Egyptian Dermatology Online Journal, Volume 4 Number 2
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Pattern of skin diseases at Riyadh Military Hospital

Abdulrahman Y. Al-Zoman1 MD, Facharizt, Abdulrahman K. Al-Asmari 2 MSC, PhD

Dermatology Department1 and Research Center2, Riyadh Military Hospital, Riyadh, Saudi Arabia

correspondence:
Abdulrahman Al-Asmari , Research Center, Riyadh Military Hospital,
Riyadh, Saudi Arabia
E. mail address: akasmari@medu.net.sa

Egyptian Dermatology Online Journal 4 (2): 4, December, 2008

Accepted for publication in November 30th, 2008.
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Abstract

Objective: Skin problems are one of the common health problems seen in the developing countries. A retrospective study was undertaken to determine the pattern of skin diseases during the period 2001-2005 at the Dermatology Clinics of a major tertiary hospital in the central region of Saudi Arabia.

Methods: Retrospective data were collected from medical records of patients for determining the pattern of common dermatological disorders seen in patients reporting at the Riyadh Military Hospital (RMH) during the period 2001-2005. RMH is a major tertiary hospital in the Central region of Saudi Arabia.

Results: During the five year period (2001-2005), a total of 58450 cases were seen at the dermatological clinics of RMH. The incidence of dermatological diseases was more in female patients 34123 (58.38%) than male patients 24327 (41.62%). Most of the cases were clinically diagnosed. The highest number of patients was in the age group of 41-50 years. Dermatitis/ Eczemas was the most common skin disorder (21.29%) followed by diseases of the hair (11.9%) and acne (11.88%). Cutaneous infections due to viruses, bacteria and fungi were seen in 9.70%, 2.97% and 4.5% of the patients respectively. The erythematosquamous diseases of the skin were recorded in only 4.61% of the patients; psoriasis (2.47%) was predominantly seen in this group of patient. On the other hand out of 10.20% patients who had pigmentary disorders 3.2%.were affected by inflammatory hyper pigmentation, 2.69% patients had vitiligo and 2.47% showed melasma.

Conclusions: Most of the patients with skin disorders reporting to dermatology clinics of the Riyadh Military Hospital were of Arab origin and the number of women was more than men. Dermatitis/ Eczemas, acne and diseases of the hair were the most common disorders in our series of patients, while the incidence of vitiligo, psoriasis and skin tumors was comparatively less. A comparison with other regions of the Kingdom also showed dermatitis to be the most common and predominant skin disorder seen in the different regions of the Kingdom. However the occurrence of acne, bacterial and viral infections, and vitiligo showed regional variations.

Introduction

The incidence of skin diseases differs widely in various geographical locations, presumably influenced by racial and environmental factors. There are few published reports on the pattern of skin diseases in general[1,2,3,4]. Riyadh is one of the major cities in Central Region of Saudi Arabia. The military hospital is one of the largest government hospitals in Riyadh region catering for military personnel and their families, as well as non-military personnel. The hospital offers secondary and tertiary care, and is equipped with modern and sophisticated facilities. The epidemiological survey of medical problems is important in the practice of general medicine because of continual changes in life style, population size, age distribution and in the quality of health care services. Skin disorders can cause considerable morbidity in elderly people[5]. An early diagnosis and identification of these conditions that are mostly curable by treatment is important as this not only helps in treating the patients but also helps in preventing the spread of communicable diseases[6]. It is necessary for any dermatologist to know the epidemiological background of common skin diseases[3].

The aim of this study is to review the pattern of skin diseases seen at the dermatology clinics at Riyadh Military Hospital during the period 2001-2005.

Methods

Riyadh Military Hospital is one of the main specialized centers of dermatology run by the Medical Services Department of the Ministry of Defense and Aviation, in the central region of Saudi Arabia. All the cases in the outpatient clinics as well as indoor consultations from various departments are seen by qualified dermatologists. A retrospective study was carried out at the hospital for the period between January 2001 and December 2005. This study was approved by the hospital ethics committee. The medical records of all patients visiting the skin clinics during the study period were reviewed. No inclusion or exclusion criteria were applied. A total of 58450 files were examined. The information on age, sex, nationality and incidence of various skin disorders were collected from the medical records by using a designed questionnaire. Data analysis was carried out using Microsoft Excel and Graph pad prism.

Results

During the study period i.e. 2001 - 2005, 58450 patients with different dermatological diseases presented to outpatient clinics of the dermatology department at the Riyadh Military Hospital. 24327 (41.62%) of the patients were males and 34123 (58.38%) were females with a male/female ratio of 1:1.4.

