Prevalence of Dermatoses and Associated Factors Among School Children in Vijayapura, Karnataka

INTRODUCTION

The school lays down the pillars for the future generation, along with the initial training for the maintenance of a healthy lifestyle.^[1,2] Proper hygiene practices, along with a nutritious diet; through proper education can go a long way in preventing various communicable and noncommunicable diseases. An individual failing to maintain this becomes susceptible to infections, particularly involving the skin.^[1]

Skin diseases pose a major health problem among individuals of all ages with substantial morbidity.^[3] Children are common victims of dermatoses as activities at school that involve personal contact help in the transmission of infectious diseases. Skin diseases significantly impact the child’s social, physical and emotional well-being, which can lead to skipping school, ultimately impact learning.^[4]

Skin diseases refer to disorders of exclusively (or predominantly) the superficial layers of the skin. In developing countries, low hygienic conditions with difficulty in access to water, climatic conditions, and the presence of overcrowding contribute to the high prevalence and incidence of skin disorders.^[5] This is usually true when it comes to infectious diseases, which are more prevalent in these countries, whereas non-infectious dermatoses are predominant in the more developed countries.

In most of the regions of India and through the majority of the year, the climate is hot and humid. In addition, the population is vast, many of whom reside in villages or slums, with widespread poverty and malnutrition, poor personal hygiene, low literacy and a lack of public understanding of cleanliness. As a result, skin problems are more common, particularly infections.

Due to better education, awareness, and changing lifestyles, developing countries are now experiencing a reduction in infectious diseases and a rise in non-infectious or noncommunicable diseases. School surveys are useful in determining the prevalence of diseases among a large number of children of a particular age group in a given community. The prevalence of skin diseases in children reflects the status of health awareness, availability of healthcare services, hygiene and personal cleanliness of that particular society.^[3]

This study was conducted to determine the prevalence of skin diseases among primary and secondary school children in Vijayapura, Karnataka and to determine the influence of various factors on them.

MATERIALS AND METHODS

This prospective cross-sectional study was conducted in private, government, and residential schools in Vijayapura, Karnataka from August 2022 to January 2023. Approval of the Institutional Ethical Committee was taken (BLDE [DU]/ IEC/807-C/2022-23). We included students belonging to the age group of 5–14 years, those with completed responses to the questionnaire and those present on the day of the school visits. Students and parents not willing to take the examination were excluded.

Schools were selected at random. Approval was taken from the schools’ principal. Two days before the school visits, a semi-structured questionnaire was handed over to the students, which was to be answered by their parents, along with informed consent. It included questions such as address and contact details, monthly income, education, and occupation of the parents (for determining socioeconomic status by modified Kuppuswamy method^[6]), number of family members living in the same home, and number of rooms (for determining overcrowding at home by Eurostat criteria^[7]), presence of pets, dietary habits, hygiene practices followed and immunisation status. The questionnaire has been included, as shown in Supplementary File 1.

On the day of the school visits, the height and weight of every child were measured to calculate basal metabolic index (BMI), weight-for-age, height-for-age, and weight-for-height (plotted on IAP graphs^[8]) to determine nutritional status. The children were asked questions regarding their diet and hygiene practices and skin, hair, and nails, excluding genitalia, were examined in a private room with good illumination, with the part being examined well exposed. If a skin lesion was found, photographs were taken and findings were documented in a pro forma. Diagnosis of skin lesions was based on clinical features. Conditions whose diagnosis was doubtful and those requiring further investigations were not recorded. The prevalence of dermatoses in school children was determined and the frequency of various factors was assessed.

RESULTS

Three private, two government, and one residential school were included in this study with a total of 2272 students. One thousand two hundred and eleven (53.3%) students were included from private schools, 438 (19.3%) students from government schools and 623 (27.4%) from residential school. The ratio of students aged more than 10 years and those aged <10 years was 1.8 and male-to-female ratio was 2.1. The distribution of various variables among different schools is depicted in Table 1.

A total of 82 dermatoses were diagnosed and grouped as non-infectious and infectious dermatoses. Under non-infectious dermatoses, 70 conditions were grouped into 10 categories and 12 infectious dermatoses were grouped into four categories. Supplementary File 2 contains the list of various dermatoses in each category. Figures 1 and 2 shows images of some of the conditions in each category of non-infectious and infectious dermatoses.

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Figure 1:

Conditions in each category of non-infectious dermatoses (AMN: Acquired melanocytic nevus).

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Figure 2:

Conditions in each category of infectious dermatoses.

