Abstract
Background
There is a paucity of literature regarding dermatologic conditions in migrant and refugee populations.
Methods
We conducted a cross-sectional study of all adult refugees resettling in a region of Connecticut, U.S. from 7 January 2015 to 20 November 2018. We conducted a manual chart review to determine dermatologic conditions diagnosed during and within one year of resettlement. We used multivariable logistic regression to determine demographic and clinical factors associated with having any dermatologic condition.
Results
We included 545 refugees primarily from Afghanistan (40.6%), Syria (24.6%) and Iraq (10.5%), with a median (interquartile range) age of 33 (28–40) years. Of the 545 participants, 213 (39.1%) had dermatologic conditions. Fifty-four participants (25%) had more than one dermatologic condition and 114 (53.5%) were diagnosed within the first month of resettlement. The most common categories of conditions were cutaneous infections (24.9%), inflammatory conditions (11.1%), and scar or burn (10.7%). Tobacco use was associated with having a cutaneous infection (OR 2.37, 95%CI:1.09–4.95), and younger age was associated with having a scar or burn (for each year increase in age, OR 0.95, 95%CI:0.91–0.99).
Conclusion
Dermatologic conditions are common among adult refugees. The majority of conditions were diagnosed in the first month following resettlement suggesting that a high number of dermatologic conditions arise or go undetected and untreated during the migration process.
Keywords: Emigrant and immigrant/dermatologic diseases, Refugees/epidemiology, Refugees/resettlement, United States, Public health, Education
Capsule summary.
-This cross-sectional study shows that dermatologic conditions are commonly diagnosed within one year of arrival in resettled refugees in the U.S.
- Cutaneous infections, inflammatory dermatitis, and scars or burns were the most commonly diagnosed conditions. Clinicians should evaluate for these conditions in the domestic refugee examination.
Alt-text: Unlabelled box
Introduction
The global population of refugees, migrants, and asylum seekers continues to rise, reaching close to 103 million people as of October 2022. (The UN Refugee Agency 2022) Over 203,000 refugees have been resettled in the U.S. since 2016, and the annual resettlement numbers are anticipated to rise in the coming years. (National Immigration Forum) While there is considerable published research about the prevalence and risk factors for communicable and chronic, non-communicable diseases in the refugee and migrant population, (Goodman et al., 2018; van Berlaer et al., 2016; Yun et al., 2012) there is a relative paucity of research evaluating the prevalence of dermatologic conditions in refugees following resettlement, even though dermatologic conditions affect many people in the U.S. and around the world. (HW Lim et al., 2017; Karimkhani et al., 2017)
Epidemiologic studies estimate that between 9 and 23% of refugees and migrants in Europe have dermatologic conditions. (Goodman et al., 2018; van Berlaer et al., 2016; Kampouras et al., 2019; Di Meco et al., 2018; Borgschulte et al., 2018) Forced migration is hypothesised to contribute to rise in dermatologic conditions because of overcrowded conditions and long periods of confinement. (Kwak et al., 2021; Padovese and Knapp, 2021) Our objective is to determine the prevalence and characteristics of dermatologic conditions in an adult refugee population following resettlement in the U.S.
Method
Study design and population
We conducted a cross-sectional study of refugees resettling in a region of Connecticut, U.S., between 7 January 2015 to 20 November 2018. Refugees resettling in this region completed their refugee health assessment in an academic medical center, and the vast majority continue to receive their longitudinal primary care through the same health system or in affiliated clinics. (Mohareb et al., 2021) We included all adult patients (18 years old and older) who completed their refugee health assessment during the study period. This review was approved by the Yale University Institutional Review Board (IRB Protocol ID: 000,022,054).
Data collection
We conducted a manual chart review of the electronic medical record for all adult refugee patients. The first author (C.A.H.) recorded demographic data including country of origin, age, sex, tobacco use, and primary language, and reviewed all medical notes for dermatologic diagnoses in the primary care and dermatology outpatient visits within one year of their date of resettlement in the U.S. In cases where subjects had skin conditions without a dermatologic diagnosis, a board-certified dermatologist (A.S.) reviewed the clinician evaluation and provided their impression of the condition. We excluded dermatologic conditions that presented after one year.
