PARIS -- From the clinical symposia to the exhibit hall, the 20th World Congress of Dermatology revealed a disturbing truth: The rich are indeed getting richer, and the poor are getting poorer and facing growing dermatologic adversities.

One need only have spent a few hours on the congress' sprawling

Exhibit halls were dominated by cosmeceutical companies marketing increasingly sophisticated moisturizers, hydroxy acid creams, and other rejuvenation products, samples of which were dispensed in seductive packaging by attractive representatives at lavish booths flowing with champagne, espresso, chocolate, croissants, fruit platters, and sushi.

And while congress symposia focused on skin diseases as opposed to cosmetic procedures, the gap in wealth and resources was evident there, too.

Clinical dermatology in the United States and Europe is increasingly high tech, as dermatologists team up with medical engineers and information scientists to advance new diagnostic imaging tools like optical coherence tomography, cutaneous ultrasound, and neural network computer software. (See story on page 6.)

But for much of the world, where a reliable supply of electricity is still a luxury advances like these are largely irrelevant.

While there were no major drug launches at the congress, dermatologic drug research marches on, and clinical investigators are finding new indications for immunomodulators like tacrolimus, pimecrolimus, and imiquimod. New biologic therapies such as alefacept, efalizumab, and infliximab are on the horizon for dermatologic disorders,

In the rest of the world, it's a different story Dermatology in Africa, Latin America, Eastern Europe, and much of Asia is about infectious disease-disfiguring, sometimes deadly infectious conditions, including sexually transmitted diseases. Diseases like leprosy considered ancient history in Western countries, still exact a huge toll in India and Africa.

While industrialized dermatology is increasingly concerned with things molecular, clinicians in Asia, Africa, and Latin America struggle with more visible foes: flies, fleas, mites, mosquitoes, and worms.

This story was told, in graphic detail, in the poster presentation halls. Congress organizers made a special effort to recruit papers from clinicians in developing countries, many of which were presented as posters. The congress subsidized expenses for these investigators to attend the Paris meeting in numbers that would not ordinarily be possible.

The posters showed clearly that for the nonindustrialized world, dermatology means daily confrontations with secondary syphilis and HIV-related opportunistic infections, leprosy cutaneous tuberculosis, septic vasculitides, disseminated staphylococcal infections, tularemia, and parasitic diseases like leishmaniasis and onychomycosis.

According to Dr. Henning Grossmann of the International Foundation for Dermatology approximately 30% of all diseases in sub-Saharan Africa are skin disease, compared with only 10% in industrialized countries. Of that, 50%-80% are infectious or parasitic and are easily preventable or treatable with inexpensive medications, when available.

Africa, already burdened with a huge number of infectious diseases, now confronts a new one: Buruli ulcer, a necrotizing ulcerative condition caused by infection with Mycobacterium ulcerans. Though first discovered in Australia, this disease is now spreading throughout West Africa, taking particularly heavy tolls in Benin, the Ivory Coast, and Ghana where prevalence is estimated to be as high as 3.19 cases per 1,000 individuals in endemic areas, reported Dr. Agustin Guedenon, a dermatologist in Cotonou, Benin. The mode of transmission is unknown, though the condition appears to be associated with marshy regions.

While Buruli ulcer, named after a region in Uganda, seldom kills its victims, it can leave them horribly disfigured and disabled. The tragedy is all the greater since the disease appears to preferentially affect children. According to the World Health Organization, more than 50% of all cases worldwide are in people under age 15 years. There are no accurate early diagnostic tests, and no known medical therapy with the exception of BCG vaccine, which is hit or miss at best, and largely inaccessible for rural Africans.

Sexually transmitted infections, including HIM continue unchecked across much of the globe. While the devastating impact in Africa and Asia has received considerable media coverage, a relatively new surge in STDs throughout Eastern Europe has received less attention. (See story on page 5.) Economic instability combined with markedly increased mobility in the former Soviet bloc nations appears to be at the root of this alarming development.

Lack of dermatologic expertise is a major problem in much of the world. According to Dr. Grossmann, there are fewer than 150 trained dermatologists in sub-Saharan Africa, a continent of about 500 million people. Half of the world's nations have between zero and two dermatologists. Roughly 3 billion people in 127 countries have no access to basic, modern skin care.

"Western-style dermatology is impractical in Africa and other parts of the world. More emphasis needs to go to training of allied health professionals, and not just as a short-term solution but as a long-term solution," Dr. Grossmann said.

Dr. Grossmann is one of the directors of the Regional Dermatology Training Center in Moshi, Tanzania, an innovative program sponsored by the IFD, the International League of Dermatological Societies, and the WHO, that has trained more than 100 nondermatologists (nurses, infectious disease specialists, lay health care providers) from 13 African countries in the basics of diagnosing and treating common dermatologic diseases. Visiting dermatologic experts from around the world converge on the RDTC to teach auxiliary health care givers.

Graduates of the 2-year program at Moshi are granted the title of "Dermatology Officer," and they return to their home countries with skills to improve dermatologic care. They are also charged with conducting clinical and epidemiologic research.

Given the limited availability of pharmaceuticals in Africa, a considerable number of research projects are aimed at exploring traditional medicines, including indigenous botanical medicine.

Another regional dermatology training center was established in Chimaltenango, Guatemala, in 1996. Dr. Terrance Ryan, chairman of the IFD, said the foundation is eyeing China as a potential site for a future RDTC. "There are 400 million people in dire need of better skin care."

A French organization called Dermatos Hors Frontieres (Dermatologists Without Borders) is also attempting to address the dire need for trained skin specialists and therapeutic supplies in developing countries. Formed by the Federation Francaise de Formation Continue en Dermato-Venereologie and representing more than 70 regional associations, this grassroots, practitioner-driven network is providing educational materials and devices like electric scalpels and reconditioned PUVA units to clinics in nations like Burkina Faso, Vietnam, and Cambodia.

While the international dermatology community is increasingly taking action, and pharmaceutical manufacturers make some effort to provide products at reduced or no cost to developing nations, it can be difficult to reconcile the billions of dollars spent on aesthetically centered "luxury" care in industrialized countries with the desperate need for basic skin care in the rest of the world.

In a small, decidedly low-tech booth tucked in a corner of one of the massive exhibit halls of the Palais de Congres, Dr. Elisante John Masenga, of Tanzania's Tumaini University and other representatives of the IFD, struggled to attract attention to the extraordinary efforts going on at the Moshi RDTC and related IFD projects.

"We are grateful for all the support and financial assistance we do get. But at the same time, it is very frustrating because the needs are so very great, and we are not even close to meeting them," he said.