Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Climate Change, Cutaneous Disease, and the Dermatology Provider

By Annika Belzer, BS, and Misha Rosenbach, MD

ABSTRACT
Climate change is a public health crisis with pervasive repercussions on health. The integumentary system faces greater exposure to the external environment than any other organ system. Cutaneous disease is therefore significantly impacted by climate change-related factors. This includes but is not limited to global warming, oceanic warming, air pollution, stratospheric ozone depletion, and extreme weather events, as well as secondary effects of climate change such as mass migration and overcrowding. Dermatology providers must understand the intersection of climate change and skin health in order to appropriately diagnose and manage cutaneous disease.

INTRODUCTION
The Intergovernmental Panel on Climate Change (IPCC) Report released in February 2022 stated there is “no inhabited region escaping dire impacts from rising temperatures and increasingly extreme weather.”1 Medical associations, including the American Academy of Dermatology (AAD), have put forth statements acknowledging the effects of climate change on health and committing to act as agents of change.2

Air Pollution and Dermatologic Disease
Approximately 99 percent of the global population is exposed to air that does not fall within World Health Organization (WHO) air quality guidelines, leading to seven million deaths annually.3 Classes of air pollutants include greenhouse gases (GHG), such as carbon monoxide, carbon dioxide, sulfur dioxide, and ozone, heavy metals, particulate matter (PM), persistent organic compounds, and volatile and semi-volatile organic compounds.4 Air pollution is associated with dermatoses including atopic dermatitis (AD), psoriasis, and pemphigus, as well as photoaging, hyperpigmentation, and acne.4,5 The incidence of AD is associated with both outdoor pollutants, including traffic-related pollutants,6-8 and indoor pollutants.9-12 Flares of psoriasis have been associated with increased concentrations of air pollutants (GHG and PM),13 while hospitalizations for pemphigus have been associated with increased levels of PM.5

Stratospheric Ozone Depletion (SOD) and Cutaneous Malignancy
The incidence of melanoma and keratinocyte carcinomas (KC) have steadily increased since the 1980s.14 Ultraviolet radiation (UVR) is a complete carcinogen that is implicated in the development of both melanoma and KC.15 Although the stratospheric ozone layer provides protection from UVR, human use of the GHG chlorofluorocarbon has caused stratospheric ozone depletion (SOD).16 With a one-percent decrease in stratospheric ozone layer thickness, melanoma is projected to increase by 1 to 2%, basal cell carcinoma by 2.7%, and cutaneous squamous cell carcinoma by 3 to 4.6%, with variation by geographic location.14,17 Further, elevated temperatures compound SOD, leading to greater UVR exposure.18

Climate Change and Vector-borne Disease
The rise in temperatures due to anthropogenic GHG emissions has continued to progress, with the 10 warmest years on record occurring after 2005.19,20 Increased temperatures, along with decreased temperature variation between seasons, extreme weather events (EWE), habitat destruction, and mass migration, have led to expanding geographic distributions of vector-borne pathogens, as well as alterations in vector and pathogen life cycles.21,22 Temperate regions in particular have seen the expansion of vectors, reservoirs, and hosts into immune naïve populations in the setting of rising temperatures.23 The effect of global warming on vector-borne disease (VBD) is diffuse, encompassing bacterial, viral, and parasitic agents, many of which cause cutaneous disease (Table 1).21,23 Along with VBD, other infectious diseases of relevance to dermatology providers such as hand-foot-mouth disease and herpangina (both due to coxsackievirus) are predicted to increase in prevalence with elevated temperatures and changes in humidity.23




Climate Change and Water-borne Disease
Oceanic warming has the potential to affect a multitude of water-borne diseases (WBD) with cutaneous manifestations (Table 2). Prevalence of jellyfish envenomation and seabather eruption due to thimble jellyfish larvae have increased, as has cellulitis due to the bacterial pathogens Vibrio vulnificus and Vibrio parahaemolyticus.23-26 Increased freshwater temperatures, in tandem with nitrogen and phosphorus runoff, are also of concern due to potential effects on blood-dwelling parasites called schistosomes and their hosts leading to increased cases of cercarial itch or “swimmer’s itch.”23,27



