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+Skin cancer is the most common cancer in the United States. 
+An estimated one in five Americans will develop skin cancer in their lifetime. 
+The single most important thing you can do to protect your skin is to reduce sun exposure.
+Skin cancer occurs when skin cells are damaged by ultraviolet (UV) rays from repeated sun exposure and sunburns. 
+Exposure to UV radiation from tanning beds and sun lamps can also increase skin cancer risk.
+The two most common skin cancers are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). They are slow-growing and seldom spread to other parts of the body. Both can be treated, but they can be disfiguring.
+Melanoma is the most dangerous skin cancer. Though less common — accounting for about 1% of skin cancers — melanoma is responsible for the majority of skin cancer deaths. Melanoma is fast-growing and more likely to spread than BCC and SCC.
+Skin cancer develops primarily on areas of sun-exposed skin, such as the scalp, face, ears, neck, lips, chest, arms, hands, and legs. But it also can form in other areas like the palms, beneath the fingernails and toenails, and genitals.
+Besides overexposure to UV rays, other factors that increase one's risk for skin cancer include having:
+* fair skin
+* blond or red hair
+* blue, green, or gray eyes
+* skin that burns easily
+* a family history of skin cancer
+* a tendency to develop moles or abnormal appearing or large moles
+* previous bad sunburns
+* older age.
+The best way to lower your risk for skin cancer is to protect your skin from UV light. 
+Use sunscreen on exposed skin whenever outside, and wear protective clothing including wraparound sunglasses and a wide-brim hat.
+Skin cancers commonly appear on the most sun-exposed areas of the body, like the face, ears, neck, lips, and backs of the hands. 
+They can also develop in scars, skin sores, or rashes elsewhere on the body. Here is what common skin cancers look like.
+Basal cell carcinoma (BCC).BCCs usually appear as tiny, painless bumps with a pink, pearly surface. 
+As it slowly grows, the center of the bump may become sore and develop into a crater that bleeds, crusts, or forms a scab. 
+Although it is commonly located on the face, basal cell cancer can develop on the ears, back, and neck.
+Squamous cell carcinoma (SCC). SCCs usually begin as a small, red, painless lump or skin patch that slowly grows and may develop into a non-healing sore. It usually occurs on the head, ears, and hands.
+Melanoma is usually visible as a single dark skin spot. It may appear anywhere on the body, but it most commonly develops on the back, chest, and legs. 
+Most of the time, melanoma develops on normal-looking skin, but it can grow out of an existing mole. Following the ABCDE guideline is a good way to recognize the warning signs for possible melanoma.
+* A: Asymmetry: One half of a mole or spot does not match the other.
+* B: Border irregularity: The edges are ragged, notched, or blurred.
+* C: Color: The pigmentation is not uniform; the coloring may include shades of tan, brown, or black; dashes of red, white, or blue can add to the mottled appearance.
+* D: Diameter: A mole or spot is greater than 1/4 inch in diameter, or about the width of a pencil eraser. However, melanomas can be smaller.
+* E: Evolving: A mole or spot looks different from others and/or changes size, shape, or color; or begins to itch, hurt, or bleed. A mole that bleeds, feels numb, or has a crusty surface also may indicate a melanoma.
+The most common types of skin cancer are basal cell carcinoma (BCC) and squamous cell carcinoma (SCC). 
+Less common are melanoma and the even more rare Merkel cell carcinoma, the two leading causes of death from skin cancer.
+Most skin cancers start in the top layer of the skin, called the epidermis. The main difference between skin cancers is the type of cell from which each originates.
+Basal cell carcinoma (BCC). BCC is the most common type of skin cancer, accounting for approximately 80% of cases. It starts in basal cells located deep in the epidermis. BCCs tend to grow slowly, and it's rare for a BCC to spread to other parts of the body. But if left untreated, BCCs can grow into nearby areas, deep into the skin, and destroy bone and tissue. If not fully eradicated during treatment, BCCs can return to the same place. People with BCCs are also more likely to get new ones elsewhere.
+Squamous cell carcinoma (SCC). About 20% of skin cancers are SCCs. They begin in the squamous cells in the middle and outer parts of the epidermis. SCCs sometimes develop from a precancerous skin growth called an actinic keratosis, a rough, scaly patch on the skin that usually affects older adults after years of sun exposure. SCCs also are slow-growing, although they are more likely than BCCs to grow into deeper layers of the skin and spread to other parts of the body.
+Melanoma. This type of skin cancer forms from melanocytes, skin cells in the bottom layer of the epidermis. Melanoma only makes up about 1% of skin cancers, but it's the deadliest because affected melanocytes can multiply and spread quickly.
+Merkel cell carcinoma. This skin cancer is 40 times more rare than melanoma and forms from Merkel cells found in the layer of basal cells. It also tends to grow and spread quickly and is the second most common cause of skin cancer death after melanoma. 
+Melanoma (also known as malignant melanoma) is the deadliest form of skin cancer. It occurs when melanocytes (the cells that give skin its color) begin to reproduce uncontrollably. Melanoma can grow quickly and spread to other parts of the body.
+Melanoma is usually visible as a single dark skin spot, often larger than 6 millimeters (mm) in diameter (about the size of a pencil eraser) but sometimes smaller. Melanoma can form from an existing mole, or develop on normal-looking skin. Certain features of moles can raise the risk of melanoma, such as:
+* a new mole appearing after age 30
+* a new mole at any age, if it is in an area rarely exposed to the sun
+* a change in an existing mole
+* one or more atypical moles — moles that resemble a fried egg, are darker than others, or have an irregular shape
+* twenty or more moles on the body larger than 2 mm across
+* five or more moles each larger than 5 mm across.
+The most common sites for melanoma are the face (especially in older people), upper trunk (primarily in men), and legs (mostly in women). 
+Melanoma can also appear on other parts of the body, such as under fingernails or toenails, the genitals, and inside the eye.
+Melanoma is often easy to spot early. Regularly check your skin to look for new moles and for changes in existing ones.
+People at increased risk for melanoma need regular checkups from their doctor or dermatologist. Because some melanomas can arise from existing moles, a doctor or dermatologist may remove atypical moles, as they may be more likely to become cancerous.
+Determining whether a mole or other spot is melanoma usually involves removing a small piece and some of the surrounding tissue and examining it for cancer.
+There are five stages of melanoma, zero to four, with each stage defined by the melanoma's thickness, how deeply it has penetrated the skin, and whether it has spread. The higher the number, the more extensive the disease and, generally, the worse the prognosis.
+Tumors on the skin's surface can usually be cured, but deeper cancers are more difficult and sometimes impossible to treat.
+If treatment begins when the tumor is less than 0.75 mm deep, the chance of a cure is excellent. More than 95% of people with small melanomas are cancer-free as long as eight years later. However, for deeper melanomas the survival rate is poor.
+To help prevent skin cancer, follow standard sun protection guidelines. For example:
+The mantra for sunscreen is to use it early and often. Apply sunscreen 15 to 20 minutes before heading outside, then reapply every two hours. Use at least two tablespoons to cover exposed areas of the face and body, with a nickel-sized dollop to the face alone. And don't forget the ears, the tops of the feet, and the backs of the legs.
+When choosing a sunscreen, focus on broad-spectrum coverage, SPF number, and water resistance.
+Broad-spectrum coverage. This means the sunscreen protects against UVB sun rays — the leading cause of sunburns — and UVA rays, which penetrate deeper into the skin and contribute to skin aging and wrinkles. Both types of UV rays can damage DNA, raising the risk of skin cancer. Other terms you might see on labels that mean the same thing are "multi-spectrum" or "UVA/UVB protection."
+This stands for sun protection factor. The higher the SPF number, the greater the protection. For instance, SPF 30 blocks 97% of the UVB rays, and SPF 50 blocks 98%. Anything higher than 70 SPF does not provide much extra protection. Stick with sunscreen with a 30 to 50 SPF.
+No sunscreen is waterproof, but water-resistant sunscreen withstands water and sweat for a limited time. It's best to reapply sunscreen after getting out of the water or if you've been sweating a lot.
+Wear a hat with at least a four-inch brim all around and sunglasses that block sunlight from the sides. As for clothing, opt for synthetic fibers such as polyester, Lycra, nylon, and acrylic. These have elastic threads that pull the fibers close together, which reduces the spaces between them and thus blocks more of the sun's UV rays. Color matters, too. Darker colors are better at protecting the skin against  UV rays than lighter colors.
+Some clothing brands offer specially designed sun protection clothing, which is marked with a UPF (ultraviolet protection factor) label and number. The number indicates what fraction of the sun's UV rays can penetrate the fabric and reach your skin. For example, a shirt with a UPF of 50 allows only one-fiftieth of the sun's rays through, according to the Skin Cancer Foundation.
+Avoid the sun from 10 a.m. to 2 p.m., when ultraviolet (UV) radiation exposure is at its peak.
