A closer look at the role of the dermatologist in championing total women’s health through the dermatology gateway

Abstract

New data collected by the Women’s Dermatologic Society (WDS) through a membership survey conducted in August 2018 reflect the key role of the dermatologist in championing the overall health of the total woman through the dermatology gateway. These meaningful results provide a first-ever metric glimpse into the myriad systemic/internal diseases, disorders, and conditions that WDS dermatologists detect and diagnose in female dermatology patients and the wide scope of our collaborations with other physician specialists to manage complex, underlying medical conditions. Insightful perspectives from medical and health experts outside of dermatology address the importance of teamwork, reaffirm the unique role that dermatologists play on the medical team, and underscore the vital importance of our proclivity toward collaboration, the latter of which is shown to be significant according to the WDS data.

Given an apparent general lack of awareness about the role of the dermatologist in the health journey of the total woman, we have an important opportunity to advance this broadened perspective among our colleagues in and outside of dermatology, our patients, the media, and the public at-large. By raising awareness, we can elevate our specialty in the medical profession and in the public eye, increase the likelihood that people will consult a dermatologist (proactively and reactively), inspire mutual referrals and greater cross-specialty teamwork and communications to benefit patients, and positively affect public health.

Viewpoint

As dermatologists, we know that the body’s systems do not work in detachment or isolation, and neither do we as specialists. The reality is that the study and practice of dermatology equip us to see the interconnectedness in all things. Our specialized training uniquely prepares us to serve as highly adept medical detectives and natural collaborators with other physician specialists on behalf of our dermatology patients. Our well-schooled eyes enable us to peer into the body’s windows, into internal health, and to understand the dermatologic signs that we observe.

Given the complex, interrelated issues that we often see, particularly in women, we are especially intrigued by the multifaceted role that we as dermatologists can and often do play in helping female patients deal with dermatologic manifestations associated with underlying systemic diseases, as well as hormonal changes and imbalances, stress, inflammation, aging, self-esteem and image concerns, weight management, diet and nutrition, related psycho-emotional problems, and more.

The dynamics are endlessly fascinating, yet remarkably unexplored as a synergistic whole. This void presents exciting opportunities for us to fill as dermatologists and as an organization of physicians, leaders, and mentors. During the spring of 2018, we launched a groundbreaking initiative: The Women’s Dermatologic Society (WDS) Transforming Interconnecting Program Project (TIPP), which strives to make a seminal contribution to our field by examining the interplay between diverse medical conditions and specialties and creating a rich, inclusive forum for collaboration.

Women’s Dermatologic Society survey results: The data begin to tell our story as champions of the total woman’s health

To lay the groundwork for the development of the WDS-TIPP, we surveyed dermatologist members of the WDS in August 2018 with an anonymous online questionnaire. Our data are based on the responses from 156 members (WDS, 2018).

Respondents reported the frequency with which they have detected and/or diagnosed underlying internal diseases in female patients by piecing together clues observed during thorough examinations of patients’ hair, skin, nails, and mucous membranes. Notably, a combined total of 88% of respondents reported that they had discovered internal disease in female patients very frequently (13%), frequently (26%), and occasionally (49%). Twelve percent of respondents answered rarely, and a mere 1% reported never (Fig 1).

Fig. 1.

How frequently do you work with physicians in specialties other than dermatology in treating your female patients?

Survey findings show that we regularly assess and help manage the treatment of numerous multifactorial conditions that cross specialty lines, necessitating collaboration with a vast array of other physician specialists. Of the responding dermatologists, 85% reported that they consult and collaborate with different kinds of physicians very frequently (21%), frequently (32%), and occasionally (32%; Fig. 2).

Fig. 2.

How frequently do you work with physicians in specialties other than dermatology in treating your female patients?

The range of medical colleagues with whom we work is considerable and illustrates the wingspan of the dermatologist. The top-ranking specialists with whom we typically collaborate include obstetricians/gynecologists (80%), rheumatologists (79%), internists (78%), mental health professionals (49%), and cardiologists and neurologists (both 29%). A combined total of 33% of respondents reported other specialists (Fig. 3).

Fig. 3.

What kinds of physicians have you collaborated and/or consulted with on behalf of your female patients?

