key: cord-0728927-hfvxvi6d
authors: Prasad, Sonya; Bassett, Ingrid V.; Freeman, Esther E.
title: Dermatology on the Global Stage: The role of dermatologists in international health advocacy and COVID-19 research
date: 2021-10-23
journal: Int J Womens Dermatol
DOI: 10.1016/j.ijwd.2021.10.003
sha: cc0ec2a3a1f2d1a9460ab867f5b68742bb81b156
doc_id: 728927
cord_uid: hfvxvi6d

Background Over the last decade there has been a surge in interest and funding for global health dermatology. Skin conditions are now recognized to be the fourth leading cause of nonfatal disease burden worldwide in disability-adjusted life years. Dermatologists are uniquely positioned within global health, given that skin conditions are often the presenting sign of severe illnesses such as neglected tropical diseases and COVID-19. Methods We review four major areas of work by dermatologists within global health: i) characterizing global burden of skin disease, ii) advocacy for dermatologic therapies on the WHO's Essential Medicines list, iii) advancements in global programming for skin-related tropical diseases, and iv) the role of the dermatologists in COVID-19 pandemic. For each area of work, the significance and impact on the health of women and girls is briefly highlighted. Results Dermatologists have led the efforts to quantify and evaluate the global burden of skin disease, the burden of which is disproportionately shared by women. The dermatology community has also championed global efforts in the elimination of skin-related neglected tropical diseases such as scabies. Through national and international policy advocacy, dermatologists have pushed for more dermatologic therapies in the World Health Organization's Model List of Essential Medicines, helping to secure better care for patients suffering from skin disease throughout the world. As of 2020, the dermatology community worked collaboratively in the fight against COVID-19, establishing a worldwide registry for cutaneous manifestations of SARS-CoV-2 and pursuing research that has allowed colleagues in the house of medicine to better understand this landmark disease. Conclusion Through the study and promotion of global health, dermatologists have an important role in the house of medicine.

 What is known about this subject in regard to women and their families? o Women share a greater burden of total skin and subcutaneous diseases as compared to men globally, as well as a greater burden of the two highest contributing skin diseases to global DALYs -acne and dermatitis o Women can be disproportionately affected by skin-related NTDs due to greater exposure in endemic areas and sociocultural stigma compared to men  What is new from this article as messages for women and their families?

o More work needs to be done in quantifying and characterizing the disparities in skin disease in women and girls o Improving access to dermatologic essential medicines has the potential to improve the social, mental and economic wellbeing of the most disadvantaged women throughout the world Abstract Background Over the last decade there has been a surge in interest and funding for global health dermatology. Skin conditions are now recognized to be the fourth leading cause of nonfatal disease burden worldwide in disability-adjusted life years. Dermatologists are uniquely positioned within global health, given that skin conditions are often the presenting sign of severe illnesses such as neglected tropical diseases and COVID-19.

We review four major areas of work by dermatologists within global health: i) characterizing global burden of skin disease, ii) advocacy for dermatologic therapies on the WHO's Essential Medicines list, iii) advancements in global programming for skin-related tropical diseases, and iv) the role of the dermatologists in COVID-19 pandemic. For each area of work, the significance and impact on the health of women and girls is briefly highlighted.

Dermatologists have led the efforts to quantify and evaluate the global burden of skin disease, the burden of which is disproportionately shared by women. The dermatology community has also championed global efforts in the elimination of skin-related neglected tropical diseases such as scabies. Through national and international policy advocacy, dermatologists have pushed for more dermatologic therapies in the World Health Organization's Model List of Essential Medicines, helping to secure better care for patients suffering from skin disease throughout the world. As of 2020, the dermatology community worked collaboratively in the fight against COVID-19, establishing a worldwide registry for cutaneous manifestations of SARS-CoV-2 and pursuing research that has allowed colleagues in the house of medicine to better understand this landmark disease.

Through the study and promotion of global health, dermatologists have an important role in the house of medicine.

