Putting care into context

By Emily Margosian, Senior Editor, January 1, 2026

A hot shower, reliable transportation, private living space. More than just everyday needs, these factors can have a serious impact on individual health.

Literature suggests social, economic, and environmental factors — social drivers of health (SDoHs) — can significantly affect care and outcomes. Estimates show that 50-90% of preventable U.S. mortality rates are determined by social factors rather than medical care (doi: 10.2340/actadv.v104.34034). In dermatology, research similarly supports an association between SDoHs and disease severity and outcomes.

This month, dermatologists discuss how asking questions and adjusting treatment to address social risk factors can improve dermatology access and outcomes.

What are social drivers of health?

SDoHs encompass the conditions in which we are born, live, learn, work, play, and age. “These are the non-medical factors that influence someone’s overall health and well-being. They include things like where you live, your access to transportation, education, income, housing stability, food security, and even how you experience discrimination or social support. Basically, they are everyday conditions that shape how easy or hard it is for people to stay healthy or get care when they need it,” said Oliva Ware, MD, FAAD, acting instructor and director of the Skin of Color Center of Excellence at the University of Washington School of Medicine.

They account for five domains:

• Economic stability

• Education access and quality

• Health care access and quality

• Neighborhood and built environment

• Social and community context

“While we often see the term ‘social drivers of health’ used in the context of a need, like limited food access or lack of stable housing, it’s important to recognize that each of us has our own social drivers of health,” said Aileen Chang, MD, FAAD, associate professor of dermatology at the University of California, San Francisco. “For some people, their social drivers of health make it easier for them to be healthy. For others, their social drivers of health are disease-promoting. Many people have a mix of social drivers — some that promote health and others that do not.”

How can social drivers of health impact dermatology patients?

Disease management

SDoHs can have a significant impact on dermatology patients’ ability to manage their skin condition(s). A patient who struggles to afford medications like topical steroids or biologics may ration doses or stop treatment altogether. Someone working multiple jobs or without flexible hours might struggle to attend follow-up visits. Access to transportation or childcare can also determine whether a dermatology patient is able to access consistent care. “On a more subtle level, language barriers, digital access, and health literacy all affect whether a patient understands how to use their treatments correctly or feels empowered to ask questions,” said Dr. Ware.

Inflammatory skin conditions often present a challenge for patients navigating various SDoHs. “Take, for example, a woman in her sixties who has atopic dermatitis, lives by herself, has difficulty reaching her back, sitting down, and bending over, and does not have anyone who could help her,” said Dr. Chang. “How will she apply topical treatments to her entire body twice a day? Another example is someone with severe atopic dermatitis who needs systemic therapy but cannot safely or reliably receive medication deliveries.”

“While we often see the term ‘social drivers of health’ used in the context of a need, like limited food access or lack of stable housing, it’s important to recognize that each of us has our own social drivers of health.”

“When we treat conditions like eczema or psoriasis, we often have a very standard approach with topical treatments,” agreed Herbert Castillo Valladares, MD, FAAD, assistant professor of dermatology at the University of California, San Francisco. “However, if someone doesn’t have access to hygiene facilities or they don’t have a place where they can safely and privately put on large amounts of topical medication, then it’s going to be very difficult for them to adhere to that initial treatment plan. In addition, there are a lot of other considerations for a patient with an inflammatory skin disease who has unstable housing. They are probably facing a lot of stress which can exacerbate inflammatory skin diseases.”

The management of ectoparasitic infestations can also be greatly affected by patients’ SDoHs. Overcrowded living conditions can be a major risk factor for scabies infestation, as direct skin-to-skin contact is the primary mode of transmission. Treatment can likewise be limited by a lack of patient resources. “Feasibility of applying topical treatments like permethrin require consideration of the patient’s ability to have privacy to apply the medicine and access to clean water to wash it off,” said Dr. Chang. “In circumstances where feasibility is a concern, oral ivermectin may be more appropriate. For body lice infestation, which occurs in individuals who are unable to maintain personal hygiene, the underlying risk factor is often infrequent access to washing facilities as occurs in persons experiencing homelessness. For bed bug infestations and avian or rat mite infestations, identification and eradication of the underlying source can be challenging due to the cost of evaluation and treatment, as well as the sometimes-elusive nature of source identification in the home or surrounding environment.”

