Climate Change: A Very Real Threat and What Dermatology Can Do

By July 1, 2021, temperatures in the Pacific Northwest of the United States and Canada reached triple digits, resulting in hundreds of heat-related deaths.¹ Farther down the coast into California, officials are bracing for the potential of another record-breaking fire season.² Increasing wildfire intensity coupled with a historic drought is causing downstream issues with water supply more inland in Colorado.³ On the other side of the continent, residents in New York City, NY, received text communications asking to conserve energy during another heat wave.⁴ Tropical Storm Elsa, the earliest fifth-named tropical storm on record, made its way through the Caribbean as a category 1 hurricane and is expected to bring heavy rains and winds again in Florida , continuing a year-on-year accelerating trend of increasing extreme storm frequency.⁵ Five months earlier, southern states such as Texas and Oklahoma experienced unprecedented snowstorms that stretched power grids to past their breaking point.⁶ Although these weather patterns are incredibly different, they have one thing in common: growing extremity due to climate change.

While climate change may not seem like an immediate concern for medicine, its effects are already impacting practices, patients, and populations. In addition to the rising sea levels and extreme weather, health care providers can expect to see increasing incidences of infectious diseases, food scarcity and safety concerns, mental health conditions, and exacerbated chronic diseases.^7-10

The skin is the body’s organ most exposed to the environment. Because of this direct connection, a growing group of dermatologists argues it is time for the specialty to take an active role in fighting the effects of climate change for patients and for the planet.

“Climate change is affecting the practice of dermatology in several ways,” said Sarah J. Coates, MD, a pediatric dermatology fellow at the University of California, San Francisco. As a leading voice exploring climate change through a dermatologic lens, she highlighted various scenarios resulting from climate change that directly affect dermatology.

“Just as we are seeing with COVID and have seen in the past with tobacco, lead, and other public health issues, there has been a proliferation of misinformation about climate change,” said Misha Rosenbach, MD, an associate professor of dermatology and internal medicine and program director of the dermatology residency program at Perelman School of Medicine at the University of Pennsylvania in Philadelphia. “Talking about climate change and its impact on health should not be something dermatologists avoid. The science is clear. The health impacts are not some far off fear—they are occurring now.”

“As the planet warms, we will see a rise in heat-related conditions, which disproportionately impact children and the elderly due to their physiologic vulnerability, as well as patients with special dermatologic conditions such as ichthyosis,” Dr Coates said. She added that the burden and geographic range of infectious diseases will shift to reach higher latitudes due to prolonged warm weather. “We are already seeing a shift in the geographic range of conditions such as coccidioidomycosis, leishmaniasis, and dengue. This is projected to worsen substantially in the next 50 years if climate change goes unchecked.”

The literature has already noted the shifts. Elston¹¹ recently recounted the appearance of Amblyomma ticks, normally found in the most southern states, close to the United States-Canadian border in New York and Michigan. Lyme disease is now known to occur in all 50 US states and has crept into Canada in part due to milder winters.¹² Curtin and Aronson¹³ detailed the potential impact of climate change on autochthonous leishmaniasis in the United States, noting models predict spread of sand flies, a known vector of Leishmania, deeper into the country past its current endemic zones of Texas and Oklahoma. Coates et al¹⁴ described a positive, statistically significant relationship between hand, foot, and mouth disease and temperature as well as humidity based on a literature review and analysis. Mosquitos, long associated with warmer, more humid weather, will play a role in increasing the spread of diseases such as dengue, chikungunya, and Zika, which are no longer only “tropical illnesses” now that cases are reported in the mainland US.¹² Benedict and Park¹⁵ outlined disaster-associated fungal infections, and Nnadi and Carter¹⁶ noted several fungal species that are thought to have emerged in association with warming temperatures, including the spread of coccidioidomycosis, also known as Valley fever, in the southwest US to a range that now stretches up to the Pacific Northwest.

