Dermatological Symptoms Research Articles

QOL-15. VALIDITY AND RELIABILITY EVALUATION OF PRO-CTCAETM FOR ADULT DIFFUSE GLIOMAS PATIENT IN CHINESE POPULATION. (VERONICA): A PRELIMINARY DELPHI STUDY

Abstract OBJECTIVES Given the increasing importance of patient’s perspective in adverse events reporting, Patient-Reported Outcomes version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE™) has been proposed as new PRO measures in oncology; however, its implementation has not yet been evaluated in glioma patients, and standardized selection process of priority symptom terms has not been applied. METHODS A total of 16 experts (13 neurosurgeons, 2 radiotherapists, 1 psychiatrist) from 14 medical centers in China were invited to participate in a consensus-seeking 2-round online Delphi survey. Participants rated the level of their agreement with each symptom term likely to occur during adult diffuse gliomas treatment on a 5-point Likert scale. Terms not reaching consensus over the first round were modified in the second rounds. Consensus was defined as content validity index (CVI) > 0.78，coefficient of variation (CV)< 0.35 and average Likert score > 3.00. RESULTS Experts reached a consensus on 21 PRO-CTCAE™ symptom terms in the first Delphi round, and 10 terms in the second round. Likert scale scoring among all experts showed significant consistency (Round 1: Kendall’s W= 0.415，p＜0.001; Round 2: Kendall’s W = 0.351，P＜0.001). The 31 terms (38.75%) screened out of all 78 terms covered neurological symptoms(n=7), psychiatric symptoms(n=6), dermatological symptoms(n=6), gastrointestinal symptoms(n=5) and other common postoperative systemic symptoms of glioma patients. CONCLUSIONS We identified a customized PRO-CTCAE™ questionnaire containing a core set of priority symptom terms for the adult diffuse glioma through a 2-round Delphi survey. Next, a prospective, multi-center, real-word study would be performed to assess the validity, reliability and responsiveness of the customized PRO-CTCAE™ for adult diffuse glioma patients in Chinese population (VERONICA).

Cutaneous epitheliotropic T-cell lymphoma in ferrets (Mustela putorius furo): 3 cases (2014–2021)

Background : Tumours are commonly encountered in ferrets and lymphoma is the third most common neoplasm in this species. Cutaneous epitheliotropic lymphoma has rarely been described in ferrets. Materials and methods : Inclusion criteria for ferrets in this study were cutaneous lymphoma diagnosed by histopathologic examination. Data collection from affected ferrets presented at the clinic between January 2014 and March 2021 included signalment, medical history, clinical signs, histopathology and immunohistochemistry results, treatments and clinical outcome when available. Results : Three ferrets met the inclusion criteria. They presented with erythematous and crusted lesions on the foot in ferrets 1 and 2, and multiple erythematous papules over the lumbar region in ferret 3. Epitheliotropic T-cell lymphoma was identified by immunohistochemistry in all cases. Chemotherapy was declined in ferret 1 and a medical treatment based on prednisolone, a skin ointment, and spirulina was initiated. Ferret 2 received lomustine and prednisolone. Ferret 3 received chlorambucil, an isotretinoin skin ointment and prednisolone. In all cases, dermatologic symptoms significantly improved or disappeared after 1 to 3 months. Ferret 1 was lost to follow up after 2 months. Ferret 2 discontinued chemotherapy after 7 months and was humanely euthanised 3 months later after recurrence and worsening of its general condition. Ferret 3 died 3 months after diagnosis from an unknown cause. Conclusion and clinical relevance : This case series describes three cases of cutaneous epitheliotropic T-cell lymphoma, with three different treatment plans and illustrates the importance of considering cutaneous epitheliotropic lymphoma as a differential diagnosis in ferrets with dermatologic symptoms.

