Genodermatoses in Las Tunas Province, Cuba, 1989–2019

INTRODUCTION Genodermatoses are a group of genetic diseases that affect the skin and adjoining tissues. They represent 15% of genetic diseases worldwide. Cuba established a National Program for the Diagnosis, Care and Prevention of Genetic Diseases and Congenital Abnormalities in 1980, which was implemented in Las Tunas in 1989. In 2010, a specialized multidisciplinary provincial service for genodermatoses patients was established in Las Tunas province. Several studies in Las Tunas show that genodermatoses represent 22.2% of genetic diseases; the most common are ichthyosis (16.7%), mastocytosis (11.7%), and neurofi bromatosis (8.3%). Children aged <12 years are the most affected (61.6%). OBJECTIVE Describe genodermatoses in Las Tunas Province, Cuba, since the implementation of the National Program for the Diagnosis, Care, and Prevention of Genetic Diseases and Congenital Abnormalities, and after the creation of a specialized multidisciplinary provincial service for genodermatoses patients. METHODS We conducted an observational, descriptive, retrospective study in 249 patients diagnosed with some type of genodermatosis who received care in Las Tunas during 1989–2019. Variables considered were: type of genodermatosis, complications, deaths and geographic location by municipality. We studied prevalence rates (1989–2019), incidence rates (2010–2019), proportion of complications, survival rates, and types of genodermatosis diagnosed by municipality in two periods (1989–2009 and 2010–2019) one before, and one after the implementation of a targeted multidisciplinary provincial care service. RESULTS The general prevalence rate of genodermatoses in Las Tunas Province was 46.51 per 100,000 population. The forms with the highest prevalence rates were neurofi bromatosis type 1 (13.6 per 100,000 population), classical Ehlers-Danlos syndrome (7.1 per 100,000), ichthyosis vulgaris (5.0 per 100,000) and cutaneous mastocytosis (2.4 per 100,000). The highest incidence rates coincided with the conditions with the highest prevalence: neurofi bromatosis type 1 (81.5 per 1000 cases in 2013), classical EhlersDanlos syndrome (44.4 per 1000 cases in 2013) and ichthyosis vulgaris (52 per 1000 cases in 2010). From 1989–2009, patients presented a greater frequency of complications, at 40% (22/55) than from 2010–2019 at 21.1% (41/194). Pyodermitis was the most common during the study period (1989–2019), with 29.1% (16/55). Survival was high, at 98.0% (only 5 deaths in 2009, 2010, 2011, 2012, and 2015, and were no deaths during other years) in the study period. The greatest share of genodermatosis cases was registered in the municipality of Majibacoa (0.07%), and consanguinity was found in cases of epidermolysis bullosa, Herlitz type and xeroderma pigmentosum. CONCLUSION In Las Tunas Province, Cuba, genodermatoses as a whole are not rare diseases. Those with the highest prevalence and incidence rates are neurofi bromatosis type 1, classical Ehlers-Danlos syndrome and ichthyosis vulgaris. After implementation of the specialized multidisciplinary provincial service for genodermatoses patients within Cuba’s National Program for the Diagnosis, Care, and Prevention of Genetic Diseases and Congenital Abnormalities, in addition to the active screening implemented by this Program, more cases were diagnosed, and a lower proportion of complications and a higher survival rates were recorded.