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The overall prevalence of dermatoses was 89.4%. Among these, the prevalence of non-infectious and infectious dermatoses was 97.9% and 9.3%, respectively. The residential school had the highest prevalence of dermatoses (92.4%) and non-infectious and infectious dermatoses were most prevalent in private (98.2%) and government (13.5%) schools, respectively. Under non-infectious dermatoses, the most common category of dermatoses was nevi and hamartomas (843; 42.4%), followed by disorders of keratinization (806; 40.5%) and inflammatory dermatoses (750; 37.7%). The three most common categories of infectious dermatoses were fungal infections (69; 36.7%), infestations (58; 30.9%) and viral infections (45; 23.9%). The prevalence of various dermatoses among different categories and schools is shown in Table 2.

DISCUSSION

In this study, we analysed the prevalence of dermatoses and associated factors among private, government, and residential school children in a semi-urban city in North Karnataka. The prevalence of dermatoses was found to be 89.4% and non-infectious dermatoses (97.9%) were more common than infectious dermatoses (9.3%). This could indicate a rising trend toward non-infectious dermatoses, probably due to increased awareness among the population as more emphasis is made on the prevention of communicable diseases.

Majority of the students belonging to all schools and private schools were aged more than 10 years and were males. Hence most of the dermatoses were found in these categories and showed a significant association. Infestations, in which pediculosis capitis was one of the conditions, show a significant association in females in all, private and government schools.

Children with poor dietary habits had a significant association with disorders of keratinization, which includes phrynoderma, acanthosis nigricans, and xerosis, which are seen in children with improper nutrition. Inflammatory dermatoses included atopic dermatitis and its various manifestations, which showed an association with children following good hygiene practices in all schools and also with those not having contact with pets in all schools and private schools. This corroborates with the hygiene hypothesis, which is one of the etiologies for atopic dermatitis. Poor hygiene practices were associated with infectious dermatoses and fungal infections in residential school children. Infectious dermatoses and fungal infections were significantly associated with overcrowding at home among all schools, which is known to be a factor in the spread of infections. Students belonging to upper-class socioeconomic status had a significant association with inflammatory dermatoses in all and private schools and papulosquamous disorders in all schools, whereas those belonging to upper lower class show an association with disorders of keratinization and infections, which could be attributed to increased education and awareness among parents and family members, better diet and hygiene practices followed by those of a higher class.

Students who were overweight (increased BMI, weight-for-age, and weight-for-height) were associated with non-infectious dermatoses, inflammatory dermatoses, papulosquamous disorders (association with metabolic syndrome), disorders of keratinization (includes acanthosis nigricans which is a cutaneous manifestation of obesity) and other dermatoses (includes acrochordons and striae which are cutaneous manifestations of obesity).

Similar studies have been conducted in various parts of India and the world among school children and their findings are mentioned in Table 4.^[1,3,4,9-19] In the studies conducted in India, the prevalence of dermatoses ranged between 15.41% and 75.4%, which was lower than the prevalence in our study (89.4%) and the majority were infectious dermatoses. An exception to this are studies by Nijhawan et al.^[9] and Vora et al.^[14] conducted in Jaipur and Anand, Gujarat, respectively, where non-infectious dermatoses were more common (69.7% and 79.6%, respectively). Non-infectious dermatoses in our study had a prevalence of 97.9%. This higher prevalence in their studies was attributed to individuals being residents of semi-urban areas and belonging to a higher socioeconomic status. Vijayapura, the location of our study, is also a semi-urban area and the majority of the students belonged to families of the upper middle class. The prevalence of infectious dermatoses was higher in other parts of the world as well, but studies done by Sula et al.^[18] in Diyarbakir, Turkey and Khalifa et al.^[19] in Baghdad found non-infectious dermatoses to be more prevalent. The former study demonstrated an association with the female gender and showed a predominance of infectious dermatoses in boarding schools, whereas the latter study found an association with parents’ education. Our study found a predominance of infectious dermatoses in students of government schools.

The prevalence of skin diseases in children helps give a rough idea about the diseases prevalent in the population of that area. This will help bring about necessary changes in the habits and practices of society for preventing these diseases by establishing relevant educational programs and raising awareness.^[3]

The population should be encouraged to take appropriate help and consultation when required as ignorance can increase morbidity, which has a higher impact on children as this is the prime age for mental and physical growth and development. School check-ups are a medium whereby the students and their parents can be kept informed about the conditions affecting the children, whether benign or otherwise, and encourage them to take necessary help if required or to be given appropriate counsel.

CONCLUSION

The prevalence of dermatoses in school children in a semi-urban city in North Karnataka, India, was found to be 89.4%, with a predominance of non-infectious dermatoses, which were significantly associated with better hygiene practices, no contact with household pets, higher socioeconomic status, and overweight students. Infectious dermatoses were less prevalent and associated with poor diet and hygiene practices, overcrowding at homes, lower socioeconomic status, and underweight children. Multiple health awareness and education programs are present for the prevention of infectious diseases, which have proven to be very effective. Similarly, awareness should be raised regarding non-infectious diseases and the population should be trained to detect such conditions and encouraged to take appropriate help when required.