The skin and the catastrophes

Bayramgürler, D, Bilen, N, Namli, S, Altinas, L, Apaydin, R . The effects of 17 August Marmara earthquake on patient admittances to our dermatology department . JEADV 2002 ; 16 : 249 – 252 The disastrous events in New York and Washington of 11 September 2001 have changed the world as we know it. We can hardly find the words to express our feelings for the victims of the catastrophe, and convey our sympathy to their families. The terrorist attacks on 11 September 2001, and the anthrax emergency that spread all over the USA in the following weeks have clearly and dramatically demonstrated that terrorism can now cause a number of victims in forms and extent which were inconceivable in the past. The word catastrophe, from the Greek katastrophè, literally means involvement. In the Oxford dictionary, the item reads 'a sudden event that causes great suffering or damage; disaster'. In the Italian Devoto-Oli dictionary, the definition is 'mournful result or event, tragic conclusion, destruction, calamity, markedly severe disaster striking a community or else event interrupting the continuity and the causal order of the physical laws, which can be scientifically analysed'. Nowadays the word catastrophe takes a very different meaning. Numerous and varied are the possible forms of catastrophes that can be observed and all of them, according to the intensity, the duration and the relevance of the phenomenon, have an effect on human skin. The catastrophic events can be grouped in natural events, such as earthquakes, seaquakes, whirlwinds, hurricanes and floods, volcanic eruptions, avalanches, noxious gas release, and events caused by the human intervention, such as war, genocide, mass deportation, refugee camps, bombings, mines, torture, terrorist attacks, biological warfare, poverty, inconsiderate exploitation and impoverishment of entire geographical areas. The most common catastrophes are the post traumatic war disorders, the mines, the earthquakes, the poverty, poisoning, biological warfare and the torture: a voiceless disaster. During the Persian Gulf War in 1990–91, almost 700 000 American service personnel were deployed as a part of Operation Desert Storm. Many studies on the dermatologic diseases observed during the recent Gulf War have been performed.1 The most frequent complaints among veterans in the Veterans Affairs Persian Gulf War Registry included the following: fatigue, rash, muscle and/or joint pain, neuropsychiatric complaints, dyspnea, sleep disturbances and gastrointestinal problems. Of a total of 370 patients who were evaluated by the Dermatological Service between 30 June 1994 and 1 June 1995, 30% had a dermatological problem. The majority of the patients were soldiers on active duty in the US Army. The five leading diagnoses (tinea pedis, seborrheic dermatitis, acne, folliculitis and xerosis/asteatotic dermatitis) account for 30% of the total.2 Despite an international treaty banning the use of landmines, tens of thousands of people are killed or injured by these weapons every year. The pain and suffering for countless victims of landmines around the world is staggering.3 Antipersonnel land mines are an epidemic afflicting the world's poorest, war-wrecked nations, maiming and killing scores of civilians each year. Sleeping in the soil of over 90 countries, these mines are deadly remnants of past and present armed conflict.4 They kill or injure more than 2000 people per month. Published studies have helped show the full impact of land mine casualties. These reports have documented the stark reality that many victims never receive medical and dermatologic care. They often present with related conditions, such as shock and infection. These injuries, if not fatal, often blind the victim, and often lead to loss of one or both arms or legs. Long-term care for survivors of all land mine injuries presents its own challenges in less developed countries In many victims of mines, dermatologic problems are common in prosthetic limb user. In these cases allergic contact dermatitis is a significant problem, and all patients with dermatitis on the residual limb should be path tested, but this is impossible in the developing countries.5 Another great problem, however, is that all prostheses, like shoes, wear out. Efforts to fund mine removal are laudable, but removal is a slow, tedious process. Prevention of these casualties is the only way to cure this disease and the only vaccine for the mine epidemic is the Mine Ban Treaty. As physician and dermatologists know so well, prevention is indeed the best medicine.6 A natural disaster such as an earthquake is recognized as inducing a number of stress-related disorders such as dermatologic disease.7, 8 On 17 August 1999, an earthquake measuring 7.4 on the Richter scale devastated north-western Turkey and killed over 17 000 people and left hundreds of thousands more homeless. On Friday 12 November 1999, a second major earthquake, measuring 7.2, destroyed much of the two towns Kaynasli and Düzce. The second earthquake is estimated to have killed almost 1000 people. On 5 December 1999, 25 days after the earthquake, four dermatologists from Gazi University, went to Duzce and examined the skin of 1200 survivors. They found dermatologic disorders in 185 and a total of 33 kinds of skin disorders were diagnosed. The most common group of disorder was parasitic infestation, such as pediculosis capitis or scabies. Another common group of skin disorder was microbial diseases such as furuncles, impetigo contagiosa, tinea pedis and cellulitis, which may also be due to a lack of hygienic conditions.9 Also an Israeli field hospital was sent to the area to help cope with the earthquake trauma and replace the damaged medical system until it recovered. During the 8 days of its active duty, approximately 40 burn patients were seen. Most of the burns were deep partial scald burns of the lower extremity, caused by hot water spill during the quake. The circumstances of evening earthquake and non-industrialized area expressed a new post–earthquake burn syndrome: multiple scald burns due