THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE
PART II - HEALTH CONDITIONS
5. HEALTH IMPACTS OF NON COMMUNICABLE DISEASES AND RELATED TIME-TRENDS
5.11. Dermatological diseases
5.11.3. Data description and analysis
5.11.3. Data description and analysis
Diseases of the skin are particularly common and varied
owing to the large size of the skin, its complex structure and its permanent
exposure to environmental influences. The number of skin diseases has been
estimated to be as high as 3000, not counting questionable or ill-defined
subtypes; this figure is higher than for that for diseases of any other organ
of the body. Every individual is affected by skin problems during lifetime. The
prevalence of skin diseases tends to increase with age, and there is hardly any
individual over 50 years of age who does not need dermatologic care (Williams
et al, 2006).
Skin diseases are a major source of morbidity. For the
population as a whole, morbidity results mainly from chronic dermatologic
illness. Occupational dermatosis (eczema) range among the most frequent causes
of occupational disability, need for job retraining, and even invalid status
with accompanying social costs (Dalgard et al, 2003).
Relatively few skin diseases are directly and acutely life
threatening; included in this small group are acute severe intolerance
reactions such as anaphylaxis and angio-edema, bee and wasp venom allergy, drug
rashes such as the carbamazepine hypersensitivity syndrome or toxic epidermal
Chronic severe skin disease accounts for the most part of
the patient’s suffering and incapacitation: psoriasis, atopic dermatitis,
recalcitrant bullous diseases, chronic wounds such as venous and decubitus
ulcers, smouldering skin lymphomas (usually mycosis fungoides), scleroderma and
geno-dermatosis including severe ichthyoses and hereditary bullous diseases.
Some of the most aggressive tumours arise in the skin: melanoma, squamous cell
carcinoma, some types of skin lymphomas, Merkel cell tumours and others (See
Some skin diseases may not seem to qualify as severe
diseases at first glance, but their psychological impact, particularly on the
developing personality, may be very detrimental. Acne vulgaris, disfiguring
birth marks or cutaneous anomalies have a high impact on wellness and the
social abilities of adolescents, as does balding (androgenetic alopecia) for
both sexes in adulthood. Psychological consequences of atopic dermatitis vexes
its bearers not only by incessant itch, but also by its appearance, (“atopic
psyche”). Dermatology has to satisfy the patients with those abundant common
and relatively mild ailments which ill the waiting rooms and may not be so easy
to diagnose and treat despite their often seemingly trivial background: viral
warts, eczemas of various kinds, simple bacterial, viral and fungal skin
infections, insect bites, dandruff (seborrheic eczema of the scalp), dry skin,
the great stigma of ageing skin, venous insufficiency of the lower limbs, etc.
Among all these, the skin specialist has always to keep in mind that skin
symptoms may be a warning signal of life-threatening internal disease.
Prevalence of selected dermatological diseases are
reported in Tables 5.11.1 and 5.11.2.
5.11.1. Prevalence of
selected dermatological diseases
Swedish birth cohort
Point prevalence at 2 yrs of age=7%
Böhme M, et al
Swedish school children (5-6 yrs)
Broberg A, et al
Italian school children (9 yrs)
Lifetime prevalence=15.2% Point
Girolomoni G, et al
Danish school children (12-16 yrs)
Lifetime prevalence=21.3% 1-year
prevalence=6.7% Point prevalence=3.6%
Mortz C, et al
German adults (population-based, nested
Prevalence=40% (any contact
Schäfer T, et al
Danish school children (12-16 yrs)
Mortz C, et al
Swedish adults (large questionnaire survey)
Prevalence=8% (including mild cases)
Meding B, et al
Swedish school children (16-19 yrs)
Yngveson M, et al
Danish school children aged 12-16 yrs
Point prevalence=3%,1-year prevalence=9%
Mortz C, et al
Summary of 18 population-based studies
Radulescu M, et al
Source: Modified from H. Williams et al. Epidemiology
of skin diseases in Europe Eur J Dermatol 2006;16:212-218
Atopic eczema (atopic dermatitis) is a chronic
inflammatory itchy skin condition that in most cases develops during in early
childhood. It is typically an episodic disease of exacerbation (flares, which
may occur as frequently as two or three times per month) and remissions and may
be continuous in some cases. Atopic eczema often has a genetic element that
leads to the breakdown of the skin barrier. This makes the skin susceptible to
trigger factors - including irritants and allergens - which can make the eczema
worse. Many cases of atopic eczema clear or improve during childhood, whereas
others persist into adulthood. Some children who have atopic eczema will go on
to develop asthma and/or allergic rhinitis; this sequence of events is
sometimes referred to as the ‘atopic march’ Although atopic eczema is not
always recognised by healthcare professionals as a serious medical condition,
it can have a significant negative impact on the quality of life for children,
as well as for their parents and carers (NICE clinical guideline).
