Can people affected by leprosy at risk of developing plantar ulcers be identified? A field study from central Ethiopia

In the ALERT leprosy control programme, 75 people affected by leprosy, in three different geographical areas, were investigated. Each person was documented as having anaesthesia to the 10 g monofilament. The study sought to determine why some people developed ulcers whilst others did not. According to the records, 43 had an ulcer during the last 5 years but 32 had never had an ulcer. In order to examine protective sensation on the sole of the foot, various sensory modalities were tested and the functional anatomy of the foot was examined. The results showed, as may be expected, that it is not possible to define a specific threshold for protective sensation that could be applied to all cases. Some people with only slightly diminished sensation developed ulcers, while many others with almost complete anaesthesia remained ulcer-free. In these rural communities, being a farmer reduced the risk of developing an ulcer, but no other demographic features were significant. Graded monofilaments were found to be the most appropriate test, with loss of sensation at any of five points tested being a 'positive' result. The 10 g filament was the most sensitive, but only 43% of feet identified by this test actually developed an ulcer. As people with partial loss of sensation were excluded from this study, this figure may be lower under programme conditions. The 50 g and 100 g filaments decrease the number of feet identified as at risk, but increase the percentage which actually develop an ulcer, to 46% and 49%, respectively. An appropriate test for selecting those for special programmes which may have a limited capacity, for example the provision of subsidized footwear or involvement in self-care groups, would be a 100 g filament, which would detect 86% of those feet likely to develop an ulcer, while reducing the number of those selected who are not at great risk. Vibrometry was found to be no better than graded filaments and an examination of functional anatomy did not help in identifying those at risk.     

Management of palmoplantar pustulosis: do we need to change?

Palmoplantar pustulosis (PPP) is difficult to treat. There is little hard evidence for the efficacy of any treatment and no published guidelines for its management. A number of exacerbating factors are well documented and there is some evidence for the importance of others. Smoking is the most recognized environmental trigger and recent research has concentrated on the role of eccrine sweat glands in this regard. Other factors, including tonsillar streptococcal infection and gluten sensitivity, may be important in selected cases. The aim of this review is to challenge dermatologists to consider alternative management strategies for PPP and design clinical trials that will enable the development of useful therapeutic guidelines.     

Access to healthcare for disabled persons. How are blind people reached by HIV services?

Disabled people are overlooked and marginalised globally. There is a lack of information on blind people and HIV-related services and it is unclear how HIV-services target blind people in a sub-Saharan urban setting.ObjectiveTo explore how blind people are reached by HIV-services in Kampala, Uganda.MethodA purposeful sample of blind people and seeing healthcare workers were interviewed, and data on their opinions and experiences were collected. The data were analysed by qualitative content analysis, with a focus on manifest content.ResultsThree categories emerged from the study, reaching for HIV information and knowledge, lack of services, and experiences of discrimination. General knowledge on HIV prevention/transmission methods was good; however, there was scepticism about condom use. Blind people mainly relied on others for accessing HIV information, and a lack of special services for blind people to be able to test for HIV was expressed. The health service for blind people was considered inadequate, unequal and discriminatory, and harassment by healthcare staff was expressed, but not sexual abuse. Concerns about disclosure of personal medical information were revealed.ConclusionAccess to HIV services and other healthcare related services for blind people is limited and the objectives of the National Strategic Plan for HIV/AIDS 2007–2012 have not been achieved. There is a need for alternative methods for sensitisation and voluntary counselling and testing (VCT) for blind people.     

The impact of leprosy control on the transmission of M. leprae: is elimination being attained?

In 1991 the World Health Assembly decided to 'eliminate leprosy as a public health problem' by the year 2000. Elimination was defined as reducing the global prevalence of the disease to less than 1 case per 10,000. In 2000 the World Health Organization (WHO) announced that elimination was reached globally. Conventionally control of disease is defined as the reduction of disease burden to a locally acceptable level. Elimination of disease is defined as the reduction to zero of the incidence in a defined geographical area, and eradication is defined as the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent. In leprosy however, WHO limited elimination to control instead of transmission, by using prevalence instead of incidence of disease. Leprosy statistics usually report on prevalence and new case detection. Prevalence is linked to length of treatment, which has changed over time. Trends in new case detection rates only reflect trends in incidence rates when no changes occur in case detection, but in the past 25 years case detection in leprosy has been determined strongly by operational factors. For the leprosy elimination strategy it was assumed that MDT would reduce transmission of M. leprae, but there is no convincing evidence for this. Data for evaluating the impact of MDT on transmission are not readily available because leprosy has a long incubation period. Also declines in case detection may have other causes, such as BCG vaccination. Mathematical modelling of the transmission and control of leprosy showed that the elimination strategy reduces transmission slowly, with a predicted annual decline in incidence ranging from 2% to 12%. Early case finding was the key factor to attain this decline. Future projections of the global leprosy burden indicated that 5 million new cases would arise between 2000 and 2020, and that in 2020 there would be 1 million people with WHO grade 2 disability. It is concluded that substantial progress has been made to control leprosy, but when elimination of disease is defined as the reduction to zero of the incidence, leprosy is definitely not eliminated. To attain elimination of leprosy it is necessary to find effective interventions to interrupt transmission of M. leprae and practical diagnostic tools to detect levels of infection that can lead to transmission. This requires extensive research in the areas of epidemiology and microbiology.     