As extreme weather patterns continue to develop, disaster-related diseases will grow in prevalence. Dermatologists in areas prone to flooding will see an increase in skin infections, mostly from bacteria such as Cyanobacter, Mycobacter spp, and Francisella tularensis, although parasites such as Dracunculus medinesis will also be of major concern.^12,17 Disease proliferation could be exponential in communities that experience a mass migration—whether to
violence, natural disaster, or uninhabitable land—and include scabies, lice (ie, typhus, trench fever), HIV, and tuberculosis.¹⁸

The above complications are only diseases resulting from external factors. “Much of the environmental changes associated with climate change can exacerbate or precipitate dermatology-specific or relevant conditions,” said Markus D. Boos, MD, PhD, associate professor in the department of pediatrics; clinical adjunct in the division of dermatology, department of medicine; and co-associate program director of the dermatology residency program at the University of Washington in Seattle.

“For instance, we have data that wildfire smoke precipitates worsening of atopic dermatitis, and issues with severe heat hold special import for our patients who suffer from ectodermal dysplasias,” he added.

While more study is needed, research has investigated the correlation of dermatologic disease severity and factors related to climate change. AD is a case example as a recent focus, given eczema’s known associations with other atopic diseases, external triggers, and skin barrier dysfunction. Disease severity and health care use by patients with AD have been associated with outdoor temperatures and humidity and various air pollutants.^19-24 Photoaging is another strong example; research has shown that extrinsic aging can be caused by UV irradiation, smoking, and air pollutants.^25-27 Evidence is growing as well for other “bread and butter” conditions, such as lentigines, melasma, psoriasis, acne, and skin cancer.²⁸

Dermatologists are not averse to the evidence of climate change and believing human behavior is a major contributing factor.²⁹ Support for a specialty-wide movement is spreading. In early 2018, the American Academy of Dermatology (AAD) formed the Climate Change and Environmental Affairs Expert Resource Group (ERG). Subsequently, the AAD released a position statement in 2018, resolving to raise awareness about the effects of climate change on skin health, work with other medical societies to promote changes in health care, and help members decrease their carbon footprint of their practices.³⁰ The ERG, co-chaired by Dr Rosenbach and Mary Williams, MD, was integral in the AAD’s membership to the Medical Consortium for Climate and Health, a multi-association organization amplifying the voice of physicians fighting climate change.

At a more individual level, dermatologists can take steps to reduce their environmental impact as a health care provider.

Access tools and education to make informed decisions. The Medical Consortium for Climate and Health has a central hub of resources from its members and affiliates on greening the workplace.³¹ The AAD also provides free access to MyGreenDoctor, a practice management tool to help make practices more environmentally friendly. Dr Rosenbach also pointed to the New England Journal of Medicine website³² as well as the January 2021 issue of International Journal of Women’s Dermatology.³³ Dermatologists can also attend sessions at conferences focused on climate change, such as the recent presentations at the AAD Virtual Meeting Experience.

Reduce travel, both for providers and for patients. A common way to reduce carbon footprint is to simply travel less, particularly by reducing air travel, and dermatologists are encouraged to find ways to make this conscious effort for the field.

Lee et al³⁴ examined the impact of reducing greenhouse gas emissions by calculating the environmental impact of isotretinoin visits, finding moving 175 appointments to a virtual format would save 45,200 kg of emissions of carbon dioxide equivalents over a 1-year period. They noted this impact could be magnified if virtual visit adoption was across the country, given the more than 1 million isotretinoin prescriptions authorized annually. Adopting this approach to other types of appointments, such as chronic disease or surgical follow-ups, could mean creating a much greater impact. Advances in telehealth since the pandemic have made this an easier change to make in practice.

In addition, dermatologists can make smarter choices by opting for virtual options for meetings and conferences. Residency programs can conduct interviews virtually to limit the cost and carbon footprint of travel for applicants.³⁵

Adopt environmentally friendly practices. Aside from using telemedicine, dermatologists and their staffs can make other conscious choices in practice. One study from the United Kingdom estimated that an individual Mohs surgery practice created a yearly generation of 194 kg of contaminated waste, 92 kg of noncontaminated waste, and 37 kg of sharps waste.³⁶ To combat this waste, changes were made to create surgery sets of essential items only, with additional equipment available on request. Staff were also trained on correct waste disposal measures, including what materials qualify for what bin and placing disposal bins in readily available areas.

