Common Skin Diseases in Africa An illustrated guide

Common Skin Diseases in Africa
An illustrated guide
Colette van Hees & Ben Naafs

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ISBN 90-9014738-1
This guide was produced by the authors and the printer on a non-profit basis.
The contents may be reproduced with proper acknowledgement,
on the condition that they are not used for financial gain.

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CONTENTS
Page
INTRODUCTION
7
THE PATIENT WITH A SKIN PROBLEM
8
SOME NOTES ON TOPICAL TREATMENT
8-9
ECZEMA
11
Atopic eczema
11-12
Pityriasis alba
13
Infantile eczema
14-15
Seborrhoic eczema
16-17
Lichen simplex
18
Infective eczema
19
Contact eczema
20-21
FUNGAL / YEAST INFECTIONS
Mycids
23
Tinea corporis
24
Tinea capitis
25
Tinea unguium
26
Athlete’s foot
27
Pityriasis versicolor
28
Candidiasis
29
Mycetoma
30
BACTERIAL INFECTIONS
Impetigo
31
Folliculitis
32
Folliculitis keloidalis nuchae
33
Erythrasma
34
Secondary syphilis
35
Yaws
36
Leprosy
37-41
Buruli ulcer
42
Noma / cancrum oris
43

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VIRAL INFECTIONS
HIV infection
45
Pityriasis rosea
46
Chickenpox 47
Herpes zoster
48-49
Herpes simplex
50-51
Kaposi’s sarcoma
52-54
Warts
55-59
Molluscum contagiosum
60
PARASITIC INFECTIONS
Creeping eruption
61
Scabies - Crusted scabies
62-63
Leishmaniasis
64
Lymphatic filariasis
65
Onchocerciasis
66
AUTO-IMMUNE DISEASE
Alopecia areata
67
Chronic bullous dermatosis
5
of childhood
68
Chronic discoid lupus
erythematodes
69
Lichen planus
70
Vitiligo
71
MISCELLANEOUS SKIN DISEASES
Acne
73
Albinism
74
Dermatosis papulosa nigra
75
Drug eruptions
76-78
Hemangioma 79
Infantile acropustulosis
80
Keloids
81
Malignant melanoma
82
Papular pruritic eruption
83
Pearly penile papules
84
Porphyria cutanea tarda
85
Psoriasis
86-87
Urticaria - Papular urticaria
88-89

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INTRODUCTION
The importance of skin diseases is often overlooked. They are
usually not life-threatening and tend to be "shrugged away".
Skin diseases are, however, a significant problem all over the
world. In 1996 11,3 % of the new attendances presenting at all OPD’s in
Masvingo Province, Zimbabwe concerned skin diseases (Masvingo
Health Profile 1996, HIS Office, PMD Masvingo). These figures are simi-
lar elsewhere. This guide originated there to provide a quick and easy
reference for diagnosis and management of common skin diseases in
Zimbabwean clinics and hospitals (Common skin diseases in Zimbabwe,
an illustrated guide, ISBN 90-9013558-8).
In order to facilitate the use of the guide in East and West
Africa as well as in Southern Africa Dr Ben Naafs has joined me in pre-
paring the current edition. His helpful comments and contributions on
leprosy and other common skin diseases occurring outside of Southern
Africa have broadened its scope substantially.
Nowadays many skin diseases are related to or influenced by
concomitant HIV infection. These conditions are presented rather than
other, rare skin diseases. There are many more congenital malformations
and syndromes, benign and malignant tumours, tropical infections, skin
7
manifestations of systemic and metabolic disease, auto-immune disea-
ses etc. which are important but fall outside the context of this book as
they are not common. On the other hand some common skin diseases like
myiasis and jiggers are not included because they seldom reach a clinic,
people know how to deal with them. Needless to say, when you are in
doubt about a diagnosis the patient should be referred to a skin
specialist.
When care is taken to make the proper diagnosis and to
institute the proper treatment the management of skin diseases often
results in great improvement and satisfaction for patient and health care
worker alike. Treatments required generally need not be expensive and
are locally available.
Our sincere thanks go to everyone who supported us in
preparing this book and notably Jan Sterken of Studio Oss for producing
the book on a non-profit basis. We would especially like to thank the
patients who appear in this book for allowing us to use their photographs
for publication.
Colette van Hees, 2001.