Respondents reportedly detected and/or diagnosed a comprehensive list of 117 diseases and conditions, including a significant number of multiple responses naming cardiovascular disease, diabetes, leukemia, lupus, malignancies (ovarian, breast, and lung), psoriatic arthritis, psychiatric disorders, and thyroid disease. Other more common systemic illnesses that respondents identified were Crohn’s disease, hepatitis B and C, HIV/AIDS, Lyme disease, metabolic syndrome, polycystic ovary syndrome, tuberculosis, and many more. In addition, WDS dermatologists reported that they had identified rare diseases such as Birt-Hogg-Dubé syndrome, familial partial lipodystrophy, Wegener’s granulomatosis, Behçet’s disease, and others.

These unprecedented data provoke considerable thought and questions and inspire further study to more fully measure the depth and breadth of our work in this arena. We are particularly intrigued by the prospect of looking more closely at quality-of-life assessments in connection with chronic diseases in women through the gateway of dermatology, and further research into this fertile field of study is currently underway (Grimes, 2018). The WDS survey findings are especially interesting in light of prevailing perceptions and limited beliefs about dermatologists.

Perceptions and reality

Some dermatologists would say that as a group, we are sometimes pigeonholed and/or isolated as physicians. In some cases, we may have been underestimated, undervalued, underrecognized, or even invisible as key players on the total patient care team. For example, unpublished data collected by the staff of the Vitiligo and Pigmentation Institute of Southern California show that among the five leading women’s health journals that serve the greater medical profession, there is not a single dermatologist on any of the editorial boards to represent the specialty of dermatology.

To fill this glaring gap, we recently reached out to these women’s health journal editors and invited them to a collaboration and involvement with our WDS-TIPP initiative. Our goal is to secure representation on one or more editorial boards of medical journals focused on women’s health issues. Similarly, we invited key journal board members and other prominent nondermatologists to serve as advisory board members of the International Journal of Women’s Dermatology (IJWD). Recent advisory board additions include Janine Austin Clayton, MD, National Institute of Health Associate Director for Research on Women’s Health; Paula J. Adams Hillard, MD, Professor of Obstetrics and Gynecology at Stanford University School of Medicine and Associate Chair for Medical Student Education; JudyAnn Bigby, MD, Secretary of Health and Human Services, Associate Professor of Medicine at Harvard Medical School, and Director of the Harvard Medical School Center of Excellence in Women’s Health; Carolyn Mazure, PhD, Norma Weinberg Spungen and Joan Lebson Bildner Professor in Women's Health Research and Professor of Psychiatry and Psychology at the Yale School of Medicine; and Cheryl L. Hurd, MD, Program Director, Psychiatry Residency, John Peter Smith Health Network, Acclaim Physician Group, Clerkship Director and Assistant Professor at the University of North Texas Health Science Center, Texas College of Osteopathic Medicine, School of Health Professions, Physician Assistant Studies.

Broadly speaking, professionals, patients, and lay people alike may hold narrow beliefs about what we actually do as dermatologists. Common misperceptions may be attributed largely to the explosive media attention focused on genuinely exciting advances in the esthetics field. As phenomenal as these innovations are, such progress on the cosmetic dermatology front may have contributed to an eclipsed or distorted view of the whole dermatologist and the full measure of our training, expertise, and capabilities. Although we are certainly not seeking accolades for being unsung heroes in medicine, we do advocate stepping up our collective efforts to deepen understanding and encourage broadened outlooks, interdisciplinary thinking, and collaborative action. Widening the lens to take in the entire picture would ultimately benefit our patients, our specialty, and the greater house of medicine.

While opinions about the dermatologist’s standing in the general medical community may vary based upon subjective experiences, published research suggests a lack of full understanding about what dermatologists actually do in the public mindset. Brezinski et al. (2014) conducted a telephone survey of 800 adults drawn randomly from 10 U.S. area codes. Forty-six percent of survey participants perceived that dermatologists spend a majority of their time managing skin cancer. Twenty-seven percent perceived that dermatologists spend a majority of their time performing cosmetic procedures. Compared with dermatologists, primary care physicians were perceived to have a more critical profession by 63% of participants. Interestingly, when analyzing the types of serious medical conditions that WDS dermatologists identify and treat, as reported in the 2018 WDS survey data, this statistic is particularly relevant to ponder.