Categorization of dermatologic conditions
We extracted the exact description of the dermatologic condition in the clinical note or documented dermatologic diagnosis. The dermatological problem was in some cases the primary presenting complaint and in other cases an incidental finding in the primary care visit. In order to categorize the dermatologic conditions, we adapted the classification from the American Academy of Dermatology Burden of Skin Disease categories, and relevant chapters of the International Classification of Diseases (ICD)−11. (World Health Organisation (WHO) 2020; American Academy of Dermatology Association) For dermatologic conditions with a named diagnosis, we utilised ICD-11 Chapter 14, Diseases of the Skin. (World Health Organisation (WHO) 2020) Based on the prevalence of dermatologic conditions in our study population, we adapted the ICD-11 classifications and categorized the dermatologic diagnoses into Pigmentation, Scarring, Burns and Trauma, Hair and Nail, Inflammatory and Autoimmune, Infection, Neoplasms and Mass, and Pruritus. For dermatologic conditions with a description, but no named diagnosis, we classified the descriptors based on ICD-11 Chapter 21, Symptoms, Signs or Clinical Findings, Not Elsewhere Classified. (World Health Organisation (WHO) 2020)
Statistical analysis
We analyzed the proportion of participants who had a dermatologic condition in the 1-year period following the refugee health assessment and the proportion of participants with more than one dermatologic condition. We report continuous variables as median (interquartile ranges) and categorical variables as frequencies (percentages). We used univariable regression association for any diagnostic categories and multivariable logistic regression to determine factors associated with having a dermatologic condition, a cutaneous infection, and a scar or burn. We used covariates thought to be relevant a priori, including age, sex, country/region of origin, and tobacco use. For this analysis, we categorized country/region of origin as: Afghanistan, Iraq, Syria, Africa, and Other. We defined statistical significance as two-tailed p<0.05, and we used R version 3.5.1 for statistical computation.
Results
A total of 545 adults, 287 males (52.7%) and 258 females (47.3%) met our inclusion criteria and were analyzed in this study. Countries of origin included Afghanistan (40.6%), Syria (24.6%), Iraq (10.5%). The median (interquartile range) age was 33 (28–40) years. Among these participants, 213 (39.1%) had at least 1 dermatologic diagnosis. The median age (IQR) of participants with a dermatologic diagnosis was 32 (27–40) years. Of these 213 patients, the majority (n = 114, 53.5%) of skin conditions were diagnosed within the first month of resettlement and 46.5% of participants had dermatologic conditions diagnosed between one month and one year of resettlement (Table 1).
Table 1.
Baseline characteristics of participants resettling in U.S. region, 2015–2018.
| Characteristics | All Refugees (n = 545,%) | Refugees with dermatologic diagnoses (n = 213,%) | |
|---|---|---|---|
| Age, years, median (IQR) | 33 (28–40) | 32 (27–40) | |
| Female sex, number (%) | 258 (47.3) | 108 (50.7) | |
| Tobacco use, number (%) | 65 (11.9) | 28 (13.1) | |
| Duration between first visit and dermatological complaint | |||
| Within first month | 114 (53.5) | ||
| 2 to 3 | 23 (10.8) | ||
| 4 to 5 | 14 (6.6) | ||
| 6th to 7 | 13 (6.1) | ||
| 8th to 10th | 21 (9.9) | ||
| 11th to 12th month | 28 (13.1) | ||
