Flood-related skin diseases: a literature review

Review Flood-related skin diseases: a literature review Therdpong Tempark1, MD, Saoraya Lueangarun2, MD, Susheera Chatproedprai1, MD, and Siriwan Wan...
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Review

Flood-related skin diseases: a literature review Therdpong Tempark1, MD, Saoraya Lueangarun2, MD, Susheera Chatproedprai1, MD, and Siriwan Wananukul1, MD

1 Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, and 2Department of Medicine, Chulabhorn Hospital, Bangkok, Thailand

Abstract Flood is one of the most common natural disasters, which commonly occurs in all parts of the world. The effects of the disasters considerably become enormous problems to overall public health systems. Flood-related skin diseases are a portion of these consequences presenting with cutaneous manifestations and/or signs of systemic illnesses. We conducted

Correspondence Therdpong Tempark, MD Department of Pediatrics, Sor Kor Building 11th Floor King Chulalongkorn Memorial Hospital Rama IV Road Bangkok 10330 Thailand E-mail: [email protected] Statement of funding: None. Conflict of interest disclosures: None.

a systematic literature review of research publications relating to flooding and skin diseases. The purpose of this review was to provide dermatologists as well as general practitioners with comprehensive conditions of flood-related skin diseases and suggested treatments. Moreover, we categorized these flood-related diseases into four groups comprising inflammatory skin diseases, skin infections, traumatic skin diseases, and other miscellaneous skin diseases in a bid to implement early interventions and educate, prevent, and efficaciously handle those skin diseases under such a catastrophic situation so that better treatment outcomes and prevention of further complications could be ultimately achieved and accomplished.

Introduction

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Flood is defined as an overflow of water expansion from hydrometeorological and geophysical disasters such as flood in Bangladesh (2004), Hurricane Katrina in the USA (2005), earthquake in Haiti (2010), the great eastern Japan earthquake and tsunami (2011), and floods in Thailand (2011). It is one of the most common catastrophes, involving about 40% of the total natural calamities worldwide,1–3 and causing multiple environmental and healthcare-related consequences, such as direct injuries to humans, animals, and other living beings, contamination of drinking water resources, food, and chemical materials, outbreaks of infectious and water-borne disease, and psychological health disturbances. Flooding also compromises the healthcare systems, such as access to crucial health services, local health services capacity, needs for evacuees, and clinic settlement,4–6 which require emergency disaster reaction to provide prompt treatment to patients such as immediate wound care, antibiotics, pain management, tetanus toxoid, and also effective management of flood-related skin diseases. Flood-related skin diseases are a portion of these complications, which manifest in cutaneous and/or signs of systemic illnesses due to prolonged exposure to contaminated water and unhygienic conditions during floods. These conditions were categorized into four groups by International Journal of Dermatology 2013, 52, 1168–1176

the authors, namely: (i) inflammatory skin diseases (e.g. irritant contact dermatitis); (ii) skin infections (e.g. fungal and bacterial infections); (iii) traumatic skin diseases; and (iv) other miscellaneous skin diseases (e.g. insect bite reaction and psycho-emotion aggravated primary skin diseases; Table 1). Because the knowledge and recognition of these floodrelated skin diseases is potentially important, we reviewed and summarized several articles as mentioned on floodrelated skin diseases, aiming to enhance such knowledge and recognition for the best and most appropriate management of these specific skin diseases under special catastrophic conditions for both dermatologists and general practitioners. Materials and methods The following databases up to January 2012 were searched through the US National Library of Medicine (PubMed), Ovid MEDLINE Databases, Scopus Database, WHO’s websites (Diseases Outbreaks News), and the CDC (Center for Diseases Control and Prevention), using keywords such as “flood disaster”, “flood-related natural disasters”, “flood and skin diseases”, and “skin manifestations in natural disasters”.

Selection criteria The topics and abstracts of original articles, reports, documents, and reviewed articles in English, including male or ª 2013 The International Society of Dermatology

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Table 1 Flood-related skin diseases Group/type

Example

Common clinical manifestations

1. Inflammatory skin diseases

● Irritant contact dermatitis

2. Infections

● Fungal skin infection (e.g. true dermatophyte, non-dermatophyte molds)

- Erythematous patches, edema, and maceration corresponding to the area of irritant exposure - Probably acquired secondary bacterial infection - Erythematous skin maceration in interdigital web spaces of the foot - Erythematous vesicles and pustules of the foot - Localized dry scaly, erythematous hyperkeratotic papules on the plantar surface and lateral aspects of the foot - Erythematous patches, plaques progress to vesicles, hemorrhagic bullae - Localized to systemic inflammatory response - Localized to systemic inflammatory response - Multiple clinical variants

