|Year : 2021 | Volume
| Issue : 2 | Page : 65-69
Epidemiology of viral skin disease: An increased burden in childhood and a correlation with atopic dermatitis and gross domestic product
Sonia Himed1, Suraj Muddasani1, Alan B Fleischer2
1 College of Medicine, University of Cincinnati, Cincinnati, OH, USA
2 Department of Dermatology, University of Cincinnati, Cincinnati, OH, USA
|Date of Submission||15-Feb-2021|
|Date of Acceptance||25-Mar-2021|
|Date of Web Publication||29-Mar-2022|
3428 Linwood Ave., Cincinnati, OH 45226
Source of Support: None, Conflict of Interest: None
Background: Viral cutaneous infections have impact globally due to several factors, including changing rates of atopic dermatitis (AD), vaccination rates, and access to trained dermatologists. Furthermore, advancements in treatments and access to vaccinations suggest an association between the wealth of countries and the burden of their disease. Purpose: The overall purpose of this study is to better understand the global impact of viral skin disease across differing demographics and time periods, as well as the burden in relation to national wealth. Methods: In this article, the prevalence, incidence, and years lived with disability (YLDs) were analyzed for viral cutaneous infections in 195 countries from 1990 to 2019, using the global burden of disease dataset. Furthermore, the disease burden was assessed as a function of gross-domestic product (GDP) and AD. Results: The prevalence of individuals affected by viral skin diseases is approximately 154 million globally. Young children (1–9 years old) were more likely to be affected. The age-standardized prevalence rates per 100,000 in the Americas and Asia decreased between 1990 and 2019 from 2819 to 2650 and from 2074 to 1906, respectively. This decrease was outside the 95% uncertainty interval. Increased GDP predicted increased prevalence and YLD (P < 0.0001). There was a relationship between 1 year lived with disability per capita of AD and an increase of 0.14 (0.07, 0.21) cases of viral skin diseases (P = 0.002). Conclusion: The increase in disease burden with increased GDP may be correlated to decreased access to dermatologists in developing countries. An increased burden with AD is likely due to skin barrier and immune regulatory dysfunction. The morbidity of skin diseases demonstrates the need for increased access to vaccination campaigns and dermatologic care across developing nations.
Keywords: Atopic dermatitis, epidemiology, viral skin disease
|How to cite this article:|
Himed S, Muddasani S, Fleischer AB. Epidemiology of viral skin disease: An increased burden in childhood and a correlation with atopic dermatitis and gross domestic product. J Dermatol Dermatol Surg 2021;25:65-9
|How to cite this URL:|
Himed S, Muddasani S, Fleischer AB. Epidemiology of viral skin disease: An increased burden in childhood and a correlation with atopic dermatitis and gross domestic product. J Dermatol Dermatol Surg [serial online] 2021 [cited 2022 Aug 16];25:65-9. Available from: https://www.jddsjournal.org/text.asp?2021/25/2/65/341203
| Introduction|| |
Viral cutaneous infections are a group of infections that represent some of the most common dermatologic presentations in adults. With increased travel and globalization, as well as changes in childhood and adult vaccination rates globally over the past several years, there are changes in the global burden of disease (GBD) across time.,, These reviews have demonstrated the increased incidence of viral and bacterial infections in the Western world as a consequence of globalization and climate change. In addition, skin conditions were the fourth leading cause of years lost due to disability in 2010, which included Molluscum contagiosum and viral warts as part of the top 50 most prevalent diseases globally.,, Studies have also shown how the incidence of viral exanthems have changed in countries with the introduction of vaccination campaigns such as the MMR vaccine, with the majority of outbreaks are among individuals how have not been vaccinated. Furthermore, the changes in resistance rates and treatments of viral conditions such varicella zoster and herpes simplex continue to evolve., With changing dynamics in international travel and disease states, it is important to better characterize and understand the impact of viral skin diseases across different demographics.
Atopic dermatitis (AD) has been increasingly correlated with increased frequency of viral skin infections as well as more disseminated infections. It is hypothesized that immune dysregulation in the skin barrier layer in AD is an important characteristic of skin barrier dysfunction that correlates to both viral and bacterial skin infections. Prior epidemiologic studies have found AD to be the 15th most prevalent of nonfatal diseases. AD has also continued to rise in prevalence globally, even within areas where it used to be uncommon, such as some lower income countries or areas of rural living.
