Community dermatology – a Utopia come true
Medicine has experienced constant progress in many areas. However, health services in developing countries still face many challenges.
1 Dermatology Service, Hospital General de Acapulco SS, Guerrero, México
2 Facultad de Medicina, Universidad Autónoma de Guerrero, México
Corresponding author: R Estrada-Castañón (firstname.lastname@example.org)
Countries in Africa and Latin America, while facing increases in population, have a markedly uneven distribution of wealth, which increases the problem of uneven distribution of health services.
Dermatological conditions in the community are seldom life threatening. However, skin diseases are common, and can be disfiguring and uncomfortable. This leads patients to feel marginalised or hopeless, particularly when the means are not available to solve their problems.
During a course covering dermatology and epidemiology in 1991 at the Center for Research of Tropical Diseases (CIET), in Guerrero State, Mexico, the concept of community dermatology1 was born (Fig. 1). A baseline study was developed by CIET, which consisted of dermatology and epidemiological research.2
Fig. 1. Participants attending the Tropical Dermatology International Course at the CIET, 1991.
The initial goal of the programme was to gather epidemiological information on skin diseases affecting patients in Guerrero State in the south of the Mexican Republic.3 This gradually evolved by improving dermatological services provided by government health institutions. Specifically, the health secretary and Family Integral Development (DIF) increased the provision of dermatological services to more communities in the seven regions of the State (Fig. 2).4 Community Dermatology Mexico was established in 2000 as a civil association.
Fig. 2. Location of Guerrero State in the Mexican Republic
The goals of the association are:
• the provision of dermatological services to poverty-stricken communities and low-income patients
• epidemiological research in dermatological conditions
• identification of health priorities
• identification of new health research areas
• referral of complicated cases to specialised hospitals
• basic dermatology training of community health personnel
• increased communication with health personnel in remote or isolated areas of Guerrero State through teledermatology
• expansion of the programme to places with similar needs.5
To date, the following has been accomplished:
• After 22 years, 132 communities have been visited throughout Guerrero State. There were approximately 20 000 consultations and treatment is free.
• The base study started with the CIET group visiting 7 626 homes, in which 20 966 patients were studied. The results showed that 50% of the patients had at least one skin problem.
• In the communities, during the jornadas (dermatological attention, treatment to patients in rural areas, as well as training of health personnel), health priorities were defined by identifying the top ten skin diseases in order of frequency:
• dyschromias (cloasma, vitiligo, pityriasis alba)
• contact dermatitis
• sweat-related diseases
• pityriasis versicolor
• seborrhoeic dermatitis
• lichen planus.2
Approximately 60% of all patients treated during the jornadas were diagnosed with these conditions,3 which allowed the teaching topics to be prioritised. Together with the American Academy of Dermatology and the International Foundation for Dermatology, a Manual of Basic Dermatology was developed.6 This was distributed free in 1 500 health centres in Guerrero State and during teaching courses to health personnel in the communities.
The way forward
The different situations in different communities have led to research studies, such as appropriate medications in community dermatology,7 pediculosis in schools,8 appropriate use of resources,9 pyodermas in tropical rural areas,10 and mycological problems, e.g. eumycetoma.11
Difficult and complicated conditions, such as skin cancers,
cutaneous tuberculosis (Fig. 3), leprosy, subcutaneous mycosis
as mycetoma or sporotrichosis, as well as deforming
genodermatoses, are of particular concern ‒ not only do they
cause marked morbidity but they may lead to death. Community
dermatology services are vital to the management of these
conditions in poor and rural communities.
Acne and solar diseases are relatively frequent (Fig. 4); therefore information brochures are necessary to provide patient education (Fig. 5). One hundred and forty-three patients with complex conditions were referred to specialist hospitals for treatment. However, only 30 - 40% of patients accept referral because of language problems and a fear of leaving their home communities.12
Fig. 5. Auxiliary brochures.
Remote areas, such as the mountainous Guerrero State, are difficult to cover. Therefore, community nurses or health promoters are an indispensable part of health provision.
Teledermatology has also become a vital part of teaching and consultation in these remote communities, as the programme no longer allows health providers to visit the communities as frequently as they did at the start of the initiative. Where possible, health workers have access to a community dermatology web page, developed by the health secretary. The health providers will have access to two dermatology courses per year. Advice on the treatment of complicated cases is also available remotely.
The last goal of our programme has been possible because of the efforts of the International Foundation for Dermatology, which has expanded the basic principles of our system, e.g. in Argentina, Malaysia and Africa.5 , 13 This sharing of information and experience will help other countries to develop their own community dermatology programmes and, in so doing, improve the quality of life of their communities.
1. Hay R, Andersson N, Estrada R. Community dermatology in Guerrero, Mexico. Lancet 1991;337:906-907. [http://dx.doi.org/10.1016/0140-6736(91)90225-E]
2. Andersson N, Martínez E, Villegas A, Rodríguez I. Vigilancia epidemiológica y atención descentralizada: El uso de los sitios centinela en Guerrero. Salud Pub Mex 1989;31:493-502.
3. Estrada R, Torres B, Alarcón H, et al. Epidemiología cutánea en dos sectores de atención médica en Guerrero, México. Dermat Rev Mex 1992;36(1):29-34.
4. Estrada R, Romero M, Chavez G, Estrada G. Dermatología comunitaria 10 años de experiencia. Estudio epidemiológico comparativo entre población urbana y rural del Estado de Guerrero. Dermat Rev Mex 2000;44(6);268-273.
5. Hay R, Estrada R, Grossman H. Managing skin disease in resource poor environments – the roll of community-oriented training and control programs. Int J Dermatol 2011;50: 558-563. [http://dx.doi.org/10.1111/j.1365-4632.2011.04954.x]
6. Estrada R. Manual de Dermatología Básica para el personal de salud en el primer nivel de atención. Academia Americana de Dermatología y Fundación Internacional para la Dermatología: Foto-Press, 2006.
7. Estrada R, Andersson N, Hay R. Community dermatology and the management of skin diseases in developing countries. Tropical Doctor 1992;suppl(1):3-6.
8. Paredes S, Estrada R, Alarcón H, et al. Can school teachers improve the management and prevention of skin disease? A pilot study based on head louse infestations in Guerrero, Mexico. Int J Dermatol 1997;36:826-830. [http://dx.doi.org/10.1046/j.1365-4362.1997.00282.x]
9. Hay R, Estrada R, Alarcón H, et al. Wastage of family income on skin disease in Mexico. BMJ 1994;309:848. [http://dx.doi.org/10.1136/bmj.309.6958.848]
10. Alarcón H, Estrada R, Hay R, Torres B, Martinez E. Piodermias en el medio trópico-rural: Factores de riesgo y costos de atención. Dermatología Rev Mex 1996;40(2):113-117.
11. Estrada R, Chávez LG, Estrada ChG, et al. Eumycetoma. Clin Dermatol 2012;30:389-396. [http://dx.doi.org/10.1016%2Fj.clindermatol.2011.09.009]
12. Estrada R, Chavez G, Estrada G, Paredes S. Specialized dermatological care for marginalized population and education at the primary care level: Is community dermatology a feasible proposal? Int J Dermatol 2012;51:1345-1350. [http://dx.doi.org/10.1111/j.1365-4632.2012.05546.x]
13. Hay R, Bendeck SE, Chen S, et al. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank, 2006:Ch. 37.
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