+Get a professional skin check from a dermatologist every one to two years. Those with previous skin cancer or strong family history should be checked more often. Also, keep an eye on your skin. Routinely check your body in the mirror for unusual spots, growths, or suspicious moles. Ask your spouse, partner, or a family member to look at your back and other areas you can't see, like the scalp and the backs of the thighs and ears. Consult your doctor or dermatologist if you notice any suspicious spots, growths, or moles that get larger, become darker, or change shape.
+Many skin cancers are treatable if caught early. Your dermatologist may recommend various treatments depending on the type of skin cancer, its size and location, how far it has spread, and whether a treated skin cancer has returned.
+Surgery is the initial treatment for melanoma that appears in just one spot. The doctor removes the visible tumor, along with 0.5 to 2 centimeters of healthy skin around the tumor, depending on its size.
+In some cases, the doctor may perform Mohs surgery, a specialized procedure in which the tumor is shaved away one thin layer at a time and examined under the microscope. If any cancer cells remain, another layer of tissue is removed, and the process is repeated until no cancer cells appear in the removed sample. This technique helps the doctor remove as little healthy skin as possible.
+If the melanoma is more than 1 millimeter deep, your doctor must determine if it has spread to nearby lymph nodes. If cancer is found, most often all of the lymph nodes in the area will be removed. However, it has not been absolutely proven that removing all lymph nodes improves the chances of survival. When a cancer has spread to only one or two other sites, surgical removal can improve survival.
+Additional therapies can often help people with thicker tumors that have grown deep into the skin, spread to other areas of the body, or both. Most often, patients are treated with immunotherapy and/or drugs designed to block major pathways that allow cancers to grow. Radiation therapy and chemotherapy are less effective, but can be used when other treatments stop working.
+Basal cell carcinoma and squamous cell carcinoma. BCCs and SCCs share similar treatments. These include:
+* cutting away the cancer and a small amount of healthy tissue around it. A skin graft may be necessary if a large area of skin is removed.
+* scraping away the cancer with a surgical tool then using an electric probe to kill any remaining cancer cells
+* freezing cancer cells with liquid nitrogen
+* destroying the tumor with radiation
+* Mohs surgery
+* applying drugs directly to the skin or injecting them into the tumor
+* using a narrow laser beam to destroy the cancer.
+Skin cancer is cancer that starts as a growth of cells on the skin.
+The cells can invade and destroy healthy body tissue. Sometimes the cells break away and spread to other parts of the body.
+Many kinds of skin cancer exist. 
+The most common skin cancers are basal cell carcinoma and squamous cell carcinoma. while these are the most common, they often can be cured. 
+The most dangerous form of skin cancer is melanoma. 
+It is more likely to spread, making it harder to cure.
+Most skin cancers happen on skin that gets a lot of sunlight. 
+The light that comes from the sun is thought to cause most skin cancers. 
+You can reduce your risk of skin cancer by covering your skin with clothes or sunscreen to protect it from the sun.
+Some skin cancers happen on skin that doesn't typically get sun. 
+This likely means that something else is causing these cancers.
+To reduce your risk of these kinds of skin cancers, check your skin regularly for any changes. 
+Report these changes to your healthcare professional.
+Signs and symptoms of skin cancer include: A new growth on the skin that might look like a mole, a bump or a scab, A rough patch on the skin, A sore on the skin that won't heal, Changes to a mole or freckle, such as getting bigger or changing color, Itchy skin around a skin growth, Pain around a skin growth.
+Make an appointment with a doctor or other healthcare professional if you notice any changes to your skin that worry you.
+Most skin cancers happen on parts of the body that get a lot of sun. 
+This includes the scalp, face, lips and ears. 
+Other parts of the body that might get sun include the arms, backs of the hands, back and legs.
+Skin cancer also can happen on skin that typically doesn't get sun. 
+This includes the palms of the hands, the genitals, and under the fingernails and toenails. 
+When skin cancer happens in people with Black or brown skin, it tends to happen in these places that don't typically get sun.
+Most skin cancers are caused by exposure to light from the sun. 
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+The light that comes from the sun is a kind of ultraviolet light. 
+That kind of light also can come from tanning beds and tanning lamps. 
+Ultraviolet light contains radiation that changes the DNA inside skin cells and leads to skin cancer.
+Not all skin cancers happen on skin that typically gets a lot of sun. 
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+This means something else also causes skin cancer. It's not always clear what causes skin cancer. 
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+But healthcare professionals have found some things that increase the risk. 
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+These include having a weakened immune system and having a family history of skin cancer.
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+Skin cancer starts when skin cells develop changes in their DNA. 
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+A cell's DNA holds the instructions that tell the cell what to do. 
+In healthy cells, the DNA tells the cells to grow and multiply at a set rate. 
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+The DNA also tells the cells to die at a set time.
+In cancer cells, the DNA changes give different instructions.
+It can be difficult to learn that you have skin cancer. You may feel frustrated, confused and/or angry. You could be facing decisions that feel overwhelming. You might be wondering what to do next.
+The good news is that you are not alone. Skin cancer is the world’s most common cancer; millions of people have battled it. And so can you. Your diagnosis is simply the first step.
+You may find peace of mind by focusing on the beneficial things you can do to be in the best position to fight skin cancer. We’re here to help you every step of the way.
+Being well-informed about your skin cancer and the options you have to fight it can be empowering. We encourage you to be proactive by educating yourself, advocating for yourself and protecting your skin from ultraviolet (UV) radiation to prevent future skin cancers. Above all, remember that a healthy lifestyle and good health care go hand in hand.
+* Contact health care providers, including your primary care physician, specialists, your dentist and pharmacist to inform them of your diagnosis and treatments. This helps providers make informed decisions for your ongoing care.
+* Ask questions. When speaking to your doctors, take notes and make sure that you fully understand your treatment options. Ask about surgery, whether you will need a plastic surgeon, treatment side effects and what to expect during recovery. Check our Do’s and Don’ts for Skin Cancer Patients for more helpful tips.
+* Find the support you need to cope. We hope you will discuss nutrition, exercise, relaxation or stress-relieving activities, sleep needs and more with your health care team. Reach out to skin cancer communities online for peer support. Check our support resources page for a list of organizations that may be able to help.
+* Take a deep breath. You’re stronger than you think, and you will get through this. See below for advice from people who have battled skin cancer and want to support you.
+Thanks to increased public awareness and advances in early detection, skin cancers today are often diagnosed and treated in the early stage. Still, any type of skin cancer, whether common or rare, can grow, spread and become dangerous or even life-threatening.
+If you are diagnosed with any form of skin cancer that becomes advanced, whether it’s a BCC, SCC, melanoma or Merkel cell carcinoma, you should always ask your dermatologist if you need to see a medical oncologist. Advanced skin cancers often require a multidisciplinary health care team.
+Check the links below for more information and resources for patients with advanced skin cancers.
+A skin cancer diagnosis can be physically, emotionally and financially challenging. You’re not alone. Our Robins Nest program provides you with a carefully curated list of organizations that offer assistance with insurance, health care costs, transportation, coping support and other issues that arise with a skin cancer diagnosis.
+It’s important to see a doctor if you have any lumps, bumps, spots, sores, or other marks on your skin that are new or changing, or that worry you for any other reason. 
+Skin cancer may not show clear physical signs at first, which can delay detection. However, some types may cause sensations like itching, tenderness, pain or a burning feeling. You might notice a spot that bleeds, crusts or doesn’t heal. Basal cell carcinoma can feel like a pearly bump or sore, while squamous cell carcinoma may be rough or scaly. Melanoma usually isn’t painful but may itch or bleed as it progresses. Since many skin cancers don’t feel different, it’s important to watch for visual changes like new or changing moles.
+Squamous cell carcinoma also tends to develop in areas of high sun exposure. In some cases, squamous cell carcinoma can affect areas that are not exposed to sunlight. 
+Melanoma can occur anywhere on the body and may develop out of existing moles. In people with darker skin tones, melanoma tends to occur on the palms or soles of the feet. 
+1 in 5 Americans will develop skin cancer by the age of 70.
+More than 2 people die of skin cancer in the U.S. every hour.
+Having 5 or more sunburns doubles your risk for melanoma.
+When detected early, the 5-year survival rate for melanoma is 99 percent.
+* The International Agency for Research on Cancer, an affiliate of the World Health Organization, includes ultraviolet (UV) tanning devices in its Group 1, a list of agents that are cancer-causing to humans. Group 1 also includes agents such as plutonium, cigarettes and solar UV radiation.19
+* Ultraviolet (UV) tanning devices were reclassified by the FDA from Class I (low risk) to Class II (moderate to high risk) devices as of September 2, 2014.20
+* Indoor tanning devices can emit UV radiation in amounts 10 to 15 times higher than the sun at its peak intensity.41
+* Twenty states plus the District of Columbia prohibit people younger than 18 from using indoor tanning devices: California, Delaware, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Nevada, New Hampshire, New York, North Carolina, Oklahoma, Rhode Island, Texas, Vermont, Virginia and West Virginia. Oregon and Washington prohibit those under age 18 from using indoor tanning devices unless a prescription is provided.21
+* Australia, Brazil and Iran have banned indoor tanning altogether.22
+* The cost of direct medical care for skin cancer cases attributable to indoor tanning is $343.1 million annually in the U.S.23
+Acne is a very common skin condition that causes pimples. 