Surveys of specific skin diseases such as childhood eczema
(atopic dermatitis) suggest that, like asthma and hay fever, is a major problem
within Europe, affecting around 10% of all children. The highest rates (around
20%) are observed in Scandinavia and UK, whilst the lowest rates of around 5%
are found in Southeastern Europe. The reasons for this North- West/South-East
gradient are unclear.
Prevalence studies of children in temperate developed
countries suggest an overall cumulative prevalence of between 5% to 20% by the
age of 11 (Kay et al, 1994; Schmied and Saurat, 1991). Point prevalences of
visible dermatitis in populations of similar ages yield values approximately
half of those for a history of never having had atopic eczema (Williams et al,
1994b) compatible with the fluctuating nature of the disease. Data on the
prevalence of severe disease is scanty but it is likely that most cases are
mild and can be managed with simple treatments. In a study of 695 school
children in London, where 8.5% were known to have visible atopic eczema, 60% of
eczema cases were considered to be very mild by the examining physician (i.e.
required only a moisturizer), 24% were mild (requiring a moisturizer and weak
topical corticosteroid) and 16% were moderate or severe (requiring stronger
topical preparations and a physician’s supervision) (Williams et al, 1995).
Prevalence estimates for adults suggest an overall frequency of atopic eczema
of between 1.2% to 10% (Rea et al, 1976; Johnson, 1978; Herd et al,
Comparisons between different studies are limited, as
diagnostic criteria suitable for epidemiological studies of atopic eczema have
only been developed recently (Williams et al, 1994b). Even allowing for changes
in the diagnostic fashion, there is reasonable direct and indirect evidence to
suggest that the prevalence of atopic eczema has increased two- to three-fold
over the last 30 years. The precise reasons for this increase in disease is not
known but it is likely that environmental factors associated to urbanization
are to be considered asimportant.
Atopic eczema in childhood shows a striking social class
gradient for both reported and examined disease, (Williams et al, 1994a) with
higher rates in socio-economically advantaged groups and smaller families.
Ethnic group may be an important factor for the expression of atopic eczema. A
recent study has found that the prevalence of atopic eczema (measured in three
different ways) was twice as common in London born Afro-Caribbean children when
compared to their white counterparts. However, studies of Asian children in
Leicester showed that, although they are three times as likely to be present in
specialist clinics than white children, no differences in prevalence rates were
seen in a community survey (Neame et al, 1995).
Although there are no recent national prevalence studies
of atopic eczema in the UK, data for examined eczema from a national birth
cohort study (the National Child Development Study or NCDS) pointed to
considerable variation in disease prevalence and region, with higher rates in
the South East and industrialized Midlands and lower rates in Wales and
dermatitis and other eczemas
The terms dermatitis and eczema are synonymous and refer
to a characteristic reaction pattern of the skin to a range of external and
internal factors. However, the term dermatitis is usually used to denote an
exogenous process, such as contact dermatitis which may or may not be related
to occupational exposure, whereas the term eczema refers to an endogenous
disease such as atopic or seborrhoeic eczema.
