Download How can we achieve `healthy skin for all?` What is healthy skin? The

How can we achieve ‘healthy skin for all?’
What is healthy skin? The World Health Organisation (WHO) defines health as ‘a
state of complete physical, mental and social well-being’. While the use of the word
‘complete’ has been criticised as making health unachievable (1), the WHO definition does
divide health into three manageable, interlinking domains. A practical way to understand the
meaning of healthy skin is to consider how unhealthy skin impairs physical, psychological
and/or social well-being (Fig. 1).
Physical damage;
‘skin failure’
Unhealthy Skin
Psychological
damage e.g.
depression
Loss of functioning
in society
Figure 1 – Features of unhealthy skin. Physical damage can result in failure of the skin to carry out its
homeostatic functions, such as maintaining a barrier to prevent entry of micro-organisms or exit of fluid.
Psychological problems, such as depression, are not uncommon consequences of skin disorders, and can
in turn result in poor skin care which might exacerbate physical illness. Finally, physically unhealthy skin
can impede one’s ability to work or otherwise function in society. All of these factors influence each
other, and are in turn influenced by external factors such as level of education and quality of healthcare.
Skin disease is an enormous health burden, accounting for approximately 15% of GP
consultations in the UK (2). Globally in 2010, it was the 4th leading cause of years lost due to
disability, and two individual skin conditions fell in the top ten most prevalent diseases
(fungal infection and acne vulgaris) (3). We are therefore a long way from ‘healthy skin for
all’; but why? What are the barriers that need to be addressed? First and foremost, there is
often limited information on basic epidemiological facts, such as prevalence, particularly in
developing countries where there is less likely to be the expertise and infrastructure to record
and report such information (3). Secondly, there are barriers preventing access to and
delivery of adequate healthcare. Finally, there is arguably an under-representation of
dermatology in public health and disease prevention programmes.
In the developing world, lack of resources, distance from healthcare centres and poor
education are major factors preventing healthy skin (4), from a public health perspective.
Solutions should therefore be cheap, simple, and involve the local community. The
International Society of Dermatology (ISD) is a great proponent of such solutions, and has
recently launched a task force: ‘Skin Care For All: Community Dermatology’, with the goal
of promoting skin care in the community by educating ‘a workforce with evidence based
intervention’ (5). Application of such an approach could have immense success. One study
conducted in Ethiopia in 2011 found that 74% of the school children examined had skin
disease, primarily fungal infections (the majority tinea capitis and tinea corporis) which are
largely preventable with appropriate hygiene measures, and readily treatable with antimicrobial agents (6). An earlier study, published in 1998, found that following the training
community health workers in the management of common skin conditions, there was a
reduction in the prevalence of dermatoses from 32.4% to 29.6%; a modest but significant
reduction (7). Success has also been demonstrated in Mexico, where a community
dermatology service that has been running for over 20 years has resulted in a reduced
prevalence of a number of skin diseases (8). Despite potential success, and a growing number
of community dermatology programmes (9), why do such preventable skin diseases still
remain so common in the developing world? Part of the answer probably lies in factors that
are simply beyond the control of small healthcare programmes, such as extreme poverty,
overcrowding and climate change. Under-funding is irrefutably one of the main obstacles.
The following words of Professor Terence Ryan, the chairman of ‘Skin Care For All:
Community Dermatology’, summarise this succinctly (10):
“Dermatology must alter its priorities, imbalances in favour of high technology supporting a
small elite, and perhaps its choice of advisors to funding agencies including governments,
and while still funding that high technology it must become a stronger advocate of poverty
alleviation, join an alliance that includes local sustainable and less costly initiatives including
collaborations with other systems of medicine, and seek funding for the delivery to all of all
that is known already.”
For dermatology to alter its priorities, there needs to be a change in attitude of its
professionals. Interest in public health should be encouraged, and contribution of expertise to
the developing world promoted as viable and compatible with a modern lifestyle. There
would also be great benefit in the creation of a central organisation to collate epidemiological
research, and act as a driving force to obtain funding. (11). Through these means, the journey
towards healthy skin for all in developing countries would be more straightforward
The practice of community dermatology is also being utilised by developed countries.
Community dermatology services in the UK have developed in response to the ‘care closer to
home’ agenda set by the Department of Health in 2006. This mainly consists of intermediatecare clinics consisting of consultant dermatologists and GPs with special interests (GPwSI),
and the provision of community specialist nurses (12). The purpose is to make skin care more
accessible to patients, and make chronic conditions more manageable in the community. In
addition, specialist nurses are well placed to further educate patients by providing disease
information and directing to patient support groups. While there is evidence that community
dermatology clinics improve accessibility and patient satisfaction (13), it remains to be seen
whether this is having an impact on ‘healthy skin’ as measured by either the prevalence or
severity of skin disease. Obtaining such information would allow any changes in the direction
of community dermatology based on clinical outcome to be evidence-based.
Though by definition, developed countries are wealthier and are likely to have more
resources available, individuals may not be as fortunate, and one must not neglect the effects
of relative poverty. With regards to healthcare, this is notably problematic in nations in which
healthcare is mainly privatised. For example in the USA, those who experience a new onset
of a chronic condition and are uninsured are less likely to obtain any medical care or receive
follow-up care, and report a subjective reduction in health status 3.5 months after disease
onset, relative to insured individuals (14). Of course, healthcare reforms in the USA are under
way and may reduce such inequalities, but this demonstrates the principle that even in
developed nations, poverty can prevent access to healthcare. A recurring theme throughout
this discussion is the impact of external factors on skin health, and alleviation of absolute and
relative poverty would arguably be the most beneficial change.
Equally important to the access of healthcare is the quality of delivery. How might the
diagnosis and management of skin conditions be improved?
