GRF 2nd One Health Summit 2013: Presentation by Peter Schmid-Grendelmeier, Allergy Unit Dept. Of Dermatology University Hospital Zuerich Switzerland

1. Allergic skin diseases
in tropical areas
Peter Schmid-Grendelmeier
Allergy Unit
Dept. Of Dermatology
University Hospital
Zuerich
Switzerland

2. Dept. Of Dermatology
University Hospital
Zuerich
Switzerland

3. RDTC

4. UGANDA
KENYA
KCMC
RWANDA
BURUNDI
Moshi
Moshi
TANZANIA
Pemba
Dar es Salaam
DCR
AA I
ML W
ZAMBIA

5. Regional Dermatology Training Centre
Training programm for „Dermatology officers“
from 14 Nations from East/Southern Africa
(Commonwealth)
2-years long Curriculum:
Dermatology
STI / HIV
Leprosy
Public Health
Teaching methods

6. Atopic dermatitis in
Zuerich,
SWitzerland
Atopic dermatitis in
Kilombero Region,
Tanzania

7. What about
Atopic dermatitis in
Cape Region
South Africa
?

8. Validation of the U.K. diagnostic criteria for atopic eczema in a
Xhosa speaking South-African population
Charmers DA et al Brit J Dermatol 2007
Brit J Dermatol 2007
Validity of the full question-based version of the U.K. diagnostic criteria
Sensitivity 43.7% (95% CI 26.3-62.3)
Specificity 97.9% (97.3-98.4)
PPV 18.4% (95% CI 10.4-28.9)
NPV 99.4% (95% CI 99.0-99.6)
Visible flexural eczema alone
Sensitivity 81.2% (95% CI 63.5-92.7)
Validation of ISAAC and
the U.K. diagnostic criteria for atopic
Specificity 99.0% (95% CI 98.6-99.3),
dermatitis in Ethiopian children
PPV 48.1% (95% CI 34.3-62.1)
Haileamlak A et al. Brit J Dermatol 2005
NPV 99.8% (95% CI 99.5-99.9)

9. Validation of the U.K. diagnostic criteria for atopic eczema in a
Xhosa speaking South-African population
Charmers DA et al Brit J Dermatol 2007
Brit J Dermatol 2007
Validity of the full question-based version of the U.K. diagnostic criteria
Sensitivity 43.7% (95% CI 26.3-62.3)
Specificity 97.9% (97.3-98.4)
PPV 18.4% (95% CI 10.4-28.9)
NPV 99.4% (95% CI 99.0-99.6)
Visible flexural eczema alone
Sensitivity 81.2% (95% CI 63.5-92.7)
Specificity 99.0% (95% CI 98.6-99.3),
PPV 48.1% (95% CI 34.3-62.1)
NPV 99.8% (95% CI 99.5-99.9)

10. Validation of the U.K. diagnostic criteria for atopic eczema in a
Flexural population
Xhosa speaking South-Africaneczema
as
Charmers DA et al Brit J Dermatol 2007 the
Brit J Dermatol 2007
key diagnostic
Feature
Of
Atopic
Eczema

11. Additional discriminating clinical features in AD
19 (11.1%)
White demographism
0
Facial erythema
0
23 (15.5%)
52 (30.4%)
Infraorbital folds
10 (6.9%)
Hertoghe's sign
36
4 (2.8%)
33 (19.3%)
Periorbital darkening
2 (1.4%)
Dry skin
133 (77.8%)
11 (7.6%)
56 (32.7%)
Palmar hyperlinearity
16 (11.4%)
Retroauricular intertrigo*
Nummular eczema*
30 (17.5%)
2 (1.4%)
3 (2.1%)
21 (12.3%)
43 (25.1%)
Pytiriasis alba*
11 (7.6%)
38 (22.2%)
Napkin rash*
1 (0.7%)
Papular lichenoid lesions*
0
93 (54.4%)
11 (7.6%)
20
* minor criteria
40
60
Non AD (644pers.)
80
100
With AD (771pts.)
,
KSasagawa-Tagahashi-type
Masenga J et al)
120
140

12. Additional discriminating clinical features in AD
19 (11.1%)
White demographism
0
Facial erythema
0
23 (15.5%)
52 (30.4%)
Infraorbital folds
10 (6.9%)
Hertoghe's sign
36
4 (2.8%)
Dry skin
Palmar
hyperlinearitiy
33 (19.3%)
Periorbital darkening
2 (1.4%)
Dry skin
133 (77.8%)
11 (7.6%)
56 (32.7%)
Palmar hyperlinearity
16 (11.4%)
Retroauricular intertrigo*
Nummular eczema*
30 (17.5%)
2 (1.4%)
3 (2.1%)
21 (12.3%)
Papular
lichenoid
lesions*
43 (25.1%)
Pytiriasis alba*
11 (7.6%)
38 (22.2%)
Napkin rash*
1 (0.7%)
Papular lichenoid lesions*
0
93 (54.4%)
11 (7.6%)
20
* minor criteria
40
60
Non AD (644pers.)
80
100
With AD (771pts.)
,
KSasagawa-Tagahashi-type
Masenga J et al
120
140

