EDITORIAL A Seat at the Big Table: Expanding the Role of Dermatology at the World Health Organization and Beyond y patient can’t breathe. From across Kaposi’s sarcoma, seborrheic dermatitis, her- the busy, open ward, you can see the pes zoster, scabies, papular pruritic eruption, Mplaques of Kaposi’s sarcoma riddling eosinophilic folliculitis, tinea, molluscum, drug her skin. The impressive woody edema has reactions, and oral candidiasis (World Health enlarged her legs to the size of small tree trunks. Organization, in press). These conditions have We don’t have access to confirmatory pulmo- a high prevalence in developing countries, but nary testing in Kenya, but she probably wouldn’t many lack internationally agreed-on standards survive a bronchoscopy anyway. of care. This deficit led to inconsistent and some- When she dies six hours later, we can be pret- times dangerous treatment approaches or lack of ty sure that it is her pulmonary Kaposi’s sarcoma, essential drugs. Critically, dermatologists were along with her underlying HIV, that killed her. involved at all levels of the guideline-develop- Her family tells us that she had dark spots on ment process, including Cochrane reviews of the her skin and swelling in her legs for more than literature, guideline development and review, a year before she presented to the hospital. Like and additional funding for the project from many of our patients in East Africa, she sought the International Foundation for Dermatology help from a traditional healer for many months (http://www.ifd.org). before turning to the biomedical health system, Although diseases such as Kaposi’s sarcoma only hours before her death. and scabies are not necessarily major issues in Lack of access to diagnostic tools, limited the US health-care system, many skin condi- early intervention, and inadequate treatment are tions pose critical mortality and quality-of-life common barriers to improving global health. issues at the global level. Dermatologists based However, increasing awareness, interest, and in resource-rich settings such as North America funding in the area of global health means that and Europe now have a launchpad from which dermatologists and investigators like ourselves to make significant contributions to contribute now have growing opportunities to make a real to global health. And, in turn, global health can difference. In resource-poor settings, skin dis- serve as an entry point for the field of dermatol- ease is often the presenting complaint that brings ogy on the world stage. patients into the health-care system. At one end There are three key ways in which dermatolo- of the spectrum are diseases with fatal conse- gists can assist in this growing effort: become quences, such as Kaposi’s sarcoma. On the other champions in health-policy organizations end are more quotidian but often stigmatizing on national and international levels, perform conditions such as scabies, tinea, or zoster. research with an eye to diseases that affect the This year, the World Health Organization poorest populations in the world, and participate (WHO) will publish, for the first time, a com- in global health education for trainees locally prehensive treatment guideline and diagnostic and abroad. After presenting a brief background, algorithm for the most common HIV-related we explore these three avenues in more detail skin conditions. The Guidelines on Skin and below. Oral HIV-Associated Conditions in Children and Adults will help health professionals and A background on skin and the WHO policy makers provide appropriate therapy for The Guidelines for HIV-Associated Skin and Oral Conditions emerged in response to pro- Journal of Investigative Dermatology (2014) 134, 2663–2665. viders in need. Practitioners and managers in doi:10.1038/jid.2014.355 low-resource settings specifically asked the US © 2014 The Society for Investigative Dermatology www.jidonline.org 2663 EDITORIAL Centers for Disease Control and Prevention (CDC) for guid- the globe, which ultimately dictates formulary choices at the ance in the area of skin disease as a priority. This request sur- country level and determines which treatments patients in prised at least one CDC official with whom I spoke. Although rural Africa are likely to have access to. skin diseases are one of the most common reasons for pre- Finally, two recent victories for the field of dermatology at sentation to primary-care settings in tropical countries and the level of the WHO are (i) the addition of scabies to the disproportionately affect vulnerable groups such as children, list of neglected tropical diseases and (ii) the endorsement by they are often considered “small-time players” (Hay et al., the 67th World Health Assembly of psoriasis as a research 2006). It was because of this request—from the level of those and health-care quality-improvement priority. These con- practicing in the field—that the CDC provided funding to the tributions to our field serve as examples of dermatologists WHO for research and guideline development in the area of identifying structures, such as committees, work