Dear Editor, Published data from around the world indicate that variations exist in relation to the spectrum of skin diseases occurring in different ethnic groups.1 However, to date, to the best of our knowledge, only one study has explored this topic in relation to the U.K.'s ethnic population,2 despite evidence of changing population demographics.3 This aforementioned study described the spectrum of skin diseases occurring in 461 black patients (defined as Africans, Afro‐Caribbeans and mixed‐race adults and children) attending a hospital‐based dermatology clinic in south‐east London.2 However, it did not explore the same in relation to other ethnic groups, in particular patients from South Asia (the largest of the U.K.'s minority ethnic groups).2 In light of the above, we sought to determine the spectrum of skin diseases occurring in a multiethnic population in north‐west London. Through a retrospective review of medical records, we collected data pertaining to age, sex, self‐classified ethnicity and dermatological diagnoses at first consultation of adults (those aged ≥ 16 years) attending the dermatology outpatient units of two hospitals located in north‐west London between 1 January and 31 December 2013. We focused our study on three ethnic groups: white British (WB; defined as white British and/or of Irish origin), Asians (AS; defined as people of Indian, Bangladeshi and Pakistani origin) and Africans/Afro‐Caribbeans (A/AC; defined as Africans, Afro‐Caribbeans and persons of mixed race). The spectrum of skin diseases for each group was summarized using descriptive statistics. Differences in proportions were tested using the χ2‐test or Fisher's exact test as required. Statistical analyses were performed using SPSS version 12·4 (SPSS, IBM, NY, U.S.A.). A total of 1617 patients were included in the final data analysis: 65% (n = 1053; 498 males, 555 females) self‐classified as WB; 23% (n = 369; 164 males, 205 females) as AS; and 12% (n = 195; 73 males, 122 females) as A/AC. The total number of diagnoses by ethnic group was 1091, 454 and 211 for WB, AS and A/AC, respectively, and respective mean ages were 64·1 (range 16–100), 48·1 (range 16–96) and 43·8 (range 16–94) years. An overview of the spectrum of skin diseases for each ethnic group is provided in Table S1, while Table S2 lists the top 10 leading diagnoses for each ethnic group (see Supporting Information). We demonstrated that skin cancers were the leading diagnosis in the WB cohort, with both basal cell carcinoma (BCC) and squamous cell carcinomas (SCC) being statistically more significant in this cohort [BCC: 16·2% WB vs. 0·7% AS vs. 0% A/AC (P < 0·001); SCC: 6·4% WB vs. 0·2% AS vs. 0·5% A/AC; P < 0·001)] and malignant melanoma only occurring in the WB cohort (6·3% WB vs. 0% AS vs. 0% A/AC). In contrast, in AS and A/AC, inflammatory dermatoses (specifically psoriasis, eczema and acne) predominated. In particular, there was a statistically significant difference in relation to the burden of eczema in the different ethnic/racial groups (9·1% WB vs. 18·3% AS vs. 11·8% A/AC; P < 0·001). Alopecia and hyperpigmentation were more commonly diagnosed in the nonwhite ethnic groups, the difference being statistically significant [alopecia: 3·1% AS and 2·8% A/AC vs. 0·5% WB; hyperpigmentation: 4·0% AS and. 5·2% A/AC vs. 0·1% WB; (P < 0·001)]. Interestingly we also demonstrated a greater burden of lichen planus in the nonwhite ethnic groups (3·5% in AS and 2·4% in A/AC) in comparison with the WB group (0·1%; P < 0·001). Acne keloidalis nuchae and pseudofolliculitis barbae were only observed in the A/AC cohort (5·2% and 1·4%, respectively). Scars (hypertrophic and keloid) were statistically more common in the nonwhite ethnic group (1·1% AS and 2·8% A/AC vs. 0·1% WB; P < 0·001). Finally, pruritus and pruritic conditions (nodular prurigo/lichen simplex chronicus) were statistically more predominant in the nonwhite ethnic groups (6·6% AS, 5·7% A/AC vs. 0·5% WB; P < 0·001). This is in keeping with recent data which hint at ethnic variation in itch, likely mediated through genetic variations in itch receptors.4 ‘Diagnosis unknown’ was more commonly cited in both our AS and A/AC cohorts (4·8% and 3·3%, respectively), in comparison with the WB cohort (0·09%; P < 0·001). This observation may be a reflection of the challenges in making a clinical diagnosis in richly pigmented skin, a possible reflection of the lack of adequate exposure and/or training in this aspect of dermatology. While differences in endogenous (genetic), as well as exogenous (environmental/cultural), factors may account for some of our observations, it may be postulated that variations in the age structure of the cohorts studied, and differences in local referral