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THE PATIENT WITH A SKIN PROBLEM
A patient who presents with a skin problem often complains of
"itchy rash all over the body". Indeed many patients are referred
to the skin clinic with "itchy rash all over the body" as a diagno-
sis. After taking a history and performing a proper skin examina-
tion you may find he or she is suffering from anything as varied as
eczema, urticaria, a drug reaction, a skin infection, scabies or
any other skin disease. A proper skin examination should be per-
formed in good light, preferably daylight. Ideally the whole skin
should be examined. The aspect, extent and localisation of all
the lesions is essential for making a diagnosis and will influen-
ce your management.
Some terms used to describe skin lesions are: Macule: Circumscribed
colour change without change in the level of the skin. Papule: Small
superficial circumscribed elevation. Plaque: Superficial circumscribed
elevation larger than a papule. Lichenification: Thickening of the skin
with exaggeration of the normal skin lines and deepening of the natural
creases, caused by scratching and rubbing. Nodule: Circumscribed, solid
8
proliferation, clearly apart from surrounding tissue and often occurring in
the dermis or subcutis. Pustule: Blister filled with pus. Wheal (hive):
Temporary elevation of the skin caused by oedema in the upper dermis
causing severe itchiness. Atrophy: thinning, wasting away of the skin.
SOME NOTES ON TOPICAL TREATMENT
Vaseline and mineral oil are widely used as a moisturiser in Africa.
They are an important cause of skin problems. They cover the pores of
sweat ducts so that sweat and other fluids are unable to get out. This
causes irritation, which will worsen any inflammatory skin condition.
Also, bacteria and fungi trapped in this warm and humid environment will
thrive and overgrow resulting in clinical infection.
Aqueous cream or emulsifying ointment are good alternatives to
vaseline for use as a moisturiser. They are generally available in super-
markets and chemists. Vegetable oils, e.g. coconut oil, can be used as
well, provided they are applied on wet skin.
Ointments or creams: as a rule a cream base is preferred for wet and
acutely inflamed lesions, an ointment for chronic, dry or lichenified
lesions.
Topical steroids: the mildest topical steroid is hydrocortison acetate

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1% cream or ointment. In cases where a steroid is indicated, for example
eczema, start with hydrocortisone 1% before prescribing a stronger
steroid such as betamethasone valerate 0.1%. Use a cream for wet and
acute lesions, an ointment for chronic and dry lesions. Always use strong
topical steroids intermittently (e.g. use 3 days, stop 4 days in a week). Do
not use strong topical steroids for the face or the genital area, or on
babies. When only strong topical steroids are available they may be
diluted on the palm of the hand with an equal amount of cooking oil.
Imidazole preparations: there are many antifungal imidazole creams
i.e. miconazole, clotrimazole, econazole, and ketaconazole. Use
whichever is available.
Potassium permanganate solution 1:4000 to 1:10.000 should always
be prepared freshly as it is inactivated rapidly after being diluted. It is an
adstringent (decreases oozing), antiseptic and mild antifungal. A pinch of
the crystals in a bucket of water should give a solution with a pink colour
(the colour of a fingernail). A purple solution is too strong, it will leave
brown stains. A degraded solution is brown in colour. Soak dressings in
the bucket or bathe affected body parts.
Coal tar paste or ointment: this has anti-inflammatory and anti-itch
properties. It is used e.g. in chronic eczema and psoriasis, as an
9
alternative to topical corticosteroids. It has photosensitising properties
and should therefore be applied at night and washed off in the morning
on sun-exposed areas. In chronic plaque psoriasis this quality of coal tar
may be used specifically: apply coal tar to psoriatic lesions, expose to
sun for a short time, e.g. 30 minutes, then wash off. The exposure time
may be increased slowly if the treatment is tolerated.
Salicylic acid ointment: removes scales and softens thickened, horny
skin and crusts.
Urea ointment or cream: urea is a strong moisturiser. It helps soften
and smooth the horny layer and aids the penetration of other drugs. It is
used in dry skin conditions, e.g. atopic eczema. It can cause a burning
feeling when used on damaged skin.
GV paint: GV or Gentian Violet solution (0,5–1%) has antifungal and
antiseptic properties. It is used for superficial infections of the skin and
mucous membranes. It stains skin and clothing. When kept for too long,
fluid may evaporate and the solution becomes too strong (>1%), this will
damage the tissues.
Sulphur: Sulphur has antiseptic properties and promotes desquamation.
It dries the skin and is antiseborrhoic.

