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Chapter 37Skin Diseases
Roderick Hay, Sandra E. Bendeck, Suephy Chen, Roberto Estrada, Anne Haddix, Tonya McLeod, and Antone Mahé.

In assigning health priorities, skin diseases are sometimes thought of, in planning terms, as small-time players in the global league of illness compared with diseases that cause significant mortality, such as HIV/AIDS, community-acquired pneumonias, and tuberculosis. However, skin problems are generally among the most common diseases seen in primary care settings in tropical areas, and in some regions where transmissible diseases such as tinea imbricata or onchocerciasis are endemic, they become the dominant presentation. For instance, the World Health Organization's 2001 report (Mathers 2006) on the global burden of disease indicated that skin diseases were associated with mortality rates of 20,000 in Sub-Saharan Africa in 2001. This burden was comparable to mortality rates attributed to meningitis, hepatitis B, obstructed labor, and rheumatic heart disease in the same region. Using a comparative assessment of disability-adjusted life years (DALYs) from the same report, the World Health Organization recorded an estimated total of 896,000 DALYs for the region in the same year, similar to that attributed to gout, endocrine disease, panic disorders, and war-related injuries. As noted later, those figures require confirmation by more detailed studies, and their practical application to health interventions needs to be tested. Assessing the impact of skin disease on the quality of life in comparison with that of chronic nondermatological diseases is difficult; however, the study by Mallon and others (1999), which was not carried out in a developing country, compares the common skin disease acne with chronic disorders such as asthma, diabetes, and arthritis and finds comparable deficits in objective measurements of life quality. Skin disease related to HIV, which may constitute an important component of the skin disease burden in developing countries, particularly in Sub-Saharan Africa, leads to a similar impact on life quality compared with non-HIV-related skin problems, although the use of antiretroviral therapy significantly improves quality of life (Mirmirani and others 2002). Those findings indicate that skin diseases have a significant impact on quality of life. Although mortality rates are generally lower than for other conditions, people's needs for effective remedies for skin conditions should be met for a number of important reasons. * First, skin diseases are so common and patients present in such large numbers in primary care settings that ignoring them is not a viable option. Children, in particular, tend to be affected, adding to the burden of disease among an already vulnerable group. * Second, morbidity is significant through disfigurement, disability, or symptoms such as intractable itch, as is the reduction in quality of life. For instance, the morbidity from secondary cellulitis in lymphatic filariasis, which may lead to progressive limb enlargement, is severe, and subsequent immobility contributes to social isolation. * Third, the relative economic cost to families of treating even trivial skin complaints limits the uptake of therapies. Generally, families must meet such costs from an overstretched household budget, and such expenses in turn reduce the capacity to purchase such items as essential foods (Hay and others 1994). * Fourth, screening the skin for signs of disease is an important strategy for a wide range of illnesses, such as leprosy, yet a basic knowledge of the simple features of disease whose presenting signs occur in the skin is often lacking at the primary care level. A shortage of elementary skills in the management of skin diseases is a further confounding problem. A number of studies assessing success in the management of skin diseases in primary care settings in the developing world find that treatment failure rates of more than 80 percent are...
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