Dermatologica Sinica

INTRODUCTION

The Republic of Palau is an island nation in West Micronesia, 7° north of the equator and 900 km east of the Philippines; 17,501 people reside in Palau.[¹] Native Palauans make up 73% of the population. Other groups in Palau include Filipinos (16%), Americans (1.6%), Japanese (1.4%), Chinese (1.1%), Taiwanese (1.1%), and Bangladeshi (0.9%).[¹]

The capital of Palau is Koror (State), home to 66.7% of Palau's residents. Health-care services in Palau are provided primarily though the government's Ministry of Health. The ministry provides both preventive and medical care through the 80-bed Belau National Hospital (BNH) in Koror and through the community health centers (CHCs). CHCs include six “super” dispensaries: East CHC (Melekeok), North CHC (Ngarchelong), West CHC (Ngaremlengui), CHC (Airai), Camp Katuu Medical Clinic (Airai), and South CHC (Peleliu). Medical care in Palau is affected by two primary issues:[¹] a small population spread across multiple islands and[²] limited technical and human resource capacity. Due to these reasons, many types of specialty care are not available on the island. Access to tertiary or specialty care frequently necessitates off-island travel to the Philippines, Taiwan, or Hawaii for diagnosis and treatment.[¹]

The Taiwan International Cooperation and Development Fund (Taiwan ICDF) has coordinated the medical resources of Taiwanese hospitals in order to provide long-term medical assistance to eight countries in the Pacific Ocean: the Marshall Islands, Kiribati, the Solomon Islands, Palau, Nauru, Tuvalu, Papua New Guinea, and Fiji.[²] Based on Mobile Medical Missions, Shin Kong Medical Assistant Program to Palau (SKMP) was initiated in 2009 by Shin-Kong Wu Ho-Su Memorial Hospital. Dermatology services began in 2015.

Medical registry and publications, as well as statistics in the dermatology services of Palau, are rarely found in literature. There is little information on the skin conditions of the Palauan population. Because of the scarcity of medical resources, pediatric patients remain an underserved population. Therefore, we aim to describe the frequency of skin diseases and dermatological complaints among Palauan pediatric patients from our SKMP dermatology services from 2015 to 2018.

BRIEF REPORTS

Patients and methods

From 2015 to 2018, the SKMP dermatology services were held for 2 weeks annually, mostly during July, in BNH and local dispensaries, including East CHC (Melekeok), West CHC (Ngaremlengui), and South CHC (Peleliu). All pediatric patients who presented with cutaneous complaints (155 patients, ages 0–21 years) were assessed for skin diseases through complete dermatological examination. Previous skin diseases, other medical conditions, and family histories were reviewed. Diagnoses of skin conditions were based on characteristic clinical features evaluated by well-trained, board-certified dermatologists. The study was approved by the Ethics Committee of the Ministry of Health of Palau (Palau Institutional Review Board – 2019-3) and informed consent was waived by IRB.

For statistical analysis, no gender or age restriction was applied in the study. Incomplete medical records were excluded. The first complaint was registered as the main diagnosis. Patients who presented with more than one skin disorder were recorded. Demographic and clinical diagnoses of the study were summarized using proportions and the mean ± standard deviations. We used Chi-square tests and t-tests to compare categorical variables and continuous variables, respectively.

RESULTS

Among the 155 patients, 63 (40.6%) were boys and 92 (59.4%) were girls, with a mean age of 8.02 ± 5.69 in boys and 8.44 ± 6.64 in girls. Table 1 summarizes the dermatologic conditions classified by gender. Eczema (all 52.9%; boys 49.2% and girls 55.4%), superficial fungal infection (all 21.9%; boys 31.7% and girls 15.2%), and bacterial infection (all 16.8%; boys 19% and girls 15.2%) were the most frequent conditions. More than 20% of patients presented with more than one concurrent skin disease (all 23.9%; boys 23.8% and girls 23.9%). Statistical analysis using Pearson's Chi-squared test showed a statistically significant difference (P = 0.015) in superficial fungal infection, which was more common in boys (31.7%) than in girls (15.2%). Among the superficial fungal infections, tinea pedis was predominantly seen in boys (4.8%, P= 0.035). Bacterial infection included impetigo, abscesses, carbuncles, and furuncles. Folliculitis and cellulitis were the third most common skin conditions in both genders. Pruritus (all 15.5%; boys 17.5% and girls 14.1%) and xerosis (all 7.1%; boys 4.8% and girls 8.7%) were also very common. Single cases of insect bite reaction, acne vulgaris, urticaria, alopecia areata, discoid lupus erythematosus, pityriasis rosea, lentiginosis, acanthosis nigricans, port-wine stain, sunburn, molluscum contagiosum, scabies, herpes virus infection, lichen planus, papular urticaria, mango allergy, pityriasis alba, and psoriasis were grouped under miscellaneous. The common clinical presentations are shown in Figure 1. Patients who suffered from more than one concurrent skin condition mostly had eczema with intractable pruritus or had localized eczema with secondary bacterial infection [Figure 1c], which were severe and extensively involved and mandated immediate medical attention.

