Indigenous Dermatology in Canada
What do we know, and what are the needs?
On March 18th and 20th, 2021 we held our first national Indigenous Skin Summit to coincide with Australia’s Close the Gap Day, chaired by Drs. Rachel Asiniwasis and Gary Sibbald. This virtual summit hosted many presenters, both Indigenous and allies, with objectives surrounding improving patient care and treatment strategies for Indigenous patients with skin disease in a culturally holistic context.
Links: Close the Gap Day: Australia Canada
Our topics of presentation and discussion during this summit included the following:
1. Dr. A. Blair Stonechild (Rachel’s dad and Indigenous historian at First Nations University of Canada): “An Overview of Indigenous History: How Did We Get Here?”
2. Dr. Carrie Bourassa: “Culturally Safe Care for Indigenous Peoples: Addressing Systemic Racism”
3. Dr. Rachel Asiniwasis: “Indigenous Dermatology: Common Skin Disorders and Diseases in Indigenous Communities”
4. Dr. Veronica McKinney: “Listening to the Indigenous Patient (Part I)”
5. Dr. Rachel Asiniwasis: “Listening to the Indigenous Patient (Part 2): Experience in Northern & Remote Communities”
6. Dr. Alika Lafontaine: “Environmental and Sustainability Considerations from an Indigenous Perspective”
7. Dr. Rachel Asiniwasis: “Indigenous Dermatology: Challenging Disorders and Diseases”
8. Dr. Veronica McKinney: “Health Comorbidities and Treatment Implications”
9. Tara-Rose Farrell (MA, CYC): “Working with Indigenous Children: An Ally’s Perspective”
10. Dr. Gary Sibbald: “Wound Healing for Indigenous Patients” and “Hidradenitis Suppurativa in Indigenous Communities”
11. Dr. Rachel Asiniwasis: “Overview of Current Research Projects in Indigenous Communities”
Summary of Rachel Asiniwasis’ presentations:
Common Skin Disorders & Diseases in Indigenous Communities
A paucity of information exists on Indigenous skin disease in Canada. The skin is a manifestation of both internal and external health, and Indigenous populations face unique challenges and barriers compared to the general Canadian population.
Complex health determinants in Indigenous communities exist, and addressing such skin disease must include a view of “the bigger picture” along with cultural safety training.
In a Canadian context, limited published existing literature, health care practitioner experiences, and media all point to concerns involving atopic dermatitis (eczema) and skin and soft tissue infections, with a poorly documented “crisis” seen in the pediatric population.
Those with atopic dermatitis (eczema) are at baseline elevated risk of skin and soft tissue infections. Canadian literature suggests that one year prevalence of atopic dermatitis in children on reserve may be up to 16.5% (Forsey, 2014), although more information is needed.
Other skin diseases such as scabies, psoriasis, hidradenitis suppurativa, photodermatoses, acne/rosacea, MRSA/general skin infections, and diabetic skin disease/ulcers and others are of concern, but more information is needed on these topics.
Environmental factors amongst other numerous barriers faced by remote Indigenous communities can play a role in exacerbation of skin disease (eg. crowded housing, communicable disease, cost/accessibility of basic skin care products including water supply and access)
Treatment strategies may include keeping it simple whenever possible, using pictoral-based handouts, aiming for proactive care, using strategies to reduce infection, addressing co-morbidities, booking follow-up, familiarizing yourself with NIHB coverage, improving health care practitioner education in Indigenous skin disease/cultural sensitivity, treating the whole household in cases of communicable infections/infestations, and “tubs not tubes” with plenty of refills.
A recent retrospective random chart review by Jeong et al. (2020) demonstrated that over a 12 month period, 60% of adult patients were prescribed one or more systemic antibiotics. A high prevalence of skin and soft tissue infections were noted around 37%, with 40% of these representing MRSA. The authors concluded, "Populations are hard to reach and under-represented in the standard surveillence system."
Indigenous Dermatology: Challenging Disorders and Diseases
Environmental factors amongst other numerous barriers and complex health determinants faced by remote Indigenous communities can play a role in exacerbation of skin disease. Poverty, housing conditions, access/cost of basic skin care regimens, clean water concerns and crowding are examples.
Barriers reported by communities in accessing appropriate dermatologic/health care services may include general lack of health care services (including dermatology), long waiting lists, transportation, and affordability/costs. The pandemic provides unique challenges.
According to the First Nations Regional Health Survey (2010), atopic dermatitis was the top condition that children and caregivers went out of their way, despite barriers, to seek out care, which indicates impact that needs to be further explored.