● Bacterial skin infection (e.g. Streptococcus pyogenes, Staphylococcus aureus, Aeromonas spp., Vibrio spp., Clostridium tetani) ● Mixed infections

3. Traumatic skin diseases

● With/without infection

4. Miscellaneous

● Insect bite reactions - Mosquitoes

- Fire ants

- Centipedes

● Psycho-emotional aggravated primary skin diseases (e.g. atopic dermatitis, urticaria, alopecia areata, psoriasis, angioedema, vitiligo)

- Cuts, lacerations, punctures, and penetration wounds - Possibly acquired secondary bacterial infection - Wheal and flare - Indurated erythematous papules - Vesicles, bullae, ecchymosis and cellulitis-like reaction (uncommon) - Wheal and flare ? superficial vesicles and localized edema ? scatter or group of vesicles, pustules with umbilication - Systemic sign of anaphylaxis (uncommon) - Painful erythematous swelling patch with two-bite puncta - Probably presented bullae - Extension of primary skin diseases

Management/treatment - Avoidance - Topical corticosteroid - Antihistamine as needed

- Keep dry - Topical and/or systemic antifungal agents

- Dressing wound - Topical and/or systemic antibacterial agents - Dressing wound - Topical combined remedies and/or systemic antimicrobial agents - Supportive treatment - Dressing wound - Topical and/or systemic antimicrobial agents - Prevention - Insect repellents - Topical corticosteroid - Antihistamine - Prevention - Topical corticosteroid A - Antihistamine - Prevention - Pain control - Topical corticosteroid - Antihistamine - Psycho-emotional support - Continuous previous treatment

female patients of any ages or ethnic origins, were screened and analyzed separately by two authors (T.T. and S.L.). The

diseases, respectively.7 The dermatological conditions after the tsunami showed 32.5, 29.8, and 29.4% of infections –

related articles and reports on topics such as disasters and

infestations, inflammatory, and traumatic skin conditions,

inflammatory skin diseases, skin infections, traumatic skin

respectively.8

diseases, insect bite reactions, and psycho-emotional aggravated primary skin diseases were included and then reviewed in the full texts.

Inflammatory Skin Diseases Irritant contact dermatitis

Findings We found 1075 English references, of which 72 articles were identified as related to our findings. The prevalence of dermatological conditions from flooding in Thailand was 57.9, 39.2, and 2.9% of inflammatory, infectious, and traumatic skin ª 2013 The International Society of Dermatology

The acute phase of irritant contact dermatitis begins with the penetration of chemicals or irritants through the permeability barrier, which causes mild damage to keratinocytes and the release of inflammatory mediators. Prolonged submergence in the inundated water is one of International Journal of Dermatology 2013, 52, 1168–1176

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the risk factors for keratinocytes damage conducing to inflammation and irritation without activation of the immune cascade.9 Onset of the symptoms varies from minutes to days depending on the concentration of the irritants and the duration of exposure. Irritation from flooding usually occurs on the location of the hand and foot. The clinical presentations classically reveal erythematous patches corresponding to the area of exposure. Symptoms of irritant contact dermatitis include burning, stinging, and soreness. These symptoms are more frequently found than pruritus.10 Irritant contact dermatitis is usually the initial presentation and at certain times subsequently followed by acquired secondary infection from bacteria, fungus, secondary skin conditions from the defect of the skin barrier, chronic irritation, and trauma. The ideal treatments are irritant avoidance and maintaining the exposed skin dry to prevent secondary skin conditions. Supportive treatment with topical corticosteroid on the inflamed skin and oral antihistamine to relieve the itchy symptoms is adequate. Prolonged irritation can cause chronic eczema and secondary fungal and bacterial infections; all these should be recognized in order to give proper management. Infection

