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Flood-related skin diseases: A literature review

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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 Abstract
Medicine, Chulalongkorn University, Flood is one of the most common natural disasters, which commonly occurs in all parts of
Bangkok, Thailand, and 2Department of
the world. The effects of the disasters considerably become enormous problems to overall
Medicine, Chulabhorn Hospital, Bangkok,
Thailand
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 a systematic literature review of research publications relating to flooding and skin
Therdpong Tempark, MD diseases. The purpose of this review was to provide dermatologists as well as general
Department of Pediatrics,
practitioners with comprehensive conditions of flood-related skin diseases and suggested
Sor Kor Building 11th Floor
treatments. Moreover, we categorized these flood-related diseases into four groups
King Chulalongkorn Memorial Hospital
Rama IV Road comprising inflammatory skin diseases, skin infections, traumatic skin diseases, and other
Bangkok 10330 miscellaneous skin diseases in a bid to implement early interventions and educate,
Thailand prevent, and efficaciously handle those skin diseases under such a catastrophic situation
E-mail: therdpmhu@yahoo.com
so that better treatment outcomes and prevention of further complications could be
Statement of funding: None.
ultimately achieved and accomplished.
Conflict of interest disclosures: None.

the authors, namely: (i) inflammatory skin diseases (e.g.

Introduction
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 east-
ern 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,13 and causing multiple environ-
mental 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 distur-
bances.
Flooding also compromises the healthcare systems, such
as access to crucial health services, local health services
capacity, needs for evacuees, and clinic settlement,46
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 compli-
cations, which manifest in cutaneous and/or signs of
systemic illnesses due to prolonged exposure to contami-
nated water and unhygienic conditions during floods.
1168 These conditions were categorized into four groups by
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 reac-
tion and psycho-emotion aggravated primary skin
diseases; Table 1).
Because the knowledge and recognition of these flood-
related skin diseases is potentially important, we reviewed
and summarized several articles as mentioned on flood-
related 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, WHOs 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

International Journal of Dermatology 2013, 52, 11681176 2013 The International Society of Dermatology
Tempark et al. Flood-related skin diseases Review 1169

Table 1 Flood-related skin diseases

Group/type Example Common clinical manifestations Management/treatment

1. Inflammatory skin diseases
2. Infections
3. Traumatic skin diseases
4. Miscellaneous
Irritant contact dermatitis
Fungal skin infection
(e.g. true dermatophyte,
non-dermatophyte molds)
Bacterial skin infection
(e.g. Streptococcus pyogenes,
Staphylococcus aureus, Aeromonas
spp., Vibrio spp., Clostridium tetani)
Mixed infections
With/without infection
Insect bite reactions
- Mosquitoes
- Fire ants
- Centipedes
Psycho-emotional aggravated primary
skin diseases
(e.g. atopic dermatitis, urticaria, alopecia
areata, psoriasis, angioedema, vitiligo)
- Erythematous patches, edema, and - Avoidance
maceration corresponding to the - Topical corticosteroid
area of irritant exposure - Antihistamine as needed
- Probably acquired secondary
bacterial infection
- Erythematous skin maceration in - Keep dry
interdigital web spaces of the foot - Topical and/or systemic
- Erythematous vesicles and antifungal agents
pustules of the foot
- Localized dry scaly, erythematous
hyperkeratotic papules on the plantar
surface and lateral aspects of the foot
- Erythematous patches, plaques - Dressing wound
progress to vesicles, hemorrhagic bullae - Topical and/or systemic
- Localized to systemic antibacterial agents
inflammatory response
- Localized to systemic inflammatory - Dressing wound
response - Topical combined
- Multiple clinical variants remedies and/or systemic
antimicrobial agents
- Cuts, lacerations, punctures, and - Supportive treatment
penetration wounds - Dressing wound
- Possibly acquired secondary - Topical and/or systemic
bacterial infection antimicrobial agents
- Wheal and flare - Prevention
- Indurated erythematous papules - Insect repellents
- Vesicles, bullae, ecchymosis and - Topical corticosteroid
cellulitis-like reaction (uncommon) - Antihistamine
- Wheal and flare ? superficial vesicles - Prevention
and localized edema ? scatter or group - Topical corticosteroid A
of vesicles, pustules with umbilication - Antihistamine
- Systemic sign of anaphylaxis (uncommon)
- Painful erythematous swelling - Prevention
patch with two-bite puncta - Pain control
- Probably presented bullae - Topical corticosteroid
- Antihistamine
- Extension of primary skin diseases - 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
related articles and reports on topics such as disasters and
inflammatory skin diseases, skin infections, traumatic skin
diseases, insect bite reactions, and psycho-emotional
aggravated primary skin diseases were included and then
reviewed in the full texts.
diseases, respectively.7 The dermatological conditions after the
tsunami showed 32.5, 29.8, and 29.4% of infections
infestations, inflammatory, and traumatic skin conditions,
respectively.8
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
The acute phase of irritant contact dermatitis begins with
the penetration of chemicals or irritants through the per-
meability barrier, which causes mild damage to keratino-
cytes and the release of inflammatory mediators.
Prolonged submergence in the inundated water is one of