Contact dermatitis refers to either:
- irritant contact dermatitis (e.g. frequent exposure to
mild irritant soaps seen in trainee nurses or hairdressers)
- allergic contact dermatitis, where subjects develop a
delayed type of allergic response to certain potentially sensitizing substances
such as metals in piercing (see Focus Box), perfumes and other cosmetics,
preservatives and rubber compounds.
allergic contact dermatitis
Piercing practices are
steadily growing among young people, and, with them, the concern about the
associated allergy risk.
Most body piercing
jewellery is made of metal, usually stainless steel, gold, titanium, platinum
or alloys. Even if stainless steel rarely causes allergic skin reactions some
stainless steel products are not “nickel-free”. Gold itself is often combined
with nickel or other metals to make alloys that have improved hardness and
durability. Moreover, jewellery with a high carat rating is commonly paired
with less expensive studs or earring backs made of nickel and plated with a
thin and imperfect layer of precious metals.
Metallic piercing with
intense linear irregularities on their surface and which have lack of
resistance to sweat corrosion are able to release metallic ions in the local
tissue and generate several types of adverse effects in the human body,
including allergic contact
dermatitis (ACD) (CRF Azevedo,
2003). ACD is characterized
by rash in the skin which is usually very itchy and consists of redness, scaling,
fissuring, vesicles, and lichenification. In addition to primary eruptions at
the site of contact, secondary eruptions might occur on the flexor surfaces
of the arms and elbows (CG Mortz and KE Andersen, 1999; DV Belsito, 1999).
Nickel allergy is the
most common and has a great socio-economic impact. The European Surveillance
System on Contact Allergies (ESSCA) linking dermatological departments from 11 European countries was founded with the aim of providing
scientific information necessary for primary prevention,. In the year 2004, altogether 11,643
patients were patch tested and the highest sensitization prevalence (32.2
%) for nickel was observed consistently for Italian departments; on the other
side of this spectrum, the lowest percentage positive for nickel (9.7%) were
reported in the Danish department
(The ESSCA Writing Group, 2008).
It is estimated that
between 10% and 15% of women and 2-5% of men in Europe are nickel-sensitised,
thus, the danger of a customer suffering bad reactions from a non-conforming
product is significant. The significant differences in prevalence between
females and males correlates with the much higher prevalence of body piercing
among women, particularly in European cultures. The 30–40% of nickel-sensitive people develop hand eczema
that may be recurrent, chronic and severe, and might affect work ability (C
Lidén et al, 2001). Moreover, nickel
allergy can be so severe as to induce asthma (LM Koenig et al, 1999). In
population studies from Scandinavian countries, the prevalence of nickel
allergy among young females with pierced skin has varied from 13 to 20% in
the 1980s (B Larsson-Stymne and L Widström, 1985), while in the 1990s it was
reported to be roughly around 30% (L Dotterud and E Falk, 1994). In Finland, the occurrence of nickel sensitivity in female
university students increased from 13 to 39% during
the 1985–1995 period (L Mattila et al. 2001).
supported the point of view that the risk of becoming allergic to piercing is
higher depending on the number of piercing applied and if the piercing is
practiced before 20 years of age (L Dotterud and E Falk, 1994). Sensitivity has even been shown to develop in infants who have their
ears pierced within the first few weeks of life (AA Fisher, 1991).
Once an allergy to
nickel has been acquired, it generally lasts for life. An individual who has become sensitized to
nickel, when re-exposed to nickel ions might have an allergic response within
a matter of hours and at a much lower concentration of nickel than that
required for inducing sensitization. Moreover, it has been demonstrated that
small pieces of nickel and other metals remain in the skin lesions of pierced
earlobes long after the studs have been removed. The researcher hypothesized
that nickel was retained in the tissues for a mean of hundreds of days (H
Suzuki, 1998). For this reason, the physical persistence of allergen can
cause prolonged irritation and various cutaneous manifestations long after a
patient stops wearing the nickel-releasing ear piercing.