INTRODUCTION
In general, most dermatological diseases are genetic in origin; almost all cases involve a genetic predisposition to skin diseases. [1] Individual immune response to infectious processes is modulated by epigenetics. The infectious dermatosis that best exemplifi es this phenomenon is Hansen's disease. [2] However, 'genodermatosis' refers to the process in which genetic anomalies (generally mutations of a single gene) play a predominant role in the origin of the disease and lead to clinical symptoms, which then manifest in the skin and adjoining tissues (adnexa). Their common characteristic is that they are all inherited. [3] Individually, genodermatoses are rare, but together they comprise a large group that is diffi cult to diagnose, treat and monitor due to their diversity in presentation and inheritance, even within the same disease. [4] Neurofi bromatosis, Leopard syndrome, Ehlers-Danlos syndrome and tuberous sclerosis are diagnosed via clinical exam, [5,6] while ichthyosis, Darier disease, epidermolysis bullosa and mastocytosis are confi rmed through histopathology. [5] In other cases, such as xeroderma pigmentosum (XP), supplemental studies are not conclusive. To diagnose the aforementioned conditions, Cuba uses histopathology, which is not conclusive, and single gel electrophoresis (SCGE) on isolated lymphocytes from peripheral blood to evaluate DNA's ability to repair itself after damage is induced by ultraviolet light, a test which is not 100% specifi c to XP. [7] In general, there are no genetic tests available for mass screening of these conditions. Genodermatosis lesions can be very visible and have a psychological impact on patients, and can result in social stigma, negatively impacting their quality of life. Many genodermatoses lead to chronic disability, others to death. [4] It is diffi cult to gather precise data on the prevalence of genodermatoses (especially in developing countries), due to the diversity IMPORTANCE This study updates understanding of genodermatoses in Las Tunas Province, after the implementation of the National Program for the Diagnosis, Care, and Prevention of Genetic Diseases and Congenital Abnormalities and the specialized multidisciplinary service that provides specialized care to patients affected with these genetic diseases.

Original Research
Peer Reviewed of diseases that are grouped under this common name, many of which go undiagnosed. In the most studied diseases, the results vary from one country to the next. Worldwide, the incidence of hypomelanosis of Ito is 1 per 7540-10,000 live births; [8] ectodermal dysplasia, 1 per 100,000 births; [9] oculocutaneous albinism, 1 per 18,000 births; [10] incontinentia pigmenti, 1 per 40,000-50,000 births; [11] tuberous sclerosis, 1-5 per 10,000 live births; [12] epidermolysis bullosa, 1 per 500,000 live births; [13] and Waardenburg syndrome, 1 per 42,000 births. [14] Few population studies on genodermatoses have been conducted in Cuba. Dorticós conducted research to characterize them in a study involving 10 hospitals in Havana from 1980 to 1986, in which ichthyosis (37.7%) and neurofi bromatosis (18.8%) were the most common genodermatoses. [15] Campo Díaz published a study on Ehlers-Danlos syndrome type III conducted in Pinar del Río Province in 2010-2011, fi nding 100% with manifestations on the skin and 59.3% with associated bleeding disorders. [16] Orraca also made a genetic, clinical and epidemiological characterization of neurofi bromatosis type 1 in Pinar del Río Province, fi nding a prevalence of 1 per 1141 in pediatric patients, above rates reported globally for this disease. [17] One study performed in 2015 in Las Tunas, an eastern Cuban province, suggested that 85% of genetic diseases treated at the Provincial Medical Genetics Department (PMGD) were diagnosed in pediatric patients; of those, 22% were dermatological. [18] WHO estimates that there are approximately 10,000 genetic diseases affecting 7% of the world population. [19] Genetic diseases make up 25% of pediatric hospital admissions, with 15% of cases affecting the skin and adnexa. [20] Since 1963, WHO has urged member states to focus on the control and prevention of genetic diseases (through early diagnosis, access to care, genetic counseling, etc.). [21] In developed countries, there are numerous foundations dedicated to the treatment of specifi c genetic diseases, but there is no unifying vision that involves all levels of health care. In 1980, Cuba's national health system implemented the National Program for the Diagnosis, Care, and Prevention of Genetic Diseases and Congenital Abnormalities, [22] which we will identify below as NGP (National Genetics Program). This program is supported by a network of Genetics Counseling Service comprising 172 Medical Genetics Municipal Departments (in every municipality in the country), 16 PMGD (located in all Cuban provinces), and the National Medical Genetics Center (CNGM), a lead institution that provides coverage to the entire population. CNGM is a collaborative center focused on genetic developments that help promote health worldwide. [22] NGP's work is guided by the Manual of Regulations and Procedures for medical genetics services in Cuba, [23] which offers standards for mass screening for some genetic diseases via specialized screening. NGP not only offers specialized medical care, but also conducts preventive prenatal, perinatal, and postnatal services (at the three levels of prevention: primary, secondary, and tertiary) for early detection of congenital diseases and abnormalities; supports research aimed at designing education strategies for patients, their families, and the general public; and works to promote social inclusion of affected persons and improve their quality of life. [22] Masters and specialists in clinical genetics regularly conduct exchanges for diagnostics and patient follow-up with those in other fi elds (gynecology and obstetrics, ophthalmology, endocrinology, orthopedics, otorhinolaryngology, neonatology, immunology, molecular biology, dermatology, pediatrics, psychology, neurology, cardiology, oral medicine, pathology and imaging, etc.). [23] NGP was established in Las Tunas Province in 1989. In 2010, a specialized multidisciplinary provincial service was established to care for genodermatosis patients. This bi-weekly service is managed by specialists in clinical medical genetics and dermatology, the service's main specialties, with support from psychologists, immunologists, pediatricians and others, depending on patient characteristics and symptoms. From 2010 to 2012, the most common genodermatoses were ichthyosis (16.7%), mastocytosis (11.7%), and neurofi bromatosis (8.3%). The most affected were patients <12 years of age (61.6%). [24] The objective of this study was to describe genodermatoses in Las Tunas Province, Cuba, since the establishment of NGP, and after the creation of a specialized multidisciplinary provincial service for genodermatosis patients.

