|Year : 2021 | Volume
| Issue : 4 | Page : 373-378
Histopathological spectrum and clinicopathological concordance of nonneoplastic skin lesions at a teaching hospital in South-Eastern Nigeria: A 16-year retrospective study
Chinedu O Ndukwe1, Michael Emeka Chiemeka1, Uchechukwu Brian Eziagu2, Chinwe Chioma Ndukwe3, Joseph Chukwuma Uzoigwe4
1 Department of Anatomic Pathology and Forensic Medicine, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria
2 Department of Histopathology, University of Uyo, Uyo, Awka Ibom State, Nigeria
3 Department of Internal Medicine, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
4 Department of Histopathology, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Submission||14-Jan-2021|
|Date of Decision||16-Feb-2021|
|Date of Acceptance||13-Jun-2021|
|Date of Web Publication||06-Oct-2021|
Chinedu O Ndukwe
Department of Anatomic Pathology and Forensic Medicine, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
Background: Only a few clinicopathological epidemiological studies detailing histopathologically diagnosed skin diseases have been carried out in Nigeria. Thus, the aim of this study was to retrospectively survey the histopathological spectrum and clinicopathological concordance of histopathologically diagnosed skin diseases in Nigeria over a 16-year period. Materials and Methods: This study involved the assessment of all skin biopsy specimens received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, from January 2004 to December 2019. Histopathological diagnoses based on these skin biopsies were made by consultant anatomical pathologists using routine hematoxylin and eosin-stained slides. All relevant demographic data and provisional clinical diagnoses were obtained from the histopathology laboratory requisition forms provided with the specimens. The skin lesions were then classified according to the International Classification of Diseases, Tenth revision (2019). Results: A total of 347 skin lesion biopsy specimens were included in this study. Most of the patients were aged 20–39 years old, with a mean age of 34.2 years. One hundred and forty-eight (42.7%) of the patients were males, whereas 199 (57.3%) were females. The most common 1CD-10 categories were disorders of skin appendages (105/347 [30.3%] cases) and papulo squamous disorders (81/347 [23.3%] cases), whereas the least common category was radiation-related disorders of the skin (2/347 [0.6%] cases). The most common disorder of the skin appendage was epidermal inclusion cyst (71/105 [71.4%] cases). Lichen planus was the most common papulosquamous disorder observed (26/81 [32.1%] cases). Only 202 cases included records of the biopsy site. The lower extremities were the most common sites of involvement (48/202 [23.8%] cases). The clinical diagnosis was concordant with the histopathological diagnosis in 55.3% of the cases, whereas it was discordant in the remaining cases. Conclusion: The most common skin diseases observed in this study were disorders of skin appendages and papulosquamous lesions. Our study provides baseline data for future population-targeted studies of nonneoplastic skin diseases.
Keywords: Histopathology, Nigeria, nonneoplastic, skin
|How to cite this article:|
Ndukwe CO, Chiemeka ME, Eziagu UB, Ndukwe CC, Uzoigwe JC. Histopathological spectrum and clinicopathological concordance of nonneoplastic skin lesions at a teaching hospital in South-Eastern Nigeria: A 16-year retrospective study. J Nat Sci Med 2021;4:373-8
|How to cite this URL:|
Ndukwe CO, Chiemeka ME, Eziagu UB, Ndukwe CC, Uzoigwe JC. Histopathological spectrum and clinicopathological concordance of nonneoplastic skin lesions at a teaching hospital in South-Eastern Nigeria: A 16-year retrospective study. J Nat Sci Med [serial online] 2021 [cited 2021 Dec 1];4:373-8. Available from: https://www.jnsmonline.org/text.asp?2021/4/4/373/327601
| Introduction|| |
The skin is the largest organ of the human body. At least 2000 different diseases, which involve all age groups, affect the skin. Skin disorders represent a major health challenge that affect a significant proportion of the world's human population. However, these disorders mainly cause distress and disability. Skin diseases are quite prevalent in developing countries. Unfortunately, they are presently not regarded as significant health problems when public health strategies are being established in these developing countries, including Nigeria., Skin disease patterns may vary widely between countries or even regions within a given country. Some authors have attributed this to variation to ecological factors, genetics, standards of hygiene, and social customs.,,
The factors such as health-seeking behavior, accessibility to health care, and socioeconomic factors may influence the results of hospital-based studies of skin diseases. However, information obtained from such studies can provide useful data on the trends of skin diseases. Furthermore, a known skin disease trend provides a better understanding of the skin disease burden, thereby providing health policy-makers with essential information necessary for health planning. Therefore, research data on skin diseases garnered from hospital-based studies can help improve the prevention and management of skin disorders.
