Dermoscopy Use in Africa: Determinants and Challenges.

INTRODUCTION: Dermoscopy has evolved over the years beyond distinguishing benign pigmented lesions from melanoma to diagnosing virtually all diseases in dermatology. Overwhelming evidence demonstrates its utility in improving diagnostic accuracy, reducing unnecessary biopsies and lesion monitoring. Dermoscopy is widely used in Western nations, hence most descriptions of lesions in literature are predominantly on Fitzpatrick skin types I-III. Current evidence shows that there are unique dermoscopic features in the dark skin as a result of pigment and pathological reactions. Nationwide surveys and reports have been conducted across several continents to highlight prevalence and factors influencing dermoscopy use with the hope of maximizing its apparent benefits. There are currently no such reports from Africa. OBJECTIVES: To evaluate dermoscopy use and its determinants among dermatologists in Africa. METHODS: A cross-sectional study. Online forms were e-mailed to individual practicing dermatologists and members of the African Society of Dermatologists and Venereologists. RESULTS: There were 196 respondents from 24 African countries. Half of them used dermoscopy. Training, practice settings and location, provision of dermatoscopes by institutions and knowledge of criteria were notable significant determinants. Multiple training exposures, knowledge of criteria, availability of dermatoscopes, use of both hand-held and videodermatoscopes, average number of patients seen per day, and a positive outlook towards dermoscopy were significant determinants of frequency of use. Leading impediments were lack of training and inadequate dermatoscopes in practice. CONCLUSIONS: Dermoscopy use in Africa is relatively low. Incorporating dermoscopy training into the curriculum with provision of dermatoscopes by training institutions will promote wider usage.

Uncovering the genetic architecture and evolutionary roots of androgenetic alopecia in African men.

Androgenetic alopecia is a highly heritable trait. However, much of our understanding about the genetics of male pattern baldness comes from individuals of European descent. Here, we examined a novel dataset comprising 2,136 men from Ghana, Nigeria, Senegal, and South Africa that were genotyped using a custom array. We first tested how genetic predictions of baldness generalize from Europe to Africa, finding that polygenic scores from European GWAS yielded AUC statistics that ranged from 0.513 to 0.546, indicating that genetic predictions of baldness in African populations performed notably worse than in European populations. Subsequently, we conducted the first African GWAS of androgenetic alopecia, focusing on self-reported baldness patterns at age 45. After correcting for present age, population structure, and study site, we identified 266 moderately significant associations, 51 of which were independent (p-value < 10-5, r2 < 0.2). Most baldness associations were autosomal, and the X chromosomes does not appear to have a large impact on baldness in African men. Finally, we examined the evolutionary causes of continental differences in genetic architecture. Although Neanderthal alleles have previously been associated with skin and hair phenotypes, we did not find evidence that European-ascertained baldness hits were enriched for signatures of ancient introgression. Most loci that are associated with androgenetic alopecia are evolving neutrally. However, multiple baldness-associated SNPs near the EDA2R and AR genes have large allele frequency differences between continents. Collectively, our findings illustrate how evolutionary history contributes to the limited portability of genetic predictions across ancestries.

Dermoscopy of Cutaneous Neoplasms in Skin of Color - A Systematic review by the International Dermoscopy Society "Imaging in Skin of Color" Task Force.

Over the last few decades, dermoscopy has been showed to facilitate the non-invasive diagnosis of both benign and malignant skin tumors, yet literature data mainly comes from studies on light photo-types. However, there is growing evidence that skin neoplasms may benefit from dermoscopic assessment even for skin of color. This systematic literature review evaluated published data in dark-skinned patients (dermoscopic features, used setting, pathological correlation, and level of evidence of studies), also providing a standardized and homogeneous terminology for reported dermoscopic findings. A total of 20 articles describing 46 different tumors (four melanocytic neoplasms, eight keratinocytic tumors, 15 adnexal cutaneous neoplasms, seven vascular tumors, four connective tissue tumors, and eight cystic neoplasms/others) for a total of 1724 instances were included in the analysis. Most of them showed a level of evidence of V (12 single case reports and six case series), with only two studies featuring a level of evidence of IV (case-control analysis). Additionally, this review also underlined that some neoplasms and phototypes are underrepresented in published analyses as they included only small samples and mainly certain tones of "dark skin" spectrum (especially phototype IV). Therefore, further studies considering such limitations are required for a better characterization.