The field of dermatology has historically been underprioritized by the international health community, traditionally receiving smaller amounts of funding for research, education, and development of the field compared to other medical specialties (Morrone 2007 , Hagstrom, Patel et al. 2015 , Seth, Cheldize et al. 2017 . Over the last two decades, however, there has been a considerable surge in interest, programming and funding, congruent with the number of academic achievements seen within the international dermatologic community (Kingman 2005) .

Skin conditions are now recognized to be the fourth leading cause of nonfatal disease burden worldwide in disability-adjusted life years (Karimkhani, Dellavalle et al. 2017) . Hence, the dermatology community has played a prominent role in setting the global health agenda for conditions ranging from HIV to neglected tropical diseases (NTDs) in recent years. It has also been increasingly recognized that dermatologists are uniquely positioned in the healthcare landscape, given that skin conditions are often the presenting face of severe systemic illnesses such as HIV and more recently, COVID-19 (Mosam, Irusen et al. 2004 , Visconti, Bataille et al. 2021 ).

While small in number, dermatologists worldwide have successfully provided and advocated for novel, cost-effective and practical approaches to rapidly address old and emerging problems in health. From the implementation of new dermatologic training sites globally to effectively steering the priorities of governing health institutions, the efforts of dermatologists to relieve outsized levels of human suffering have been widely successful (Hay and Marks 2004, Hay 2012 ). This section of the issue on House of Medicine and Dermatology will showcase four major areas of work for dermatologists within global health: i) characterizing global burden of skin disease, ii) advocacy for dermatologic therapies on the WHO's Essential Medicines list, iii) advancements in global programming for skin-related tropical diseases, and iv) the role of the dermatologists in COVID-19 pandemic. Each section will also briefly highlight how each area of work has significant implications for the health of women and their families worldwide.

Skin disease greatly contributes to the overall global burden of disease, especially in resource resource-limited areas of the world. Over the last decade, data published by the Global Burden of Disease Project (GBD) has been an essential tool in measuring the impact of dermatologic disease worldwide. The GBD is a collaborative effort of thousands of health experts, coordinated by the Institutes of Health Metrics and Evaluation (IHME) and funded by the Bill and Melinda

Gates Foundation. It provides access to high-fidelity and comprehensive global mortality and morbidity estimates in disability adjusted life years (DALYs) for a broad range of diseases, including those that affect the skin (IHME 2019). Indeed, per the GBD, illnesses that directly affected the skin were found to be the fourth leading cause of nonfatal disease burden worldwide (Boyers, Karimkhani et al. 2014) . The most recent GBD data released in 2019 also revealed that the global number of DALYs attributable to skin or subcutaneous diseases approximated over 42 million.

Dermatologists have been instrumental in leading the efforts to quantify global skin disease in the last decade, both in collaboration with the IHME and through independent research efforts.

Notably, dermatologists such as Dr. Roderick Hay and Dr. Robert Dellavalle have led or contributed significantly to the publication of many of the highest impact papers analyzing and estimating the overall global burden of skin disease (Hay, Johns et al. 2014 , Karimkhani, Boyers et al. 2014 , Karimkhani, Dellavalle et al. 2017 declared its commitment to making skin health a realizable global objective, starting with data collection and analysis that will improve our understanding of the worldwide burden of skin disease (Hay, Augustin et al. 2015) .

Efforts to quantify skin disease throughout the world have been crucial for identifying those diseases which disproportionately affect women and girls. For instance, the 2019 GBD data showed that women overall tended to have a higher burden of skin disease than men ( DALYs 1 )(IHME 2019). Given the evident contribution of skin conditions to the overall global burden of disease, even more work needs to be done in quantifying their scope and impact, as well as understanding how and why these diseases affect females disproportionately.

