The Dermatology Divide: Tackling Barriers to Care Globally

Many patients with dermatologic conditions have not received appropriate dermatologic consultation or ongoing care for their conditions. This article aims to explore the literature to discuss some of the barriers patients face in seeking and obtaining dermatologic care.

A national cross-sectional survey in 2021 identified insurance or financial challenges as the most common reasons for delaying or avoiding a visit to a dermatologist about hair, nail, or skin problems.¹

Another US survey of patients with chronic inflammatory skin diseases found that racial and ethnic minority patients, especially Black and Hispanic individuals, were disproportionately affected by barriers to care.² The reasons for delays in seeking consultation, follow-up care, or obtaining prescriptions included:

• the inability to afford care
• transportation issues
• work commitments
• childcare responsibilities
• caring for an adult
• living in a rural area too far from a provider

High costs particularly preventing patients from obtaining prescription medications. Additional risk factors for obtaining care included having Medicaid insurance, lower household income, and less education.

In another US survey-based study, the most reported barrier to outpatient dermatologic care was the high cost of healthcare.³ This barrier was more for patients who were female, young, uninsured, or had a low annual household income. In this study, Asians and African Americans reported higher barriers compared to other racial groups. Strategies discussed in this article for expanding access to care include employing mobile clinics, providing free skin examinations, conducting community educational opportunities in the short term, and addressing underlying economic disadvantages in the long term.

In the US, there are 34 dermatologists per million individuals, but this distribution is inequitable, with many rural or minority patients lacking access to a dermatologist.⁴ In sub-Saharan Africa, there are only 0-3 dermatologists per million people.⁵ Globally, there is a  significant need to improve access to dermatologic care for many populations. More than 1 billion people worldwide are affected by skin diseases, but less than half have access to adequate healthcare.⁶

One of many needed strategies to target disparities in access to dermatologic care for rural and minority populations in the US, as well as in global populations, is the use of a mobile clinical decision support system such as VisualDx.^7,8 While access to such a system is not equivalent to care by a dermatologist, it has been shown to improve outcomes when consultation with a dermatologist is inaccessible. For example, it aids in diagnosing conditions like cellulitis in hospital settings.^9,10 For patients with skin of color, VisualDx can enhance clinical accuracy by providing one of the largest medical image libraries of conditions in skin of color, with 28.5 percent of images representing skin of color.¹¹

Other important strategies to reduce disparities in dermatologic care globally include:

• supporting organizations that promote health equity,
• volunteering in and sponsoring expanded educational training programs, and
• investing in and mentoring diverse individuals within their communities.

Despite these challenges, a united effort is essential to improve access to dermatologic care for patients worldwide.

References

1. Venkatesh K, Brito G, Nelson K, Friedman A. Barriers to Care-Seeking and Treatment Adherence Among Dermatology Patients: A Cross-Sectional National Survey Study. J Drugs Dermatol. 2022;21(6):677-680.
2. Nock MR, Barbieri JS, Krueger LD, Cohen JM. Racial and ethnic differences in barriers to care among US adults with chronic inflammatory skin diseases: A cross-sectional study of the All of Us Research Program. J Am Acad Dermatol. 2023;88(3):568-576.
3. Zaino ML, Purvis CG, Bray JK, Hrin ML, Ahn CS, Feldman SR. The impact of demographic and socioeconomic status on patient perception of barriers to outpatient dermatologic care. J Am Acad Dermatol. 2022;87(4):864-865.
4. Glazer AM, Farberg AS, Winkelmann RR, Rigel DS. Analysis of Trends in Geographic Distribution and Density of US Dermatologists. JAMA Dermatol. Vol 153. United States2017.
5. Mosam A, Todd G. Dermatology Training in Africa: Successes and Challenges. Dermatol Clin. 2021;39(1):57-71.
6. Hay RJ, Johns NE, Williams HC, et al. The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions. J Invest Dermatol. 2014;134(6):1527-1534.
7. Ndlovu K, Stein N, Gaopelo R, et al. Evaluating the Feasibility and Acceptance of a Mobile Clinical Decision Support System in a Resource-Limited Country: Exploratory Study. JMIR Form Res. 2023;7:e48946.
8. Cheraghlou S. In defence of the machines: How artificial intelligence may help to improve dermatologic outcomes and diminish barriers and disparities in care. Australas J Dermatol. 2023;64(1):e106-e107.
9. David CV, Chira S, Eells SJ, et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.
10. Dezman ZDW, Lemkin D, Papier A, Browne B. The impact of a point-of-care visual clinical decision support tool on admissions for cellulitis in the University of Maryland medical system. J Am Coll Emerg Physicians Open. 2023;4(3):e12969.
11. Kim W, Wolfe SM, Zagona-Prizio C, Dellavalle RP. Skin of Color Representation on Wikipedia: Cross-sectional Analysis. JMIR Dermatol. 2021;4(2):e27802.
12. Freeman EE. Global health dermatology: An emerging field addressing the access to care crisis. Indian J Dermatol Venereol Leprol. 2023;90(1):3-4.