|Year : 2018 | Volume
| Issue : 1 | Page : 68-73
Photodermatoses in the Nigerian albino: A study in an urban hospital in southern Nigeria
Madubuko C Roli, Onunu Abel
Department of Medicine, University of Benin Teaching Hospital, Benin City, Nigeria
|Date of Web Publication||29-May-2018|
Dr. Madubuko C Roli
Department of Medicine, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Introduction: The tropical sunshine is deleterious to the albino skin predisposing their melanin deficient skin to lentigenes, dermatoheliosis, actinic keratosis, and skin cancers. Many of them die in the early adulthood or middle age from cutaneous malignancy. We determined the prevalence and types of photodermatoses and their relationship with sun protective methods in people living with albinism in Benin City, Nigeria.
Materials and Methods: This was a descriptive cross-sectional study that involved 73 albinos and 73 age and sex-matched controls. Data were collected using an interviewer-administered questionnaire and relevant information on sociodemographics, history of dermatological problems, and use of sun protection methods were obtained. Diagnosis of photodermatoses was made on clinical grounds, and dermatoscopic evaluation and skin biopsy punches were utilized where applicable to boost diagnostic accuracy.
Results: The mean ages for the albino population and their controls were 24 ± 11 years and 24 ± 11 years, respectively (P = 0.994). The male:female ratio of both groups was 1:1.3 The prevalence of photodermatoses in the albino population vs. control was 57 (78.1%) vs. 7 (9.6%) (P≥0.001). The observed photodermatoses in albino population were solar lentigenes 46 (63.0%), photoaging 33 (45.2%), actinic keratosis 22 (28.6%), sun burn 12 (16.3%), and skin cancers 9 (12.3%). Photodermatoses in the albinos, occurred more frequently in those who did not use sun screens and this finding was statistically significant for solar lentigenes (P = 0.038). The spectrum of photodermatoses seen in the controls included exogenous ochronosis 6 (8.2%) and polymorphic light eruptions 1 (1.4%).
Conclusion: Photodermatoses are highly prevalent in albinos. The common types were solar lentigenes, photoaging, and actinic keratosis. Photodermatoses are more common in albinos, who do not use sun protection.
Keywords: Dermoscopy, photodermatoses, sun protection
|How to cite this article:|
Roli MC, Abel O. Photodermatoses in the Nigerian albino: A study in an urban hospital in southern Nigeria. J Med Trop 2018;20:68-73
| Introduction|| |
The prevalence of albinism in Nigeria is ranked among the highest in the world with an estimated figure of two million albinos in the country. This is quite different from the study by Okoro in 1975, where a prevalence of 1 in 15,000 for East Central parts of Nigeria was made. The increasing prevalence of albinism in Nigeria translates to a higher burden of this pigmentary disorder and its attendant complications such as photodermatoses and skin cancers, which affect the individuals and their loved ones medically, socially and psychologically. Theoretically speaking, this prevalence may be low in comparison with other major health problems. However, these figures and the even larger numbers of indirectly affected persons qualify albinism as a public health issue deserving further attention.
Few studies have been performed on photodermatoses in albinos in Nigeria. This study, hence, sought to determine the prevalence of photodermatoses among albinos in Benin City, Nigeria. Furthermore, it sought to determine the types of photodermatoses in them, and finally the relationship between the use of sun protection methods and photodermatoses.
A similar study was performed in Tanzania by Samson et al., on the quality of life and people living with albinism. The focus of that study was on the quality of life and photodermatoses them. This study is a new one in this locality and was conducted in the University of Benin Teaching Hospital (UBTH) in Benin City, Edo State, Nigeria via an albino outreach clinic.
| Materials and methods|| |
The study was conducted in the Dermatology Unit through an albino outreach clinic at the UBTH. The hospital is located in the South-South geopolitical region in Nigeria, Benin City, Edo State. It is situated at Ward 10 Egor Local Government Area, Benin City Edo State. It is one of the four public tertiary health care institutions in Edo State.
A descriptive cross sectional study was utilized.
All clients with albinism, presenting at the Dermatology Outreach Albino Clinics in the University of Teaching Hospital, Benin City, who fulfilled selection criteria were recruited for the study.
All patients with albinism consenting to the study, attending the albino outreach clinics were included in the study, while all patients with albinism, who did not consent to study, were excluded.
The controls were all nonalbino patients consenting to study attending the general outpatient clinics.
Sample size determination
Using the Fisher’s formula,
n = minimum sample size; Z = normal standard deviation (SD) 99% confidence level of 2.58; p = prevalence; q = 1−p; d = margin of error = 0.01.
Studies describe a prevalence of 1 in 1000, i.e., 0.1%.
Altrition rate of 10% = 6.65.
Hence, sample size = 73.