In addition, there is
emerging evidence that other
metals such as chromium, cobalt, gold, platinum and palladium are also
sensitizing agents. The ESSCA data revealed a percentage of European people allergic to cobalt
chloride which varied from 1.1% in Denmark to 17.6% in Italy, and to
potassium dichromate from 1.3% in Sheffield (UK) to 9.1% in Liverpool (UK) (The ESSCA Writing Group, 2008). In a Swedish girls group (956), a total of 44 (4.6%) had contact allergy to both nickel and cobalt,
whereas 7 (0.7%) had contact allergy to cobalt (B Larsson-Stymne and L Widström, 1985). Evidence that ear piercing increases the risk of gold
sensitization is that there were significantly more positive reactions to
gold chloride in the patients with pierced ears than in those without pierced
ears (T Nakada et al, 1997). In Portugal, contact allergy to gold sodium
thiosulfate (0.78%) was found in 23 patients; all the reactors were women and
had their ears pierced with gold earrings (R Silva et al, 1997). Silver may also cause problems such as
localized argyria; this lesion has been typically associated to embedded
jewellery. The skin is believed to
become discovered from the leaching of silver with formation of silver salts
(LM Koenig et al, 1999). Last but not least, as most patients with
strong sensitization to nickel also react to other elements such as palladium
because of cross-reactivity, piercing posts that do not leach nickel but
which contain other elements such as palladium do not represent a safe
There is a widespread
unanimity among dermatologists that the main way in which sensitization can
be induced appears to be by contact with a high concentration of
sweat-soluble nickel from a localized area. In the case of piercing, where the duration of
exposure may occur for an entire life, the chronic exposure to a low
concentration of allergenic metal in the alloy might be sufficient to elicit
a response. On this basis,
the European Directive 94/27/EC limited the content of nickel in products
where intimate and prolonged skin contact will result in solubilization of
nickel at a rate exceeding 0.5 µg/cm2/week. It should be noticed
that the 0.5 µg Ni/cm2/week release rate is likely not to protect
100% of sensitized people from ACD elicitation. However, clinical data
indicate that the vast majority of sensitized individuals would not
experience ACD at this level of nickel release, whilst the vast majority of
individuals not previously sensitized require substantially higher
concentrations than 0.5 µg Ni/cm2/week to be released into the
skin for sensitization to occur.
represented the instrument for the primary and secondary prevention of nickel
ACD. Many of the major
suppliers have included nickel in their quality control programme and are
trying to follow the regulation. Since some years have elapsed from the Directive
emanation, one of the chief
questions is “has the
limitation had a real impact in reducing allergies?” Actually,
some reports indicate a decrease in the sensitization rate to nickel. Among Danish children aged 0–18 , nickel
allergy decreased significantly from 24.8% to 9.2% over a 12-year period (CS
Jensen et al, 2002). In 2002-2003, the Swedish market showed
that only 8% of the tested piercing posts released nickel compared to a
percentage of 25% in 1999 (C Lidén and K Norberg, 2005). In
a study published in 2003, nickel sensitization was found to have decreased
significantly from 36.7% to 25.8% among German women below 30 years over a
9-year period (A Schnuch, and W Uter, 2003). In the USA, where no nickel
regulation has been introduced, nickel continues to be responsible for
clinical disease among youngsters (SH Nguyen et al, 2008).
In other countries the
situation is different. In Italy, in 2005, the percentage of subjects living
in Rome allergic to nickel contained in cheap jewellery was the same as that
found in 1994 and a part of the jewellery market was not yet in compliance
with the law standards (B Bocca et al, 2007). Similarly, in Finland, in the years 1995–97 and 2000–02 the patch
tests revealed percentages of 20.8%
and 21.9 % for nickel allergy, thus testifying that the frequency of allergy had remained at the same
level (T Hasan et al. 2005).
