Flood and skin diseases

Dr Dharmakanta Kumbhakar

(The writer can be reached at drkdharmakanta@yahoo.com)

Most of the skin diseases during or after flood occur due to usage of damp and wet cloth, excessive exposure to contaminated water, prolonged immersion in water, friction, high humidity and unhygienic environment and cutaneous manifestations of many flood-born communicable diseases.

Eczema is the most common skin problem during the period of flood. Skin maceration at web space(s) of toes are chronic irritant dermatitis with secondary bacterial colonization. Superficial fungal infection and bacterial skin infection are accounted in most cases. Whenever skin integrity is breached, the normal flora colonizing the skin can become source of infection to cause cellulitis.

Trichphyton mentagrophytes (ringworm) infection among flood-affected people is directly related to occlusion of the skin (causes low CO2 tension on skin surface) by wet clothing.

Schistosome cercaria, is able to penetrate human skin and causes Cercarial Dermatitis presenting with skin rash. Mycobacterium marinum may form granulomatous infections with a sporotrichoid pattern. Skin abrasions even superficial cuts, can provide potential portal of entry for Clostridium tetani to cause tetanus. Rat bites are a risk for rare organisms such as Spirillum minus and Streptobacillus moniliformis, which has been described as popular urticariabacterial folliculitis.

Injuries to the feet from prolonged immersion in water or contact with dampness, in a range of environmental temperatures, may present as "immersion foot syndromes." Continuous immersion of the foot in water or mud of temperatures above 22°C for periods ranging from 2 to 10 days may cause tropical immersion foot or "paddy foot". The erythema affects the dorsum of the foot but not the plantar surfaces. Papules, vesicles, or both may appear, sometimes with a hemorrhagic component. It can be prevented by 24-hour drying after each 48 hours of water exposure. Rapid-drying boots and socks may delay the onset of tropical immersion.

After one to three days of intermittent exposure to warm water or mud, there may cause Warm Water Immersion Foot or "moon-boot syndrome", where pain and tingling on foot along with thickened, severely wrinkled soles and macerated changes on the sides of the foot seen. But they do not affect the dorsum. Shortly however, thick portions of the sole begin to fissure and peel, shedding completely within 1 to 2 weeks. During this peeling, the stratum corneum may be more susceptible to infection via the fissures. It can be prevented by drying the feet for 6 to 8 hours (overnight) of every 24 hours. Silicone grease applied to the entire foot or to the soles alone retards the development of warm water immersion foot.

Continuous immersion of the foot in water or mud below 15 °C may cause skin maceration along with infection at web space(s) of toes. This is called Trench foot Skin Diseases.

Leptospirosis, Dengue Hemorrhagic Fever (DHF), meningococcal meningitis, typhoid fever and few viral haemorrhagic (VHF) fever may spread during and after flood which has skin manifestation (fever and skin rash).

Leptospirosis is a potentially serious epidemic-prone bacterial infection, transmitted directly from contaminated flood water with rat urine. Transmission occurs through contact of the skin and mucous membranes with flood water, damp soil mud contaminated with rodent urine. Those with open wounds have a higher risk of getting infected. Skin manifestations usually appear on the trunk and take the form of macules, papules, urticaria and petechiae. Erythema nodosum and Kawasaki syndrome are rare complication. Early in the disease, the skin is warm and flushed. Later in severe disease, jaundice and purpura can develop. Human cases of leptospirosis are diagnosed by serologic tests: microscopic agglutination test (MAT), or ELISAs. It can be prevented by a simple antibiotic prophylaxis—taking doxycycline 200 mg, one capsule once weekly.

The skin manifestations of DHF caused by four types of dengue virus transmitted by A aegypti mosquito are petechiae, purpura, oozing from venipuncture and injection sites. More often, a morbilliform eruption begins on the third to fifth day on the inner surfaces of the upper arms, the lateral surface of the thorax, and in the lumbar area. The macular or scarlatiniform rash spreads to the face, neck, shoulders, and thorax. Pruritus can occur if the hands and feet are involved. In the case of dengue, skin eruptions appear in 80% of patients during the remission of fever. They may appear as centrifugal macular, maculopapular, scarlatiniform or petechial eruptions. The rash characteristically starts on the dorsum of hands and feet and spreads to the arms, legs, and torso, while the face is relatively spared. The eruption seen in dengue lasts two hours to several days.

As outbreaks of meningococcal meningitis, patients presenting with fever and rash may occur during flood. Here rash is characteristically petechial, small and irregular and is often raised with pale greyish vesicular centres. It is commonly located on the extremities and the trunk.

In case of typhoid fever, the rose spots appear as slightly raised, non-tender, pink papules that blanch on pressure. They usually appear in crops of 10 to 20 lesions and are often located between the nipple area and the umbilicus on the anterior trunk.

VHF an acute illness due to infection by four viral families (Arenaviridae, Bunyaviridae, Filoviridae and Flaviviridae) may present with skin rash. For patients with septicaemic plague, they may present with purpuric skin lesions, together with gangrene of acral regions leading to Black Death.

Never use wet and damp cloths. Use cloths after washing and drying in sunshine, once the flood is over. Stop prolonged immersion in water or contact with dampness. After exposure to water or mud, wash the feet with clean water, dry it and use antiseptic cream. One can use silicone grease on legs to avoid direct contact of flood water. Never walk in flood water on naked feet, use shoes. Drink pure water, wash your hand before eating and protect from mosquito bite. Wash your house, floor, walls and ceilings with antiseptic, once the flood is over. Take doctor's advice if you notice any skin problem.