The associated factors pertaining to flood-related disaster and infection are specific diseases in endemic areas (e.g. leptospirosis, melioidosis, dengue hemorrhagic fever in South Asia and Southeast Asia, or malaria in Africa, South America, and Asia), the natural course (e.g. flood from seawater or contaminated water) and the severity of the disaster. Usually, public health policy provides the responsibility in management and alleviation of these consequential problems. However, treatments and laboratory investigations like the culture for infectious organisms are usually limited and unavailable in this catastrophic situation. These infections resulting from flood include the risk of soft tissues, ophthalmology, respiratory, gastrointestinal, vector-borne infections from pathogen inoculations, overcrowdedness of the survivor displacement, elimination of water supplies, alteration of vector breeding, and zoonotic reservoir.11

type of tinea pedis (Fig. 1). Vesicles and pustules of vesicular type and moccasin type, manifesting as localized dry scaly, erythematous hyperkeratotic papules on the plantar surface and the lateral aspects of the foot could also present (Fig. 2a and b). True dermatophytes vs. non-dermatophyte molds Non-dermatophyte molds (Scytallidium dimidiatum, Scytallidium hyalinum, Fusarium spp.) are frequently reported as causes of tinea pedis in normal situations.12–14 Although the clinical findings of non-dermatophyte molds are indistinguishable from the true dermatophytes, the fungal culture on Sabouraud’s dextrose agar (without cycloheximide) is usually useful to identify these organisms leading to more specific and efficacious treatments. Ungpakorn et al. reported the prevalence of tinea pedis in dermatological outpatient departments was 3.8%.14 Non-dermatophyte molds (57.9%), for example Scytallidium diminiatum (54%) and Fusarium spp. (3.9%) were the leading pathogens of tinea pedis in normal situations compared with true dermatophytes, which were found in 36.8%, comprising of Trichophyton mentagophyte (18.4%), Trichophyton rubrum (13.2%), and Epidermophyton floccosum (5.2%). Candida albican (2.6%) was found to beget tinea pedis in this study group. However, the predominant role of non-dermatophyte as the leading cause of tinea pedis in Thailand contradicts the findings of previous studies.15–17 Scytallidium dimidiatum (Hendersonula turuloidea) causes cutaneous manifestations similar to Trichophyton rubrum infection.18 The interdigital type is the most common pattern of tinea pedis caused by this mold, followed by the moccasin type.19,20 The patients should be excluded of this mold infection before treatment, regarding the minimal sensitivity to oral griseofulvin and ketoconazole medication.12,13,18 Also, in normal situations, non-dermatophyte molds possibly have a role in the pathogenesis of the diseases during the flood-

Fungal skin infection

Accordingly, prolonged exposure to flood water increases the risk of superficial fungal skin infection. The foot is the most common area submerged under contaminated water. The presentation of erythematous skin maceration with itching between the interdigital web spaces of the foot is a common finding, also known as the interdigital International Journal of Dermatology 2013, 52, 1168–1176

Figure 1 Tinea pedis, interdigital type ª 2013 The International Society of Dermatology

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(a)

(b)

Figure 2 (a and b) Tinea pedis, moccasin type

ing situation. Further studies are required to elucidate the prevalence of these organisms. With limited access to laboratory investigations during the flooding period, such as fungal culture, clinical presentation could not determine the real causes of fungal pathogen. Subsequently, specific diagnosis and standard regimens were then unable to be achieved and prescribed. Rather, generalized treatments had to be given to cover possible pathogens, for example broad spectrum topical antifungal agents for at least 2–4 weeks. As for the cases with unidentified specific fungal pathogen(s) for inflammatory lesions and/or suspected polymicrobial agent(s), a combination of topical remedies could be served as treatment objective. Polymicrobial infection Skin maceration on the interdigital web of the foot is not only a manifestation of fungal infection but also chronic irritant dermatitis of the foot with secondary bacterial colonization. Vachiramon et al. studied fungal culture results taken from interdigital webs of 16 cases of foot maceration from flooding in Thailand and revealed only ª 2013 The International Society of Dermatology

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12.5% positive fungal growth (2/16; Trichosporon mucoides and non-spore forming hyaline fungi); in spite of the Gram-negative bacilli, Corynebacterium spp. and Staphylococcal spp. were found in 87.5% (14/16), 25% (4/16), and 25% (4/16) of the specimens, respectively.7 The authors discussed the growth of Gram-negative bacilli bacteria potentially overwhelming the positive fungal culture effect,21,22 and the duration of specimen collection after the onset of flooding may also affect the culture results because of the slow growth of the fungi. The most suitable topical preparations to cover these mixed organisms are the combination of topical antiinflammation, antibacterial, and antifungal remedies.7 The ability of the anti-inflammatory effect of corticosteroids in combination remedies the disturbing symptoms faster than monotherapy alone in normal host patients.23 The short duration of treatment possibly leads the patients to misunderstand the clearance and subsequently causes the discontinuation of the medication before the specific antifungal agents could act sufficiently against the pathogens.23 This topical combination consists of multiple formulas, including anti-inflammatory (Triamcinolone, Fluocinonide, Betamethasone), antibacterial (Neomycin sulfate, Gramicidin, Polymyxin B, Garamycin), and antifungal (Nystatin, Ketoconazole, Clotrimazole). Tinea pedis vs. tinea corporis A previous study reported that tinea pedis was the most common superficial fungal skin infection in post-earthquake situations. On the contrary, Lee et al. reported that the prevalence of tinea corporis was more common than tinea pedis due to submergence during the tsunami, hot humid weather, and unhygienic circumstances.8 However, secondary condition of tinea corporis should be recognized. Bacterial skin infection

