Abstract
In Olmsted County, Minnesota, population-based epidemiologic research studies are possible because of a unique medical records linkage system, the Rochester Epidemiology Project (REP), which has been in place for almost half a century. We present a summary of epidemiologic data describing the incidence of skin diseases derived from the REP. Since 1966, more than 2000 articles have been published by the REP team. Each published article was reviewed by both authors in conjunction with the REP team to select all articles that described the incidence of skin and selected skin-related diseases. Collectively, these reports suggested that the incidence of most of the studied skin diseases has increased over the decades.
Abbreviations and Acronyms:
REP (Rochester Epidemiology Project), SLE (systemic lupus erythematosus)Article Highlights
- ▪Reliable population-based studies that estimate the incidence of skin diseases are few because of the lack of well-enumerated populations from which affected patients can be identified.
- ▪In Olmsted County, Minnesota, the Rochester Epidemiology Project, a unique research infrastructure system, enables population-based research studies of the epidemiology of diseases.
- ▪We present a summary of published data from the past 4 decades that describes the incidence of skin and skin-related diseases derived from the Rochester Epidemiology Project.
- ▪Reports found that the incidence of most of the studied skin diseases has increased over the decades.
Epidemiologic data are vital to understanding the implications of human disease. An understanding of the incidence of specific diseases is fundamental to decision making regarding allocation of resources for clinical care and research, for example. Population-based studies are the criterion standard for the study of epidemiology and yield the most accurate and generalizable estimates of incidence. Unfortunately, there are few population-based cohorts worldwide in which it is possible to study the epidemiology of disease.
In Olmsted County, Minnesota, long-term, population-based, epidemiologic research studies are possible because of a unique medical records linkage system, the Rochester Epidemiology Project (REP). The REP is a research infrastructure system that has captured health care information on virtually all residents of Olmsted County starting in 1966.
1
Details about the REP’s history are described elsewhere.Rochester Epidemiology Project. What is the Rochester Epidemiology Project? http://www.rochesterproject.org/. Accessed May 1, 2012.
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, 3
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Population-based studies describing the epidemiology of skin diseases are relatively lacking. The REP has been a resource for population-based studies on the incidence of skin diseases studied over the decades and provides generalizable data on the epidemiology of the studied skin diseases. It is therefore important for dermatologists and other specialists to be aware of these data.
Because these epidemiologic data have been published in different journals over several decades, many are not aware that these data are available. The objectives of this study were to gather available epidemiologic data describing skin and skin-related diseases derived from the REP and to standardize presentation of the data, if needed, so that the reported findings can be easily compared. These data will be a rich resource to those studying many aspects of skin disease.
Patients and Methods
More than 2000 articles have been published by the REP team.
4
In conjunction with the REP team, we reviewed each article to select all articles that described the incidence of skin and selected skin-related diseases such as systemic lupus erythematosus (SLE) and psoriatic arthritis. We agreed on the articles to be included in this review. Thus, all published population-based studies on the incidence of skin and skin-related diseases that had been performed by using the REP from 1966 (the date the REP started) to January 2013 were included in this review. Articles that reported only cumulative incidence rates (lifetime risk) as well as those that reported studies involving 10 or fewer cases were excluded.We abstracted the following information from the published studies: time period reported in the study, population characteristics, total number of cases included in the study, and number of cases by sex and age group. If the number of cases by sex and age group were not reported in the publication, then the counts were obtained from the archived data.
For each study, age- and sex-adjusted incidence rates were estimated by dividing the number of cases by sex and age group by the Olmsted County (or the city of Rochester) population assumed to be at risk. The Olmsted County (or the city of Rochester) population was obtained from decennial census data, with linear interpolation for intercensal years. The 95% CIs were calculated on the basis of the assumption that the number of cases by age and sex group followed a Poisson distribution. For consistency, all rates were standardized to the 2000 US white population. If the number of cases by sex and age group were not available, then the counts were obtained from the archived data reported in the Table.
