Dermatologic Care of Persons Experiencing Homelessness

Homelessness is a growing problem in the US, affecting urban and rural populations from coast to coast. Key drivers of homelessness—including poverty, housing unaffordability, the opioid epidemic, and climate change—remain unaddressed on a large scale, suggesting that the US will be grappling with it for years to come. Dermatologists are responsible for effectively addressing the skin health needs of this vulnerable population but might not have received sufficient training to identify and care for persons experiencing homelessness (PEH). In this Viewpoint, we discuss the scope and causes of homelessness in the US, relevant skin conditions, best practices for identifying and caring for PEH, and recommendations for educating dermatologists and trainees to care for this population.

In 2018, the number of PEH in the US rose for the second consecutive year, reversing a more than decade-long downward trend.¹ While per capita prevalence remains highest in East Coast cities,¹ unsheltered homelessness is especially visible on the West Coast, where housing is progressively unaffordable and the favorable climate permits living outdoors year-round. San Francisco, where the authors practice, has the nation’s largest unsheltered homeless population.¹ However, homelessness is by no means confined to coastal cities. Nearly 1 in 5 PEH live in rural areas; nationwide, this geographic subgroup has the highest rate (40%) of unsheltered status.¹ In this setting, climate change–related extreme weather events are an affordable housing crisis multiplier. For example, Category 5 Hurricane Michael (Florida panhandle, October 2018) and the Camp Fire (Paradise, California, November2018) caused extensive property damage and displaced tens of thousands of people. Housing instability may be exacerbated by coexisting psychiatric illness and/or substance abuse, particularly given the ongoing opioid epidemic. Homelessness is, therefore, a complex social condition affecting a growing, diverse range of people in the US for compounding reasons. Homelessness is also dynamic and may be temporary, episodic, or chronic. Persons experiencing homelessness is the favored term to identify this population because it appropriately re-frames homelessness as an experience rather than a defining, enduring trait.

Homelessness is associated with high overall morbidity and mortality, along with numerous specific poor health outcomes.² Relevant to dermatology, PEH experience high rates of ectoparasitic, fungal, and sexually transmitted infections; chronic wounds; skin cancer; malnutrition; and cutaneous consequences of injection drug use.³ Prevalence of hepatitis C, tuberculosis, and HIV is higher among PEH than in the general population²; these chronic infections are associated with numerous skin manifestations. Persons experiencing homelessness also experience higher rates of group A streptococcal skin abscesses compared with housed patients⁴ and are 53.3 times more likely than the general population to have invasive group A streptococcal infection.⁵

In addition to a unique disease burden, PEH face special challenges in managing common, highly morbid skin diseases, including atopic dermatitis, psoriasis, prurigo nodularis, and hidradenitis suppurativa. For example, lack of privacy and poor access to clean water and bathing/shower facilities can make it challenging for PEH to implement treatment plans involving application of large quantities of topical medications. Moreover, inability to store medications, particularly biologics that require refrigeration, and comorbid systemic disease, such as tuberculosis, HIV, or viral hepatitis, can be barriers to using the most effective therapies.

Dermatologists should take a standardized approach to assessing housing status. Assumptions should not be made based on age, appearance, or insurance, given that families with children (30% of the total homeless population), older adults, and employed persons are increasingly experiencing housing instability.¹ The importance of recognizing and addressing social determinants of health (SDOH), such as housing, is prioritized by the Centers for Medicare & Medicaid Services,⁶ the Centers for Disease Control and Prevention, and the World Health Organization. A Centers for Medicare & Medicaid Services screening tool asks, “What is your housing situation today?”⁷ The Veterans Health Administration’s universal screen for housing instability⁸ asks: “In the past two months, have you been living in stable housing that you own, rent, or stay in as part of a household?” and “Are you worried or concerned that in the next two months you may NOT have stable housing that you own, rent, or stay in as a part of a household?” The American Academy of Family Physicians’ Every ONE Project⁹ also uses this question to assess housing status. When housing instability is identified, dermatologists should ask follow-up questions regarding access to water, sanitation, and hygiene facilities. Universal screening for SDOH by clinicians is recommended or under consideration by many professional societies. Dermatologists are encouraged to incorporate elements of SDOH screening into their practice setting.

Given the barriers to addressing skin health needs in PEH, developing a person-centered care plan requires thinking in a broad, creative, multidisciplinary fashion. For scabies, for example, a recommendation to apply topical permethrin, shower the following morning, repeat in 7 days, and bag clothing assumes the patient has privacy, access to water, and possession of extra clothes. Oral ivermectin and provision of clean clothing is a more appropriate alternative. For PEH with skin or soft tissue infections, dermatologists should assess for an underlying disease predisposing to bacterial superinfection, such as ectoparasitic infestation (scabies, body lice), dermatophyte infection, venous stasis, or intradermal/intravenous drug abuse. Given the increased risk of group A streptococcal infections in PEH, it is appropriate to obtain cultures and add empirical coverage with a first-generation cephalosporin because treatment with antibiotics targeting methicillin-resistant Staphylococcus aureus, such as trimethoprim-sulfamethoxazole and vancomycin, may yield a suboptimal response.

Additional person-centered measures can be adopted based on available resources. For example, at the safety net hospital in San Francisco that cares for many PEH, our team provides donated clothing for patients diagnosed with scabies or body lice. We also encourage patients to access mobile bathing and laundering services of a local nonprofit organization, Lava Mae (https://lavamaex.org), and hygiene services at shelters. The National Coalition for the Homeless website lists shelter directories at https://nationalhomeless.org/references/directory/. For PEH who require biologic therapy, we partner with our hospital’s pharmacy to allow patients to store medication there for administration at our clinic. For PEH with uncontrolled chronic skin diseases necessitating hospital admission, we prioritize postdischarge placement in a medical respite care facility, where PEH who are too ill to return to the streets are provided a safe recovery environment. Respite facilities nationwide are listed at https://nhchc.org/clinical-practice/medical-respite-care/medical-respite-directory/.

Learning to develop person-centered care plans for PEH should begin with inclusion of formal didactics on caring for PEH within dermatology residency curricula and encouragement of resident participation in local homeless shelter clinics. At academic meetings, lectures that focus on comprehensive approaches to caring for PEH, including updates on the dynamic disease burden seen in this population, are an essential component of continued education currently lacking from the American Academy of Dermatology annual meeting. In the clinical setting, dermatologists have a responsibility to educate colleagues in other specialties to recognize the manifestations of dermatologic illnesses prevalent among PEH and provide up-to-date treatment recommendations. Dermatologists with a special interest in caring for PEH should consider joining “street medicine” teams that engage in direct outreach, and those regularly caring for PEH should describe their experiences in the academic literature.

In an era of rising income inequality, housing unaffordability, a nationwide opioid epidemic, and more frequent climate change–related extreme weather events, the face of homelessness is evolving, and caring for PEH is increasingly common. It is our duty as dermatologists to use a standardized approach for identifying homelessness and develop a person-centered care plan for PEH.