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Vol. 93. Núm. 6.
Páginas 916-928 (1 novembro 2018)
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Profile of dermatological consultations in Brazil (2018)*
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Sociedade Brasileira de Dermatologia1, Hélio Amante Miot2, Gerson de Oliveira Penna3,4, Andréa Machado Coelho Ramos5, Maria Lúcia Fernandes Penna6, Sílvia Maria Schmidt2, Flávio Barbosa Luz2, Maria Auxiliadora Jeunon Sousa2, Sérgio Luiz Lira Palma2, José Antonio Sanches Junior2
1 Brazilian Society of Dermatology (SBD) - Rio de Janeiro (RJ), Brazil
2 Board of directors of the Sociedade Brasileira de Dermatologia, Rio de Janeiro (RJ), Brasil
3 Tropical Medicine Nucleus, Universidade de Brasília, Brasília (DF), Brasil
4 Fiocruz School of Government, Fundação Oswaldo Cruz, Brasília (DF), Brasil
5 Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brasil
6 Universidade Federal Fluminense, Niterói (RJ), Brasil
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Table 1. Main diagnoses of dermatological consultations (n = 9629)
Table 2. Primary diagnoses by age group
Table 3. Main diagnoses by skin color
Table 4. Distribution of diagnoses by gender
Table 5. Distribution of diagnoses by type of funding for consultation
Table 6. Distribution of diagnoses by type of consultation
Table 7. Distribution of diagnoses by region in Brazil
Table 8. Frequencies of (standard) treatments resulting from consultations
Table 9. Frequencies of (standard) treatments by type of funding for consultation
Table 10. Multivariate analysis (multiple logistic regression) comparing the frequency of Hansen disease, psoriasis, and nonmelanoma skin cancer by region in Brazil, gender, age group, city size, skin color, funding type, and consultation type
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Abstract

Background: Dermatological diseases are among the primary causes of the demand for basic health care. Studies on the frequency of dermatoses are important for the proper management of health planning.

Objectives: To evaluate the nosological and behavioral profiles of dermatological consultations in Brazil.

Methods: The Brazilian Society of Dermatology invited all of its members to complete an online form on patients who sought consultations from March 21-26, 2018. The form contained questions about patient demographics, consultation type according to the patient’s funding, the municipality of the consultation, diagnosis, treatments and procedures. Diagnostic and therapeutic decisions were compared between subgroups.

Results: Data from 9629 visits were recorded. The most frequent causes for consultation were acne (8.0%), photoaging (7.7%), nonmelanoma skin cancer (5.4%), and actinic keratosis (4.7%). The identified diseases had distinct patterns with regard to gender, skin color, geographic region, type of funding for the consultation, and age group. Concerning the medical conducts, photoprotection was indicated in 44% of consultations, surgical diagnostic procedures were performed in 7.3%, surgical therapeutic procedures were conducted in 19.2%, and cosmetic procedures were performed in 7.1%.

Study limitations: Nonrandomized survey, with a sample period of one week.

Conclusion: This research allowed us to identify the epidemiological profiles of the demands of outpatients for dermatologists in various contexts. The results also highlight the importance of aesthetic demands in privately funded consultations and the significance of diseases such as acne, nonmelanoma skin cancer, leprosy, and psoriasis to public health.

Keywords:
Dermatology
Diagnosis
Epidemiology
Therapeutics
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Introduction

Dermatological diseases are frequent among those who seek health care and are among the initial causes of the demand for outpatient services.1 Because they are often visible to others, they are a source of embarrassment and social rejection, leading to psychological suffering.2,3 Although certain dermatological diseases can be treated in the primary care setting, many require specialized care.4

A 2017 publication reported that in the US, the burden of dermatological diseases is high and that its direct and indirect costs are comparable with those of other diseases, such as diabetes and cardiovascular diseases. This tremendous expense is due to the implementation of treatments – not to the diagnostic phase. Overall, 1 in 4 individuals of all ages in the US were seen by a doctor for at least 1 skin disease in 2013. In 2013, skin diseases resulted in direct health costs of 75 billion USD and, indirectly, opportunity costs of 11 billion USD in the US.5

Skin diseases place a huge burden on global health. Collectively, skin conditions were the fourth leading cause of nonfatal disease burden, expressed in years lost due to disability, in 2010. Taking into account the loss of health due to premature death, expressed in disability-adjusted life years (DALYs), skin is the 18th leading cause. Based on the distribution of dermatological diseases by age, DALYs peak between age 10 and 20 years due to acne and at age 60 years due to nonmelanoma skin cancers.1

However, there is a trend toward the nonvalorization of such diseases by those who are responsible for defining health care policies, due to the underestimation of their lethality and morbidity as a health problem. Several studies have shown that dermatological diseases have a significant impact on the quality of life of those who are affected, especially those who are chronically ill, highlighting the need for their valorization as a health issue by those who formulate public policies, because they are, in fact, valued by affected patients. Individuals with dermatological diseases perceive their health to be affected, feel limited in performing their daily tasks, and experience a loss of vitality, lowering their quality of life.6-14 Dermatological diseases are therefore limiting, causing school and work absenteeism, and their carriers are more likely to experience anxiety and depression.3,15-17

Studies on the distribution of these diseases are important for the proper management of health planning, with regard to health plans and the Brazilian public health care system (SUS). The incorporation of new procedures, in association with an aging population, is contributing to the rise in the demand for and cost of care in dermatology.

