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First responders

Exploring dermatology's role in identifying and treating public health trends

Dermatology World abstract illustration of doctor's kit

First responders

Exploring dermatology's role in identifying and treating public health trends

Dermatology World abstract illustration of doctor's kit

By Emily Margosian, content specialist

The world is a dangerous place. The health impact of natural disasters, man-made disasters, changes in climate, emergence of entirely new diseases, and the re-emergence of diseases thought long-since eliminated, loom not only in recent media reports — but also potentially in dermatologists’ own waiting rooms. Throughout medical history, dermatologists have been some of the first to identify major disease outbreaks — from the HIV epidemic, to the emergence of Lyme disease, to the 2001 anthrax attacks. The specialty continues to serve a crucial role in identifying and managing today’s public health concerns. “We can serve as part of a response team certainly, but also function as kind of a public health sensor — or pulse — based on what we’re seeing in our routine clinic patients. Hopefully we help catch an epidemic earlier than it otherwise would have been,” says Justin Bandino, MD, assistant professor of dermatology and dermatopathology at San Antonio Military Medical Center.

Dermatology World talks with physicians from across the specialty about how dermatologists fit into the unfolding public health concerns of today. This feature will explore the dermatologic consequences posed by ongoing public health threats such as climate change, natural disasters, dangerous water conditions, and emerging communicable diseases. It will also address the importance of recognizing when a single patient’s condition is a danger to the wider community, and how to appropriately report the threat.

Heating up

While pundits and politicians seem to spar over global climate change, scientists agree that “over the past few decades, our planet has entered a period of major changes in climate and weather patterns, almost certainly as a result of human activity” (J Am Acad Dermatol. 2016;76(1):140-147). Changes in global climate may create a variety of dermatologic consequences, including newly favorable habitats for disease vectors and reservoirs, longer and more intense transmission seasons for potential viral epidemics, and higher rates of skin cancers. “Dermatologists in Puerto Rico can look to Hurricane Maria, those in Texas can look to Harvey, those in California can look to droughts, and all of us can look at the links between climate change, population migration, civil strife, war, and refugees,” says Misha Rosenbach, MD, associate professor of dermatology and internal medicine at the Perelman School of Medicine at the University of Pennsylvania and leader the of the AAD’s recently formed Expert Resource Group on Climate Change and Environmental Affairs. “It’s easy to come up with dozens, if not hundreds, of reasons why dermatologists should be paying attention — but it’s hard to not sound alarmist, and then be dismissed out of hand. There is a consensus on this in the scientific community, and it is a critical issue.”

Climate change can enable the spread of infectious diseases in particular, as the warming of the planet facilitates the expansion of the natural range of pathogens, hosts, reservoirs, and vectors that allow diseases to appear in immunologically naive hosts (J Am Acad Dermatol. 2016;76(1):140-147). Examples of this phenomenon include an uptick in incidence of Lyme disease, as the range of infected ticks expands as the habitat of their mammalian hosts also broadens. “The simplest link between dermatologic illness and climate change is to look at vector-borne diseases, where we are now seeing dengue, chikungunya, and Zika in the continental United States, while Ixodes tick territory has expanded far northwards — both due to global warming,” says Dr. Rosenbach. CDC data back up this observation. In May 2018, the New York Times reported that disease cases from mosquito, tick, and flea bites more than tripled in the U.S. from 2004 to 2016, as per a recent CDC report. “Warmer weather is an important cause of the surge, according to the lead author of a study published in the CDC’s Morbidity and Mortality Weekly Report,” notes the NYT story.

Beyond vector-borne disease, climate change has also been linked to increasing instances of deep fungal infections, such as coccidioidomycosis, due in part to longer dry seasons and more frequent wind storms that aerosolize the fungal spores throughout the southwest and western parts of the United States (J Am Acad Dermatol. 2016;76(1):140-147). “Droughts have dramatically expanded the typical places where one can acquire coccidioidomycosis. This list really goes on and on,” says Dr. Rosenbach. “Dermatologists are physicians — part of the house of medicine. It’s important to know what’s going on with the world at large, and for us to reflect on how we as the caretakers of the skin are involved in those changes.”

While the links between climate change and skin cancer are not yet clear, studies suggest that “ozone depletion by chlorofluorocarbons has resulted in an increased risk of skin cancer for the foreseeable future,” as elevated temperatures alone may result in greater ultraviolet damage from the same ultraviolet light dose (J Am Acad Dermatol. 2016;76(1):140-147). In addition, warmer weather may negatively influence sun exposure and ultraviolet-protective behaviors, as patients may be inclined to spend more time outside without wearing sunscreen or protective clothing.

