Lessons from Greenland: Overcoming barriers to dermatologic care for Indigenous patients
Language, cultural barriers, and a lack of local dermatologists contribute to poor treatment adherence (1,700 words, 7 minutes)
Patients in Greenland’s remote areas, including the Inuit and Sami peoples, face many health challenges that compound their skin issues, Dr. Carsten Sauer Mikkelsen told the 3rd annual Indigenous Skin Spectrum Summit on Nov. 25, 2023. Language and cultural barriers worsen these problems.
Dr. Mikkelsen (pictured below) has been a board-certified dermatologist in Denmark and Norway since 1999. He is passionate about global dermatology, interested in minority groups, and particularly interested in Inuit culture and Arctic dermatology. He is the founder of ArcticDerm.com, a website that aims to raise awareness of dermatology issues in the Arctic region and help the Inuit and Sami peoples.
High rates of psychiatric disorders, including anxiety and depression, as well as domestic violence, complicate all medical care in the area, Dr. Mikkelsen said.
Therefore, communicating with the patient is even more critical, as patient-centred values are very important in Greenland, said Dr. Mikkelsen. One problem the country faces is that many doctors come from Denmark on short-term contracts, which can result in language barriers. What a doctor from Denmark says to a patient in Greenland may be lost in translation or cultural differences. Physicians need to take a holistic approach, listen carefully and make sure that non-verbal communication is accepted by the patient.
One area where cultural competence and communication are critical in the Greenland experience is educating patients about treatment compliance, said Dr. Mikkelsen. Patients want treatment when the itching from a condition such as atopic dermatitis is prevalent but may not adhere to treatment when the itching stops.
The patient needs to have some tools to deal with their condition, said Dr. Mikkelsen. They will not follow the treatment if they don't understand the condition. One program that tries to improve communication is the Eczema School, which uses cartoons and podcasts to teach patients and their families how to follow a proper course of treatment for atopic dermatitis and helps them understand the disease.
Dr. Mikkelsen said there is a lack of research on dermatologic conditions in Greenland. The rates of AD are comparable to those in countries in Africa. There are also many cases of molluscum contagiosum among those with AD, especially children.
Dr. Mikkelsen said rates of psoriasis and hidradenitis suppurativa may also be higher in Greenland than in the rest of Europe, but more studies are needed.
Bottom Line: Learning how to educate and communicate with patients in Greenland is very important for treatment. There is a lack of research on dermatologic conditions in Greenland. Communication and education efforts are hampered by a lack of local dermatologists and prevalent mental health challenges in the population.
Save the Date: Acne Summit
On June 22, 2024, from 10 a.m. to 1 p.m. EDT, Skin Spectrum Summit presents the inaugural Acne Summit, a one-day virtual medical education event seeking the highest-quality acne education to help Canadian patients receive the best care possible. Drs. Geeta Yadav and Jerry Tan are the co-chairs of the event.
You can join your colleagues to learn more about the incidence of and the latest therapies for acne through live Q&As and lectures.
The Acne Summit is a landmark opportunity to learn to:
Effectively communicate about acne with patients and their families
Diagnose acne across all skin phototypes
Manage post-acne sequelae, including scarring and pigmentary changes
Watch this space for more details.
From the literature on Indigenous and Northern dermatology
Ethnic endotypes in pediatric atopic dermatitis depend on immunotype, lipid composition, and microbiota of the skin
Noting that the endotypes of atopic dermatitis (AD) differ with ethnicity, researchers examined the skin microbiota, cytokine, and lipid profiles in Greenlandic Inuit and Danish children with the skin condition.
Investigators clinically examined 25 Inuit children with AD and 25 Inuit control children and compared the data to previously collected data from 25 Danish children with AD. Researchers analyzed the levels of cutaneous immune biomarkers, free sphingoid bases and their (glycosyl)ceramides and characterized the bacterial species communities.
