Identifying top priorities for Canadian Indigenous skin health
Eczema, skin infections, and the complications of diabetes require healthcare resources, research, and attention from stakeholders (1,500 words, 7 minutes)
Atopic dermatitis (AD), bacterial skin infections, and diabetic skin complications are the three top dermatology priorities that need management, research, and funding for the Canadian Indigenous population, said Dr. Rachel Asiniwasis during the 3rd Indigenous Skin Spectrum Summit on Nov. 25, 2023.
Dr. Asiniwasis is a dermatologist practicing in Regina. She also provides service to several remote and northern First Nations communities in Saskatchewan via in-person and teledermatology clinics.
Findings from national and provincial Regional Health Surveys show that the atopic triad, starting with AD, are among the most common conditions physicians are seeing in Canadian Indigenous children and youth, Dr. Asiniwasis said. She added many of the cases are moderate-to-severe, poorly controlled, and comorbid.
Citing medical literature and feedback from clinicians and patients, Dr. Asiniwasis identified skin bacterial skin infections—including Staph, Strep, MRSA, and others—and diabetic skin infections as the second and third highest priority to address among dermatologic conditions in Indigenous communities. These are priorities not only because of their impacts on health, but for the mental health and social impacts. The communicability and curability of bacterial skin infections also raise the priority for treatment, she said.
“Other areas of interest that are starting to come up include psoriasis and infestations such as scabies. . . hidradenitis suppurativa, autoimmune disease, photodermatoses, and diseases of the hair and mucous membranes,” she said. We are seeing information in our main sources that these diseases may need more exploration.” She noted that, much like bacterial skin infections, infestations are also communicable and curable, which raises their priority for treatment, research, and attention by stakeholders.
Bottom line: Skin health issues are common in Canada’s First Nations, Inuit and Metis communities. Healthcare providers and other stakeholders should prioritize atopic dermatitis, bacterial skin infections, and diabetic skin complications for research, funding, and attention.
From the literature on dermatology in skin of colour
Ethnic endotypes in pediatric atopic dermatitis depend on immunotype, lipid composition, and microbiota of the skin
Researchers clinically examined the skin of 25 Greenland Inuit children with AD and 25 Inuit control children and compared the findings to previously collected data from 25 Danish children with AD. Using skin tape strips and skin swabs from lesional and non-lesional skin, the investigators analyzed levels of cutaneous immune biomarkers, free sphingoid bases and their ceramides. The researchers also characterized bacterial species communities.
They 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, and 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).
The Danish AD children had a higher α-diversity than Inuit children in non-lesional (p<0.05) but not in lesional skin.
Investigators identified significantly higher levels of the 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. They found higher levels of long-chain glucosylceramide (GlcCER)[S](d26:1) in lesional (p<0.001) and non-lesional (p<0.001) Inuit skin compared with Danish AD skin. Natural moisturizing factorlevels were similar in Inuit and Danish AD skin.
Culturally supported health promotion to See, Treat, Prevent (SToP) skin infections in Aboriginal children living in the Kimberley region of Western Australia: A qualitative analysis
This paper describes an information-gathering project to understand an Australian Aboriginal worldview of wellness in the context of reducing the prevalence of skin infections and their downstream consequences.
Researchers conducted culturally appropriate yarning sessions—a form of informal conversation—with community members between May 2019 and Nov. 2020. They also conducted semi-structured, face-to-face interviews and focus groups with school and clinic staff.
The investigators found that overall, there was a strong knowledge of the recognition, treatment, and prevention of skin infections. However, this did not extend to the role skin infections play in causing acute rheumatic fever, rheumatic heart disease, or kidney failure.
This study confirmed three main findings, the authors write: 1. The biomedical model of treatment of skin infections remained strong in interviews with staff living in the communities; 2. Community members have a reliance on and belief in traditional remedies for skin infections; and 3. Ongoing education for skin infections using culturally appropriate health promotion resources is needed.
Skin morbidity in Indigenous children in relation to housing conditions in remote communities in Northwestern Ontario, Canada
This study was conducted to determine whether skin morbidity was associated with indoor environmental quality factors in Canadian First Nations (FN) children living in remote communities.
Researchers quantified indoor environmental quality (IEQ) in the homes of FN children younger than four years of age living in four remote communities in the Sioux Lookout region of Northwestern Ontario, Canada. This included a quantitative housing inspection, including measuring the surface area of mould (SAM), and monitored air quality for five days in each home, including carbon dioxide and relative humidity and quantified endotoxin in settled floor dust. Investigators reviewed the medical charts of participating children for skin conditions and administered a health questionnaire.