From an experimental
point of view, alloys used for piercing are mostly
uncharacterized especially for the content of new emerging metals; the metal amount from piercing that penetrates the
skin and transports mechanisms in the human body is almost unknown. Moreover,
we little is known about other health effects of piercing, in particularly
about long-term effects. Consequently, the importance of efforts in
collecting and analyzing data to create a common base of knowledge about this
emerging health problem is definitely important for obtaining an overview of
the dangers and adopt prevention programs. Moreover, the phenomenon is so
widespread that its observation and understanding represent a challenge that
stimulates researchers, doctors, parents, teachers and the young people
The identification of
new metals as significant contact sensitizers can be the basis for the
development of standardized patch tests, in vitro predictive tests, in vitro
skin absorption assays and chemical methods that in the future could be
available for dermatologists, medics and scientists. Moreover, the knowledge
about the occurrence of metals in products and the concentration of metals
that does not induce an allergic response and does not penetrate the skin
might be the basis for labelling products or use concentration limitation not
only for nickel but also for new allergens. Alternatively, new chemical
formulations of alloys with new candidate materials for ear piercing with an
higher corrosion resistance and also a non-toxicity pattern could be a part
of future outcomes.
In addition. gaining
more information on the chemical risk induced by metals at pierced sites will
assist in reviewing some aspects related to the piercing industry, in
particular those regarding toxicity requirements and could be a tool for the
decision-makers to improve and reinforce the actual legislation.
Characterisation of metallic piercings, Engineering Failure Analysis,
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dermatology in general medicine, IM Freedberg, AZ Eisen, K Wolff, KF Austen, LA Goldsmith, SI Katz, TB Fitzpatrick (eds), 5th
ed. New York:McGraw-Hill,
Bocca B, Forte G, Senofonte O,
Violante N, Paoletti L, De Berardis B,
Petrucci F, Cristaudo A.
A pilot study on the content
and the release of Ni and other allergenic metals from cheap earrings
available on the Italian market, Science of the Total Environment,
L Dotterud, E Falk, Metal allergy in north
Norwegian schoolchildren and its relationship with ear piercing and atopy, Contact Dermatitis, 1994;31:308–313.
AA Fisher, Nickel dermatitis in children, Cutis,
Rantanen T, Alanko K, Harvima RJ, Jolanki R,
Kalimo K, Lahti A, Lammintausta K, Lauerma AI,
Laukkanen A, luukkaala T, Riekki R, Turjanmaa K,
Varjonen E, Vuorela AM, Patch test reactions to cosmetic allergens in 1995–1997 and 2000–2002
in Finland – a multicentre study, Contact Dermatitis, 2005;53:40–45.
CS Jensen, S Lisby, O Baadsgaard, A
Vølund, T Menné, Decrease in nickel sensitization in a Danish schoolgirl
population with ears pierced after implementation of a nickel-exposure
regulation, British Journal
of Dermatology, 2002;146:636–642.
LM Koenig, M Carnes, Body Piercing. Medical
Concerns with Cutting-Edge Fashion, Journal of General Internal Medicine 1999;14(6):379–385.
B Larsson-Stymne, L Widstrom, Ear
piercing–a cause of nickel allergy in schoolgirls?, Contact Dermatitis,1985;13:289–293.
C Lidén, M Bruze, T Menné, Chapter 41
Metals. In: Textbook of
Contact Dermatitis, RG Rycroft,
T Menné, PJ Frosch, J-P Lepoitterin (eds), 3rd ed. Berlin:Springer,
C Lidén, K Norberg, Nickel on the Swedish market. Follow-up
after implementation of the Nickel Directive, Contact Dermatitis, 2005;52:29–35.
L Mattila, M Kilpeläinen, EO Terho, M
Koskenvuo, H Helenius, K Kalimo, Prevalence of nickel allergy among Finnish university students in
1995, Contact Dermatitis, 2001;44(4):218-23.
CG Mortz, KE Andersen, Allergic contact
dermatitis in children and adolescents, Contact Dermatitis, 1999;41:121-130.
T Nakada, M Iijima, H Nakayama, HI Maibach, Role of ear
piercing in metal allergic contact dermatitis, Contact Dermatitis,
SH Nguyen, TP Dang, C Macpherson, H
Maibach, HI Maibach, Prevalence of patch test results from 1970
to 2002 in a multi-centre population in North America (NACDG), Contact Dermatitis, 2008,58:101–106.