In 2018, the Brazilian Society of Dermatology (SBD) conducted a survey on diagnoses and procedures that were performed during dermatological consultations, advancing the initiative that was begun in 2006, when the nosological profile of consultations was published.18

Methods

The SBD invited all 8800 dermatologists who were current members to participate in the study, which consisted of the completion of an online form on all patients who were treated from May 21–26, 2018 — the same week of the study that was conducted in 2006.18 The form included the patient’s age, gender, and skin color; city and state size; ICD-10 diagnosis; and their procedures.

For the analysis, certain related diseases were grouped, such as all superficial fungal infections, contact dermatitis, nonmelanoma skin cancers (basal cell and squamous cell carcinoma), and the ectoparasitoses. We also created the category “Others,” which incorporated the diagnoses that were to be elucidated and those diseases with an occurrence of less than 10 cases in the sample.

The main outcome was the frequency of diagnoses that were established at each consultation. Multinomial confidence intervals (95%) were calculated from 10,000 bootstrap replications.19

To evaluate the statistical significance of the univariate analyses of the diagnoses by gender, we applied Spearman’s rank correlation coefficient to the entire set of diagnoses from each table.

To examine the association of known variables with frequent and important diagnoses with regard to public health, we hypothesized a case control study with an outpatient basis, in which the main diagnosis corresponded to the cases, while the other diagnoses corresponded to the controls. We then estimated the association, based on the adjusted odds ratio by multivariate logistic regression. 20

The study was approved by the research ethics committee of UNESP (n° 2.668.226).

Results

Eight hundred eighty-five dermatologists completed the survey, which corresponds to 10% of the members of the Society at the time. Data were collected from 9629 consultations, with 13,293 diagnoses, wherein 61.9% of patients had only 1 diagnosis, 29.7% had 2, 7.7% had 3, and 0.7% had 4.

The 9629 patients had a mean (standard deviation) age of 42.8 (21.1) years (Figure 1); 65.1% (6266) was female, and 68.6% (6601) was Caucasian. Regarding funding for the consultation, 48.7% (4685) was financed by health plans, 25.0% (2409) was privately (out of pocket) funded, and 26.3% (2535) was funded by the SUS.

Figure 1.

Age histogram of attended patients (n = 9627)

(0.02MB).

Table 1 shows the 60 most frequent diagnoses in the consultations, corresponding to 98.3% of attended cases. Acne was the most frequent diagnosis (8.0%), followed by photoaging (7.7%), nonmelanoma skin cancer (6.6%), actinic keratosis (4.7%), and superficial mycoses (4.5%).

Table 1.

Main diagnoses of dermatological consultations (n = 9629)

  Diagnosis  95% CI* 
Acne  771  8.0  7.5-8.6 
Photoaging /Skin aging  746  7.7  7.2-8.3 
Nonmelanoma skin cancer  633  6.6  6.1-7.1 
Actinic keratosis / Actinic cheilitis  451  4.7  4.3-5.1 
Superficial mycosis (tinea versicolor, dermatophytosis, onychomycosis)  437  4.5  4.1-5.0 
Psoriasis  421  4.4  4.0-4.8 
Melasma  357  3.7  3.3-4.1 
Others**  349  3.6  3.3-4.1 
Melanocytic nevus  333  3.5  3.1-3.8 
10  Atopic dermatitis  326  3.4  3.0-3.8 
11  Contact dermatitis (allergic, irritant)  325  3.4  3.0-3.7 
12  Male or female pattern androgenetic alopecia  307  3.2  2.8-3.5 
13  Seborrheic keratosis  300  3.1  2.8-3.5 
14  Acne in adult women  250  2.6  2.3-2.9 
15  Seborrheic dermatitis  223  2.3  2.0-2.6 
16  Viral wart  207  2.1  1.9-2.5 
17  Telogen effluvium  196  2.0  1.8-2.3 
18  Epidermal cyst / trichilemmal cyst  169  1.8  1.5-2.0 
19  Acrochordon (skin tag) / molluscum pendulum  167  1.7  1.5-2.0 
20  Vitiligo  158  1.6  1.4-1.9 
21  Leprosy  137  1.4  1.2-1.7 
22  Rosacea  124  1.3  1.1-1.5 
23  Alopecia areata  120  1.2  1.0-1.5 
24  Folliculitis  110  1.1  0.9-1.4 
25  Cutaneous xerosis / Asteatosis  106  1.1  0.9-1.3 
26  Hypertrophic scar/Keloid  97  1.0  0.8-1.2 
27  Lichen simplex chronicus/ Prurigo / Chronic eczema  94  1.0  0.8-1.2 
28  Pruritus (sine materiae)  85  0.9  0.7-1.1 
29  Scabies / Pediculosis  84  0.9  0.7-1.1 
30  Solar lentigo / Solar melanosis  83  0.9  0.7-1.1 
31  Cicatricial alopecia (lupus, folliculitis decalvans, lichen planus pilaris)  82  0.9  0.7-1.0 
32  Urticaria /Angioedema  73  0.8  0.6-0.9 
33  Molluscum contagiosum  71  0.7  0.6-0.9 
34  Melanoma  64  0.7  0.5-0.8 
35  Post-inflammatory hyperpigmentation  63  0.7  0.5-0.8 
36  Cutaneous lupus erythematosus  60  0.6  0.5-0.8 
37  Striae distansae  58  0.6  0.5-0.8 
38  Chronic lower limb ulcer  58  0.6  0.4-0.8 
39  Impetigo and ecthyma  55  0.6  0.4-0.7 
40  Drug eruptions  53  0.6  0.4-0.7 
41  Onycholysis / Onychomadesis/ Onychomalacia / Onychodystrophy  53  0.6  0.4-0.7 
42  Acne scar  49  0.5  0.4-0.7 
43  Pemphigus and pemphigoid  46  0.5  0.3-0.6 
44  Anogenital warts (HPV) / Condyloma  44  0.5  0.3-0.6 
45  Keratosis pilaris  43  0.4  0.3-0.6 
46  Cutaneous lymphoma and lymphomatoid proliferations  42  0.4  0.3-0.6 
47  Lipoma  41  0.4  0.3-0.6 
48  Cutaneous / systemic scleroderma  37  0.4  0.3-0.5 
49  Pityriasis rosea  34  0.4  0.2-0.5 
50  Herpes zoster  31  0.3  0.2-0.4 
51  Ingrown toenail / Onychocryptosis  30  0.3  0.2-0.4 
52  Dermatofibroma  29  0.3  0.2-0.4 
53  Genital / extralabial herpes  25  0.3  0.2-0.4 
54  Hidradenitis suppurativa  24  0.2  0.2-0.4 
55  Pityriasis alba  22  0.2  0.1-0.3 
56  Subcutaneous / Systemic mycosis  21  0.2  0.1-0.3 
57  Syringoma / Sweat glands neoplasms  20  0.2  0.1-0.3 
58  Lichen planus  19  0.2  0.1-0.3 
59  Hemangioma  18  0.2  0.1-0.3 
60  Syphilis  17  0.2  0.1-0.3 
*

