Defining the Burden of Skin Disease in the United States—A Historical Perspective

Nearly one-third (312.4 per 1000 population), or an estimated 60 million of the US population age 1 to 74 y, had some skin pathology: one or more significant conditions that called for evaluation by a physician.

The prevalence of significant skin pathology increased rapidly with age from 14.2% at age 1 to 5 y to 36.5% at age 12 to 17 and 36.5% at age 18 to 24 (Figure 1). The prevalence continues to increase with advancing age, reflecting cumulative increases in such diagnoses as psoriasis and vitiligo and the accelerated appearance of malignant and benign tumors, as well as actinic and seborrheic keratoses.

Among the specific types of skin pathology, the most prevalent were diseases of sebaceous glands, dermatophytoses, tumors (malignant and benign), seborrheic dermatitis, atopic dermatitis/eczema, contact dermatitis, and ichthyosis/keratosis (Figure 2).

Nearly one-fourth (23.9%) of adults 18 to 74 y of age with significant skin pathology indicated exposure in the work place to chemicals, fumes, vapors, oils, or insecticide or to prolonged immersion of the hands and feet. Occupational exposure was twice as high among men (32.4%) compared to women (14.4%); among both sexes the rates drop off at age 65 to 74.

In addition to gathering data about normal variations and the presence of benign lesions as well as pathology, one-third of the examination form focused on specific diagnosis and details about the atopic individual, the psoriatic, for example. But of greater interest for a consideration of the burden of the problem is that one-third of the form gathered data about the impact of the dermatologic diagnosis on the individual and his or her psyche as well as soma and how it troubled him or her and interfered with function, livelihood, and social interactions. We also asked the examiner to weigh the handicap and, further, to assess the problem from the standpoint of care. Was the patient receiving the best care for that problem and if not, why not? Was the patient or his physician unaware that there was helpful treatment—or was the care too distant, the treatment too expensive?

There was also in this section a focus on the examinee's concern, their complaints, and their perception of their problem. Some 11.8% or an estimated 22.9 million of the US population 1 to 74 y of age had one or more conditions about which they complained or expressed concern. Most (96%) complained about a specific condition affecting a specific part of the body: their hands (9%) and feet (16%) and, for 75%, their face or neck or other areas of the body.

Persons with significant skin pathology diagnosed in the survey examination were most likely to express concern if the condition were psoriasis (69%), atopic dermatitis (59%), contact dermatitis (47%), malignant tumors (34%), and diseases of the sebaceous glands (35%).

Almost 30 y have passed since HANES was undertaken, and a HANES redux in all its comprehensive and expensive finery is highly unlikely. Since the early 1970s, the US population has grown from 193 million to 281 million. Since 1971 to 1974, substantial changes have occurred in the ethnic distribution of the US population, primarily owing to immigration (). For example, Hispanics are now the largest minority group, exceeding 35 million. In two of our largest cities, Los Angeles and New York, the “minorities” are becoming majorities. Most of the population growth in the US has occurred in cohorts of younger ages. Thus, the HANES-documented prevalence rates in older persons (65 y and older) have not been confounded by substantial new additions and can be reliably extrapolated to the current older population. For example, in the HANES 65- to 74-y age group, the highest prevalence rates were for skin tumors (18.4%), all malignant skin cancers (3.6%), basal cell carcinoma (2%), and precancerous including actinic keratoses (8%). By the year 2000, the number of persons age 65 to 74 in the United States had increased by 5.6 million. In 2000, persons 75 y and older (a group not included in HANES) numbered 16.6 million; the HANES data extrapolated rate of malignant cancers for this group is 6%. The total estimated numbers of additional persons with malignant skin cancer is 204,000 in the 65- to 74-y age group and 996,000 for persons 75 y and older. The steep increases reflect the aging of America: 35 million persons 65 y or older, with 1 in 8 now more than 80 y of age.

Nevertheless, a repeat survey in 2003 would be likely to discover new and additional dermatologic morbidity related to the leading causes of illness and death in the US population: cardiovascular disease (42%) and cancer (23%). Immunosuppression, cardiovascular drugs, and chemotherapy have attendant dermatologic morbidity. Also, HANES preceded the epidemic in the United States of HIV-AIDS. Further, since HANES predated the ubiquitous implementation of managed care, its estimates on access to dermatologic care and the quality of care received can serve only as a 1971 to 1974 baseline.

In the past 30 y, US dermatology has made an enormous advance in biomedical science and technology. To what extent derived clinical benefits are accessible in the dermatologic care of the US population, particularly to 40 to 60 million un- and underinsured, is a key question in assessing the burden of skin disease.

I believe that the purpose of a new initiative on the burden of skin disease, aside from updating the magnitude of the problem and identifying the most burdened, is to identify obstacles to mitigating the burden. In 1969 the National Program for Dermatology sought “to conquer disability due to skin disease through patient service, education, and research” (). In 2003, we have, within universal reach, powerful communications technologies available that can improve with great effect and efficiency the pattern and quality of care of the system of delivering care to those who bear the burden of skin disease.