A Schnuch, W Uter, Decrease in nickel
allergy in Germany and regulatory interventions, Contact Dermatitis, 2003; 49:107–108.
R Silva, F Pereira, O Bordalo, E Silva, A Barros , M Gonçalo, T Correia, G Pessoa, A Baptista, M Pecegueiro,
Contact allergy to gold sodium thiosulfate. A comparative study, Contact Dermatitis, 1997;37(2):78-81.
H Suzuki, Nickel and gold in skin lesions of pierced earlobes with
contact dermatitis: a study using scanning electron microscopy and x-ray
microanalysis, Archives of Dermatological Research, 1998;290(10):523-7
The ESSCA Writing Group. The European
Surveillance System of Contact Allergies (ESSCA): results of patch testing
the standard series, 2004. Journal of the European Academy of Dermatology and
Although both mechanisms may occur simultaneously,
distinction between the two requires further investigation by means of patch testing,
a process whereby a standard battery of known allergens is applied in
non-irritant concentrations on the subject’s back and read 48 to 96 hours
later. If the subject is found to be positive to a particular substance which
is clinically relevant to that person’s dermatitis, then complete avoidance of
that substance offers the opportunity of a permanent cure.
Other eczemas in this section refer to any eczema that is
not contact eczema or atopic eczema. Examples are seborrhoeic eczema, discoid
eczema, asteatotic eczema, pompholyx eczema, varicose eczema, photosensitive
eczema and lichen simplex. Detailed prevalence rates for the various endogenous
eczemas are not available, but a study suggested that around 1% of the
population had clinically significant eczema that was not atopic eczema or
contact dermatitis (Johnson, 1978). Seborrhoeic dermatitis was recorded
separately in that study, while clinically significant disease was found to
affect 2.8% of the population, mainly adults. Asteatotic eczema may be
especially common in old age, affecting around 29% of those in residential old
people’s homes (Weismann et al, 1980).
Overall estimates of the prevalence and incidence of
contact dermatitis in the general population are scarce, whereas a number of
studies have looked at special groups such as occupations at high risk of
disease. The Lambeth study found a bimodal distribution of eczema prevalence
thought to warrant medical care with 7.3%, 3.4% 8.9% and 3.8% in the following
age groups:15–24, 25–34, 35–54 and 55–74, respectively (Rea et al, 1976). This
study did not distinguish between endogenous and contact eczema. Younger ages
may also suffer from contact dermatitis and a study in Sweden found that 9% of school girls had nickel allergy, with the highest rates in those
with pierced ears (Larsson-Stymne and Widstrom, 1985).
Age-specific prevalence showed a bimodal distribution to
the Lambeth study probably corresponding to a peak of irritant dermatitis
occurring in housewives in their 20s and occupational hand eczema in men and
women in the 40 to 60 years of age group (Rea, 1976).
A study of an unselected population of Danish adults found
that 15.2% were allergic to one or more
substances when patch tested but the proportion with
clinically relevant dermatitis was not clear (Nielsen and Mennè, 1992).
Irritant and allergic contact dermatitis are also a
serious problem affecting around 10% of adults in Europe.
Hand eczema represents one of the four most common
occupationally-related diseases, accounting for substantial lost earning
potential in otherwise young healthy populations (van Coevorden et al, 2004).
Psoriasis is a common, chronic, relapsing, inflammatory
skin disorder with a strong genetic basis. The plaque type is the most common,
although several other distinctive clinical variants of psoriasis are
recognized. Plaque psoriasis is most typically characterized by
circular-to-oval red plaques distributed over extensor body surfaces and the
scalp. The plaques usually exhibit scaling as a result of epidermal
hyper-proliferation and dermal inflammation. The extent and duration of the
disease is highly variable from patient to patient, and up to 10-20% of
patients with plaque psoriasis also experience psoriatic arthritis. Acute
flares or relapses of plaque psoriasis may also evolve into more severe
diseases, such as pustular or erythrodermic psoriasis.