Non infective disorders including eczema, acne, pigmentary disorders, and erythematosquamous skin disorders were seen in around 60% of the patients, while skin diseases due to infection were seen in around 18% of the patients. Other miscellaneous diseases were recorded in around 17% of the patients.

The different skin diseases diagnosed are shown in Table 1. The diseases included different types of eczema (21.29%), infectious diseases (17.48%,), pigmentary disorders (10.20%), erythematous and erythematosquamous diseases of skin (4.61%), disorders of skin appendages (13.07%), hair diseases (11.90%), vascular disorders (0.18%), urticaria (1.55%), tumors 2.17%, bullous disorders (0.14%), connective tissue diseases (0.88%) and other miscellaneous diseases (16.55%).

In the eczema dermatitis group, atopic dermatitis (40.10%) was the most common followed by seborrheic dermatitis (29.76%) and contact dermatitis (20.20%).

Among the infectious skin diseases viral infection (9.7%) was the most common followed by fungal (4.5%) and bacterial (2.97%) infections. Viral warts accounted for around 88% of the viral infections followed by Molluscum contagiosum(4.07%), Herpes zoster (3.33%), and Herpes simplex (1.81%).

Pityrosporon folliculitis (30.90%) was the major dermatomycoses among the fungal diseases followed by Candidal intertrigo (16.42%), Onychomycosis (11.85%) and Tinea pedis (11.52%).

Psoriasis was the most common erythematosquamous disorder accounting for 53.4% of the cases in that group followed by dermatoses due to Lichen planus (24.7%), Pityriasis rosea (6.15%) and Acanthosis nigricans (6.11%).

Among the pigmentary disorders post inflammatory hyperpigmentation was the major disorder accounting for 38.41% of the patients in that group followed by Vitiligo (26.37%) and Melasma (24.19%).

The details regarding different races of the patients who reported to the dermatology clinic are shown in Table 2. Arabs, including Saudi citizens constituted the majority of patients at 57286 (98.01%) with non-Arabs numbering only 1164 (1.99%). Women outnumbered men irrespective of nationality (Table 2). The sex distribution was done according to the age range. Dermatological diseases were seen more in the female than male.

Skin disorders were recorded in a large number of patients between 41 and 50 years of age (32.77%) followed by 21 and 30 years (18.32%), 31- 40 years (16.01%) and 11- 20 (15.53%) age groups respectively. On the other hand the frequency of skin diseases was less in patients of the age groups between 51- 60 years (4.16%) and 61-70 (2.2%) (Table 3).

A comparative incidence of few common dermatoses in different regions of Saudi Arabia and cities of different countries are shown in Table 4 and Table 5.

Skin Disorders  Diagnosis Total Male Female %
Dermatitis  / Eczemas and related Atopic dermatitis 4991 2563 2428 8.54
Contact dermatitis 2514 1060 1454 4.3
Seborrheic dermatitis 3704 1519 2185 6.3
Lichen simplex chronicus 629 323 306 1.08
Actininc keratosis 8 4 4 0.01
Keratosis pilaris 115 39 76 0.2
Dariers Disease 4 3 1 0.01
Subcorneal pustular dermatosis 5 2 3 0.01
Pityriasis alba 310 172 138 0.53
Seborrheic keratosis 164 78 86 0.28
Total 12444 5763 6681 21.29
Infectious diseases
 Bacterial Folliculitis 1621 644 977 2.78
Pyoderma 23 10 13 0.04
Erythrasma 38 17 21 0.07
Leprosy 3 1 2 0.01
Lupus vulgaris 9 3 6 0.02
Erysipelas 38 18 20 0.04
Carbuncle 1 0 1 0
Staphylococcal Scaled
Skin Syndrome (SSSS)		 1 0 1 0
Bullous impetigo 3 1 2 0.01
Total 1737 694 1043 2.97
Viral  Warts 5046 2806 2240 8.64
Hand, foot and mouth disease 3 1 2 0.01
Chickenpox 71 39 32 0.12
Herpes simplex 103 51 52 0.18
Eczema Herpeticum 12 6 6 0.02
Herpes Zoster 189 103 86 0.32
Molluscum contagiosum 231 123 108 0.4
ORF 16 10 6 0.03
Total 5671 3139 2532 9.7
Fungal (Dermatomycosea) Candidiasis 83 35 48 0.14
Onychomycosis 304 131 173 0.52
Tinea capitis 303 159 144 0.52
Tinea corporis 243 128 115 0.42
Tinea pedis 416 189 227 0.71
Tinea Faciei 3 0 3 0.01
Tinea Manuum 26 5 21 0.05
Intertrigo 432 191 241 0.74
Pityrosporon Folliculitis 813 260 553 1.39
Actinomycosis 1 1 0 0
Mycetoma 7 3 4 0.01
Total 2631 1102 1529 4.5
Parasitic Total 177 95 82 0.3
Erythematous & Erythematoquamous Disease of skin Erythema Elevatum diutinum 2 0 2 0
Pityriasis lichenoides acuta 8 8   0.01
Pityriasis lichenoides chronica 39 19 20 0.07
Pityriasis rubra pilaris 12 8 4 0.02
Acanthosis nigricans 165 54 111 0.28
Lichen planus 663 340 323 1.14
Keratoderma 37 13 24 0.06
Psoriasis (Vulgaris, Pustular) 1441 752 689 2.47
Pityriasis rosea 166 84 82 0.28
Dermatosis Papulosa Nigra 51 12 39 0.09
Erythema Induratum (Bazin) 2 0 2 0
Ichthyosis 112 66 46 0.19
Total 2698 1356 1342 4.61
Pigmentary Disorders Freckles/Café-au-lait 359 90 269 0.61
Melanocytic nevi 89 32 57 0.15
Melasma 1443 376 1067 2.47
Pigmentation 13 5 8 0.02
Post inflammatory
hyperpigmentation		 2291 752 1539 3.92
Post inflammatory
hypopigmentation		 196 98 98 0.34
Vitiligo 1573 806 767 2.69
Total 5964 2159 3805 10.2