BAD WATER

“Although it is hard to definitively correlate stronger hurricanes with climate change, the Earth’s surface is steadily warming, and warmer temperatures lead to increased evapotranspiration, dramatic and unexpected changes in precipitation patterns, and therefore more frequent and intense flooding,” says Dr. Bandino. As much of the United States continues to urbanize, increasingly common natural disasters pose a wide range of health implications, many of which are dermatologic in nature. “Skin diseases are the most common medical issue” in the aftermath of flooding, says Dr. Rosenbach. The aftermath of major storms has historically led to a spike in reported skin infections (2017’s Hurricane Harvey being a recent example), as floodwaters contain a wide variety of contaminants and hazards that can result in bacterial, mycobacterial, and fungal infections, as well as increased arthropod bites, laceration injuries from debris, immersion foot, contact dermatitis, and more. 

“I’m in San Antonio, Texas, and when Hurricane Harvey hit the state, its center of impact ended up shifting enough so that it grazed us but unfortunately ravaged nearby Corpus Christi and Houston. We definitely saw some of the sequelae,” says Dr. Bandino. Traumatic wounds are often the most immediate and pressing concern following a major instance of flooding. These can take the form of puncture wounds and lacerations, as well as electrical injuries due to downed power lines, and an increase in wild and domestic animal bites. Insects can have a particularly vicious impact as they compete for space with humans. “In the post-recovery period where there’s a lot of stagnant water, the breeding ground for mosquitoes or other arthropods increases. Malaria and many other arthropod-borne diseases may subsequently increase, but there are also simple noninfectious bug bites to contend with as well,” says Dr. Bandino. “In the aftermath of Hurricane Harvey there were literally floating fire ant colonies — one of those things you would never think about — but if you get enough fire ant stings on your body, especially if it’s a little kid, that can be serious — and potentially fatal.” 

However, beyond more common skin and soft tissue infections that can develop after exposure to flood waters, it is the atypical pathogens found within them that can often pose the greatest cause for concern. “The nature of a flooding disaster — whether it’s a hurricane or a tsunami — is that it stirs up the soil, unearthing pathogens that we aren’t normally exposed to,” explains Dr. Bandino. “If you have even a superficial cut from being thrown into a disaster scenario, particularly if you are nutritionally deprived or immunosuppressed, those infectious organisms are much more likely to establish a potentially dangerous infection.” 

Beyond flooding, overall increases in water temperature and decreased ocean pH may also have dermatologic consequences. Invasions of non-native species due to changes in habitat can have skin-related consequences for unsuspecting swimmers. Growing jellyfish populations have posed a particular problem worldwide; large aggregations of the often painful and sometimes fatal Portuguese man-of-war have begun appearing along the southeastern U.S. coastline. Meanwhile, the Great Lakes region is expected to see a substantially higher uptick in precipitation, leading to more outbreaks in waterborne disease (J Am Acad Dermatol. 2016;76(1):140-147). 

While at first glance, post-hurricane relief may seem to be outside the responsibilities of the average dermatologist, Dr. Bandino says the specialty’s skill for quick and accurate assessment of the skin can be a boon in disaster situations. “It really boils down to the quick, simple morphological assessment with our eyes that we can provide that really no one else has the training to do. Being able to point to something and say, ‘that’s Vibrio vulnificus infection, because of x, y, and z,’ is something that few other physicians can do as readily,” he explains. “In a disaster scenario, certainly emergency personnel are most important in the immediate aftermath to save life and limb. But where dermatologists start to contribute is in the days or weeks after, being able to lend our eyes to someone’s skin and put puzzle pieces together to make diagnoses or at least narrow differentials without having to get cultures or do expensive lab tests — which are often impossible to do in a disaster scenario. You can’t sit there and say, ‘I’m going to culture this,’ because the lab itself may be underwater and you need answers now.” 

public-health-quote.pngMother Nature is not to blame for all water-related skin crises, however. Flint, Michigan dermatologist Walter Barkey, MD, can relate first-hand the devastating effects that man-made meddling can have on a community’s health. In 2016, Dr. Barkey spearheaded a collaboration between local Flint-area dermatologists and the CDC to explore a potential connection between Flint’s contaminated water and a surge of reported skin rashes among its residents. (To read more about the project, read Dermatology World’s August 2016 feature, “On the front lines in Flint.”) While the study ultimately concluded that approximately 20% of the rashes among the local residents surveyed were unrelated to Flint’s water condition, it deduced that the remaining 80% may have been related. The most common type of rash observed in the latter group was eczema — known to have a variety of aggravating factors including irritation, dryness, and stress. 

Dr. Barkey was compelled to get involved with the wider investigation being conducted by federal officials after hearing that primary care providers were going to be brought in to diagnose the reported rashes. “That’s awful, I thought. They can’t do it. Somebody had to step in and help them with diagnoses,” he says. “I figured it would be maybe a dozen people, a couple afternoons.” While Dr. Barkey’s full involvement ended up involving screening several hundred patients, recruiting and organizing other local dermatologists to help, and coordinating with the CDC, EPA, and other national health organizations over a period of several months, the experience was worth it, he says. “It was such a learning experience, not just participating but also navigating all the politics that went on. It was a real hot potato issue as far as the press was concerned, and the CDC was very concerned about how the findings were going to be spun.”