95% CI: 95% confidence interval calculated from 10,000 bootstrap replications;

**

Diagnoses with fewer than 10 occurrences or to be clarified

Tables 2 to 7 present the leading 10 causes by age group, skin color, gender, type of funding for the consultation, type of consultation (first or second appointment), and demographic region. In these tables, differences were statistically significant between age groups, genders, and types of funding for consultation; there was no significance between the classifications by phototype, type of consultation, and demographic region.

Table 2.

Primary diagnoses by age group

0-12 years old12-24 years old
  Diagnosis  Diagnosis 
Atopic dermatitis  212  25.8  Acne  557  41.2 
Molluscum contagiosum  61  7.4  Contact dermatitis  58  4.3 
Viral wart  55  6.7  Atopic dermatitis  55  4.1 
Acne  48  5.8  Superficial mycosis  49  3.6 
Others  34  4.1  Melanocytic nevus  42  3.1 
Superficial mycosis  32  3.9  Psoriasis  40  3.0 
Melanocytic nevus  32  3.9  Viral wart  34  2.5 
Scabies / Pediculosis  29  3.5  Others  32  2.4 
Vitiligo  29  3.5  Striae distensiae  31  2.3 
10  Alopecia areata  24  2.9  Male or female pattern androgenetic alopecia  31  2.3 
11  Seborrheic dermatitis  20  2.4  Seborrheic dermatitis  28  2.1 
12  Contact dermatitis  19  2.3  Acne in adult women  28  2.1 
13  Impetigo and ecthyma  18  2.2  Telogen effluvium  24  1.8 
14  Psoriasis  18  2.2  Alopecia areata  23  1.7 
15  Hemangioma  14  1.7  Folliculitis  20  1.5 
16  Diaper dermatitis  14  1.7  Vitiligo  19  1.4 
17  Pityriasis alba  14  1.7  Hypertrophic scar  19  1.4 
18  Lichen simplex chronicus  12  1.5  Scabies / Pediculosis  15  1.1 
19  Xerosis / Asteatosis  11  1.3  Epidermoid cysts  15  1.1 
20  Keratosis pilaris  1.1  Urticaria  14  1.0 
25-59 years old60 years and older
  Diagnosis  N  %  Diagnosis  N  % 
1  Photoaging  540  10.5  Nonmelanoma skin cancer  446  19.3 
2  Melasma  341  6.6  Actinic keratosis  299  12.9 
3  Psoriasis  251  4.9  Photoaging  202  8.7 
4  Superficial mycosis  244  4.7  Seborrheic keratosis  144  6.2 
5  Melanocytic nevus  225  4.4  Psoriasis  112  4.8 
6  Male or female pattern androgenetic alopecia  221  4.3  Superficial mycosis  112  4.8 
7  Acne in adult women  220  4.3  Contact dermatitis  78  3.4 
8  Others  208  4.0  Others  75  3.2 
9  Nonmelanoma skin cancer  179  3.5  Male or female pattern androgenetic alopecia  52  2.3 
10  Contact dermatitis  170  3.3  Pruritus (sine materiae)  44  1.9 
11  Acne  156  3.0  Acrochordon /skin tag  42  1.8 
12  Seborrheic keratosis  149  2.9  Epidermoid cysts  42  1.8 
13  Actinic keratosis  149  2.9  Lower limb ulcer  38  1.6 
14  Seborrheic dermatitis  143  2.8  Xerosis / Asteatosis  35  1.5 
15  Telogen effluvium  141  2.7  Melanocytic nevus  34  1.5 
16  Acrochordon /skin tag  116  2.3  Seborrheic dermatitis  32  1.4 
17  Epidermoid cysts  109  2.1  Leprosy  32  1.4 
18  Vitiligo  95  1.8  Rosacea  30  1.3 
19  Viral wart  90  1.7  Solar lentigo / Solar melanosis  30  1.3 
20  Leprosy  88  1.7  Telogen effluvium  29  1.3 

Spearman rank R: −0.07 t=−7.23 p<0.01

Table 3.