In total, the researchers included 98 children in the descriptive analyses, of whom 86 had complete data and were evaluated in multivariate analyses for dermatological outcomes (mean age 1.6 years). Of these 86 children, 55% had made one or more visits to the local health centre for skin and soft tissue infections and 25.5% for eczema. The authors write that annualized eczema visits were inversely associated with SAM (RR=0.14; 95% CI 0.01-0.93), which they didn’t expect. There was a trend suggesting an inverse relationship between endotoxin and healthcare encounters for eczema and skin and soft tissue infections.
The social and home environment: Impacts of determinants of health on atopic dermatitis, pathways towards solutions, and unique considerations for rural and remote North American Indigenous populations
This review highlights a variety of social and environmental exposures as important determinants of health which must be addressed to achieve optimal management of atopic dermatitis. The authors discuss a “Rainbow model” as a framework to illustrate how complex environmental and social forces impact both atopic dermatitis presentation and therapeutic success.
The authors also examine the limitations of practical applications and outcome metrics for health promotion in rural and remote communities. They emphasize the importance of expanding the focus of atopic dermatitis management beyond basic science and clinical trials. Efforts to improve outcomes should recognize and address health disparities and promote optimal health and well-being in patients.
VIDEO: Dr. Mary Logue on rural dermatology
Dr. Mary Logue is a dermatologist in Minot, N.D. In this video, she discusses topics such as rural dermatology, pediatric dermatology, psychocutaneous dermatology, and giving back to the community.
At the intersection of skin and society
The largest First Nation in British Columbia by population has voted to take over authority of child and family services for its residents, reports CBC News.
According to the news outlet, in a vote held by the Cowichan Tribes on Friday, Nov. 24, 2023, 83% of the 416 citizens who cast ballots were in favour of the new law that would prioritize support to keep children with their families or place them with relatives or in other Indigenous homes.
Negotiator Robert Morales, who helped develop the new law, said the Government of Canada decided what was best for Indigenous children for more than 150 years and chose to remove them from their families and culture when placing them in the child welfare system.
“[The new law] represents a significant step in the self-determination of the Cowichan people,” he said in an interview.
“The ability to make determinations as to what's in the best interests of your children is a very fundamental right, and one that the community should have a significant say in and not have outside governments making those determinations.”
These negotiations between the Cowichan Tribes—which has approximately 5,300 members—and provincial and federal governments have been ongoing for years, the CBC notes.
Morales says those negotiations are expected to wrap up by January and the Cowichan Tribes are hoping to take over by April 2024.
For now, he said the new law will apply to members living anywhere on Vancouver Island and on the Gulf Islands but could eventually be applied to all members of the First Nation in the child welfare system anywhere in Canada.
“Under the federal legislation, they have not set any geographic boundaries. So Indigenous laws apply as far as the Indigenous nations say they want their laws to apply,” Morales said.
“But the federal government has also said that their position is that each nation would need to negotiate a coordination agreement with the province.”
Morales said roughly 100 child members of Cowichan Tribes are currently covered under provincial child safety laws.
This week
Dec. 6 is the National Day of Remembrance and Action on Violence Against Women in Canada
Dec. 10 is Human Rights Day
Something to think about in the week ahead…
—Virgil Thomson, U.S. composer, 1896-1989
Next week
In a presentation at the 9th annual Skin Spectrum Summit, Dr. Monica Li discussed important considerations in using cosmetic injectables in Asian patients.
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:
Drs. Irina Turchin (Fredericton, N.B.), Ron Vender (Hamilton, Ont.), and Ashley O’Toole (Peterborough, Ont.) discuss advances in psoriasis treatment.
Dr. Joel DeKoven (Toronto) details the most common contact allergens based on North American Contact Dermatitis Group data.
An essay from Dr. Fabian Rodriguez-Bolanosi (Toronto) submitted to the 2022 Dermatology Industry Taskforce on Inclusion, Diversity and Equity (DiTiDE) short essay contest. Dr. Rodriguez-Bolanosi wrote about his experience working with Black women in the hair clinic.
Plus regular features, including the popular column “Vender on Psoriasis” by dermatologist Dr. Ron Vender
Read a recent digital edition of The Chronicle of Skin & Allergy here. To apply for a complimentary* subscription or to receive a sample copy, please email health@chronicle.org with your contact information.
The Women in Dermatology e-newsletter updates new findings concerning dermatologic issues that affect women and the female dermatologists who care for them. Read the current issue here.
Season three the Vender on Psoriasis podcast with Dr. Ron Vender has begun. Listen to the new season here. In episode three, Dr. Vender discusses comorbid obesity, the effect of smoking on psoriasis, and apremilast in real-world studies.
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.