Strategies for prevention of scars: what can we learn from fetal skin?

Fetal wound healing occurs rapidly and without scar formation early in gestation. Studying the mechanisms of scarless repair can lead to novel scar‐preventive approaches. In fetal wounds, collagen is deposited early and is fine and reticular with less cross‐linking. Several important differences of fetal vs. postgestational wound‐healing response have been determined, such as the presence of less inflammation, higher hyaluronic acid concentration and a greater ratio of collagen type III to type I. Compared with typical wounds, there are also altered ratios of signaling molecules, such as higher ratios of transforming growth factor (TGF)‐β3 to TGF‐β1 and ‐β2, and matrix metalloproteinases to tissue inhibitors of metalloproteinases. Furthermore, fetal fibroblasts do not exhibit TGF‐β1‐induced collagen production compared with their mature counterparts. Patterning genes (homeobox genes) involved in organogenesis are more active in the fetal period and are believed to be the “first domino” in the fetal cutaneous wound repair regulatory cascade. The recommended scar‐preventive agents, such as Scarguard MD^®, silicone gel and sheet, Seprafilm^® Bioresorbable Membrane, topical hyaluronan, onion extract, oral tamoxifen and 585‐nm pulsed dye laser are reviewed in this study. Despite the lack of supporting evidence, there is a widespread false presumption that the acceleration of healing with the widely assumed scar‐preventive commercial agents is associated with decreased scar formation. Humans are erroneously inclined to make a negative correlation between the healing rate and the degree of scar formation, while such a correlation does not exist in reality. Despite the importance of scar prevention, no FDA‐approved therapy for this purpose is available in the 21st century, which reflects the important challenges, such as the presence of redundant pathways, that these approaches are facing.     

What would make your life better? A needs analysis of leprosy settlements in the middle belt region of Nigeria

A needs analysis using rural appraisal and matrix ranking techniques was done in six leprosy communities in the middle belt region of Nigeria. Asked 'what would make their life better?' whole village groups were made to list, prioritize and rank their expressed needs by voting in a matrix table drawn on the ground. Out of a total of 504 votes, 31% was for health care or drugs for their general ailments, 23.6% for money and less than 10% for other needs that ranged from water, trade and housing to love and, least, mobility aids. Health care was prioritized in all communities but got the highest votes in three communities, money got the highest in the only two communities where it was prioritized and water in one. The need ranked the highest in each settlement seemed to be a reflection of its peculiar socio-economic situation. Apart from the similar priorities of health care and money, men's differing priorities were water, housing, clothes and assistance with farming, and women's, school fees for children, family, trade and food. These reflect their different traditional roles. Considering the variety of needs we think that there is no one solution to rehabilitation in the Nigerian context, but the situation and context of individual settlements should be considered, looking at general health care, income generation or loans schemes, schooling and water supply.     

The prevalence of seborrheic keratoses in people aged 15 to 30 years: is the term senile keratosis redundant?

BACKGROUND: Seborrheic keratoses (SKs) are common skin lesions that have been shown to occur with increasing age, although the age of onset is not well recorded. OBJECTIVE: To determine the prevalence, nature, and distribution of SKs in young people. METHODS: One hundred seventy people aged 15 to 30 years were given a total body examination during which the presence, number, site, and size of SKs were recorded. Biopsy specimens were taken from the first 22 people who had lesions clinically diagnosed as SKs. Data on age, skin type, eye color, and hair color were recorded for all respondents. RESULTS: Forty (23.5%) of 170 respondents had at least one SK, with no significant difference between the sexes. There was an increase in prevalence with age from 15.7% in 15- to 19-year-olds to 32.3% in those aged 25 to 30 years. The size of the SKs also increased with age. A total of 77.5% of SKs were found on the trunk and 22.5% on the limbs, head, and neck. There was no correlation between SKs and any particular hair and eye color or skin type. CONCLUSIONS: These findings confirm that SKs are common lesions in young Australians, appearing in a substantial proportion of people younger than 30 years. The term senile keratosis is no longer appropriate for these lesions.     

Conundrum: Who should care for the dermatologic needs of the medicaid patient? Facts and controversies

With the impending implementation of Obamacare in the context of a depressed American economy; an unsustainable national deficit and debt; and increasing personal dependency upon government largesse, a perfect storm is developing in the United States. This perfect storm is embodied by the paradox that an expanding population of Title XIX insured patients is increasingly dependent upon a diminishing number of American dermatologists to provide essential dermatologic care. In this context, we discuss whose responsibility it is to care for the dermatologic needs of Title XIX patients.