A total of 73 albinos and 73 age and sex-matched controls who fulfilled inclusion criteria was involved in the study. They were selected using a snowball sampling technique where all albino clients presenting to the albino outreach clinic that consented to the study were observed and then subsequently encouraged to nominate another albino. Nominated patients were also observed and the process continued until sample size was achieved. The controls were nonalbino clients who were age and sex matched.
Permission was sought from all clients, in whom this study was done, after obtaining ethical approval from the hospital. Respondents had the purpose of the research, drawbacks, and benefits of the research explained to them. In addition, information received was treated with utmost confidentiality.
A snowball sampling technique was utilized. An albino outreach clinic was set up in the Dermatology Unit of the UBTH, Benin City, southern Nigeria. All clients with albinism, presenting at the clinics and consented to study was encouraged to nominate another albino. The nominated patients were observed and this continued in the same way until the total number of clients were obtained.
The control subjects were age and sex matched.
An interviewer-administered questionnaire containing five aspects was administered to each respondent. These four aspects included the following: sociodemographics, the use of sun-protection methods, history of dermatological problems, and physical examination findings. Cutaneous diagnosis of photodermatoses was made on clinical grounds, and clinical pictures were taken of skin lesions seen in the course of the study. Dermatological tools such as dermatoscopic evaluation and skin biopsy punches were utilized, wherever applicable to boost diagnostic accuracy.
All data generated were analyzed using the Statistical Package for the Social Sciences version 21.0 software (SPSS Inc., Chicago, IL, United States). Results were presented in tabular form. Discrete variables were presented as frequency and percentages. Continuous variables were presented as mean and SD. Chi-square with Yates correction was used to determine association between categorical variables, while t-test was used to compare means. P < 0.05 was taken as significant.
| Results|| |
Seventy-three albinos and 73 age and sex-matched controls participated in the study. There were 32 males and 41 females in each group. The mean age for the albino population was 24 ± 11 years with an age range of 3–53 years, while the mean age for the control group was 24 ± 11 years (t = 0.007, P = 0.994) [Table 1].
A total of 122 different photodermatoses were identified in 57 persons in the albino population with an average of 2.1 per patient. The diagnosis of photodermatoses was made by clinical evaluation, use of diagnostic tools such as dermoscopy to boost diagnostic accuracy, and furthermore, skin biopsies were also conducted where indicated to confirm clinical suspicion especially for cutaneous cancers.
The observed photodermatoses were solar lentigenes 46 (63.0%), photoaging 33 (45.2%), actinic keratosis 22 (28.6%), sunburn 12 (16.3%), and skin cancers 9 (12.3%). Among the skin cancers 8 (11.0%) were squamous cell carcinoma, while 1 (1.3%) was basal cell carcinoma. The basal cell carcinoma occurred on the head. Six squamous cell carcinomas occurred on the head and one on the upper chest wall [Figure 1].
Seven (9.6%) photodermatoses were observed in the controls. Six (8.2%) of these were exogenous ochronosis, while 1 (1.4%) was polymorphic light eruption [Figure 1].
In the albino population, sunburn, photoaging, skin cancers, actinic keratosis, and solar lentigenes were more frequently observed in those, who did not use sunscreens than in those who did. These findings were statistically significant for solar lentigenes (P = 0.038) [Table 2].
|Table 2: Relationship between photodermatoses and sunscreen use in the albino population|
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Six persons in the control population had exogenous ochronosis. Among these persons, 5 (83.3%) did not use sun screens. Polymorphic light eruption was present in only one person, and she did not use sunscreens.
Sunburn, photoaging, skin cancers, actinic keratosis, and solar lentigenes were more frequently observed in those who did not use sun protective clothing than in those who did in the albino patients. These finding was not statistically significant [Table 3].
|Table 3: Relationship between photodermatoses and use of sun protective clothing in the albino population|
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Among the persons who had exogenous ochronosis, 5 (83.3%) did not use sun protection clothing. The control subject who had polymorphic light eruption did not use sun protection clothing.
| Discussion|| |
The sun and society are hostile to the albinos. Under the tropical sunshine, their melanin-deficient skin develops wrinkles, lentigenes, actinic keratoses, and epitheliomata. Cutaneous cancers may result from chronic sun exposure, from which they may die in early adult life or in middle age.
The mean ages for the albino respondents and their controls were 24 ± 11 years and 24 ± 11 years, respectively. This trend agrees with some previous studies. A mean age of 32.2 years was seen in another study by Samson et al. This higher mean ages, may be attributed to the outreach skin care programs actively functioning in Tanzania for those with albinism. These programs continuously offer health education, community awareness, and early treatment of skin cancer. Morbidity and mortality at an early age are thus reduced; hence, Tanzanian albinos have normal life expectancy like their nonalbino counterparts. Lund et al. reported that people with albinism in rural resource settings were highly susceptible to skin cancers and were expected to have a lower life expectancy.