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+You’ll usually get pimples on your face. 
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+Clogged pores cause acne. 
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+Teenagers and young adults most often get acne, but it can also occur during adulthood for many people. 
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+Treatment is available to clear acne from your skin and prevent scarring.
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+Acne is a common skin condition where the pores of your skin clog.
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+Pore blockages produce blackheads, whiteheads and other types of pimples. 
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+Pimples are pus-filled, sometimes painful, bumps on your skin.
+The medical term for acne is acne vulgaris.
+Cystic acne: Cystic acne causes deep, pus-filled pimples and nodules. These can cause scars.
+Fungal acne (pityrosporum folliculitis): Fungal acne occurs when yeast builds up in your hair follicles. These can be itchy and inflamed.
+Hormonal acne: Hormonal acne affects adults who have an overproduction of sebum that clogs their pores.
+Nodular acne: Nodular acne is a severe form of acne that causes pimples on the surface of your skin, and tender, nodular lumps under your skin.
+All of these forms of acne can affect your self-esteem, and both cystic and nodular acne can lead to permanent skin damage in the form of scarring. 
+It’s best to seek help from a healthcare provider early so they can determine the best treatment option(s) for you.
+Acne usually affects everyone at some point in their lifetime. 
+It’s most common among teenagers and young adults undergoing hormonal changes, but acne can also occur during adulthood. 
+Adult acne is more common among women.
+You may be more at risk of developing acne if you have a family history of acne (genetics).
+The most common places where you might have acne are on your: Face, Forehead, Chest, Shoulders, Upper back.
+Oil glands exist all over your body. The common locations of acne are where oil glands exist the most.
+There are several ways to treat acne. 
+Each type of treatment varies based on your age, the type of acne you have and the severity. 
+A healthcare provider might recommend taking oral medications, using topical medications or using medicated therapies to treat your skin. 
+The goal of acne treatment is to stop new pimples from forming and to heal the existing blemishes on your skin.
+Your healthcare provider may recommend using a topical acne medication to treat your skin. 
+You can rub these medications directly onto your skin as you would a lotion or a moisturizer. 
+These could include products that contain one of the following ingredients: Benzoyl peroxide, Salicylic acid, Azelaic acid, Retinoids, Antibiotic, Dapsone. 
+You can’t completely prevent acne, especially during hormone changes, but you can reduce your risk of developing acne by: Washing your face daily with warm water and a facial cleanser, Using an oil-free moisturizer, Wearing “noncomedogenic” makeup products and removing makeup at the end of each day, Keeping your hands away from your face.
+Atopic dermatitis is the most common type of eczema. The exact causes of eczema remain a mystery to experts, but it is generally believed to be a combination of genetic and external environmental factors.
+What is known is, kids typically develop eczema early on in childhood, but teens hitting puberty can develop it too. Usually teens with allergies or asthma develop this scaly, itchy, red rash. Temperature changes, stress, fragrances and overly hot water can make it worse.
+Psoriasis is a skin disease that causes a rash with itchy, scaly patches, most commonly on the knees, elbows, trunk and scalp.
+Psoriasis is a common, long-term (chronic) disease with no cure. It can be painful, interfere with sleep and make it hard to concentrate. The condition tends to go through cycles, flaring for a few weeks or months, then subsiding for a while. Common triggers in people with a genetic predisposition to psoriasis include infections, cuts or burns, and certain medications.
+Treatments are available to help you manage symptoms. And you can try lifestyle habits and coping strategies to help you live better with psoriasis.
+​​Some patients have a related condition called psoriatic arthritis, which can be characterized by stiff, swollen, or painful joints; neck or back pain; or Achilles heel pain. If you have symptoms of psoriatic arthritis, it is important to see your doctor soon because untreated psoriatic arthritis can lead to irreversible damage.
+The symptoms of psoriasis can come and go. You may find that there are times when your symptoms get worse, called flares, followed by times when you feel better.
+Psoriasis is an immune-mediated disease, which means that your body’s immune system starts overacting and causing problems. If you have psoriasis, immune cells become active and produce molecules that set off the rapid production of skin cells. This is why skin in people with the disease is inflamed and scaly. Scientists do not fully understand what triggers the faulty immune cell activation, but they know that it involves a combination of genetics and environmental factors. Many people with psoriasis have a family history of the disease, and researchers have pinpointed some of the genes that may contribute to its development. Many of them play a role in the function of the immune system.
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+Overview of Acne
+Acne is a common skin condition that happens when hair follicles under the skin become clogged. Sebum—oil that helps keep skin from drying out—and dead skin cells plug the pores, which leads to outbreaks of lesions, commonly called pimples or zits. Most often, the outbreaks occur on the face but can also appear on the back, chest, and shoulders.
+Acne is an inflammatory disorder of the skin, which has sebaceous (oil) glands that connects to the hair follicle, which contains a fine hair. In healthy skin, the sebaceous glands make sebum that empties onto the skin surface through the pore, which is an opening in the follicle. Keratinocytes, a type of skin cell, line the follicle.  Normally as the body sheds skin cells, the keratinocytes rise to the surface of the skin. When someone has acne, the hair, sebum, and keratinocytes stick together inside the pore. This prevents the keratinocytes from shedding and keeps the sebum from reaching the surface of the skin. The mixture of oil and cells allows bacteria that normally live on the skin to grow in the plugged follicles and cause inflammation—swelling, redness, heat, and pain. When the wall of the plugged follicle breaks down, it spills the bacteria, skin cells, and sebum into nearby skin, creating lesions or pimples.
+For most people, acne tends to go away by the time they reach their thirties, but some people in their forties and fifties continue to have this skin problem.
+Who Gets Acne?
+People of all races and ages get acne, but it is most common in teens and young adults. When acne appears during the teenage years, it is more common in males. Acne can continue into adulthood, and when it does, it is more common in women.
+Types of Acne
+Acne causes several types of lesions, or pimples. Doctors refer to enlarged or plugged hair follicles as comedones. Types of acne include:
+* Whiteheads: Plugged hair follicles that stay beneath the skin and produce a white bump.
+* Blackheads: Plugged follicles that reach the surface of the skin and open up. They look black on the skin surface because the air discolors the sebum, not because they are dirty.
+* Papules: Inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch.
+* Pustules or pimples: Papules topped by white or yellow pus-filled lesions that may be red at the base.
+* Nodules: Large, painful solid lesions that are lodged deep within the skin.
+* Severe nodular acne (sometimes called cystic acne): Deep, painful, pus-filled lesions.
+Causes of Acne
+Doctors and researchers believe that one or more of the following can lead to the development of acne:
+* Excess or high production of oil in the pore.
+* Buildup of dead skin cells in the pore.
+* Growth of bacteria in the pore.
+The following factors may increase your risk for developing acne:
+* Hormones. An increase in androgens, which are male sex hormones, may lead to acne. These increase in both boys and girls normally during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy can also cause acne.
+* Family history. Researchers believe that you may be more likely to get acne if your parents had acne.
+* Medications. Certain medications, such as medications that contain hormones, corticosteroids, and lithium, can cause acne.
+* Age. People of all ages can get acne, but it is more common in teens.
+ The following do not cause acne, but may make it worse.
+* Diet. Some studies show that eating certain foods may make acne worse. Researchers are continuing to study the role of diet as a cause of acne.
+* Stress.
+* Pressure from sports helmets, tight clothes, or backpacks.
+* Environmental irritants, such as pollution and high humidity.
+* Squeezing or picking at blemishes.
+* Scrubbing your skin too hard.
+What causes acne?
+Acne develops when pores become clogged. What type of acne you get depends on what clogs your pores. You’ll find pictures of the different types of acne, along with a description of how each type of blemish forms at: Acne: Signs and symptoms
+While scientists are still trying to figure out why some people skin seems more likely to develop acne, it’s likely that hormones play a role.
+Why does acne usually develop during the teenage years?
+Hormones may explain why acne is so common in teenagers. During puberty, hormones called androgens increase the size of the skin’s oil glands. These glands start making more oil, which can clog pores.
+Can acne start before (or after) your teen years?
+Yes. People can get acne at almost any age.
+Around 20% of newborns develop a type of acne called neonatal acne, which usually appears between the second and fourth weeks of life. This type of acne goes away on its own without causing scars. It also does not increase the risk of developing severe acne later in life.
+Some children develop infantile acne, which begins between 3 and 6 months of age. Infantile acne can cause deep acne nodules and cysts, leading to permanent acne scars. Fortunately, infantile acne is rare.
+Acne is also a growing problem for women over 25 years of age. Most of these women had acne as teens and continue to get breakouts as adults. Some of these women had teenage acne that cleared. Now years later, they are experiencing acne breakouts again. About 20% to 40% of women who have adult acne develop it for the first time as an adult.