practices, may also have played a role. In conflict with this hypothesis is the fact that our findings mirror those of other researchers. For example, Child et al. demonstrated that the top‐five leading diagnoses in black adult patients (n = 274) in a hospital in south‐east London were acne vulgaris (13·7%), acne keloidalis nuchae/scalp folliculitis (13·7%), eczema (9·6%), psoriasis (4·8%) and keloids (4·1%).2 Postinflammatory hyperpigmentation was the seventh leading diagnosis in their cohort. Another study, undertaken by Arsouze et al. in Paris, involving 836 black (A/AC) adults, found that acne was the leading diagnosis (29·2%) in this cohort.5 Other common dermatoses included dyschromias (25·0%), alopecia (7·0%) and eczema (6·8%). To the best of our knowledge, this is the first U.K. study that has explored the spectrum of skin diseases in adult South‐Asians, although similar studies have been undertaken in other countries. For example, a survey‐based study involving South‐Asian residents in New York (n = 190) by Shah et al. demonstrated the leading dermatological diagnoses to be acne (37%), eczema (22%) and moles (8%), and the leading skin concerns to be dry skin (25%), hair loss (22%), uneven skin tone (21%), dark spots (18%) and acne (17%);6 these results are in keeping with the findings of the current study. However, in contrast to our study, Shah et al. also highlighted fungal infections (11%) and warts (8%) to also be in the top‐five leading diagnoses in their cohort.6 Our study also demonstrated an over‐representation of lichen planus in our AS and A/AC cohorts in comparison with the WB group. The greater burden of lichen planus in South‐Asians is supported by the work of Kumar and Hay,7 who demonstrated an over‐representation of individuals from the Indian subcontinent in a series of patients with oral lichen planus. A study by Balasubramaniam et al. also demonstrated that South‐Asians were over‐represented in a cohort of children with lichen planus attending a specialist dermatology centre in Birmingham, U.K.8 Unlike the present study, the research by Child et al. found that lichen planus represented 0·7% of the diagnoses made in black adult patients.2 However, a study of children with lichen planus in the U.S.A. demonstrated a greater burden of the disease in African American children [72% African American in a cohort of 36 children; OR 9·63 (P < 0·001)].9 In reviewing these data it is important to highlight the limitations in comparing the general population with disease‐specific studies. The spectrum of skin diseases occurring in the WB population can be inferred from a study by Doe et al.,10 which compared skin diseases diagnosed in 3883 consecutive new patients attending the William Harvey Hospital (WHH), Kent, U.K., from 1 January 1991 to 31 December 1995, with those of patients attending a hospital in Kumasi, Ghana. Similar to the results of this present study, tumours (malignant and premalignant) were the leading diagnoses (22·2%) in the cohort from WHH, while pigmentary and hair disorders were rare (0·7% and 0·6%, respectively).10 Despite the limitations of our study (e.g. hospital rather than community‐based study, the use of retrospective data and the inability to verify that all incidental observations have been documented), our findings indicate that variations do exist in relation to the spectrum of skin diseases occurring in different ethnic groups. The results of this study should help inform the planning and delivery of dermatological services, to ensure they serve the U.K.'s increasingly multiethnic population. Furthermore, in resource‐poor countries, our findings can assist in ensuring that limited resources (economic and manpower) are used efficiently, by focusing public health attention on the more common dermatoses pertinent to specific ethnic groups. A future prospective study on a multiethnic population, using a validated proforma, will allow true prevalence data on the spectrum of skin diseases to be collected, without bias, and will help validate our findings. This work was presented as a poster at the 95th annual meeting of the British Association of Dermatologists, July 2015. We would like to thank Mr Paul Bassett from Statsconsultancy Ltd for his assistance with the statistical analysis. Conflicts of interest: O.E.D. is the founder and director of London Ethnic Skin Limited. Table S1. The spectrum of skin diseases occurring in three ethnic groups in north‐west London. Table S2. The top 10 leading diagnoses in three ethnic groups attending a hospital‐based dermatology clinic in north‐west London.
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Banner et al. (2016) studied this question.
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