RELIABILITY OF BANANA-SPECIFIC IGE TESTING PRIOR TO ORAL FOOD CHALLENGE

<h3>Introduction</h3> Allergy to direct fruit is relatively rare, and when present is commonly associated with fruits such as kiwi and avocado. True IgE-mediated allergy to banana is uncommonly reported in the literature, as is data regarding the reliability of specific IgE testing prior to oral food challenge (OFC). <h3>Methods</h3> Retrospective chart review was performed on six patients with purported banana allergy who underwent banana-specific IgE testing prior to banana OFC. Their charts were reviewed for demographic data, banana-specific IgE testing, total IgE testing, other food allergies, atopic conditions, and banana OFC results. <h3>Results</h3> All six patients were found to have a history of atopic conditions and other food allergies. Two of the six patients failed their OFC, and the remaining four patients passed. The primary symptom(s) reported at initial ingestion was emesis for the patients who failed versus hives/rash and facial swelling for those who passed. Average banana-specific IgE for patients who failed OFC=1.56 (SD:1.12 N=2), patients who passed OFC=3.13 (SD:3.65 N=4), and all patients=2.60 (SD:2.98 N=6). <h3>Conclusion</h3> This study finds that elevated banana-specific IgE is likely not a reliable pre-test predictor for OFC failure. In our study sample, average banana-specific IgE was higher in patients who passed OFC than in those who failed. However, symptomatology may provide better predictive value given that the patients who failed OFC both had emesis with initial banana exposure versus dermatologic symptoms in patients who passed OFC.

Prevalence and Characteristics of Persistent Symptoms in Children During the COVID-19 Pandemic: Evidence From a Household Cohort Study in England and Wales.

Prevalence and Characteristics of Persistent Symptoms in Children During the COVID-19 Pandemic: Evidence From a Household Cohort Study in England and Wales.

Comparative Safety of the BNT162b2 Messenger RNA COVID-19 Vaccine vs Other Approved Vaccines in Children Younger Than 5 Years

SARS-CoV-2 vaccines are authorized for use in most age groups. The safety of SARS-CoV-2 vaccines is unknown in children younger than 5 years. To retrospectively evaluate the safety of the BNT162b2 vaccine used off-label in children younger than 5 years compared with the safety of non-SARS-CoV-2 vaccines in the same sample. This investigator-initiated retrospective cohort study included parents or caregivers who registered children for SARS-CoV-2 vaccination in outpatient care facilities in Germany. The study was performed as an authenticated online survey. A total of 19 000 email addresses were contacted from vaccination registration databases between April 14 and May 9, 2022. Inclusion criteria were child age younger than 5 years at the first BNT162b2 vaccination and use of a correct authentication code to prove invitation. Off-label BNT162b2 vaccination and on-label non-SARS-CoV-2 vaccinations. Reported short-term safety data of 1 to 3 doses of 3 to 10 μg BNT162b2 in children from birth to younger than 60 months are presented. Coprimary outcomes were the frequencies of 11 categories of symptoms after vaccination with bivariate analyses and regression models adjusting for age, sex, weight, and height. The study included 7806 children (median age, 3 years [IQR, 2-4 years]; 3824 [49.0%] female) who were followed up of for a mean (SD) of 91.4 (38.8) days since first BNT162b2 vaccination (survey response rate, 41.1%). A 10-μg dosage was more frequently associated with local injection-site symptoms compared with lower dosages. In the active-comparator analysis, the probability of any symptoms (odds ratio [OR], 1.62; 95% CI, 1.43-1.84), local symptoms (OR, 1.68; 95% CI, 1.38-2.05), musculoskeletal symptoms (OR, 2.55; 95% CI, 1.32-4.94), dermatologic symptoms (OR, 2.18; 95% CI, 10.7-4.45), or otolaryngologic symptoms (OR, 6.37; 95% CI, 1.50-27.09) were modestly elevated after BNT162b2 compared with non-SARS-CoV-2 vaccines, whereas the probabilities of general symptoms (OR, 0.77; 95% CI, 0.63-0.95) and fever (OR, 0.42; 95% CI, 0.32-0.55) were lower after BNT162b2. Symptoms requiring hospitalization (n = 10) were reported only at BNT162b2 dosages above 3 μg. In this cohort study, the symptoms reported after BNT162b2 administration were comparable overall to those for on-label non-SARS-CoV-2 vaccines in this cohort of children younger than 5 years. The present data may be used together with prospective licensure studies of BNT162b2 efficacy and safety and could help guide expert recommendations about BNT162b2 vaccinations in this age group.