To our knowledge, only a few epidemiological studies detailing histopathologically diagnosed skin diseases have been conducted in Nigeria. Therefore, the aim of this study was to fill this knowledge gap by conducting an analysis of the histopathological spectrum, frequency, pattern, and clinicopathological concordance of histopathologically diagnosed skin diseases treated at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, South-eastern Nigeria over a 16-year period.
| Materials and Methods|| |
This was a cross-sectional, retrospective, hospital-based study of all skin biopsy specimens received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, from January 2004 to December 2019. As the major tertiary hospital in Anambra state, it serves as a referral center and provides a wide range of medical and outpatient services to the state and other neighboring states. The hospital has a total bed capacity of approximately 440. The histopathological diagnoses were made by a consultant anatomical pathologist using routine hematoxylin and eosin-stained slides. Furthermore, special stains, such as Ziehl–Neelsen, periodic acid-Schiff, and Fite-Faraco, were used when required. We obtained all relevant demographic data and provisional clinical diagnoses from the histopathology laboratory requisition forms provided with the skin specimens. For ease of analysis and comparison with other skin studies, the skin lesions were classified according to the International Classification of Diseases, Tenth revision (ICD-10) (2019), for disorders of the skin and subcutaneous tissue. The skin lesion categories included infectious disorders, bullous disorders, dermatitis/eczema, papulosquamous disorders, urticaria/erythema, radiation-related disorders, disorders of skin appendages, and other categories/miscellaneous. The principal investigator reviewed all the skin lesion cases to corroborate the diagnoses and stratify them into their proper categories. The data generated were entered into SPSS Statistics for Windows, Version 21.0. IBM Corp. Armonk, NY, USA for the statistical analysis.
The ethical approval was granted by Ethics Committee of Nnamdi Azikiwe University Teaching Hospital, Nnewi on 18th February, 2020 with approval number NAUTH/CS /66 /VOL 11 /15. A written informed consent was not obtained as there was no contact with the patient and the collected retrospective data was anonymized. The study adhered to the ethical guidelines of the Declaration of Helsinki.
| Results|| |
We found that of 751 skin biopsy specimens analyzed, 394 (52.5%) were neoplastic and 347 (46.2%) were nonneoplastic skin lesions. Hence, we included 347 skin lesion specimens in this study. The number of skin lesions specimens included in this study represents 3.0% of all surgical biopsy specimens received at the Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria, during the study period. The age of the patients in the study population ranged from 6 months to 97 years old. Most of the patients (37.2%) were in the 20–39 years age group [Figure 1]. The mean age of the patients was 34.2 years, whereas their median age was 31.0 years. Of note, 148 of the cases (42.7%) were males, whereas 199 (57.3%) were females (male: female ratio, 1:1.3) [Table 1].
|Table 1: Mean age, sex distribution, frequency, and clinicopathological concordance of the various international classification of diseases groups|
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The most common ICD-10 categories observed were disorders of skin appendages (105/347 [30.3%] cases) and papulosquamous disorders (81/347 [23.3%] cases), whereas the least common ICD-10 category observed was radiation-related disorders of the skin (2/347 [0.6%] cases) [Table 1].
The most common disorder of the skin appendage was epidermal inclusion cyst (71/105 [67.6%] cases) [Table 2]. Lichen planus was the most common disease among papulosquamous disorders (50/81 [61.7%] cases) [Table 3]. Interestingly, we found that the most common skin infection was viral warts [Table 4].
|Table 2: Mean age, sex distribution, frequency, and clinicopathological concordance of disorders of skin appendages|
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|Table 3: Mean age, sex distribution, frequency, and clinicopathological concordance of papulosquamous disorders|
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|Table 4: Mean age, sex distribution, frequency, and clinicopathological concordance of skin infections|
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The dermatitis and eczema group consisted of 15 (42.9%) cases of chronic spongiotic dermatitis, seven (20.0%) cases of lichen simplex chronicus, five (14.3%) cases of stasis dermatitis, and four (11.4%) cases of prurigo nodularis. There was also a case each of allergic contact dermatitis, nummular dermatitis, seborrheic dermatitis, and atopic dermatitis.