The authors found bacterial β-diversity was significantly different between Inuit and Danish AD skin in both lesional (p<0.001) and non-lesional (p<0.001) AD skin. There was a higher relative abundance of Staphylococcus aureus in Danish compared to Inuit lesional (53% vs. 8%, p<0.01) and non-lesional skin (55% vs. 5%, p<0.001).
They also found Danish AD children had a higher α-diversity than Inuit children in non-lesional (p<0.05) but not in lesional skin. Significantly higher levels of type 2 immunity cytokine interleukin (IL)-4 (p<0.05) and IL-5 (p<0.01) were identified in Inuit compared to Danish AD children. In contrast, IL-33 (p<0.01) was higher in Danish lesional and non-lesional AD skin. Higher levels of long-chain glucosylceramide (GlcCER)[S](d26:1) were found in lesional (p<0.001) and non-lesional (p<0.001) Inuit skin compared with Danish AD skin. NMF levels were similar in Inuit and Danish AD skin.
Melanoma characteristics and overall survival predictors in American Indians and Alaska Natives: An analysis of the national cancer database from 2004 to 2018
In this study, researchers used data from the U.S. National Cancer Database (NCDB) on cases of biopsy-confirmed primary cutaneous invasive melanoma diagnosed between 2004 and 2018 to explore demographics, tumour characteristics, and overall survival predictors in patients who self-identified as American Indian, Alaskan Native (AI/AN), or Eskimo.
The investigators identified a similar five-year overall survival rate (75.0%) to that of a Surveillance, Epidemiology, and End Results study (Arch Intern Med2006; 166:1907-1914) of 52 AI/AN patients (69.8%). However, they write further prognostic information, which has been minimal until now, given the rarity of melanoma in AI/AN. They say these findings include the ability to comprehensively assess the impact of independent prognostic factors on overall survival in AI/AN with melanoma. “Rates of late-stage disease at diagnosis in our study were nearly double that of a smaller study, but as our sample size is nearly 10-fold, our stages at diagnosis may be more representative of this population”, they write.
The primary site associated with the highest independent mortality risk was the trunk in AI/AN, in contrast to the head and neck in predominantly White patients.
Researchers note that this study's limitations include a lack of disease-specific survival, the database's grouping of “AI, Aleutian, or Eskimo” so that these groups could not be analyzed independently, and changes in melanoma treatment that may affect overall survival estimates.
Erythema nodosum in northern Finland between 1996 and 2019: A register-based study
The authors of this paper studied the etiology and characteristics of erythema nodosum (EN) in Northern Finland by analyzing the medical records of all patients with a diagnosis code for EN between 1996 and 2019 from Oulu University Hospital in Finland.
There were 142 EN cases, and most patients (n=112, 72.9%) were female. The mean age of the patients was 35.9 years. Five cases were diagnosed with EN in children younger than two.
Almost one-third of the patients had EN nodules in multiple anatomical locations. In addition to skin findings, systemic symptoms were common (81.0%) and seen more often in men (p<0.05). The most common etiological factors in children and adolescents were gastroenteritis caused by Yersinia, Salmonella, or Campylobacter, followed by inflammatory bowel diseases and hormonal contraception. Bacterial infections were the most common etiological factor among adults. In 28.2% of the cases, no causative factor was identified.
Comparison of the Skindex-Teen and the Skindex-29 quality of life survey instruments in a predominantly American Indian adolescent population
This study directly compared adolescents' responses to the Skindex-29 and Skindex-Teen quality-of-life instruments in a predominantly American Indian or Alaska Native population.
The author notes this population is underrepresented in medical research. Although skin-related quality-of-life issues are widespread, American Indian and Alaska Native adolescents are not well-represented in related studies.
Investigators collected data in person through a self-report survey at two regional powwows in Denver, Colorado, in 2021 and 2022. Respondents completed the full Skindex-29 and Skindex-Teen (40 unique items total). A total of 86 adolescents aged 12 to 17 completed the survey.
