ARTICLE
Auteur(s) : María
Pilar Albares Tendero, Isabel Belinchón Romero, Jose Manuel
Ramos Rincón, José Sánchez Payá, Ana Lucas Costa, María Pérez
Crespo, Juan Francisco Silvestre Salvador
Servicio de Dermatología, Hospital General Universitario de
Alicante, 03010 Alicante, Spain
accepté le 14 Novembre 2008
Nowadays there are notable inequalities among the different
countries, many of which are immersed in political conflicts and
others in which a large proportion of the population lives in
poverty. There is a lack of aid for development and a widening gap
between rich and poor countries. This situation has led to an
increase in migration, with the result that Europe, and in
particular Spain, has become the destination of a considerable
number of immigrants.
In 2006, 4.14 million foreigners were registered in Spain,
accounting for 9.3% of the population resident in this country. Of
the foreign population, 1.9 million were born in Latin America. The
lack of difficulties with the language and the cultural affinity
have favoured a predominance of the Latin American population.
These people have a very diverse range of skin types, since many of
them have pigmented skin (American Indian or black), whereas others
are pale-skinned, similar to the majority of the Spanish
population. Dermatoses in Latin American immigrants could differ
from those in the native population both due to the skin type and
to the social situations associated with immigration. Nevertheless,
this has not been studied so far in a European setting.
The purpose of this study is to describe the cases of dermatosis
seen in the immigrant Latin American population and compare them
with those found in the control Spanish population. We also
performed a comparative study of the types of dermatosis seen in
these immigrants, depending on their skin type.
Patients and methods
From 1st February 2005 to 31st January 2006,
all the visits of economic immigrants seen in the different units
of the Dermatology Section of the Hospital General Universitario de
Alicante were prospectively recorded.
Dermatological health care is provided in two centres: the
Specialities Centre (specialist out-patient clinic) and the General
Hospital (specialized hospital clinic, operating theatre and the
dermatological emergency department of the hospital). A visit
is defined as each time a patient is seen in any of the health care
units of the Dermatological Section.
An economic immigrant is defined as a person who was not born in
any of the 25 member states of the European Union or in a country
with a gross national product (GNP) per capita greater than that of
Spain in January 2005 (the United States, Switzerland, Norway,
Canada, Japan, Iceland, Kuwait or Israel). The children of
immigrants born in Spain are considered immigrants.
We centred our study on Latin Americans, since the immigrant
population in our area belongs mainly to this group. We defined
three types of skin: a) white: including phototypes I, II, III and
IV with Caucasian phenotype characteristics; b) American Indian:
including phototypes III, IV and V with a phenotype specific to
Latin America; c) black: including phototypes V and VI.
The demand (number of visits per 100 people registered) was
calculated by estimating the number of Latin Americans in the
catchment area of our hospital based on the census of our
province.
In order to compare the dermatoses in the Latin American
population with those in the Spanish population, a control group
was selected from the Spanish patients seen. This group was
obtained by recording all the patients who attended any of the
health care units on a specific day of each month of the study
period. The age limit for the control group was 60 years, since
only a very small number of Latin American patients were over this
age. In addition, an analysis adjusted for age and sex was carried
out due to the differences in these variables between the two
populations.
For each new patient different epidemiological variables were
collected (age, sex, country of birth, duration of stay in Spain,
skin type), together with date of visit, area of dermatological
health care, type and duration of skin diseases. The countries of
birth were grouped by geographical areas: Latin America, North
Africa, Eastern Europe, Sub-Saharan Africa and Asia. The cases of
dermatoses detected were coded according to the international
classification of disease criteria, (CIE-9, 9th
edition). Skin diseases were classified as: a) infectious:
dermatoses caused by microorganisms (virus, bacteria, fungi,
parasites or ectoparasites); b) inflammatory: dermatoses due to
activation of the immune response, excluding infectious dermatoses;
c) tumoral: caused by a proliferation of cells not controlled by
the organism’s regulatory systems. These are subdivided into benign
tumoral dermatoses and malignant tumoral dermatoses, depending on
the capacity to infiltrate and invade neighbouring organs and
provoke metastasis; d) pigment alterations; e) hair alterations; f)
ungueal alterations; g) drug eruptions; h) vascular alterations; i)
mucosal alterations; j) without lesions: patients with symptoms who
have no lesions at the time of diagnosis and k) others. Cases of
dermatoses in each skin type (American Indian, white or black) were
compared with those in the other skin types.