Disorder of Skin appendages  

Diseases of the sebaceous Follicles Acne 6943 2584 4359 11.88
Rosacea 523 141 382 0.9
Perioral Dermatitis 169 62 107 0.29
Total 7635 2787 4848 13.07
Diseases of the Hair Total 6953 1971 4982 11.9
Vascular disorders Total 105 48 57 0.18
Urticaria Total 903 380 523 1.55
Tumours Total 1266 621 645 2.17
Bullous disorder Total 80 46 34 0.14
Connective tissue Disease Total 515 238 277 0.88
Other diseases Total 9671 3928 5743 16.55
Total Total 58450  24327 34123 100

Table 1: Some Common Skin diseases seen at Riyadh Military Hospital, Riyadh
 
Race Total Male Female %
Africans 78 31 47 0.133
Americans 25 9 16 0.04
Arabs 57286 24058 33228 98.01
Asians 801 159 642 1.37
Australians 24 4 20 0.04
Europeans 208 53 155 0.36
Others 28 13 15 0.05
Total 58450 24327 34123 100

Table 2 : Distribution of patients according to race
 
Age group Total % Male Female
1-10 5763 9.86 3122 2641
11-20 9079 15.53 3723 5356
21-30 10706 18.32 3933 6773
31-40 9359 16.01 3711 5648
41-50 19156 32.77 7924 11232
51-60 2429 4.16 927 1502
61-70 1280 2.2 596 684
71-80 486 0.83 275 211
81-90 154 0.26 90 64
91-100 30 0.05 22 8
101-110 8 0.01 4 4
Total 58450 100 24327 34123

Table 3 : Age group distribution according to sex
 
Skin disorders Riy Aba  Joub Hab Jedb Najb E. PRb Maka Asrb
Dermatitis 21.29 25.68 34.14 16.3 18.64 37 19.6 23.8 25.7
Acne 11.88 5.45 9.57 12.4 9.48 12.8 13.8 4.8 5.4
Viral warts 8.64 2.49 2.85 8.4 6.78 6 11.9 2.5 2.5
Bacterial infections 2.97 13.19 10.87 2.8 7.65 5 4.8 11.2 13.2
Vitiligo 2.69 3.03 3.35 3.9 3.12 7 5 0.7 3
Psoriasis 2.47 2.1 5.33 3.6 3.01 1.5 3.4 1.8 2.1
Lichen planus 1.14 1.32 1.21 1.2 0.64 1.1 1.7 0.7 1.3

a: reference No [10], b: reference No [11] Riy: Riyadh, Ab: Abha, Jou: Al-Jouf, Ha: Hail, Jed: Jeddah, Naj: Najran, E.PR: Eastern Province, Mak: Makkah and Asr: Asir.

Table 4: Comparison of incidence (%) of some common skin diseases in Riyadh and other regions of Saudi Arabia
 
Skin Disorder Riyadh
%		 Abu Dhabi[1]
%		 Doha[1]
%		 Calcutta[1]
%		 Bamako[1]
%		 Canada[11]
%		 Kenya[10]
%
Dermatitis 21.29 20.98 24.64 15.2 20.4 39.2 28.1
Acne 11.88 9.07 8.4 3.5 4.2 7.3 3.9
Viral warts 8.64 5.47 9.9 2 0.9 6.8 2
Bacterial infection 2.97 2.55 2.6 30-40 5.9 5.7 6.4
Vitiligo 2.69 3.18 1.9 4 0.9 - 2.9
Psoriasis 2.47 4.49 1.9 0.5-1.5 0.5 4.7 3.2
Lichen planus 1.14 0.95 0.5 0.5-1.5 0.8 - 1.6
[1],[11],[10]: references

Table 5 : Comparison of incidence (%) of some common dermatoses in different studies

 

Discussion.