Disease presentation and severity

SDoHs may also shape how diseases appear and are recognized across different populations. “I see patients at Harborview Medical Center, a tertiary care and safety-net hospital affiliated with the University of Washington, and I’ve noticed the prevalence of moderate-to-severe disease or late-stage diagnosis in patients who have one or several SDos,” said Dr. Ware. “A person who can’t afford consistent care might let a rash or lesion go unchecked until it becomes infected or malignant. Someone without stable housing may not be able to refrigerate medications or follow complex regimens.”

SDoHs such as English proficiency and insurance status may hinder a patient from successfully interfacing with the health care system. “This might also result in late presentations of skin conditions or skin cancers, due to someone not knowing how to navigate our referral systems or how to advocate for themself to get an appointment with a specialist,” said Dr. Castillo Valladares.

“In general, patients who have unmet social needs often present with more severe or advanced skin disease,” said Dr. Chang. “While this has not been well-studied, we understand this to be largely due to a delay in diagnosis, a delay in treatment, or both. Another aspect is the extent to which the social risk factors themselves cause chronic inflammatory skin diseases or drive the severity of inflammatory skin disease from activation of stress-related pathways. The correlation seems plausible, but the causation is hard to prove.”

“Knowledge of a patient’s social circumstances could impact the care provided or influence how long it takes to get the correct diagnosis,” added Dr. Chang. “For example, when seeing a patient with chronic leg ulcers who is experiencing unstable housing, we might anchor on a diagnosis of chronic venous stasis ulcers. When in reality, the underlying process is vasculitis, and the patient lost their housing after being unable to work due to the pain and functional impairment from undiagnosed vasculitis. Social context influences health, but health can also influence social context.”

Pediatric dermatology

In pediatric dermatology, SDoHs often play a significant role in patient access. “I see many pediatric patients with vitiligo. Phototherapy is often a first-line treatment, however practically speaking, it can be difficult to come into an office three times a week,” said Cristy Garza-Mayers, MD, PhD, FAAD, assistant professor in the department of pediatrics at the University of Washington and pediatric dermatologist at Seattle Children’s Hospital. “The child likely must leave school, and the parent must leave work. For anybody, that number of visits can be difficult. If you have transportation issues or can’t pay repeat parking fees, that adds an extra layer.”

Management of atopic dermatitis, a common childhood skin disease, often requires navigation of SDoHs impacting both parent and child. “When we talk about treatment for atopic dermatitis, I take into consideration things like parent schedules. Telling them to put something on the skin even twice a day can be challenging,” said Adena Rosenblatt, MD, PhD, FAAD, associate professor of medicine and pediatrics at the University of Chicago. “We’ve also started giving out ‘medication passports’ at our institution. It’s a card with a picture of a person and shows what treatment goes where because that can be a common area of confusion depending on language and health literacy. When it comes to skin care, I am very mindful about giving recommendations that are affordable to families.”

Often, chronic conditions like atopic dermatitis require frequent follow-up in pediatric patients, presenting additional challenges among vulnerable patients. “One of the things that we looked at during the pandemic was telehealth. However, you need to consider issues with connectivity. Do they have a stable Wi-Fi to do a video visit? Do they have a device? It’s important to understand the constraints a family may have, whether that’s an issue with transportation, or being able to take time off work,” said Dr. Rosenblatt.

Dermatologists may also see more advanced disease among pediatric patients in vulnerable populations; however, they should also be mindful of different populations with undocumented individuals where the current environment may keep them from seeking health care.

Framework for assessing social risk factors in vulnerable patients

The dermatology practice is often a busy place. “Often, clinics have many patients and limited appointment time. That creates a barrier to longer discussions about potential risk factors,” acknowledged Dr. Castillo Valladares. “Adding screening questions during patient intake is something that can be easily incorporated into the practice workflow.”