Cutaneous metastases of embryonal rhabdomyosarcoma in a black African child: the role of dermoscopy in reducing time to and cost of diagnosis.

Cutaneous metastases are an uncommon feature of solid organ malignancies. The cost of multiple investigations and prolonged processing time of biopsies may lead to diagnostic delays especially in resource limited practice settings. Dermoscopy can provide useful clues and has been found to be useful in the diagnosis of cutaneous metastases. Dermoscopic findings of skin lesions may limit unnecessary investigations and shorten time to diagnosis. There are limited data on dermoscopic features of embryonal rhabdomyosarcoma in the literature. We report dermoscopic features of cutaneous metastasis of embryonal rhabdomyosarcoma seen in a black African child.

African black soap: Physiochemical, phytochemical properties, and uses.

The African black soap is popular for its cleansing and medicinal properties particularly amongst those of African descent. The "traditional" African black soap" refers to soaps made from the ash-derived alkali from agricultural waste and oil extracted from vegetable matter without the addition of cosmetic enhancing products. Production of black soap has been traced to west Africa especially Nigeria and Ghana. The raw materials are readily available in the region making the soap available and affordable for most in sub-Saharan Africa. It has been described as gentle, super fatted and hypoallergenic. It is advertised as antimicrobial, anti-acne, exfoliating, skin toning, scar fading, and having medicinal properties. It is popular for its management of skin diseases, although some of the claims remain anecdotal. Generations of Africans abroad continue to use modified versions of the soap and claim they are satisfied with the results obtained. However, in the management of patients with skin disorders, especially eczema, in sub-Saharan Africa, prescribing an ideal skin cleanser can be challenging as many cannot afford the imported nonsoap cleansers with skin friendly pH. Studies have shown that the traditional black soap does have antimicrobial properties against Staphylococcal and some Streptococcal organisms, which are commonly seen in the tropical climate. The recent ban of some antiseptics in popular antibacterial soaps in this environment, emphasizes the need for production of safer antimicrobials. The antimicrobial, physiochemical, and phytochemical properties of the African black soap suggest it may have beneficial effects on the overall skin health.

Histopathologic patterns of cutaneous malignancies in individuals with oculocutaneous albinism in Anambra state, Nigeria: a paradigm swing?

BACKGROUND: A high proportion of skin cancers in Nigeria occur in Individuals with oculocutaneous albinism (OCA). A reduction or absence of melanin, a skin pigment with photoprotective properties, makes them susceptible to skin malignancies such as squamous cell carcinomas (SCCs), basal cell carcinomas (BCCs) and rarely melanomas. Globally, BCCs are the commonest cutaneous malignancies among Caucasians and in fair-skinned Africans. This has been attributed to the greater effect of melanin in protecting against UV damage in the basal layer of the epidermis. Older retrospective studies on African albinos suggested that SCCs accounted for a higher prevalence of skin cancers in albinos, followed by BCCs. Melanoma has been consistently documented to be rare in all of these reports. Recent reports however noted BCCs to occur at an increasing frequency, suggesting a higher frequency than previously documented. These conflicting reports reflect the need to re-explore the pattern of cutaneous malignancies in albinos in order to reconcile the role of pigmentation, UV exposure and the variance between the frequencies of the different keratinocyte skin cancers among extreme skin phenotypes. This study explores the pattern of cutaneous malignancies seen in albinos in South East Nigeria. OBJECTIVE: To determine the pattern of cutaneous malignancies among albinos in Anambra state, Nigeria. MATERIALS AND METHODS: A cross-sectional study conducted in Anambra State, Nigeria. Ninety albinos from the Albino foundation Anambra state were recruited. Malignant dermatoses were characterized clinically and confirmed by histology. Fifty-eight lesions from 30 albinos were biopsied to determine the presence of malignancy. RESULTS: Skin cancers were seen in 20.98% of all participants and in 18 (60%) of all the albinos who had skin biopsy. The SCC/BCC ratio was 1.0: 2.3. There was no cutaneous melanoma. CONCLUSION: Contrary to previous reports, it would appear that the pattern of cutaneous malignancies in albinos shows the same trend as that seen in Caucasians and fair-skinned Africans.

Trichoscopic features of tinea capitis among primary school children in north central Nigeria.