2013 The International Society of Dermatology International Journal of Dermatology 2013, 52, 11681176
1170 Review Flood-related skin diseases
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 presenta-
tion and at certain times subsequently followed by
acquired secondary infection from bacteria, fungus, sec-
ondary skin conditions from the defect of the skin barrier,
chronic irritation, and trauma.
The ideal treatments are irritant avoidance and main-
taining the exposed skin dry to prevent secondary skin
conditions. Supportive treatment with topical corticoste-
roid 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 con-
sequential problems. However, treatments and laboratory
investigations like the culture for infectious organisms are
usually limited and unavailable in this catastrophic situa-
tion.
These infections resulting from flood include the risk of
soft tissues, ophthalmology, respiratory, gastrointestinal,
vector-borne infections from pathogen inoculations, over-
crowdedness of the survivor displacement, elimination of
water supplies, alteration of vector breeding, and zoo-
notic reservoir.11
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, 11681176
Tempark et al.
type of tinea pedis (Fig. 1). Vesicles and pustules of vesic-
ular 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 pres-
ent (Fig. 2a and b).
True dermatophytes vs. non-dermatophyte molds
Non-dermatophyte molds (Scytallidium dimidiatum, Scy-
tallidium hyalinum, Fusarium spp.) are frequently reported
as causes of tinea pedis in normal situations.1214
Although the clinical findings of non-dermatophyte molds
are indistinguishable from the true dermatophytes, the
fungal culture on Sabourauds dextrose agar (without
cycloheximide) is usually useful to identify these organ-
isms 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 Scytalli-
dium 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 Epidermo-
phyton 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.1517
Scytallidium dimidiatum (Hendersonula turuloidea)
causes cutaneous manifestations similar to Trichophyton
rubrum infection.18 The interdigital type is the most com-
mon 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-
Figure 1 Tinea pedis, interdigital type
2013 The International Society of Dermatology
Tempark et al.
(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 pre-
sentation 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 24 weeks. As for the cases
with unidentified specific fungal pathogen(s) for inflam-
matory lesions and/or suspected polymicrobial agent(s), a
combination of topical remedies could be served as treat-
ment 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
2013 The International Society of Dermatology
Flood-related skin diseases Review 1171
12.5% positive fungal growth (2/16; Trichosporon muco-
ides and non-spore forming hyaline fungi); in spite of the
Gram-negative bacilli, Corynebacterium spp. and Staphy-
lococcal 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 fun-
gal culture effect,21,22 and the duration of specimen col-
lection 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 anti-
inflammation, antibacterial, and antifungal remedies.7
The ability of the anti-inflammatory effect of cortico-
steroids in combination remedies the disturbing symp-
toms faster than monotherapy alone in normal host
patients.23 The short duration of treatment possibly leads
the patients to misunderstand the clearance and subse-
quently causes the discontinuation of the medication
before the specific antifungal agents could act sufficiently
against the pathogens.23 This topical combination con-
sists of multiple formulas, including anti-inflammatory
(Triamcinolone, Fluocinonide, Betamethasone), antibac-
terial (Neomycin sulfate, Gramicidin, Polymyxin B, Ga-
ramycin), 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-earth-
quake 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 infec-
tions 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 septice-
mia.
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.2426 Pseudomonas spp.,
rapid growing mycobacteria, and Burkholderia pseudo-
mallei (melioidosis) are uncommon pathogens, possibly
found in contaminated wounds from water and water-soil
mixtures.11,27
International Journal of Dermatology 2013, 52, 11681176
1172 Review Flood-related skin diseases
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 infec-
tion in the deluge post-hurricane Katrina,28 as well as 18
cases with Vibrio spp. wound infections after this hurri-
cane 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 influ-
ence 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 dur-
ing and following restoration of working time after disas-
ter. 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
Table 2 Pathogens of bacterial skin infection from traumatic wounds
Special considerations of bacterial pathogen
Common secondary bacterial skin infection
Condition
Streptococcal pyogenes Fresh water
Staphylococcal aureus Contaminated water
Clostridium tetani Watersoil mixtures water
Sea water
International Journal of Dermatology 2013, 52, 11681176
Tempark et al.
