Dermatological Disorders in Tuvalu Between 2009 and 2012
LI-JUNG LAN1, YING-SHUANG LIEN2,3, SHAO-CHUAN WANG4,5, YU-LIN YEH1, CHIEN-HAN
TSAO4,6, YI-CHOU YU3,4, CHUN-TZU CHEN7, KO-HUANG LUE4,8, JING-GUNG CHUNG9,10 and
YU-PING HSIAO1,4,*
1
Department of Dermatology, Chung Shan Medical University Hospital, Taichung,
Taiwan, R.O.C.; 2Department of Obstetrics & Gynecology, Chung Shan Medical
University Hospital, Taichung, Taiwan R.O.C.; 3Department of Anesthesiology,
Chung Shan Medical University Hospital, Taichung, Taiwan, R.O.C.; 4Institute of
Medicine, School of Medicine, Chung Shan Medical University, Taichung, Taiwan,
R.O.C.; 5Department of Urology, Chung Shan Medical University Hospital, Taichung,
Taiwan, R.O.C.; 6Department of Otolaryngology, Chung Shan Medical University
Hospital, Taichung, Taiwan, R.O.C.; 7Department of Chief Room Secretary Group,
Chung Shan Medical University Hospital, Taichung, Taiwan, R.O.C.; 8Department of
Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan, R.O.C.;
9
Departments of Biological Science and Technology, China Medical University,
Taichung 404, Taiwan, R.O.C.; 10 Department of Biotechnology, Asia University,
Taichung 413, Taiwan, R.O.C.
Running Title: Dermatological Disorders.
Correspondence to:
Jing-Gung Chung, Department of Biological Science and Technology, China Medical
University, No 91, Hsueh-Shih Road, Taichung 404, Taiwan. Tel: +886 4 2205 3366
ext 2161, Fax: +886 4 2205 3764, e-mail: jgchung@mail.cmu.edu.tw
Yu-Ping Hsiao, M.D., Department of Dermatology, Chung Shan Medical University
Hospital, No.110, Sec.1, Chien-KuoN.Rd. Taichung City 402, Taiwan, R.O.C. Tel:
886-4-24739595; E-mail address: skin.csmu@gmail.com
1
Abstract. There is a paucity of knowledge on the prevalence of skin disorders in
Tuvalu. The aim is to assess common cutaneous diseases and to evaluate access
dermatological care in Tuvalu. We examined cutaneous disorders of people in Tuvalu
in between 2009 and 2012. The most common skin conditions were eczema/dermatitis,
superficial fungal infections, impetigo, carbuncles, furuncles, folliculitis, acne, scabies,
warts, and keloid. Infrequent skin conditions included infectious granulomatous
diseases, albinism, actinic keratosis, skin cancers, cutaneous lupus erythematosus, and
mammary Paget’s diseases which required medical attention. This is the first
epidemiological report on skin disorders in the southwest Pacific Island Country,
Tuvalu.
Key Words: Tuvalu, dermatological disorders, epidemiology.
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Introduction
Tuvalu, is a country made up of a group of nine islands and reefs, located in the
southwest Pacific Ocean (5 to 10 degrees south latitude; 176 to 179 degrees east
longitude) (1). The distance from Tuvalu’s capital (Funafuti) to Fiji 's capital (Suva) is
about 1,100 kilometers, and about 4,200 kilometers from Funafuti to Sydney(1). The
national land area of Tuvalu is only 25.9 square kilometers, and the highest point does
not exceed four meters above sea level(1). Currently, an estimated 11,000 people live
in Tuvalu (1). Taiwan’s first overseas medical mission was initiated in 1962 to Libya,
and in the following years, Taiwan went on to provide long-term medical assistance
(2). The Taiwan International Cooperation and Development Fund (Taiwan ICDF) has
coordinated medical resources of Taiwanese hospitals in order to provide long-term
medical assistance to 8 countries (Marshall, Kiribati, Solomon Islands, Palau, Nauru,
Tuvalu, Papua New Guinea, and Fiji) in the Pacific Ocean (2). Based on the Mobile
Medical Missions, Chung Shan University Hospital sent dermatologists to Tuvalu
beginning in 2009. There is little information on skin conditions of the Tuvalu
population. The aim of this study was to determine the most common skin diseases
and to assess access to dermatology care in a sample of Tuvalu individuals.
Methods
A total of 332 patients from Tuvalu, ages 1 to 76 years, were assessed for skin
diseases by a complete dermatological examination between 2009 and 2012. All
participants were asked about any previous skin diseases, other medical conditions,
and family history. Diagnosis of various cutaneous conditions was based on
characteristic clinical features. In some instances, the diagnosis of superficial fungal
3
infections was confirmed by the potassium hydroxide assay (3, 4).