| Region/ Country of Origin | Number (%) | ||
| Eastern Mediterranean | 178 | ||
| Afghanistan | 221 (40.6) | 86 (41.0) | |
| Iran | 10 (1.8) | 3 (1.4) | |
| Iraq | 57 (10.5) | 24 (11.3) | |
| Sudan | 19 (3.5) | 8 (3.7) | |
| Syria | 134 (24.6) | 56 (26.7) | |
| Others – Jordan, Pakistan | 4 (0.7) | 1(0.5) | |
| Africa | 26 | ||
| Congo | 48 (8.8) | 17 (8.0) | |
| Others – Angola, Burundi, Central African Republic, Chad, Ethiopia, Eritrea, Guinea, Kenya, Rwanda, Tanzania, Uganda | 30 (5.5) | 9 (4.2) | |
| Americas | 6 | ||
| Colombia, Cuba, Guyana | 11 (2.0) | 6 (2.8) | |
| Europe/ Central Asia | 1 | ||
| Azerbaijan, Ukraine | 6 (1.1) | 1 (0.5) | |
| Southeast Asia | 2 | ||
| Myanmar, Thailand | 4 (0.7) | 2 (1.0) | |
There were 213 adults (39.1%) with dermatologic diagnoses and 286 dermatologic conditions in total, in both diagnostic and descriptive categories. The diagnostic categories consisted of infectious (n = 72), inflammatory (n = 50), scarring and burns (n = 31), hair and nail conditions (n = 27), neoplasms and masses (n = 22), and pigmentation conditions (n = 15). We classified diagnoses that did not fit into the aforementioned categories as others (n = 69) and included hyperkeratosis, striae, keratosis pilaris, tattoo removal, and cutaneous manifestation of drug reaction. Overall, the most common conditions were fungal infection (n = 27, 9.4%), acne vulgaris (n = 17, 5.9%), and contact dermatitis (n = 12, 4.2%) (Tables 2 and 3).
Table 2.
Dermatologic conditions diagnosed in refugees resettling in a U.S. region, 2015- 2018.
| Adapted ICD-11 Classification | Number (%) of Diagnoses n = 286 |
Number (%) of Subjects n = 213 |
|---|---|---|
| Infectiousa | 72 (25.2) | 47 (22.1) |
| Fungal | 27 | 14 |
| Bacterial | 20 | 14 |
| Viral | 10 | 8 |
| Parasitic | 15 | 11 |
| Inflammatory | 50 (17.5) | 40 (18.8) |
| Neoplasms and Masses | 22 (7.7) | 18 (8.5) |
| Scarring, Burns | 31 (10.8) | 26 (12.2) |
| Pigmentation Conditions | 15 (5.2) | 10 (4.7) |
| Hair and Nail Conditions | 27 (9.4) | 23 (10.8) |
| Other | 69 (24.1) | 49 (23.0) |
Majority of fungal infections were dermatophyte (tinea) infections and tinea versicolor; Bacterial infections were folliculitis and skin abscesses; Viral infections were caused most by Herpes Simplex Virus (HSV) and Human Papilloma Virus (HPV); Parasitic infections were most commonly scabies and bed bugs; there was one case of schistosomal dermatitis.
Table 3.
Common dermatologic conditions by region of origin.
| Region of Origin (n = 213) | Common Dermatologic Conditions |
|---|---|
| Eastern Mediterranean (n = 178) -Afghanistan, Azerbaijan, Syria, Iraq, Iran |
Acne Vulgaris Fungal Infection Contact Dermatitis |
| Africa (n = 26) -Democratic Republic of Congo, Eritrea, Rwanda, Sudan, Tanzania, Uganda |
Fungal Infection Folliculitis Lipoma Scars Scabies |
| Americas (n = 6) -Colombia, Guyana |
Hypopigmentation Xerosis |
| Europe/ Central Asia and Southeast Asia (n = 3) -Myanmar, Pakistan |
Atopic Dermatitis Scar Fungal Infection |
Dermatologic conditions were not associated with age, sex, country/region of origin, or tobacco use by multivariable logistic regression (Table 4). Participants with tobacco use were more likely to have cutaneous infections (OR 2.37, 95%CI: 1.09–4.95). Younger age was associated with having a scar or a burn (for each year increase in age, OR 0.95, 95%CI: 0.91–0.99). There was no association between country or region of origin and the dermatologic conditions evaluated.
Table 4.