S3450 Atypical Endoscopic and Clinical Presentation of Strongyloidiasis

Introduction: Strongyloidiasis is a helminthic parasitic infection caused by the nematode Strongyloides stercoralis. Due to its replication cycle within the human host, acute infection classically presents sequentially with skin irritation, dry cough, and then non-specific gastrointestinal (GI) symptoms. Mild GI and dermatologic symptoms appear to be more prevalent in chronic infections. Here we present a case of strongyloidiasis manifesting in atypical symptoms with normal endoscopic findings. Case Description/Methods: An 81-year-old female with a medical history of diverticulosis, hypertension, type 2 diabetes mellitus, hypercholesterolemia, and chronic kidney disease was admitted to the hospital for anorexia, abdominal pain, and unintentional 26-pound weight loss over 6 months. Computed tomography of chest, abdomen, and pelvis revealed a moderate left-sided pleural effusion and uncomplicated sigmoid diverticulitis. Pleural fluid studies showed exudative features, with negative cultures and cytology. She was started on ciprofloxacin and metronidazole for diverticulitis. The patient also had a chronic iron deficiency anemia with an average hemoglobin of 7.4 g/dL. Absolute eosinophil count, total IgE, sedimentation rate, and c-reactive protein were elevated. Enteroscopy up to the mid jejunum appeared normal except for a 4 cm hiatal hernia. Random duodenal biopsies showed chronic active duodenitis with several eosinophils and parasitic organisms (Figure). Colonoscopy was deferred due to acute diverticulitis. Strongyloides serum antibodies were positive. Stool studies were not analyzed due to lab errors. The patient was treated with oral ivermectin 200 mcg/kg/day for 14 days due to concern for disseminated infection and scheduled for an outpatient endoscopy and colonoscopy. Discussion: This case highlights the need to keep parasitic infections on the differential when patients present with symptoms concerning for malignancy, such as weight loss, anemia, abnormal laboratory markers, and new pleural effusions. While S. stercoralis has been found to mimic inflammatory bowel disease, it has not been associated with diverticulitis thus far. In addition, typical endoscopic findings include edematous and erythematous mucosa with white villi, however, this patient had normal endoscopic findings despite the extent of her infection. The duodenal biopsies aided in making the diagnosis for this case and should be considered in patients with similar presentations.Figure 1.: Duodenal biopsies showing chronic active duodenitis with several eosinophils and parasitic organisms.

Post-COVID-19 Syndrome

Although acute COVID-19 usually lasts for 12 weeks from the onset of symptoms, some patients experience variable persistent symptoms. Post-COVID-19 syndrome is defined as persistent symptoms and/or long-term complications that appear during or after COVID-19, persist for more than 12 weeks, and cannot be explained by an alternative diagnosis. The common symptoms of post-COVID-19 syndrome include general, pulmonary, hematological, cardiovascular, neuropsychiatric, renal, endocrine, gastroenterological, and dermatological symptoms. As the natural course and pathophysiology of COVID-19 are not yet clear, close monitoring is needed for various sequelae in multiple organs that occur in post-COVID-19 syndrome. In particular, patients who have been hospitalized in the intensive care unit or who have recovered from severe COVID-19 require close monitoring for the development of post-COVID-19 syndrome. Multidisciplinary collaboration is essential to provide integrated outpatient care for patients with post-COVID-19 syndrome.

Pharmaceutical Characterization and in vivo Evaluation of the Possible Anti-Inflammatory Effect of Topical Allopurinol Gel in an Animal Model.

Dermatitis, like inflammation, is a group of common dermatological symptoms and may be associated with systemic and skin diseases. The objective of the current study is to evaluate the potential anti-inflammatory effect of the topical allopurinol against inflammation like skin dermatitis induced by1-isobutyl-1H-imidazo [4,5-c]quinolin-4-amine (IQA) in mice model. The current study allocated the thirty-two mice into four groups (n=8) as follows: i) control group, mice where a white petroleum jelly base applied topically on the dorsal of mice once daily; ii) induction group, mice were received IQA cream (62.5 mg) of (5%) on their back once daily; and iii) the treatment group, mice were treated with both (62.5 mg) of (5%) IQA and (5%) allopurinol gel topically; the betamethasone group, mice were treated with both (62.5 mg) of (5%) IQA and betamethasone ointment topically. All groups were treated daily for seven days period. The allopurinol-treated group exerted non-significant differences compared with the induction group in both visional and histopathological changes. The present study revealed that the allopurinolgel (5%) did not affect skin inflammation- induced by IQA in the laboratory mice.

Somatization in dermatology.

