At least ten of the diseases included in World Health Organization’s (WHO) list of neglected tropical diseases can present with manifestations on the skin. These so-called skin NTDs include Buruli ulcer, cutaneous and post-kala azar dermal leishmaniasis, leprosy, lymphatic filariasis, onchocerciasis, mycetoma, yaws, chromoblastomycosis and other deep mycoses, and scabies and other ectoparasites. Due to their common manifestations, skin NTDs can be targeted with similar case detection and disease management approaches. Additionally, skin-related NTDs are often associated with lifelong disabilities, stigma and mental health problems. These commonalities, and the frequent co-endemicity of these diseases in many regions, present opportunities for the integration of interventions.
Integrated control and management of skin NTDs
Integrating programmes for skin NTDs creates an opportunity to address multiple conditions simultaneously, resulting in increased efficiency through sharing of resources and expanded programme coverage. Integrated approaches are also promoted in the WHO NTD road map 2021–2030 to reduce morbidity, disability and the psychosocial impact of skin NTDs. One of the road map targets for 2030 is that 40 countries adopt and implement integrated skin NTDs strategies. The WHO has developed a strategic framework to assist endemic countries in identifying potential areas, players and resources for integration, as well as systems to embed interventions within national programmes.
The areas in which integrated approaches can be developed include: advocacy; active case detection; clinical and laboratory diagnosis; integrated planning; mass drug administration (MDA); stigma and mental well-being; monitoring and evaluation; One Health; rehabilitation; self-care; social mobilization; inclusion and human rights; surgery (e.g., sharing infrastructure and resources); surveillance and data management; training and capacity-building; wound and lymphoedema management; and water, sanitation, and hygiene (WASH). Some of these approaches are further discussed below – additional descriptions of integrated approaches can be found in this WHO’s publication on the strategic framework.
Active case detection
Active case detection activities are essential to limit delays in diagnosis and reduce the risk of further transmission. Integrated activities to actively screen populations at risk for various skin NTDs can be an effective and efficient way to enable early case detection, timely access to treatment services, and prevent the development of (further) disabilities. Visual skin examinations aiming to detect a variety of skin conditions (both NTDs as well as common skin conditions) can also help in avoiding stigma associated with certain diseases, which may otherwise be a significant barrier to attend single-disease screening activities. An example of integrated active case detection activities are community skin health events (skin camps).
Wound and lymphoedema management
All skin NTDs that present with wounds (Buruli ulcer, cutaneous leishmaniasis, leprosy, yaws and others) require similar wound care approaches; this includes maintaining the wound bed and changing dressings on a regular basis. For skin NTDs that present with lymphoedema (e.g. lymphatic filariasis, podoconiosis, leprosy reactions), the approaches for lymphoedema management are also similar; this includes lymphatic drainage / limb massage, compression therapy and exercise. Important care methods for both wound- and lymphoedema-causing conditions are washing of the skin and the use of skin care, which is vital to avoid secondary infections, avert malodour, promote healing processes and prevent stigma and disabilities. Severe or extensive wounds and skin problems have to be treated at an appropriate health facility, whereas many simple wounds and skin problems can be managed at home by the affected person him or herself or for example with the help of family members. Health care workers and community health volunteers could be trained in washing, wound dressing and bandaging, recognizing complications in time, appropriate referral pathways and in teaching self-care methods to persons affected by different NTDs and to members of self-care groups.
Training and capacity building
A potential challenge to the integration of skin NTD interventions may be the lack of adequately trained staff. As skin NTDs rely mostly on clinical diagnosis, adequate training of healthcare workers and community volunteers is an essential aspect of disease control programmes. Integrated training and capacity building programmes can enhance the knowledge and motivation of health workers and community volunteers; advance their skills to diagnose and treat skin-related NTDs and knowing when referral is needed and thus strengthen local healthcare systems. Training modules for health personnel should be designed to meet context specific needs, by focusing on skin conditions that are prevalent within a community, locally available treatment and management options, as well as including pictures with representing skin colours. Technological applications, like the NLR SkinApp and the WHO Skin NTDs App, have been developed to support health workers in recognizing early signs and symptoms. Additionally, NLR has invented the Skin Games as an interactive method to train peripheral health workers involved in skin disease screening activities, and the WHO has developed a training guide on how to identify NTDs through changes on the skin. Such innovations can be used to support and promote common skin screening activities.
Stigma and mental wellbeing
Persons affected by skin NTDs are frequently stigmatised and discriminated. Stigmatizing beliefs, myths and misconceptions associated with skin conditions can cause mental distress and may negatively affect one’s social participation and quality of life. Stigma can be reduced by offering integrated services for diagnosis, control and treatment of skin NTDs and common skin conditions. Joint delivery of psychosocial and stigma reduction interventions (e.g. community education and counselling) suitable for for multiple skin NTDs can also help to improve access to these services and improve the quality of life of persons affected.