Extreme Weather Events
The August 2021, an IPCC report demonstrated evidence that anthropogenic GHG emissions have led to increasingly extreme weather, including floods, heavy precipitation, droughts, heat waves, wildfires, and hurricanes.28 Wildfire-induced air pollution has been associated with increased healthcare visits among patients with a diagnosis of AD or a chief concern of primary pruritus.29 Flooding leads to an increase in skin and soft tissue infections (SSTI), including atypical infections such as Vibrio vulnificus, leptospirosis, and melioidosis due to contaminated water (Table 2).21,23,30 Rates of cutaneous coccidioidomycosis have increased due to aerosolization of pathogenic fungi Coccidioides immitis and Coccidioides posadasii spores in the setting of dry weather and heavy precipitation.21 Heatwaves and heat-related-illnesses (HRI) are also relevant as genetic and inflammatory dermatologic diseases and drugs prescribed by dermatology providers, such as anti-histamines, can increase HRI risk.31

Climate Displacement and Migration
The repercussions of climate change are expected to lead to mass migration events in the coming years.32 With displacement and extended periods in overcrowded temporary shelters comes increased risk of communicable diseases that thrive in high-density populations such as scabies and lice (Table 3).32,33 Increased frequency of EWEs that require temporary shelters such as heat waves similarly elevates risk of communicable disease. Serious louse-borne conditions, including epidemic typhus, trench fever, and relapsing fever, are also more common in overcrowded settings such as refugee camps (Table 3).32 In addition, mass displacement and migration lead to potential for a lapse in care of chronic diseases with cutaneous manifestations such as human immunodeficiency virus (HIV) and tuberculosis.32



Climate Justice
The burden of climate change falls disproportionately on communities of color, low-income communities, and pediatric and geriatric populations.34 Examples of climate injustice include increased air pollution due to heavy traffic and greater vulnerability to EWEs such as floods due to faulty infrastructure.34 Urban heat islands also affect systematically disadvantaged populations, leading to increased air pollution and risk of HRI.35

The Role of Dermatology Providers
A survey of members of the International Society of Dermatology demonstrated that 88% felt dermatology providers should act as advocates in climate change-related health issues.36 Along with cultivating one’s knowledge of the effects of climate change on dermatologic health, dermatology providers should be aware of the ways in which healthcare contributes to climate change.

The healthcare sector is responsible for 4.4% of GHG emissions globally and 8.5% within the United States.37 Strategies to reduce emissions in the outpatient setting include replacing energy-inefficient systems and decreasing energy use during inactivity, making modifications to lighting and temperature systems, using sustainable alternatives when possible, decreasing regulated medical waste, and installing water conservation systems (Table 4).38 My Green Doctor (available at https://mygreendoctor.org/) is an online management tool that can be used by dermatology practices interested in simple and streamlined protocols to decrease their carbon footprint.39

CONCLUSION
The impact of climate change on cutaneous disease is far-reaching and pervasive. Dermatology providers must educate themselves on the effects of climate change on cutaneous disease in order to act as effective clinicians.

This should include a specific emphasis on the ways in which climate change impacts the health of vulnerable and marginalized patient populations. As healthcare providers treating climate change-related disease, physician assistants in dermatology are in a position to act as advocates for their patients and the health of the general public.

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Annika Belzer, BS, is from Yale School of Medicine in New Haven, Connecticut.
Misha Rosenbach, MD, is from the Department of Dermatology at Perelman School of Medicine in Philadelphia, Pennsylvania.

Funding: This article has no funding source.

Disclosures: Ms. Belzer has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article. Dr. Rosenbach is co-chair of the American Academy of Dermatology’s Expert Resource Group on Climate & Environment; he is writing on behalf of himself and not the Academy.

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