+Can nicotine cause acne?
+One study found that smoking may play a role for some women with acne. In this study, the women had noticeable whiteheads and blackheads that often covered a large area of their face. Some also had a few pimples.
+The researchers found that many of the women in this study smoked cigarettes. They also found that the more cigarettes a woman smoked, the more severe her acne. Some of these women developed icepick-type acne scars when the acne cleared.
+Link to smoking
+Most women in the study who develop noticeable whiteheads along with a few pimples smoked.
+ woman's forehead with whiteheads 
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+Other studies have found that smokers are more likely to have acne than non-smokers. This repeat finding suggests that smoking cigarettes may trigger acne.
+Can stress cause acne?
+While stress cannot cause acne, stress may worsen existing acne. Results from studies suggest that when stress intensifies, the severity of the acne increases.
+Can food or anything else worsen acne?
+Yes. Acne may worsen if you:
+* Get too little sleep
+* Eat certain foods
+* Use oily makeup and skin care products
+* Apply oily hair care products, such as pomade
+You’ll find more about how food can affect acne at Can the right diet get rid of acne?
+Are some people more likely to get acne?
+Nearly everyone develops at least a few breakouts during the teenage years. It’s impossible to predict who will develop more severe acne, but you have a higher risk if one or both of your parents (or other close blood relative) had severe acne that left them with acne scars.
+The good news is that you don’t have to live with acne. Today, virtually every case of acne can be treated successfully. Sometimes, this requires the help of a board-certified dermatologist.
+Acne signs vary depending on the severity of your condition:
+* Whiteheads (closed plugged pores)
+* Blackheads (open plugged pores)
+* Small red, tender bumps (papules)
+* Pimples (pustules), which are papules with pus at their tips
+* Large, solid, painful lumps under the skin (nodules)
+* Painful, pus-filled lumps under the skin (cystic lesions)
+
+
+
+
+How to combat dry skin
+Keeping moisture in the skin
+Skin moisturizers, which rehydrate the top layer of skin cells and seal in the moisture, are the first step in combating dry skin. They contain three main types of ingredients. Humectants, which help attract moisture, include ceramides (pronounced ser-A-mids), glycerin, sorbitol, hyaluronic acid, and lecithin. Another set of ingredients — for example, petrolatum (petroleum jelly), silicone, lanolin, and mineral oil — helps seal that moisture within the skin. Emollients, such as linoleic, linolenic, and lauric acids, smooth skin by filling in the spaces between skin cells.
+In general, the thicker and greasier a moisturizer, the more effective it will be. Some of the most effective (and least expensive) are petroleum jelly and moisturizing oils (such as mineral oil). Because they contain no water, they're best used while the skin is still damp from bathing, to seal in the moisture. Other moisturizers contain water as well as oil, in varying proportions. These are less greasy and may be more cosmetically appealing than petroleum jelly or oils.
+What can you do about dry skin?
+Here are some ways to combat dry skin that are effective if practiced consistently:
+1. Use a humidifier in the winter. Set it to around 60%, a level that should be sufficient to replenish the top layer of the skin.
+2. Limit yourself to one 5- to 10-minute bath or shower daily. If you bathe more than that, you may strip away much of the skin's oily layer and cause it to lose moisture. Use lukewarm rather than hot water, which can wash away natural oils.
+3. Minimize your use of soaps; if necessary, choose moisturizing preparations such as Dove, Olay, and Basis, or consider soap-free cleansers like Cetaphil, Oilatum-AD, and Aquanil. Steer clear of deodorant soaps, perfumed soaps, and alcohol products, which can strip away natural oils.
+4. To avoid damaging the skin, stay away from bath sponges, scrub brushes, and washcloths. If you don't want to give them up altogether, be sure to use a light touch. For the same reason, pat or blot (don't rub) the skin when toweling dry.
+5. Apply moisturizer immediately after bathing or washing your hands. This helps plug the spaces between your skin cells and seal in moisture while your skin is still damp.
+6. To reduce the greasy feel of petroleum jelly and thick creams, rub a small amount into your hands and then rub it over the affected areas until neither your hands nor the affected areas feel greasy.
+7. Never, ever scratch. Most of the time, a moisturizer can control the itch. You can also use a cold pack or compress to relieve itchy spots.
+8. Use fragrance-free laundry detergents and avoid fabric softeners.
+9. Avoid wearing wool and other irritating garments next to your skin.
+
+
+
+
+
+
+How to combat oily skin
+1. Cleansing regularly
+Washing the face with a gentle, pH-balanced, nonsoap cleanser every morning and evening is crucial to maintaining clean, healthy skin.
+People may also benefit from choosing gentle face washes. This is because strong, harsh products can trigger additional oil production.
+2. Limiting alcohol use
+Chronic alcohol consumption can damage the blood vessels. It can cause blood vessels and oil glands to enlarge, which also enlarges the skin’s pores.
+As a result, people with oily skin may benefit from reducing alcohol consumption.
+3. Using salicylic acid products
+Gentle exfoliation, ideally using a chemical-based exfoliator such as salicylic acid weekly, can help remove dead skin cells, excess oil, and other debris from the skin’s surface.
+For best results, people should apply exfoliating products in gentle, small, circular motions for around 30 seconds or less using warm water.
+4. Using blotting papers or medicated pads
+Blotting papers and medicated pads can usually help absorb excess oil from the skin’s surface.
+People can gently press blotting papers or pads against the skin for a few seconds. It’s best to use a new paper or pad when it becomes filled with oil or debris.
+5. Moisturizing regularly
+Some people think that moisturizers increase the amount of oil on the skin or clog the pores, but oil-free, noncomedogenic moisturizers help keep the skin hydrated.
+For especially oily skin, people can try using a higher formula moisturizer at night, such as switching from heavy cream to a serum or gel.
+6. Making a facial mask
+Although scientific evidence is limited, people have used various herbal or natural products to reduce excess skin oil. It is possible to incorporate many of these products into homemade masks.
+According to recent research, some of the most studied and recommended masks for reducing oily skin include clay and parsley.
+Clay — especially green clay — has several cosmetic uses, including absorbing and removing debris, dirt, and oil from the skin’s surface.
+Parsley contains a diverse mixture of vitamins and minerals that help manage sebum production and absorption. Masks containing around 4% parsley powder could be effective in managing excess oil.
+7. Using products with green tea
+The antioxidant polyphenols in green tea could help treat various skin conditions, including oily skin. Although more research is necessary, one 2017 review
+Trusted Source
+ found that the polyphenols in green tea may reduce sebum secretion.
+People may benefit from using moisturizers, toners, or facial washes with a 3%
+Trusted Source
+ green tea extract.
+8. Making dietary changes
+The American Academy of Dermatology suggests that high glycemic foods and beverages may stimulate inflammation and sebum production as they raise blood sugars quickly.
+Therefore, people with oily skin should try to focus on eating low glycemic foods, such as:
+* most fresh vegetables
+* some fresh fruits
+* pulses and legumes
+* most whole grain oats and cereals
+Given its glycemic index, cow’s milk can also trigger acne through inflammatory pathways. This results in clogged pores.
+9. Reducing stress
+Stress can trigger the release of hormones
+Trusted Source
+, including cortisol, that help produce sebum.
+As a result, reducing stress may reduce oil production in the skin. A person may wish to try stress-reducing techniques, such as:
+* doing yoga
+* practicing meditation
+* avoiding nicotine or alcohol
+* sleeping well
+* exercising regularly
+* staying hydrated
+10. Using mineral and setting powders
+Oil-free and water- or mineral-based makeup products are less likely to clog the pores. Setting powders that do not contain talc can also help absorb excess facial oils.
+11. Removing makeup before going to bed
+When a person leaves makeup on overnight, it can clog the pores and irritate the skin.
+Always remove makeup before bed using a gentle, pH-balanced cleanser. Remember to gently dab the face dry with a clean cloth rather than scrubbing it.
+12. Using a sonic cleanser
+Using sonic brush cleansers can provide deeper cleansing and exfoliation that may help reduce excess sebum.
+One 2019 review
+Trusted Source
+ concluded that sonic cleansers may offer a gentle, effective way to remove debris without stripping away too much sebum.
+Learn more about unclogging pores on the nose here.
+13. Using products with retinoids
+Derivatives of vitamin A called retinoids may reduce sebum production and pore size. However, a 2017 review
+Trusted Source
+ concluded that further research is necessary to assess the provisional link between retinoids and sebum production.
+These are prescription products, so a person should talk with a board certified dermatologist for more information.
+14. Using products with niacinamide
+Niacinamide, a derivative of vitamin B3, could help reduce sebum excretion rates and reduce the appearance of oily skin.
+According to one 2017 review
+Trusted Source
+, 100 people who applied topical products with 2% niacinamide experienced significant reductions in sebum production rates after 2–4 weeks of use.