The GBD 2019 dataset was examined to describe the epidemiology of viral skin diseases over the past 30 years. In doing so, we hoped to better understand the impact of viral skin diseases across different age groups and world regions. Furthermore, the gross domestic product (GDP) and sociodemographic index (SDI) were tools also utilized to better understand the burden of viral skin disease in relation to national wealth. With the increasing prevalence of AD, as well as its association with viral skin infections, the GBD dataset was also used to better understand the possible relationship between the disease burden of AD and the prevalence of viral skin diseases.
| Methods|| |
The GBD 2019 is a broad epidemiologic database that characterizes mortality, morbidity, and injury in over 195 countries and territories from 1990 to 2019. In doing so, the GBD created a resource that gathered data, including age, sex, and time to quantify global populations with information of a myriad of diseases.
Using the GBD database, the incidence, prevalence, and years lived with disability (YLD) of viral skin diseases between 1990 and 2019 were assessed across the four major world regions: the Americas, Asia, Africa, and Europe. The ages were standardized for both sexes and reported as a rate per 100,000 of the population. Subsequently, the highest and lowest SDIs were also utilized to evaluate the above variables. To better characterize possible effects of wealth on viral skin disease burden, GDP per capita data were obtained from Worldometer and was interconnected with 166 countries with data from the GBD. However, 2017 GDP data were utilized as that is what was available through Worldometer and were compared to 2017 data in the GBD database. In addition, the incidence and prevalence rates were compared across the GDP in United States Dollars of the 166 countries. Furthermore, we compared the rates of YLD per capita for viral skin disease with YLD rates for AD.
The data were analyzed using the SAS University Edition (SAS Institute Inc., Cary, NC, USA).
| Results|| |
In 2019, the global prevalence of viral skin disease was approximately 154,000,000, or about 2% of the world's population, as depicted in [Table 1]. The age standardized global prevalence rate in 1990 per 100,000 people was 2170 and 2070 in 2019. Furthermore, the rates were 2819 and 2650 in the Americas, 2074 and 1906 in Asia, 2087 and 2140 in Europe as well as 2020 and 2032 in Africa. The decrease in the prevalence rates in the Americas and in Asia between 1990 and 2019 was outside of the 95% confidence interval. Globally, age-standardized males had a prevalence rate of 2105 and women had a prevalence rate of 2045. This difference was within the 95% uncertainty interval. Furthermore, the age range with the highest prevalence rate per 100,000 is between 5 and 9 years of age that did not have an overlap in uncertainty with other age ranges. Countries in the highest quintile of SDI had an age standardized prevalence rate of 3524 per 100,000 in 2019 that fell from 3572 in 1990. The lowest quintile had a lower prevalence rate of 1913 in 2019 that was higher than the prevalence rate of 1894 in 1990. For both the highest quintile and the lowest quintile SDI, the differences between the years 1990 and 2019 were within the uncertainty interval. A 1,000 US dollar increase in GDP predicted an increase of 15 (7, 22) prevalent cases (P < 0.001) of viral skin disease per 100,000 people. [Figure 1] compares the prevalence rate of viral skin disease to GDP.
|Figure 1: Prevalence of viral skin diseases in 2017 by gross domestic product|
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Globally, the age standardized incidence rate of viral skin diseases was 1384 per 100,000 in 1990 and 1367 per 100,000 in 2019. Furthermore, the rate was 1507 and 1469 in the Americas, 1279 and 1340 in Asia, 1279 and 1283 in Europe, as well as 1379 and 1380 in Africa. These changes were all within the 95% uncertainty interval. The incidence rate globally was highest between the ages of 1–4 years. The highest quintile of SDI had an age-standardized incidence rate of 1609 per 100,000 in 2019 and 1625 per 100,000 in 1990. The lowest quintile of SDI had an age-standardized incidence rate of 1270 per 100,000 in 2019 and 1342 in 1990. For both the highest quintile and the lowest quintile SDI, the differences between the years 1990 and 2019 were within the uncertainty interval. A one US dollar increase in GDP predicted no difference in incident cases (P = 0.14)
The age standardized YLD globally had a rate of 64 per 100,000 in 2019 and a rate of 66.9 in 1990. The Americas had a rate of 81 and 86.2, Asia had a rate of 58.8 and 63.9, Europe had a rate of 66.2 and 64.5, and Africa had a rate of 62.6 and 62.1. The changes in YLD between 1990 and 2019 were all within the 95% uncertainty interval. The highest quintile SDI had an age standardized YLD rate of 108 in 2019 and 110 in 1990. The lowest quintile of SDI had an age standardized rate of 58.8 in 2019 and 58 in 1990. Both the highest quintile and the lowest quintile SDI were within the 95% uncertainty level between 1990 and 2019. A 1,000 US dollar increase in GDP predicted an increase of 0.46 (0.24, 0.68) YLD (P < 0.0001). [Figure 2] demonstrates the relationship between YLD of viral skin disease and GDP. A 1 year lived with disability per capita of AD predicted to an increase of 0.14 (0.07, 0.21) cases of viral skin diseases (P = 0.002).
