The latest Global Burden of Disease Skin Disease Morbidity and Mortality study showed that in 2013, skin conditions contributed 1.79% to the global burden of disease measured in disability-adjusted life years (DALYs).²

Individual skin diseases varied in size effects from 0.38% of total burden for dermatitis (atopic, contact, and seborrheic dermatitis), 0.29% for acne vulgaris, 0.19% for psoriasis, 0.19% for urticaria, 0.16% for viral skin diseases, 0.15% for fungal skin diseases, 0.07% for scabies, 0.06% for malignant skin melanoma, 0.05% for pyoderma, 0.04% for cellulitis, 0.03% for keratinocyte carcinoma, 0.03% for decubitus ulcer, and 0.01% for alopecia areata. All other skin and subcutaneous diseases composed 0.12% of total DALYs.²

A 2003 South African study showed that the most common skin condition among all population groups in Johannesburg was atopic dermatitis (AD) also called atopic eczema (30%).³

In Black patients the commonest skin diseases were AD (32.7%), acne (17.5%) and superficial fungal infections (5.7%). In White patients the commonest skin diseases were benign skin tumours (29.7%), AD (17.8%) and malignant tumours (15%).³

In Indian patients the commonest skin diseases were AD (30.4%), superficial fungal infections (11.8%) and psoriasis (9.6%) and in People of Colour, the commonest skin diseases were AD (34.5%), acne (13.9%) and warts (8.1%).³

A more recent study by Dlova et al (2017) conducted in the public healthcare setting in KwaZulu-Natal, showed that AD (43.7%) was the most common type of skin condition among patients included in the study,  followed by psoriasis (24.8%) and seborrhoeic dermatitis (SD 13.4%). The prevalence of SD has been increasing in South Africa since the 1980s. HIV could contribute to this increase. About in 20%–40% of HIV-infected patients have SD. In Indian patients, psoriasis was the most prevalent skin disorder.^3,4

Acne and rosacea were the third most common cause (9%) skin condition. Acne vulgaris was the most common (71.5%), followed by steroid-induced acne, then rosacea. A high prevalence of steroid-induced acne (12%) among Black patients was reported.⁴

Skin conditions and their impact on patients

According to Flohr and Hay, diseases are not only highly prevalent, but is also associated with significant morbidity ranging from severe itching to disfigurement. Furthermore, skin conditions such as psoriasis and skin cancer require novel treatments, which are costly.¹

Acne has a severe impact on the psychological well-being of patients because it is high visibility. Furthermore, acne often results in scarring. Topical and oral antibiotics are commonly used as treatments, and there is an increasing concern about the risk of antibiotic resistance.¹

Although chronic urticaria is less common than AD, psoriasis and acne, its impact on patients’ quality of life is often profound, because of severe itching, resulting in sleep disturbances. Studies show that more than 30% of people with urticaria have a history of anxiety or depression, sexual dysfunction, and interference with life activities.¹

Challenges in providing quality skin care in South Africa

According to Tiwari et al, the prevalence of skin diseases in low- and middle-income countries ranges from 50% to 80%. Despite this high burden of disease, there is a severe shortage of dermatologists in most African countries – including South Africa (4.4 per million population). The situation is exacerbated by the fact that the majority of dermatologists practice in urban settings, and 78% work in the private sector.⁵

Tiwari et al recommended the following to improve skin care in South Africa:⁵

1. Increasing the number of dermatologists working in the public sector
2. Increasing the number of dermatologists working in urban areas
3. Addressing wage differentiations (urban vs rural and public vs private)
4. Training general practitioners and nurses in dermatological care
5. Implementing teledermatology programmes.

Conclusion

Flohr and Hay conclude that it is not only the individual patient who carries the burden of their disease, but this burden often extends to their partners and society. A holistic understanding of the burden of skin diseases is key to the development of a concerted and sustained global response towards reducing their burden.¹

REFERENCES:

1. Flohr C, Hay R.Putting the burden of skin diseases on the global map. Br J Dermatol, 2021.
2. Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global Skin Disease Morbidity and Mortality: An Update From the Global Burden of Disease Study 2013. JAMA Dermatol, 2017.
3. Hartshorne S. Dermatological Disorders in Johannesburg, South Africa. Clinical and Experimental Dermatology, 2003.
4. Dlova N, Chateau A, Khoza N, Skenjane A. Prevalence of skin diseases treated at public referral hospitals in KwaZulu-Natal, South Africa. BJD, 2017.
5. Tiwari R, Amien A, Visser WI, Chikte U. Counting dermatologists in South Africa: number, distribution, and requirement. BJD, 2022.