Factors associated with dermatologic conditions in multivariable analysis of 547 refugees resettling in a U.S. region, 2015- 2018.
| Variable | Any dermatologic diagnosis Adjusted OR (95% CI) | Cutaneous infection Adjusted OR (95% CI) | Scars and Burns Adjusted OR (95% CI) | |
|---|---|---|---|---|
| Age (continuous) | 0.98 (0.97–1.00) | 1.00 (0.98–1.03) | 0.95 (0.91–0.99)* | |
| Sex | ||||
| Female | Reference | Reference | Reference | |
| Male | 1.28 (0.89–1.83) | 1.65 (0.96–2.89) | 0.64 (0.27–1.45) | |
| Country/ Region of Origin | ||||
| Afghanistan | Reference | Reference | Reference | |
| Iraq | 1.23 (0.67–2.24) | 1.27 (0.50–2.96) | 1.30 (0.28–4.52) | |
| Syria | 1.17 (0.74–1.84) | 0.99 (0.48–1.97) | 1.82 (0.71–4.63) | |
| Africa | 0.84 (0.51–1.39) | 1.59 (0.77–3.19) | 0.51 (0.8–1.99) | |
| Other | 0.91 (0.42–1.88) | 0.66 (0.15–2.08) | 2.23 (0.47- 7.98) | |
| Tobacco Use | ||||
| None | Reference | Reference | Reference | |
| Yes | 1.31 (0.75–2.28) | 2.37 (1.09–4.95)* | 2.24 (0.81–5.70) | |
p<0.05.
Discussion
In this study of adult refugees who resettled in the U.S. between 2015 and 2018, 39% of participants had dermatologic conditions diagnosed within one year of resettlement. The most common were cutaneous infections and inflammatory or autoimmune conditions, together accounting for more than half of the participants with any dermatologic condition. Scars and burns were present in 12.2% of participants in this study. The majority of participants with dermatologic conditions (114 people, 53.5%) had diagnoses documented in the first month after arrival, which suggests that many dermatologic conditions either present or go untreated during the migration process. We observed that 24% of participants had more than one dermatologic condition. These findings support the importance of including a thorough dermatologic exam in the health assessment for newly resettled refugees.
Our study suggests that dermatologic conditions may be more common in refugee patients at destination health services, than the general adult population in the United States and globally. A meta-analysis of the global burden of disease showed that skin conditions were present in 1.79% of the population in the world. (Karimkhani et al., 2017) Of these, dermatitis (0.38%), acne vulgaris (0.29%), psoriasis (0.19%) and urticaria (0.19%) were at the top of the list of dermatologic conditions in the world. (Karimkhani et al., 2017) In a 2013 study using insurance claims data, an estimated 27% of the U.S. population was evaluated by a physician for skin diseases. (HW Lim et al., 2017) The most common claims based dermatologic conditions are noncancerous skin growth and cutaneous infections, including viral and fungal diseases. (HW Lim et al., 2017; Karimkhani et al., 2017)
Skin diseases are generally underreported. A cross-sectional screening study in Germany in 2019 reported 64.5% of an unreferred cohort examined in a real-life setting had a skin condition. (Tizek et al., 2019) Our study found a higher frequency of dermatologic conditions compared to other studies of refugees. A refugee camp in Brussels reported a prevalence of dermatologic conditions of 9% and an outpatient refugee clinic in Germany reported a prevalence of 9.5%. (van Berlaer et al., 2016; Borgschulte et al., 2018) Compared to a group of asylum seekers in Germany, we found a relatively higher proportion of participants with dermatitis (8.3% in Germany versus 25% in our cohort) and approximately the same amount of neoplastic conditions (6.9% in Germany versus 8% in our cohort). (Goodman et al., 2018) None of these studies were focused on dermatologic conditions and thus a review of general health conditions may have underestimated the prevalence of skin diseases. The initial refugee health assessment at our site is comprehensive including a thorough review of organ systems including the skin. In addition, our study time period extended over one year whereas other studies evaluated refugees and asylum seekers at one time point, potentially missing conditions that developed beyond that single assessment. Within the design of our study, we were unable to evaluate the proportion of patients whose dermatologic conditions were diagnosed incidentally.