| Discussion|| |
It was found that the prevalence rates of viral skin diseases remained stable in two of the four major world regions between 1990 and 2019, while the prevalence in the Americas and Asia decreased. However, the YLD and incidence of viral skin diseases have remained stable in the four major world regions between 1990 and 2019. Young children between the age group of 1-9 were more likely to be affected. In children, the incidence rate was highest between the ages of 1 and 4 while the prevalence rate was highest between the ages of 5 and 9, as demonstrated in [Figure 3]. There appeared to be a positive relationship between countries GDP per capita and the prevalence and YLDs of viral skin infections. There was no relationship observed between GDP per capita and incidence rate. Furthermore, there was a positive relationship between the YLD of AD and an increase in cases of viral skin disease.
|Figure 3: Prevalence and incidence of viral skin diseases in both sexes in 2017|
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The decrease in prevalence rates in the Americas and Asia may be related to improved treatments in managing viral skin disease.,, Skin infections also appeared to be slightly more common in younger age groups, which is consistent with known evidence. Infections such as molluscum contagiosum are more commonly seen in children, as are viral skin exanthems such as hand foot and mouth disease, varicella zoster virus, and measles, rubella, and mumps.,, In addition, the correlation between AD and viral skin infections is most likely due to immune dysregulation as well as barrier dysfunction in the skin. Prior studies have shown that patients with AD that exhibited disseminated eczema herpeticum had a down regulation of interferon-gamma as well as a deficiency in interleukin-37, a cathelicidin peptide.,, AD has also been associated with disseminated coxsackie virus, as well as increased frequency and more widespread molluscum contagiosum infections.
The finding that disease burden increased with national wealth was unexpected. It may be related to the increased availability of healthcare and dermatologists able to diagnose viral skin infections., One study of 30 households in South West Ethiopia demonstrated that 67% of households that did not report skin disease were found to have at least one treatable skin condition upon examination. In addition, viral skin diseases tend to occur more often in rural areas and areas with overcrowding. Furthermore, countries with lower national wealth tend to have lower rates of vaccination, further increasing the populations susceptibility to viral infections.,, Therefore, it is likely that many viral skin infections are undiagnosed in countries with lower national wealth. In addition, climate change is impacting infectious diseases, as well as their spread, and may impact the prevalence of certain viral infections in countries where they were previously not prevalent at higher latitudes.
Viral skin disease continues to be a major cause of disease burden worldwide. It is imperative to increase access to dermatologic care in lower income countries as many cases are likely to be undiagnosed.
| Conclusion|| |
The decrease in prevalence in the Americas and in Asia may by correlated to the increased use of antivirals for treatment. Furthermore, the increase in disease burden with increased GDP was unexpected and may be correlated to decreased access to dermatologists in developing countries. An increased burden with AD is likely due to skin barrier and immune regulatory dysfunction. However, the social burden and morbidity of skin diseases demonstrates the increased need for better vaccination campaigns and to adequate dermatologic care across developing nations.
Financial support and sponsorship
Conflicts of interest
Dr. Fleischer is a consultant for Boerhringer-Ingelheim, Dermavant, Incyte, Qurient, SCM Lifescience, Syneos and Trevi. He is an investigator for Galderma and Trevi.
| References|| |
Yeroushalmi S, Shirazi JY, Friedman A. New developments in bacterial, viral, and fungal cutaneous infections. Curr Dermatol Rep 2020;9:152-65.
Hochedez P, Caumes E. Common skin infections in travelers. J Travel Med 2008;15:252-62.
Restrepo-Méndez MC, Barros AJ, Wong KL, Johnson HL, Pariyo G, França GV, et al
. Inequalities in full immunization coverage: trends in low- and middle-income countries. Bull World Health Organ 2016;94:794-805B.
