Approaching the dermatologic care of people experiencing unsheltered homelessness through a volunteer street dermatology model

Abstract

To the Editor: Although contemporary health care delivery models aim to tackle health care disparities, the most vulnerable patient populations continue to suffer from reduced access to care. A street-based approach presents a framework for clinical outreach to this truly underserved population that bears a disproportionate burden of disease.1Petrovich J.C. Hunt J.J. North C.S. Pollio D.E. Roark Murphy E. Comparing unsheltered and sheltered homeless: demographics, health services use and predictors of health services use.Community Ment Health J. 2020; 56: 271-279https://doi.org/10.1007/s10597-019-00470-0Crossref PubMed Scopus (9) Google Scholar Patients who would otherwise be unable to attend structured, charitable clinics can instead be evaluated in their own setting and on their own terms. Such “house-calls for the homeless” can bridge notable gaps in care, especially for essential yet difficult to access services like dermatology.2Stefanowicz M. Feldman B. Robinson J. House calls without walls: street medicine delivers primary care to unsheltered persons experiencing homelessness.Ann Fam Med. 2021; 19: 84https://doi.org/10.1370/afm.2639Crossref PubMed Scopus (3) Google Scholar The distinction between sheltered and unsheltered populations is not often made in medical literature, as previous studies involving people experiencing homelessness utilize shelter-based cohorts.3Koh K.A. Roncarati J.S. Racine M.W. O'Connell J.J. Gaeta J.M. Unsheltered vs. Sheltered adults experiencing homelessness: health care spending and utilization.J Gen Intern Med. 2022; 37: 2100-2102https://doi.org/10.1007/s11606-021-07153-1Crossref PubMed Scopus (1) Google Scholar In the absence of reliable shelter, people experiencing unsheltered homelessness (PEUH) are exposed to conditions that increase their risk of suboptimal dermatologic health leading to cellulitis and osteomyelitis.4Raoult D. Foucault C. Brouqui P. Infections in the homeless.Lancet Infect Dis. 2001; 1: 77-84https://doi.org/10.1016/S1473-3099(01)00062-7Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar Street Dermatology is a model to provide direct dermatologic care for PEUH living near sidewalks, encampments, and overpasses. Many of these patients live in squalid conditions with both food and medical insecurity, and lack the means to coordinate formal health care visits. After registering with the state health department, ethical approval was obtained by the University of Miami Institutional Review Board (IRB) in conjunction with established volunteer street medicine providers. PEUH encountered face-to-face were offered basic medical care by a team of providers supervised by a physician. Although board-certified dermatologists were invited to participate in the outreach, most initial dermatologic input was provided via store-and-forward telemedicine (Fig 1). Skin conditions were documented among 160 PEUH encountered in Miami-Dade County from January to June 2022. A total of 125 dermatologic diagnoses (Table I) were made. We reviewed patient history, clinical presentation, and recommended treatment weekly. There was a wide distribution of dermatologic disease noted, with infectious (28.0%, n = 35), inflammatory (24.0%, n = 30), ulcers/erosion/wounds (12.8%, n = 16), UV-induced/neoplastic disorders (10.4%, n = 13), and pruritus (7.2%, n = 9) being prevalent. Patients received treatment and education about their condition including preventative measures. Patient information was stored on a secure, custom REDCap medical record.Table IDermatologic conditions encountered over a 6-month periodType of conditionNumber of diagnoses (% of total)Inflammatory30 (24.0) Acne4 (3.2) Pseudofolliculitis barbae1 (0.8) Dermatitis20 (16.0)Contact5 (4.0)Chronic dermatitis/Lichen simplex chronicus8 (6.4)Photodermatitis2 (1.6)Venous3 (2.4)Unspecified2 (1.6) Psoriasis2 (1.6) Seborrheic dermatitis2 (1.6) Lichen planus1 (0.8)Infectious35 (28.0) Tinea cruris1 (0.8) Tinea pedis10 (8.0) Tinea manuum1 (0.8) Onychomycosis10 (8.0) Verruca vulgaris4 (3.2) Erosio interdigitalis blastomycetica5 (4.0) Pityriasis versicolor1 (0.8) Scabies3 (2.4)Ulcerations/erosions/wounds16 (12.8) Erosions and wounds11 (8.8) Burn2 (1.6) Post-trauma scars3 (2.4)Nail disorders6 (4.8) Paronychia2 (1.6) Micronychia1 (0.8) Leukonychia1 (0.8) Beau’s lines1 (0.8) Clubbing1 (0.8)Pruritus10 (8.0) Prurigo nodularis1 (0.8)Cutaneous neoplasm or UV damage13 (10.4) Seborrheic keratosis6 (4.8) Actinic keratosis3 (2.4) Solar lentigo2 (1.6) Idiopathic guttate hypomelanosis1 (0.8) Melanoma1 (0.8)Miscellaneous10 (8.0) Arthropod assault4 (3.2) Acrochordon1 (0.8) Corns1 (0.8) Ichthyosis vulgaris1 (0.8) Xerosis2 (1.6) Terra firma-forme dermatosis1 (0.8)Unspecified, requiring dermatology evaluation5 (4.0)Total125 (100) Open table in a new tab Life-changing diagnoses were also made. For roughly 15 years, one patient had a slow growing, quarter-sized hyperpigmented lesion on his cheek. During street evaluation, the characteristics of his lesion raised concern for melanoma. He was immediately connected to our dermatology service where he received biopsies which confirmed the diagnosis of melanoma at a depth of 1 mm. Subsequently, surgery was coordinated. In this way, PEUH could now be connected to reliable, specialized care. This model’s reproducibility varies on a regional basis but can be adopted by a multidisciplinary team of medical providers, educators, and social workers.5Doohan N.C. Mishori R. Street medicine: creating a “classroom without walls” for teaching population health.Med Sci Educ. 2019; 30: 513-521https://doi.org/10.1007/s40670-019-00849-4Crossref PubMed Scopus (6) Google Scholar Notable drawbacks include unpredictability of follow-up care due to the inherently informal structure of our evaluations. Funding is dependent on charitable contributions and first-line treatments may be unavailable. Such outreach works for patients whose condition does not warrant urgent medical care but still requires timely management. Street Dermatology demonstrates the vital role our specialty can play in the care in one of the most underserved populations. None disclosed.