Traumatic wounds are commonly primary skin condition, followed by secondary bacterial infection. Wound infections initially present with increased redness, swelling that rapidly progresses to vesicles, and hemorrhagic bullae. Extensive infections occasionally occur, such as cellulitis, gangrene, necrotizing fasciitis, pyomyositis, and septicemia. The usual pathogens responsible for secondary bacterial infections are Streptococcal pyogenes and Staphylococcal aureus. In contaminated water, Aeromonas spp. is one of the special considered pathogens.24–26 Pseudomonas spp., rapid growing mycobacteria, and Burkholderia pseudomallei (melioidosis) are uncommon pathogens, possibly found in contaminated wounds from water and water-soil mixtures.11,27 International Journal of Dermatology 2013, 52, 1168–1176

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Despite seawater exposure, after significant storm surges physicians should be aware of Vibrio spp. and atypical mycobacteria (Mycobacterium marinum). Vibrio vulnificus has been reported as a cause of wound infection in the deluge post-hurricane Katrina,28 as well as 18 cases with Vibrio spp. wound infections after this hurricane in the USA in 2005.29,30 Tetanus from Clostridium tetani and gas gangrene from Clostridium perfringens infections also presented in wound infections are associated with sea and fresh water contamination.31 However, polymicrobial organisms are the most common causes of wound infection from mixed sea, fresh water, and soil contamination (Table 2).27,32 Underlying diseases of the patients, such as diabetes mellitus, chronic venous insufficiency, peripheral nerve impairment, and immunocompromised status, also influence the type of pathogens, healing time, treatment, and prognosis of these wounds. Wound dressing is one of the most effective treatments for infected wounds. Prophylactic antibiotics are often prescribed in cases of contaminated to dirty wound with high risk of severe infection. The selective regimens of antibiotics are supposed to cover the suspected pathogens depending on individual hosts. Tetanus antitoxin, toxoid, and/or immunoglobulin are also important, particularly in cases of incomplete immunization or in the areas of low immunization coverage rates. Furthermore, wound care and systemic signs and symptoms of illness should also be monitored. Traumatic Skin Diseases Unsurprisingly, traumatic skin diseases usually occur during and following restoration of working time after disaster. The prevalence of this condition ranges from 2.9% in floods7 to 29% in tsunami survivors8 and relies on the severity of natural catastrophes and onset and duration of

studies. Sex predilection occurred approximately three more times in males than females.8 Dermatological lesions predominantly present with cuts, lacerations, punctures, and penetration wounds. The hands and feet are the most frequently affected locations.8 Open wounds from trauma potentially have secondary bacterial infection. Several pathogens causing secondary infection vary on the type, duration of the wound, foreign body, initial dressing, and treatments. Wound culture results from tsunami survivors in Thailand demonstrated 71.8% mixed organisms with Gram-negative bacilli predominance (95.5%), such as Aeromonas spp. (22.6%), Escherichia coli (18.1%), and Klebsiella pneumonia (14.5%). Besides, Gram-positive bacteria were only 4.5% isolated.33 Miscellaneous Insect bite reaction

The stagnation of contaminated water increases the breeding of mosquitoes as well as the number of insects escaping from floodwater including ants, fire ants, and centipedes. Insect bite reactions increasingly occur, particularly in the area of prolonged flood. Mosquitoes Mosquitoes are not only vectors of systemically transmitted diseases such as dengue hemorrhagic fever and malaria, but they also impair the quality of life of the flood victims. The factors causing mosquito attraction are carbon-dioxide production, odor, and estrogen surrounding human skin.34 The inflammatory response from mosquito bites results from the reaction of sensitized immunity to their saliva protein.35 The pathogenesis is composed of saliva-specific immunoglobulin E (IgE), IgG antibodies, and T cell-mediated delayed-type hypersensitivity reaction.35,36

