The burden of co-existing dermatological disorders and their tendency of being overlooked among patients admitted to muhimbili national hospital in Dar es Salaam, Tanzania

Background Skin diseases are underestimated and overlooked by most clinicians despite being common in clinical practice. Many patients are hospitalized with co-existing dermatological conditions which may not be detected and managed by the attending physicians. The objective of this study was to determine the burden of co-existing and overlooked dermatological disorders among patients admitted to medical wards of Muhimbili National hospital in Dar es Salaam. Study design and settings A hospital-based descriptive cross-sectional study conducted at Muhimbili National hospital in Dar es Salaam, Tanzania. Methods Patients were consecutively recruited from the medical wards. Detailed interview to obtain clinico-demographic characteristics was followed by a complete physical examination. Dermatological diagnoses were made mainly clinically. Appropriate confirmatory laboratory investigations were performed where necessary. Data was analyzed using the 'Statistical Package for Social Sciences' (SPSS) program version 10.0. A p-value of < 0.5 was statistically significant. Results Three hundred and ninety patients admitted to medical wards were enrolled into the study of whom, 221(56.7%) were females. The mean age was 36.7 ± 17.9 (range 7-84 years). Overall, 232/390 patients (59.5%) had co-existing dermatological disorders with 49% (191/390) having one, 9% (36/390) two and 5 patients (1%) three. A wide range of co-existing skin diseases was encountered, the most diverse being non-infectious conditions which together accounted for 36.4% (142/390) while infectious dermatoses accounted for 31.5% (123/390). The leading infectious skin diseases were superficial fungal infections accounting for 18%. Pruritic papular eruption of HIV/AIDS (PPE) and seborrheic eczema were the most common non-infectious conditions, each accounting for 4.3%. Of the 232/390 patients with dermatological disorders, 191/232 (82.3%) and 154/232 (66.3%) had been overlooked by their referring and admitting doctors respectively. Conclusion Dermatological disorders are common among patients admitted to medical wards and many are not detected by their referring or admitting physicians. Basic dermatological education should be emphasized to improve knowledge and awareness among clinicians.


Background
Skin diseases are diverse in clinical presentation, severity and epidemiology although dermatology may simply be considered by many as an outpatient service with very little attention given to admitted patients. Data from several studies on the overall community-based prevalence of skin diseases in developing countries indicate that they are quite common, ranging from 20% to 80% and most of them result from infections such as superficial mycoses, pyodermas and scabies [1][2][3][4]. Dermatological disorders affect all age groups of both sexes, however, children are more vulnerable and have been extensively studied worldwide [1,[5][6][7][8]. The fact that dermatological disorders are very common in the general population and therefore, expected to be common even among hospitalized patients should not mean that they are of less medical importance than other systemic diseases.
There are, but relatively few studies which have documented on dermatological disorders in hospitalized patients [9][10][11][12][13]. The prevalence of dermatological disorders among admitted patients reported by some of these studies shows an almost similar spectrum, differing only in magnitude between developing and developed countries [14]. Conditions such as Stevens Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), autoimmune blistering diseases, necrotizing fasciitis, leg ulcers, dermatological malignancies and psoriasis have been reported as the common indications for hospital admission in developing as well as the developed countries [14,15].
Reports from other studies rarely mention dermatological disorders as a primary reason for hospital admission. Most skin diseases may be overlooked by health professionals despite being important indicators of some underlying internal diseases. Skin diseases may coincidentally co-exist with other medical illnesses or be specific markers/manifestations of underlying systemic diseases. Some of the systemic diseases that can be suspected through cutaneous manifestations include chronic renal failure, endocrine disorders, lymphomas, nutritional deficiencies and HIV/AIDS. The HIV/AIDS pandemic has increased the number of hospital admissions worldwide, particularly in sub Saharan Africa and has been associated with a wide range of dermatological syndromes [16][17][18]. Cutaneous malignancies, candidiasis, dermatophytoses, molluscum contagiosum, seborrheic dermatitis and pruritic papular eruption have been frequently reported in individuals with HIV/AIDS, seen as inpatients or outpatients [19]. The objective of this study was therefore to describe the burden of co-existing dermatological disorders among patients admitted to medical wards of Muhimbili National hospital in Dar es Salaam and document the tendency if any, of being overlooked by their attending clinicians.

Study design and setting
This was a hospital-based cross sectional descriptive study conducted in the medical wards of Muhimbili National Hospital in Dar es Salaam, Tanzania. Muhimbili National Hospital is the largest tertiary referral and teaching hospital receiving patients from all regions and Dar es Salaam is the largest city in the country.