+15. Using products with L-carnitine
+Some research
+Trusted Source
+ shows that L-carnitine, an amino acid the body produces to help break down fatty acids, may help decrease the appearance of oily skin.
+16. Using isotretinoin
+Isotretinoin, an oral retinoid, can reduce the amount of sebum the sebaceous glands produce. However, this medication is only suitable for the treatment of severe acne.
+People should only take isotretinoin as prescribed by a healthcare professional.
+17. Trying hormonal therapy
+Hormonal medications, such as antiandrogens, could be effective in reducing sebum production.
+In one study
+Trusted Source
+, dermatologists used spironolactone to treat oily skin in females. They found that their skin produced less sebum.
+Studies
+Trusted Source
+ show that cyproterone acetate (not available in the United States) reduced sebum production in females.
+18. Taking oral contraceptives
+Oral contraceptives may help balance hormones that can trigger excess oil production. Estrogen, in particular, seems to reduce
+Trusted Source
+ sebum production.
+However, it is worth noting that some types of progestin that a person may take with estrogen can actually increase sebum production.
+Therefore, people should discuss their contraceptive plan with a doctor to ensure that they receive a type of progestin that is not associated with oily skin.
+19. Receiving Botox injections
+Botulinum toxin (Botox) injections inhibit the growth of sebaceous glands and reduce sebum production.
+Injections may produce results
+Trusted Source
+ within a week, but a person may need treatment every few weeks or months to maintain the results.
+
+
+Before diving into insurance coverage, it’s essential to understand the difference between medical and cosmetic dermatology. Medical dermatology focuses on diagnosing and treating conditions affecting your skin’s health, such as acne, eczema, and skin cancer.
+Cosmetic dermatology, on the other hand, aims to improve your skin’s appearance through procedures like Botox, fillers, and chemical peels. Whether a procedure is covered depends on whether it is deemed “medically necessary,” underscoring the importance of this distinction. Additionally, the extent of your out-of-network benefits may vary based on your health plan’s summary.
+Health insurance generally covers medically necessary dermatology services that address conditions impacting your physical health. These include:
+Acne Treatments
+Coverage for acne treatment often depends on severity and your specific insurance plan. Treatments such as topical medications and oral antibiotics may be covered. For more severe cases, isotretinoin or medically necessary chemical peels might also be included.
+Eczema and Psoriasis
+Insurance typically covers treatments for chronic conditions like eczema and psoriasis. This includes topical creams, phototherapy, and systemic medications. In severe cases, prior authorization may be required.
+Skin Cancer Screenings and Treatment
+Insurance plans almost always cover skin cancer screenings and treatments. Annual screenings promote early detection, while medically necessary procedures like biopsies, mole removal surgeries, or ongoing cancer care are also covered. Removal of benign lesions, however, might not be included unless they are painful or impair daily functions.
+Cosmetic procedures, which focus on improving appearance rather than health, are generally not covered by insurance. Be prepared for out-of-pocket expenses for the following:
+Botox and Fillers
+These treatments primarily target wrinkles and facial volume loss, making them ineligible for coverage. While they may have emotional benefits, most insurance companies classify these as cosmetic.
+Chemical Peels and Microdermabrasion
+Procedures like chemical peels and microdermabrasion, aimed at enhancing skin texture and tone, are also not covered. In some cases, however, chemical peels may be partially covered if they are part of a medically necessary acne treatment plan.
+Laser Hair Removal
+As a purely cosmetic procedure, laser hair removal for reducing unwanted hair is not covered by insurance.
+Even when insurance covers medically necessary treatments, expect some out-of-pocket costs. These can include:
+* Deductibles: The amount you pay before insurance starts covering treatments.
+* Co-pays and Coinsurance: Fixed fees or a percentage of the treatment cost after meeting your deductible.
+* In-Network vs. Out-of-Network Costs: Visiting in-network providers minimizes costs, whereas out-of-network visits may increase expenses.
+Navigating insurance policies can feel overwhelming, but these tips can help:
+* Review Your Policy Documents: Check for specifics about covered dermatology procedures.
+* Contact Your Dermatologist’s Office: They can help clarify billing and payment options.
+* Utilize Online Physician Finders: Tools from insurance companies can help you locate in-network dermatologists.
+Penn Dermatology Specialists offer top-notch acne scar removal services in Bucks County and Southampton, PA, helping patients regain their confidence with clear, healthy skin.
+If a needed procedure isn’t covered, or you lack insurance, consider these affordable options:
+* Community Health Clinics: Offer reduced-fee services for qualifying patients.
+* HSA or FSA Funds: Use pre-tax savings for eligible medical expenses.
+* Payment Plans: Many dermatologists provide flexible payment options to make treatments more accessible.
+Understanding what dermatology procedures are covered by insurance can seem daunting, but it’s manageable with the right knowledge and resources. Reviewing your policy, prioritizing in-network providers, and seeking clarity from dermatology offices can help you take control of your skin health and finances.
+
+
+Health disparity refers to “a chain of events signified by a difference in: 1) environment, 2: access to, utilization of, and quality of care, 3: health status, or 4) a particular health outcome that deserves scrutiny.”1 Disparities can be broad and across a variety of demographic variables including, but not limited to, race, age, sex, education, and health insurance status. The 2010 U.S. Department of Health and Human Services National Healthcare Disparities Report confirms substantial health care-related barriers. The report identified access to and quality of care as inadequate, particularly for ethnic minorities and persons with low income.2 Over the 8 years that the Agency for Healthcare Research and Quality (AHRQ) has reported on the status of health care quality and disparities, they have observed that, though quality of care is improving, access to care and the state of health disparities are not.2 In collaboration with the AHQR, the Institute of Medicine Committee on Future Directions for the National Healthcare Quality and Disparities Reports identified eight national priority areas to address including population health, safety and access. Evidence of health disparities across race, ethnicity, and socioeconomic status was demonstrated for all eight priorities areas.
+The paucity of and great need for data on epidemiology, natural history, clinical presentation, complications, and treatment of specific skin diseases in people of color has also been highlighted recently in the dermatologic literature.3 According to a recent report, “empiric evidence regarding access to and use of dermatologic care services [in minority populations] is scant.”4
+Race is a poorly defined term that, at times, is used interchangeably with the term ethnicity. Practically, race is a political and social construct more than a biologic phenomenon.5 In contrast, ethnicity refers to “ … large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background.”6 Despite the complexities of defining race and ethnicity, health disparities between those who define themselves as white compared to others clearly exist. Since 1974 the number of office visits to dermatologists nearly doubled (from 18 million to 36 million by 2000) and the majority of patients seen by dermatologists are white (92%)—whereas this number for non-dermatologists is 84%.7 The reasons for lower dermatologic care utilization by racial minorities are unclear. For this appraisal of dermatologic health disparities, skin cancer and atopic dermatitis were selected for review as each is relatively common, and the association with health disparities has been examined for both diagnoses. Clearly there are many other skin diseases seen by both dermatologists and nondermatologists including acne, rosacea, psoriasis, and many others, but there are little to no data on dermatologic health disparities related to those conditions. Other topics addressed in this review include health reform and the dermatologic workforce, dermatologic education, and research.
+Skin cancer morbidity and mortality are disproportionally higher in blacks, Hispanics, and people of low SES.8-12 Melanoma is more common in non-Hispanic whites and people of high socioeconomic status (SES)13, yet blacks, Hispanics, people of low SES13-14, and older age persons often present with more advanced disease or have increased mortality.8-10, 15-16 The 5-year melanoma survival is 74.1% for blacks compared to 92.9% for whites.16 Nonmelanoma skin cancer (NMSC) in blacks is uncommon with an incidence of 3.4 per 100,000.17 Despite the lower incidence of NMSC in ethnic minorities, blacks as a whole, present with later stage or more aggressive squamous cell carcinomas.9 The less educated tend to have lower SC screening rates and more often have poor or inaccurate perceptions of their skin cancer risk.18-19 Like the less educated, ethnic minorities, the elderly, and people with lower income may be more likely to have inaccurate skin cancer risk perceptions.19 Lack of insurance and increased age also negatively impact skin cancer outcomes.14, 20
+The incidence of childhood eczema in the United States is approximately 10.7%.21 Large scale reports estimate the prevalence is between 8.3% and 18.1%21-23 and it may be increasing.24-25 Black race or multiracial background was significantly correlates with eczema prevalence. 21 Similarly, black and Asian children are more often seen for the diagnosis of AD than white children25-26, suggesting increased prevalence or severity of this disorder among these racial minorities. Just as increased SES is associated with higher rates of melanoma13-14, greater than high school education by a household member is significantly associated with the increased prevalence of eczema.21 It is unclear if, like skin cancer, the morbidity of atopic dermatitis is increased with decreased SES. Beyond race, urban setting, health insurance status, single mother household, and smaller family size, are also associated with increased risk of childhood eczema.21 Presence of eczema appears to be significantly greater in the insured that the uninsured21; however, one consideration is that those without insurance are often without health care access as well and thus are not diagnosed leading to prevalence data that in all probability is an underestimate.