While Flint’s recovery is still ongoing, Dr. Barkey cites his involvement with the aftermath of the water crisis as an example of dermatology’s potential to be key collaborators in public health. “What we did with the study was at least steer people straight. I had great cooperation from both my local and national colleagues in dermatology. We’re the only ones that can really diagnose skin conditions with any accuracy — and everything starts with getting a diagnosis,” he says. “It’s not natural for us in our outpatient world to have contact with other groups, other specialties, and this really made me come into contact with members of the health care community I never would have otherwise. Now we are colleagues, and they have a lot of respect for dermatologists. They always thought we were pretty bright, but very focused on what we do. Now I think that perception has changed in Flint for our medical community.” 

Get involved

public-health-icon9.pngDid you know dermatologists can join the Medical Reserve Corps? The MRC is made up of a network of volunteers comprised of professionals from across the medical and public health community — including physicians, nurses, pharmacists, dentists, veterinarians, epidemiologists, and more. 

Focused at the local, regional, state, and national levels, the MRC was established after the 9/11 terrorist attacks to provide a way to activate medical and health professionals to respond to unfolding disasters and other public health emergencies. 

Visit https://mrc.hhs.gov/HomePage for more information about the program. 

THEY’RE BACK 

Beyond active disaster zones, dermatologists have historically been some of the first physicians to observe major disease outbreaks — a role they likely will reassume at the re-emergence of major infectious diseases. “Dermatologists have been critical in identifying public health threats in the recent past,” says Dr. Rosenbach. “The country is facing a resurgence in syphilis — our field used to be dermatology, venereology, and syphilology — and some dermatologists have been critical in getting the word out.” 

As noted by Academy Vice President Ted Rosen, MD, at the 2018 AAD Annual Meeting, “Virtually every continent is experiencing increased instances of syphilis with the exception of Europe and Antarctica. Keep syphilis in mind when seeing patients.” According to CDC, despite record lows in incidence between 2000 and 2001, the syphilis rate has increased almost every year since then. Between 2015 and 2016, the national syphilis rate increased by 17.6% to 8.7 cases per 100,000 population — the highest reported rate in the United States since 1993. 

Due to increased global travel and the formation of concentrated groups of unvaccinated communities, outbreaks of measles have begun to reappear throughout the United States. As per the CDC, while there were only 63 reported cases of measles in the United States in 2010, by 2014 the number of reported cases surged to 667. Dermatologists should be aware of the possibility of encountering measles in their clinics, despite the once-rare likelihood of a confirmed diagnosis. “Most of our diagnoses are clinical, and we do things to confirm them — but first you have to suspect what it might be to even do a test to see if it’s measles,” says Dr. Barkey. “An old guy like me — I’ve seen measles. When you know the full differential, it’s a skill, and it’s very nice to be able to apply that.” 

WHAT CAN YOU DO? 

While the average dermatologist may not see themselves as a gatekeeper of public health, their specialized knowledge of the skin — where the first and most visible signs of illness often appear — makes them an essential part of the broader health community. Although climate change, natural disasters, and emerging infections may not immediately seem to be the purview of dermatology, why then should dermatologists stay engaged and up-to-date with these issues? “To me, that’s the important question in a nutshell,” says Scott Norton, MD, MPH, MSc, chief of dermatology at Children’s National Health System, in a 2017 episode of Dialogues in Dermatology. “Although dermatologists may not realize it, we have a front row seat in so many disease outbreaks in the United States and around the world. When we think about diseases like HIV infection or Lyme disease, dermatologists are the ones who see the index cases,” said Dr. Norton, who will lead a 1.5-day course on tropical dermatology Oct. 27-28 in New Orleans as part of the American Society of Tropical Medicine and Hygiene’s annual meeting. "Even noninfectious diseases, like the outbreak of the gadolinium-induced fibrosis, are conditions that are seen by dermatologists first. We need to realize that when we recognize a novel presentation, that it may not just be a great case, but it may indeed be an index case and worthy of reporting to your local or state health authorities.” 

Dr. Rosenbach agrees, citing dermatology’s eye for catching on to new disease patterns as being crucial to the management and prevention of public health outbreaks. “Dermatologists are expert diagnosticians and skilled in pattern recognition. It is essential that we actively participate in public health — both in identifying new and emerging threats, and helping address those that others have reported on,” he says. 

For Dr. Barkey, stepping up to serve one’s community in times of crisis is simply part of being a good physician. “Take yourself out of the one-on-one, thinking that you’ll just see patients in your office, and stick your head out the window to see that there is a whole community of people out there,” he says. “You serve that community — you don’t just serve individuals in it. If you have a skill that’s needed, you have to be willing to step up if you’re called.”