A basic set of SDoH screening questions can be found via the Accountable Health Communities Health-Related Social Needs Screening Tool developed by CMS. Access the tool and learn more about how to apply it. “These are straightforward, open-ended questions that do not stigmatize the patient and allow us to get the information that we need,” said Dr. Castillo Valladares. “This framework can easily be incorporated into either a screening questionnaire before or during patient intake or can be used during the visit itself to learn more about the patient.”

A sample framework might include the following questions:

• Housing/living situation: What is your living situation today? Do you have access to clean water? Do you have access to a bathtub? Can you store medications in a refrigerator? Can you accept deliveries of medications?

• Food: Within the past 12 months, have you worried that your food would run out before you got money to buy more? (often true, sometimes true, never true)

• Transportation: In the past 12 months, has lack of reliable transportation kept you from attending medical appointments, meetings, work, or from getting things needed for daily living? (yes, no) Are there challenges you might have getting to our clinic?

• Financial strain: How hard is it for you to pay for the very basics, like food, housing, medical care, and heating? (very hard, somewhat hard, not hard at all)

“There’s no single best way to ask,” said Dr. Chang. “Generally, I try to use language that provides context for why the questions are being asked. For example, ‘I’d like to ask you some questions about your living situation so I can better understand what treatments to recommend,’ or ‘Sometimes people who can’t bathe regularly can get an itchy rash like yours. How often are you able to take a bath or shower?’”

“I think dermatologists can start by normalizing the conversation; explaining that they ask everyone about life factors to make sure treatments are realistic and effective,” agreed Dr. Ware. “Simple and open-ended questions go a long way. For example, ‘Do cost or insurance issues ever make it hard to get your medications?’ or ‘What challenges might make it hard to come back for follow-up visits?’ Sometimes it really is the basic things we learn in medical school — using interpreters, avoiding jargon, and employing teach-back techniques — that can make patients feel respected and understood.”

According to Dr. Chang, dermatologists should keep some key lessons in mind when inquiring about social risk factors during patient visits:

• Explain why you are asking

• Be specific in your question

• Social circumstances are dynamic;do not assume what is written in the chart is still true

If a patient does share vulnerable information during a visit, dermatologists may be unsure how to address what is shared. “Sometimes asking these questions can lead to patients sharing a lot more than you expect they will, some of it deeply personal,” said Dr. Chang. “We might feel like we don’t know how to respond, yet it’s very important to say something, even a simple acknowledgement.”

Read more about how to approach difficult conversations with patients, including mental health concerns and domestic abuse.

Addressing patients’ social risk factors: Considerations for treatment

Incorporate social support and resources

In resource-limited settings, simplicity and practicality are key. In some instances, dermatologists may be able to connect patients to additional resources to help address SDoHs negatively impacting their skin and overall health. “What resources are available depends on the dermatologist’s practice setting and what city, county, and state the patient lives in. Understanding what resources are available locally is a critical first step,” said Dr. Chang.

Some ways dermatologists can help patients get connected to resources include:

• Providing information about community resources (food banks, transportation options, financial assistance programs, local shelters) that can help patients manage their condition. Some health care systems also subsidize rides with ride share companies or provide taxi vouchers.

• Connecting patients with patient navigators and social workers or case managers who can help coordinate care and provide support for accessing resources.

“For dermatologists who care for hospitalized patients, this is a great opportunity to advocate for resources to address a patient’s social drivers. It’s easier to get connected to and mobilize those resources while the patient is in the hospital, compared to the patient trying to navigate this complex system on their own once they are discharged,” recommended Dr. Chang. “For uninsured or underinsured patients, I emphasize with the primary team that the patient needs to be seen by our institution’s eligibility team as soon as possible to see what insurance plan or access program they qualify for. For patients with daily wound care or daily treatment regimens with skin-directed therapy, I advocate for home health services for patients being discharged back home. If the patient has a complex social situation, I advocate for a case manager.”

Consider medication accessibility

Dermatologists may further tailor care by prioritizing prescribing medications that are affordable and accessible, or suggest alternatives if cost is a barrier. “We can streamline regimens to once-daily routines, prescribe affordable generics, and recommend accessible moisturizers like petroleum jelly,” said Dr. Ware. “For patients who can’t attend frequent visits or have housing instability, longer-acting treatments can help.”

