DERMATOLOGICAL PROBLEMS IN NATIVE HIGHLANDERS OF LADAKH

Dear Editor

The skin is exposed to increased level of ultraviolet radiation with a shift of spectral intensity towards the shorter wavelengths. The hypoxia and hypocarbia of the mountain environment coupled with extreme cold and lowered atmospheric pressure influence the cutaneous circulation. The hostile environment under these circumstances leads to various medical problems eg. acute mountain sickness, high altitude pulmonary oedema and cold injuries etc [1]. Not much is known about other medical problems in this region. An attempt was made to evaluate dermatological problems in the local population of Ladakh.

A cross sectional study was carried out by holding medical camps in villages in the interior of Ladakh sector with effect from Dec 1995 to Sep 1997. 14 such medical camps were held. Total 1552 outpatients were recorded between 1 to 70 years age group. 29 out of these presented with dermatological problems (Table 1). The diagnosis was primarily clinical. Basic investigations like haemoglobin estimation and urinalysis were done where required. High altitude dermatopathy was observed in 3 (10.4%), high altitude koilonychia in 2 (6.9%) and viral warts in 6 (20.7%). Bacterial infections in 4 (13.8%), pityriasis alba in 3 (10.4%); rosacea, alopecia areata, acne vulgaris and seborrhoeic dermatitis in 2 (6.9%) each; and discoid lupus erythamatosus, vitiligo and keloid in 1 (3.4%) each.

TABLE 1.

Incidence of skin diseases in Ladakh

Disease	Numbers	Percent
High altitude dermatopathy	03	10.4
High altitude koilonychia	02	6.9
Bacterial infections	04	13.8
Viral warts	06	20.7
Pityriasis alba	03	10.4
Seborrhoeic dermatitis	02	6.9
Acne vulgaris	02	6.9
Rosacea	02	6.9
Alopecia areata	02	6.9
Discoid lupus erythamatosus	01	3.4
Vitiligo	01	3.4
Keloid	01	3.4
Total	29	100

The study was conducted to evaluate the incidence of skin diseases in local population in Ladakh region over a radius of 150 kms at a height varying from 3100 to 3300 metres. The temperature in this region varies from plus 34 to minus 26 degree Celsius.

Velocity of wind is high particularly in the afternoons leading to blizzards and biting cold resulting from windchill factor. Weather is dry and humidity is low i.e. 44% to 75%. There is no vegetation in winter. The hills are barren in summer except covered with sparse green grassy mossy plants. By and large the whole area is covered with snow in winter. It is rightly called the cold desert or desert in the sky.

The native highlanders wear lose clothing with many layers, a loose headgear and a loose footwear, almost around the year. They occasionally consume local Chhang; and salted tea which tastes more like soup. The source of drinking water is from spring and for washing purpose from the Indus river. The river water is not spoiled by throwing filth in the flowing water of the Indus.

The overall incidence of cutaneous disorders published is around 7.0 [1] to 22.5 [2] of outpatients in western literature. Although the figures vary from country to country [3, 4, 5]. The incidence recorded in the present study was comparatively very low i.e. 1.9%. Influence of race, effects of high altitude or some other factors playing role in such low incidence of dermatological disorders remains a mute debatable point.

High altitude dermatopathy recorded in three patients manifested as hyperkeratosis on the exposed skin of the native highlanders with horny keratin plugs around hair follicles and sweat glands. The affected skin was hyperpigmented, thickened and revealed furrowing.

This was prominent on the face; and the back of the neck where the characteristic pattern led to its being referred commonly as cutis rhomboides nuchae. Ageing of nonexposed skin manifested as thinning with decrease in the amount of subcutaneous fat. Degenerative changes on the exposed parts of the hands and limbs were recorded similar to those on the face.

High altitude koilonychia first recorded in Ladakh about a decade back [6] was seen in finger nails of two patients. In one patient koilonychia was unilateral confined to all fingers of one hand, possibly resulting from mud plastering often undertaken by the natives while constructing houses in summer seasons. Because of well known association between iron deficiency anaemia and koilonychia, haemoglobin estimation in the affected subjects revealed levels of 15–16g/dl. These levels of Hb were seen in patients without koilonychia as well. It was observed that koilonychia was seasonal being worse in summer; and in winter the nails were normal or much improved. Seasonal Koilonychia in Ladakhis was observed by Dolma et al as well [7]. It was of interest that without benefit of medical investigations, the villagers of Chuchot called the condition ’Chusent’ or water nails.

Viral warts observed in six patients were present on the exposed parts i.e. hands face and neck. The lesions were multiple large, fulminant, exuberant and at places coalesced to form large plaques. The relatively high number of this disorder may be explained on the basis of exposure to shortwave ultraviolet light, hypoxia, diminished circulation to exposed areas and extreme low temperature. It is likely that lowered cell mediated immunity may be playing its role at high altitude in high incidence of this condition. However, more work will be required to prove the exact etiological role with clinical manifestations of viral warts. Bacterial infections were observed in four, pityriasis alba in three, roasacea, alopecia areata, acne vulgaris and seborrhoeic dermatitis in two each; discoid lupus erythemetosus, vitiligo and keloid in one patient each. It was worth recording that papulosquamous disorders, parasitic disease, effects of cold injuries, cutaneous malignancies, leprosy and sexually transmitted diseases were not recorded in the present study.

To conclude, high altitude dermatopathy, high altitude koilonychia and relatively high incidence of large exuberant viral warts, and no case of papulosquamous disorders, effects of cold injuries, cutaneous malignacies, leprosy and sexually transmitted diseases; and extremely low incidence of dermatological disorders in native highlanders of Ladakh are the highlights of the study.