The data were statistically analysed using the statistical
programme SPSS version 12.0. for Windows (SPSS Inc; Illinois,
EEUU). Quantitative variables were expressed as medians with their
interquartile range (IQR). Qualitative or categorical variables
were expressed as absolute and relative frequencies (as a
percentage) of each of the values of the different variables. The
χ2 test with Yates’s correction was used to study the association
between variables, or Fisher-s exact test when the conditions to
apply the χ2 test were not met. A value of p < 0.05 was
considered statistically significant. When comparing the dermatoses
between the Latin American and Spanish populations the odds ratios
(OR) with 95% confidence limits adjusted for age and sex were
calculated.
Results
During the study period 39,160 visits were recorded. Of these 1625
(4.1%) were generated by 1085 immigrant patients, of whom 706 (65%)
were Latin American. Latin American patients had a mean age of
30.05 years (± 16.49) with a predominance of women (61.2%). On the
other hand, Spanish control patients had a mean age of 33.34 years
(± 15.93), 56.1% women. Table 1 shows
the most important sociodemographic characteristics of the Latin
American population compared with the Spanish population. Eighty
percent of the Latin Americans came from Ecuador, Colombia or
Argentina. The demand of Ecuadorians, Colombians and Argentinians
was similar (around 9 visits), whereas that of patients from the
Dominican Republic was much greater (19.2 visits) and that of
Bolivians and Cubans considerably lower (4.5 visits). The demand of
the Spanish population was 13.9 visits (table
2).
The Latin American patients accounted for 1108 visits, in which
1246 cases of dermatoses were diagnosed; of these, 875 were
recorded for the first time during the study period. Of the 875
pathologies, inflammatory pathology (41.5%) was the most common,
followed by benign tumoral pathology (21.9%) and infectious
pathology (16.8%). By type of dermatoses, the most frequent were
eczema (18.2%), acne (6.5%) and non-genital viral warts (6.3%).
Table 3 shows the groups of pathologies
and types of dermatoses diagnosed on more than 7 occasions.
Table 4 shows a comparison of the
groups of dermatoses and dermatoses between the Latin American and
Spanish populations, together with their analysis adjusted for age
and sex. When comparing the groups of dermatoses between the
immigrant Latin American and Spanish population after adjusting for
age and sex, inflammatory dermatoses (p = 0.001) and pigment
alterations (p < 0.001) were found to be more frequent in the
Latin American population, whereas both malignant and benign
tumoral pathology were less common in this population (p <
0.001). The comparative study of dermatoses after adjusting for age
and sex found a greater frequency of eczema, alopecia, melasma,
herpes simplex, pilar keratosis, xerosis, and scabies (p ≤ 0.04) in
the Latin American population. On the other hand, melanocytic nevi
and melanoma were less frequent in these patients (p <
0.001).
Analysis of the different types of eczematous dermatitis showed
a greater frequency of atopic dermatitis (4% vs 1.8%; p = 0.006),
contact eczema (3.6% vs 2%; p = 0.04) and pityriasis alba (3.5% vs
0.2%; p < 0.001) in Latin Americans than in the Spanish
population.
We compared the dermatoses in each skin type with the addition
of the dermatoses in the other two skin types. Melanocytic nevi
(9.8% vs 4.3%) (p = 0.003), seborrhoeic keratosis (4.9% vs 1.7%) (p
= 0.01) and epidermal cysts (4.5% vs 1.6%) (p = 0.02) were found to
be more frequent in patients with pale skin, whereas eczematous
dermatitis (13.5% vs 20%) (p = 0.03) and melasma (0.4% vs 3.2%) (p
= 0.03) were less frequent. In patients with American Indian type
skin, melasma (3.5% vs 0.3%) (p = 0.008) was more frequent, whereas
seborrhoeic keratosis (1.7% vs 4.3%) (p = 0.04) and epidermal cysts
(1.2% vs 4.7%) (p = 0.003) were less frequent. In black skinned
patients melanocytic nevi (2% vs 6.1%) (p = 0.03) were less
frequent (table 5).