Study type and participants
A descriptive observational study was performed, with cross-sectional and retrospective components. It was conducted at the PMGD's specialized multidisciplinary provincial genodermatoses service in Las Tunas Province, Cuba, and comprised the years 1989-2019. The universe was composed of 942 patients with genetic disease diagnoses, registered in the PMGD database and, for nonprobability sampling, 249 patients who met the diagnostic criteria of genodermatoses.
Inclusion criteria Patients seen at the service, who met genodermatosis diagnostic criteria, and who gave written informed consent to participate in the study (in the case of minors, parents or guardians authorized patient participation).
Exclusion criteria Patients seen at the service, but whose medical records did not contain all data necessary for the study, or who had psychiatric conditions that would prevent necessary data collection.
Diagnostic criteria Genodermatoses are considered clinical conditions whose primary phenotypic manifestations involve the skin and adnexa and that have a genetic component. Patient genealogy was examined to determine genetic history, inheritance patterns and the diagnosis of new cases in the family since the proband case. [23] In all cases the diagnosis was confi rmed by a clinical geneticist.
Supplemental studies were performed to corroborate the diagnosis or presence of complications. These studies were: hematological (liver transaminases, eosinophil count, peripheral blood smears to explore the presence of mast cells in peripheral blood); [25] histopathological (skin biopsy for microscopic diagnosis of aplasia cutis, cutis laxa, cutis verticis gyrata, congenital ectodermal dysplasia, Darier disease, Hailey-Hailey disease, epidermolysis bullosa, hypomelanosis of Ito, ichthyosis,

Original Research
incontenencia pigmenti, mastocytosis, pityriasis rubra pilaris, porokeratosis of Mibelli, palmoplantar keratoderma, Netherton syndrome, Proteus syndrome, and Rothmund-Thomson syndrome); [1,2] imaging (ultrasonography, computed tomography, and magnetic resonance imaging; fundamental in diagnosing neurofi bromatosis, tuberous sclerosis and Sturge-Weber syndrome); [23] genetic, to corroborate genodermatosis diagnoses whose clinical presentations were not conclusive on their own or to differentiate them from other clinically similar conditions, such as SGCE on isolated lymphocytes XP diagnosis; [7] indirectly using fi ve markers: four microsatellite markers (IVS27AAAT2.1, IVS38GT53.0, IV27AC28.4 and Mfd15) and one restriction fragment length polymorphism (Rsa I NF1 exon 5) to diagnose neurofi bromatosis type 1; [17] and other studies required to diagnose infectious complications, such as bacterial and fungal cultures. [2] The foundation of all diagnoses in the study were initial clinical exam and personalized physician-patient relationships, the fundamental pillars of diagnostics in general, especially when advanced technology is not available to corroborate the suspected clinical condition. [ Complications We considered complications secondary to skin abnormalities due to genodermatosis, such as secondary pyoderma (Bacterial I), [2] superfi cial cutaneous mycoses (Fungal I) and within these, dermatophytosis and mucocutaneous candidiasis, erythroderma, sun damage (sun burns, sun freckles, elastosis, premalignant lesions, skin cancer) and systemic infl ammatory response syndrome (SIRS). The number of patients with each complication were considered.