Main diagnoses by skin color

COLOR - WhiteCOLOR - Non-white
  Diagnosis  Diagnosis 
Photoaging  628  9.5  Acne  225  7.4 
Nonmelanoma skin cancer  564  8.5  Superficial mycosis  175  5.8 
Acne  546  8.3  Melasma  168  5.5 
Actinic keratosis  418  6.3  Psoriasis  159  5.3 
Melanocytic nevus  281  4.3  Atopic dermatitis  128  4.2 
Superficial mycosis  262  4.0  Photoaging  118  3.9 
Psoriasis  262  4.0  Contact dermatitis  116  3.8 
Others  246  3.7  Others  103  3.4 
Seborrheic keratosis  215  3.3  Acne in adult women  97  3.2 
10  Male or female pattern androgenetic alopecia  211  3.2  Seborrheic dermatitis  97  3.2 
11  Contact dermatitis  209  3.2  Male or female pattern androgenetic alopecia  96  3.2 
12  Atopic dermatitis  198  3.0  Leprosy  91  3.0 
13  Melasma  189  2.9  Seborrheic keratosis  85  2.8 
14  Acne in adult women  153  2.3  Acrochordon / skin tag  70  2.3 
15  Viral wart  142  2.2  Nonmelanoma skin cancer  69  2.3 
16  Telogen effluvium  138  2.1  Viral wart  65  2.1 
17  Seborrheic dermatitis  126  1.9  Epidermoid cysts  63  2.1 
18  Rosacea  113  1.7  Telogen effluvium  58  1.9 
19  Epidermoid cysts  106  1.6  Vitiligo  58  1.9 
20  Vitiligo  100  1.5  Alopecia areata  56  1.8 

Spearman rank R: 0.01 t=0.815 p=0.42.

Table 4.

Distribution of diagnoses by gender

FemaleMale
  Diagnosis  Diagnosis 
Photoaging  682  10.9  Acne  385  11.4 
Acne  386  6.2  Nonmelanoma skin cancer  312  9.3 
Melasma  335  5.3  Actinic keratosis  193  5.7 
Nonmelanoma skin cancer  321  5.1  Superficial mycosis  192  5.7 
Actinic keratosis  258  4.1  Psoriasis  180  5.4 
Superficial mycosis  245  3.9  Atopic dermatitis  138  4.1 
Acne in adult women  243  3.9  Melanocytic nevus  128  3.8 
Psoriasis  241  3.8  Others  109  3.2 
Others  240  3.8  Seborrheic dermatitis  105  3.1 
10  Contact dermatitis  224  3.6  Contact dermatitis  101  3.0 
11  Male or female pattern androgenetic alopecia  206  3.3  Androgenetic alopecia  101  3.0 
12  Seborrheic keratosis  206  3.3  Seborrheic keratosis  94  2.8 
13  Melanocytic nevus  205  3.3  Viral wart  86  2.6 
14  Atopic dermatitis  188  3.0  Leprosy  76  2.3 
15  Telogen effluvium  187  3.0  Acrochordon /skin tag  71  2.1 
16  Viral wart  121  1.9  Photoaging  64  1.9 
17  Seborrheic dermatitis  118  1.9  Alopecia areata  64  1.9 
18  Vitiligo  115  1.8  Epidermoid cysts  61  1.8 
19  Epidermoid cysts  108  1.7  Folliculitis  53  1.6 
20  Acrochordon /skin tag  96  1.5  Vitiligo  43  1.3 

Spearman rank R: −0.15 t=−15.00 p<0.01

Table 5.

Distribution of diagnoses by type of funding for consultation

COVERAGE / HEALTH INSURANCEPRIVATE / OUT OF POCKET PAYMENTSUS / PUBLIC
  Diagnosis  Diagnosis  Diagnosis 
Acne  497  10.6  Photoaging  495  20.5  Nonmelanoma skin cancer  297  11.7 
Superficial mycosis  261  5.6  Acne  160  6.6  Psoriasis  225  8.9 
Actinic keratosis  230  4.9  Nonmelanoma skin cancer  155  6.4  Leprosy  131  5.2 
Melasma  227  4.8  Others  149  6.2  Actinic keratosis  128  5.0 
Photoaging  201  4.3  Male or female pattern androgenetic alopecia  114  4.7  Superficial mycosis  121  4.8 
Seborrheic keratosis  200  4.3  Actinic keratosis  93  3.9  Acne  114  4.5 
Melanocytic nevus  187  4.0  Contact dermatitis  88  3.7  Atopic dermatitis  90  3.6 
Nonmelanoma skin cancer  181  3.9  Psoriasis  85  3.5  Others  83  3.3 
Atopic dermatitis  179  3.8  Melasma  80  3.3  Melanocytic nevus  70  2.8 
10  Acne in adult women  172  3.7  Melanocytic nevus  76  3.2  Vitiligo  68  2.7 
11  Contact dermatitis  171  3.6  Atopic dermatitis  57  2.4  Contact dermatitis  66  2.6 
12  Male or female pattern androgenetic alopecia  154  3.3  Superficial mycosis  55  2.3  Seborrheic dermatitis  51  2.0 
13  Seborrheic dermatitis  140  3.0  Acne in adult women  55  2.3  Photoaging  50  2.0 
14  Acrochordon /skin tag  138  2.9  Seborrheic keratosis  51  2.1  Melasma  50  2.0 
15  Telogen effluvium  137  2.9  Rosacea  46  1.9  Seborrheic keratosis  49  1.9 
16  Viral wart  134  2.9  Telogen effluvium  39  1.6  Alopecia areata  45  1.8 
17  Epidermoid cysts  124  2.6  Vitiligo  38  1.6  Chronic ulcer  42  1.7 
18  Others  117  2.5  Seborrheic dermatitis  32  1.3  Viral wart  41  1.6 
19  Psoriasis  111  2.4  Viral wart  32  1.3  Pemphigus and pemphigoid  41  1.6 
20  Folliculitis  60  1.3  Cicatricial alopecia  30  1.2  Male or female pattern androgenetic alopecia  39  1.5 

Spearman rank R: −0.09 t=−8.52 p<0.01

Table 6.