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 pre-
dominance (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, partic-
ularly in the area of prolonged flood.
Mosquitoes
Mosquitoes are not only vectors of systemically transmit-
ted 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 surround-
ing human skin.34 The inflammatory response from mos-
quito bites results from the reaction of sensitized
immunity to their saliva protein.35
The pathogenesis is composed of saliva-specific immu-
noglobulin E (IgE), IgG antibodies, and T cell-mediated
delayed-type hypersensitivity reaction.35,36
Pathogen Frequency
Clostridium perfringens report
Aeromonas spp. report
-Polymicrobial common
-Pseudomonas spp. uncommon
-Rapid growth of mycobacterium uncommon
-Burkholderia pseudomallei uncommon
-Vibrio spp. report
(e.g. Vibrio vulnificus)
-Atypical mycobacterium report
(Mycobacterium marinum)
2013 The International Society of Dermatology
Tempark et al.
There are variable cutaneous reactions and clinical
presentations to mosquito bites. Immediate reaction pre-
sents with a wheal and flare 210 mm in diameter that
peaks within 20 minutes; while the delayed reaction pre-
sents with indurated erythematous papules that peak at
2436 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 under-
lying 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 preven-
tion. 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 medica-
tion 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 protec-
tion time of DEET repellents is approximately 2
3 hours.43,44 The concentration of 530% DEET is avail-
able over the counter. The efficacious time for insect pro-
tection 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
2013 The International Society of Dermatology
Flood-related skin diseases Review 1173
Health Canada and the Canadian Pediatric Society recom-
mended DEET for children older than 6 months old, lim-
ited concentration  10%, and the number of
reapplication per day varies in each age group.44
Botanical insect repellents, such as 515% 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 epider-
mis.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, repre-
senting as wheals and flares of 12 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 umbilica-
tion 810 hours later.48,51 These sterile pustules are usu-
ally scattered or grouped in what is described as a rosette
pattern.49 Vesiculopustular lesions are common and per-
sist 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 0.62%
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 ana-
phylaxis in the English literature.5557 Other systemic
reactions, including nephrotic syndrome58 and neurolog-
ical disorders, such as mononeuropathy, seizure, optic
neuritis, and demyelination of the brain, had rarely
been reported.53,59
Additional supportive care includes symptomatic treat-
ments, such as cleansing the lesion with mild soap, local
compression with ice pack, soothing preparations, and
scratch avoidance to prevent secondary bacterial infec-
tion, which is the most common complication of these
stings.60 Prophylactic antibiotics use is not routinely rec-
ommended.49 Topical corticosteroid and systemic antihis-
tamine for relief of the itchy symptoms and pain are
adequate treatments.48
International Journal of Dermatology 2013, 52, 11681176
1174 Review Flood-related skin diseases
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 hypoten-
sion and respiratory distress syndrome) from type IV or
delayed-type hypersensitivity.61
The characteristic presentation is a painful erythema-
tous 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 rhabdomy-
olysis 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 cortico-
steroid 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 aggra-
vated psoriasis, atopic dermatitis, or urticaria after a tsu-
nami disaster.8
Exacerbation of atopic dermatitis by stress after earth-
quake 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
International Journal of Dermatology 2013, 52, 11681176
Tempark et al.
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 hor-
mone-proopiomelanocortin axis.69
The evidence indicates that acute emotional stress can
precipitate alopecia areata by the activation of over-
expressed 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 hygi-
enic 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 varie-
ties including environmental factors (endemic area, the
natural course, and severity of disaster) and personal
factors (medical and dermatological underlying dis-
eases). 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 sys-
tem. Psychological health issues from loss should be
determined and alleviated. Most importantly, dermatol-
ogists and general practitioners should comprehensively
enhance with the basic knowledge of these conditions
for the accomplishment of efficacious and best treat-
ment outcomes.
Acknowledgments
The authors would like to thank Mano Mettanando
Laohavanich, MD, PhD, and Ms. Sunattee Kessung for
helping with the English manuscript.
2013 The International Society of Dermatology
Tempark et al.
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