TableIncidence of Skin Diseases in Olmsted County, Minnesota
| Reference, year | Time period | Skin disease | Population defined by age (y) | Total no. of cases | Age- and sex-adjusted incidence rate per 100,000 person-years (95% CI) |
|---|---|---|---|---|---|
| Skin cancer | |||||
| Chuang et al, 5 1990 | 1976-1984 | Basal cell carcinoma | All | 657 | 171.2 (157.8-184.5) |
| Christenson et al, 6 2005 | 1976-2003 | Basal cell carcinoma | ≤40 | 417 | 23.4 (21.1-25.6) |
| Chuang et al, 7 1990 | 1976-1984 | Squamous cell carcinoma | All | 169 | 47.9 (40.6-55.3) |
| Christenson et al, 6 2005 | 1976-2003 | Squamous cell carcinoma | ≤40 | 68 | 3.9 (3.0-4.8) |
| Gray et al, 8 1997 | 1984-1992 | Squamous cell carcinoma | All | 511 | 114.6 (104.5-124.7) |
| Resseguie et al, 9 1977 | 1950-1974 | Cutaneous malignant melanoma | All | 42 | 4.9 (3.4-6.5) |
| Popescu et al, 10 1990 | 1950-1985 | Cutaneous malignant melanoma | All | 107 | 8.2 (6.6-9.8) |
| Reed et al, 11 2012 | 1970-2009 | Cutaneous malignant melanoma | ≥18 to 39 | 256 | 16.9 (14.8-19.0) |
| Connective tissue diseases | |||||
| Durosaro et al, 12 2009 | 1965-2005 | Cutaneous lupus erythematosus | All | 156 | 4.3 (3.6-5.0) |
| Classic discoid LE | All | 129 | 3.6 (2.9-4.2) | ||
| Subacute cutaneous LE | All | 23 | 0.6 (0.4-0.9) | ||
| Peterson et al, 13 1997 | 1960-1993 | Morphea | All | 82 | 2.7 (2.1-3.3) |
| Bendewald et al, 14 2010 | 1976-2007 | Dermatomyositis and its subtypes | All | 29 | 1.0 (0.6-1.3) |
| Pillemer et al, 15 2001 | 1976-1992 | Primary Sjögren syndrome | All | 53 | 4.1 (2.9-5.2) |
| Uramoto et al, 16 1999 | 1980-1992 | SLE | All | 48 | 6.4 (4.5-8.2) |
| Kurland et al, 17 1969 | 1951-1967 | SLE | All | 29 | 5.6 (3.5-7.6) |
| Nobrega et al, 18 1966 | 1950-1965 | Combined SLE | All | 25 | 3.3 (2.0-4.6) |
| Michet et al, 19 1985 | 1950-1979 | SLE | All | 25 | 2.3 (1.4-3.2) |
| Suspected SLE | All | 21 | 1.9 (1.1-2.7) | ||
| Discoid LE | All | 24 | 2.3 (1.4-3.3) | ||
| Scleroderma | All | 13 | 1.2 (0.5-1.8) | ||
| Psoriasis, psoriatic arthritis, and other papulosquamous diseases | |||||
| Tollefson et al, 20 2010 | 1970-1999 | Psoriasis | ≤18 | 357 | 40.8 (36.6-45.0) |
| Icen et al, 21 2009 | 1970-2000 | Psoriasis | ≥18 | 1633 | 78.9 (75.0-82.9) |
| Bell et al, 22 1991 | 1980-1983 | Psoriasis | All | 132 | 61.2 (50.2-72.1) |
| Shbeeb et al, 23 2000 | 1982-1991 | Psoriasis | ≥18 | 1056 | 107.7 (101.2-114.2) |
| Wilson et al, 24 2009 | 1970-1999 | Psoriatic arthritis | ≥18 | 147 | 7.2 (6.0-8.4) |
| Shbeeb et al, 23 2000 | 1982-1991 | Psoriatic arthritis | ≥18 | 66 | 9.3 (7.0-11.6) |
| Chuang et al, 25 1982 | 1969-1978 | Pityriasis rosea | All | 939 | 140.7 (131.1-150.3) |
| Infections and infestations | |||||
| McNamara et al, 26 2007 | 1999 | Lower extremity cellulitis | ≥18 | 176 | 213.0 (181.2-244.9) |
| Matteson et al, 27 1992 | 1983-1990 | Lyme disease | All | 17 | 2.3 (1.1-3.4) |
| Ragozzino et al, 28 1982 | 1945-1959 | Herpes zoster | All | 590 | 131.0 (…) |
| Guess et al, 29 1985 | 1960-1981 | Herpes zoster | ≤20 | 173 | 48.6 (41.3-55.9) |
| Yawn et al, 30 2007 | 1996-2001 | Herpes zoster | ≥22 | 1669 | 374.0 (355.8-392.2) |
| Chuang et al, 31 1983 | 1965-1979 | Herpes progenitalis | All | 392 | 49.8 (44.7-54.9) |
| Chuang et al, 32 1984 | 1950-1978 | Condyloma acuminatum | All | 746 | 48.7 (44.9-52.5) |
| Wentworth et al, 33 2013 | 1980-2009 | Cutaneous nontuberculous mycobacterial infection | All | 40 | 1.3 (0.9-1.7) |
| Vazquez et al, 34 2013 | 1968-2008 | Hidradenitis suppurativa | All | 268 | 6.1 (5.4-6.9) |
| Other skin diseases | |||||
| Calamia et al, 35 2009 | 1960-2005 | Behçet disease | ≥18 | 13 | 0.4 (0.2-0.5) |
| Reed and Davis, 36 2009 | 1976-2005 | Erythromelalgia | All | 33 | 1.3 (0.8-1.7) |
| Safavi et al, 37 1995 | 1975-1989 | Alopecia areata | All | 292 | 19.9 (17.6-22.3) |
| Heit et al, 38 2001 | 1966-1990 | Venous stasis syndrome | ≥15 | 1131 | 87.0 (81.8-92.1) |
| Venous ulcer | ≥15 | 263 | 23.0 (18.4-23.5) | ||
a LE = lupus erythematosus; SLE = systemic lupus erythematosus.