Distribution of diagnoses by type of consultation

FIRST APPOINTMENTSECOND APPOINTMENT
  Diagnosis  Diagnosis 
Acne  386  8.2  Photoaging  260  9.9 
Superficial mycosis  282  6.0  Acne  386  7.9 
Photoaging  260  5.5  Nonmelanoma skin cancer  255  7.7 
Nonmelanoma skin cancer  255  5.4  Psoriasis  115  6.2 
Contact dermatitis  202  4.3  Actinic keratosis  190  5.3 
Atopic dermatitis  197  4.2  Others  160  3.9 
Seborrheic keratosis  197  4.2  Melasma  170  3.8 
Actinic keratosis  190  4.0  Male or female pattern androgenetic alopecia  140  3.4 
Melanocytic nevus  189  4.0  Superficial mycosis  282  3.2 
10  Melasma  170  3.6  Melanocytic nevus  189  2.9 
11  Others  160  3.4  Atopic dermatitis  197  2.6 
12  Seborrheic dermatitis  148  3.1  Contact dermatitis  202  2.5 
13  Acne in adult women  146  3.1  Viral wart  90  2.4 
14  Male or female pattern androgenetic alopecia  140  3.0  Acne in adult women  146  2.1 
15  Telogen effluvium  120  2.5  Seborrheic keratosis  197  2.1 
16  Psoriasis  115  2.4  Leprosy  36  2.1 
17  Acrochordon / skin tag  99  2.1  Vitiligo  61  2.0 
18  Epidermoid cysts  93  2.0  Telogen effluvium  120  1.6 
19  Viral wart  90  1.9  Epidermoid cysts  93  1.6 
20  Xerosis / Asteatosis  72  1.5  Seborrheic dermatitis  148  1.5 

Spearman Rank R: 0.01 t=0.95 p=0.34

Table 7.

Distribution of diagnoses by region in Brazil

NorthNortheastSoutheastSouthMidwest
  Diagnosis  Diagnosis  Diagnosis  Diagnosis  Diagnosis 
Acne  110  7.6  Photoaging  52  10.9  Photoaging  374  8.6  NM skin cancer  195  8.9  Acne  119  9.8 
Atopic dermatitis  72  5.0  Acne  38  8.0  Acne  336  7.7  Photoaging  185  8.5  Photoaging  87  7.1 
Superficial mycosis  63  4.4  Leprosy  24  5.0  NM skin cancer  281  6.5  Actinic keratosis  171  7.8  NM skin cancer  73  6.0 
Melasma  63  4.4  NM skin cancer  23  4.8  Superficial mycosis  224  5.2  Acne  168  7.7  Superficial mycosis  56  4.6 
NM skin cancer  61  4.2  Melasma  20  4.2  Psoriasis  205  4.7  Psoriasis  105  4.8  Male or female pattern androgenetic alopecia  55  4.5 
Others  56  3.9  Psoriasis  20  4.2  Actinic keratosis  186  4.3  Melanocytic nevus  100  4.6  Acne in adult women  54  4.4 
Contact dermatitis  54  3.8  Superficial mycosis  18  3.8  Others  180  4.1  Seborrheic keratosis  79  3.6  Contact dermatitis  51  4.2 
Photoaging  48  3.3  Atopic dermatitis  17  3.6  Melasma  154  3.5  Superficial mycosis  76  3.5  Actinic keratosis  51  4.2 
Psoriasis  44  3.1  Seborrheic keratosis  17  3.6  Melanocytic nevus  149  3.4  Contact dermatitis  72  3.3  Melasma  49  4.0 
10  Acrochordon /skin tag  44  3.1  Acne in adult women  16  3.4  Contact dermatitis  135  3.1  Melasma  71  3.2  Psoriasis  47  3.9 
11  Seborrheic dermatitis  43  3.0  Male or female pattern androgenetic alopecia  15  3.2  Atopic dermatitis  134  3.1  Male or female pattern androgenetic alopecia  69  3.2  Seborrheic keratosis  44  3.6 
12  Scabies / Pediculosis  42  2.9  Actinic keratosis  15  3.2  Seborrheic keratosis  130  3.0  Others  66  3.0  Melanocytic nevus  39  3.2 
13  Male or female pattern androgenetic alopecia  39  2.7  Seborrheic dermatitis  14  2.9  Male or female pattern androgenetic alopecia  129  3.0  Atopic dermatitis  65  3.0  Atopic dermatitis  38  3.1 
14  Epidermoid cysts  39  2.7  Contact dermatitis  13  2.7  Acne in adult women  104  2.4  Viral wart  52  2.4  Others  36  3.0 
15  Acne in adult women  36  2.5  Acrochordon /skin tag  12  2.5  Viral wart  104  2.4  Vitiligo  51  2.3  Seborrheic dermatitis  30  2.5 
16  Melanocytic nevus  33  2.3  Melanocytic nevus  12  2.5  Seborrheic dermatitis  100  2.3  Telogen effluvium  49  2.2  Acrochordon / skin tag  25  2.0 
17  Seborrheic keratosis  30  2.1  Others  11  2.3  Telogen effluvium  89  2.0  Rosacea  48  2.2  Alopecia areata  25  2.0 
18  Actinic keratosis  28  1.9  Epidermoid cysts  1.9  Epidermoid cysts  80  1.8  Acne in adult women  40  1.8  Telogen effluvium  24  2.0 
19  Telogen effluvium  26  1.8  Viral wart  1.9  Vitiligo  65  1.5  Seborrheic dermatitis  36  1.6  Leprosy  21  1.7 
20  Viral wart  26  1.8  Telogen effluvium  1.7  Leprosy  62  1.4  Acrochordon /skin tag  30  1.4  Cicatricial alopecia  17  1.4 

