Q&A: Understanding exposures affecting skin health of migrant populations
Key takeaways:
- Exposures before, during and after migration, plus structural factors, are associated with the skin health of migrant populations.
- Critical literature gaps present opportunities for research.
Migrants traveling into the United States face a range of exposures and social factors that can adversely impact skin health, but the prevalence of specific dermatologic skin conditions remains poorly researched, which can complicate care.
Immigrants represent nearly 14% of the U.S. population and refugees and asylum seekers represent 32% of the total migrant population, yet a “critical gap” remains when it comes to research on migrant skin health, according to Herbert B. Castillo Valladares, MD, MHS, assistant clinical professor of dermatology at University of California San Francisco.
In a scoping review recently published in JAMA Dermatology, Castillo Valladares and colleagues found that existing studies highlighted the unique dermatologic challenges migrants face due to environmental exposures and occupational risks specific to their regions of origin and migration routes. The articles discussed a range of dermatologic conditions including infections (51.7%), inflammatory conditions (37.9%), traumatic wounds (18.4%), neoplasms (11.5%), pigmentary disorders (11.5%), signs of torture/violence (4.6%), cosmetic disorders (3.4%), hair/nail disorders (1.1%) and genodermatoses (1.1%). Mexico was the most frequently reported country of origin, followed by Guatemala and Vietnam.
“From the broader migrant health literature, it is evident that social drivers of health are associated with health and health care access, including limited health care resources, language barriers, and socioeconomic factors,” the researchers wrote.
Healio spoke with Castillo Valladares about the need to understand the prevalence of specific skin conditions affecting migrant populations, occupational and environmental exposures common among migrant groups and need for more balanced research that does not advance stereotypes.
Healio: What led you and your colleagues to conduct this review focusing on migrant populations?
Castillo Valladares: The topic and the patient population that we talk about in this scoping review is front and center for our group because we work at San Francisco General Hospital, which is a safety net hospital. Our hospital is serving a large population of immigrant patients. We have a diversity of experience and expertise that led us to come up with a question: What gaps are in the existing literature when it comes to a comprehensive understanding of migrant skin health is in the United States? That is the lens through which we conducted our review, informed by our clinical experience.
Healio: What are the key takeaways from this review that you want to highlight for dermatologists?
Castillo Valladares: We identified 87 articles. Of these, 42.5% were cross-sectional studies and 41.4% were case reports or case series, plus three qualitative studies and a mixed-methods study. In reading them, we were able to conduct a thematic analysis yielding four main themes.
The first theme was exposures before entering migration that led to dermatologic conditions. Most of these articles were case reports and cross-sectional studies of endemic infections before or during migration. The second theme was occupational and environmental exposures for migrants at the site of their destination. Studies exploring this theme were also mostly case reports and cross-sectional studies, focusing on farm workers nail salon employees and poultry processing workers, and how those environmental exposures led to dermatologic conditions.
The third theme was looking at structural factors that limit access to dermatologic care. A few articles touched on how, for some migrant communities, there is a lot of self-management of dermatologic conditions, especially among migrant farm workers.
The last theme was educational interventions for learners to understand how to improve the skin health of migrants. There were only three articles focused on this theme.
Healio: The review notes that there were frequent reports of infectious conditions among migrant populations; however, the Global Burden of Disease Study Estimate suggests migrant populations are more likely to have inflammatory conditions. What might this tell us?
Castillo Valladares: It is important to point out that most articles focus on infectious conditions; however, these are mostly case reports and cross-sectional studies. Most of the articles focus on nonendemic infections. We cannot extrapolate further on the prevalence of these infections among migrant populations because of the low-quality level of the evidence. What we are concluding is that because there are a lot of these case reports — especially for parasitic infections, which, again, do not have a large enough burden compared with the global burden estimates — there may be a lack of familiarity within our U.S. clinician community of these nonendemic infections, and researchers are interested in reporting on and learning about these conditions. But it is important to understand that this can have repercussions. If that is the large body of evidence that we have, we want to make sure we are not creating the social perception that migrants are associated with infectious diseases. The conclusion for us is, because these are low-evidence case reports, there is a large research gap. There should be more studies detailing the prevalence of infectious conditions and more studies are needed on other conditions, such as inflammatory skin conditions and a broader range of infections. The most reported-on conditions were parasitic infections. We want to learn more about other infectious conditions as well.
Healio: The review also noted there were no articles that focused on migrant health policy. What needs to be done to improve access to dermatologic care for migrant communities?
Castillo Valladares: We found no articles focused on migrant policy. There is a great need for more targeted research on the prevalent dermatologic conditions, barriers to care and structural determinants of health for migrant populations. Then, that evidence with more robust and diverse research can then inform policy that is responsive to what the true needs are.
Healio: What more do we still need to learn?
Castillo Valladares: We just mentioned a large research gap related to migrant health policy; however, there are many other gaps that we identified. Migrant populations represent a heterogeneous group of people with a wide range of socioeconomic, cultural and language backgrounds and reasons for migration. We did not see a big focus on women or children in our review. More research is needed on the full age and gender spectrum. Additionally, there were some reports about housing and exposures, but more research is needed on all of the structural and social drivers that affect this population. And the smallest theme was education. It is important to expand upon how to best educate clinicians about how to improve skin health of migrants.
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For more information:
Herbert B. Castillo Valladares, MD, MHS, can be reached at Herbert.castillovalladares@ucsf.edu.