Number of deaths and diagnosis
Deceased patients with genodermatosis and genodermatosis diagnosis at death.
Geographic location by municipality All municipalities of the province were considered: Amancio Rodríguez, Colombia, Jesús Menéndez, Jobabo, Las Tunas, Majibacoa, Manatí, and Puerto Padre. This variable provides important epidemiological elements pertaining to inheritance patterns, potential consanguinity and prevalence of specifi c genodermatoses within particular regions.
Data collection and analysis Information was collected using primary sources consisting of patients of legal age and parents or guardians of patients who were minors, and secondary sources consisting of the patient's medical record and records from PMGD and specialized multidisciplinary provincial service for patients with genodermatoses. Techniques used to obtain information included participatory structured observation, faceto-face medical interviews, and general and more targeted physical examinations, as well as a review of secondary sources. All information was gathered in a Microsoft Excel database and was processed using the SPSS Version 18 for Windows.
Prevalence rates were calculated per 100,000 population, taking into consideration the population of Las Tunas Province in 2019 (535,335 inhabitants), according to the Cuban National Statistics and Information Bureau (ONEI). [27] The annual incidence rate of genodermatosis was calculated for 2010-2019 (the period following the implementation of the specialized multidisciplinary provincial service for patients with genodermatoses), as was the proportion of complications. Two periods of time were compared, from the start of the National Genetics Program in 1989 to implementation of the specialized multidisciplinary provincial service for patients with genodermatoses in 2009, and during the service's operation in 2010-2019. We also calculated the survival index (100 x number of survivors annually/total patients), fatality rate (100 x number of deaths per year/total patients), and number of genodermato-

Original Research
ses diagnosed per municipality (number of patients/municipality population) x 100) for each genodermatosis.
To compare results among municipalities, the population of each was taken into consideration (according to ONEI data): 37,695 inhabitants in Amancio; 32,167 in Colombia; 48,208 in Jesús Menéndez; 42,603 in Jobabo; 211,596 in the municipality of Las Tunas; 41,287 in Majibacoa; 29,930 in Manatí, and 91,879 in Puerto Padre. [27] Ethical considerations The research protocol was approved by the research ethics committee and scientifi c council at Mártires de las Tunas Provincial Pediatric Hospital and research was conducted in accordance with the Declaration of Helsinki. [28] To participate in the study, written informed consent was obtained from patients (or parents or guardians of patients who were minors). The written information provided explained the importance of participation, the risks and benefi ts, participants' rights and study characteristics. Data was coded to protect patient identity.

RESULTS
From 1989 through 2019, general prevalence rate of genodermatoses in Las Tunas Province was 46.5 per 100,000 population. Neurofi bromatosis type 1 was predominant at 13.6 cases per 100,000 population, followed by classical Ehlers-Danlos syndrome at 7.1 per 100,000, ichthyosis vulgaris at 5 per 100,000 and cutaneous mastocytosis at 2.4 per 100,000 ( Figure 1).  (Table 1) The municipality with the highest proportion of genodermatosis cases was Majibacoa (0.07%), followed by Las Tunas (0.06%) and Colombia and Jobabo, both at 0.05%. The municipalities with the lowest prevalence were Amancio and Puerto Padre, both at 0.02%. There was consanguinity in the municipality of Manatí, with a case of junctional epidermolysis bullosa, Herlitz type; in the municipality of Colombia there were two cases of XP.