Spearman rank R: −0.01 t=−0.08 p=0.94

Figure 2 shows the age histograms of the frequency of atopic dermatitis, acne, nonmelanoma skin cancer, and photoaging; Figure 3 shows the age histograms for superficial mycoses, leprosy, actinic keratosis, and psoriasis.

Figure 2.

Age histograms for patients diagnosed with atopic dermatitis, acne, nonmelanoma skin cancer, and photoaging

(0.06MB).
Figure 3.

Age histograms for patients diagnosed with superficial mycoses, Hansen disease, actinic keratosis, and psoriasis

(0.05MB).

With regard to skin color, diagnoses of photoaging (9.5%), nonmelanoma skin cancer (8.5%), and acne (8.3%) were more frequent among whites, compared with acne (7.4%), superficial mycoses (5.8%), and melasma (5.5%), in non-whites. Although acne was the third most common condition in whites, its frequency was higher among non-whites. This phenomenon resulted non-significant regarding the ordination (rank) distribution, although diagnoses of photoaging and nonmelanoma skin cancer were more frequent among whites.

Between genders, women were most frequently diagnosed with photoaging (10.9%) and acne (6.2%), versus acne (11.4%) and nonmelanoma skin cancer (9.3%) in men, confirming that the demand for dermatological care for aesthetic reasons is greater in females.

Regarding infectious diseases, the most frequent diagnosis was superficial mycoses, with 437 cases (4.5%). Moreover, 44 (0.5%) patients had a diagnosis of genital warts, 137 (1.4%) had leprosy, 61 (0.6%) had syphilis, 84 (0.9%) had scabies / pediculosis, and 71 (0.7%) had molluscum contagiosum.

When we considered all consultation-based diagnoses - not only the main diagnosis - the most relevant result was the increase in the proportion of patients who were affected by the most common diseases. For example, 48.4% of patients aged between 13 and 24 years had a diagnosis of acne, and 24.1% of those aged 60 years and older had a diagnosis of nonmelanoma skin cancer, whereas these diseases were the chief diagnoses in the consultations in 41.2% and 19.3% of the age groups above.

Table 8 shows the most frequent standard treatments and the proportion of patients to whom they were administered. Table 9 shows the practices and the proportion of patients by funding type. Notably, each patient received more than 1 treatment, for example, 2.51 indications on average in consultations funded by health plans, compared with 2.61 for private funding and 2.16 for SUS-funded consultations.

Table 8.

Frequencies of (standard) treatments resulting from consultations

CONDUCT  % of patients 
Topical Medications1  4922  51.1 
Sunscreen  4232  44.0 
Moisturizers and emollients  3002  31.2 
Oral medications2  2379  24.7 
Topical cosmeceuticals3  1859  19.3 
Therapeutic surgical procedure4  1838  19.1 
Diagnostic clinical procedure5  801  8.3 
Diagnostic surgical procedure6  706  7.3 
Cosmetic surgical procedure7  674  7.0 
Nutraceuticals, antioxidants and food supplements  605  6.3 
Botulinum toxin  524  5.4 
Fillers/volumizers  303  3.1 
Phototherapy8  149  1.5 
Immunobiologicals9  65  0.7 
1

e.g., corticoid, antifungal, antimicrobial, tretinoin, minoxidil

2

e.g., antimicrobials, antihistamines, isotretinoin, immunosuppressants

3

e.g., antioxidants, retinoids, soaps

4

e.g., electrocoagulation, excision and suturing, cryosurgery

5

e.g., dermatoscopy, Wood’s lamp, esthesiometer

6

e.g., biopsy, puncture, mycological examination

7

e.g., peeling, laser, needling, microdermabrasion

8

e.g., PUVA, NBUVB, PUVA sun

9

e.g., anti-TNF, anti-IgE, anti-IL17

Table 9.

Frequencies of (standard) treatments by type of funding for consultation

CONDUCT / PRESCRIPTIONCoverage / health insurancePrivate / Out of pockeSUS / public
    % of patients  % of patients  % of patients 
All procedures  11741  250.6  6266  260.1  5474  215.9 
Topical medications  2657  56.7  1045  43.4  1220  48.1 
Sunscreen  2203  47.0  988  41.0  1041  41.1 
Moisturizers and emollients  1456  31.1  672  27.9  874  34.5 
Oral medications  1056  22.5  583  24.2  740  29.2 
Topical cosmeceuticals  1128  24.1  525  21.8  206  8.1 
Therapeutic surgical procedure  1012  21.6  349  14.5  477  18.8 
Diagnostic clinical procedure  415  8.9  212  8.8  174  6.9 
Diagnostic surgical procedure  338  7.2  126  5.2  242  9.5 
10  Cosmetic surgical procedure  181  3.9  432  17.9  61  2.4 
11  Nutraceuticals and antioxidants  355  7.6  213  8.8  37  1.5 
12  Botulinum toxin  134  2.9  381  15.8  0.4 
13  Fillers/volumizers  79  1.7  222  9.2  0.1 
14  Phototherapy  43  0.9  46  1.9  60  2.4 
15  Immunobiologicals  14  0.3  18  0.7  33  1.3 