The prevalence of photodermatoses was 78.1% and 9.6% in the albinos and controls, respectively. The difference was statistically significant. This was in keeping with the study by Olumide, on photodermatoses in Lagos, where seven out of ten persons with endogenous photodermatoses were people with albinism. A similar observation was made by Okoro in the study of 1000 Nigerian albinos. Photodermatoses were found to be high in that study. This was contrary to the finding by Samson et al., where no cutaneous morbidity was found in all of their study population. Absent cutaneous morbidity in their study was attributed to regular use of sun protective measures by their respondents. Everyone’s skin needs extra protection from the sun, but people with albinism are particularly vulnerable to photodermatoses because of the reduction or absence of melanin in their skin.
The observed photodermatoses in the albino population were solar lentigenes 46 (63.0%), photoaging 33 (45.2%), actinic keratosis 22 (28.6%), sunburn 12 (16.3%), and skin cancers 9 (12.3%). The hostility of the tropical sun in Nigeria may have contributed to the high prevalence of photodermatoses. For example, the hallmark of photoaged skin is solar elastosis, which is probably an end product of elastic fiber degradation. Exposure of human skin to a certain threshold of ultraviolet (UV), infrared radiation, and heat leads to an influx of neutrophils. These neutrophils are packed with potent proteolytic enzymes capable of degrading collagen and, particularly, elasticfibers.
Skin cancers occurred in 9 (12.4%) of the albino respondents but did not occur in the controls. This was a statistically significant finding. It was in keeping with studies by Joseph et al., on skin cancers in albinos in north western Tanzania, where it was found that exposure to light appeared to be the single most important risk factor for the development of skin cancers in albinos. Squamous cell carcinoma was the most common cancer seen in this study 8 (11%). Seven occurred on the head while one occurred on the chest. This is similar to the trend seen by Yakubu and Mabogunje and Kromberg et al. where squamous cell carcinoma was found to be the most common skin cancer seen in albinos. The life time risk of squamous cell carcinoma in an albino is said to be 1000-fold compared to the general population and the most favored site is the head and neck.
The photodermatoses found in the controls were exogenous ochronosis 6 (8.2%) and polymorphic light eruption 1 (1.4%). This finding corroborates the observation by Olumide in a study conducted on photodermatoses in Lagos, where exogenous ochronosis was found to be the most common exogenous photodermatoses found in that study. The explanation for this may be the high demand for skin-lightening agents by many Nigerians, who will go to any length to get a brighter skin tone in the shortest possible time. Currently, skin bleaching continues to have an impact on dermatological practice in many sub-Saharan African communities, with prevalence rates of this practice in community and clinic settings documented to be between 26 and 67%.,,,,,,,,
A desire to lighten skin color is cited as a primary motivating factor for skin bleaching., This is because in some countries, white skin is still perceived to be associated with social privileges, including better job and marital prospects. However, some skin bleachers may not desire white skin, but instead desire radiant skin.
Forty (87%) of the solar lentigenes recorded in the albinos occurred in those, who did not use sunscreens. This was a statistically significant finding. It collaborates the fact that sunscreens reduce the incidence of solar lentigenes and other photodermatoses, an observation in concordance with the Tanzanian study by Samson et al.
The frequency of use of sunscreens in the albino population was 20.5%. Adequate sun protection factor (SPF) levels were observed in 15% of the population. This finding is quite different from the observation by Samson et al., where they reported a high prevalence of sunscreen (96%) use by their respondents. The explanation for the difference may be as a result of the albino health awareness training programs embarked upon by the Tanzanian government. In addition, easy accessibility to government-subsidized sunscreens at cheap rates may also explain this difference. Encouraging photoprotection and ensuring the availability of affordable sun screens with high SPF are preventive health strategies employed by physicians involved in the skin care of people living with albinism. This is because exposed areas of skin typically the face, chest, and extensor surfaces of the arms display the majority of extrinsically aged skin as a result of cumulative effects of life-long UV radiation exposure.Sun protective clothing was used in 31.5% of the albino population. This was quite different from the observation by Samson et al., where 86% of their respondents used sun protective clothing. Like the former, good awareness of the benefit of sun protective measures by their respondents may be the reason for the disparity. Clothing is a very good form of sun protection. Hats are the most important articles of clothing. It should be a wide circumferential brim hat to be able to serve the purpose of good sun protection. The fabric type is not as important as the tightness of the weave. A dry fabric offers more sun protection than a wet fabric. The color of clothing play a small role in sun protection with dark colors offering better protection than light colors.
Information was based on self-reporting (i.e., information was gotten from clients) so verification of their claims was not possible.
Some persons declined participation, since participation was voluntary, despite efforts to resolve these limitations, by assuring participants that the information they gave would be treated as confidential.
Patients in this study had a one-time assessment for photodermatoses. Studying them over a longer period of time would have been better.
| Conclusion|| |
This study showed that photodermatoses are common in people living with albinism, as they are faced with enormous challenges under the equatorial sun. In addition, the poor use of sun protective measures by the albinos would have contributed to sun-induced morbidities in them.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]