It’s important to note that a large proportion of skin conditions are treated by General
Practitioners and non-dermatologist hospital doctors. It is therefore vital for all clinicians to
be able to recognise and manage skin common disease. The British Association of
Dermatologists (BAD) has designed a UK undergraduate curriculum for dermatology based
on recommendations by the General Medical Council (GMC) and British Association of
University Teachers of Dermatology (BAUTOD) (15). One study was published following
the release of the initial curriculum that suggested that there remained significant variability
in the extent of dermatology teaching and exposure between universities (16), and this may
well have implications further down the line. A survey of 118 junior doctors showed that
84% wished for more exposure to dermatology at an undergraduate level, only 20% felt
confident in their ability to describe a rash and’ only 8% felt confident in initiating basic
therapy for a skin complaint’ (17). Further, despite the high caseload of skin disease in
primary care, dermatology is not a compulsory component of GP training (18). Concerns
about the level of dermatology education are not confined to the UK (19), and clearly this is
an issue that need to be addressed if there is to be a workforce competent in basic
dermatology. The factors influencing the quality of undergraduate teaching are vast, but at
the very least, there should be a specified minimum clinical exposure and formal assessment
of knowledge and skills, as with other core specialities. This might reduce the
aforementioned variability between universities. In medicine, education certainly does not
stop after university, and post-graduate training courses in dermatology have been shown to
boost the confidence of primary care doctors and reduce referral rates, at least eight months
after the training course (20). Whether this effect is sustained and affects the quality of
patient care is not known, but it would follow logically that adequate training through such
measures would contribute to good quality skin care.
Alongside development of the professionals, there must be continued drive to develop
new, effective therapies. Perhaps the most well-known recent example is the development of
BRAF-inhibitors for use in metastatic melanoma. Though specific details are beyond the
scope of this essay, the need for new treatments and extent of ongoing research is vast, and
essential to achieve healthy skin for all.
Prevention of disease is always better than cure, and can be extremely successful (one
needs only to think of the eradication of smallpox as an example). Dermatology is a field that
has suffered a relative lack of public health initiatives, perhaps due to a similarly lacking
epidemiological data and evidence base for specific interventions (3). The success of
melanoma prevention programmes is an exception to this. A review article by Marks (2004)
uses examples of programmes used in Australia to demonstrate a number of crucial points
(21). Firstly, there is clear epidemiological and behavioural data suggesting that sunlight
exposure in childhood is a risk factor for the development of melanoma, and that people
intentionally seek direct sun exposure to develop a tan. This formed the basis of the primary
prevention programmes that have educated schools, health workers, sports organisations and
others about the risk of excessive sun exposure. In addition, widespread education about the
features of malignant melanoma has prompted the public to seek medical attention early.
Secondly, there is evidence that these programmes have been successful. At the time of the
review, the mortality rate in the younger cohorts in Australia was decreasing, and the
incidence rate was levelling. There has also been an improvement in mortality rates in the UK
(Fig. 2), though the increase in overall incidence rates may be attributed to sun-exposure on
holidays abroad or increased surveillance and detection (22). Thirdly, and most importantly,
these public health principles can be applied to design prevention programmes for other skin
diseases. For example, head lice infestation, or pediculosis capitis, has known risk factors for
transmission which can be targeted. A study in Mexico compared the prevalence of head lice
in different schools, and found that pupils at the school with the highest adherence to a head
lice prevention programme were far less likely to have head lice than pupils at the other
schools (23). This is an example of how simple, local intervention can have significant
results.
Figure 12 – age standardised ten-year survival of patients with malignant melanoma in Endland. Image
taken from www.cancerresearch.org.uk (22). Further data is also available for one and five-year survival.
Sometimes, however, public health interventions can’t necessarily be as
straightforward. Scabies is a condition is caused by the mite Sarcoptes scabiei. It is
transmitted by direct contact, and causes intense pruritis and subsequent sleep disturbance,
social stigmatisation, excoriation and potentially secondary bacterial infection. It is common
in areas of poverty. It would therefore appear to be an obvious target: it has a known cause, it
is preventable, and its eradication would certainly contribute to the goal of healthy skin for
all. Indeed, its eradication has been suggested (24).
However, previous eradication
programmes have had mixed success, as there are significant challenges in ensuring
adherence to treatment (especially of asymptomatic contacts) and in sustaining eradication
efforts. Nonetheless, if done on a large enough scale and if it is predicted to be cost effective,
the elimination of scabies in areas of high prevalence would certainly improve skin health for
many. These are just a couple of examples of what could be implemented on a large scale.
Potentially many more schemes could be, given that there is sufficient need, reversible or
preventable risk factors and financial backing.
A huge amount can be done to improve skin health globally. In many developing
countries, there is an urgent need to provide basic skin care for common preventable and
treatable conditions. This would be most achievable by educating the local population, and by
bringing dermatology to the community. While there will be emphasis on doing this cheaply,
large scale projects will require investment, and gaining investment requires robust evidence
of clinical efficacy and cost-effectiveness of specific interventions. In developed countries,
though one cannot neglect the importance of expensive research into new, advanced
therapies, the priorities are also to improve access to skin care, to educate the public through
public health initiatives, and to ensure adequate dermatological training for healthcare
professionals. Crucial, though perhaps neglected in this discussion, is the importance of the
psychosocial components of skin disease (Fig. 1). Psychological and social implications can
be just as important as physical complications of disease, and all clinicians should be actively
vigilant of these issues, which patients may not volunteer or even be aware of. Can we
achieve healthy skin for all? The burden of skin disease is far too great to eliminate in its
entirety. That should not preclude us from trying, however. The focus should be on
providing, at the very least, basic skin care to those in need: “health for all is utopian,
skincare for all...is not.” (5)
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