groups, HIV-associated skin disease. or advisory panels, on which they may serve and making Expanding the role of dermatology within large organi- an impact on policy at the international level, which will zations that affect global policy, such as the WHO, is highly ultimately affect the lives of our patients suffering from skin relevant to our specialty. Establishing partnerships to ensure disease. We need more such champions in our midst. that high-quality dermatologic research informs international health policy is critical to developing quality policies, spread- Global health research ing knowledge about skin disease more widely, and improving Developing research projects to describe the multinational prevention and treatment globally. Barbara Gilchrest’s desig- burden of skin conditions is also critical. There are several nation of unity in action as this year’s theme for the JID signi- current international efforts to highlight the burden of skin fies unity not only across the dermatologic community but also disease worldwide, which will help raise the profile of skin with the larger medical community beyond our specialty, both conditions affecting our patients and ultimately translate into nationally and internationally (Gilchrest, 2014). For example, allocation of health resources. Most notable is the Disease dermatology has been conspicuously absent from the agenda Control Priorities Project, which includes the global burden of HIV/AIDS policy makers; there have been few abstracts of disease. As published in the JID, skin disease worldwide is in the area of dermatology at the largest HIV/AIDS meeting the fourth leading nonfatal cause of years lost due to disabil- such as the International AIDS Conference. With efforts such ity, ahead of diabetes, asthma, and chronic obstructive pul- as the WHO Guidelines for HIV-Associated Skin and Oral monary disease (Hay et al., 2014). This ranking may actually Conditions, our HIV patients suffering from skin disease have underestimate the true impact of skin disease, as conditions become relevant to the overall fight against HIV. such as melanoma are counted separately under cancer, Prior WHO guidance in the field of dermatology is leishmaniasis under infectious disease, and the effects of sys- extremely limited. Disease-specific treatment recommen- temic lupus erythematosus under musculoskeletal disease. dations include those issued for leprosy, Buruli ulcer, and Research in the area of dermatologic health-care delivery leishmaniasis. INTERSUN, a global UV-light program that in resource-poor settings is also key. When there are only a addresses UV’s health effects and sun protection, authored handful of dermatologists for an entire country, delivery of two of the relatively few WHO publications in the field of care must follow a different model. For example, a recent dermatology, Artificial Tanning Sunbeds: Risks and Guidance study by our collaborators in Uganda shows that in rural and Sun Protection and Schools in 2003 (World Health Africa, where diagnosis of Kaposi’s sarcoma is often made on Organization, 2003a, 2003b). clinical impression alone or delayed until excision by a sur- Therefore, this year’s WHO guidelines represent a new geon can be scheduled, training nurses and low-level clinic chapter in the collaborative effort in international health pol- staff in skin biopsy techniques allows for safe, correct, and icy in the field of dermatology. But the guidelines represent more rapid diagnosis (Laker-Oketta et al., 2013). My Kenyan only a whisper of the future role that dermatology could play patient might have been diagnosed with Kaposi’s sarcoma in the field of global health and international health policy. much earlier if such a service existed in her area. Finally, high-quality disease-specific research on skin con- Global health champions ditions affecting large numbers of people globally, not just in To expand dermatology’s role, dermatology champions are the United States, must be expanded. For the Guidelines on needed to participate in committees and work groups within HIV-Associated Skin and Oral Conditions, Cochrane reviews health policy organizations. Although few in number, der- of the literature were performed or updated on all 11 of the matologists have played key roles at the WHO. For exam- HIV-associated conditions mentioned previously. All the ple, Robert Chalmers co-leads the Topic Advisory Group for recommendations were based on evidence quality that was Dermatology, tasked with reviewing upcoming International considered “low” or “very low” (Guyatt et al., 2008), with Classification of Diseases–11th Revision coding. This impor- the single exception of the evidence on the treatment for oral tant effort will ultimately affect all who care for patients candidiasis. Clearly, we still have much to improve on in and bill for diagnoses and services rendered. Roderick Hay terms of the breadth and quality of our evidence base. (chair of the International Foundation for Dermatology) has served on the Committee on the Selection and Use of Global health education Essential Medicines for many years.