Table 1 Epidemiological characteristics of Latin
American patients and Spanish control group
|
Latin American population
|
Spanish population
|
p
|
|
Age, years
|
n = 695
|
n = 950
|
< 0.001
|
|
Median (IQR)
|
30 (17-41)
|
32 (21-48)
|
|
|
Age group
|
N (%)
|
N (%)
|
|
|
0-14 years
|
143 (20.6)
|
123 (12.9)
|
|
|
15-44 years
|
418 (60.1)
|
541 (56.9)
|
|
|
> 44 years
|
134 (19.3)
|
286 (30.1)
|
|
|
Sex
|
N (%) n = 706
|
N (%) n = 950
|
0.04
|
|
Male
|
274 (38.8)
|
417 (43.9)
|
|
|
Female
|
432 (61.2)
|
533 (56.1)
|
|
|
Duration of stay in Spain, months
|
n = 679
|
-
|
|
|
Median (IQR)
|
48 (24-60)
|
-
|
|
|
Stay in months (n = 679)
|
N (%)
|
-
|
|
|
0-24
|
187 (27.5)
|
|
|
|
25-48
|
264 (38.9)
|
|
|
|
> 48
|
228 (33.6)
|
|
|
|
Type of patient
|
N (%) n = 706
|
-
|
|
|
Immigrant
|
654 (92.6)
|
|
|
|
Child of immigrants
|
52 (7.4)
|
|
|
|
SKIN TYPE
|
N (%) n = 698
|
N (%) n = 949
|
< 0.001
|
|
American Indian
|
456 (65.3)
|
0
|
|
|
White
|
204 (29.2)
|
948 (99.9)
|
|
|
Black
|
38 (5.4)
|
1 (0.1)
|
|
|
Profession
|
N (%) n = 676
|
N (%) n = 825
|
< 0.001
|
|
Student
|
194 (28.7)
|
239 (29.1)
|
|
|
Domestic service
|
144 (21.3)
|
34 (4.1)
|
|
|
Service sector
|
99 (14.6)
|
260 (31.5)
|
|
|
Catering
|
61 (9)
|
28 (3.4)
|
|
|
Construction
|
58 (8.6)
|
26 (3.2)
|
|
|
Others
|
162 (17.8)
|
238 (28.8)
|
|
Table 2 Spanish and Latin American demand by country
|
Country
|
N° patients (%)
|
N° visits
|
N° on census
|
N° visits per 100 people
|
|
Spain
|
*
|
37537
|
270216
|
13.9
|
|
Ecuador
|
234 (33.1)
|
376
|
4104
|
9.2
|
|
Colombia
|
190 (26.9)
|
287
|
3528
|
8.1
|
|
Argentina
|
144 (20.4)
|
196
|
2264
|
8.7
|
|
Dominican Rep.
|
27 (3.8)
|
41
|
214
|
19.2
|
|
Venezuela
|
22 (3.1)
|
32
|
347
|
9.2
|
|
Peru
|
19 (2.7)
|
29
|
304
|
9.5
|
|
Uruguay
|
17 (2.4)
|
25
|
414
|
6.0
|
|
Brazil
|
15 (2.1)
|
23
|
253
|
9.1
|
|
Bolivia
|
10 (1.4)
|
19
|
426
|
4.5
|
|
Cuba
|
10 (1.4)
|
15
|
340
|
4.4
|
|
Chile
|
9 (1.3)
|
15
|
201
|
7.5
|
*Information on the total number of Spanish patients
seen is not available.