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ECZEMA
The terms eczema and dermatitis are often used to describe the same
condition. Eczema is a non-infectious inflammation of the skin. It may be
acute, subacute or chronic and is influenced by many factors, i.e.
constitutional, irritant (vaseline, mineral oils, soaps and detergents –
vegetable oils usually are no problem), allergens, heat, stress, infection
etc. An acute eczema characteristically shows redness, swelling,
papules, blisters, oozing and crusts. Progressing to the subacute stage,
the skin is still red but becomes drier and scalier and may show pigment
changes. In the chronic stage lichenification, excoriations, scaling and
cracks are seen. There are many different types of eczema, the most
common ones will be presented on the following pages. They may have
predominantly acute, subacute or chronic phases. Itching is often the
major complaint.
ATOPIC ECZEMA
Atopic eczema is a multifactorial skin disease seen in patients with an
atopic constitution. This means that they have a genetic pre-disposition
for hypersensitivity reactions such as asthma, hay fever and atopic
eczema. The eczema comes and goes and may be triggered or worsened
11
by dryness of the skin, infections, heat, sweating, contact with allergens
or irritants and emotional stress. Atopic eczema in children and
adults appears in elbow- and knee-folds, on the wrists and ankles and
on the face and neck, in some cases it may become generalised. Itch is
an important feature. In long-standing disease lichenification is common.
Management of atopic eczema in children and adults
- Explain to the patient the recurrent nature of the disease! Take the time to explain
daily skin care as described below, and how to use the drugs prescribed.
- Stop the use of irritants such as vaseline, mineral oils and soap. Avoid temperature
extremes and contact with wool. Use a non-greasy moisturiser such as aqueous
cream, if the skin is very dry urea 5% or 10% ointment. Soap is an irritant, especially
if not rinsed off properly after use. In active phases of eczema use aqueous cream
or emulsifying ointment as a soap.
- In severe eczema, the patient should take rest.
- Lesions: - A mild topical steroid such as hydrocortisone 1% (cream for acute or
wet, ointment for chronic or dry lesions) once to twice daily until lesions
clear, usually in about 2 weeks.
- In severe or refractive cases a stronger steroid e.g. betamethasone

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0.1% once daily for 1-2 weeks. Do not use strong steroids in the face.
- Always use topical steroids intermittently when they are used over
longer periods of time.
- Chronic lichenified cases: coal tar 2-10% paste/ointment at night.
- For severe itchiness use antihistamines e.g. promethazine 25 mg at night.
- For bacterial superinfection use betadine shampoo as a soap or when weepy bathe
in potassium permanganate 1:4000 solution. In severe or widespread infection give
antibiotics (cloxacillin, erythromycin) as in impetigo.
Fig. 1 & 2. Recurrent atopic
eczema in an 8 year old
boy showing lichenification
in the elbow folds.
12
1
2

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PITYRIASIS ALBA
Pityriasis alba is a mini-form of eczema which occurs predominantly in
infants, children and adolescents. Multiple hypopigmented, vaguely
bordered, very finely scaling patches are found on the face and/or trunk,
and sometimes the extremities. This can persist for years and the
hypopigmentation usually does not clear with steroids, but will clear in
time.
Management of pityriasis alba
A short course of hydrocortisone 1% cream or ointment for pityriasis alba may be given
in case of itchiness or when there is evidence of concomitant atopic eczema. Usually
it is enough to explain to the patient or the parents that the condition is not serious
and will disappear in time.
3
Fig. 3. Scaling
hypopigmented macules
of pityriasis alba after
concomitant atopic
13
eczema was treated.
4
Fig. 4. Pityriasis alba on
the back of a
4 month old girl.

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