Atopic dermatitis, skin infections and infestations (eg. scabies) are top concerns, and the presence of more than one complication can complicate the treatment picture. Crowded housing and general lack of access/barriers play a role. Strategies must be employed to help reduce this burden of communicable disease (see “calls to action”), as these are curable conditions.
Uncontrolled, severe, chronic and co-morbid skin disease (eg. impetiginized eczema) can have a significant functional (physical, psychosocial and economic) impact on suffering individuals and families.
There is a “crisis” involving pediatric cases that must be addressed, as these conditions unfortunately appear to have become normalized in our system (see media below).
Systemic co-morbidities must be addressed to reduce overall burden, and thus collaboration amongst health care practitioners and organizations is needed.
Those requiring systemic immunosuppressants or biologic treatment (eg. for moderate to severe atopic dermatitis or psoriasis) face unique barriers in remote Indigenous communities.
Strategies to address such issues may include:
See the strategies in “Common Disorders and Diseases”; in addition:
More research is needed to inform policy makers
NIHB coverage must be reassessed and streamlined
Communicable skin disease strategies (eg. infection/infestation)
Improving education to health care practitioners on cultural safety and Indigenous skin disease
Optimizing teledermatology and virtual care
See “Calls to Action” below
Overview of Current Research Projects in Indigenous Communities:
A paucity of literature exists on Indigenous skin disease in North America, this includes both Canada and the United States.
Most literature is out of Australia, and highlights concerns with skin and soft tissue infections, and infestations (similar to what is being seen in Canada with the limited information we have.)
Both Australia and Canada’s Indigenous population face similar complex health determinants, and we may be able to learn from Australia’s experience.
A survey of remote health care practitioners in Saskatchewan Indigenous communities done by Asiniwasis et al. (2020) showed that the most commonly encountered dermatologic conditions include atopic dermatitis (eczema), impetigo (MRSA/non-MRSA), skin infections, scabies, diabetic skin complications or ulcers, lice, psoriasis and infestations. Barriers reported by survey participants include cost, transportation, long wait times, travel barriers, level of comprehension with skin instructions/reading instructions, supply and access, proximity, access to healthy water sources, and cultural barriers.
North American Indigenous skin disease research is currently being led out of Origins Dermatology Centre under Rachel Asiniwasis MD as the principal investigator and her team. Current projects include a systematic review, retrospective chart reviews, virtual care community-based participatory action oriented research projects, and national surveys. Our centre is now liasing with other Indigenous researchers with an ultimate goal of involving and empowering the communities in their own health care.
Research on Indigenous skin disease is important to raise awareness around these conditions to inform policy and decision makers that there are issues that need to be recognized and addressed.
Listening to the Indigenous Patient: Experience in Northern and Remote Communities
Indigenous communities face complex health determinants and co-morbidities, it takes time to listen and understand issues faced.
There often is distrust of the medical system due to historical and institutional trauma, and patients need to be able to “tell their own stories”.
Some patients may be using traditional medicines as well as accessing the health care system.
Indigenous communities are not alone in facing issues: Health care providers have barriers to care as well. Due to time and resource pressures as well as provider burnout leads to challenges in providing proactive care.
The dermatological fee for service system is often not compatible with addressing Indigenous health disparities, complex cases along with high overhead costs in dermatology due to the paperwork, equipment, admin, nursing and general resource burden can add up. Not sustainable long term unless support is provided.
The ultimate goal with regards to Indigenous skin disease is time to listen, counsel, understand and follow-up in a culturally sensitive context.
The last Canadian residential school closed its doors only in 1996, and was located in southern Saskatchewan.
Closing Remarks and Calls to Action:
Although a poorly understood topic, Indigenous skin disease in Canada is a manifestation of the “bigger picture” engrained in complex webs of health determinants faced by Canadian Indigenous populations.
Whereas Canada consistently has top placement in the UN Human Development Index, Canadian Indigenous ranks 78th on the same scale (Waldram, 2006). There is a problem in our own back yard that we must not ignore, but rather aim to proactively address.
Calls to Action must be made and followed through on to reduce this burden.
Calls to Action may include: To “Close the Gap” in Canada on Indigenous health disparity and skin disease:
Improve remote health care practitioner education in Indigenous cultural safety and skin disease diagnosis and management.
Encourage focus on proactive care of skin disease and management/prevention of secondary infection which have been identified as problems.
National treatment strategies (eg. focus groups) need to be developed to address widespread communicable disease, such as skin infections and infestations.
