Dermatologic needs of Afghan refugees

Over 40 years of conflict, violence, and poverty has made Afghanistan one of the largest sources of refugees in the world.¹ This exodus worsened in 2021 because of recent geopolitical changes and economic sanctions that brought the Afghan economy to the brink of collapse.¹ As a result of these changes, dermatology clinics may see an increase in the number of Afghan refugee patients; however, the specific dermatologic needs of Afghans are largely unknown and were last published in 1975. An influx of refugees also raises various public health concerns, including communicable diseases and skin diseases preventable with vaccines, such as measles. Here we highlight the burden of skin diseases in Afghanistan as a correlate for new Afghan refugees, which may aid dermatologists in identifying the risk factors and health needs of this vulnerable population.

Our data were obtained from the Global Burden of Disease Study database, which was created by the Institute of Health Metrics and Evaluation at the University of Washington to quantify the prevalence of disease or risk factors and the relative harm they cause.² Using the latest Global Burden of Disease Study results from 2019, we analyzed the prevalence of skin disease and the most common dermatoses in Afghanistan. We also studied the burden of these dermatoses using disability-adjusted life years, which are the years of life lost because of premature death and years of healthy life lost because of disability from disease.³

Skin and subcutaneous disease, including cutaneous leishmaniasis, was the fourth most prevalent disease category in 2019, with 28.44% of Afghans affected (Table I).² This corresponds to a disease burden of 1.98% for all disability-adjusted life years.² When stratified by age, there was a bimodal distribution, with the greatest disease prevalence and burden at ages 15 to 19 years and >80 years.²

Table I.

Prevalence and DALYs of dermatoses in Afghanistan in 2019^∗

Diseases	Prevalence, %	DALYs, %
All skin and subcutaneous diseases (including cutaneous leishmaniasis)	28.44	1.98
Cutaneous leishmaniasis	7.56	1.02
Other skin conditions†	5.61	0.07
Acne vulgaris	3.73	0.17
Fungal skin diseases	2.3	0.03
Viral skin diseases	2.29	0.15
Atopic dermatitis	1.72	0.16
Urticaria	1.11	0.14
Scabies	1.09	0.06
Contact dermatitis	0.78	0.04
Pruritus	0.71	0.02
Pyoderma	0.60	0.02
Psoriasis	0.45	0.08
Seborrheic dermatitis	0.30	0.01
Alopecia areata	0.17	0.01
Cellulitis	0.02	0.00
Decubitus ulcer	0.00	0.00

DALY, Disability-adjusted life year.

^∗Data from Global Burden of Disease Study 2019 results.³

^†Encompasses dermatoses such as bullous diseases, connective tissue diseases, and cutaneous drug reactions.

It is important to also consider the unique and significant health risks of refugees owing to migration and resettlement. Overcrowding, exposure, migration, food insecurity, lack of medical care, and violence are risk factors that may contribute to the skin disease burden in various refugee populations.⁴ Reports from refugee camps and transit centers suggest that dermatitis, skin ulcers, and communicable diseases, such as scabies and cutaneous leishmaniasis, are especially common (Table II).^4,5 Compared with other refugees, certain skin diseases may be more common in Afghan refugees because of the high rates of infectious diseases, malnutrition, migration on foot, and lack of access to health care in this population (Table II).¹

Table II.

Common risk factors and skin diseases observed in refugees^∗

Risk factor	Associated dermatologic conditions or manifestations
Environmental exposure	Irritant dermatitis (sea water and sun) Chemical burns Scald burns Frostbite Miliaria Sunburns Infections from water exposure (Vibrio, Mycobacterium marinum, and Aeromonas)
Migration	Bacterial cellulitis Deep abscesses Tissue necrosis Patera foot Friction blisters (can cause plantar callouses, keratoderma, and infected wounds if ruptured)
Food insecurity/malnutrition	Generalized desquamation Hyperpigmentation or hypopigmentation Alopecia Scurvy (hyperkeratosis and corkscrew hair) Pellagra (photosensitive rash)
Overcrowding	Lice and scabies (can be secondarily infected with Staphylococcus aureus or Streptococcus pyogenes) Impetigo Neglected tropical diseases (cutaneous leishmaniasis, schistosomiasis, and strongyloidiasis) Fungal infections
Lack of medical care	Communicable diseases that are preventable with vaccines (measles and varicella) Leprosy Exacerbation of previously well-controlled non-communicable diseases (atopic dermatitis and psoriasis)
Violence	Chemical burns Contusions Electric shock injuries

Specific dermatologic needs of Afghan refugees are bolded.

^∗Data from Padovese and Knapp⁴ (2021) and Knapp et al⁵ (2020). These data apply to various refugee populations.

The Global Burden of Disease Study database has several limitations, and the burden of skin disease is likely underestimated. Disability is only reflected with symptoms of itch or disfigurement, and the database fails to classify the dermatologic manifestations of systemic illnesses.³ Moreover, because these data were from 2019, they were not characteristic of the Afghan refugees from previous migration waves in the early 1980s and 2000s. We also expect to see more nutritional dermatoses owing to high rates of food insecurity and the collapse of the Afghan health care system in 2021.¹ Awareness of these common dermatoses and recent events in Afghanistan may help dermatologists address the burden of skin disease in this population.

Conflicts of interest

None disclosed.