Vol 36, No 1 March 2023

  • Papular urticaria:
  • Diagnosis and management in primary healthcare
  • Diagnosing and managing childhood asthma effectively with limited resources
  • Food allergy in the resource-limited setting
  • Atopic dermatitis in resource-scarce settings
  • Chronic Urticaria: An approach in resource-limited settings
  • Baker’s allergy and asthma in an industrial bakery

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Author: Eugene G Weinberg

Abstract: A recent report by Garcia-Marcos et al1 was featured on the ALLSA website. It details the findings of a large study involving 453 473 individuals, both adults and children, with asthma in 35 countries – its focus is on their asthma control in particular. Unsurprisingly, the outcome of the study was that asthma management and control is frequently inadequate, particularly in low-resource settings. Garcia-Marcos et al recommend that strategies should be implemented worldwide to improve adherence to asthma treatment guidelines, especially in low- and middle-income countries, and that the emphasis should be on access to affordable and quality-assured essential asthma medicines.

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Author: Pieter J de Waal

Abstract: Papular urticaria is commonly seen in emergency departments and primary healthcare clinics and is often incorrectly diagnosed as atopic eczema. This annoying condition is caused by a chronic relapsing hypersensitivity reaction to mostly biting insects. The lesions are intensely pruritic. Owing to continuous scratching, lesions often become secondarily infected. Although adults are also affected, children are more likely to suffer from papular urticaria. Lesions are typically confined to the skin, but in rarer cases, systemic involvement and even anaphylaxis may ensue in susceptible individuals. Insects may also be vectors of various viruses, bacteria and parasites and can transmit vector-borne diseases, for instance, malaria. Although this is a mostly benign condition that is outgrown, some patients with papular urticaria may have serious underlying systemic illnesses or may be immunocompromised. In this article, common offenders, including fleas, bed bugs and mosquitoes, are discussed; as an underlying cause of papular urticaria, scabies is also highlighted. Diagnostic guidance for primary healthcare practitioners, practical examples of insect and parasite eradication and avoidance strategies, in addition to the supportive treatments available in primary healthcare clinics and emergency departments, are explored.

Keywords: urticaria, insects, scabies, fleas, bedbugs, mosquitoes, papular eruption

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Authors: André van Niekerk, Eugene G Weinberg

Abstract: Childhood asthma must be diagnosed and managed correctly. It is the most common and potentially fatal chronic noncommunicable disease in children. The prevalence of asthma is increasing in both resource-limited and well-resourced settings. Up to 96% of asthma deaths occur in low- and middle-income countries where medical care must often be offered against a background of limited resources. Simple diagnostic steps, accessible treatment options and a good understanding of childhood asthma and asthma education will benefit all asthmatic patients, especially those who rely on resource-limited healthcare. This review is not an academic appraisal of data on the topic; it aims instead to extract practical solutions from asthma guideline documents to bring correct diagnoses and simple, yet effective management options to resource-limited settings.

Keywords: childhood asthma, resource-limited setting, practical solutions

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Author: Claudia L Gray

Abstract: Developing countries, which are frequently resource-limited, have not been spared the food allergy epidemic. Noncommunicable diseases such as allergies are often not afforded the recognition and budget that acute and infectious diseases are given, making management in resource-limited settings potentially challenging. However, there is scope to run a cost-effective and competent food allergy service in resource-limited areas using evidence-based, affordable testing and management strategies, as is discussed in this article. Awareness and recognition of potential food-allergic patients must be started in peripheral clinics and baby immunisation clinics, which will require staff to be educated in these areas. As important as recognition of food allergies is the provision of culturally appropriate affordable nutritional alternatives. The prevention of food allergies with evidence-based strategies should be promoted at grass-roots level.

Keywords: food allergies, resource-limited setting, evidence-based diagnostic and management approaches

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Authors: Ameshin Moodley, Ahmed I Manjra, Anisa Mosam

Abstract: Atopic dermatitis (AD) is one of the most common skin conditions; it affects approximately 10% of children.1 It is a chronic relapsing skin condition that starts early in life, persisting into adulthood, and it has a negative impact on patients and their caregivers. AD is a heterogeneous disease with many phenotypes. The presentation varies depending on age, geographical location, the type of inflammation, psychosocial stressors and ethnicity. The spectrum of the disease ranges from mild – manifesting as a few plaques, to severe – recalcitrant disease with secondary infection and erythroderma requiring admission.

