was conducted. All relevant demographic and clinical data were collected. Possible associations were evaluated by making use of statistical analysis. RESULTS: Seventy-four (70%) of the investigated population were HIV-positive, and 46 (44%) patients were being treated for drug-resistant TB. The most prevalent dermatosis was xerosis (n = 83, 79%), followed by oral candidiasis (n = 33, 31%) and scars (n = 33, 31%), finger clubbing (n = 31, 29%), leukonychia (n = 29, 28%), striae (n = 25, 24%), and facial hyperpigmentation (n = 22, 21%). Anemia was detected in 90 (86%) patients, and 75 (71%) were classified as being underweight. Three patients were diagnosed with cutaneous TB. CONCLUSIONS: Patients hospitalized with TB have on average four different dermatoses, but xerosis remains the leading dermatological finding, irrespective of HIV status or TB drug sensitivity. Anemia and malnutrition are associated with numerous skin conditions found in this population. The prevalence of cutaneous TB among patients hospitalized with TB remains low, despite the high rate of TB and HIV co-infection.