Here’s a situation: Your patients can’t use the cutting-edge modality you just sat through an hour-long lecture to learn about. Wherever you may practice, the story is likely the same.
In a suburban doctor’s office, 17-year-old Hunter is miserable. He has huge, pizza-like acne on his forehead and cheeks. His mother is strapped for time and resources and can’t afford his prescription for clindamycin/adapalene/benzoyl peroxide (Cabtreo; Ortho Dermatologics), let alone isotretinoin treatments.
Mike, who is 72 years old and living in a nursing home, cannot advocate for risankizumab (Skyrizi; AbbVie) treatments for his plaque psoriasis when his insurance refuses to pay, especially in between his already grueling dialysis sessions.
For 6-year-old Stacy, who is in foster care, even the most welcoming of foster homes may not be able to chase down treatment for her eczema that flares upon every relocation.
Judith, 29, is incarcerated, and the large cysts under her breasts and armpit are starting to ooze and smell. The best she can get from the nurse practitioner at the clinic is a cream. She should be out on parole in 6 months, but there is almost no chance she will be seeing the inside of a dermatologist’s office then.
And finally, 97 years young, Jean is going strong, but so is the 3.5-cm squamous cell carcinoma on her lower leg. She has zero interest in Mohs surgery, radiation, or injected fluorouracil (Efudex; Bausch Health Companies) and just wishes she could stop the crusting wound from seeping.
You know how to help these patients; maybe you even have the tools at the ready. But they won’t work here.
Key Takeaways
- Dermatologic care must account for real-world access, not just ideal therapies.
- Resource limitations are common in many “developed world” clinical settings.
- The best treatment is useless if patients can’t obtain or use it consistently.
- Clinicians should assess financial, social, and logistical barriers before prescribing.
- Patient education is a central, high-impact intervention.
- Clear, practical instructions often improve outcomes more than medication changes alone.
- OTC and low-cost regimens can be effective for many common conditions.
- Treatment plans should prioritize sustainability and simplicity.
- Realistic expectations improve adherence and satisfaction.
- Success often means meaningful improvement, not complete cure.
Resource-poor environments are not limited to third-world nations and post-catastrophe environments. Although Wounds AFRICA is an excellent resource for dermatology and wound care in resource-poor environments, we also face similar issues in the developed world.1 Resource-poor environments can also apply to residents in nursing homes and assisted living facilities, children in foster care, incarcerated individuals, mentally challenged persons, persons with unreliable caregivers, those with financial constraints or lack of insurance coverage, and people who are just too overwhelmed with life’s onslaught of tasks to focus all their resources on this particular issue.2
Much research time is spent on the new and innovative, but what patients need is the affordable and accessible. They need to be met where they are, and their skin issue addressed in a more holistic manner.
This starts with education. Many individuals lack a basic medical understanding of their condition. Googling symptoms or getting artificial intelligence summaries further confuses them, or maybe they don’t have access to or understanding of how to use even these basic technologies. Providing a thoughtful and concise understanding of their medical condition goes a long way not only to improve adherence but also to help them think creatively about their circumstances and how best to address them within the constraints of their lives. In a busy clinic, this may look like prepared brochures on common conditions and patient education handouts. This may also look like presenting at a nursing home or prison clinic to educate medical staff on how to recognize and manage common dermatological complaints using modalities available to them.
I’m reminded of 3-year-old Mimi, a wide-eyed, curly-haired child with atopic dermatitis. She had the requisite food allergies and miserable red, raw, chafed eczematous skin creeping up the neck above her pink Strawberry Shortcake shirt. Her mother called me for a house call and, although she had already been to multiple dermatology visits, was still woefully undereducated as to how to manage an eczema-prone child. She had been handed a prescription for triamcinolone and told to help Mimi moisturize her skin. The mother had 6 other children and worked part-time, and Mimi screamed every time the cream was applied to her chafed skin. We discussed ointments vs. creams, colloidal oatmeal, bleach baths, immediate moisturization of wet skin, cotton undergarments, sensitive-skin detergents, screening for environmental and food allergies, and a humidifier/air filter trial. Just this past weekend, I saw Mimi, and her skin is crystal clear. Education bridges this gap between clinical knowledge and real-world application and is absolutely essential, in clinic or out.
The next step is to examine the options available to the patient and consider conservative lifestyle modifications, as well as whether over-the-counter (OTC), less expensive medications may be appropriate. Can we perhaps craft a skin-care regimen for Janet’s rosacea using OTC products? Can we start Brian on OTC ketoconazole (Nizoral) or coal tar shampoo to treat his seborrheic dermatitis? Maybe Frank can use a foot soak of vinegar and tea tree oil for his toe fungus? Many OTC or “folksy”- sounding remedies have documented efficacy in mild cases of dermatological maladies and can be ordered online or picked up at a local discount store.
A key component here is adjusting expectations. Your patients need to know that they can’t expect dramatic overhauls of their skin with a week of topical application. They need to know that their psoriasis may continue to smolder and their eczema continue to flare with even the most diligent topical applications. And that ultimately, they may either be forced to proceed with more advanced modalities or accept an improvement rather than a resolution of their skin complaints. Clear communication of expectations, including pros, cons, and alternative options, is crucial.
Ultimately, our job as clinicians is to treat the patient, not the disease. If our patients can’t access our prescriptions or understand our recommendations, we have not helped; we have harmed.
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References
- Serena TE. A global perspective on wound care. Adv Wound Care (New Rochelle). 2014;3(8):548-552. doi:10.1089/wound.2013.0460
- Font S, Haddock Potter M. Socioeconomic resource environments in biological and alternative family care and children's cognitive performance. Sociol Inq. 2019;89(2):263-287. doi:10.1111/soin.12262