+Multiple studies have shown that breastfeeding is associated with a reduced risk of atopic dermatitis, as well as a variety of other ailments (e.g., asthma, obesity, childhood leukemia, and diabetes).27-28 As a result, the American Academy of Pediatrics29 and the U.S. Surgeon General30 have all established recommendations to increase breastfeeding initiation and duration. The current level of breastfeeding costs the U.S. an estimated excess of 13 billion dollars annually28 in preventable health care costs and death. This is particularly true in populations in which disparities in health care are most prevalent, including blacks, younger women, less educated, and lower income women.31-32 Such disparities may help to explain the increased risk of AD among some racial minorities, but conflicts with the increased rate of AD in high SES children.
+The Patient Protection and Affordability of Care Act and the Reconciliation Act was passed and signed into law in March 2010. (Figure 1) Despite the varied and polarized opinions on the legislation, it is clear that some of the measures would improve health disparities. Recent figures indicate that there are more than 50 million (16.7%) uninsured persons in the U.S. and this number has been increasing since 2000.33 Ten percent of those uninsured are children (7.5 million).33 Of insured, 30.6% are covered by government programs such as Medicare (43.4 million) and Medicaid (47.8 million).33 The U.S. economy loses $207 billion each year as a result of the poorer health and decreased lifespan of uninsured, and in 2008, $43 billion was spent on the uncompensated health care of the uninsured.34 A major goal of the health care reform act is to increase insurance coverage to nearly all Americans, thereby providing cost-sharing leading to lower overall premiums. By 2014, the individual mandate for health insurance purchase by most Americans will be enforced and at that time health insurance exchanges will open. It is estimated that the number of uninsured nonelderly people will decline to 21 million within 2 years of this mandate.35 The majority of the nonelderly persons remaining uninsured will be unauthorized immigrants (approximately 30%) and those eligible for, but not enrolled in Medicaid (approximately 25%).36 The specific effects of this legislation on dermatologic health disparities are not known. The dramatic increase in insured patients would likely lead to a shift in care of previously uninsured patients from emergency rooms and urgent care centers to primary and specialty care offices. To address the increased need, the legislation dedicated $250 million to expand the primary care workforce.37 This will help to some extent; however, some specialties--including dermatology—already have a shortage of providers. According to the 2009 American Academy of Dermatology (AAD) practice profile survey38, 38% of dermatologists report that there is a shortage of dermatologists in their community. This shortage was greatest in rural settings. Nearly one-third of survey respondents indicated that they were actively looking for another dermatologist to join their practice.38 The average wait time for new patients was 33.9 days and, for established patients was 17.9 days.38 These results are similar to the previous surveys done in 2007, 2005, and 2002. These shortages are despite the fact that a majority of dermatologists’ patient care time is dedicated to medical dermatology (67.1%) with only 25.1% on non-cosmetic surgical dermatology, and 7.8% on cosmetics.38 The anticipated increase in insured patients coupled with a lack of funding to expand the dermatology workforce may only worsen the current shortage. In order for dermatologists to provide a sufficient amount of dermatologic care, innovative methods to prevent excessive patient wait times and lack of access to dermatologic care are needed.
+Dermatology education and health disparities
+A variety of studies have found that U.S. medical students are exposed to very little dermatology in comparison to other clinical specialties. U.S. medical students receive an average of is between 16 and 22 hours of dermatologic training—less than 1% of their undergraduate medical education.39-41 Consequently, fewer than 40% of primary care residents feel that their medical school curriculum adequately prepared them to manage common skin conditions.42 Similarly, a recent survey of United Kingdom students found that the majority (55.7%) believed that their undergraduate medical education did not provide adequate education in dermatology.43
+In a recent U.S. survey, 47% of dermatologists and dermatology residents reported that their medical training (medical school and/or residency) was inadequate in training them on skin conditions in blacks.44 Those who felt their training in this area was lacking identified the need for greater exposure to black patients and training materials.44 These findings highlight the need to expose dermatology residents to a diverse patient population as well as provide them with the didactics, textbooks and peer-reviewed literature necessary to prepare them to address special considerations in skin of color to prevent disparities in quality of care.
+There is little research on the adequacy of current dermatologic training to produce dermatologists with cross cultural competence, confidence, and skill in treating patients from diverse backgrounds. A pubmed search of the terms dermatology, residency, and education reveals just 1 manuscript since 2000 that addresses residency training and ethnic skin. In that study45, 52.4% of chief residents and 65.9% of program directors surveyed reported that their residency provided lectures or didactics integrating ethnic skin into the curriculum. This and the knowledge of the growing ethnic minority proportion of the U.S. population (Figure 2) underscore the need for a vigorous assessment of medical education to ensure dermatologists are adequately prepared to provide quality care to patients of diverse racial and ethnic backgrounds.
+Disparities in research
+It is well known that racial and ethnic minorities have been historically underrepresented in medical research.46-48 This may be a reflection of study recruitment49, minorities’ disinterest or distrust48, 50, lack of access48, or other factors. Limited minority participation in research studies may affect the applicability of clinical trial results, potentially leading to detrimental patient outcomes. Given this research disparity, Congress enacted the National Institutes of Health (NIH) Revitalization Act of 1993, PL 103-4351, which mandated that both women and racial minorities be represented in clinical research. The NIH defines clinical research as:
+(1) Patient-oriented research. Patient-oriented research includes: (a) mechanisms of human disease, (b) therapeutic interventions, (c) clinical trials, and (d) development of new technologies; (2) Epidemiologic and behavioral studies; and (3) Outcomes research and health services research.51
+Consistent with this, a review of the literature reveals a steady increase in dermatologic clinical studies involving ethnic minorities. In contrast, there remains a scarcity of robust basic dermatologic research examining skin of color.3
+There is little evidence on how health disparities affect dermatologic research. A systematic review of the literature failed to identify any research citing specific barriers to subject participation in dermatologic research.48 A study analyzing survey responses of black and white parents of pediatric dermatology patients and found that black parents had significantly less trust for the medical research community (p = 0.03), were three times more likely to believe their child would be treated like a guinea pig” if they participated in research (p = 0.03), and were significantly less likely to enroll their children in a clinical study in the setting of being cared for by an established provider (p = 0.0001).52 They also found that black parents had less exposure to research advertisements.52 Despite these findings, their study found that black parents were as likely as white parents to enroll their children in low-risk research studies. This is consistent with data on pediatric cancer clinical trials, in which minority children are proportionately represented.53 With such limited data, however, it is clear that additional studies are needed to determine what and how health disparities challenge dermatologic research so that barriers minority participation may be targeted and overcome.
+As a dermatologic community, our work is cut out for us. Healthcare disparities in dermatology clearly exist, but need better definition in order to be properly addressed. There is inadequate epidemiologic data on dermatologic health disparities and the current data are effectively limited to the diagnoses of skin cancer and atopic dermatitis or eczema. Ample room exists to further explore the extent and nature of these and other inequities across a spectrum of dermatologic diseases. In addition, a variety of health disparities exist beyond those detailed in this manuscript, including those secondary to culture or language barriers, additional socioeconomic barriers (transportation, education and literacy), age, disability, differential treatment, and outcomes. Potential solutions that merit further exploration include patient navigators, patient centered medical homes, professional translators, child care, and literacy assistance, among others.54
+Addressing the need for further health disparities research is an identified priority of National Institute of Arthritis and Musculoskeletal and Skin Disease3, but this has not yet been fully recognized by the dermatologic research community. Increasingly, U.S. institutions are establishing minority health research centers with goals focused on reducing health disparities. These range from enhancing minority health research infrastructure and training skilled minority health researchers to providing patient and community-focused programs to directly eliminate inequities.55-56 Such efforts present an opportunity for dermatologic researchers and providers to fill in the major gaps in current knowledge and literature by establishing health disparity focused careers within supportive academic environments.
+Increased research as well as collaboration between dermatologic organizations that aim to eliminate healthcare disparities will help dermatologists to develop united and clear set goals. Recently the AAD created the Access to Dermatologic Care Task Force (ATDCTF) with the goal “to raise awareness among dermatologists of health disparities affecting populations identified by but not exclusive to race/ethnicity, socioeconomic status, geography, gender, age, and disability status and to develop policies that increase access for these groups to dermatologic services.”57 The ATDCTF also serves as the link between the AAD and other physician organizations focused on reducing healthcare inequities, such as the American Medical Association (AMA). The AMA Commission to End Health Disparities focuses on collaboration to “increase awareness among physicians and health professionals; use evidence-based and other strategies; and advocate for action, including governmental, to eliminate disparities in health care and strengthen the health care system.”58 Through increased research, awareness, education, outreach, and public policy, dermatologic and general health disparities can be decreased resulting in improved health for all Americans.