to hot liquid spills.10 The Great Hanshin Earthquake, which killed over 5500 people and injured around 40 000, occurred on 17 January 1995 in Kobe, Japan. This catastrophe caused a great deal of stress for those who experienced it. Kodama et al. detected 1457 patients with Atopic Dermatitis (AD), to study the consequences of disaster on their skin. The data were obtained from a self-administered questionnaire given to patients with AD after experiencing the Great Hanshin Earthquake. Patients were divided into three groups: area A, severe damage to buildings and houses; area B, mild damage; and control area, no damage. Exacerbation of skin symptoms was found in 38% and 34% of patients in areas A and B, respectively, whereas similar exacerbation was seen in 7% of control patients. The earthquake caused stress in 63% and 48% of the patients in areas A and B, respectively, but fewer patients felt stress in undamaged areas (19%). The study strongly suggested that stress caused by a natural disaster influences AD symptoms. In Ventura County, between 24 January and 15 March, 1994, 203 outbreak-associated coccidioidomycosis cases, including three fatalities, were identified. The majority of cases (56%) occurred in the town of Simi Valley, a community located at the base of a mountain range that experienced numerous landslides associated with the earthquake. Diseases onset for cases peaked 2 weeks after the earthquake centred in Northridge, California. Environmental data indicated that large dust clouds, generated by landslides following the earthquake, were dispersed into nearby valleys by north-east winds. Both the location and timing of cases strongly suggested that the coccidioidomycosis outbreak was caused when arthrospores were spread in dust clouds generated by the earthquake. Dermatologist awareness, especially in endemic earthquake areas following similar dust cloud-generation events, may result in prevention and early recognition of acute coccidioidomycosis.11 Cutaneous disease is a frequent cause of morbidity in homeless people. A variety of infectious and non-infectious conditions have been described in this population that are exacerbated by malnutrition, exposure to a hazardous environment, psychiatric disease, physical injuries, and limited access to healthcare.12 Homelessness, poverty, drug abuse, and physical violence are seen with increasing frequency in poor communities. Dermatologic diseases are very common in the homeless, and foot related problems such as cellulitis and pyoderma are frequent. Unusual patterns of scarring and bruises in different stages of healing are seen in victims of physical violence. Trauma and sexually transmitted diseases result from sexual abuse. Serious skin infection and self-mutilating scarring are seen in intravenous drug abusers. Also in this case dermatologists are able to diagnose and treat the many skin problems seen in the poor people and they can be sensitive to these issues and can educate their staff and communities about the severity of these problems.13 Since 1983 large numbers of people are being encountered with arsenic toxicity due to drinking of arsenic contaminated water in six districts of West Bengal. This water is used by the villagers for drinking, cooking and other household purpose. These six districts have an area of 34 000 km2 and hold a population of 30 million. More than 175 000 people are showing arsenical skin lesions that are the late stages of manifestation of arsenic toxicity. The common symptoms are conjunctivitis, melanosis, depigmentation, keratosis and hyperkeratosis; cases of gangrene and malignant neoplasms are also observed. Clinical and laboratory investigations were carried out on 156 patients. All of them had typical rain drop like skin pigmentation while thickening of palm and sole were found in 65.5% patients. There were five deaths of which one had skin cancer.14 After the disastrous events of 11 September 2001, in the USA, from 4 October to 2 November 2001 the first ten confirmed cases of inhalational anthrax and 12 cases of cutaneous anthrax, caused by intentional release of Bacillus anthracis, were identified.15 Epidemiologic investigation indicated that the outbreak resulted from intentional delivery of B anthracis spores through mailed letters or packages. The dermatologist plays a very important role in the face of a Biological Warfare (BW) terrorist attack. The skin specialist may be one of the most valuable assets who can use highly trained clinical skill to diagnose the cause of the attack. The ecchymotic and purpuris changes seen in septicemic plague, the early centripetal, papular eruption of Ebola and Marburg haemorrhagic fevers, are important distinctive skin signs. A small, painless, red macule that progresses to a papule that vesiculates, ruptures, ulcerates and forms a black eschar surrounded by significant oedema, is the distinctive lesion of Cutaneous Anthrax. Prompt recognition of the dermatologic features of BW – associated diseases, can lead to a more rapid mobilization of public health and medical assets, leading to implementation of vaccines, chemoprophilaxis and appropriate therapy. Torture sequelae and associated diagnostic problems within the field of the skin are very common.16 In front of a torture suspect, the dermatologist has to examine the entire body surface to detect signs of generalized skin disease including signs of vitamin A, B, C, and E deficiency, pretorture lesions or lesions inflicted by torture, such as abrasions, contusions, lacerations, puncture wounds, burns from cigarettes or heated instruments, electrical injures, alopecia and nail removal. It is important to stress the origin of the lesions: inflicted or self-inflicted, accidental or the result of a disease process. If dermatology may be defined as 'the study of the skin and its diseases' or 'the branch of science which treats of the skin', dermatologists cannot confine themselves merely to a study of the skin, or internal medicine, but must study also environmental, psychological, economic and social factors which so frequently cause skin problems.