Dermatoses in Himalayas : Pattern of Skin Diseases in Himalayan Region of Nepal

Background: Skin diseases are the major cause of out-patient visit in Nepal. Department of Health Services, Nepal ranks skin diseases as fourth common cause of out-patient visit throughout the country. The objective of the study was to determine the pattern of different skin diseases in Himalayan region of Nepal. Material and methods: A cross sectional descriptive study design was conducted in a health camp setting in which 148 community people visited the camp with dermatological diseases. Information about socio-demographic and dermatological diseases were collected with a structured performa. Results: The most common primary diagnosis was pigmentary anomaly (20.3%) followed by Eczemas (18.9%), Superficial mycoses (10.8%), and acne (10.1%). In all skin diseases male were more affected as compared to female. Conclusions: The dermatoses of Himalayan region are pigmentary anomalies being most common, followed by eczemas, superficial mycoses, acne, photodermatoses, scabies, urticaria, benign tumours and pyodermas.


Introduction
S kin diseases are the major cause of out-pa ent visit in Nepal.According to the annual report, Department of Health Services 2010/2011, skin diseases was 4 th common cause of out-pa ent visit throughout the country. 1 There are only couple of studies which show the prevalence of the skin diseases in Nepal.All these studies vary in the methodology and outcome with resultant varia on in prevalence of skin diseases.Most of the studies are hospital based and few of them are community based [2][3][4][5] .The study on pa ern of skin diseases in Himalayan district of Nepal has not been documented.This study is an a empt to defi ne the pa ern of skin diseases in one of the Himalayan district of Nepal, Humla district.Humla district, one of Nepal's highest and most inaccessible district, is situated in far northwest of Nepal, bordering the Tibet, China.The common means of transporta on are mules which bring required products from the Tibetan border to Simikot.The closest road-head to Humla is nine days walk to the south; and from Tibet six days walk away to the northeast.Humla has a popula on of about 50,858. 6ts eleva on ranges from 1,524 to 7,337 meters above the sea level.We chose Simikot, headquarters of Humla district arbitrarily to see the pa ern of skin diseases in Himalayan region of Nepal.The objec ve of the study was to determine the pa ern of diff erent skin diseases in Himalayan region of Nepal.This type of study has never been conducted in Humla district before.

Material and methods
A cross sec onal descrip ve health camp based study design was adopted.The camp was organized on the last week of October 2013 by Kathmandu based organiza on, Society of Dermatologists, Venereologists & Leprologists of Nepal (SODVELON) with a team comprising of two Dermatologists, and two medical offi cers at Simikot district hospital.A week ahead of the health camp, informa on about the skin health camp was aired from Simikot based FM radio sta on for seven days.In the informa on, all the person who think of having skin diseases were asked to visit the one-day skin health camp for free of cost examina on, treatment and counseling.The camp was open from 8.30 am to 4.30 pm.Informed consent was taken before registering the pa ents.All the pa ents were examined once for the skin disease by registered Dermatologist.In addi on to the primary complaint, the pa ent were examined in to for any other skin diseases they are living with.When a diagnosis was in doubt, opinion of a second Dermatologist was taken.The skin diseases were divided into a number of categories as defi ned by Interna onal founda on of Dermatology namely scabies, superfi cial mycoses, pyoderma, pediculosis, eczema, HIV related Dermatoses, pigmentary anomalies, and acne. 7Ur carias, benign tumours, and appendageal tumours were also added in addi on to these diseases.The demographic details and the diagnosis of the disease were recorded in preformed proforma.
Individuals who were iden fi ed as having individual skin disease were given appropriate treatment and advice free of cost.Only the cases requiring histopathological examina on were referred to ter ary care centres (TU Teaching Hospital, Kathmandu or Nepalgunj Medical College, Nepalgunj).

Results
A total of 148 pa ents were examined for skin diseases out of which 102 (68.9%) were males and 46 (31.1%) were females.The mean age was 25.3 years ±11.95SD.The age range of those examined was 3 months to 60 years.
More than half (55.4%) of the total pa ents were from Brahmin/Chhetri/ Thakuri ethnic group.Most of the pa ents who came for health check up were offi ce worker (34.5%), followed by students (33.1%), farmers and housewives (21.6%).The other group consisted preschool kids, Monks and business people (table 1).
Of these pa ents (62.0%) had SLC and above educa on while 12.0% were uneducated.Almost all the pa ents were from Humla district (88.5%) whereas only 11.5% were from other districts.
The median me travelled to camp by walking was 3 hours (Q1= 30 minutes, Q3=24 hours).Forty-four (30.0%) of total camp visitors, walked more than 24 hours to reach the camp.One of the pa ents had traveled 96 hours to reach the camp.

Discussion
In recent few years, the epidemiological studies on skin diseases in Nepal has increased.However, most of these studies are confi ned to Terai and Hilly regions of Nepal.In one of the studies conducted by Shrestha R et al 8 in rural village development community of hilly region of Nepal, the camp prevalence of skin diseases was 83% with eczema (36.4%), followed by infec ons (28.4 %), acne (22%), Pigment disorders (34%), and Ur caria (12.3%).In another similar study in Terai region by Walker SL et al 3 , the point prevalence of skin disease in camp was 62.2% with dermatophyte infec ons (11.4%) being the commonest followed by P. versicolor (8.9%), Acne( 7.7%), Melasma (6.8%), eczemas 5.6%) and P. alba (5.2%).In another study by Shrestha DP et al 2 , in which a house-to-house survey of skin disease was done, overall prevalence of Skin disease was shown to be 20.1%, with eczemas (12.2%) being the most common dermatoses followed by pigment disorder (4.1%), acne( 2.7%), ur caria(2.4%),and moles and lumps(1.6%).The same study had concluded that skin disease has large impact on quality of life of people of Nepal.The two studies from hilly region of Nepal shows eczema as one of the most common dermatoses in this region while infec ons were the most common predomina ng in Terai Region.
In our Study, the dermatoses of Himalayan region of Nepal were most commonly seen in males than females, with the disease seen across all age group, the most common being the adult group (21-30 years).The reason could be because the males might have more health seeking behavior compared to females in this region.Offi ce worker were most common group In this study it was seen that the pa ent had traveled to camp by walking up to 96 hour to reach to our camp.This refl ects the diffi culty of receiving health service because of complex geography of this region.Moreover, it could jus fy introduc on of newer technology such as telemedicine in this region especially in Dermatological services.
Pigmentary anomaly was the most common dermatoses seen in our study in contrast to eczemas and fungal infec ons seen in hilly and Terai region respec vely.The high intensity of Ultraviolet rays in this region could explain this pa ern.However, there were no cases of cutaneous malignancies despite the assumed high Ultraviolet rays exposure, which could be explained by protec ve skin type in our popula on or else it could be ques on of next research.

Conclusion
The dermatoses of Himalayan region are slightly diff erent from the dermatoses of hilly and Terai region of Nepal with pigmentary anomalies being most common, followed by eczemas, superfi cial mycoses, acne, photodermatoses, scabies, ur caria, benign tumours and pyodermas.These dermatoses pa ern refl ect the basic data of one of the Himalayan region of Nepal.

Table 1 :
Socio-demographic characteris cs of the pa ents

Table 2 :
Pa erns of Dermatoses to visit the camp which could be because of awareness of disease in this group.Hindus were more in number to seek the health related service in our camp, and it could be because of awareness of health seeking behavior in this group.The educated group of people were most common to seek the service probably because of increased percep bility of disease in this group.