+
+
+The Global Burden of Disease project has shown that skin diseases continue to be the 4th leading cause of nonfatal disease burden world-wide. However, research efforts and funding do not match with the relative disability of skin diseases. International and national efforts, such as the WHO List of Essential Medicines, are critical towards reducing the socioeconomic burden of skin diseases and increasing access to care. Recent innovations such as teledermatology, point-of-care diagnostic tools, and task-shifting help to provide dermatological care to underserved regions in a cost-effective manner.
+Summary
+Skin diseases cause significant non-fatal disability worldwide, especially in resource-poor regions. Greater impetus to study the burden of skin disease in low resource settings and policy efforts towards delivering high quality care are essential in improving the burden of skin diseases.
+Keywords: Global health, Dermatology, Dermatoepidemiology, Health Equity, Task Shifting, Point of Care Diagnostics
+Introduction
+Understanding the impact of dermatological diseases in resource-poor areas of the world is critical in developing a concerted and sustained global response towards reducing this burden (1). Skin conditions are often the presenting face of more severe systemic illnesses, including HIV and neglected tropical diseases (NTD), such as elephantiasis and other lymphedema causing diseases (2) (3). Furthermore, skin and subcutaneous disorders were the 4th leading cause of nonfatal disease burden worldwide in 2010 and 2013, emphasizing the role of dermatology in the ever-expanding field of global health (4).
+Recent recognition of skin disease at the global stage re-affirms the need for developing dermatologic guidelines. The World Health Organization’s “Guidelines on Skin and Oral HIV-Associated Conditions in Children and Adults”(5), the first such guideline on the dermatologic manifestations of HIV, illustrates a new wave of interest in ensuring that skin disease is included in the global public health agenda. Additionally, scabies was added to the list of neglected tropical diseases and psoriasis was recognized as a priority for health care quality improvement by the 67th World Health Assembly (1). Yet, these conditions only represent a fraction of the dermatological burden in resource-poor settings that demands better support.
+This article reviews our current understanding of the burden of dermatological disease from an epidemiological and socioeconomic standpoint, with recommendations for interventions to improve quality of care. A global health perspective of dermatology will help to provide a better framework for delivering resources and care.
+Burden of Skin Disease
+One method of understanding the epidemiological burden of skin disease is through the Global Burden of Disease (GBD). The Global Burden of Disease (GBD) project is based at the Institutes of Health Metrics and supported by the Bill and Melinda Gates Foundation. It provides disability and mortality estimates for a broad range of diseases, injuries, and risk factors. Disability burden is calculated using DALY, or disability-adjusted life years, and YLD, or years lived with disability, which both account for life years lost due to disease and allow for comparison across conditions. Each revision of the GBD incorporates new studies, novel methodologies, and existing uncertainties. This allows for a dynamic data source for informing future policy and research. The 2013 and recently published 2015 iterations of GBD provide an overview of the burden of skin disease globally and allows for comparison of disease across time (6).
+In 2013, skin conditions contributed 1.79% to the total global burden of disease measured in DALYs across 306 diseases and injuries. When comparing absolute DALYs/YLDs, skin and subcutaneous disorders were the 4th leading cause of non-fatal disease burden, directly following iron-deficiency anemia, tuberculosis, and sense organ diseases. 15 skin disease categories were assessed: dermatitis, psoriasis, cellulitis, pyoderma, scabies, fungal skin diseases, viral skin diseases, acne vulgaris, alopecia areata, pruritus, urticarial, decubitus ulcer, malignant skin melanoma, and keratinocyte carcinoma (including basal and squamous cell carcinomas), and other skin conditions. Dermatitis (encompassing atopic, seborrheic, and contact types) resulted in the greatest burden of the skin conditions, costing 9.3 million DALYs (6).
+As expected, the burden of skin disease shows both geographic and age-related variation. Melanoma causes the greatest burden in resource-rich regions such as Australia and North America, while dermatitis has the highest DALY rate in Sub-Saharan Africa. Mortality due to melanoma was found to be 4.7 times higher in resource-rich countries compared to resource-poor in 2010, while mortality due to measles was found to be 197 times greater in resource-poor nations compared to resource-rich (7). Additionally, GBD reveals variation by age, with infectious causes of skin conditions, such as viral warts, pyoderma, cellulitis, and scabies, causing greater burden among children. Persons of older age suffer disability burden from psoriasis, alopecia areata, urticaria, fungal skin diseases, and decubitus ulcers. These variations emphasize the need for region and population specific studies to truly understand the dermatologic needs of a community (6).
+However, epidemiological estimates of the burden of skin disease are likely to be underestimated due to a variety of factors. First, the GBD is based on the ICD classification system, which leads to categorization of certain skin conditions under other entities, for example, melanoma is classified under “cancer.” Furthermore, the dermatological manifestations of systemic illnesses are not necessarily individually categorized; the burden of lupus erythematosus is therefore entirely included under that of musculoskeletal disease(4). Second, the stigma associated with dermatological diseases, such as psoriasis, leads to underreporting by patients, leading to global underestimation (8). Third, available data is often limited in geographic coverage and collected in ways difficult for inclusion into larger studies. For example, the GBD estimates for skin and subcutaneous diseases in Sub-Saharan Africa, a designation that encompasses 46 independent nations, are based on only 53 studies, while estimates for the United States alone, with a population of approximately 1/3rd the size, are based on 62 studies. This underscores the need for strengthening of a global dermatologic research infrastructure towards finer granularity of dermatologic disease burden in both resource-poor and resource-rich regions.
+Skin conditions pose significant threat to patients’ well-being, mental health, ability to function, and social participation, a measure of disability defined broadly by the WHO as a person’s ability to be involved and engaged in relations with others. Quality of life (QoL) tools help to estimate the impact of medical conditions on these determinants of health. Multiple QoL measurement tools, such as the Dermatology Life Quality Index (DLQI) and the Skindex, exist and can be adapted to different settings (9–11).
+The effects of skin conditions on QoL in resource-replete settings is profound and well-documented (4,10,12). Far fewer studies exist examining the QoL of patients with skin conditions in the resource-poor world (9,13). Fewer still directly compare QoL in resource-poor to resource-replete settings (13). Conditions that constitute the highest disability burden are often characterized by disabling symptoms like pruritus. These conditions include dermatitis, prurigo, and papular urticaria (9,13). A study of QoL in South African patients with skin complaints found that patients with these diseases had significantly poorer QoL compared to controls in realms such as depression, anxiety, effect on work or study, clothing choice, looking after one’s home (9).
+Dermatologic QoL is also more impaired for members of vulnerable groups: people of advanced age, women, and children. Women reported greater impact on self-esteem, clothing choice, treatment problems and clothing choice in the South African study. Seniors were much more likely to experience disability due to a skin condition. Brazilian children with scabies reported high rates of teasing (26%) and social exclusion (17%) secondary to their disease (14). In addition to its detrimental effects on current QoL, teasing can have devastating long-term effects on mental health, predisposing children to anxiety disorders and social phobias (15).
+Assessing risk factors for decreased QoL in resource-poor and resource-replete settings is challenging. Increased clinical severity was an independent predictor of decreased QoL in a study of skin conditions among South Africans (9). However, clinical severity has not been uniformly associated with decreased QoL (16). This is because clinical severity, as measured by clinicians using formal grading scales, does not always correlate with patients’ perceptions of their condition’s severity. The discrepancy appears to be disease-specific. Some dermatologic diseases have their most salient impact on appearance, which is closely connected to self-worth for many patients, but is a difficult quality for clinicians to assess. Clinical severity of acne, for example, has not been shown to correlate with the patient’s perception of its severity. In contrast, diseases that impact more quantifiable domains, such as physical ability, have a higher correlation with patient perception. The clinical severity of psoriasis correlates more to patient perception due to the presence of comorbid psoriatic arthritis (16–18).
+The most salient symptoms of a skin condition have a considerable impact on quality of life. For example, a study of QoL in Ugandan patients found a significant burden of depressed mood and poor self-image secondary to pruritus (13). Approximately 8% of participants reported suicidal ideation. Pruritus had an adverse effect on QoL in both primary dermatoses and systemic disorders, though primary dermatoses were more commonly associated with poor self-image. Ugandan patients with itch were younger, more likely to have HIV, and less impacted by itch when compared to German patients. German patients were older, more likely to have end-stage renal disease, and more impacted by itch. These results suggest that demographic, socioeconomic and cultural factors may play a role in QoL perception.
+Socioeconomic factors contribute greatly to the epidemiology of skin disease in resource-poor settings. High household density, for example, is especially associated with transmissible skin disease—this factor was more important than salary, literacy, the use of shoes, distance to a water source, and quality of home construction in a Tanzanian study (19). These findings are perhaps unsurprising. We know that living in close quarters predisposes one to infection; this knowledge is the underpinning of such public policy measures as meningococcal vaccination for American college students living in dormitories (20). Infectious skin conditions are prevalent among disenfranchised people. The homeless, prisoners, and victims of violence are disproportionately affected in these settings (14,21). Skin conditions are the primary reason members of the homeless population seek medical care (21). Etiologies are diverse. Cellulitis and tinea pedis occur from inappropriate footwear; skin infections are sequelae of burns and physical trauma; mite infestations such as scabies are common in people with poor hygiene living in close quarters (21).