Spearman rank R: 0.03 t=4.33 p<0.01

Table 10 presents the results of the logistic regression, comparing certain diseases by region in Brazil, gender, age group, and funding type. Leprosy was associated with regional differences, a preponderance of SUS-based care, males the working age group, non-white skin color, and the need for subsequent appointments. The frequency of psoriasis was higher in the south of Brazil, those in the public health care system, males, the economically productive age group, and those who required return visits. Nonmelanoma skin cancers were more common in those who were on public assistance, males, resident of smaller towns, and those with white skin color.

Table 10.

Multivariate analysis (multiple logistic regression) comparing the frequency of Hansen disease, psoriasis, and nonmelanoma skin cancer by region in Brazil, gender, age group, city size, skin color, funding type, and consultation type

LEPROSYPSORIASISNONMELANOMA CA
    OR*  OR*  OR* 
Region  2.07  0.02  0.78  0.37  1.62  0.07 
  NE  4.52  0.00  0.83  0.70  1.30  0.95 
  0.25  0.00  1.16  0.02  1.22  0.60 
  MW  1.24  0.99  0.74  0.17  1.35  0.66 
  SE       
Funding type  Coverage / health insurance  0.01  0.00  0.31  0.00  0.32  0.00 
  Private /out of pocket payment  0.03  0.03  0.42  0.03  0.42  0.01 
  SUS       
Gender  Female  0.44  0.00  0.69  0.00  0.50  0.00 
  Male       
Age group (years)  0-12  0.30  0.02  0.50  0.01  0.02  0.00 
  13-24  0.78  0.95  0.72  0.37  0.02  0.00 
  25-59  1.50  0.00  1.24  0.00  0.19  0.00 
  >60       
City  <100,000 inhabitants  0.74  0.53  0.57  0.24  1.62  0.01 
  100-300,000 inhabitants  1.07  0.54  0.54  0.05  1.24  0.86 
  >300,000 inhabitants       
Skin color  White  0.53  0.01  0.85  0.15  3.94  0.00 
  Non-white           
Consultation type  First appointment  0.51  0.00  0.47  0.00  0.98  0.83 
  Second appointment       
*

OR: odds ratio

Discussion

Dermatology, as a medical specialty, typically encompasses a high number of nosological entities from skin, mucosae and skin appendages. In parallel, it assists many populations, enclosing all age groups and genders, which, added to the sociocultural, climatic, and ethnic differences of the Brazilian population, results in individualized patterns of disease occurrence.21 All of these elements should be weighed in planning specialty care, public health policies, and medical education.22-26

The most frequent primary diagnosis of the consultations in our study was acne, as well as in a previous report from 2006.18 Actually, acne is the main cause for consultations in Saudi Arabia27 and the US.28 In a study with dermatologists in Spain,4 the most frequent diagnosis was nonmelanoma skin cancer, although acne was the chief diagnosis among those aged under 18 years. The inconsistency between our results and those in Spain is due to the disparate age groups between study populations.

Differences in the occurrence of conditions between ages are expected and are characteristic of the natural history of dermatoses, such as ectoparasitoses and childhood viral infections, in contrast to melasma and acne in adult women and nonmelanoma skin cancers and seborrheic keratosis among the elderly.29-33 Chronic diseases, such as psoriasis and androgenetic alopecia, tend to increase progressively in frequency, depending on the age group.21,34-36 Conversely, more limited diseases, such as acne and atopic dermatitis, become less common in adulthood. Superficial mycoses, in contrast, are frequent in all age groups.

The skin is an organ that interfaces directly with the environment, and external insults can promote several dermatoses. The ethnic and climatic variety in Brazil is considered in the type of epidemiological examination that we performed in this study. Contact dermatitis became frequent in consultations, especially beginning in adolescence, when work activities initiate. Nonmelanoma skin cancer and actinic keratoses were frequent among the elderly, especially those with light skin color who were treated by the public health system, reflecting chronic exposure to ultraviolet radiation in such activities as agriculture and fishing.35,37,38 Melasma was typical in women and non-white adult patients, due to the role of female hormones and miscegenation in its pathogenesis.32, 38-41

In comparing our results with those of the 2006 study, which used only the general ICD-10 category codes, a major difference arose between the two sets of patients with regard to the inclusion of patients with a primary diagnosis of photoaging, which reflects the cosmetic demand for dermatologists, especially in private consultations and among white women. When using the same type of coding as in the previous study, a diagnosis of acne (L70) was given to 10.6% (1021) of patients, whereas skin alterations due to chronic exposure to non-ionizing radiation (L57) was diagnosed in 12.4% (1197) of patients, versus 14.0% and 5.1% in the 2006 study, respectively.

Notably, in our study, superficial mycoses were the fifth most frequent diagnosis (4.5%) compared with the second most common diagnosis in the 2006 study (8.7%). This difference is attributed to the finding that in SUS-funded patients, this was the main diagnosis in 2006 (9.8%) but remained the fifth most frequent diagnosis in our subjects (4.8%) (Table 5), likely reflecting a greater capacity for diagnosis and treatment for basic care in the SUS system.