Seth D, Cheldize K, Brown D, Freeman EE. Global burden of skin disease: Inequities and innovations. Curr Derm Rep 2017;6:204-10.
Karimkhani C, Dellavalle RP, Coffeng LE, Flohr C, Hay RJ, Langan SM, et al
. Global skin disease morbidity and mortality: An update from the global burden of disease study 2013. JAMA Dermatol 2017;153:406-12.
Hay RJ, Fuller LC. The assessment of dermatological needs in resource-poor regions: Assessment of dermatological needs in resource-poor regions. Int J Dermatol 2011;50:552-7.
Salavastru CM, Stanciu AM, Fritz K, Tiplica GS. A burst in the incidence of viral exanthems. Indian Dermatol Online J 2014;5:144-7.
] [Full text]
Brunnemann AK, Bohn-Wippert K, Zell R, Henke A, Walther M, Braum O, et al
. Drug resistance of clinical varicella-zoster virus strains confirmed by recombinant thymidine kinase expression and by targeted resistance mutagenesis of a cloned wild-type isolate. Antimicrob Agents Chemother 2015;59:2726.
Jiang YC, Feng H, Lin YC, Guo XR. New strategies against drug resistance to herpes simplex virus. Int J Oral Sci 2016;8:1-6.
Langan SM, Abuabara K, Henrickson SE, Hoffstad O, Margolis DJ. Increased risk of cutaneous and systemic infections in atopic dermatitis-A cohort study. J Invest Dermatol 2017;137:1375-7.
Ong PY, Leung DY. Bacterial and viral infections in atopic dermatitis: A comprehensive review. Clinic Rev Allerg Immunol 2016;51:329-37
Laughter MR, Maymone MBC, Mashayekhi S, Arents BWM, Karimkhani C, Langan SM, et al
. The global burden of atopic dermatitis: lessons from the Global Burden of Disease Study 1990–2017*. Br J Dermatol 2021;184:304-9.
Suaini NHA, Tan CPT, Loo EXL, Tham EH. Global differences in atopic dermatitis. Eigenmann P, editor. Pediatr Allergy Immunol 2021;32:23-33.
Bansal R, Tutrone WD, Weinberg JM. Viral skin infections in the elderly: Diagnosis and management. Drugs Aging 2002;19:503-14.
Opstelten W, Eekhof J, Neven AK, Verheij T. Treatment of herpes zoster. Can Fam Physician 2008;54:373-7.
Meza-Romero R, Navarrete-Dechent C, Downey C. Molluscum contagiosum: An update and review of new perspectives in etiology, diagnosis, and treatment. Clin Cosmet Investig Dermatol 2019;12:373-81.
Olsen JR, Gallacher J, Piguet V, Francis NA. Epidemiology of molluscum contagiosum in children: a systematic review. Family Practice 2014;31:130-6.
Xing W, Liao Q, Viboud C, Zhang J, Sun J, Wu JT, et al
. Hand, foot, and mouth disease in China, 2008-12: an epidemiological study. Lancet Infect Dis 2014;14:308-18.
Hata TR, Gallo RL. Antimicrobial peptides, skin infections, and atopic dermatitis. Semin Cutan Med Surg 2008;27:144-50.
Howell MD, Wollenberg A, Gallo RL, Flaig M, Streib JE, Wong C, et al
. Cathelicidin deficiency predisposes to eczema herpeticum. J Allergy Clin Immunol 2006;117:836-41.
Ong PY, Ohtake T, Brandt C, Strickland I, Boguniewicz M, Ganz T, et al
. Endogenous antimicrobial peptides and skin infections in atopic dermatitis. N Engl J Med 2002;347:1151-60.
Mosam A, Todd G. Dermatology training in Africa: Successes and challenges. Dermatol Clin 2021;39:57-71.
Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, et al
. The global burden of skin disease in 2010: An analysis of the prevalence and impact of skin conditions. J Invest Dermatol 2014;134:1527-34.
Saleh R, Nada E, Hamed AF, Hussien WM. Epidemiologic trends of viral skin infections in egypt: A cross-sectional hospital-based study. Dermat Res and Pract 2019;2019:1-4.
Duke T, Mgone CS. Measles: not just another viral exanthem. Lancet 2003;361:763-73.
Coates SJ, Norton SA. The effects of climate change on infectious diseases with cutaneous manifestations. Int J Womens Dermatol 2021;7:8-16.
[Figure 1], [Figure 2], [Figure 3]