DISCUSSION
The most predominant inheritance patterns of genodermatoses in Las Tunas are those with autosomal dominant Mendelian inheritance, such as neurofi bromatosis type 1, classical Ehlers-Danlos syndrome, ichthyosis vulgaris, and cutaneous mastocytosis. [29] In this type of inheritance, traits or conditions are present in all generations, even if the individual is heterozygous; it affects both sexes, with a 50% probability of transmitting the affected allele to their offspring, [29] and accordingly, the proportion of affected individuals in a population will be higher. These conditions often present low fatality, which contributes to increasing prevalence.
According to WHO, rare diseases are those that affect less than 5 persons per 100,000 population. [30,31] Other authors internationally have reported prevalence rate of neurofi bromatosis type 1 at 1 per 2500-3000 population, [32] classical Ehlers-Danlos syndrome at 1 per 5000 births, [33,34] ichthyosis vulgaris at 1 per 250-1000 population, [35] and cutaneous mastocytosis at 2 per 300,000 births. [36] Considering the results of our study, these diseases, as a group, and by this defi nition, are not rare in Las Tunas Province; neither are neurofi bromatosis type 1, classical Ehlers-Danlos syndrome,

Original Research
and ichthyosis vulgaris. However, cutaneous mastocytoses have lower rates in the province than those reported at globally.
The multidisciplinary service offers genetics counseling for families including a discussion of reproductive options. While not all families perceive risk the same way, genetic counseling has increased the birth rate of individuals with conditions that are not lethal or whose life expectancy is higher. High prevalence rates may be due in part to increased treatment effectiveness and genetics counseling availability in the province.
In many genodermatoses, including neurofi bromatosis type 1, classical Ehlers-Danlos syndrome, and ichthyosis vulgaris, among others, [5] patients do not manifest signs and symptoms in the fi rst year after birth, which makes it very diffi cult to determine prevalence rates at birth. However, when incidence rates are studied in relation to specifi c genodermatoses diagnosed per year, the most commonly-diagnosed genodermatoses in any one year can be identifi ed. For genodermatoses whose manifestations begin in the fi rst year, like congenital ectoder-mal dysplasia, oculocutaneous albinism, epidermolysis bullosa, and incontinentia pigmenti, [5] incidence rates coincide with prevalence rates at birth.
The fact that annual rates are higher for genodermatoses that do not present symptoms at birth suggests that diagnosis is based on active case screening, identifi cation of affected members of the same family as the proband case, use of genealogical trees and effectiveness of the risk counseling process. This is possible thanks to NGP working at all three levels of care, both for the patient and their family, facilitating better control of these diseases. [23] When skin is damaged, as occurs in most genodermatoses, it loses its barrierprotective function, which allows bacteria and fungi to colonize the skin. [37] Comparing the most common complications in both periods, we found fewer during the second period, which coincides with the 2010 implementation of the specialized multidisciplinary provincial service for patients with genodermatoses, the multidisciplinary work between the geneticist and dermatologist, and the application of treatments to improve the clinical status of the patient with consequent complication prevention.
General orientations provided by the service included hygiene, sun protection, skin self-examination, a balanced diet rich in fruits and vegetables (vitamin therapy), adequate skin hydration and use of emollients for xerodermic or ichthyosiform skin. [2] Preventive therapeutic measures included emollient and antibiotic creams used in combination for diseases with high risk of damage to skin integrity, such as ichthyosis, Darier disease, epidermolysis bullosa and pityriasis rubra, [2] as well as antifungals, since fungal infections such as palmoplantar keratoderma and epidermolytic hyperkeratosis may occur. [2] For pyodermitis, antibiotics such as penicillins and cephalosporins were employed, as these are effective against Staphylococcus aureus and group A beta-hemolytic Streptococcus, bacteria that commonly colonize the skin and may even lead to systemic complications. [1] While patient survival was high, fi ve deaths occurred, all due to complications, described as follows: One patient had junctional Herlitz-type epidermolysis bullosa. [38] This patient presented symptoms of generalized blistering from birth that left atrophic scars, with marked epidermal detachment, presence of the Nikolsky sign (except the palms of the hands and soles of the feet) and nail dystrophy, with no tooth development and madarosis. Skin lesions were poten-  Original Research tial entry points, which led to symptoms of sepsis, immunodefi ciency, delayed psychomotor development, protein-energy undernutrition, [38] and fi nally, multiorgan failure, with death at 11 months.