More simple changes, which can also be implemented in everyday life, include^37,38:

• Using energy efficient lightbulbs (ie, compact fluorescent or light-emitting diode) with an automatic shut-off
• Set heating and cooling systems to function only during occupancy hours and maintain temperatures of 74 ˚F in the summer and 68 ˚F in the winter
• Unplug electronics at the end of the day
• Replace older, energy-inefficient appliances and bathroom hardware with greener alternatives
• Look for products that use less packaging

Use your professional voice. All three physicians recommended joining the ERG and being vocal about making sustainable changes at society levels.

“Check out the work being done by the Climate Change and Environmental Affairs ERG. We have a quarterly newsletter, regular educational sessions, and opportunities to get involved in improving education around this issue,” said Dr Coates.

“Destigmatize talking about [climate change] in your practice, hospital, state or local society, and at the AAD and a national level,” said Dr Rosenbach. “The impact we can make as a group far outweighs any one person’s individual impact. Educate yourself, and then support groups or organizations that are making a difference.”

“Our job as health care providers is to educate, treat, and mitigate those exposures that negatively impact patients’ health,” added Dr Boos. “Sometimes that means pushing outside of our comfort zones to educate our patients, and to advocate and aggressively push our elected leaders, not to mention hospital administration, to make the widescale changes that are needed—essentially to create a society that is decarbonized.”

A final suggestion for dermatologists looking to help the cause is to express the impact to patients directly.

“I live in California, and this comes up every wildfire season,” said Dr Coates. “I am trying to be more intentional about communicating with patients directly about the health effects of climate change. It validates their experience of, for example, their atopic dermatitis worsening in response to poor air quality during the increasingly severe wildfire seasons.”

Dr Coates noted that a publication is forthcoming regarding this topic, but she shared a few key tips to conveying the importance of climate change to patients and their families:

• Storytelling, which communicates messaging through personal experience (eg, “This situation reminds me of when our son’s eczema got worse after the wildfires last fall. It was hard to avoid breathing in smoke, and I can imagine that seeing these eczema flares is tough on your family as well. I’d be happy to share some of the resources we used to track air quality and minimize the effects of indoor air pollution,” suggested Dr Coates)
• Targeted risk communication, which (“I want to make sure that you and your family know about Hurricane X and the latest recommendations from FEMA. Is there anything preventing you from evacuating by tomorrow night?”, Dr Coates added)

“It is important that we depoliticize climate change by discussing it openly in our clinic. That the climate is changing is a scientific fact, and its effects on our patients are increasingly obvious. The more we approach this matter-of-factly, the better,” Dr Coates said.

Dr Boos described a similarly personal approach with patients and their caregivers. “Typically, I try to loop any conversation into the child’s diagnosis or a comment parents make about the weather. For example, if a parent comments that their child’s eczema is flaring in the summertime, I use that as an opportunity to point out that longer and more intense pollen seasons and wildfire smoke exacerbate atopic dermatitis, and these are happening secondary to climate change,” he said. “A 20-minute visit does not lend itself to the thorough conversations that are required to truly educate about climate change, but the more that you make people aware of it and connect these changes to health (a very personal issue), the more they start to take notice.”

Dr Rosenbach added that many dermatology appointments offer a window to bring climate change up in conversation. “If I see someone with a tick, I discuss how there are more ticks, biting earlier and later in the year, in an expanded geographic region due to climate change. If I see someone with hand-foot-mouth, I discuss how there are climate-associations with viral illnesses. If I see someone in February and it’s 80 ˚F in Philadelphia, I mention that it’s not ‘nice weather’ but ‘another sign of the dramatic, rapid change we are causing to our planet’s climate.’”

“My personal belief,” said Dr Boos, “is that it is our moral imperative to keep the world habitable for future generations (not to mention ourselves). This is possible if collective action is taken—we are all in this fight because we all have a stake in it.”