Keywords: atopic dermatitis, chronic relapsing skin condition

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Authors: Janet van der Walt, Pieter de Waal

Abstract: Chronic urticaria is a mast cell-mediated condition, with episodes of urticaria (with or without angioedema) lasting for longer than 6 weeks. It leads to significant patient morbidity and affects both social and occupational functioning. Recurrent episodes of angioedema can also occur in isolation and may be life-threatening. Although state-of-the-art targeted treatments have been published globally, third- and fourth-line treatment options are not always accessible and affordable to patients in South Africa. The immediate availability of emergency medicines for acute, life-threatening angioedema episodes, also remains a major concern, and in the private healthcare sector, medical schemes often requiring extensive authorisation processes before these drugs can be administered to patients. Although medical practitioners are advised to adhere to international management guidelines on urticaria and angioedema, in South Africa, ‘off-label’, less effective medications are often used in an attempt to achieve symptom control and to treat life-threatening attacks of angioedema.

Keywords: chronic urticaria, angioedema, resource-limited setting

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Allergies in the workplace

Authors: Yumna Williams, Shahieda Adams

Background: Occupational exposure to allergens in the baking industry is well documented. Two workers employed in the industrial baking industry for more than 30 and 17 years respectively presented with symptoms suggestive of asthma, preceded by conjunctivitis and rhinitis. Their symptoms were worse during exposure to flour dust in the front-end areas of the bakery, particularly the mixing and dough-making areas, and were relieved by the avoidance of exposure to flour dust.

Methods: The clinical assessment of the workers included an evaluation of their respiratory function using spirometry with a bronchodilator challenge. Serial peak-flow (PEF) monitoring over four weeks was conducted and included periods at and away from work. A work effect index (WEI) was generated from the PEF data using the OASYS® software to assess the work-relatedness of symptoms. An immunological assessment included the detection of atopy using skin-prick tests (SPTs) to common aeroallergens and the detection of specific IgE to baking allergens, including wheat and rye flour, and fungal α-amylase.

Results: Occupational rhinitis (OR) and asthma (OA) associated with sensitisation to wheat, rye and fungal α-amylase was diagnosed in both workers. The diagnosis was based on the clinical presentation of work-related symptoms, diurnal variation in PEF exceeding 20% and elevated specific IgE to wheat (290 kU/L and 2.02 kU/L), rye (92.8 kU/L and 1.40 kU/L) and fungal α-amylase (3.53 kU/L and >100 kU/L). The serial PEF analysis of Worker 1 revealed a WEI of 3.71, whereas Worker 2’s PEF data were suboptimal for analysis. The workplace visit confirmed inadequate risk mitigation of baking allergen exposure; and exposure to high flour-dust levels (5–16 mg/m3) in the mixing area was confirmed by a recent hygiene survey.

Conclusion: These cases of baker’s asthma and allergy highlight the persistent role of inadequate exposure-control measures in industrial bakeries. Specific South African exposure standards for flour-dust allergens are needed to prevent the development of allergic diseases such as asthma and to mitigate the risk in bakery workers.

Keywords: occupational asthma, occupational rhinitis, wheat, rye, α-amylase

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Ethics Article

Author: Sharon Kling

Abstract: Patients and their family members faced with difficult medical decision-making may resort to asking health professionals (HPs) what they would do if faced with a similar situation. HPs struggle with knowing how to approach this question and may hedge or refuse to answer. The situation shows patients’ and families’ trust in the HP, and generally the HP is advised to answer as honestly as possible, after clarifying exactly what they are being asked.

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Adhesive dressing contact dermatitis

Authors: Shaunagh Emanuel, Di Hawarden

Abstract: After an uneventful total thyroidectomy, 33-yearold Mrs Field is discharged home on day two post-operatively. She feels comfortable and her pain is well controlled on oral analgesics. On day three she looks in the bathroom mirror whilst carefully performing her sponge bath and is alarmed to see that she has broad, bright pink, linear marks on her cheeks.

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The pain of the grain

Authors: Petri Swanepoel, Sylvia van den Berg, André van Niekerk

Abstract: Please assist me with the work-up of this young lady. Ms SS is a 22-year-old woman presenting with a longstanding history of intermittent abdominal pain, chronic diarrhoea and two previous episodes of Giardiasis, for which she was treated. According to her medical history, she has been treated for numerous sinusitis episodes by her general practitioner. She had grommets inserted as a child and suffers from prolonged lower respiratory tract infections, especially during winter.

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