The “others” category consisted of 31 (41.3%) cases of keloid, eight (10.7%) cases of calcinosis cutis, five (6.7%) cases each of corn and xanthogranuloma, and four (5.3%) cases each of cutaneous lupus, panniculitis, and postinflammatory hyperpigmentation. There were also two (2.7%) cases each of acrokeratosis veruciformis, hypertrophic scar, and nevus sebaceous, and one (1.3%) case each of collagenoma, ichthyosis congenita, lymphocytic vasculitis, atrophoderma, morphea, ochronosis, sarcoidosis, scleroderma, vitiligo, and Waardenburg syndrome in the “others” category.
Only 202 cases included records of the biopsy site. We found that the lower extremities were the most common sites of involvement (48 [23.8%] cases) [Table 5]. Disorders of skin appendages affected the trunk in 27.3% of the cases, whereas papulosquamous disorders affected the lower limbs in 46.5% of the cases. The common site for epidermoid cysts (12/42 cases) and pilar cysts (4/10 cases) was the trunk, whereas the common sites for dermoid cysts were the scalp and face (6/13 cases). Both lichen planus (15/28 cases) and psoriasis (5/13 cases) were more commonly observed in the lower extremities. The most common site for keloid was the ear (8/15 cases).
The clinical diagnoses were concordant with histopathological diagnoses in 55.3% of cases, whereas they were discordant in the remaining cases [Table 1].
| Discussion|| |
Several factors determine the pattern of skin diseases. The major factors include socioeconomic factors, literacy level, various climatic factors, industrialization, access to primary health care, and religious, ritual, and cultural practices.
Histopathological evaluation of skin lesion biopsies is considered the gold standard for the diagnosis of both benign and malignant skin diseases. Hence, it is a very crucial modality that assists dermatologists in their understanding of the general patterns of skin diseases, expert management, and enabling proper clinicopathological correlation.
Histopathology-based literature on nonneoplastic skin diseases in Nigeria is scant. Interestingly, most medical skin lesion articles recently published in Nigerian medical research literature were written by dermatologists and are understandably predominantly related to clinical practices and differential diagnoses rather than clinicopathological correlations. To our knowledge, the present study is the first to describe the histopathological pattern and clinicopathological correlation of nonneoplastic skin diseases in South-Eastern Nigeria.
It should be noted that most skin lesions do not get biopsied for histopathological assessment. This is expected as dermatologists can treat and manage the majority of these skin lesions clinically. This observation may explain the relatively small sample size (347 cases) of this study, particularly when compared with other clinically based studies of nonneoplastic skin lesions with similar study durations.,,
Our study results showed a slightly lower proportion of nonneoplastic skin lesion cases (46.2%) than neoplastic skin lesion cases. Abubakar et al. and Bezbaruah and Baruah also reported similar findings in their studies., This may be related to the fact that clinicians are less likely to biopsy nonneoplastic skin lesions than neoplastic skin lesions.
The highest frequency of skin disease in the present study was observed among patients in the 20–39 years age group. This finding in is line with those of similar works conducted in Nigeria. Ogun and Okoro, working in Ibadan, South-Western Nigeria, and Abubakar et al., working in Sokoto, Northern Nigeria, both reported that the modal age group in their studies was 20–29 years., The findings of other international studies are also in agreement with this result. Bezbaruah and Baruah reported that the modal age group in their study was 21–30 years. In addition, Adhikari et al. found that patients in the 31–40 years old age group had highest frequency of skin disease in their study. However, Chalise et al. and Padmaja et al. reported contrary results, which is that patients in the 41–50 years age group had the highest frequency of skin diseases in their studies., This finding of a greater disease frequency in a younger age group in Nigeria may be related to the demographic of the Nigerian population, which is predominantly youthful. In addition, this young adult population is known to actively explore different modalities of skin cosmesis. This may predispose them to these skin lesions. Furthermore, these young persons are more likely to be worried about their skin for cosmetic reasons, and hence, are more likely to visit dermatologists and have lesions biopsied for histopathologic assessment.