For another more informal glimpse into what laypeople think about dermatologists, the WDS has had opportunities to randomly capture public opinion through its community outreach program “Play Safe in the Sun,” which has provided free skin cancer screenings and sun safety education at numerous public events around the United States since 2004. As previously reported by WDS volunteer dermatologists and support teams over the years, individuals who visited WDS booths for free skin checks periodically expressed surprise to learn that dermatologists are actually real doctors.

Moreover, a perusal of social media discourse and popular women’s magazines suggests that the whole picture of what we do and why as dermatologists is simply not conveyed fully and consistently. However, recent informative articles in popular mainstream and medical media can help gradually change perceptions (McIntosh, 2018).

Furthermore, an important awareness campaign introduced in 2017 by the American Academy of Dermatology, known as SkinSerious, highlights the critical role that dermatologists play in collaboration with other health care providers and addresses the impact of skin disease on patients and U.S. society in general. The SkinSerious campaign is supported by data from the Burden of Skin Disease in the United States report (Lim et al., 2017), which quantifies the economic burden of 24 skin disease categories on patients and the health care system in the United States based on an analysis of insurance claims in 2013. This report showed that 85 million Americans were seen by a physician for at least one skin disease in 2013, with estimated direct health care costs of $75 billion and indirect lost opportunity costs of $11 billion. Mortality was noted in half of the 24 skin disease categories.

We align fully with the American Academy of Dermatology’s SkinSerious campaign and to this broad effort; we contribute our special emphasis on interrelated issues that uniquely pertain to total women’s health and well-being. Let us build on this momentum together and move toward creating positive paradigm shifts and eradicating this mentality in concert with our colleagues in dermatology and other medical specialties.

Other medical and health experts weigh in

Rheumatologist R. Swamy Venuturupalli, MD, FACR, founder of Attune Health in Beverly Hills, California, and associate clinical professor of medicine at the University of California Los Angeles, points out: “As a rheumatologist, I think dermatology is a particularly interesting and important field because dermatologists get to see patients at the beginning stages of illness…sometimes they are the only practitioners that patients will go see, because they have a visible problem that they want solved. So having an astute dermatologist who understands that there’s more than the skin involved here, who refers patients for additional medical opinions, is extremely important for patients.” As a physician focused on autoimmune disease, inflammation care, and research, Dr. Venuturupalli notes that the ideal collaborative scenario with dermatologists includes “mutual record-sharing, constant communications, and ongoing teamwork” on behalf of shared patients.

Cardiologist Sheila Kar, MD, FACP, FACC, past clinical chief of cardiology at Cedars-Sinai Medical Center in Los Angeles, California, says that she works “hand-in-hand with dermatologists for her patients.” Increasingly so, she treats women in their 50s and older (mirroring the frequent dermatology patient), who now exhibit earlier signs of cardiovascular disease due to growing stress levels, increased smoking, and working in major positions in corporations. She notes that there is a great deal of overlap between cardiology and dermatology. Symptoms that are detected by each specialist often pertain to the other specialist. For example, medications that are respectively prescribed to patients to treat various conditions can cause side effects that then need to be evaluated and treated by the other specialist. She comments: “I’d be blind without a dermatologist. I know skin, or the outer wrapping, is often a mirror of internal health. We need dermatologists to be an integral part of our work for patients, and it’s so important that we specialists work closely together.”

Lee Bell, board-certified holistic nutritionist and associate clinical director of nutrition at The Hypertension Institute at St. Thomas West Hospital, in Nashville, Tennessee, remarks: “Any time you are working with a patient who has to manage a chronic health condition, it is done best in teams. With everything so specialized these days, it’s impossible to properly manage autoimmune diseases and other serious conditions without collaboration among specialists. The patient and physicians involved benefit enormously from the expertise and wisdom from many perspectives.” From Ms. Bell’s standpoint, “it's impossible to overstate how diet affects every cell in the body and human health overall. So it’s very helpful for dermatologists and dermatology patients to recognize the importance and influence of nutrition in the maintenance of skin.”

