The characteristics of dermatology inpatients seen at the quaternary Inkosi Albert Luthuli Central Hospital in Durban, South Africa, over a 5-year period - 2015 - 2020.

BACKGROUND: In recent years, dermatology has been offered as an outpatient service, with decreasing inpatient dermatology admissions. However, dermatology consultation services have remained active, offering care to patients admitted for non-cutaneous indications by other specialties. OBJECTIVES: To describe the clinical spectrum and characteristics of inpatient dermatology diseases managed at a quaternary South African (SA) hospital. METHODS: We retrospectively reviewed and analysed electronic records of all dermatology inpatients managed by dermatologists from 2015 to 2020 at Inkosi Albert Luthuli Central Hospital (IALCH) in Durban, South Africa. Demographic and clinical data on the International Classification of Diseases (ICD) 10 dermatology diagnosis and admitting specialty were collected and analysed. RESULTS: A total of 4 867 patients were managed by the IALCH dermatology service during the study period. Females accounted for 2 527 (51.9%), while black African, coloured, Indian/Asian, white and unclassified patients constituted 3 146 (64.6%), 106 (2.2%), 1 129 (23.2%), 431 (8.9%) and 55 (1.1%), respectively. The median (interquartile range) age of the study population was 42.0 (28.0 - 58.0) years. Of 867 patients, 183 (3.8%) were dermatology inpatient admissions, whereas the remainder, 4 684 (96.2%), were seen as consults from other specialties. Most (1 010 (20.7%)) of the dermatology consults were received from plastic and reconstructive surgeons, while bacterial infections, decubitus ulcers and lower limb ulcers were the three most common referred diagnoses overall. CONCLUSION: A broad range of diagnoses is managed through the dermatology inpatient service, particularly as consultations. These services remain essential in the holistic management of patients.

A descriptive study of the spectrum of dermatological surgery services provided by the University of KwaZulu-Natal Department of Dermatology at Inkosi Albert Luthuli Central Hospital.

A descriptive study of the spectrum of dermatological surgery services provided by the University of KwaZulu-Natal Department of Dermatology at Inkosi Albert Luthuli Central Hospital.

Introducing an Ethics Framework for health priority-setting in South Africa on the path to universal health coverage.

BACKGROUND: South Africa (SA) has embarked on a process to implement universal health coverage (UHC) funded by National Health Insurance (NHI). The 2019 NHI Bill proposes creation of a health technology assessment (HTA) body to inform decisions about which interventions NHI funds will cover under UHC. In practice, HTA often relies mainly on economic evaluations of cost-effectiveness and budget impact, with less attention to the systematic, specific consideration of important social, organisational and ethical impacts of the health technology in question. In this context, the South African Values and Ethics for Universal Health Coverage (SAVE-UHC) research project recognised an opportunity to help shape the health priority-setting process by providing a way to take account of multiple, ethically relevant considerations that reflect SA values. The SAVE-UHC Research Team developed and tested an SA-specific Ethics Framework for HTA assessment and analysis. OBJECTIVES: To develop and test an Ethics Framework for use in the SA context for health priority-setting. METHODS: The Framework was developed iteratively by the authors and a multidisciplinary panel (18 participants) over a period of 18 months, using the principles outlined in the 2015 NHI White Paper as a starting point. The provisional Ethics Framework was then tested with multi-stakeholder simulated appraisal committees (SACs) in three provinces. The membership of each SAC roughly reflected the composition of a potential SA HTA committee. The deliberations and dedicated focus group discussions after each SAC meeting were recorded, analysed and used to refine the Framework, which was presented to the Working Group for review, comment and final approval. RESULTS: This article describes the 12 domains of the Framework. The first four (Burden of the Health Condition, Expected Health Benefits and Harms, Cost-Effectiveness Analysis, and Budget Impact) are commonly used in HTA assessments, and a further eight cover the other ethical domains. These are Equity, Respect and Dignity, Impacts on Personal Financial Situation, Forming and Maintaining Important Personal Relationships, Ease of Suffering, Impact on Safety and Security, Solidarity and Social Cohesion, and Systems Factors and Constraints. In each domain are questions and prompts to enable use of the Framework by both analysts and assessors. Issues that arose, such as weighting of the domains and the availability of SA evidence, were discussed by the SACs. CONCLUSIONS: The Ethics Framework is intended for use in priority-setting within an HTA process. The Framework was well accepted by a diverse group of stakeholders. The final version will be a useful tool not only for HTA and other priority-setting processes in SA, but also for future efforts to create HTA methods in SA and elsewhere.

Waterborne outbreak of gastroenteritis on the KwaZulu-Natal Coast, South Africa, December 2016/January 2017.

An unexpected increase in gastroenteritis cases was reported by healthcare workers on the KwaZulu-Natal Coast, South Africa, January 2017 with >600 cases seen over a 3-week period. A case-control study was conducted to identify the source and risk factors associated with the outbreak so as to recommend control and prevention measures. Record review identified cases and controls and structured-telephonic interviews were conducted to obtain exposure history. Stool specimens were collected from 20 cases along with environmental samples and both screened for enteric pathogens. A total of 126 cases and 62 controls were included in the analysis. The odds of developing gastroenteritis were 6.0 times greater among holiday makers than residents (95% confidence interval (CI) 2.0-17.7). Swimming in the lagoon increased the odds of developing gastroenteritis by 3.3 times (95% CI 1.06-10.38). Lagoon water samples tested positive for norovirus (NoV) GI.6, GII.3 and GII.6, astrovirus and rotavirus. Eleven (55%) stool specimens were positive for NoV with eight genotyped as GI.1 (n = 2), GI.5 (n = 3), GI.6 (n = 2), and GI.7 (n = 1). A reported sewage contamination event impacting the lagoon was the likely source with person-to-person spread perpetuating the outbreak. Restriction to swimming in the lagoon was apparently ineffective at preventing the outbreak, possibly due to inadequate enforcement, communication and signage strategies.

Acne in South African black adults: A retrospective study in the private sector.

BACKGROUND: Acne vulgaris is the most common skin disorder affecting teenagers and young adults, and is becoming increasingly common in middle-aged women. It affects all skin types and ethnic groups, but dark-skinned individuals are burdened by post-inflammatory hyperpigmentation (PIH) as a sequela. PIH causes distress in acne patients even after the inflammatory lesions have resolved. OBJECTIVE: To describe the characteristics of acne in black South African adults in the private health sector in Durban, KwaZulu-Natal Province. METHODS: A retrospective study of records of patients attending two large private dermatology clinics in central Durban, mainly catering for black patients, was performed. Data were collected for the period January - December 2014. Records with acne as a diagnosis were retrieved and analysed with regard to age, demographics, type and severity of acne, therapy, HIV status and outcomes. RESULTS: Of a total of ~3 000 charts available for the 12-month period, 242 had acne as a diagnosis and were retrieved and analysed. Of these patients, 204 (84.3%) were female and the remainder were male. The mean age was 28.5 years (under-18s were excluded from the study). Inflammatory acne was the most frequently encountered form (58.6%). Fifteen patients (6.2%) were on topical treatment only, and 226 (93.4%) were on topical plus systemic treatment. PIH was the most common sequela (81.0% of patients). CONCLUSIONS: The majority of the patients were young females with inflammatory acne, and PIH was the most common sequela. Early and vigorous treatment of acne may minimise its complications, including those seen mainly in black patients.

Rosacea in black South Africans with skin phototypes V and VI.

Rosacea is a chronic facial dermatosis considered to affect primarily white patients with light phototype skin, and is poorly documented in black patients. The aim of this study was to document the clinical features of rosacea in patients with phototypes V and VI. An 8-year retrospective chart review of patients with a clinical and histological diagnosis of rosacea or acne rosacea was undertaken. Of 6700 patients, 15 (0.2%) had rosacea. All were of African descent with skin phototype V or VI. Mean age was 47 years, and female : male ratio was 14 : 1. Of the 15 patients, 5 (33%) were positive for human immunodeficiency virus; 5 (33%) had used topical steroids to treat the roseacea; 6 (40%) had phototype V and presented with erythema, telangiectasia and erythematous papules, while 9 (60%) had phototype VI skin and presented with skin-coloured papules; and 10 (67%) had histology showing granulomatous rosacea, while 5 (33%) declined a facial skin biopsy. A high index of suspicion is required to diagnose rosacea in black patients as the classic signs of erythema and telangiectasia are difficult to discern.

Topical herbal medicines for atopic eczema: a systematic review of randomized controlled trials.

Despite the availability of medicines with proven efficacy, many patients use complementary or alternative medicines (CAMs) to manage atopic eczema (AE). Due to the lack of objective information on topical CAMs, this systematic review evaluates the current evidence for the efficacy and safety of topical herbal preparations in AE. Using Cochrane systematic review methodology, PubMed, the Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (via EBSCO), MEDLINE (via EBSCO), Proquest Health and Medical Complete, GREAT and CAM-QUEST were searched from inception until June 2014. Bibliographies of retrieved studies were hand searched for further relevant trials. All controlled clinical trials of topical herbal medicines for AE in humans of any age were included regardless of the control intervention or randomization. Only English-language publications were considered. Eight studies met the inclusion criteria. Seven investigated extracts of single plants and one an extract from multiple plants. Only two studies that showed a positive effect were considered to have a low risk of bias across all domains (those of liquorice gel and Hypericum perforatum). In these two, the test product was reported to be superior to placebo. Despite variations in diagnostic criteria and lack of validated tools for outcome assessments in one of these, the promising results may warrant continued research in better-designed studies. No meta-analysis was performed due to heterogeneity in all studies. There is currently insufficient evidence of efficacy for any topical herbal extract in AE. Many studies had methodological flaws and even those showing efficacy were single trials with small patient cohorts.

Primary cutaneous malignancies in the Northern Cape Province of South Africa: A retrospective histopathological review.

BACKGROUND: Excessive sun exposure and a high prevalence of HIV increase skin cancer risk in South Africa (SA). OBJECTIVE: To describe the nature and extent of skin cancers presenting in the public and private health sectors of the Northern Cape Province of SA. METHODS: A retrospective analysis of histologically confirmed new primary cutaneous malignancies from 1 January 2008 to 31 December 2012 was conducted using public and private health sector databases. Types, quantity and distribution of common invasive malignancies by population group, age, gender, anatomical site and health sector were explored. One-year cumulative incidence was calculated and logistic regression models were used to analyse incidence and melanoma thickness trends. RESULTS: A total of 4 270 biopsies (13 cutaneous malignancies) were identified. The commonest was squamous cell carcinoma (SCC), followed by basal cell carcinoma, Kaposi's sarcoma (KS), cutaneous malignant melanoma (CMM) and basosquamous carcinoma, in descending order. The odds of a white male developing SCC increased by 8% each year (odds ratio (OR) 1.08, 95% confidence interval (CI) 1.01 - 1.15; p=0.022), while the odds of a black male developing SCC and KS decreased by 9% (OR 0.91, 95% CI 0.84 - 0.99; p=0.033) and 18% (OR 0.82, 95% CI 0.70 - 0.97; p=0.022), respectively, each year. SCC and CMM were diagnosed at more advanced stages in the public than in the private healthcare sector. CMM is being detected earlier, as indicated by low-stage depth increasing by 72% annually (OR 1.72, 95% CI 1.04 - 3.01; p=0.042). CONCLUSIONS: Results suggest that reported skin cancer patterns are changing. There is a need for further research and equitable appropriation of financial resources and effort towards developing primary skin cancer prevention initiatives in SA.

Cutaneous cytomegalovirus infection on multi dermatomal herpes zoster scars: an isotopic immune response.

As more patients with human immunodeficiency virus (HIV) are surviving, despite severe immune suppression, clinicians are faced with atypical manifestations of both common and uncommon dermatoses. A 30-year-old black South African woman presented with a 10-month history of multiple chronic ulcers appearing on a multidermatomal herpes zoster (HZ) scar. The woman was infected with HIV, and her CD4 count was 45 cells/µL. Histology and PCR revealed cytomegalovirus (CMV) infection. This case highlights an unusual presentation of cutaneous CMV occurring as an isotopic immune response on a pre-existing multidermatomal HZ scar.

An evaluation of the early effects of a combination antiretroviral therapy programme on the management of AIDS-associated Kaposi's sarcoma in KwaZulu-Natal, South Africa.

Roll-out of combination antiretroviral therapy (cART) in South Africa should impact on AIDS-associated Kaposi's sarcoma (KS). Government provision began in 2003, with 23% coverage for World Health Organization (WHO) stage IV AIDS in 2006. To assess the effect of cART availability on KS management, we evaluated records from 701 KS patients seen at a tertiary oncology centre in KwaZulu-Natal, South Africa, from 1995 to 2006. Associations between cART use and measures of KS care were evaluated. cART availability was 0% prior to 2001, 9.6% (2001-2003) and 44% (2004-2006). Documentation of HIV status increased incrementally from 65% to 92%. cART was associated with chemotherapy administration: 56% on cART versus 17% not on cART (P < 0.001); and less loss to follow-up, 13% on cART versus 38% not on cART (P < 0.001). cART availability improves the care of AIDS-associated KS. Further increases in cART availability for this population are needed in South Africa.

A population-based study of how children are exposed to saliva in KwaZulu-Natal Province, South Africa: implications for the spread of saliva-borne pathogens to children.

OBJECTIVES: In sub-Saharan Africa, many viral infections, including Epstein-Barr virus, cytomegalovirus, Kaposi's sarcoma-associated herpesvirus and hepatitis B are acquired in childhood. While saliva is an important transmission conduit for these viruses, little is known about how saliva is passed to African children. We endeavoured to identify the range and determinants of acts by which African children are exposed to saliva. METHODS: To identify the range of acts by which African children are exposed to saliva, we conducted focus groups, semi-structured interviews and participant observations in an urban and a rural community in South Africa. To measure the prevalence and determinants of the identified acts, we administered a questionnaire to a population-based sample of caregivers. RESULTS: We identified 12 caregiving practices that expose a child's oral-respiratory mucosa, cutaneous surfaces or anal-rectal mucosa to saliva. Several acts were heretofore not described in the contemporary literature (e.g., caregiver inserting finger lubricated with saliva into child's rectum to relieve constipation). Among 896 participants in the population-based survey, many of the acts were commonly practised by all respondent types (mothers, fathers, grandmothers and siblings). The most common were premastication of food, sharing sweets and premastication of medicinal plants that are spit onto a child's body. CONCLUSIONS: African children are exposed to saliva through a variety of acts, practised by a variety of caregivers, with no single predominant practice. This diversity poses challenges for epidemiologic work seeking to identify specific saliva-passing practices that transmit viruses. Most acts could be replaced by other actions and are theoretically preventable.

Corticosteroid/cyclophosphamide pulse treatment in South African patients with pemphigus.

BACKGROUND: Treatment of pemphigus remains a challenge. Corticosteroid/cyclo-phosphamide pulse treatment has been used to reduce the morbidity associated with long-term treatment with high-dose corticosteroids. We describe our experience with pulse treatment in South African patients with pemphigus. OBJECTIVES: To assess, in patients who achieved remission of pemphigus, the number of pulses, time and total amounts of steroid and cyclophosphamide required to achieve remission of pemphigus, any side-effects and the long-term outcome. METHODS: Patient charts were reviewed retrospectively. In those who had remission of disease (resolution of cutaneous lesions and no new mucosal lesions), details of medication were analysed. The relationships between medication, disease severity, type of disease and patient demographics were investigated. RESULTS: Of the 70 patients, 35 achieved remission as defined in the study criteria; 43% of them with < 6 treatment pulses. Neither the type nor severity of pemphigus correlated with the number of treatment pulses or time to remission. However, 73% of patients who presented with severe disease did receive additional oral corticosteroids between treatment pulses. Lymphopenia occurred in 80% of patients, who needed more treatment pulses (P = 0.002) and thus larger total amounts of oral (P = 0.006) and intravenous (P = 0.02) cyclophosphamide to eventually achieve remission. Of the 35 patients who achieved remission, 94% remained in remission, although seven patients required retreatment to achieve this. CONCLUSIONS: Pulse treatment in our setting was associated with minimal morbidity. In the nine patients who relapsed, the regimen was not strictly followed, emphasizing the importance of compliance. Our use of low-dose oral corticosteroids between treatment pulses, early in the management of poorly controlled patients, supports the current modified recommendation of Pasricha.