Medically unexplained dermatologic symptoms, such as pruritus, numbness and burning are known as somatization. These cutaneous symptoms can be very difficult to treat because of an absence of an objective explanation and they may not fit neatly into any known dermatological or psychiatric condition. These disorders are more commonly encountered in primary care and in dermatology, rather than in psychiatry. Certain skin disorders, for example, pruritus, could be a manifestation of somatization and others may predispose to somatic symptoms, for example, atopic dermatitis and psoriasis. Although there has been increasing research in the interconnection between psychiatry and dermatology, psychodermatology is a relatively new crossover discipline in clinical practice and recognition of psychodermatological conditions, such as cutaneous somatic disorders, can be difficult. Somatization may occur with or without the existence of a dermatological disease. When a dermatological disorder is present, somatization should be considered when the patient is worrying too much about their skin, spending too much time and energy on it and especially if the patient also complains of many non-cutaneous symptoms. Purely cutaneous somatic conditions include for example, the genital pain syndromes or Gardner-Diamond syndrome, characterized by unexplained bruising, which usually affects women. Effective management tools may include mindfulness therapies, pharmacotherapy with selective serotonin reuptake inhibitors, tricyclic antidepressants and cognitive conduct therapy. Electroconvulsive therapy can also be considered in extremely rare cases for treatment of severe somatization on a background of mood disorders. This paper discusses somatization, its relationship to immunodermatoses and its relevance to clinical practice.

Dermatologic Symptoms and Syndromes Associated with Headache.

Headache disorders are often accompanied by associated symptoms involving organ systems other than the central and peripheral nervous system, including the integumentary, cardiovascular, and musculoskeletal system. However, skin changes or conditions are not commonly associated with headache disorders. Recognition of possible etiologies of headache in patients with bruising, rash, or neurocutaneous disorders can help guide workup and management. The purpose of this article is to review the various dermatologic presentations associated with headache. Multiple review articles and retrospective studies have noted the association between head pain with dermatologic changes including ecchymoses, inflammatory skin conditions, and neurocutaneous disorders. Postulated mechanisms include activation of the trigeminal autonomic system and involvement of similar pro-inflammatory molecules. In this review, we discuss three different classes of rashes including ecchymoses, inflammatory skin conditions, and neurocutaneous disorders, all of which have been associated with migraine and/or headache. We discuss the possible underlying pathophysiology and treatment options.

33639 Symptomatic burden and treatment needs in adult atopic dermatitis

Objective: Atopic dermatitis (AD) is a common, chronic, flaring, inflammatory skin disease causing a variety of dermatologic signs and symptoms. While treatment options are available, they are of variable effectiveness. This study sought to describe patient-reported current treatment utilization and continued disease burden.

TO STUDY INCIDENCE, PROGRESSION, AND BURDEN OF LONG COVID AMONG POST COVID PATIENTS AND ITS IMPLICATION IN HEALTHCARE SETTINGS.

Introduction- The long-term effects of SARS-CoV-2 infection are becoming a signicant burden on society and healthcare systems. Data on post-COVID-19 syndrome in the general population is needed to organise healthcare treatments and resources in a timely manner.(1) In adults hospitalised with severe coronavirus illness, long-term symptom duration and impairment are typical (COVID-19). Understanding the complete spectrum of COVID-19–associated disease and adjusting public health messages, treatments, and policies requires characterising return to baseline health among outpatients with milder COVID-19 illness.(2) Aims and Objectives This study aims to nd incidence and assess progression and burden of long covid among post covid patients. Methodology- A cross sectional interview-based study was conducted for a period of 3 months among post covid patients to nd the incidence of long Covid. The list of respondents was obtained from health departments records listing post covid patients from March 2021 to November 2021. Results- Our study found that symptoms of Covid persisted long after patient was declared Covid negative. Majority of the patients 78 patients reported dermatological symptom of hairfall along with memory loss and muscle weakness. Conclusion- This study will help the public health care providers, clinicians and the policymakers to be prepared for the symptoms faced in post COVID-19 and general public in the coming months and years. It will also throw light into the possible factors which are associated with persistent post-acute COVID-19 infection.