+The definition of socioeconomic burden includes functional impairment with subsequent lost opportunities in professional life (indirect cost) and healthcare expenses (direct cost) (8). In the United States, the direct and indirect cost of skin disease in 2013 was $75 billion and $11 billion, respectively (22). Little is known about the socioeconomic burden of skin disease in resource-poor settings. Studies examining the cost of skin care in these settings are rare. The socioeconomic burden is also country-specific and closely tied to the healthcare delivery model. In India, where healthcare is paid out-of-pocket, the median value of healthcare cost was 73% of per capita monthly income—a significant burden (23). Musculoskeletal and connective tissue disorders (including skin diseases) comprised 3.7% of the total cost burden. Overall, cost is difficult to estimate because systems operate on a mixed economy where cash, electronic financial assets, and the barter system are used equally, evading systematic study. The highly prevalent use of community-based traditional healers operating on a barter system in these settings is also a significant barrier to comprehensive cost analysis (19,24)
+In resource-poor settings, the availability of dermatologic treatment is governed by the cost of medications. Fortunately, dermatologic diseases are receiving more attention and have increasingly been included on the WHO List of Essential Medicines (25). This is a list of cost-effective medicines that are of relevance to public health and serves as a platform for advocacy. Even so, many dermatologic medicines from this list are not available in hospital pharmacies (26). Integrative care models have been proposed to control costs and provide efficient care in limited resource settings with loose healthcare networks. Integrative care models focusing on neglected tropical diseases aim to use a small, inexpensive arsenal of therapeutic agents to combat a wide range of transmissible diseases, including skin diseases. It is estimated that USD$0.40 per person per year could prevent a majority of the top neglected tropical diseases in Africa (27). Successful models of cost-effective public health efforts against dermatologic diseases feature close collaboration between the national medical system and international health organizations. For example, a Peruvian initiative against the spread of mucocutaneous leishmaniasis successfully improved the scope of treatment and follow-up of patients with funding of medications and resources by the Ministry of Health (28). Further research is needed to comprehensively describe and address socioeconomic barriers to care.
+The high burden and socioeconomic impact of dermatological disease, both studied and as experienced by the authors of this review, demand more attention, more resources, and more guidelines at multiple levels of care (Figure 1). There remains a mismatch between resource allocation and the skin diseases with the greatest disability burden – both in grant funding and systematic reviews (29,30). When the amount of NIH funding was compared with the relative disability burden of skin conditions, seven skin diseases (cellulitis, decubitus ulcer, urticaria, acne vulgaris, viral skin diseases, fungal skin diseases, scabies, and melanoma) were underrepresented (29). This is concerning because these grants and systematic reviews lead to the development of international guidelines. There is a dearth of high quality trials on treatment approaches for skin conditions, such as HIV-associated skin conditions. Without international guidelines, healthcare professionals in already resource strapped settings may be pushed to rely on unvalidated information, leading to patient harm (31–33). Therefore, continued advocacy and research will is necessary to inform the treatments selected in resource-poor settings.
+To overcome barriers to care, such as lack of trained dermatology professionals and limited ability to perform biopsies, recent goals of research include developing remote care and non-invasive diagnostic methods. Even within the United States, regions with no practicing dermatologists are associated with greater melanoma mortality (34). Teledermatology can help to overcome these gaps in care, allowing for better access to a trained dermatologist, reduced travel and waiting times, and support for local staff (35). There are a number of teledermatology networks in the resource-poor world, such as in Western Africa, South Africa, Botswana, Nepal, and Latin America. Mobile teledermatology uses cell phones to transmit images, allows for more versatility than its often more unwieldy store-and-forward counterpart, and has good concordance with the outcomes of a face-to-face visit (36–39). Teledermatology has been validated in both infectious conditions such as HIV-associated skin conditions and chronic conditions, such as atopic dermatitis (37,40). A cross-sectional survey of HIV positive patients in Botswana found that 91% of patients felt that a mobile teledermatology visit would provide the same level of care as a face-to-face visit (41). The validity and acceptance of teledermatology therefore make it an obvious choice for expanding dermatology services.
+Another way to improve access to care is to develop point-of-care diagnostic tools for dermatology. Distance to care, lack of connectivity, and poor laboratory infrastructure in many resource-poor areas precludes the widespread adoption of resource-heavy diagnostic techniques, such as skin biopsy reads by dermatopathologists (42–45). There is a shortage of literature that addresses the development of innovative diagnostic tools for dermatology in resource-poor settings. The case of visceral leishmanisis, a neglected tropical disease, can illustrate how government advocacy and collaboration can prompt better diagnostic tools even without an economic motive (44,46). The governments of India, Nepal, and Bangladesh pledged to eliminate visceral leishmaniasis by 2015, which along with improved treatment access, prompted the development of a simple point-of-care diagnostic tool which detects antibody agglutination (43,45).
+Similarly, we are engaged in an ongoing collaboration with the Infectious Disease Institute in Kampala, Uganda, to develop a point-of-care diagnostic tool for Kaposi’s Sarcoma (KS), a cancerous cutaneous manifestation of HIV. In resource poor settings, KS is often diagnosed based on skin exam alone, or when based on biopsy, limited to the few hospitals with the required pathologists and equipment. Diagnosis by exam alone is strife with error, with 23% rate of misdiagnosis (47). Developing a point of care diagnostic tool, ideally one that leapfrogs over the need for biopsy, will help to improve KS diagnosis and shorten time to treatment.
+A third way to respond to barriers in dermatologic care is to broaden the options for in-person treatment, expanding beyond the role of the dermatologist. The shortage of trained dermatologists in many regions of the world requires transitioning of care. Task shifting describes the process by which highly trained individuals facilitate the passing of their skills to individuals with little or no prior training in a specific area (48,49). As the process is collaborative and the newly trained healthcare worker continues to be supported by a mentor, the term task sharing has also been employed (48). Task shifting in the field of mental health has been widely successful, demonstrating that community health workers can be trained to provide care to individuals with mental health conditions in lower and middle income countries (48). In the field of HIV/AIDS, task shifting has been deemed imperative with evidence that nurses can prescribe antiretroviral treatments just as effectively as physicians (50,51).
+There is a sparsity of physicians with dermatological training in many of low and middle income countries (52). In the field of dermatology, unlike in HIV or obstetrics (53–56), there are few examples of task shifting in resource-poor settings, but the limited application of this technique has been successful. In one study, US dermatologists taught physicians, nurses, clinical officers and technicians in East Africa how to perform bunch biopsies, allowing for same day KS biopsies (57). As adapted from the mental health field (48), an apprenticeship model could allow dermatologists to train community health workers in resource limited settings on diagnosis and treatment of the most common dermatological conditions, such as dermatitis, psoriasis, acne, and tinea. Therefore, task shifting provides a potential model for collaborative capacity building.
+Building local capacity also requires building educational programs to train future generations of dermatologists. In Nigeria, for example, it is estimated that in 2015 that 80 formally trained dermatologists served the nation’s population of 182 million (58,59). The Regional Dermatology Training Center in Tanzania was established in 1992 to provide dermatologic training for nurses in the Sub-Saharan region (60). Toby Maurer of University of California, San Francisco is also working to establish a dermatology residency training program in Uganda and Kenya. Sustained efforts are required to train regional cohorts of dermatologists to serve resource-poor regions.
+Based on the Global Burden of Disease Project, skin diseases were the 4th leading cause of non-fatal morbidity worldwide in 2010 and 2013 (4,6). This epidemiological birds-eye view highlights variations by region and by condition – with resource-poor areas more likely to suffer the burden of infectious skin conditions, while resource-rich areas shoulder the burden of malignancies. Due to few high-quality trials in resource-poor settings, there is little data on the true impact of dermatological conditions in these regions. The limited data that highlights regional and cultural variations in the impact of dermatological symptoms, such as quality of life relating to pruritus, further underscores the need for setting-specific research. Extrapolation of findings from resource-rich nations is therefore not advised; more funding towards more studies and more services for dermatological needs in resource-poor settings is needed.
+Addressing this mismatch between resource need and allocation will require dynamic solutions. Teledermatology offers one such solution by channeling dermatological expertise to areas in need. Improving dermatological training programs and task shifting care to community health workers in these areas will be critical in delivering a more tactile solution to this problem as well. Point-of-care diagnostic tools, such as for Kaposi’s sarcoma, offer a glimpse into the future by bringing patients closer to life-saving treatments. In the development of solutions, however, we must remain vigilant and devoted to quality. Improving access to care is not the same as increasing access to high quality care (61). Our solutions to inequities must not propagate more disparities. The devastating social stigma associated with skin diseases means that many patients are not actually “seen” by research trials and international organizations. However, these inequities in global dermatology should only further propel us towards increased commitment to delivering care to all patients, seen and unseen.