CONTACT: Donna Stein
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CHALLENGES OF URBAN DERMATOLOGY
ORLANDO, FL (March 1, 1998) - Bellevue Hospital Dermatology Clinic in New York City is the epicenter of current rumblings in urban Dermatology. This public city hospital treats the poor and underinsured regardless of their ability to pay. The dermatology clinic is the busiest outpatient specialty clinic in the hospital, treating over 21,000 outpatients a year.
Mary M. Mancewicz, MD, Assistant Professor of Dermatology, Perelman Department of Dermatology, NYU, spoke today at the American Academy of DermatologyÃs 56th Annual Meeting in Orlando, about the challenge of providing high quality respectful and accessible health care services to people throughout the city.
"We see a wide range of dermatology issues. Many are relatively common, and some are as diverse as the patients we treat. A large percentage of our patients are homeless, destitute, or illegal immigrants. The dermatological problems associated with these issues are often complicated by AIDS, drug abuse, neglect and violence," Dr. Mancewicz said.
The dermatologist in the urban setting is often in the position of truly making a difference in a patientÃs life. While some symptoms of domestic abuse, child abuse or elderly abuse, may mimic dermatologic problems, often the cause stems from some sort of trauma or violence. For example, a cigarette burn on the skin can mimic lesions found in erothyma multiformie. Yet, upon further investigation of the patient such as looking at inappropriate dress, (long sleeves in summer, that may in fact be covering other marks) or the wearing of dark glasses inside, may be indications that there are other issues involved.
"I offer all of my patients a full body-exam. Many that decline have other problems that they are trying to hide. Dermatologists in the urban setting often make the initial identification of abuse cases. It is rewarding to be able to step in and break the cycle of abuse," stated Dr. Mancewicz.
Likewise, intervention can result from patients being treated that have substance abuse problems. Scars, needle tracks and skin popping are often indications of drug use. Certain growths, infections and skin eruptions may signal HIV infection. By completing a full history, all the pieces can come together to indicate a possible AIDS test, or substance abuse counseling.
There has been a rise in the number of AIDS cases being seen that are related to drug abuse and heterosexual transmission. A large number of African American and Hispanic women are becoming infected. On the positive side, the advent of the protease inhibitors has produced a drop in the number of classic AIDS dermatologic conditions such as severe psoriasis, KaposiÃs sarcoma, and EPF (Eosin postular folliculitis) which causes hard to treat itchy skin eruptions. The new drugs have a positive effect on T-cells, which directly affect skin conditions when they are in short supply. While the protease inhibitors have made a huge difference in classic AIDS dermatology, dermatologists are seeing new drug reaction patterns in those patients that are surviving longer. It is an ongoing challenge.
Conditions attributed to neglect and homelessness include skin infections, fungus, basal cell carcinomas, scabies, and Trichomycosis axillaris. This bacterial overgrowth looks like a fungus, but is in fact due to bacterial growth in the hair of the armpit due to poor hygiene--a lack of soap and water. Most of these conditions are common and relatively easy to treat, yet are complicated by the issues surrounding homelessness, mental illness, poverty and neglect.
A large number of African Americans suffer a high mortality rate from squamous cell carcinoma. It is highest in African Americans, even more than basal cell carcinomas. "Due to the dark pigmentation of the skin, suspicious marks, moles, or lesions can go unnoticed because they are not as noticeable as on lighter skin. The delay of diagnosis can be deadly, so dermatologists need a high incidence of suspicion when treating African American patients," Dr. Mancewicz said.
Another problem often affecting African Americans is traction alopecia. This hair loss condition is the result of hair that is pulled or knotted so tightly, that the follicular root is damaged, and the hair falls out. Corn-rolled hair, braided hair and hair extensions are the current cause of this condition. Additionally, braids can be a breeding ground for some fungal infections because the hair is not thoroughly cleansed as often as unbraided hair.
Other interesting cases result from immigrants to this country. Cases of leprosy and hookworm have been seen from Latin American and Asia. A number of Central African patients have been afflicted with Onchocerciasis, a worm infection that results from a black-fly bite, or Leishmaniasis, the result of a sand-fly bite. The flies are not native to this country.
T-cell lymphoma is on the rise in persons from the former USSR. Often the condition was not previously diagnosed, or if it was, treatment was not implemented. Ethnic practices are yet another source of interesting dermatologic conditions. Certain tribal markings and scars develop into keloids, and some Asian practices result in serious bruising. Many of these conditions are exacerbated by poverty, neglect and the language barrier.
Urban dermatology presents an ongoing challenge to dermatologists to deal with skin, hair and nail conditions aggravated by the harmful effects of poverty, neglect and homelessness.
The American Academy of Dermatology is the worldÃs largest organization of dermatologists.
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