Most respondents (70.9%, 61/86) self-identified as American Indian and Alaska Native.
Researchers found that nearly two-thirds (64.0%, 55/86) of respondents had a Skindex-29 score, which revealed that their quality of life was impaired at least mildly by skin disease. The Skindex-29 and Skindex-Teen demonstrated good reliability, with substantial concordance between responses to the two measures (r values ranged from 0.88 to 0.97 for similar subscales).
Compared to younger adolescents (aged 12 to 14 years), older adolescents (aged 15 to 17 years) reported worse dermatology-related quality of life and emotional toll based on higher Skindex-29 total, Skindex-Teen total, Skindex-29 Emotional subscale, and Skindex-Teen Psychosocial Functioning subscale scores.
Canadian Skin of Colour & Diversity Scholarship 2024
This year, the Skin Spectrum Summit Conference & Pfizer Canada are pleased to announce the 2nd annual Canadian Skin of Colour & Diversity Scholarship program.
The scholarship invites dermatology residents across Canada to propose projects to address an education or care gap not wholly or already fulfilled in medical dermatology within underrepresented populations, including Canadians with deeper skin tones, Indigenous people, and other racialized groups.
Selected recipients will be awarded $20,000 to support the development and implementation of their project, which will have a tangible impact on dermatology. The deadline to apply is August 26th, 2024.
Links to apply:
At the intersection of skin and society
The governments of Nunavut and Canada have reached an interim funding agreement on the Non-Insured Health Benefits Program (NIHB) for Nunavut Inuit, reports CBC News.
This two-year deal includes an additional $190 million from the federal government for medical travel, is retroactive to April 1, 2022, and ends next spring.
In a news release, the Nunavut government said the agreement is a step in the right direction, but both governments “recognize it is not a comprehensive solution.”
“We must improve access to health services to reduce the need for medical travel outside of the territory and support health equity for Inuit in the territory,” the release says.
The release quotes John Main, Minister of Health for Nunavut, who said signing this agreement ensures the territory can cover the needed comprehensive healthcare coverage and reinforces the importance of strengthening partnerships under the Katujjiluta mandate. “This represents one significant piece of the puzzle in our ongoing negotiations and efforts to ensure that all Nunavummiut have access to the healthcare they need.”
This week
June is National Indigenous History Month in Canada
June is National Caribbean American Heritage Month in the U.S.
June 5 is World Environment Day
Something to think about in the week ahead. . .
—William Morris, English designer (1834–1896)
Next week
In recognition of International Albinism Awareness Day on June 13, 2024, Skin Spectrum Weekly highlights a recent report on challenges faced by persons with albinism in the U.K.
If you like Skin Spectrum Weekly, why not check out Chronicle’s other publications, podcasts, and portal?
Established in 1995, The Chronicle of Skin & Allergy is a scientific newspaper providing news and information on practical therapeutics and clinical progress in dermatologic medicine. The latest issue features:
Dr. Michelle Ramien (Calgary) describes developing a new categorization system for pediatric blistering disease that more accurately captures how these conditions present in younger patients.
Dr. Maxwell Sauder (Toronto) details the relationship between cancer treatments and skin reactions and advises managing those reactions while supporting the oncologic treatment.
Drs. Jennifer Lipson (Ottawa), Catherine Zip (Calgary), Jerry Tan (Windsor, Ont.) and Marcus Tan (Ottawa) provide an overview of new and in-development therapies for rosacea.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender.
You can read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary subscription or to request a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates readers with new findings concerning dermatologic issues affecting women and the female dermatologists who care for them. Read the current issue here.
Season three of the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode five, Dr. Vender discusses whether vitamin D influences psoriasis severity, sex differences in psoriatic inflammation itch, and the risk of psychiatric disorders associated with acitretin.
And if you’re looking for a web destination for all things derm, visit derm.city, “Where Dermatology Lives.” Please like, rate, review, and share it with your colleagues.