13. Papular lichenoid lesions

14. Palmar hyperlinearity

15. Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

16. Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

17. Worldwide Variation of Asthma, allergic rhinitis and
atopic dermatitis
ISAAC Study, Lancet 1998

18. Prevalence of AD in childhood in SubSaharan Africa
Study
Nation
Yemaneberhan H Ethiopia
Number
Prevalence
Source
12876
3.1 %
Clin Exp Allergy 2004
Nornuka EN
Nigeria
1026
8.5 %
Int J Dermatol 2004
Oguunyi I et al
Nigeria
1048
absent
Ped Dermatol 2005
Sibanda EN
Simbabwe
12042
6.9%
Int Arch Allergy Immunol 2004
Mercer MJ
South Africa
4947
11.9 %
Pediat Allergy Immunol
RDTC
Tanzania
3427
4.9 %
in prep
RDTC
Zambia
185
8.61 %
in prep
RDTC
Swaziland
350
9.14 %
in prep

20. Prevalence of AD has increased between ISAAC I and II

21. Prevalence of AD has increased between ISAAC I and II

22. Brit J Dermatol 2005; 152: 202

23. Brit J Dermatol 2005; 152: 202

24. Hygiene hypothesis dos not fit for atopic eczema
Infections may worsen AE
Early antibiotic intervention may worsen AE
Brit J Dermatol 2005; 152: 202

25. 306 children with AD; prevalnece 4.4 %
426 controls
aged
in Jimma, Southwest Ethiopa
J Allergy Clin Immunol 2005;115:370

26. J Allergy Clin Immunol 2005;115:370

27. J Allergy Clin Immunol 2005;115:370

28. Askaris
J Allergy Clin Immunol 2005;115:370

29. Associated factors with AD in SubSaharan Africa
Associated with
asthma and wheezing
positive SPT
parasite infestation (Trichuris)
urbanization
De Souza East Arican Med J 1992
Haileamlak A J Allergy Clin Immunol 2005
South african childhood atopic eczema working group South African Med J 2005
Dinkela A et al Int J Dermatol 2007

31. Staphylococci in AD
Increased skin permeability
Upregulation of IL-31
Increased expression of CLA

32. Staphylococci in AD
Increased skin permeability
Prolongation and Upregulation of IL-31
worsening of AD

33. Staphylococci in AD
Increased skin permeability
Prolongation and Upregulation of IL-31
worsening of AD
Sepsis and
Death

34. Atopic dermatitis in
Zuerich,
SWitzerland
Atopic dermatitis in
Kilombero Region,
Tanzania
Infectious agents
play an important role
In AD
- direct effects
- Senstizitation
- for therapeutic approach

35. What about
Atopic dermatitis in
Cape Region
South Africa
?

36. Xhosa speaking population in South Africa
With atopic eczema
72 patients with atopic eczema
(found in 3069 participants)
Mean age 17.8 years (12-51 years
Female: Male 52.4 : 47.6
Fatema Esmail
Gail Todd
Dept of Dermatology
Groote Schur Hospital

37. Pollen measurement in Tanzania / South Africa
Goal of the study:
Unknown data
Climate changes in Africa
ISAAC Questionaire Hard data

38. Xhosa speaking population in South Africa
Goal of the study:
What are the
sensitization patterns
In AD patients
?

39. Xhosa speaking population in South Africa
With atopic eczema
Sensitization patterns in Atopic Eczema
72 patients with atopic eczema
(found in 3069 participants)
Mean age 17.8 years (12-51 years
Female: Male 52.4 : 47.6

40. Xhosa speaking population in South Africa
With atopic eczema
Sensitization patterns in Atopic Eczema
72 patients with atopic eczema
Mean age 17.8 years (12-51 years
Female: Male 52.4 : 47.6
Mean Total Serum IgE:
7284.3 kU/l

41. Xhosa speaking population in South Africa
With atopic eczema
Sensitization patterns in Atopic Eczema
72 patients with atopic eczema
(found in 3069 participants)
Mean age 17.8 years (12-51 years
Female: Male 52.4 : 47.6
Mean Total Serum IgE:
7284.3 kU/l
(2 - > 5000 kU/L)
(max 31‘000 kU/l)

42. Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC
35
30
25
20
15
10
5
31.4
29.5
26.4
21.3
3.45
3.25
3.12
3.09
1.7
1.39
1.27
0.91
0.82
17
0.56
0.53
0.32
0.32
0.3
0.28
4.55
2.22
3.07
0
1.44
1.04
0.99
0.66
0.89
0
14.8
0.4612.3
0.25
0
0.65
0
0.78
0.92
2.07
0
0.82
0.7
0
0.74
0.99
0.36
0.57
0
0
0
5.8
0.25
8.3
4.58
3.55
3.54
0
2.01
1.82
0.7
1.14
0.79
0
0.55
11.7
0
0
0.96
0
0
Der p Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bos b Gal d Pen a
1
1,2, 4
1-3
1
3.6
2.72
3.29
0
2.12
2.36
0.98
1.57
1.35
0
0.81
0.4
0.5
1.14
0.34

43. Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC
35
30
25
31.4
29.5
26.4
21.3
20
15
10
5
3.45
3.25
3.12
3.09
1.7
1.39
1.27
0.91
0.82
17
0.56
0.53
0.32
0.32
0.3
0.28
4.55
2.22
3.07
0
1.44
1.04
0.99
0.66
0.89
0
14.8
0.4612.3
0.25
0
0.65
0
0.78
0.92
2.07
0
0.82
0.7
0
0.74
0.99
0.36
0.57
0
0
0
5.8
0.25
8.3
4.58
3.55
3.54
0
2.01
1.82
0.7
1.14
0.79
0
0.55
11.7
0
0
0.96
0
0
Der p Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bos b Gal d Pen a
1
1,2, 4
1-3
1
House dust mites Cockroaches
Grass pollen
Cat
3.6
2.72
3.29
0
2.12
2.36
0.98
1.57
1.35
0
0.81
0.4
0.5
1.14
0.34

44. Xhosa speaking population in South Africa
With atopic eczema
Specific IgE by ISAC
35
30
25
31.4
29.5
26.4
21.3
20
15
10
5
3.45
3.25
3.12
3.09
1.7
1.39
1.27
0.91
0.82
17
0.56
0.53
0.32
0.32
0.3
0.28
4.55
2.22
3.07
0
1.44
1.04
0.99
0.66
0.89
0
14.8
0.4612.3
0.25
0
0.65
0
0.78
0.92
2.07
0
0.82
0.7
0
0.74
0.99
0.36
0.57
0
0
0
5.8
0.25
8.3
4.58
3.55
3.54
0
2.01
1.82
0.7
1.14
0.79
0
0.55
11.7
0
0
0.96
0
0
Der p Der f 1 Bla g 2 Bla g 5 Phl p 1 Ph l 5 Fel d 1 Bos b Gal d Pen a
1
1,2, 4
1-3
1
House dust mites Cockroaches
Grass pollen
Cat
Milk
Egg
Tropo
myosin
3.6
2.72
3.29
0
2.12
2.36
0.98
1.57
1.35
0
0.81
0.4
0.5
1.14
0.34

45. Tropomyosin
Crossallergy
Anisakis
Mites
Cockroachs
Seafood

46. Reasons of foot dermatitis

47. Reasons of foot dermatitis

48. Reasons of foot dermatitis

49. Reasons of foot dermatitis

50. Contact allergy to Thiuram Mix

51. „Patch test series in 158 patients
at the RDTC inTanzania
1. Nickel Sulfate
2. Thiuram Mix
3. Mercapto Mix
4. Wood mix
5. p-Phenylendiamin PPDA
6. PPD-Mix
7. Potassium dichromat
8. Fragrance -Mix
9. Balsam of Peru
10. Cobalt chloride
11. Colophony
12. Thiomersal
13. Neomycine sulfate
Entemesi et al J int Dermatol (in press)

52. 27-years female

53. 27-years female
Contact allergy
to
Colonphony senitization

54. Travel souvenirs

55. Travel souvenirs
Henna-Tattoo
Lawsonia insermis L.

56. le
Contact allergy to
Henna-Tattoo
(due to
Para-phenylen-Diamin PPD)
Blair J, Brodell RT, Nedorost ST.
Postgrad Med. 2004

57. le
Contact allergy to
Henna-Tattoo
(due to
Para-phenylen-Diamin PPD)
Blair J, Brodell RT, Nedorost ST.
Postgrad Med. 2004

58. Contact allergy
to
PPDA senitization

59. TEN due Trimethoprim

61. Dr. Shiang-Ju, the local host and Dr Philippe Eigenmann, Organizer,
opening the meeting

62. More than 200 highly interested doctors listening in Gabarone

63. Proff. Antonella Murano and Adnan Custovic
with the president of AllSA

64. The faculty at AllSA meeting in South Africa

65. T
H
A
N
K
Y
OU

66. H
T
A
N
K
Y
OU
Dept of Dermatology
Groote Schur Hospital
SNF
GA2LEN
Ulrich-Müller-Foundation
Fatema Esmail
Gail Todd
Allergy unit
Zuerich
Barbra Fischer
Susanne Haug
Nada Juricevic
Antonie Roll
Brunello Wüthrich
Günter Burg
Swiss Institute of
Allergy Research
SIAF, Davos
Sabine Zeller
Beate Rückert
Reto Crameri
Axel Trautmann
Cezmi Akdis
Kurt Blaser
Regional Dermatology
Hospital, Ifakara,
Training Centre
Tanzania
Moshi, Tanzania
St Francis Disctrict
Swiss Tropcial
Institute Basel
Almuth Dinklea
Julia Ferie
Christop Hatz
Elisante Masenga
Henning Grossmann

67. 14. International CME for
Dermatology and STI in the tropics
12.-14. January 2010
RDTC Moshi, Tanzania

68. 14. International CME for
Dermatology and STI in the tropics
12.-14. January 2014
RDTC Moshi, Tanzania