Skin is not only an envelope protecting the inner body, or a membrane that allows exchange between exterior and interior of the body. It also serves as a mingling point between the outer world and inner self, and between body and soul.    

  — Miru Kim, American photographer and film maker

When Hamlet contemplated ‘the thousand natural shocks that flesh is heir to,’ he no doubt meant more than the envelope protecting the inner body that Miru Kim describes.  But that outer envelope is heir to more than 3,000 different disorders – from acne to zoster, with all of the attendant stigma that has attached to diseases of the skin for centuries.

From the earliest recorded histories, we know that individuals with skin diseases were cast out from society in ancient times, labeled unclean and ostracized.  Often diagnosed with leprosy, they probably really suffered from other skin diseases, such as eczema and psoriasis.

Leprosy is considered the oldest infectious disease among humans. The Bible mentions leprosy no fewer than 40 times, always insisting that the sufferer is unclean, both physically and spiritually.  The disease was considered a curse, a punishment for sins committed.  Individuals diagnosed with leprosy were not allowed to live in any community of their own people; in fact, among the sixty-one defilements of ancient Jewish laws, leprosy was second only to a dead body in seriousness. The disease was considered so revolting that lepers weren’t permitted within 150 feet of anyone when the wind was blowing. Lepers lived in communities with other lepers until their skin was healed or they died.

So prevalent was leprosy (correctly diagnosed or otherwise) in ancient times that the disease has been the subject of artists throughout history.  Renaissance painters often included detailed portrayals of these lesions in their work – such as the image seen here.

Others throughout history were also misdiagnosed, and also suffered the indignity of being labeled unclean.  Robert I of Scotland (1274 – 1329), also known as Robert the Bruce, ruled Scotland from 1306 until he died.  He was diagnosed with what contemporary accounts described as “an unclean ailment,” the traditional view being that his death was caused by leprosy.  In fact, according to a March 17, 2016 article in The Scotsman, the national newspaper of Scotland, “The propaganda machine was working against King Robert and the worst thing that you could have said about someone in those times is that he had leprosy.  It is true that King Robert’s father had and died of the disease, but the King himself died peacefully in his bed in the modern day village of Renton, medieval Cardross at the age of 54 due to an illness.”  Particularly after his exhumation and facial reconstruction, historians have suggested such varying contributing factors as eczema, tuberculosis, syphilis, motor neuron disease, cancer or stroke, or even his diet of rich court food.

Even today, because skin is exposed for everyone to see, these diseases are often obvious and visible; and unfortunately, the stigma remains, imposing on patients the dual difficulty of having to deal with their skin condition as well as the disdainful glances and comments of others.  Because the social stigma can be so insidious, diagnosis is frequently delayed, with sometimes severe consequences.

In fact, skin diseases are very common, affecting nearly everyone at some point in their lives.  with acne being the most common and melanoma the most deadly – and while treatments for these conditions have become much more effective, the biggest challenge these patients may face in the future may well be lack of access to dermatologic care.

From the US National Library of Medicine, National Institutes of Health, comes this abstract from 2007:

Since 1999, multiple surveys have documented a stable undersupply of dermatologic services in the United States. Factors contributing to the imbalance include changes in the demographics of the physician workforce, increased demand for services, and a limited number of training positions for new physicians. In response to the demand, there has also been a substantial influx of nonphysician clinicians into dermatology offices.

The statistics have not improved.  As a January 2012 article in Dermatology Times reported, patient requests are exceeding the time slots available at dermatologists’ offices across the country. Some of the numbers are slowly changing, but wait times remain lengthy, and solutions are complicated.  A 2013 report compiled by Harris Williams & Co., entitled Dermatology Market Overview, revealed that in that year there were an estimated 9,600 dermatologists and 7,800 dermatology practices in the United States.  The report indicates that the current shortage is expected to persist for the foreseeable future.

All this, at a time when there is an increasing demand for dermatological services, driven primarily by the rising occurrence of skin cancer, in particular melanoma, and the aging of the population.  According to a 2015 One Key report prepared by Cegedim Relationship Management, dermatologists “represent a very small number of the total number of physicians in the US. There are currently 13,847 dermatologists practicing across the country. Most dermatologists focus on a single specialty; only 13.5 percent have a secondary specialty. The number of dermatologists has certainly not kept up with demand. Since 2010, there has only been about a 10 percent increase in the number of dermatologists.”

Additionally, the report continues, the Affordable Care Act (ACA) has contributed to additional demand for dermatology services – dermatologists are among the top five specialists booked by ACA patients.  And it’s the southern states that have the highest concentration of dermatologists: a third of the country’s dermatologists practice in the south, outweighing the northern states by about 70 percent.

The American Academy of Dermatology addressed the growing problem at its 74th annual meeting in March 2016, reporting that expansion of coverage under the ACA is expected to increase still further.  The report noted:

With projected GDP growth of 3% annually, the supply of dermatologists will be 24.4% short of the estimated demand for dermatologic care assuming current trends in dermatology resident training continue…

The report concluded that the US faces “a substantial shortage of dermatologists in the next 30 years, which may reach 25% of anticipated demand.”

While growth in the NP and PA workforce may help to partially alleviate the severity of these workforce shortages, highly trained dermatological specialists and subspecialists – like Dr. Brian L. Johnson, Dr. Abby S. VanVoorhees, Dr. Luke Coker and Dr. Leslie Coker, whose exceptional work in the field of dermatology is profiled in this issue of Hampton Roads Physician – will always be in demand.