The current study is the first to describe the pattern of skin diseases in RMH as a referral center for primary clinics in the central region of the Kingdom of Saudi Arabia. Although this study was limited to a single hospital, we believe that the results represent a rough estimate of the incidence of skin diseases in central region and that the distribution of dermatoses according to age and sex reflect the true incidence. The results indicate that skin diseases in Riyadh Military Hospital (RMH) are more predominant in women which are in agreement with earlier report[7]. This could be partly due to the greater awareness of Saudi women of health issues in general. The pattern of skin diseases differs from one locality to another due to many factors and variables[1]. We compared our results with data of studies from other regions of KSA and data from Arabian Gulf, Asian, and African countries. These countries include United Arab Emirates (Abu-Dhabi), Qatar (Doha), India (Calcutta), and Mali (Bamako) as shown in Table 4 and 5. The results of the present study were comparable with similar published studies from other regions of Saudi Arabia. Table 4 shows a comparison of the incidence of some common dermatoses in different regions of Saudi Arabia. One of the most common skin disease observed was different types of eczemas seen in our study (we found that atopic dermatitis counts were highest (40.11%) followed by seborrheic dermatitis (29.76%) then contact dermatitis, (both are allergic and of cumulative types). Contact dermatitis is also one of the commonest skin disorders worldwide, as shown by studies from industrialized countries[8,9]. However viral, bacterial, parasitic and fungal skin infections are more prevalent in some developing countries[6]. In the present study we found that the bacterial infections and vitiligo was lower in the central region than other regions, but the incidence of viral warts was higher than other regions except eastern province (Table 4). The incidence of dermatitis/eczema was similar to that observed in Abu Dhabi, Calcutta and Bamako[1] but higher percentage was reported from Doha, Canada and Kenya[1,10,11]. The cases of bacterial infections accounted for 2-3% of the total number in our study, similar to that reported from to Doha and Abu Dhabi[8] but were more in Western and Asian countries (Table 5). The incidence of skin tumors in RMH (Riyadh Military Hospital) is less compared to Southern region,[1]. The southern region has a different weather and it is comparatively less hot during summer, while Riyadh is very hot reaching up to 50 ˚ C . This might be related to the type of variation between the sun rays in high altitudes. The incidence of all forms of skin tumors among the white population is increasing worldwide as a result of increased exposure to sun[12,13,14]. The fewer incidences of skin tumors in the Islamic world may be due to the way of dressing, which discourages body exposure, especially in women[5]. Acne has a high morbidity among young population especially women and cosmetic and psychological effects might be the main cause[15]. The cases of acne made up 11.88% of all skin diseases in this study, which is similar to that reported from Abu Dhabi[1] (9.07%) but this number was higher than that of other Saudi Arabian region[16]. Stress, seasonal variation and pre-menstrual period may affect the severity of acne vulgaris. Females had higher prevalence than males[16]. This could be because of a higher consciousness of self image among the youth in those countries and the easy availability of free medical services, as well as perhaps the racial influence[2]. Many acne patients believed that their acne was exacerbated by certain aspects of diet including chocolate, fatty food, fried food, eggs, cakes and biscuits, spices, coffee and tea [15]. Psoriasis and vitiligo (2.47% and 2.69%) are considered the two dermatological disorders mostly affecting the quality of life of patients with these problems. These diseases which make them depressed hiding their self from the social activities and wearing special clothes not allowing any lesion to be exposed as this may affect the future life and difficult to find a partner. The incidence of psoriasis (2.44%) is comparable to that of other studies[17], while vitiligo (2.69 %) was less recorded in our study compared with other investigations[1,10,18]. The incidence of viral warts in our study was higher than in other studies. This may be due to changes in place and environment. In conclusion, the incidence of skin diseases and conditions among females is very high and differed significantly among different age groups. Dermatitis and acne were the most common disorders in our study while the incidence of vitiligo; psoriasis and skin tumors were comparatively less. Our results showed no major differences in the incidence of skin diseases in the published reports from different regions in Saudi Arabia. Skin diseases cause considerable morbidity in elderly people; health promotion and education can do much to reduce the risks of these disorders in the elderly people.

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