In addition to helping quantify disease globally, dermatologists have also researched and advocated for better access to treatments that would alleviate the burden of dermatologic conditions worldwide. By 2021, the World Health Organization (WHO) will release its update of the Model List of Essential Medicines (WMLEM), which recommends the most efficient, safe, and cost-effective therapies that meet the minimum needs of a health system. The WMLEM is used globally by high-and low-income countries to assist in the development of local lists of essential medicines. The list is updated every two years and dermatologic therapies have been It should be noted that access to essential medicines has salient effects on the health of women and their families. Access to dermatologic medications is of great importance in societies where gender norms may disproportionately impact socioeconomically disadvantaged women (WHO 2016 , Germain, Augustin et al. 2021 . Disability and changes in appearance resulting from dermatologic conditions can limit women's employment prospects and marriageability, impacting their mental and social wellbeing. It is also possible for women and girls to suffer disparate socioeconomic consequences if they are expected to take time away from school or work secondary to the stigma of dermatologic disease. Hence, improving access to dermatologic medications has significant ramifications for especially the most marginalized and disadvantaged women globally.

Great strides have also been made for dermatology in the broader public health context with respect to Neglected Tropical Diseases (NTD) . In 2017, scabies was added to the official WHO portfolio of 20 NTDs, given its large global prevalence and substantial global burden in DALYs.

Additionally, it became increasingly recognized that secondarily infected scabies by streptococcal species had the serious and potentially lethal sequelae of post-streptococcal nephritis and chronic renal failure (Chung, Wang et al. 2014 ). The inclusion of scabies has not only paved the way for a more integrated approach to addressing skin NTDs, but signaled a poignant acknowledgment that dermatologic conditions are a priority on the global health agenda (Engelman, Cantey et al. 2019 ). The addition was the result of a long-term collaborative effort by advocacy groups like the NTD Network, International Alliance for the Control of Scabies (IACS) and individual WHO country offices (WHO 2017) . For at least a decade, these groups worked collaboratively with the global dermatology community in their appeals to the WHO Department of NTDs, conducting widescale studies to map the burden of scabies, its impact on the world's poorest populations, and develop strategies for control and management. The appeal eventually met success using the strong foundation of evidence and literature that was largely built by the dermatology community (Hay, Steer et al. 2012 , Engelman, Fuller et al. 2016 .

Dermatologists are also ideally positioned to aid in the advocacy work of most NTDs, given that most of 20 NTDs in the WHO portfolio have recognizable skin manifestations (Table 3) .

New programmatic focus within the organization has been given to skin- Advocacy for the prioritization of NTDs on the global health agenda has significant implications for the health of women and girls. NTDs have widely been acknowledged to impact females disproportionately, not only due to disparate levels of exposure compared with males but also due to socio-cultural effects and stigma of NTD infection (Arakaki, Kidane et al. 2016) . For instance, adult women can be up to four times more likely than men to develop trichiasis, since they are more likely to be infected through close contact with children (Courtright and West 2004) . Women and girls are also at much greater risk to develop schistosomiasis, as they perform two-thirds of water collection in endemic areas of the world (WHO 2009 ). As previously discussed, disfigurement and disability secondary to dermatologic disease -especially NTDsoften lead to stigma that limits employment, marriageability prospects and socioeconomic wellbeing (Hotez 2009 ). Hence, the work by dermatologists to help eradicate NTDs globally serve to substantially improve the health of women and girls globally.

The last area of work by dermatologists to be featured include the recent COVID-19

pandemic and ongoing reporting of cutaneous manifestations of SARS-CoV-2. Since 2020, the pandemic has posed a unique and prominent role for the dermatology community to aid in the early identification of COVID infection among individual patients and in turn, affect transmission. Unsurprisingly, dermatologists were the first to report skin manifestations as presenting signs of COVID, which ranged from pernio-like lesions, or "COVID-toes," to urticarial rashes and morbilliform eruptions. An international registry aimed at collecting case reports of COVID-19 skin manifestations was born early in the pandemic out of collaborative efforts by the American Academy of Dermatology and the International League of Dermatologic Societies . The registry allowed the medical community to gather vital prospective data on the timing of patients' symptoms, dermatologic condition details and other infection-related symptoms that could aid in recognizing early infection. The registry comprises over 1,000 cases of skin manifestations and a spectrum of over 30 different skin conditions . In some states like Massachusetts, the registry's real time data even served as the catalyst for policy change, prompting the addition of skin symptoms to the criteria for early testing (The Commonwealth of Massachusetts Executive

