A Histopathological Study of Skin Lesions in Individuals with Oculocutaneous Albinism in Togo in 2019

Objective The aim of this study was to study the histopathological patterns of skin lesions in persons with albinism (PWA) in Togo in 2019. Method During two mobile skin care clinics in 2019, biopsies/excisional biopsies were performed in PWA in case of clinical doubt or in front of lesions suspected to be cancerous for histological examination. Anatomopathological reports were thus analysed. Results During the two mobile skin care clinics, 115 biopsies/excisional biopsies were carried out in 79 PWA, with a mean age of 24 ± 16.1 years. Histological examination led to a diagnosis in 110 cases (95.6%) and was inconclusive in 5 cases (4 cases of uncertain histological diagnosis and one case of nonspecific histological lesions). Fourteen different histological diagnoses were made, with a frequency ranging from 0.9% (one case) to 26.9% (31 cases). The four most frequent diagnoses in descending order were basal cell carcinomas (BCCs) (31 cases; 26.9%), invasive squamous cell carcinomas (SCCs) or Bowen's disease (23 cases; 20%), keratosis (20 cases; 17.3%), and cysts (seven cases; 6.1%). The 54 skin carcinomas were diagnosed in 33 (41.8%) of the 79 patients who underwent skin biopsies/excisional biopsies. The BCC/SCC ratio was 1.3. No cases of cutaneous melanoma had been diagnosed. Conclusion Skin cancers represent the main histological diagnosis in PWA (46.9%) in Togo in 2019. The pattern of cutaneous malignancies in PWA shows the same trend as that seen in Caucasians with a predominance of basal cell carcinomas.


Introduction
Oculocutaneous albinism is an inherited disease characterized by the total or partial absence of melanin in the skin, hair, and eyes [1,2]. Melanin, the pigment responsible for skin colour, is photoprotective against carcinogenic ultraviolet radiation [3]. Its deficiency in people with albinism (PWA) predisposes them to the harmful effects of this radiation, with the development of actinic damage and a major risk of skin cancer [4][5][6]. e diagnosis of skin diseases in PWA very often requires histological examination [2,[7][8][9], especially in the case of skin lesions suspected of being cancerous. Indeed, the fear of the practitioner is the early detection of these skin cancers in this population because of their very high frequency, varying from 23 to 26% depending on the series [9][10][11][12]. We conducted this study in order to study the histopathological patterns of skin lesions in persons with albinism (PWA) in Togo in 2019.

Method
Two rounds of free mobile skin care clinics took place throughout the Togolese territory in 2019 in order to treat malignant and premalignant lesions in PWA. ese campaigns covered 10 cities in Togo, the first in June and July 2019 and the second in October and November 2019. Dermatological consultations were provided by a senior dermatologist. Biopsies/excisional biopsies were carried out in case of clinical doubt or in front of lesions suspected of being malignant and sent to the laboratory of pathology of the Sylvanus Olympio University Hospital or to the histopathology unit of the Mélia clinic in Lomé for histological examination. Two pathologists assisted in carrying out the histological examinations. Anatomopathological reports were collected and analysed. e data collected were sociodemographic (age and sex) and histological diagnosis.

Results
During these two campaigns, 115 biopsies/excisional biopsies were carried out for histological examination in 79 patients, with an average of 1.5 biopsies/excisional biopsies per PWA. Indeed, 24 of the 79 patients had more than one biopsy/excisional biopsy (15 had two biopsies/excisional biopsies, 6 had three biopsies/excisional biopsies, and 3 had four biopsies/excisional biopsies). e mean age of the 79 patients was 24 ± 16.1 years (extremes: 7 and 75 years), and the sex-ratio (M/F) was 1. All of these 115 biopsies were cutaneous.
Histological examination led to a diagnosis in 110 cases (95.6%) and was inconclusive in 5 cases, including 4 cases of uncertain histological diagnosis and 1 case of nonspecific histological lesions.