Clinical work up
Patients referred by medical officers (MD) from peripheral hospitals all over the country to Muhimbili national hospital's medical wards, were consecutively recruited into the study. Patient's files were systematically scrutinized to obtain useful demographic and clinical data. The referral dermatological diagnoses were retrieved from the patient's referral medical notes. Complete physical examination was conducted at admission by the admitting medical officer who made the 'dermatological diagnosis at admission'. These diagnoses were finally confirmed by one of the three dermatologists based in the hospital, and where necessary consultative discussions were held to make a common final diagnosis. The majority of the dermatological diagnoses were made clinically and where necessary and feasible, appropriate laboratory investigations were arranged.

Laboratory procedures
Appropriate specimens were collected and sent to the general pathology laboratory (since there is no specialized dermatology laboratory in the hospital) for bacteriological, mycological, parasitological or histopathological studies as appropriate. Specimens from suspected fungal lesions underwent microscopic examination after treatment with 10% potassium hydroxide solution. Skin scrapings from scabies lesions were obtained from burrows and examined for mites under a light microscope with a drop of normal saline. Skin biopsy specimens were placed in bottles containing 10% buffered formalin before being stained with Haematoxylin and Eosin and then mounted on Dextrene Polystyrene Xylene (DPX), followed by microscopic examination.

Data analysis
Data analysis was done using statistical package for social sciences (SPSS) computer program version 10.0. P-value less than 0.05 was regarded as significant.

Ethical considerations
Ethical clearance was obtained from the ethical clearance board of the Muhimbili University of Health and Allied Sciences (MUHAS). Permission to conduct the study in the medical wards of Muhimbili National Hospital (MNH) was sought from the hospital authority. Fully informed verbal and written consent was obtained from every patient who participated in the study.

Discussion
It may commonly been remarked that dermatology is usually considered as an outpatient specialty associated with low mortality [15]. This notion could lead to less dermatological attention given to hospitalized patients by some of their attending physicians. Less dermatologic attention paid to admitted patients may allow most of the skin diseases to run a chronic course with significant effects on the general health as well as the quality of life of the affected individual. Certain systemic disorders can be suspected through cutaneous symptoms and signs. This hospital-based cross sectional study has described the magnitude of coexisting dermatological disorders among patients admitted to medical wards of a national consultant hospital. Almost all forms of skin diseases (infectious, noninfectious, neoplastic, non-specific rashes) were encountered although at different frequencies. When specific types of dermatological disorders were analyzed, the most common were fungal infections (18%), bacterial infections (7.1%), and viral infections (5.3%). Many community based studies conducted in developing tropical countries have described infectious dermatological disorders, especially fungal and bacterial infections as being the most commonly encountered [1][2][3]11].
The pattern of co-existence between dermatological and other medical conditions in our study demonstrated that, over three-quarters of patients with PPE, seborrheic dermatitis, oral candidiasis, cutaneous warts and psoriasis had HIV/AIDS. On the other hand, all patients with Kaposi's sarcoma (11/11; 100%) were HIV infected. HIV infection has been reported to cause its greatest impact on the skin whereby, today over fifty different types of HIV-related skin diseases have been documented [14][15][16]. Various studies on HIV related mucocutaneous manifestations conducted worldwide, have documented HIV related skin diseases as being very   common [14][15][16][17]. In this study it has also been observed that, a wide variety of systemic diseases co-existed with dermatological conditions. Systemic diseases which demonstrated high frequency of dermatological disorders (>50%) included diabetes mellitus, chronic kidney disease, hematological disorders hepatic diseases and neurological diseases. The finding of cellulitis in only 1.5% of admitted patients in our study, while cellulitis tends to be one of the frequent causes of admission in developed countries may not be surprising since in our set up, mild forms of cellulitis would normally be managed at peripheral hospitals while severe cellulitis which is usually associated with dermal necrosis and fasciitis would be admitted to surgical (and not medical) wards for surgical interventions such as surgical toilet, slouphectomy and even skin grafting.
The prevalence of dermatological disorders at preadmission (referral) and admission periods, was grossly underestimated for all disorders except for Kaposi's sarcoma which was over-diagnosed. Most skin diseases were overlooked by the referring and admitting doctors.
In many areas, health professionals have been reported as being unaware of the burden of dermatological diseases [5]. Health workers tend to overlook or even ignore skin diseases despite the fact that some of them form important signs or symptoms of the underlying internal diseases. This apparent 'unawareness' attitude has been partly attributed to inadequate knowledge of dermatological disorders among clinicians [5]. On the other hand, it could also be speculated that the majority of patients presenting to hospitals for various diseases, may not complain about their accompanying dermatological problems (which would have enabled clinicians to easily detect them), probably due to the assumption that skin diseases are a mere cosmetic nuisance, not associated with any serious suffering. All these factors may lead to delays in diagnosing the underlying serious and even life threatening systemic diseases.

Conclusion
Dermatological disorders are very common and diverse among patients admitted to medical wards but they are rarely documented as primary or additional diagnoses

Study limitation
Lack of a specialized dermatology laboratory led to failure to make some confirmatory tests like virological identification of viral infections, immunofluorescent microscopy for blistering diseases and antinuclear antibody tests for connective tissues disorders.