Teledermatology for AD in Indigenous patients
Remote care could improve outcomes for condition common in this population but systemic barriers remain (1,500 words, 7 minutes 30 seconds)
Virtual care could help physicians provide better care to remote Indigenous communities, Dr. Rachel Netahe Asiniwasis said during the 7th annual Skin Spectrum Summit on November 6. This virtual care could help lessen the incidence of atopic dermatitis (AD) and other common chronic inflammatory skin diseases in northern communities. Still, significant barriers remain to establishing virtual contact with these communities, she said.
Dr. Asiniwasis is a dermatologist in Regina. She and her team serve remote northern First Nations communities through fly-in visits and teledermatology clinics.
Indigenous populations are under-represented in the literature, she said. Still, research does show that AD is one of the top chronic conditions reported in Indigenous children and is one of the first steps in the atopic march. She also sees the atopic triad—AD, asthma and hay fever—in these populations.
AD may even be a crisis in some communities, said Dr. Asiniwasis. Worse, AD is not just a skin problem, she said.
“We know particularly with moderate to severe [disease], [AD] is associated with significant physical, psychosocial and even financial impacts, which can influence someone holistically,” she said.
As well as AD, skin and soft tissue infections are common in remote Canadian communities, she said. The common themes of these conditions are a primary dysfunctional skin barrier and dysfunctional antimicrobial proteins. “An immune response on top of a primary skin barrier defect can lead to an increased risk of secondary skin infections such as bacterial infections.”
There are many barriers to health in Indigenous communities, said Dr. Asiniwasis. These can include long waiting lists, inadequate or unavailable healthcare services, limits to transportation, inadequate housing conditions, unsafe water and the high cost of even basic items. As an example, she said laundry detergent can cost $37 in northern communities. Availability of products is also an issue, especially in poorer communities.
Over-crowding due to limited housing can lead to an increased risk of communicable diseases, including methicillin-resistant Staphylococcus aureus, impetigo and scabies.
Dr. Asiniwasis said that improving virtual care would be a major advance in care for remote Indigenous communities and could save millions in costs associated with patients travelling south for care.
She said that teledermatology and virtual care could be a high-quality and low-cost alternative to in-person visits that would improve patient access to dermatologic care.
However, said Dr. Asiniwasis, discussing virtual care might be premature without addressing internet connectivity issues. She referred to a federal government report from 2017 on high-speed internet access.
That report “states that compared to 97% of urban homes, there is a rural disparity [in internet access]. But there is also an even more significant disparity in the number of rural Indigenous households that can access adequate speed for [real-time] virtual care.”
Bottom Line: Atopic dermatitis and skin infections are the most frequent skin conditions in remote Indigenous communities. However, more study is needed on how to address those conditions in these communities. These communities face many unique barriers, including many social determinants of health. Virtual care and teledermatology may be a solution to reducing significant access problems and transportation and accommodation costs. However, these communities must address internet infrastructure to make this viable.
From the literature on atopic dermatitis in underserved populations
Atopic dermatitis among children and adolescents in the Arctic region—a systematic review and meta-analysis
This systematic review and meta-analysis examined the prevalence, clinical manifestations and risk factors for atopic dermatitis (AD) among children and adolescents in the Arctic. The authors identified 21 studies from eight different Arctic regions, with 31,403 participants.
The cumulative incidence of AD was 23% (95% CI 20-26), with a one-year prevalence of 19% (95% CI 15-25).
Arctic parts of Scandanavia saw a higher incidence of AD, while the incidence was lower in Greenland and Russia.
Children of Indigenous descent had a slightly lower incidence of AD (19%, 95% CI 13-26) compared to the overall population.
Most of the AD recorded was mild to moderate on flexural surfaces and the face. Roughly 20% to 30% of children with AD also had asthma and allergic rhinitis.
Structural racism and its pathways to asthma and atopic dermatitis
In this review, the authors argue that structural racism is a root cause of disparities in atopic disease between ethnic and racial minorities and the general population. They write that residential segregation, socioeconomic position, and mass incarceration may lead to changes in the innate and adaptive immune response and the augmentation of physiologic stress responses.
