The Unique Challenges of Having Eczema in Rural America

People dealing with eczema and live in rural areas may face unique challenges when seeking medical care from dermatologists and other skincare specialists.

While eczema symptoms can fluctuate from mild to severe, flare-ups can include skin dryness and redness, rashes and more. Anyone dealing with this condition may need to see a doctor for treatment, but is it more difficult to seek help for those living in rural settings?

“Dermatologists in rural America have been decreasing in number relative to their urban counterparts,” write Caroline Garraway and Adam C. Byrd in the 2021 book, Dermatology in Rural Settings.¹ “This has had a negative impact on the health of rural Americans.”

At the 2021 summer meeting of the American Academy of Dermatology (AAD), Dr. Robert Brodell presented on the new approaches taken by the Department of Dermatology at University of Mississippi to address this issues, including developing a rural residency track designed to attract more dermatologists to the area.²

In Mississippi, one of the most rural states in the country, much of the population lives two or more hours from the nearest major city with a dermatology center.

“The well documented problems related to access to care in rural areas are the result of many things,” Dr Brodell said at the conference. “Over and over again in rural Mississippi we see issues related to access to care associated with delayed diagnosis and delayed treatment.”

As much as some rural communities might be isolated or lack access to certain health services, living in these areas may have other benefits. You might experience greater air quality, have closer family connections or enjoy a slower pace of life that can benefit your overall health. Let’s explore how many people need treatment and programs that are working help more rural Americans get the care they need.

By the numbers

The Census defines rural as areas that are sparsely populated, have low housing density and are far from urban centers.

About 60 million people, or one in five Americans, live in rural America, according to data from the U.S. Census Bureau.³

More than 31 million people, or about 10 percent of the U.S. popularion.⁴ At that rate, about 60,000 people in rural areas may be living with the condition. While there is no one-size-fits all approach to treating eczema, certain lifestyle changes, customized skin care or prescription medications can help. Many find relief when working with a doctor, particularly when skin discomfort impacts sleep and day-to-day activities, or when symptoms worsen after trying over-the-counter or home remedies.

Managing gaps in care

Research continues to suggest that those living in rural settings may not be getting the care they need.

“Health inequities stemming from rural barriers to care extend to dermatologic diseases,” write researchers for an editorial for JAMA Dermatology.⁵ “Urban areas have 40 times the concentration of dermatologists per 100,000 citizens as rural areas, and measurable consequences may result from this disparity.”

A 2019 mixed-methods study found that significant geographic barriers to dermatology care exist for rural American Indian communities, as well.⁶ This research identified innovations in teledermatology as a vital way for this rural patient population to receive care.

The Extension for Community Healthcare Outcomes (ECHO), developed by Sanjeev Arora, M.D. at the University of New Mexico Health Sciences Center, is another model that offers a way to expand health care access in rural areas.

With Project ECHO, primary care doctors participate in a teleconference once a month with dermatologists, who present case reviews using images submitted by the primary care physicians. The program helps to train local primary care doctors to perform routine dermatologic screening and patient education to better serve the rural patients.

“When I lived in rural northern New York, there were many years where we didn’t have a dermatologist in our community, so I’d drive three hours to Burlington, Vermont, to get my skin checked several times a year,” said Sarah Harris, a NEA Ambassador who lives with eczema. “It was challenging, especially during the winter as I’d have to cancel appointments if there was a big snowstorm that prevented me from traveling, and it could take months to rebook.”

Are rates of eczema lower in rural areas?

A 2010 systematic review found some evidence that those living in rural areas have less risk for developing eczema than those in urban areas, suggesting that where you reside may have a role in the pathogenesis of eczema.⁷

Interestingly, sunlight may also play a part. Researchers in a 2012 study from the European Centre for Environment & Human Health found that children living in areas with lower levels of sunlight were at greater risk of developing both eczema and food allergies, compared to those in areas with higher UV.⁸

“This investigation has further underlined the association between food allergies, eczema and where you live,” wrote lead researcher Dr. Nick Osborne in the study.