For women’s mental and emotional well-being, we know empirically as practitioners that there is a strong, bidirectional connection between the mind and skin, arguably more so in women than in men. In our dermatology practices, we have seen countless patients who suffer emotional, psychologic, and psychiatric problems in connection with various bothersome, life-altering, or disfiguring dermatologic conditions. Notably, Gupta et al. (2005) reported that significant psychiatric and psychosocial comorbidity is present in at least 30% of dermatologic patients. Our understanding of the interrelationship between acute and chronic dermatologic diseases and the fields of psychology and psychiatry is evolving, as evidenced in the growing field of psychodermatology or psychocutaneous medicine (Rivers, 2013).

With respect to how dermatologists can help patients who suffer from psychological or psychiatric issues associated with dermatologic disorders, Sharon S. Dunas, MFT, president emeritus of the National Alliance on Mental Illness Westside Los Angeles, offers that dermatologists can encourage patients to seek emotional and psychological support. She urges dermatologists to have a list of qualified local therapists to give to patients in need. Dunas stated: “It’s important to remember that these emotional experiences about disfigurement or challenging dermatologic conditions are very normal. It is really helpful to be very compassionate and aware, so as to help patients cope with, and even grieve over, their diseases.”

Mrs. Dunas cites the five stages of grief as one model for coping, as outlined by Swiss-American psychiatrist Elisabeth Kübler-Ross who first introduced these ideas in her book, On Death and Dying (1969). Dr. Kubler-Ross’ five chronological stages include denial, followed by rage, then bargaining, grief, and ultimately acceptance. The five stages of grief (and other more recent models for grieving) were primarily designed to cope with terminal illness and loss, but we believe that this approach is highly relevant to our dermatology patients with chronic skin and systemic diseases. From emotional distress to full-blown psychiatric disorders, many of us indeed see a wide continuum of psychodermatologic issues that affect patients who struggle to deal with their conditions. Further study into this major area is warranted.

All considered, the totality of these aforementioned perspectives suggest that there is much more to examine as we aim to raise the bar on caring for the total woman who enters the expansive doors of dermatology. These and other viewpoints from various specialties can help us broaden our vistas to make us better dermatologists and collaborators.

Conclusions

Our call to action: Through TIPP, the WDS aims to widen the lens, raise awareness, and build alliances to advance total women’s health. Through the WDS’s nascent TIPP efforts, we aim to foster impactful collaborations and communications, bringing together thought leaders in dermatology and several other medical specialties with which we regularly collaborate on behalf of our dermatology patients, along with influencers in industry, the media, and community organizations. We strive to be a driving force in unifying all stakeholders in the total women’s health story.

We have begun this work with the WDS membership survey discussed in this article, which hopefully will be the first of a series of research projects spawned by our interest to better understand the interrelated, intertwined components of total women’s health, as navigated through the dermatology gateway. As of this writing, we are in the process of creating the WDS-TIPP Think Tank, which will provide a rich forum for the exchange of ideas and best practices to benefit women’s health from a wide variety of medical disciplines and perspectives.

We have also established a community service component of this project to address the total woman, her health and well-being, and her empowerment. The program provides educational outreach in women’s shelters and addresses proper skin care, nutrition, social skills, and other facets of healthy living.

In addition, through this journal, we have developed the IJWD Women's Health Highlight as part of this initiative. This includes a signature contribution, featured as the first article in each issue of IJWD, presented as a report, review, or study on a topic related broadly to women's health with relevance across the disciplines of medicine, through the gateway of dermatologic health. A Patient Piece accompanies each Women’s Health Highlight. Our first article in this series appears in this edition, with a seminal article written by George Kroumpouzos, MD, PhD, FAAD, clinical associate professor of dermatology at Brown University and professor of dermatology, collaborator, at Jundiaí Medical School, São Paulo, Brazil, who contributed The Ethics of Dermatologic Cosmetic Therapy in Pregnancy. Dr. Kroumpouzos is the Associate Editor for the IJWD Women’s Health Highlight.

Through these trailblazing efforts, we aspire to inspire our colleagues and patients. We aim to widen the lens, raise awareness, and build alliances to advance the health and well-being of the total woman through the dermatology gateway. Join us!

For more information, contact: wds@womensderm.org