Mutations du gène GATA2 : à propos de 3 cas

IntroductionHeterozygous germline mutations of GATA2 gene (guanine-adenine-thymine-adenine binding protein 2) are hereditary mutations that can be pathogenic, sometimes occurring sporadically, responsible for a florid clinical-biological picture, sometimes serious and quickly leading to the death. Case reportsWe reported two women and one man with germline mutations in the GATA2 gene. The first patient, aged 19, initially presented with monocytopenia and chronic lymphedema of the four limbs, suggestive of Emberger syndrome. The second patient, 28-years-old, presented with a disseminated atypical mycobacterium (Mycobacterium kansasii) infection, raising suspicion of an immune deficiency such as MonoMAC syndrome (deficiency syndrome of dendritic cells, monocytes, B lymphocytes and NK cells). The last patient, 30-years-old, presented with pancytopenia, leading to the diagnosis of a family form of myelodysplastic syndromes and acute myeloid leukemia characterized by a mutation of the GATA2 gene. ConclusionsEach case illustrates a typical clinical presentation of GATA2 deficiency, although the evolution of these syndromes ultimately reveals a complex, heterogeneous and intricate picture of hematological, dermatological, infectious, pulmonary, ENT or oncological symptoms. Mutations in the GATA2 gene remain a diagnostic and therapeutic challenge for the internist, and require multidisciplinary management given the florid picture that can be of interest to all specialties. The clinical spectrum of these GATA2 mutations as well as the latest management recommendations from the recent litterature and the “GATA2 club” are described in this article.

Representation in medical illustration: the impact of model bias in a dermatology pilot study

As greater attention is paid to representation and the ‘decolonizing’ of education and media, the field of medical illustration must stay current. Multiple previous studies have concluded that the majority of medical textbooks depict primarily ‘default’ young, white men. Many have expressed that this lack of representation resulted in feelings of alienation; others posited it is a contributing factor for the disparity of care for marginalised groups. This research took arguably the most identifiable feature, skin colour, to explore this disparity – the variation of dermatological symptom expression on melanin-dense skin for four conditions. To evaluate the impact of having a diverse range of models, a study was devised to demonstrate identification rates of melanin-dependent dermatological symptoms in a quantifiable, though non-statistically significant manner. Participants were split into two groups and asked to review four different skin conditions (Group-A receiving illustrations of homogeneous pale skin tones, and Group-B receiving illustrations depicting diverse skin tones) before identifying clinical photographs. While the group with a diverse reference pool performed marginally better overall, they performed better identifying specific conditions in which melanin levels impact the appearance of the condition. This pilot study serves as a strong base for a more developed future study.

Lichen planus and itch-related psychosomatic disorders

BACKGROUND: The relevance of studying psychosomatic disorders associated with itching in patients with lichen planus (LP) is due to a wide range of transnosological comorbidity of nosogenic and depressive disorders with clinical phenotypes of LP.&#x0D; AIMS: Clinical verification and typological differentiation of psychosomatic disorders associated with itching in accordance with the LP phenotypes we identified in patients of the studied sample.&#x0D; MATERIALS AND METHODS: 120 patients (77 women and 43 men, average age 47.65.2 years) with various LP phenotypes and comorbid psychosomatic disorders associated with itching were examined. Dermatological, using the modern lichen planus area and severity index (LPASI); questionnaire of the severity of itching (behavioral rating scores, BRS), the dermatological quality of life index (DQLI) questionnaire; psychopathological, using the Hospital Anxiety and Depression Scale (HADS); clinical-psychological.&#x0D; RESULTS: Psychosomatic disorders associated with itching were identified and typologically differentiated in patients with lichen planus: nosogenic reactions that develop in response to manifestations of a skin disease (depressive, sociophobic, beauty hypochondria), as well as recurrent depression. For each type of psychosomatic disorders, different ratios of dermatological and psychosomatic symptoms have been identified. Nosogenic reactions that develop within the considered ratios are comparable to nosogenies in severe somatic diseases and are clinically manifested by anxiety and depressive disorders. In other cases, the key trigger is not the severity of the dermatosis, as in nosogenic depression, but the cosmetically significant localization of the rash. These psychosomatic disorders are represented by sociophobic nosogenic reactions, as well as beauty hypochondria nosogenies, in the formation of which constitutionally determined somatoperceptual accentuations with deformation of the body image make a significant contribution.The role of constitutional factors and somatoperceptive accentuations is determined. The structure of amplified pruritus was analyzed, including the stressful impact of the SARS-CoV-2 pandemic. Methods of effective therapy based on an integrated interdisciplinary approach are presented.&#x0D; CONCLUSION: Effective diagnosis and treatment of psychosomatic disorders associated with itching contribute to a significant optimization of the course of LP and improve the quality of life of patients.