The skin conditions were also analyzed by region. The mean age of the patients was 7.72 ± 6.06 years for BNH and 10.37 ± 6.63 years for dispensaries (P = 0.032, Mann–Whitney U-test). The most frequent skin diseases were similar. However, atopic dermatitis was more commonly seen in patients from BNH (P = 0.04, Pearson's Chi-squared test), whereas bacterial infections were more frequent in patients seen at the dispensaries (P = 0.000, Pearson's Chi-squared test).

DISCUSSION

Palau has a maritime tropical climate that consists of warm semi-arid weather with periods of drought. The annual average temperature is 30°C. The dry season runs from November to April, with maximum temperatures of around 32°C and lows of 27°C.[³] The majority of populations in rural areas use water from rain collection tanks. Hot climate, frequent marine activities, and poor hygiene in rural areas due to lack of clean water supply could be the risk factors for skin disease.

To date, there is only one work of literature that describes an outbreak of scrub typhus in Palau.[⁴] Our study is the first known report of the frequency of skin disease in the Palauan pediatric population. Our study demonstrates that, as opposed to the literature report showing skin infections as the most common health problem in Pacific island nations,[^5,6,7] the most common skin disease in the Palauan pediatric population is eczema. Eczema in Palauan children often adopts localized lichenified plaques associated with significant postinflammatory hyperpigmentation, with a greater risk of chronicity and progression to severe forms. Our study also shows that atopic dermatitis was more common in urban areas (BNH) than in rural areas, most likely due to the differences in dietary and living conditions. Other common skin conditions were xerosis and pruritus; this finding is suggestive of inadequate skin care education.

Dermatophytosis was the major cause of skin infection in the Palauan pediatric population. Tinea versicolor, tinea corporis, and diffuse fungal infection involving multiple body areas were the common presentations. The high frequency of superficial fungal infection could be due to frequent marine activities (especially among boys) and humid weather. We noticed that apart from superficial fungal infection, the patients seen at the local dispensaries had a higher frequency of bacterial infection compared to the patients seen at BNH. Lower socioeconomic status, household overcrowding, hot weather, poor hygiene, and underlying conditions are important risk factors for skin infection. Despite the common belief that scabies is widespread among the pediatric population in Pacific island nations,[^5,6,7] minimal cases of scabies were noted in our study, most likely due to the availability of topical scabicidal agents.

This study is subject to a few limitations. First, limited access to medical and laboratory facilities may have affected the accuracy of diagnoses. Second, at the local dispensaries, a shorter service hour and a smaller number of patients may have caused selection bias and therefore influenced the results. Third, because 23.8% of patients presented with more than one concomitant condition, the principal diagnoses may also be subject to selection bias. Nevertheless, because the diagnoses in our dataset were determined by board-certified dermatologists, we feel that they represent a reasonable summary of common skin diseases in this population.

Skin disease is a neglected public health problem[⁸] that can cause long-term morbidity, which can have significant impacts on patients' quality of life. Better information sources and proper instruments for correct measurement of the prevalence of skin diseases, their impacts on patients, and their economic burdens are needed.[^9,10] Future studies are required which should ensure that clinical assessments are made and that current treatment approaches are evaluated. Preventable skin diseases should be identified, and health education is necessary for establishing skin care knowledge, ensuring proper wound management, limiting the spread of infectious diseases, reducing the associated morbidity, and improving the health status of the population.[⁷] A dermatologic training project such as the Integrated Management of Childhood Illness may be able to significantly reduce the burden of common tropical childhood skin diseases and morbidities through the prevention of invasive bacterial infections.[⁶] Long-term results of a dermatology project within the primary health-care system should be reviewed.[¹¹]

CONCLUSION

Publications about Palau are scarce in medical literature. For the first time, we have described the pattern of skin diseases in Palauan children. Educational programs to improve community knowledge and management of common skin conditions are valuable. Proper dermatologic training and a public health approach will reduce long-term financial burden and morbidity and ultimately enhance the quality of life of patients suffering from chronic skin conditions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES