Is enough dermatology training given to primary health physicians?

Large numbers of patients with minor skin ailments are being referred by primary health physicians to skin clinics with little attempt at diagnosing and treating these cases. This study evaluated whether primary health physicians were exposed to enough dermatology in their training to diagnose and treat simple dermatoses. In this retrospective cross-sectional survey the diagnosis, treatment, source of referral of all patients seen between January and June 1997 in two health centres in East Trinidad, Sangre Grande (SG) and Arima (A), were reviewed. There werer 146 registered patients at Sangre Grande and 189 at Arima. The commonest skin disorder was eczema (SG 37 percent, A 38 percent). The ability to diagnose this condition was 25 percent in Arima and 7 percent in Sangre Grande. Atopic exzema was the commonest in childhood (A 16 percent, SG 13 percent). Fungal infections, which included tinea corpois (A 8 percent, SG 7 percent) and tinea capitis ( A 15 percent, SG 8 percent), were the next most common dermatoses seen. The diagnostic ability for tinea corpois was: A 13 percent SG 0 percent; but there was a higher diagnostic index for tinea capitis (A 52 percent, SG 50 percent). Psoriasis (A 21 percent, SG 7 percent), like tinea capitis, had a diagnosis index of 50 percent. The most common referring diagnosis was skin rash (43 percent, SG 45 percent) or fungal rash (A 38 percent, SG 36 percent). There were significant differences in gender (P <0.05) and ethnicity (P<0.001) in Arima. In conclusion, the commonest dermatoses seen in both centres, were the eczemas, fungal infections and psoriasis. Diagnostic ability was low for the eczemas and tinea corporis, the commonest skin disorders, but better for tinea capitis and psoriasis. Increase referrals fof common skin disorders leads to overcrowding, decreasing the time for the dermatologist to do procedures, to teach and to give earlier and more frequent appointments to needy patients. Cost of treatment of patients and to Government is lower when the diagnosis is made on the initial visit, and loss of school days for tinea capitis can be decreased by prompt and effective treatment.(AU)

Primary idiopathic cutaneous amyloidosis: can coconut oil be a contributing factor? - abstract

Twenty patients who presented clinically with either macular or lichen amyloidosis at clinics at the Port of Spain General Hospital or the St. Joseph Health Centre had skin biopsies done. Two control groups of male and female patients were randomly selected. They presented with other unrelated skin conditions and either used coconut oil only occasionally or used other types of oil. Skin biopsies were stained with haematoxylin and eosin and congo red/methyl violet. The study group were all female Indo-Trinidadians who had daily applied coconut oil to the arms, legs and hair for an average period of 31 years (range 4 months - 40 years). In 15 patients, there was histological confirmation of amyloid. Seven patients had at least 1 family member with a similar skin condition. Papular and macular skin lesions were seen on the anterior aspect of the leg and the extensor aspect of the arm and scapular region. It is proposed that the common practice among female Indo-Trinidadians of daily application of coconut oil to arms, legs and hair is a risk factor in the development of primary cutaneous amyloidosis and that genetic and familial factors are also involved in this condition (AU)

Cutaneous histoplasmosis in the acquired immune deficiency syndrome: a report of three cases from Trinidad

Three cases are reported of patients with the acquired immune deficiency syndrome (AIDS) and cutaneous histoplasmosis. Their initial presentation was that of a generalised malculopapular rash. Two patients were bisexual males and the third was an unmarried female. The range of opportunistic infections seen in AIDS patients in Trinidad is mentioned and clinicians are alerted to the fact that in areas endemic for histoplasma capsulatum maculopapular rash in patients with AIDS may suggest disseminated histoplasmosis. The value of skin biopsy is mentioned. (AU)

Skin biopsy and cutaneous histoplasmosis in the acquired immune deficiency syndrome in Trinidad - abstract

Eighteen patients with the acquired-immunodeficiency syndrome (AIDS) presented with primary skin manifestations at the Port-of-Spain General Hospital in 1986. The lesions included local (3) and generalised (4) dermatitis, pustules, plaques (2), crateriform ulcers (2), erythematous lesions (4) and maculo-papular rashes (7). Some patients had a mixture of lesions. The maculo-papular rashes were commonest. Full-thickness skin biopsies were stained with periodic acid-Schiff and methamanine silver; yeast forms of Histoplasma capsulatum were found in 11 cases. Three of these cases had a post-mortem examination; this revealed the presence of the fungus in all the tissues sampled which included brain, liver, spleen and lymph nodes. The skin lesions were the only presenting clinical manifestations of disseminated histoplasmosis in these patients. Histoplasmosis capsulatum is endemic in Trinidad and Tobago but clinical infection was extremely rare before the advent of the AIDS epidemic. In areas endemic for H. capsulatum, clinicians should be alerted to the fact that cutaneous lesions in patients with AIDS may suggest histoplasmosis. Given the facts that cultures may be negative and unnecessarily delay treatment, that the histoplasmin skin test is of doubtful value and that serological titres are unreliable in the immunocompromised, we advocate full-thickness skin biopsy to diagnose histoplasmosis in AIDS patients (AU)

Behcet's syndrome with unusual manifestations

A patient with two uncommon manifestations of Behcet's Syndrome, oesophageal ulceration, and glomerular disease is presented. In both systems, as in all others affected by Behcet's Syndrome, there was vasculitis principally involving veins, venules, and capillaries. Response to conventional management was not successful. (AU)

Immunopathological studies in a mixture of pemphigus and pemphigoid - abstract

This is the first report from the Commonwealth Caribbean of a mixture of two rare forms of vesiculobullous diseases. A mixture of both bullous pemphigoid and pemphigus vulgaris was present in a 61 year-old East Indian man. He presented at the Dermatology Clinic of the Port-of-Spain Hospital with vesiculobullous lesions of both the tense and flaccid types extending throughout his trunk, limbs and face. Skin biopsies showed both immunoglobulin and complement at the intercellular spaces of the epidermis of the flaccid bulla and at the basement membrane zone (BMZ) from the tense bulla supporting the existence of both pemphigus and pemphigoid but the fourth confirmed the above findings. This patient gave a favourable clinical response to corticosteroid therapy with the disappearance of pemphigus antibodies but the anti-BMZ antibodies (typical of pemphigoid) persisted, as expected. It is clear from these findings that immunopathological investigations are not only essential in the early diagnosis of these rare bullous forms but also in prognosis (AU)

Characterisation of mixed connective tissue disease - abstract

Of sixteen patients with MCTD, 10 62 percent) presented with the clinical features of systemic lupus erythematosus (SLE) and 6 (37 percent) with SLE-scleroderma. Ninety-four per cent had a speckled antinuclear factor pattern and 100 percent had IgG deposits in a speckled pattern within the epidermal cell nuclei of the skin. Seventy per cent of these patients had nRNP antibodies. These characteristics are more typical of the mixed connective tissue syndrome than of SLE or scleroderma. The low incidence of Raynaud's phenomenon in our group of patients (18 percent) with MCTD is probably due to the tropical climate. The IgM deposits in the skin of a significant number (67 percent) of the patients with the clinical picture of SLE-scleroderma probably represent an early stage in the development of the disease. The significance of high serum IgA in the clinically diagnosed SLE group is not understood and is now being further investigated. This study strongly suggests that laboratory investigations are of primary importance in distinguishing MCTD from SLE and other forms of collagen vascular diseases (AU)

Racial and other characteristics of human T cell leukemia/lymphome (HTLV-1) and AIDS (HTLV-111) in Trinidad

Adult T cell leukaemia/lymphoma was first recognised as a clinical entity in southwest Japan. Subsequently the Caribbean has been found to be another area where the disease is endemic, and sporadic cases have been identified in different parts of the world. The human T cell leukaemia/lymphoma virus (HTLV-1) is causally related to adult T cell leukaemia/lymphoma. A sub-group of HTLV, designated HTLV-111, has recently been isolated from many patients with the acquired immunodeficiency syndrome (AIDS) and preAIDS, and there is now evidence that this variant is the primary cause of AIDS. This is the first report from Trinidad to describe twelve cases of adult T cell leukaemia/lymphoma and 14 of AIDS. All were in patients of African descent. No cases were seen in subjects of East Indian descent, who, like those of African descent, comprise as much as 40 percent of the population

Ataxia Telangiectasia: A case report

The case of an eight year old girl with Ataxia Telangiectasia (AT) is described. She presented at seven years of age with gait problems and was found to have the neurological, dermatological and immunological features characteristic of AT along with a history of frequent sino-pulmonary infections. This report highlights the refractory nature of the disease, the difficulties in medical management, and the problems posed by late diagnosis which can comprise patient care. This is a rare inherited form of ataxia which has not been previously reported in West Indian literature. (AU)