b Standardized to the 2000 US white population unless noted otherwise.
c Unable to identify age and sex counts for additional calculation. The reported result is the originally published age- and sex-adjusted incidence rate standardized to the 1980 US white population.
d Unable to identify age and sex counts for additional calculation. The reported result is the originally published age- and sex-adjusted incidence rate standardized to the 1990 US white population.
e Unable to identify age and sex counts for additional calculation. The reported result is the originally published age-adjusted incidence rate standardized to the 1970 US white population; the 95% CI was not provided.
Results
A total of 34 articles met the study inclusion criteria. The incidence rates of skin and skin-related diseases for final reporting were grouped as follows: (1) skin cancer; (2) connective tissue diseases; (3) papulosquamous diseases, including psoriasis (including psoriatic arthritis); (4) infections and infestations; and (5) other skin diseases (ie, those skin diseases not categorized in the preceding groups). The Table summarizes the abstracted data from each of the articles, along with the age- and sex-adjusted incidence rates (standardized to the 2000 US white population).
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The risk of developing certain skin diseases such as nonmelanoma skin cancer, psoriasis, pityriasis rosea, herpes zoster, condyloma acuminatum, and lower extremity cellulitis was found to be relatively high in Olmsted County.Discussion
We present a summary of population-based data describing the incidence of skin and skin-related diseases in Olmsted County. Despite some limitations (described subsequently), these data are generalizable to other populations in the United States and worldwide. The incidence rates are listed in the Table. Many of the included studies also calculated the trends in the incidence rates during the time period studied; incidence rates were often reported in 5- to 10-year intervals. These reports found an increase in the incidence of most of the studied skin diseases over the decades. The reasons for the increase in the incidence of many of the skin diseases are unknown but may include a true change in incidence, changes in patterns of diagnosis over the decades, greater physician awareness of the diagnoses, and other specific risk factors for each of the reported skin diseases.
Can different studies of the same disease using REP data be compared for epidemiologic trends? Nonmelanoma skin cancer, malignant melanoma, SLE, psoriasis, psoriatic arthritis, and herpes zoster have been the subject of repeated reports from different time periods. These studies were not always comparable because of differences in the diagnostic classification criteria, differences in the age groups included, and overlapping study time periods.
The epidemiology of skin cancers has been extensively studied. The incidence of basal cell carcinoma has been gradually increasing,
5
in particular in patients younger than 40 years.6
The incidence of squamous cell carcinoma has dramatically increased over the past couple of decades8
compared with previous decades7
; the incidence rate has also been increasing over each decade.6
The incidence of cutaneous melanoma has been studied9
, 10
: the incidence rates were relatively stable from 1950 through 1967 but increased from 1968 to 1985. In younger patients, the incidence of melanoma has been found to be increasing rapidly, especially in women. From 1970 to 2009, the incidence of melanoma increased 8-fold in young women and 4-fold in young men.11
There are a number of articles about the incidence of lupus erythematosus, dermatomyositis, and other connective tissue diseases. Durosaro et al
12
studied the incidence of cutaneous lupus and found that the incidence of cutaneous lupus alone (excluding patients with concurrent SLE) was comparable to that of SLE. Discoid lupus erythematosus was the most common form of cutaneous lupus. The incidence rate of SLE has been estimated at different time periods and has been found to increase almost 3-fold from the 1950s to 1992.16
The incidence of morphea was found to be higher than that reported previously.13
Bendewald et al14
studied the incidence of dermatomyositis and found that the recently described amyopathic dermatomyositis accounted for approximately 20% of the cases of dermatomyositis. The incidence of primary Sjögren syndrome was much higher in women than in men.15
The incidence of papulosquamous diseases, including psoriasis and the related psoriatic arthritis, has been the subject of multiple REP studies. The incidence rate of psoriasis in adults (patients aged 18 years and older) has been estimated at different time periods
21
, 23
and has been found to increase almost 2-fold from the 1970s to 2000s.19
The incidence of pediatric psoriasis in patients younger than 18 years has been found to be less than that in adults, but it increases with the increase in age.20
The incidence of psoriatic arthritis was much less than that of psoriasis in 2 separate studies.23
, 24
The incidence of pityriasis rosea was found to be high.25
The epidemiology of selected skin-related infections and infestations has been studied. The incidence of herpes zoster has repeatedly been found to be very high,
28
though higher in adults30
than in children.29
Lower extremity cellulitis in adults is also very common.26
Condyloma acuminatum32
and herpes progenitalis31
are quite common, whereas hidradenitis suppurativa,34
Lyme disease,27
and cutaneous nontuberculous mycobacterial infection33
are much less common.Other miscellaneous skin or skin-related diseases that have been studied by using the REP include Behçet disease
35
and erythromelalgia,36
both of which had relatively low incidence rates. The incidence of venous stasis syndrome and venous ulcers in adults38
has been found to be high. The incidence of alopecia areata is also quite high.37
Strengths and Limitations
The strengths of studies using the REP infrastructure system are the availability of complete medical records of more than 4 decades and the ability to examine trends by using consistent eligibility criteria.