For patients who are unable to receive medication deliveries reliably, dermatologists may consider partnering with a pharmacy for safe storage. “In our clinic, we store medications for patients,” said Dr. Castillo Valladares. “Instead of having patients be responsible for the safekeeping of their medications, we’ve partnered with our local pharmacy to store them. The patient can then come in and have injections done in the clinic so that they’re in a safe setting and feel like they can continue with the treatment plan.”

Dermatologists can also help patients navigate patient assistance programs, and offer samples or discount cards, when possible, to help patients manage the cost of prescriptions. “Small changes, like aligning refill schedules with the other medications a patient takes, or connecting patients to discount programs can make a big difference,” said Dr. Ware.

Personalizing the treatment plan

Once SDoHs have been assessed, dermatologists may consider a patient’s living conditions, employment, and daily routine when recommending treatments.

“My care setting is a safety net clinic for patients who come from all walks of life, including a lot of patients who are unhoused,” said Dr. Castillo Valladares. “If we identify that someone does not have access to hygiene facilities or housing, then we might think about systemic treatments, such as pills or injections, so that a patient isn’t focused on skin-directed treatments that might be hard to adhere to.”

“For patients with chronic venous stasis leg ulcers with light-to-moderate exudate and limited capacity to perform frequent wound care, treatment plans that do not require daily wound care should be considered,” advised Dr. Chang. “After the ulcer is cleansed, silver alginate dressings or Acticoat 7 dressing can be left on the wound as the primary dressing for several days if there is moderate exudate and up to seven days if there is light exudate.”

Dermatologists can also tailor treatment by recognizing cultural, language, or literacy differences and provide education in a way that is approachable and understandable by using plain language or translation services. “Keep in mind the education level and readability of any information you give to patients and families,” said Dr. Garza-Mayers. “From a language perspective, is it something that makes sense to them? Is paper or electronics better? What mode is easier for them to access? If you have the time during a visit, it’s nice to do read-back feedback. If you say something, ask them what their understanding is of the next step.”

“Education is crucial,” agreed Dr. Ware. “Providing written or illustrated instructions, or using pictures and demonstrations can help overcome literacy barriers.”

Bridging the gap: Ensuring dermatology care is effective and equitable

While SDoHs can have a significant — and negative — impact on skin health and outcomes, dermatologists have a range of tools, both big and small, to help bridge the gap. “In our clinic, we keep a bag of clean clothing for unhoused and marginally housed patients with an ectoparasitic infestation who don’t have access to laundering,” said Dr. Chang.

“True equity in dermatology means recognizing that skin health is tied to social context and adapting our care so that every patient — regardless of circumstance — has a fair chance to heal.”

Dr. Garza-Mayers says her institution has worked to strengthen ties with pediatricians, primary care physicians (PCP), and emergency physicians to broaden access to dermatology care in at-risk populations. “At Seattle Children’s we are working to optimize our e-consult system. It is a physician-to-physician service where we provide specialty care via specialty knowledge to non-dermatologists,” she explained. “Often when patients are having access issues, they are more likely to seek care in the emergency room. We’ve been trying to partner with our emergency colleagues to optimize diagnosis and implementation of first-line therapies in an emergency department presentation, the same way a PCP might triage a referral to dermatology clinic, and encouraging them to discuss with the family that more regular and long-term care might be needed.”

According to Dr. Ware, dermatologists can help address SDoHs by meeting patients where they are — both literally and figuratively. “That means offering teledermatology for those with transportation barriers, collaborating with community health centers, and making educational materials culturally relevant and multilingual,” she said. “On a systems level, clinics can stock low-cost emollients or build referral pathways to social services. Dermatologists can also advocate for more formalized training in how to mitigate SDoHs in residency. True equity in dermatology means recognizing that skin health is tied to social context and adapting our care so that every patient — regardless of circumstance — has a fair chance to heal.”

Additional DermWorld Resources