This population of the present study showed a slight female preponderance, a distribution which is similar to those in the studies by Bezbaruah and Baruah and Adhikari et al. However, Padmaja et al. and Kumar et al. reported male preponderance in their studies.,,, This female preponderance has been generally attributed to the higher health consciousness/health-seeking behavior of females, and specifically, to their greater attention to skin health for cosmetic reasons.
Skin appendage disorders were the most common types of skin diseases observed in this study. This group included cases of epidermoid and trichilemmal cysts. Our results are similar to those of studies conducted in Saudi Arabia.
The frequency of papulosquamous lesions was relatively high in this study, with lichen planus and psoriasis being more common. Their persistent irritating and poor cosmetic effects have been adduced as the most probable reasons why patients willingly consent to have a biopsy for histopathological evaluation to establish a specific diagnosis. Albasri and Ansari and Ogun and Okoro also found that psoriasis and lichen planus were the most common papulosquamous diseases in their studies., However, our result contrasts with those of Chalise et al. and Adhikari et al., who found that erythema dyschromicum perstans was the most common papulosquamous disease in their studies.,
Notably, viral warts (69%) were the most common infectious skin diseases in our study. Chalise et al. also reported similar findings in their study. Excision biopsy of such lesions helps in arriving at a definitive histopathologic diagnosis, is therapeutic, and serves as a good cosmetic outcome for the patient. Interestingly, superficial fungal infections, which are the most common causes of skin infections based on the results of clinical studies, were not prominent in our study. This is probably because these lesions do not usually require a biopsy for diagnosis and therapy.
In the present study, skin lesions were commonly observed in the lower extremities and trunk. Similarly, Chalise et al. found that the extremities and trunk were the most common sites of involvement for skin lesions in their study.
Our findings showed an overall clinicopathological concordance of 55.3% in a wide range of skin diseases diagnosed by clinicians. This result is similar to those of previous studies that assessed the accuracy of clinical diagnoses with subsequent biopsy confirmation. In a study conducted in Turkey, the concordance between the first three clinical differential diagnoses and histopathologic definitive diagnoses was 58.7%. A review of more than 6700 skin biopsies over 3 years in a hospital in Greece showed that the pathological diagnoses were concordant with the clinical diagnoses in 68% of the cases. In addition, a review of 371 skin biopsies over 1 year in a hospital in India showed that histopathological diagnoses were concordant with provisional diagnoses in 67.4% of the cases. Interestingly, some dermatologists and clinicians generally do not require a biopsy for case presentations that are typical of certain diseases. They only reserve biopsies for the investigation of diseases that have several differential diagnoses or for cases where there is a diagnostic dilemma. These scenarios inadvertently lower the clinicopathological agreement of skin lesion cases. More importantly, it has been reported that the clinicopathological concordance of skin diseases diagnosed by nondermatologists is between 34% and 45%, whereas that of skin diseases diagnosed by dermatologists is between 71% and 75%. The clinicians involved in the present study included a mix of dermatologists and nondermatologists. These factors may account for the reduced concordance observed in this study. Use of ancillary techniques, such as dermoscopy and immunofluorescence, where appropriate, help improve diagnostic accuracy. However, the equipment required for these techniques are lacking in our hospital and in most hospitals in Nigeria. The lack of these equipment may have also contributed to the relatively poor clinicopathological concordance in this study.
This study is limited by its intrinsic nature. Its main limitation is its retrospective, histopathology laboratory-based, and single-center design. In addition, insufficient patient history details, such as lack of information on occupational history, type of residence, exposure to sun, and irritants, is another limiting factor. However, despite these limitations, we believe that our results represent an estimate of the spectrum of nonneoplastic skin diseases in Anambra State, South-Eastern Nigeria. It also provides basic demographic and clinicopathological data, which can be compared with those of national and international studies reported in the available literature.
| Conclusion|| |
A variety of nonneoplastic skin lesion cases, which involved patients across a wide age range, were observed in this study. The most common skin diseases observed were skin appendages and papulosquamous lesions. This study can serve as a baseline tool for future population-targeted studies of nonneoplastic skin diseases in our environment. However, future histopathological studies of larger cohorts at national and international levels are required to corroborate the findings of this study.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]