BACKGROUND: The myriad of coexisting risk factors for tinea capitis (TC) in parts of Africa makes it common among schoolchildren from this region. Diagnosis ideally involves microscopy and culture of scalp scrapings, which is not always feasible in resource-poor settings. Small-scale reports have identified trichoscopy (dermoscopy of hair and surrounding skin) as a cheap, quick, and simple tool for evaluating TC. We sought to describe the trichoscopic features of TC among Nigerian children. METHODS: A total of 204 children with clinically diagnosed TC had trichoscopy of their scalp lesions and culture of scalp scrapings. Trichoscopic features and culture results were noted. RESULTS: Perifollicular scaling (78.4%), interfollicular scaling (69.1%), and black dots (44.1%) were the commonest trichoscopic features. Others include regrowing hairs (18.6%), comma hairs (14.7%), broken hairs (13.2%), corkscrew hairs (3.4%), zigzag hairs (2.5%), and peripilar casts (2.0%). All children with comma, corkscrew, and zigzag hairs, as well as most with black dots (88.9%), broken hairs (88.9%), and regrowing hairs (77.5%) had positive cultures, irrespective of the isolated dermatophyte. Comma hairs were specific for Tinea infection with positive culture of dermatophytes. The presence of black dots in combination with individual features like broken hairs, regrowing hairs, perifollicular scaling, or interfollicular scaling also had a high specificity for positive cultures. CONCLUSION: In the management of children with TC, trichoscopy is useful as a diagnostic tool, especially where access to laboratory evaluation is either not instant or unavailable.

Higher vitamin D levels in Nigerian albinos compared with pigmented controls.

BACKGROUND: Several studies have suggested that the lower vitamin D levels in blacks is attributable to the effect of increased pigmentation in blocking cutaneous ultraviolet (UV)-mediated production of vitamin D. Albinos are devoid of melanin and should invariably have higher vitamin D levels when compared with their pigmented counterparts. However, strict photoprotection required in their medical management has been shown to reduce UV-dependent vitamin D production. Associations between low vitamin D and several diseases suggest that the pattern of vitamin D in the black African albino be investigated. OBJECTIVE: To compare the vitamin D levels between albinos and normal pigmented controls in Anambra State, Nigeria, and thus highlight the impact of skin pigmentation and sun protection practices on vitamin D levels. METHODOLOGY: This was a cross-sectional study of a consecutive series of albinos from the Albino Foundation, Anambra State. The vitamin D levels of 61 albinos and 58 matched pigmented controls were analyzed. The sun exposures of the participants were calculated using validated sun exposure questionnaires. RESULTS: The albinos had significantly higher vitamin D levels (median 95.9 [50.1-177.4] ng/ml) than the controls (78.2 [12.1-250] ng/ml). None of the albinos had low vitamin D levels. None of the sun protection practices had significant effects on vitamin D levels. CONCLUSION: This study contests the claim that black Africans including albinos have low vitamin D levels. Albinos living in South East Nigeria have significantly higher vitamin D levels than their pigmented counterparts.

Pseudofolliculitis barbae; current treatment options.

Pseudofolliculitis barbae (PFB) is a chronic inflammatory disorder of follicular and perifollicular skin characterized by papules, pustules, and post-inflammatory hyperpigmentation. It occurs more frequently in men of African and Asian descent. The etiology of PFB is multifactorial. Shaving or plucking the hair precipitates the onset of an inflammatory reaction that results from the penetration of the adjacent skin by the growing sharp tips. The curved shape of the hair follicle allows for the downward curvature and penetration of the growing hair tips into the skin. The onset of the foreign body reaction leads to itching and the development of papules, pustules, and post-inflammatory hyperpigmentation, especially in the beard area although other shaved areas of the body may be affected. Keloids have also been known to develop after the onset of PFB, giving rise to extensive unsightly scars. Diagnosis is clinical. Cessation of shaving or removal of the involved hair follicles usually terminates the development of PFB. Individuals with the single nucleotide substitution in the hair follicle companion layer specific keratin gene (K6hf) have a six fold increased chance of developing PFB.

Occupational skin disorders in a subset of Nigerian hairdressers.