Psoriasis was the tenth most frequent diagnosis in 2006 (2.5% of patients) but the sixth most frequent cause of consultations (4.4%) in 2018. This increase is likely due to greater awareness by the patients, generating greater demand for diagnosis and better adherence to treatment.42 Disease chronicity, associated with population aging, also contributes to the increased need for specialized care.43,44 The distribution of diagnoses between regions reflects the survey of capital cities in 2014, in which psoriasis was more prevalent in the south and southeast.34 Our regional differences in the rates of vitiligo, leprosy, and hidradenitis suppurativa also reproduced the findings of population-based studies in Brazil, which might be attributed to the regional ethnic composition.45-48

The differences in diagnoses regarding funding source (public, health insurance, and out of pocket payment) reflect the socioeconomic variation in patients and the need for referrals to specialists in comparing those who are covered by SUS and health insurance. Regarding socioeconomic differences, leprosy constituted 5.2% of diagnoses in SUS subjects (third most frequent) but was absent from the 20 most frequent diagnoses in health insurance and private consultations. The initial cause in diagnoses among private consultations was photoaging, with 20.5% of diagnoses, demonstrating the importance of the demand for cosmetic consultations in self-financed private practice. This pattern is reflected in the procedures that were performed, wherein the use of botulinum toxin and fillers was much more prevalent in private versus SUS and health insurance consultations. There were also more prescriptions for topical cosmeceuticals among insurance-based consultations (24.1% of patients) and for private patients (21.8%).

Before we discuss the logistic regression results, we must highlight the proposal to consider the data as a case control study — ie, considering the diagnoses for leprosy (and psoriasis and nonmelanoma cancer, analyzed separately) as “cases” and the other diagnoses as their “controls,” assuming that these groups are comparable if their selection has not been biased. To have a bias, the selection of the patient pool should alter the proportion of cases and other aspects of interest (eg, age, gender, region in Brazil). The regression results, expressed as odds ratios as a measure of association, are controlled by other items (covariables) that are included. These non-biased results can be extrapolated to the general population.

Leprosy and psoriasis were more frequent in second appointments, which is consistent with the fact that they are chronic diseases. As expected, the risk of leprosy was greater among the population that was covered by the SUS, males, non-whites, and those aged over 24 years. Unexpectedly, the northeast region of Brazil was at greater risk than those in the midwest, in contrast to published epidemiological data, although the detection rates in northeast have risen significantly.47,48 Another interpretation is that there was selection bias, because the northeast region was the least adherent in this study.

By regression analysis, there was a higher risk of psoriasis consultations in the southern region, the SUS-covered population, and those aged between 25 and 59 years, whereas for non-melanoma cancers, there was no statistically significant difference between regions, with a higher risk among those aged over 60 years and cities with fewer than 100,000 inhabitants. The latter association - a greater risk for cities - can be explained by such cities harboring populations with a history of outdoor work, such as agriculture and livestock.30,37

Finally, it is important to highlight the high proportion of patients with prescriptions for sunscreen (44%), which demonstrates a preventive approach and an attitude toward health education that are adopted by professionals.49 Diagnostic and therapeutic surgical procedures were indicated in 26.4% of visits, highlighting the prevalence of such methods in the actual clinical practice of Brazilian dermatologists.

Cosmetic/aesthetic procedures, such as the application of botulinum toxin and fillers, were more frequent among private consultations than those that were funded by health insurance or the SUS. Conversely, prescriptions for immunobiologicals were more common in SUS-based consultations, although it is unusual (1.3% of SUS patients, 0.7% of private patients, and 0.3% of health insurance-covered patients), likely reflecting their high cost, which is dependent on public funding.

The study limitations primarily concern the lack of randomization due to the spontaneous and heterogeneous adherence of dermatologists; however, all covariates (demographic, geography, and care) were considered. Another limitation was that the sample comprised only one epidemiologic week, which might have influenced the frequency of diseases with seasonal characteristics, such as psoriasis, leishmaniasis, and mycoses.50 Nevertheless, the same epidemiological week was chosen as in the 2006 study to allow comparisons to be made, constituting the main source of information on the demand for dermatological services in Latin America.

Conclusion

This research has allowed us to determine the epidemiological profile of outpatient demand for Brazilian dermatologists in various contexts. The results also highlight the importance of the demand for surgical and cosmetic procedures for private consultations and the significant of such diseases as nonmelanoma skin cancer, leprosy, and psoriasis to the public health.

Acknowledgements

The SBD members who contributed to this study.

This is an original article of institutional authorship of the Brazilian Society of Dermatology (SBD). It was elaborated from a study coordinated by Dr. Hélio Amante Miot, Dr. Gerson Oliveira Penna, Dr. Andréa Machado Coelho Ramos and Dr. Maria Lúcia Fernandes Penna; under the promotion of the directors: Dr. José Antonio Sanches Júnior, Dr. Sérgio Luiz Lira Palma, Dr. Flávio Barbosa Luz, Dra. Maria Auxiliadora Jeunon Sousa e Dra. Sílvia Maria Schmidt. The main authorship belongs to all the dermatologists who contributed to the construction of knowledge about the health of the skin of the Brazilian population, to whom the SBD acknowledges.

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Work conducted at Brazilian Society of Dermatology, Rio de Janeiro (RJ), Brazil.

Financial support: Brazilian Society of Dermatology.

Conflict of interest: None.

Copyright © 2018. Anais Brasileiros de Dermatologia
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To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.