Sunlight exposure might play in a role in skin conditions because it provides the body with the fuel to create vitamin D in the skin, and locations closer to the equator typically receive higher levels of sunshine. Those living in rural areas may spend more time outdoors than people in urban areas. It’s important to mention that UX exposure can be harmful, too.

Another factor that impacts eczema is pollution. Studies have found that people who have exposure to higher levels of indoor or outdoor pollution, particularly fine particulate matter, ozone, carbon monoxide and lead, are more likely than others to develop symptoms of eczema.⁸ Toxic pollutants can trigger inflammation and skin barrier disruption in eczema-prone skin. So far, researchers have found a high prevalence of eczema in urban areas linked to that pollution, though with climate change and changes in ozone, people living in rural areas should also be prepared.

How to take charge of your health

For parents or caregivers of those dealing with eczema, longer trips to the doctor, finding a specialist with experience in eczema (let alone complicated cases), all may delay getting a diagnosis or treatment, so it’s important to mitigate rural barriers.

Many allergy experts consider eczema as an early step in the “atopic march,” a clinical progression found in children, where eczema turns into to food allergies and, sometimes, to respiratory allergies and allergic asthma. Scientists have discovered a link in children with both eczema and food allergies, as they exhibit structural and molecular differences in the top layers of healthy-looking skin near eczema outbreaks.⁹

If you live in a rural area, you can still find ways to improve your health by identifying your specific needs and looking for resources that can help you overcome obstacles to care. You can ask about telehealth options or if you have limited internet access, you may start by speaking with a doctor on the phone. Another resource is to use the Eczema Provider Finder to help find a health care provider near you with experience treating eczema and related conditions.

Sources:

[1] Garraway, C.P., Byrd, A.C. (2021). Rural Dermatology Private Practice: A Life Worth Living. In: Brodell, R.T., Byrd, A.C., Firkins Smith, C., Nahar, V.K. (eds) Dermatology in Rural Settings. Sustainable Development Goals Series. Springer, Cham. https://doi.org/10.1007/978-3-030-75984-1_17

[2] Peckel, Linda, “How the University of Mississippi is Overcoming Gaps in Rural Dermatology Care,” Dermatology Advisor. https://www.dermatologyadvisor.com/home/topics/practice-management/mississippi-is-overcoming-gaps-in-rural-dermatology-care

[3] “What is Rural America?” U.S. Census Bureau website. https://www.census.gov/library/stories/2017/08/rural-america.html

[4] “Eczema Stats,” National Eczema Association website. https://nationaleczema.org/research/eczema-facts

[5] Pearlman, Ross, MD; Brodell, Robert, MD; Byrd, Adam, MD, “Enhancing Access to Rural Dermatological Care: The Time to Start Is Now,” JAMA Dermatol. 2022;158(7):725-726. doi:10.1001/jamadermatol.2022.1470, https://jamanetwork.com/journals/jamadermatology/article-abstract/2792448 

[6] Morenz, Anna, MD, “Mapping Barriers to Dermatology Care for Rural American Indian Communities,” Harvard Medical School. https://hmshsdmcommunityservice.com/scholarly-projects/mapping-barriers-to-dermatology-care-for-rural-american-indian-communities

[7] M.E. Schram,A.M. Tedja,R. Spijker,J.D. Bos,H.C. Williams,Ph.I. Spuls, “Is there a rural/urban gradient in the prevalence of eczema? A systematic review,” British Journal of Dermatology, 16 March 2010. https://pubmed.ncbi.nlm.nih.gov/20331459

[8] Nicholas J. Osborne, Obioha C. Ukoumunne, Melissa Wake, Katrina J. Allen, “Prevalence of eczema and food allergy is associated with latitude in Australia,” Journal of Allergy and Clinical Immunology, 2012. 10.1016/j.jaci.2012.01.037

[9]  “Does Pollution Cause Eczema? Experts Weigh In,” Medical News Today, 22 February, 2022. https://www.medicalnewstoday.com/articles/does-pollution-cause-eczema-experts-weigh-in#pollution-and-overall-health [1] D Leung, et al. “Non-lesional skin surface distinguishes atopic dermatitis with food allergy as unique endotype,” Science Translational Medicine, 2019. 10.1126/scitranslmed.aav2685

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