INTRODUCTION: Hairdressing is associated with a wide range of disorders. This is particularly true in the African hairdresser, who is saddled with the responsibility of 'taming' the rather difficult-to-manage African hair, and is thus exposed to a wide range of chemical, biological and physical materials in the hair grooming process. We therefore sought to determine the prevalence and pattern of occupational skin disorders among hairdressers in Ibadan, one of the oldest and largest cities in Nigeria. METHODS: This was a cross sectional study of hairdressers conducted in 2013 in Ibadan, Nigeria. Hairdressers and their apprentices were interviewed using a structured questionnaire, following which a thorough physical examination was performed to identify any skin disorder. RESULTS: A total of 226 hairstylists were recruited. The prevalence of occupational skin disorders in the study was 68.13%. The prevalence of specific skin disorders was 32.74% for nail disorders; 28.75% for traumatic skin disorders; and 2.64% for hand dermatitis. CONCLUSION: There is a high prevalence of occupational skin disorders among hairdressers, and this may have personal and public health implications.

Occupational skin disorders in a subset of Nigerian hairdressers

Introduction: hairdressing is associated with a wide range of disorders. This is particularly true in the African hairdresser, who is saddled with the responsibility of 'taming' the rather difficult-to-manage African hair, and is thus exposed to a wide range of chemical, biological and physical materials in the hair grooming process. We therefore sought to determine the prevalence and pattern of occupational skin disorders among hairdressers in Ibadan, one of the oldest and largest cities in Nigeria.Methods: this was a cross sectional study of hairdressers conducted in 2013 in Ibadan, Nigeria. Hairdressers and their apprentices were interviewed using a structured questionnaire, following which a thorough physical examination was performed to identify any skin disorder.Results: a total of 226 hairstylists were recruited. The prevalence of occupational skin disorders in the study was 68.13%. The prevalence of specific skin disorders was 32.74% for nail disorders; 28.75% for traumatic skin disorders; and 2.64% for hand dermatitis.Conclusion: there is a high prevalence of occupational skin disorders among hairdressers, and this may have personal and public health implications

Acne keloidalis nuchae: prevalence, impact, and management challenges.

Acne keloidalis nuchae (AKN) also known as folliculitis keloidalis nuchae (FKN) is a chronic form of scarring folliculitis seen mostly in men of African descent. The term AKN is commonly used even though the condition is not a keloid, and the affected individuals do not have a tendency to develop keloids in other areas of the body. It is seen in post pubertal men and is rare after the age of 55 years. A few cases have been reported in females. which has been classified as a primary cicatricial alopecia since the exact cause of acne keloidalis (AK) remains unknown. However, a few inciting agents have been suggested which include androgens, inflammation, infection, trauma, genetics, and ingrowing hairs. AK shares some similar features with other forms of cicatricial alopecia and may occur together. Papules, pustules, and sometimes tumorous masses in the nuchal or occipital regions of the scalp hence the name "bumps" evolved in the environment. Despite its common occurrence, only a few seek help in hospital when lesions start to unsightly affect the individual's quality of life. The presences of the keloidal lesions are more stressful compared to the resulting alopecia. Various attempts to reduce the bumps with corrosives, acids, and car engine oils lead to larger lesions or unsightly scars. Active lesions produce bleeding during haircuts. This is worrisome as a couple of individuals with active AK share shaving instruments at the barber shop and are at risk of acquiring or transmitting blood-borne infections. There is an urgent need to encourage safe shaving habits and treatment of lesions at onset so as to prevent unsightly lesions.

Association of diet with acne vulgaris among adolescents in Ibadan, southwest Nigeria.

BACKGROUND: Acne vulgaris is a chronic inflammatory disease of the pilosebaceous units that affects 85% of the world's population aged 11-30 years. Diet is believed to affect the severity of acne vulgaris. OBJECTIVES: This study was designed to identify possible associations of diet with acne vulgaris in Nigeria. METHODS: A cross-sectional study was conducted among adolescents in Ibadan in 2011. Students were interviewed for demographic data, history of acne, and frequency of intake of specific foods in the previous 12 months. Each participant was examined for facial acne. Body mass index (BMI) was calculated for each participant. RESULTS: Data for 464 students were analyzed. The mean ± standard deviation age of all subjects was 13.6 ± 3.6 years, and the mean BMI was 17.8 kg/m(2) . A total of 299 (64.4%) students were found to have acne vulgaris. Frequencies of intake of various foods varied widely. Prevalences of acne were higher among those who reported an at least daily intake of milk as beverage (72.6% vs. 62.0%; P = 0.035), corn (76.6% vs. 62.3%; P = 0.016), fried beef (75.0% vs. 62.1%; P = 0.042), and cake (77.8% vs. 62.3%; P = 0.012), and less common among those students who reported an at least daily intake of bananas (55.3% vs. 67.6%; P = 0.032). CONCLUSIONS: The present findings suggest associations between some foods and acne in the Nigerian context. An interventional dietary study will be required to further ascertain the effects of these foods on acne vulgaris.