200 Impact and burden of pityriasis rubra pilaris on quality of life: An exploratory focus group

Pityriasis rubra pilaris (PRP) is a severe inflammatory skin disorder with major impacts on patients’ quality of life. Current treatment plans focus on dermatologic symptoms, however PRP may also cause severe deficits in other areas, including mobility, thermoregulation, and mental well-being. This qualitative study aimed to identify the diversity of symptoms experienced by PRP patients in order to capture a broader disease experience. To this end, we conducted four, two-hour focus group sessions (n=45 English-speaking participants with PRP from six different countries) mediated by a representative from the PRP Alliance, followed by a post-session 23-question survey (completed by n=45 (100%) participants). In regards to most impactful physical symptoms, participants reported severe skin itch and pain, as well as palmoplantar involvement that caused difficulty with performing daily activities and mobility. Non-skin impacts included body temperature dysregulation, anhydrosis, skin buildup in the ears that affecting hearing, rhinorrhea, and joint pain. Difficulty sleeping and excessive daytime fatigue was one of the most often cited systemic impacts. Furthermore, most participants agreed that the mental aspect of PRP was equal to or worse than the physical impact, citing depression, loss of self-worth, feelings of isolation, and passive suicidal ideation. Participants felt that their providers did not adequately address the mental health impacts of PRP. In conclusion, this study found that PRP has debilitating health effects from a broad variety of symptoms and quality of life impacts. These included skin and non-skin symptoms, as well as systemic symptoms and mental health. PRP patients are best treated by a multidisciplinary team that includes mental health management.

Psychopathological symptoms in dermatology: A basic approach toward psychocutaneous disorders.

Dermatological conditions impact not only an individual's physical body but also their psychological health. Similar to how cutaneous conditions can affect one's psychological health, worsening psychological conditions can exacerbate or even induce dermatological conditions. There are four common psychiatric pathologies typically found in dermatology practices: depressive symptoms, anxiety symptoms, obsessive-compulsive disorder behaviors, and psychosis. Common cutaneous disorders associated with these psychopathological symptoms include, but are not limited to, psoriasis, acne vulgaris, atopic dermatitis, urticaria, trichotillomania, excoriation disorder, and delusions of parasitosis. The goal of this review is to examine the relationship between these four psychopathological symptoms with common psychodermatological conditions and to help providers better diagnose and implement appropriate psychological support to treat their patients.

Face mask-induced skin changes: a new common phenomenon during the coronavirus disease 2019 pandemic.

Coronavirus disease 2019 is a severe acute respiratory syndrome, and wearing a mask is an important preventive measure. However, long-term use can cause maskne, or mask-induced acne. This study evaluated the prevalence, clinical characteristics, and severity of mask-induced acne and its effect on pre-existing dermatosis using an online questionnaire. The questionnaire comprised 15 questions on 6 primary topics: demographic data, type of face mask, dermatological symptoms after using a mask, preexisting dermatological conditions, the duration of use, and the effects of mask use on existing dermatological conditions. We included 1,025 participants; 48.6% had dermatological symptoms after using masks. The most common symptoms were red papules (33.8%) and itching (27.2%). Individuals who wore masks for more than 4 hours daily experienced more dermatological symptoms, for example, healthcare providers, who had a higher risk of maskrelated dermatosis than participants with other occupations. Moreover, masks significantly increased the severity of rosacea, contact dermatitis, and seborrheic dermatitis. These results suggest that board-certified dermatologists should assess patients in larger-scale studies to determine adequate management strategies.

Milium cysts on hands; hypertrichosis on face.

The patient's dermatologic symptoms and his history of a particular chronic condition pointed toward the diagnosis.

Prevalence of self-reported dermatologic symptoms among farmers living in Gracias a Dios, Honduras

To the Editor: In 2013, dermatologic disorders were the fourth leading cause of nonfatal disease burden worldwide.1 Limited access to health care services, finances, and safe drinking water have been suggested to increase the burden of dermatologic diseases prevalent in rural regions.2