Dermatologists also demonstrated leadership in the COVID-19 pandemic by recognizing that skin manifestations can also be part of "long COVID," a condition in which patients experience prolonged symptoms at least 4 weeks after initial SARS-CoV-2 infection. Recent data has suggested that long COVID symptoms may occur in up to 87% of infected patients (Carfi, Bernabei et al. 2020 , Carvalho-Schneider, Laurent et al. 2021 . As such, the dermatology community has been advocating for skin manifestations to be considered a recognized symptom of long COVID (WHO 2021) . A study published by our group in the Lancet Infectious Diseases in January 2021 showed that 6.8% of patient cases of pernio reported to the international COVID registry lasted for more than 60 days, of which two cases were laboratory-confirmed (McMahon, Gallman et al. 2021 ).

The dermatology community has also played a significant role in COVID-19 vaccination efforts and informing public opinion of mRNA vaccine side effects. One common reason for vaccine refusal is fear of side effects, such as adverse skin reactions (Bono, Faria de Moura Villela et al. 2021) , and dermatologists are well-poised to address these concerns. In a multiinstitutional study published in May 2021, dermatologists in the U.S. were among the first to report the morphology and timing of COVID-19 post-vaccination reactions early in vaccine roll out. The study also described the differences in cutaneous reactions between the 2 vaccine doses, which provided guidance for the medical community regarding vaccine counseling. This study revealed that vaccine reactions were generally minor and self-limited and should not discourage The study showed that among users who reported testing positive on swab test, approximately 8.8% had associated skin rash, and the prevalence of reported body rash was higher among females compared to males (OR 1.60, 95% CI 1.08 -2.44, p = 0.02) (Visconti, Bataille et al. 2021) . Other studies examining immune responses to SARS-CoV-2 have shown significant differences in viral loads, antibody titres and plasma cytokines when comparing male and female patients (Takahashi, Ellingson et al. 2020 ).

For instance, researchers have found higher levels of innate immune cytokines associated with worse disease progression in female patients. Even for COVID-19 and other types of vaccination, women consistently report more frequent adverse effects of the vaccine as compared to men, which also holds true for vaccine skin reactions (Fischinger, Boudreau et al. 2019 , Fathi, Addo et al. 2020 

Global health has offered the field of dermatology an opportunity to find its place on a worldwide stage. Through national and international policy advocacy, the dermatologic community has championed efforts to eliminate scabies and other skin related NTDs. Dermatologists helped push for more dermatologic therapies on the Essential Medicines list that will help secure better care for millions of patients suffering from debilitating skin diseases. The COVID-19 pandemic gave dermatologists the opportunity to pursue quality research and data collection with an international focus, changing the way the medical community looked at the evolving landscape of a landmark disease and influencing national policy decisions. Each area of work by dermatologists holds key importance for the health and wellbeing of women globally.

As evidenced by the work of dermatologists discussed here, the dermatology community has shown its commitment to further establishing research, education, and advocacy initiatives throughout the world. In 2019, GLODERM formed as a partnership between dermatologists to promote skin health worldwide through enhanced access to care, training, advocacy, capacity building, clinical care and research (Oyesiku, McMahon et al. 2021) . Organizations like the ILDS and the GLODERM Alliance are focusing efforts on educating trainees, bringing together the larger global dermatologic community to reduce the burden of both common and neglected skin diseases. Since its founding, GLODERM has grown to include over 500 dermatologists, nurses, trainees and health experts across the world -highlighting the need for and interest in global health opportunities. Dermatologists have much to offer in the advancement of international health, and the field of global health provides the dermatology community a prominent role in the house of medicine. 