Mucocutaneous Disorders of Pediatric HIV in South West Nigeria: Surrogates for Immunologic and Virologic Indices.

OBJECTIVES: Nigeria has the world's highest burden of pediatric HIV. In the face of paucity of monitoring tests in Nigeria, we studied the spectrum of pediatric mucocutaneous manifestations and evaluated their clinical utility as surrogate markers for immunodeficiency and plasma viral load levels. METHODS: Cross-sectional study comparing mucocutaneous manifestations in 155 HIV-positive children aged 12 weeks to 14 years with 155 HIV-negative children. Relationships between mucocutaneous manifestations in HIV-infected patients and their immunologic and virologic indices were analyzed. RESULTS: Mucocutaneous lesions were seen in 53.5% of HIV-infected children compared with 18.1% of the controls. Prevalence of lesions increased with worsening levels of immunodeficiency and increasing viral loads (P < .01). Oral candidiasis, angular stomatitis, and fluffy hair were associated with more severe degrees of immunodeficiency. CONCLUSION: Mucocutaneous disorders are common in HIV-infected children. Oral candidiasis and nutritional dermatoses can be used as surrogates for advanced or severe immunodeficiency.

Recurrent hair loss resulting from generalized proximal trichorrhexis nodosa in a nigerian female.

Hair and scalp disorders commonly seen in the African female have been associated with hair care practices. Distal trichorrhexis nodosa (TN) has been commonly reported with various forms of trauma to the hair from hair grooming practices. We report the case of recurrent generalized hair loss resulting from proximal TN in a 28-year-old Nigerian female with atopy. The use of chemical relaxers precipitated each episode of hair loss. Generalized proximal TN has been reported in those of afro Caribbean descent. The acute nature and extent of the hair loss suggest there may be some underlying structural defect in such individuals.

Giant melanocytic nevus with malignant melanoma: a rare disorder in a black African child.

INTRODUCTION: Giant congenital melanocytic nevus (GCMN) is rare in babies of African descent. Unfortunately, it has an increased potential for malignant transformation. REPORT: A 3-year-old female child presented with a 6-month history of multiple nodules on an existing giant congenital melanocytic nevus and swelling in the right axilla of four weeks duration. Skin biopsy of the nodular skin lesions was in keeping with a metastatic malignant melanoma (Clark stage 4). She completed a full course of chemotherapy but subsequently died four months after presentation. CONCLUSION: Patients with large GCMN should be counseled and followed up appropriately to improve and prolong life.

Prevalence of Linea nigra in patients with benign prostatic hyperplasia and prostate carcinoma.

BACKGROUND: Linea nigra (LN) is linear hyperpigmentation occurring from the umbilicus to the pubic symphysis. Although commonly associated with pregnancy (when it is known as linea gravidarum), it has been found in normal male and female individuals, particularly in the younger age group where estrogen or lack of sensitivity of androgen receptors has been suggested as a possible factor. From a previous study the incidence of LN varied in different genders, age groups, and certain clinical status such as pregnancy and, in men, benign prostate hyperplasia (BPH)/prostate carcinoma (PC). OBJECTIVE: The need to get a clinical feature that can aid diagnosis of PC, the commonest male neoplasm in Nigeria, at an affordable cost prompted us to look at the incidence of LN in three male populations (i.e., one with BPH, one with PC, and a control population unaffected by these two conditions). Gynecomastia and female hair distribution, two features considered hormone related were looked for additionally in the study population. The study was carried out in a teaching hospital in Ibadan, southwestern Nigeria. RESULTS: LN was found in 48% of PC, 26% of BPH, and 8% of controls. Female pubic hair was found in 48% of PC, 26% of BPH, and 12% of controls. Gynecomastia was found in 36% of PC, 12% of BPH, and 0% of controls. Differences between patients with BPH, PC, and controls regarding incidence of LN and female pubic hair were deemed explicable by chance (P = 0.17, Fisher exact test). Differences between PC and BPH patients with respect to gynecomastia were deemed inexplicable by chance (P = 0.008, Fisher exact test). CONCLUSION: LN alone cannot be used to differentiate PC and BPH. Further studies will be needed to characterize the role of LN in these conditions in men before and after treatment.