Psoriasis affects 1–5% of Europeans overall, with rates as
high as 6% in France and Germany (Fouere et al, 2005). The disease afflicts men
and women equally and is present in all races and socio-economic classes and
usually begins in early adulthood. Heredity is strongly involved in the
pathogenesis, and a series of genetic susceptibility loci have been described.
Examination of available population-based studies reveals
prevalences ranging from 0.2% to 4.8%. The highest prevalence, observed in Norway, was obtained by relying on ascertainment by questionnaire without validation of
positive responses. In another study from Denmark, after validation of a subset
of positive questionnaire respondents by dermatological examination,
prevalences were adjusted downward by 25%. With the exception of the Norwegian
questionnaire study, the highest reported incidences in Europe have been in Denmark (2.9%) and the Faeroe Islands (2.8%), with the average for northern Europe being around 2%
(Gudjonsson and Elder, 2007).
Acne is so common as to be almost universal during teenage
years. Yet surveys have suggested that only few affected individuals receive
good medical advice regarding the most appropriate treatment that can prevent
lifelong facial scarring. Acne vulgaris is a very common condition
characterized by papules, pustules, comedones (blackheads) and scars. It is
caused by a combination of factors such as excessive and abnormal grease
production, a bacterium (Propionibacterium acnes) and other abnormalities of
the skin which lead to plugging of pilo-sebaceous openings. Mild degrees of
acne are extremely common among teenagers and some have even considered it as a
physiological disorder. In discussing disease prevalence it is essential that
some form of further breakdown according to disease severity is considered. It
is also important to realize that whilst these severity gradings are reasonably
objective, they do not usually take into account the points of view of the
sufferer. Acne vulgaris is a common skin disease that affects 85-100% of people
at some time during their lives.
Historically, skin diseases have been mainly perceived as
caused by internal disease (“skin as a mirror of the body”). While it is clear
that this extrapolation was generally untenable, it still holds true for some
skin disorders. Metabolic diseases (e.g. diabetes, hyperlipidemias, porphyrias,
amyloidosis) are often accompanied by highly specific skin symptoms which may
alert the physician to the correct diagnosis; the same is true for a spectrum
of cardiovascular, pulmonary and
digestive tract diseases (e.g. dermatitis herpetiformis
accompanying gluten sensitive enteropathy) and cancer of internal organs which
may be associated to pathognomonic paraneoplasias of the skin.
Systemic autoimmune disorders – collagen vascular
diseases, systemic vasculitides – are regularly associated to skin symptoms.
The skin is also the target of organ specific autoimmune diseases (e.g.
alopecia areata, vitiligo) and of autoimmune bullous disorders (pemphigus and
Therefore, it is quite easy to forget the importance of
rare skin diseases such as epidermolysis bullosa (a genetic form of mechanical
blistering which can result in severe scarring and deformity), vitiligo (a
patchy and disfiguring complete loss of pigment in the skin), and severe
autoimmune blistering disorders such as pemphigus (resulting in large areas of
eroded skin and increased morbidity) when considering skin disease only from a
public health perspective. The study of such rare skin diseases is an area
which lends itself very well to a Europe-wide approach. This allows to have a
sufficient number of patients to conduct reliable studies e.g., the mapping of
molecular defects underlying genetic skin diseases that may greatly profit from
such joint European enterprises (see also Chapter 7 on “Rare
Melanoma and non-melanoma (basal and squamous cell
carcinoma) skin cancer (NMSC) are now the most common type of cancer in fair
skinned populations. The incidence of skin cancer has reached epidemic
proportions (Diepgen and Mahler, 2002; Boyle et al, 2004).
According to recent population-based studies from Australia, the incidence rate is over 2% for basal cell carcinoma (BCC) in males, 1% for
squamous cell carcinoma (SCC) and over 50 new cases of melanoma per 100,000.
Many cancer registries probably underestimate the true incidence, especially of
NMSC (Table 5.11.3).