Table 2 Pathogens of bacterial skin infection from traumatic wounds Special considerations of bacterial pathogen Common secondary bacterial skin infection

Streptococcal pyogenes Staphylococcal aureus Clostridium tetani

Condition

Pathogen

Frequency

• Fresh water • Contaminated water • Water–soil mixtures water

Clostridium perfringens Aeromonas spp. -Polymicrobial -Pseudomonas spp. -Rapid growth of mycobacterium -Burkholderia pseudomallei -Vibrio spp. (e.g. Vibrio vulnificus) -Atypical mycobacterium (Mycobacterium marinum)

report report common uncommon uncommon uncommon report

• Sea water

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There are variable cutaneous reactions and clinical presentations to mosquito bites. Immediate reaction presents with a wheal and flare 2–10 mm in diameter that peaks within 20 minutes; while the delayed reaction presents with indurated erythematous papules that peak at 24–36 hours, which gradually resolve within days or weeks (Fig. 3).36,37 Other mosquito bite presentations are vesicles, bullae, ecchymosis, and cellulitis-like local inflammatory reaction (Skeeter syndrome).38 Regarding severe allergic reaction, it may represent with hemorrhagic bullae, necrosis, or ulcer healing with residual scarring.39 Patient with underlying diseases such as hematological malignancies frequently had more severe mosquito bite reaction.40,41 Kulthanan et al., who studied and assessed the clinical features of patients with mosquito allergy in Thailand, revealed the common cutaneous lesions as erythematous papules (68.6%) and immediate wheal (67.1%). The most common area of involvement is the leg.42 Mosquito bite avoidance is certainly the ideal prevention. This can be achieved by limiting the exposure time at dawn and dusk, wearing protective clothing, and the use of mosquito nets and insect repellents, etc. Symptomatic treatment with oral anti-pruritic medication and topical corticosteroid are effective treatments. Insect repellents containing N,N-diethyl-m-toluamide (DEET), also known as N,N-diethyl-3-methylbenzamide, is the most widely used effective medication. The protection time of DEET repellents is approximately 2– 3 hours.43,44 The concentration of 5–30% DEET is available over the counter. The efficacious time for insect protection is directly related to the concentration of DEET.44 However, the adverse effects from systemic absorption should also be considered. A large-scaled population-based study revealed that infants and children have lower rates of moderate to severe or fatal adverse events from DEET than adults.45 However,

Figure 3 Mosquito bite reaction ª 2013 The International Society of Dermatology

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Health Canada and the Canadian Pediatric Society recommended DEET for children older than 6 months old, limited concentration  10%, and the number of reapplication per day varies in each age group.44 Botanical insect repellents, such as 5–15% citronella, have a mean protection time of less than 20 minutes. They do not provide adequate protection compared with DEET-containing remedies.43 Fire ants Solenopsis richteri and Solenopsis invicta are the red and black fire ants, respectively, in Order Hymenoptera. These species are mostly found in Thailand. Their sizes vary from 2 to 6 mm in length. They live in built mounds and underground tunnels in the soil and trees.46,47 They inflict the victims in swarms and usually attack them many times. Two steps of fire ant attacks are bites, stings, and release of venom into the superficial epidermis.48 These toxic alkaloid venoms initially increase plasma membrane permeability, followed by histamine releasing from the mast cells.49,50 The reactions after envenomation are immediate, representing as wheals and flares of 1–2 mm up to 10 cm in size within seconds, whereas the delayed-type reaction represents superficial vesicles containing clear fluid and edema of the tissue within several hours. Consequently, the clear fluid changes to cloudy as pustules and umbilication 8–10 hours later.48,51 These sterile pustules are usually scattered or grouped in what is described as a rosette pattern.49 Vesiculopustular lesions are common and persist for days to weeks.52 This local reaction varies on the amount of venoms and sensitized immunity of the victims. Itchy symptoms often develop within 20 minutes after stings.49 The systemic reaction from fire ant stings has been estimated to be about 16% of the cases, while 0.6–2% of them have life-threatening anaphylaxis.50,51,53 Khan et al. reported 10 cases of anaphylaxis due to the sting of S. richteri.54 There were multiple cases of fatal anaphylaxis in the English literature.55–57 Other systemic reactions, including nephrotic syndrome58 and neurological disorders, such as mononeuropathy, seizure, optic neuritis, and demyelination of the brain, had rarely been reported.53,59 Additional supportive care includes symptomatic treatments, such as cleansing the lesion with mild soap, local compression with ice pack, soothing preparations, and scratch avoidance to prevent secondary bacterial infection, which is the most common complication of these stings.60 Prophylactic antibiotics use is not routinely recommended.49 Topical corticosteroid and systemic antihistamine for relief of the itchy symptoms and pain are adequate treatments.48 International Journal of Dermatology 2013, 52, 1168–1176