Results
Dermatological diseases in Tuvalu
Among the 332 patients, 177 (53.3%) were women, and 155 (46.7%) men with an
average age of 30.2 6.3 years. Skin conditions frequently observed were pruritus,
excoriations, scratching, painful wounds, unhealed ulcers, skin discoloration, acne and
keloid. The most common dermatological diseases and their respective prevalence
were eczema/dermatitis (37.7%), superficial fungal infections (34.3%), impetigo
(21.7%), carbuncles and furuncles (16.9%), folliculitis (11.1%), cellulitis (9.3%), acne
(15.6%), prurigo nodularis (12.3%), intertrigo (9.6%), scabies (14.4%), warts (7.5%)
and keloid (5.4%) noted in Table1. Eczema/dermatitis included atopic dermatitis,
seborrheic dermatitis, contact dermatitis, dyshidrotic eczema, summer eczema,
nummular eczema, stasis dermatitis,and lichen simplex chronicus. Superficial fungal
infectionswere tinea capitis, tinea barbae, tinea corporis, tinea cruris, tinea mamuum,
tineapedis, onychomycosis, and mucocutaneous candidiasis. Infrequent skin
conditions listed in Table 2 included port-wine stain (Fig. 1A), discoid lupus
erythematosus (Fig. 1B, 1C), neurofibromas (Fig. 1D), vitiligo, mammary Paget’s
diseases, albinism (Fig. 1E~1H), actinic keratosis, squamous cell carcinoma (Fig. 1G),
and infectious granulomatous diseases (Fig. 1I~1L) that required medical treatment.
Discussion
This report is the first epidemiological study which investigated the prevalence of
dermatological diseases in Tuvalu. Leppäniemi AK had reported on several surgical
procedures and surgical cases in Tuvalu between 1990-1993 (5-8). Nelesone T et al.
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established a successful African outbreak surveillance model for poliomyelitis,
cholera, diarrhoea, dysentery, typhoid, measles, meningococcalmeningitis, and
outbreaks of febrile diseases of unknown origin (9). However, medical staff and
access to care were inadequate in the past. The climate is usually hot, and hygiene is
poor because of lack of a tap water supply. Majority of people collect rainwater from
the roof of buildings and store it for daily use (1). Skin infections are a common health
problem in Tuvalu that is similar with other Pacific island countries (10). Superficial
fungal infection sand scabies were found in 34.3% and 14.4% in Tuvalu respectively,
and the ratio of scabies was similar with Tanna in Vanuatu (10). Our results are also in
agreement with Steer AC et al. that the most common skin problems in the children in
Fiji were infected scabies (22.2%), impetigo (20.2%), non-infected scabies (9.7%)
and abscess or localized cellulitis (8.1%) (11). After the introduction of crotamiton
lotion and/or permethrin cream, theincidence of scabies in Tuvalu has been in decline.
We also found that after education on treating of skin wound care (avoid contacting
seawater), other infectious disease such as impetigo, carbuncles, furuncles, and
cellulitis were cured with short courses of amoxicillin or cephalosporin.
The rare but important issue was the suspicion of infectious granulomatous
diseases in Tuvalu. Skin biopsy, histopathology, and tissue culture were not available
and so the actual diagnosis of these granulomatous diseases is difficult. Tuvalu's
major diseases are tuberculosis, leprosy, nematodes and parasitic diseases.1Four
non-endemic
cases
in
Pacific
Island
patients
are
described
to
have
chromoblastomycosis caused by Fonsecaea pedrosoi (12). Chromoblastomycosis,
deep fungal infection, leprosy, tuberculosis cutis, or sarcoidosismust be included in
the differential diagnosis in these patients with granulomatous diseases (Fig 1I-1L).
There are several patients with albinism suffered from severe photosensivities, actinic
keratosis, and skin cancers in Tuvalu (Fig. 1E~1G). Similar issue was discussed in
5
Africa.12This is particularly problematic for albinos living in tropic countries with
intense UV exposure, and the albinos would suffer both emotionally and physically
from dermatologic malignancies (13-15). The gene MC1R variants in oculocutaneous
albinism increased susceptibility to skin cancer (14). We should perform frequent skin
evaluation and educate patient for the sun protection for these patients.
Conclusion
This study is the first epidemiological report of skin disorders in Tuvalu. Future
studies are needed in which clinical assessments by dermatologists are made and
evaluation of current treatment approaches.
Acknowledgements
We gratefully acknowledge the Medical Project in the Pacific Island Countries and
Mobile Medical Missions supported by the Taiwan International Cooperation and
Development Fund (Taiwan ICDF) and Chung Shan Medical University Hospital,
Taiwan. We also acknowledge the epidemiological information provided from Bureau
of Consular Affairs, Ministry of Foreign Affairs, Republic of China (Taiwan), and we
thank the helps from Dr. Nese Ituaso, Dr. Stephen Homasi, Pelesala Kaleia, and
medical team, in Princess Margaret Hospital, Tuvalu.
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Fig. 1 The infrequent dermatological diseases requiring medical assistance.
(A) A 25-year-old woman with port-wine stain.
(B) A 39-year-old woman with discoid lupus erythematosus over the lips and chin.
(C) A 39-year-old woman with scarring alopecia over the scalp.
(D) A 12-year-old girl with several neurofibromas.
(E) A 57-year-old women with Albinism.
(F) A 57-year-old women with Albinism and skin cancers over the right leg.
(G) A 27-year-old Albinism patient holds her daughter.
(H) A 8-year-old boy with Albinism.
(I) A 16-year-old girl with infectious granulomatous diseases over the right knee.
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(J) A 26-year-old man with infectious granulomatous disease over the right thigh.
(K) A 26-year-old man with infectious granulomatous disease over the left arm.
(L) A 25-year-old man with infectious granulomatous disease over the right wrist.
Table 1.
Table2.
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10