Table 5.11.3. Age-standardized rates
of non melanoma skin cancer in European fair skinned population (per 100 000).
There is little information systematically collected and
available regarding NMSC in Europe. In Trentino, Italy, the Skin Cancer
Registry calculated (for the period 1993–1998) that an incidence rate of 88 per
100 000 for BCC, of 29 per 100 000 for SCC and 14 per 100 000 for melanoma (de
Rijke et al, 2000). This tendency was confirmed in Izmir, Turkey, where nearly half the lesions appeared on the face and, while SCC was equally common in men
and women, BCC were nearly three times more frequent in men (Ceylan et al,
In Vaud, Switzerland, BCC was the most common form of skin
cancer reported in both men and women. Its incidence has been rising steadily
since registration was introduced in the mid 1970s (Levi et al, 2001). In Sweden, 39 805 SCC were registered between 1961 and 1995 (Levi et al, 2001). Incidence
rates increased substantially in men (by 42%) and in women (by 146%) during
this period and interpretation of mathematical models led the authors to
conclude that these increases could probably be explained by increased cumulative
sun exposure and increasing incidence among the elderly (Wassberg et al, 2001).
Between 1978 and 1995, the Slovakian Cancer Registry
registered 38 629 cases of NMSC (19 600 in men and 19 029 in women). During this period, incidence rates of BCC increased by 70.4% in men and 65% in women,
while incidence rates of SCC increased by 13.5% in men and 18.8% in women. Head
and neck were the most common sites (84.2% BCC and 74.7% SCC) followed by the
trunk for BCC (17% in men and 11% in women) and upper limbs
for SCC (12% in men and 12.5% in women) (Plesko et al, 2000).
Mortality from NMSC is almost always from SCC, a form of
cancer whose risk is strongly linked to cumulative lifetime sun exposure (Rosso
et al, 1996). NMSC mortality in Europe presents an entirely different picture
than melanoma. The rates are higher in men and women in Southern European
countries (Greece, Spain, Portugal and Italy) and low in the Nordic countries
(Boyle and Smans, 2003).
Both basal cell carcinoma and squamous cell cancer are
cured by adequate surgical removal. The capacity of many current health care
systems to cope with such surgical demand, associated with skin cancers, is
currently stretched to a maximum in some European countries due to the
increasing incidence of NMSC.
Melanoma is the most serious form of skin cancer, and its
incidence has been rising steeply in the fair skinned population over the last
30 years (doubling the number of cases every 10-15 years), probably due in part
to an increased leisure exposure to the sun. It is estimated that in 2000 there
were 132 000 cases of melanoma diagnosed world-wide and 37 000 deaths caused by
melanoma. In Europe, it is estimated that in 2000 there were 35 000 cases of
melanoma diagnosed and 9000 deaths caused by melanoma. The annual world-wide
melanoma burden is split unevenly between high-resource countries (104 000
cases and 25 000 deaths) and low- and medium-resource countries (28 500 cases
and 12 000 deaths) (Ferlay et al, 2001). The death incidence ratio is strikingly
different in these categorizations.
In Europe, during the 1990s, incidence rates were higher
in northern and Western Europe whereas mortality was higher in men in eastern
and southern Europe. Mortality rates have been rising steadily and in Northern Europe a deceleration has been taking place since the early 1980s. Mortality rates
have also leveled off in Western Europe whereas in eastern and southern Europe both incidence and mortality are still rising (De Vries et al, 2003). The net effect
is that melanoma mortality rates in the mid-1990s (1993–1997) are higher in
Nordic countries and lower in southern European populations, such as Greece, Spain and Portugal (Boyle and Smans, 2003).
Melanoma is at least to some degree preventable, but
approaches to educate the public on the dangers of sunbathing have been
variable, ranging from unsatisfactory in some European countries to highly
proactive educational campaigns aimed at primary prevention (preventing the
development of skin cancer in the first place) and secondary prevention
(catching established disease early) in others. Although melanoma is curable
when recognised at an early stage, availability of facilities for detecting
such early cases varies widely within relatively short distances in Europe.