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Centipedes Centipedes are arthropods widely distributed throughout the world. They are nocturnal creatures preferring dark and moist places. A large number of the bites occur indoors. The size ranges from 3 to 250 mm in length, and they have one pair of legs per body segment.61 Balit et al. postulated that centipedes possibly produce a venom that induces local inflammatory reactions similar to bee and wasp stings, and potentially more generalized hypersensitivity reactions according to the reported cases of immunogenic properties and fatality (severe hypotension and respiratory distress syndrome) from type IV or delayed-type hypersensitivity.61 The characteristic presentation is a painful erythematous swelling patch with two-bite puncta. Bullae and itchiness are also seen.62 Pain is a universal presentation of definite bites, the severity of which varies according to their species. Large species cause more pain and higher incidences of swelling.61 The duration of pain ranges from 30 to 120 minutes (median time 30 minutes).61 The signs and symptoms probably persist for more than 48 hours. Nevertheless, the consequent secondary bacterial infection is uncommon. Severe reaction from centipede bite is rarely reported in the literature, including Wells syndrome63 and rhabdomyolysis with renal failure.64 Supportive treatment and pain control with ice pack, hot water immersion, and systemic analgesics improve the pain from envenomation.62 Ice pack treatment is safe and suitable for pre-hospital management.62 Topical corticosteroid is also helpful to decrease the inflammation and swelling.

Psycho-emotion Aggravated Primary Skin Diseases Stress can induce psychodermatological diseases due to the effect of psycho-emotional factors that aggravate the primarily underlying diseases, such as atopic dermatitis, urticaria, alopecia areata, angioedema, psoriasis, and vitiligo.65 Stewart and Goodman reported a case of urticaria that occurred immediately after an earthquake.66 In the study of Lee et al., they reported 12 patients who had aggravated psoriasis, atopic dermatitis, or urticaria after a tsunami disaster.8 Exacerbation of atopic dermatitis by stress after earthquake was proposed by Kodama et al.67 Amano et al. reported that mice under the water avoidance stress test developed atopic dermatitis-like skin lesions and elevated levels of serum immunoglobulin E.68 The inhibitory effect

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of corticotropin-releasing factor was a presumptive hypothesis of the aggravation.68 Kim et al. proposed the pathogenesis of psychological stress-aggravated psoriasis by alteration of the cellular constituents of the immune system that target the skin appendages and peripheral corticotropin-releasing hormone-proopiomelanocortin axis.69 The evidence indicates that acute emotional stress can precipitate alopecia areata by the activation of overexpressed type 2 beta corticotropin-releasing hormone (CRH) receptors around the hair follicles. CRH or related peptides could have pro-inflammatory effects leading to local destruction of the hair roots.70 This theory was approved by Katsarou-Katsari et al. through scalp skin biopsy for in situ hybridization of CRH receptors.70 Manolache et al. demonstrated the significant role of stressful events in aggravating vitiligo in both children and adults.71,72 In children, vitiligo cases and control group experienced stressful events of 57 and 23.8%, respectively, with odds ratio (OR) of 4.26.72 Moreover, adult vitiligo cases significantly underwent more stress than the control group (65 vs. 22%, P = 0.002, OR 6.81).71 The factors involving this condition include poor hygienic conditions, inadequate systemic to topical medication compliance, and uncontrollable environmental factors. Conclusion Flood-related skin diseases represent various clinical spectrums. Multiple factors associated with these varieties including environmental factors (endemic area, the natural course, and severity of disaster) and personal factors (medical and dermatological underlying diseases). Inflammatory skin diseases and infections from bacteria, fungus, traumatic skin diseases, vector-borne diseases, and psycho-emotional disorders potentially cause the enormous problems in the public health system. Psychological health issues from loss should be determined and alleviated. Most importantly, dermatologists and general practitioners should comprehensively enhance with the basic knowledge of these conditions for the accomplishment of efficacious and best treatment outcomes.

Acknowledgments The authors would like to thank Mano Mettanando Laohavanich, MD, PhD, and Ms. Sunattee Kessung for helping with the English manuscript.

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