Add Indigenous dermatology to medical education curriculum and residency programs.
Improve research to inform policy and decision makers.
Reassess and streamline NIHB coverage criteria for skin disease.
Phototherapy units for moderate to severe psoriasis and atopic dermatitis amongst other uses should be made more available to remote communities in need as they are relatively safe and may reduce morbidity.
Liase with Australian leaders in Indigenous skin disease – can we learn from them?
Recognize that health care practitioners face their own burnout and barriers working in these communities, and support programs are needed.
• Abedi, M. and Russell A. (Feb 7, 2019). ‘We’re not bluffing’: Ontario First Nation Urges Trudeau, O’Regan to Witness Housing Crisis. CBC News. Retrieved from https://globalnews.ca/news/4934630/cat-lake-first-nation-housing-health-crisis/
• CBC News (No Author listed). (2016, Mar 21.) Kashechewan children’s skin lesions not caused by water: health minister. CBC News. Retrieved from https://www.cbc.ca/news/canada/sudbury/kashechewan-water-health-skin-rash-update-1.3500631
• Dehaas, J. (2016, Mar 23.) ‘Social emergency’: Kashechewan skin problems blamed on poverty, overcrowding. CTV News. Retrieved from https://www.ctvnews.ca/canada/social-emergency-kashechewan-skin-problems-blamed-on-poverty-overcrowding-1.2830199
• Dehaas, J. (2016, March 24.) Kashechewan skin infections exacerbated by ‘social emergency’. CTV News. Retrieved from https://www.ctvnews.ca/canada/kashechewan-skin-infections-exacerbated-by-social-emergency-1.2831317 • https://cutoff.vice.com/updates/canada-is-evacuating-kids-from-this-first-nation-because-of-a-mysterious-rash • https://www.cbc.ca/radio/thecurrent/the-current-for-march-25-2016-1.3507260/kashechewan-rash-outbreak-highlights-woeful-first-nations-health-care-say-critics-1.3507262
Allan, B. & Smylie, J. (2015). First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute.
Andrews, R. M., Kearns, T., Connors, C., Parker, C., Carville, K., Currie, B. J., & Carapetis, J. R. (2009). A regional initiative to reduce skin infections amongst aboriginal children living in remote communities of the Northern Territory, Australia. Plos Neglected Tropical Diseases, 3(11). Link
Asiniwasis R, Eglington T, Odeshi O, Richels L, Hinther K, Phillipz Z, Pandey M. (2020). Saskatchewan Rural Communities and Skin Diseases: A Health Practitioner Survey on Dermatologic Conditions seen in Saskatchewan’s Remote Indigenous Communities. Presented at Saskatchewan Research Showcase Nov 2020.
Aung, P., Cuningham, W., Hwang, K., Andrews, R. M., Carapetis, J. R., Kearns, T., Clucas, D., McVernon, J., Simpson, J. A., Tong, S., & Campbell, P. T. (2018). Scabies and risk of skin sores in remote Australian Aboriginal communities: A self-controlled case series study. Plos Neglected Tropical Diseases, 12(7), 1-11. Link
Carr, G., & Tait, C. (2018). Dermatological learning needs among aboriginal health workers in rural and remote Australia: A cross‐sectional survey. Australasian Journal of Dermatology, 59(1), e84–e86. Link
Chuchvara, N., Patel, R., Srivastava, R., Reilly, C., & Rao, B. K. (2020). The growth of teledermatology: Expanding to reach the underserved. Journal of the American Academy of Dermatology, 82(4), 1025–1033. Link
Currie, B. J. & Carapetis, J. R. (2000). Skin infections and infestations in Aboriginal communities in northern Australia. Australasian Journal of Dermatology, 41, 139-143. Link
Davidson, L., Knight, J., & Bowen, C. A. (2020). Skin infections in Australian Aboriginal children: a narrative review. The Medical Journal of Australia, 212(5), 231-237. Link
Eczema Society of Canada. (2017). Atopic dermatitis quality of life report. Moderate to severe disease: 2016/2017 survey results. Link
Eedy D. (2016). Dermatology: a specialty in crisis. Clinical medicine (London, England), 16(1), 61. Link
First Nations Regional Health Survey (RHS 2010). First Nations Information Governance Centre (FNIGC, 2012)
Forsey R. G. (2014). Prevalence of childhood eczema and food sensitization in the First Nations reserve of Natuashish, Labrador, Canada. BMC pediatrics, 14, 76. Link