Discussion
In our study, 115 biopsies/excisional biopsies were performed in 79 PWA, an average of 1.5 biopsies/excisional biopsies per PWA. is rate is comparable to that found (1.6 biopsies per PWA) in Tanzania where 134 biopsies were performed on 86 PWA [2]. In Nigeria [9], 58 biopsies were taken from 30 PWA, corresponding to 1.9 PWA biopsies.
ese results show that suspicious skin lesions requiring skin biopsy are most often multiple in the same PWA, probably due to the effects of ultraviolet radiation. Moreover, the main reason for biopsies/excisional biopsies in PWA is especially when skin lesions are suspected to be malignant, as the practitioner's obsession is the early detection of these skin cancers in this population because of their very high frequency [9][10][11][12]. In the series of Enechukwu et al. [9], skin biopsy was performed on suspicion of premalignant or malignant lesions in 38% and 32% of cases, respectively.
Histological examination resulted in a histological diagnosis of certainty in 110 (95.6%) of the 115 biopsies/excisional biopsies in our study. In a French study on penile dermatosis in the general population [13], this histological examination led to a diagnosis in 85.5% of cases. Rajaratnam et al. [14] in Ireland found in the study of general population that, in 55% of cases of inflammatory dermatosis, histology led to a diagnosis of certainty, even without any clinical information provided to the pathologist. ese results show the value of histology in dermatology for the diagnosis of skin diseases.
In our study, there was a predominance of BCC with a BCC/SCC ratio of 1.3.
is predominance could be explained by the fact that, in our case, it is the dermatologist who goes to the PWA, which allows us to detect mild cases. In Nigeria [9], BCC was also the most frequent skin carcinoma (55%), followed by SCC (22%), basosquamous carcinoma (12%), and collision tumour (BCC and SCC, 3.4%). In Brazil [10], 62% were BCC, 51% were SCC, and 7% were melanoma. All three studies, including ours, were population-based studies. However, most of the African studies, all hospital series, show that SCC is the most common cancer in this population [2,[17][18][19]. Finally, melanoma is rare in PWA with a similar incidence in the general population [10], a tumour that was not by us and Enechukwu et al. [9].
Limitations of study: the main limitation of this study is that histological examinations were performed by general pathologists and not dermatopathologists. Nevertheless, in 95.6% of cases, the histological examination made a diagnosis. Journal of Skin Cancer

Conclusion
e results of this study show that skin cancers represent the main histological diagnosis in PWA (46.9%) in Togo in 2019. e pattern of cutaneous malignancies in PWA shows the same trend as that seen in Caucasians with a predominance of basal cell carcinomas. e popularization and respect of photoprotection measures and systematic and regular examination of the skin of these PWA will allow early detection and management of these skin cancers.

ANAT:
National association of albinos of Togo BCC: Basal cell carcinoma NGO: Nongovernmental organization PWA: Patients with albinism SCC: Squamous cell carcinoma SOTODERM: Togolese society of dermatology and sexually transmitted infections UV: Ultraviolet.

Data Availability
Extracted data are with the authors and available for sharing on request.

Ethical Approval
is study was authorized and approved by the National Association of Albinos of Togo (ANAT), the Togolese Society of Dermatology and Sexually Transmitted Infections (SOTODERM), the Maxillofacial and Plastic Surgery Department, and the Ministry of Health of Togo. Consent e authors obtained oral consent from patients who participated in the study.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
BS, PP, and GM were responsible for the conception of the study, participated in the study design, undertook the field study, conducted the data collection, analysis, and interpretation, and wrote the manuscript. ey have revised and finalized the manuscript. JNT, PK, SA, SAK, PG, and YEM were involved in the data collection, analysis, and interpretation. ey wrote and finalized the manuscript. AMT, TD, and KK were involved in data analysis and interpretation. All the authors were responsible for the overall scientific management of the study, for analysis and interpretation, and the preparation of the final manuscript. Finally, all the authors read and approved the final manuscript to be submitted for publication.  (2); benign (14); HPV/wart (4).
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