Table 3 Types of dermatoses in the Latin American
population
|
Types of dermatoses*
|
N° diagnosis (%) (n = 875)
|
Dermatoses
|
N° diagnosis (%) (n = 875)
|
|
Inflammatory diseases
|
363 (41.5)
|
Eczema
|
159 (18.2)
|
|
Benign tumours
|
192 (21.9)
|
- Atopic dermatitis
|
34 (3.9)
|
|
Infectious diseases
|
147 (16.8)
|
- Contact eczema
|
30 (3.4)
|
|
Pigment alterations
|
60 (6.9)
|
- Pityriasis alba
|
29 (3.3)
|
|
Hair alterations
|
32 (3.7)
|
- Other eczemas
|
28 (3.2)
|
|
Ungueal alterations
|
22 (2.5)
|
- Chronic eczema
|
26 (3)
|
|
Other dermatoses
|
18 (2.1)
|
- Dyshidrotic eczema
|
12 (1.4)
|
|
Malignant tumours
|
13 (1.5)
|
Alopecia
|
26 (3)
|
|
Drug eruptions
|
5 (0.6)
|
Seborrhoeic keratosis
|
23 (2.6)
|
|
Vascular alterations
|
4 (0.5)
|
Melasma
|
21 (2.4)
|
|
Mucosal alterations
|
3 (0.3)
|
Epidermal cyst
|
21 (2.4)
|
|
|
Onychomycosis
|
20 (2.3)
|
|
|
Molluscum contagiosum
|
17 (1.9)
|
|
|
Angiomas and vascular changes
|
16 (1.8)
|
|
|
Seborrhoeic dermatitis
|
16 (1.8)
|
|
|
Ingrown toenail
|
16 (1.9)
|
|
|
Pruritus
|
13 (1.5)
|
|
|
Vitiligo
|
13 (1.5)
|
|
|
Scar
|
11 (1.3)
|
|
|
Urticaria
|
11 (1.3)
|
|
|
Alopecia areata
|
9 (1)
|
|
|
Dermatofibroma
|
9 (1)
|
|
|
Herpes simplex
|
9 (1)
|
|
|
Pilar keratosis
|
9 (1)
|
|
|
Tinea
|
9 (1)
|
|
|
Acne rosacea
|
8 (0.9)
|
|
|
Scabies
|
8 (0.9)
|
|
|
Folliculitis
|
8 (0.9)
|
|
|
Solar lentigo
|
8 (0.9)
|
|
|
Xerosis
|
8 (0.9)
|
|
|
Condyloma acuminatum
|
7 (0.8)
|
|
|
Postinflammatory hyperpigmentation
|
7 (0.8)
|
|
|
Pityriasis versicolor
|
7 (0.8)
|
*No lesions 9 (1%), without diagnostic 7 (0.8%)
Table 4 Types of dermatoses in which there were
significant differences (with and without adjusting for age and
sex) between the Latin American and Spanish population under 60
years old
|
Types of dermatoses
|
Population
|
P
|
Adjusted OR*
|
Ajusted P*
|
|
Latin American (n = 830)
|
Spanish (n = 1107)
|
|
|
|
|
N (%)
|
N (%)
|
|
|
|
|
Inflammatory diseases
|
354 (42.7)
|
371 (33.5)
|
< 0.001
|
1.37 (1.14-1.66)
|
0.001
|
|
Benign tumours
|
174 (21)
|
374 (33.8)
|
< 0.001
|
0.54 (0.44-0.66)
|
< 0.001
|
|
Infectious diseases
|
141 (17)
|
151 (13.6)
|
0.05
|
1.23 (0.95-1.58)
|
N.S
|
|
Pigment alterations
|
56 (6.7)
|
35 (3.2)
|
< 0.001
|
2.32 (1.49-3.61)
|
< 0.001
|
|
Malignant tumours
|
8 (1)
|
72 (6.5)
|
< 0.001
|
0.22 (0.1-0.48)
|
< 0.001
|
|
Dermatoses
|
|
|
|
|
|
|
Eczema
|
157 (18.9)
|
94 (8.5)
|
< 0.001
|
2.32 (1.76-3.66)
|
< 0.001
|
|
Melanocytic nevus
|
48 (5.8)
|
144 (13)
|
< 0.001
|
0.38 (0.27-0.53)
|
< 0.001
|
|
Seborrhoeic keratosis
|
17 (2)
|
44 (4)
|
0.02
|
0.73 (0.41-1.32)
|
N.S.
|
|
Alopecia
|
26 (3.1)
|
12 (1.1)
|
0.002
|
3.14 (1.55-6.34)
|
0.001
|
|
Actinic keratosis
|
4 (0.5)
|
28 (2.5)
|
< 0.001
|
0.35 (1.21-1.65)
|
N.S
|
|
Onychomycosis
|
17 (2)
|
14 (1.3)
|
N.S.