A patient with occipital horn syndrome presented hypotonia, with frequent symptoms of diarrhea, cutis laxa, joint hypermobility, coarse hair, clotting disorder, and an aortic aneurysm, [39] which led to his death at eight months. This syndrome, formerly known as type IX Ehlers-Danlos syndrome, was excluded from the classifi cation of variants of Ehlers-Danlos syndrome established by an international expert consortium in 2017, [40] and is currently classifi ed in the connective tissue disorder group caused by abnormalities in copper metabolism.
Another patient with a Rothmund-Thomson syndrome presented with typical features of the disease, such as xeroderma, poikiloderma of the face, congenital cataracts, photophobia, delayed physical growth, immunodefi ciency and sepsis [41,42] and died at under fi ve months of age.
One patient presented with Netherton syndrome, a rare disease transmitted through autosomal recessive inheritance and defi ned by the characteristic triad of congenital ichthyosiform erythroderma, hair shaft abnormalities and immunological disorders. [43,44] From birth, this patient had symptoms of erythroderma accompanied by frequent skin infections, leading to repeated admissions to intensive care units and ultimately death from sepsis at two years of age.
Another patient had neurofi bromatosis type 1 associated with congenital cardiovascular malformations that led to cardiogenic complications and death. Neurofi bromatosis type 1 is a multisystem disease, considered a neuroectodermal syndrome (currently called neurocristopathy), transmitted through autosomal dominance through the nf1 gene located at locus 17q11.2 and affecting mainly the skin and nervous system. It produces melanic manifestations of the skin and tumors, but is often not lethal. [45] In this patient, more than six cafe-au-lait spots and a genetic family history of the disease were identifi ed, but congenital heart disease led to the patient's death at age two.
The literature considers genodermatoses to be genetic diseases of the skin with high morbidity that, in some cases, present systemic conditions that may be fatal; in most lethal genodermatoses, death often occurs in the fi rst year of life. [5] This study facilitated identifi cation of geographic distribution (by municipality) and affected families. In general, the number of cases diagnosed was not proportional to the population density of each municipality. The highest proportion of cases was in Majibacoa, which had the fi fth highest population density in the province, but a place also characterized by greater involvement of dermatologists in the community. The municipalities with the highest population densities, such as Puerto Padre and Amancio Rodríguez, recorded lower proportions of cases. This may be due to poor screening and less availability of dermatological care. Despite existence of a specialized multidisciplinary provincial service for genodermatoses patients that includes both clinical geneticists and dermatologists, the latter are in the highest demand for these patients, and their greater participation in the NGP is needed. [24] A case of epidermolysis bullosa (Herlitz type) was diagnosed in Manatí municipality. The patient had a family history of the disease, including a maternal uncle who died of it, and parental consanguinity. In Colombia municipality, a case was confi rmed of xeroderma pigmentosum with familial ties to an affected family from another province (Ciego de Avila) in which consanguinity was determined. Consanguinity is the genetic union of two people descended from common ancestors, (second-degree cousins or closer). Currently, over 1.2 billion people worldwide are in consanguineous marriages and it is estimated that 10.4% of the world population is married to a biological relative or is the offspring of a consanguineous union. [46] A consanguineous marriage increases the risk of autosomal recessive diseases transmission by 25%-50% because it increases the probability of two affected alleles being combined and thus the birth of an affected child. [46] CONCLUSIONS In Las Tu nas Province, Cuba, genodermatoses as a whole are not rare diseases according to WHO defi nitions. Those with the highest prevalence and incidence rates are neurofi bromatosis type 1, classical Ehlers-Danlos syndrome and ichthyosis vulgaris. After implementation of the specialized multidisciplinary provincial service for genodermatoses patients within Cuba's NGP, in addition to active screening, more cases were diagnosed, and a lower proportion of complications and a higher survival index were recorded. However, improving the quality of care for patients with genodermatosis is necessary with the implementation of a methodology protocolizing their care and establishing follow-up algorithms.

ACKNOWLEDGMENTS
This study was conducted with support from the National Program for the Diagnosis, Care and Prevention of Genetic Diseases and Congenital Abnormalities. The authors thank the Las Tunas Provincial Medical Genetics Department for its contributions to the study.