Compared with a study which looked specifically at dermatologic conditions among refugees in Italy, (Di Meco et al., 2018) our study found relatively fewer participants with scabies (0.5% versus 58%) and pediculosis (1.9% versus 8.8%). Possible reasons for these differences may be rooted in the fact that our cohort participants’ regions of origin, migration experiences, and access to medical care and treatment may have differed compared to those in Europe. For instance, participants in our cohort were resettled and obtained housing through an established resettlement program while published studies in Europe may be more likely to sample individuals who recently or actively lived in refugee camps. (Travel.State.Gov.) We did not have detailed data on migration history of refugees in our study cohort to ascertain effect of factors such as duration of migration and countries of transit on the presence and type of dermatologic conditions seen. Ideally, we would have analysed diseases by country of origin, however, there were small number of patients from certain countries of origin that precluded meaningful analysis. We use regions of origins as certain regions may share similar socio-political, geographic and epidemiological characteristics.
In our study, there were 26 (12.2%) participants with scarring from burns or trauma, and younger age was associated with having a scar or a burn. Skin sequalae is the most common physical findings of physical torture. (Padovese and Knapp, 2021; Clarysse et al., 2019) In a prior study, one in three persecuted refugees reported both incarceration and physical punishment. (Yun et al., 2016) Hence, awareness of skin conditions resulting from physical trauma is important for primary care clinicians who treat refugee patients. (Clarysse et al., 2019; Volpato et al., 2012) Dermatologic consultations should be sought if needed; in our population, only 9 participants required specialty referral for a dermatology consultation.
We observed that 28 (13.1%) individuals with at least one dermatological diagnoses smoke. Participants with tobacco use were more likely to have cutaneous infections. Research has shown that tobacco use promotes inflammation and infection. (Arcavi and Benowitz, 2004)
Rare infective dermatologic conditions were reported in previous studies on refugee health. (World Health Organisation 2018) Although majority of our participants (80.6%) were from countries reported by the World Health Organization to account for the majority of global reported incidence of Cutaneous Leishmaniasis. (Amman, 2019), none from our clinic had Leishmania. This may be due to lack of transmission and better living conditions after resettlement. Clinicians treating patients from countries with dermatologic conditions rare in the United States should retain a reasonable index of suspicion to make a timely diagnosis.
Among the infectious diseases in our cohort, fungal infections were the most common, with tinea as the most common diagnosis. Onychomycosis was also seen in 4 patients, but under our system of classification, this was included under the hair and nails category. Among the inflammatory and autoimmune conditions, the most common diagnosis was acne vulgaris followed by contact dermatitis and then atopic dermatitis. In the neoplasms and masses category, benign soft tissue growths such as lipoma and acrochordon were among the more common diagnoses. The scarring and burns were most commonly from healed traumatic wounds followed by burn injuries. Pigmentation conditions included both hypopigmentation and hyperpigmentation with 2 and 1 cases of vitiligo and lentigo respectively. Hair loss including female pattern baldness and androgenic hair loss was seen in several cases. Other commonly seen conditions included generalized pruritus, xerosis and different types of rashes.
Our findings should be interpreted within the limitations of the study design. First, our study reflects a single institution in the U.S., so results may not be generalizable to other sites, particularly those with different resettlement populations. Second, the data in this study were retrospectively collected and so were dependent on clinician documentation. It is possible that not all clinicians documented the findings of a skin evaluation, which would underestimate the burden of disease. We were not able to extract some clinical data, including medications, which limited the analyses we were able to complete.
Conclusion
In this study of refugee patients who presented for a refugee health assessment and ongoing primary care, we found that 39.1% of participants were identified as having dermatologic conditions within the first year after resettlement. The types of conditions varied with fungal skin infections being the most common. Our findings indicate the need for attention to dermatologic conditions in the refugee health assessment and in longitudinal care. Future studies should better characterize the differences in dermatologic conditions among different refugee groups.
Funding
AMM reports funding support from the National Institutes of Health (NIH) T32 AI007433. The National Institutes of Health had no role in the design or authorship of this publication. The article contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.
Declaration of Competing Interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Amir M. Mohareb reports a relationship with National Institutes of Health that includes: funding grants.
Acknowledgment
Ms Leslie Koons from Integrated Refugee and Immigrant Services for her valuable assistance.
Appendix
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