|
2.07 (0.99-4.33)
|
0.053
|
|
Melasma
|
21 (2.5)
|
6 (0.5)
|
< 0.001
|
5.05 (1.99-12.7)
|
0.001
|
|
Basal cell carcinoma
|
4 (0.5)
|
22 (2)
|
0.008
|
0.45 (0.15-1.37)
|
N.S
|
|
Melanoma
|
0
|
13 (1.2)
|
0.004
|
ND
|
< 0.001
|
|
Herpes simplex
|
9 (1.1)
|
2 (0.2)
|
0.01
|
6.71 (1.42-31.7)
|
0.01
|
|
Hidradenitis suppurativa
|
1 (0.1)
|
10 (0.9)
|
0.02
|
0.14 (0.01-1.12)
|
N.S
|
|
Pilar keratosis
|
9 (1.1)
|
1 (0.1)
|
0.003
|
9.15 (1.15-72.8)
|
0.04
|
|
Xerosis
|
8 (1)
|
0
|
0.001
|
ND
|
< 0.001
|
|
Scabies
|
7 (0.8)
|
0
|
0.003
|
ND
|
< 0.001
|
aOdds ratios adjusted for age and sex; 95% confidence
limits are shown in parentheses.
Table 5 Comparative study of most frequent dermatoses
seen in patients from the main Latin American countries and in
different skin types
|
Dermatoses
|
Skin type
|
|
American Indian (n = 575)
|
White (n = 244)
|
Black (n = 50)
|
|
N (%)
|
N (%)
|
N (%)
|
|
Eczema
|
113 (19.7)
|
33 (13.5) **
|
12 (24)
|
|
Acne
|
40 (7)
|
14 (5.7)
|
2 (4)
|
|
Melanocytic nevus
|
26 (4.5)
|
24 (9.8) *
|
1 (2) **
|
|
Non-genital viral wart
|
36 (6.3)
|
18 (7.4)
|
1 (2)
|
|
Soft fibroma
|
23 (4)
|
10 (4.1)
|
3 (6)
|
|
Psoriasis
|
16 (2.8)
|
10 (4.1)
|
1 (2)
|
|
Alopecia
|
14 (2.4)
|
11 (4.5)
|
0
|
|
Seborrhoeic keratosis
|
10 (1.7) **
|
12 (4.9)**
|
1 (2)
|
|
Melasma
|
20 (3.5) *
|
1 (0.4) **
|
0
|
|
Epidermal cyst
|
7 (1.2) *
|
11 (4.5) **
|
3 (6)
|
|
Onychomycosis
|
15 (2.6)
|
5 (2)
|
0
|
|
Molluscum contagiosum
|
9 (1.6)
|
6 (2.5)
|
1 (2)
|
|
Angiomas and other vascular alterations
|
10 (1.7)
|
6 (2.5)
|
0
|
|
Seborrhoeic dermatitis
|
13 (2.3)
|
3 (1.2)
|
0
|
|
Ingrown toenail
|
12 (1.4)
|
4 (1.6)
|
0
|
|
Pruritus
|
9 (1.6)
|
3 (1.2)
|
1 (2)
|
|
Vitiligo
|
10 (1.7)
|
2 (0.8)
|
1 (2)
|
Discussion
The progressive growth of the immigrant population in Europe should
be taken into consideration in the field of dermatology. The skin
type of these people is sometimes different to that of the European
population, with the result that there has been a change in the
frequency of certain dermatological pathologies and the way in
which they present. Latin Americans make up the largest immigrant
population in Spain (46% of all immigrants), a fact that together
with their diverse range of skin types was the reason for this
study.
It is noticeable that the demand for doctor visits of the Latin
American population was less than that of the Spanish population
(except in the case of patients from the Dominican Republic). We
believe that this is due to the fact that, on the one hand, the
Latin American population is younger and has fewer health problems,
while on the other, these immigrants find it more difficult to
visit the doctor due to their working conditions.
The most frequent types of dermatoses in Latin American patients
were eczema, acne and non-genital viral warts. In our setting no
similar studies are available to compare these data. However,
outside Europe, we want to point out the article by M. Sánchez et
al., (New York) whose authors also found that eczema was the most
frequent diagnosis in the Latin American population seen in state
clinics, followed by viral warts and acne [1].
In our study we found that eczema, xerosis, pilar keratosis,
alopecia, melasma, herpes simplex and scabies were more frequent in
the Latin American population than in the Spanish controls; whereas
melanocytic nevi and melanoma were less frequent in Latin
Americans.