We acknowledge the limitations of the present study. All included REP studies also had several potential limitations. The REP resources are limited in that a disease or disorder is captured only after it is recognized by the physician, recorded, and then retrieved for research purposes. As a result, diseases that do not come to medical attention would not be included. Furthermore, inhomogeneity among the physicians who make the diagnoses may occur. Some of the included studies were also published before the adoption of accepted diagnostic classification criteria, which may result in a higher or lower incidence of a certain skin disease. The racial profile of Olmsted County is not representative of the United States. The population of Olmsted County is mostly white. Certain racial and ethnic groups are underrepresented in this population. Skin types of different races and ethnicities place individuals at varying risks of certain skin diseases. Olmsted County is relatively small (about 146,000 persons according to 2011 census data), and so there may be few cases of a rare disease. Also important to consider is the possible effect of Olmsted County’s geographic latitude on the incidence of certain skin diseases. Moreover, because the health care system is the largest employer in this county, the population of Olmsted County may be more aware of the possibility of a skin disease and may more often seek care for it than does the general US population. Only skin and selected skin-related diseases have been studied by using the REP. Furthermore, all included studies may have some limitations because of their retrospective design. Finally, we reviewed only the published data. We did not assess the patient files ourselves.
Conclusion
Epidemiologic data are essential to an understanding of human disease and its implications and are most reliably derived from population-based studies. Reliable population-based studies that assess the incidence of skin diseases are few because of the lack of well-enumerated populations from which affected patients can be identified. The REP is a resource that enables population-based studies of the epidemiology of diseases in Olmsted County. We present a summary of published REP data describing the incidence of skin and skin-related diseases in Olmsted County. In studies in which trends in incidence rates were estimated, an increase in incidence of the studied skin diseases over the decades was reported.
Acknowledgments
We acknowledge Mary G. Roberts for her assistance with the list of published REP studies, Jennifer St. Sauver, PhD, for her assistance with organizing the data, Jill M. Killian and Amy L. Weaver for their assistance with statistical review and analysis of the data, and Alanna M. Chamberlain, PhD, for her assistance with epidemiologic data.
References
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- Epidemiology of herpes zoster in children and adolescents: a population-based study.Pediatrics. 1985; 76: 512-517
- A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction.Mayo Clin Proc. 2007; 82 ([published correction appears in Mayo Clin Proc. 2008;83(2):225]): 1341-1349
- Incidence and trend of herpes progenitalis: a 15-year population study.Mayo Clin Proc. 1983; 58: 436-441
- Condyloma acuminatum in Rochester, Minn., 1950-1978, I: Epidemiology and clinical features.Arch Dermatol. 1984; 120: 469-475
- Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980-2009: a population-based study.Mayo Clin Proc. 2013; 88: 38-45
- Incidence of hidradenitis suppurativa and associated factors: a population-based study of Olmsted County, Minnesota.J Invest Dermatol. 2013; 133: 97-103
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- Incidence of erythromelalgia: a population-based study in Olmsted County, Minnesota.J Eur Acad Dermatol Venereol. 2009; 23: 13-15
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- Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study.J Vasc Surg. 2001; 33: 1022-1027
Article Info
Footnotes
Grant Support: This study was made possible by the Rochester Epidemiology Project (grant number R01-AG034676 ; Principal Investigators: Walter A. Rocca, MD, MPH, and Barbara P. Yawn, MD, MSc).
Identification
Copyright
© 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.