World Health Organization model list of essential medicines for children: 7th list 2019, World Health Organization

Neglected tropical diseases: women and girls in focus

Factors Affecting COVID-19 Vaccine Acceptance: An International Survey among Low-and Middle-Income Countries

Global mortality from conditions with skin manifestations

Persistent Symptoms in Patients After Acute COVID-19

Follow-up of adults with noncritical COVID-19 two months after symptom onset

Scabies increased the risk of chronic kidney disease: a 5-year follow-up study

Contribution of sex-linked biology and gender roles to disparities with trachoma

The public health control of scabies: priorities for research and action

Opportunities for Integrated Control of Neglected Tropical Diseases That Affect the Skin

Sex Differences in Immunity: Implications for the Development of Novel Vaccines Against Emerging Pathogens

Sex differences in vaccine-induced humoral immunity

Putting the burden of skin diseases on the global map

The American Academy of Dermatology COVID-19 registry: Crowdsourcing dermatology in the age of COVID-19

The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries

Stigma in visible skin diseases-a literature review and development of a conceptual model

Comparing cutaneous research funded by the US National Institutes of Health (NIH) with the US skin disease burden

The International Foundation for Dermatology: an exemplar of the increasingly diverse activities of the International League of Dermatological Societies

The role of international dermatology organizations

Board of the International League of Dermatological and g. the Grand Challenges Consultation

The global burden of skin disease in 2010: an analysis of the prevalence and impact of skin conditions

Scabies in the developing world--its prevalence, complications, and management

Empowering women and improving female reproductive health through control of neglected tropical diseases

GBD Results Tool. I. f. H. M. a. E. (IHME)

Global burden of skin disease as reflected in Cochrane Database of Systematic Reviews

Global Skin Disease Morbidity and Mortality: An Update From the Global Burden of Disease Study

Growing awareness of skin disease starts flurry of initiatives

The global burden of atopic dermatitis: lessons from the Global Burden of Disease Study 1990-2017

WHO NTD 2021-30 Road Map to eradication: opportunities and challenges for dermatology

Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based study of 414 cases

Long COVID in the skin: a registry analysis of COVID-19 dermatological duration

Poverty, health and development in dermatology

The impact of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) on skin disease in KwaZulu-Natal, South Africa

Developing a Platform for Global Health Dermatology Mentorship and Collaboration: Introducing the International Alliance for Global Health Dermatology

Evaluating the World Health Organization Model List of Essential Medicines for skin disease

Global Burden of Skin Disease: Inequities and Innovations

COVID-19 Vaccines and the Skin: The Landscape of Cutaneous Vaccine Reactions Worldwide

Sex differences in immune responses that underlie COVID-19 disease outcomes

Letter to Healthcare Providers, Clinical Laboratories and Local Boards of Health on Testing of Persons with Suspect

Diagnostic value of cutaneous manifestation of SARS-CoV-2 infection

Women and health: today's evidence tomorrow's agenda, World Health Organization

Global report on psoriasis

Request for adoption of an additional Neglected Tropical Disease: Scabies. Dossier submitted to the Director of the Department of Control of Neglected Tropical Diseases

World Health Organization model list of essential medicines: 21st list 2019, World Health Organization

Neglected Tropical diseases of the skin: WHO launches mobile application to facilitate diagnosis

A clinical case definition of post COVID-19 condition by a Delphi consensus, World Health Organization

Distribution of Buruli ulcer lesions over body surface area in a large case series in Ghana: uncovering clues for mode of transmission

Review of a Neglected Skin Mycobacterial Disease

Cutaneous leishmaniasis: clinical aspect

Post-kala-azar dermal leishmaniasis

Clinical manifestations of bancroftian filariasis with special reference to lymphoedema grading

A clinical classification and grading system of the cutaneous changes in onchocerciasis

Guidelines for the diagnosis, treatment and prevention of leprosy

A study of mycetoma in eastern India

Scabies and pediculosis

Endemic treponematosis: review and update

Dracunculiasis (guinea worm disease)

African trypanosomiasis in the United States

Cercarial dermatitis

Larva currens; a distinctive variant of cutaneous larva migrans due to Strongyloides stercoralis

Cutaneous larva migrans in travelers: synopsis of histories, symptoms, and treatment of 98 patients

Progression of active trachoma to scarring in a cohort of Tanzanian children

Snakebite envenoming

Rabies in a nineyear-old child: The myth of the bite

Cutaneous Disease as the First Manifestation of Cystic Echinococcosis

Cutaneous paragonimiasis due to triploid Paragonimus westermani presenting as a non-migratory subcutaneous nodule: a case report