Treatment of atopic dermatitis, dermatophytes, and syphilis by Indigenous peoples prior to 1850
This paper discusses natural treatments for dermatological conditions discovered by the Iroquoian and Algonquian-speaking Peoples of North America. The authors discuss the anthropological evidence for specific plant sources for these treatments, as well as the literature that discusses active agents present in these plants. The authors conclude that references to these botanical medicinal discoveries later being implemented into European literature reaffirms the impact of Indigenous medicine on contemporary dermatology.
Teledermatology and inflammatory skin conditions during Covid-19 era: New perspectives and applications
This is a systematic review of case reports, case series, epidemiological studies, reviews, and systematic reviews regarding teledermatology and inflammatory skin diseases. Particular attention was given to the four most common inflammatory skin conditions, atopic dermatitis, psoriasis, hidradenitis suppurativa, and acne.
The review findings suggest that the use of teledermatology has led to patients having better clinical access to hospital and specialized health care services, better access to specialized dermatology care for people living in remote areas, and reductions in healthcare-related costs.
The positive aspects of teleconsultations reported by both patients and physicians included easy accessibility, safety, and effectiveness. However, there were also reports that an inability to use or lack of availability of internet-based platforms or technological devices limited many individuals' access to telehealth services.
VIDEO: Soft tissue infections in rural Indigenous communities
At the intersection of skin and society
Canada’s seed vault has asked for help from First Nations peoples to identify important tree varieties that should be preserved.
The CBC reports that the National Tree Seed Centre in Fredericton has collected and catalogued seeds from Canadian tree and shrub species and stored them in freezers below ground. Initially, the centre’s role was to make seed available to researchers internationally, but that role has expanded to conservation, according to the report.
For about 15 years, the centre has worked with Indigenous communities, but in an interview with the CBC centre coordinator, Donnie McPhee described the relationship as “ad hoc.” The federal government’s priorities and the seed centre came first, and there was little concern for what First Nations were noticing around them, he said.
However, that relationship has been changing.
“One thing we’ve really begun to notice over the last few years is when we’re working with Indigenous communities, no matter where you are in the country, there are different species that are of concern to them,” McPhee said.
“Maybe they’re not a registered species at risk, but the local community has noticed that there’s a decline in their populations for this particular species.”
A new program launched by Natural Resources Canada aims to have the seed centre increase focus on species that First Nations consider important.
As part of that program, the seed centre will be training volunteers from Indigenous communities to identify and collect the seeds they deem important.
The CBC report notes as an example that the Mi’kmaq ad Wolastoqey in New Brunswicksay say that black ash, a wood that has been historically used in Indigenous art, has become rarer in modern times.
Similarly, it has become more difficult to find white birch trees large enough to provide enough bark for traditional birch-bark canoes.
More details about the program can be found in the CBC article here.
This week
April is National Fair Housing Month in the U.S.
April 4 is National Vitamin C Day in the U.S.
April 7 is World Health Day
Something to think about in the week ahead…
Next Week
The University of Toronto, with assistance from global research and development-based pharmaceutical company AbbVie, has established an endowed Chair in Ethnodermatology. Chronicle Senior Editor John Evans spoke with Dr. Christina Pelizon, Country Medical Director for AbbVie Canada, about the importance of collaborative international research on ethnodermatology and how establishing this new research position will serve those goals. Next week’s edition of Skin Spectrum Weekly will feature part of that conversation.
Coming soon
The 2022 Summit on Atopic Dermatitis will be here very soon. This one-day virtual medical educational event will be held on April 23, 2022.
The Summit was developed to address an unmet need for education on the incidence of and latest therapies for atopic dermatitis (AD) among dermatologists and general practitioners.
Co-chairs Drs. Neil Shear and Marissa Joseph will lead a discussion of the most current treatments for all disease severities. The conference will also emphasize AD diagnosis in skin of colour and will provide resources for patient and caregiver support.
Registration for the Summit on Atopic Dermatitis is open and available. As a Skin Spectrum Weekly subscriber, you will not be charged for registration if you use this link.