The most common types of eczema in Latin Americans were atopic
dermatitis, pityriasis alba and contact eczema. A large
proportion of this population has pigmented skin in which
pityriasis alba appears to be more frequent and with greater
clinical expression. On the other hand, the occupational activity
of the Latin American population, in which domestic service,
catering and construction prevails, together with their skin type,
leads to the development of contact eczema.
The greater frequency of melasma in the Latin American
population coincides with that observed in other studies [1, 2].
When this pathology is studied in relation to skin type it is found
to predominate in people with American Indian type skin as compared
with those with pale skin, whose lighter skin seems to protect them
from the development of melasma.
On univariate analysis we found that infectious pathology was
more frequent in Latin American patients, although after
standardising for age and sex this difference was found to be no
longer statistically significant. The only infectious pathologies
that were significantly more frequent in Latin Americans were
scabies and herpes simplex. However, other infectious pathologies
such as molluscum contagiosum (2% vs 1.2%), onychomycosis (2% vs.
1.3%) and tinea (1.1% vs 0.45%) were more frequent in Latin
Americans but without reaching statistical significance. The poor
sanitary-hygienic conditions in which some of the Latin Americans
live may favour the greater frequency of scabies and other
infectious pathologies.
The lower frequency of melanocytic nevi in the Latin American
population in our study is due to the fact that most of them have
pigmented skin. In these people, compared with other skin types, as
reported in the literature [3-6], these lesions are less common; to
which we should add that certain genetic peculiarities should also
be considered. Likewise, the lower frequency of malignant tumoral
pathology is explained by the fact that people with pigmented skin
are less likely to develop skin cancer [7-10], since the melanine
content and distribution of melanosomas has a protective effect
[7].
In black-skinned Latin American patients the lower frequency of
melanocytic nevi should be mentioned. This was to be expected since
this pathology in persons with this type of skin is rare, as
reported by other authors [3-5].
The limitations of this study arise from the characteristics of
its design, since it is an analytical transversal study and
therefore the subjects studied are selected during its evolution,
which implies that some cases of dermatoses may not have been
considered. Another limitation is that the data on the immigrant
population are only compared with those of a percentage of the
Spanish population seen in the same period of time, and not the
total native population.
In conclusion, we may say that the skin type and socio-sanitary
conditions of the Latin American population lead to a greater
frequency of eczema, melasma and scabies. In addition, the skin
type favours a lower frequency of skin tumours. We believe that
further studies are needed to acquire a greater understanding of
the dermatological pathology of Latin American immigrants.
Acknowledgements
The authors declare no conflict of interest and no financial
support.
References
1 Sánchez M. Cutaneous diseases in Latinos. Dermatol Clin
2003; 21: 689-97.
2 Sánchez NP, Pathak MA, Sato S,
Fitzpatrick TB, Sánchez JL, Mihm Jr. MC.
Melasma: a clinical, light microscopic, ultrastructural, and
immunofluorescence study. J Am Acad Dermatol 1981; 4: 698-710.
3 Gallagher RP, Mc Lean DI. The epidemiology of
acquired melanocytic nevi. A brief review. Dermatol Clin 1995;
13: 595-603.
4 Coleman 3rd W, Gately 3rd LE,
Krementz AB, Reed RJ, Krementz ET. Nevi, lentigines
and melanomas in blacks. Arch Dermatol 1980; 116: 548-51.
5 Pack G, Davis J, Oppenheim A. The relation of
race and complexion to the incidence of moles and melanomas. Ann NY
Acad Sci 1963; 100: 719-42.
6 Reddy CR, Yellama A, Satyanarayana BV,
Sundareshwar B. Incidence and evolution of moles and the
relationship to malignant melanoma in Eastern India. Int Surg 1976;
61: 469-71.
7 Taylor S. Skin of color: Biology, structure, function and
implications for dermatologic disease. J Am Acad Dermatol 2002; 46:
S41-S62.
8 Taylor S. Epidemiology of Skin diseases in people of
color. CUTIS 2003; 71: 271-5.
9 McCall C, Chen S. Squamous cell carcinoma of the
legs in African Americans. J Am Acad Dermatol 2002; 47: 524-9.
10 Halder RM, Ara CJ. Skin cancer and photoaging in
ethnic skin. Dermatol Clin 2003; 21: 725-32.
|
Printable version
Version PDF