Greater Access for Patients Partnership (GAPP) (2018). Patients Are Waiting. America’s Dermatology Appointment Wait Times Crisis. Retrieved from www.dermpa.org/resource/resmgr/GAPP_Wait_Time_Report_final.pdf
First Nations Information Governance Centre (2018). National Report of the First Nations Regional Health Survey Phase 3: Volume One. Gracey, M., & King, M. (2009). Indigenous health part 1: Determinants and disease patterns. Lancet (London, England), 374(9683), 65–75. Link
Hall, G., & Sibthorpe, B. (2003). Health benefits of swimming pools in remote Aboriginal communities. British Medical Journal (Clinical Research Ed.), 327(7412), 407–408. Link
Heyes, C., Chan, J., Halbert, A., Clay, C., Buettner, P., & Gebauer, K. (2011). Dermatology outpatient population profiling: Indigenous and non-Indigenous dermatoepidemiology. The Australasian Journal of Dermatology, 52(3), 202–206. Link
Jennett, P. A., Hall, L. A., Hailey, D., Ohinmaa, A., Anderson, C., Thomas, R., Young, B., Lorenzetti, D., & Scott, R. E. (2003). The socio-economic impact of telehealth: A systematic review. Journal of Telemedicine and Telecare, 9(6), 311–320. Link
Jeong, D., Nguyen, H.N., Tyndall, M., & Schreiber, Y. (2020). Antibiotic use among twelve Canadian First Nations communities: a retrospective chart review of skin and soft tissue infections. BMC Infectious Diseases, 20(118), 2-8. Link
Kozera, E. K., Yang, A., & Murrell, D. F. (2016). Patient and practitioner satisfaction with tele- dermatology including Australia's indigenous population: A systematic review of the literature. International Journal of Women's Dermatology, 2(3), 70–73. Link
Loane, M. A., Bloomer, S. E., Corbett, R., Eedy, D. J., Hicks, N., Lotery, H. E., Mathews, C., Paisley, J., Steele, K., & Wootton, R. (2000). A comparison of real-time and store-and-forward teledermatology: a cost-benefit study. The British journal of dermatology, 143(6), 1241–1247. Link
McMeniman, E., Holden, L., Kearns, T., Clucas, D., Carapetis, J., Currie, B., Connors, C., & Andrews, R. (2011). Skin disease in the first two years of life in Aboriginal children in East Arnhem Land: Skin disease in Aboriginal children. Australasian Journal of Dermatology, 52(4), 270–273. Link
Nepal, S., Thomas, S. L., Franklin, R. C., Taylor, K. A., & Massey, P. D. (2018). Systematic literature review to identify methods for treating and preventing bacterial skin infections in Indigenous children. Australasian Journal of Dermatology, 59(3), 194–200. Link
Romani, L., Steer, A. C., Whitfeld, M. J., & Kaldor, J. M. (2015). Prevalence of scabies and impetigo worldwide: a systematic review. The Lancet Infectious Diseases, 15(8), 960– 967. Link
Smylie J. (2000) A guide for health professionals working with Aboriginal peoples: Health issues affecting Aboriginal peoples. Journal of the Society of Obstetricians and Gynecologists of Canada, 100(1), 54–68. Link
Thomas, S., Crooks, K., Taylor, K., Massey, P. D., Williams, R., & Pearce, G. (2017). Reducing recurrence of bacterial skin infections in Aboriginal children in rural communities: new ways of thinking, new ways of working. Australian Journal of Primary Health, 23(3), 229–235. Link
Tilakaratne, D., Warren, L. and Menz, J. (2016). A Casemix study of patients seen by dermatology trainee in rural and outpatient settings. Australasian Journal of Dermatology, 57(1), 33-38. Link
Vekic, D.A., Woods, J. and Cains, G.D. (2018), Hidradenitis suppurativa: A neglected disease in Indigenous Australians. Australasian Journal of Dermatology, 59(2), 138-140. Link
Waldram, J., Herring, D., Ann, Y., Kue, T. (2006). Aboriginal Health in Canada: Historical, Cultural and Epidemiological Perspectives (2nd ed.) University of Toronto Press.
Yaghmaie, P., Koudelka, C., & Simpson, E. (2013). Mental health comorbidity in patients with atopic dermatitis. Journal of Allergy and Clinical Immunology, 131(2), 428–433. Link
Yeoh, D. K., Anderson, A., Cleland, G., & Bowen, A. C. (2017). Are scabies and impetigo "normalised"? A cross-sectional comparative study of hospitalised children in northern Australia assessing clinical recognition and treatment of skin infections. Plos Neglected Tropical Diseases, 11(7). Link