Kaposi's sarcoma in sub-Saharan Africa: a current perspective.

PURPOSE OF REVIEW: The aim of this review is to summarize the most recent published literature on HIV/AIDS Kaposi's sarcoma in sub-Saharan Africa (SSA). We attempted to update readers on the epidemiology of Kaposi's sarcoma herpesvirus infection and HIV Kaposi's sarcoma in SSA, as well as clinical features, therapy and immune reconstitution inflammatory syndrome associated with HIV Kaposi's sarcoma. RECENT FINDINGS: Seroprevalence rates of Kaposi's sarcoma herpesvirus differ across SSA; it is low in South African children as compared to endemic areas like Uganda. The major route of transmission in SSA is horizontal rather than sexual. The incidence of Kaposi's sarcoma has increased exponentially with the HIV/AIDS pandemic with a shift in trend demonstrating a dramatic increase in females and occurrence in younger individuals. Kaposi's sarcoma specific therapy is underutilized due to poor access to highly active antiretroviral therapy and financial constraints in SSA. As highly active antiretroviral therapy becomes available, clinicians treating HIV/AIDS in SSA need to have a high index of suspicion of Kaposi's sarcoma immune reconstitution inflammatory syndrome events. SUMMARY: Kaposi's sarcoma is a public health concern in SSA. More studies appropriate to therapy for Kaposi's sarcoma in resource-poor environments like SSA are imperative. We are hopeful that with the increased availability of highly active antiretroviral therapy, the incidence of HIV Kaposi's sarcoma will decrease and management will improve, as it has in the West.

Increasing incidence of Kaposi's sarcoma in black South Africans in KwaZulu-Natal, South Africa (1983-2006).

The aim of the study was to describe the temporal trends in the incidence of Kaposi's sarcoma (KS) in black South Africans in KwaZulu-Natal (KZN). The study was designed as a retrospective record review. The incidence of Kaposi's sarcoma was estimated using administrative records for patients receiving care for KS through public sector oncology clinics in KZN, 1983-2006. Annual age-standardized incidence rates were calculated using provincial census data for the denominator. Age-specific rates were calculated for the pre-AIDS (1983-1989) and for the generalized AIDS epidemic eras (2006). Age-standardized incidence of KS increased in KZN from <1:100,000 in 1990 to at least 15:100,000 in 2006; this increase was observed in both men and women. There was a shift in the peak age-specific incidence rates from the sixth decade of life in the pre-AIDS era to the fourth and fifth decades in the AIDS era. In conclusion, KS is a growing public health problem in KZN, South Africa. These data reinforce the need for comprehensive national access to and roll-out of antiretroviral drugs, given their success in prevention and treatment of KS in first-world settings.

Characteristics of HIV-1-associated Kaposi's sarcoma among women and men in South Africa.

Despite the increase of HIV-1-associated Kaposi's sarcoma (KS), little is known about HIV-associated KS in the African setting, particularly among women. A descriptive study of the demographic, clinical, immunological and virological features of AIDS-associated KS from KwaZulu-Natal, South Africa was undertaken. Consecutively, recruited patients were clinically staged; CD4/CD8 cell counts, HIV-1 viral loads and clinical parameters were evaluated. Of the 152 patients (77 male and 75 female) 99% were black. Females were significantly younger (P = 0.02) and had poorer disease prognosis (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.4-5.4, P = 0.003) and were more likely to have extensive cutaneous KS when compared with males (OR = 3.1, 95% CI = 1.4-6.7, P = 0.003). One-third of patients had coexisting HIV-related disease, most commonly tuberculosis, and these were more frequent in females (56.7 vs. 43.3%). In conclusion, HIV-associated KS in South Africans has an equal female-to-male ratio. Females are younger and have more severe disease than males.