Stepping up efforts to support Ukrainian refugees: the role of the dermatological community
Conflicts of interest: the author declares no conflicts of interest.
The onset of the conflict in Ukraine has triggered Europe’s biggest humanitarian crisis since World War II. According to the United Nations,1 more than 4 million people have fled war-torn areas, heading for the neighbouring territories of Poland, Hungary, Romania, Slovakia and Moldova. Most are vulnerable people, such as unaccompanied and separated children, women, people with disabilities and chronic health conditions, and the elderly. An additional 6·5 million people have been displaced within the country and are in need of protection and access to drinking water and food.2
The conflict has brought Ukraine’s already fragile healthcare system3 to its knees, and disrupted critical healthcare services and the pharmaceutical supply chain. Health workers have been under attack from the Russian military and are consequently forced to move critically ill patients from hospitals into underground bomb shelters for safety.4 Likewise, access to primary healthcare and specialized services has been interrupted, threatening people’s achievement of health.
Skin conditions are reported to be common among displaced populations, although prevalence data are limited and restricted to migrants arriving in Europe from the Mediterranean and Western Balkans.5 The most common skin conditions observed in refugees from Somalia, Eritrea and Sudan on arrival in Italy and Malta were related to the dangerous sea crossings, overcrowding in Libyan detention centres and overall perilous journeys. Bacterial and fungal skin infections, scabies, burns and other injuries were among the 10 most common dermatological conditions recorded.6
Similar findings have been reported in refugees from Syria, Afghanistan and Iraq reaching Western Europe from Turkey via the Balkan route. Communicable skin diseases were the most common skin conditions in children living in refugee camps in mainland Greece7 and in the Moira refugee camp, located on the island of Lesbos.8 Refugee camps were initially designed for the short-term stay of refugees in transit to the mainland. These so-called ‘hotspots’ were then converted into ‘detention’ facilities for long-term shelter. Overcrowding, poor hygiene and deficient nutrition are the leading causes of skin disease in these camps. Such diseases consist mainly of superficial skin and soft tissue infections.5, 6
Ukrainian refugees are travelling on foot for many kilometres or standing at the international border for hours in cold temperatures of between −5 and −10 °C. Published data show that cold and dry weather increases the prevalence and risk of flares of atopic dermatitis.9 Noncommunicable skin diseases such as atopic dermatitis and eczema, triggered by the harsh winter weather and exposure to extreme heat and ultraviolet radiation in summer, were prevalent in Syrian refugees seen in the Al Za’atari camp and in noncamp settings in Northern Jordan.10 Barriers to healthcare access, limited availability of a dermatological formulary and lack of trained health workers all play a role in increasing the severity of clinical presentations.
In 2019, measles outbreaks were reported in Ukraine with over 57 000 notified cases, representing more than half of the total number reported in the World Health Organization European Region.11 Suboptimal vaccination coverage of routine and childhood immunizations, including measles and poliomyelitis, increases the risk of re-emergence and transmission of vaccine-preventable diseases. Immunization services in Ukraine were further disrupted by the lockdown measures imposed during the COVID-19 pandemic, which increased the potential for outbreaks of communicable diseases.
Vaccinations against COVID-19, measles and poliomyelitis are especially important for refugees at risk of severe outcomes, such as older adults and people with underlying health conditions, and to prevent the spread of highly contagious diseases in temporary common shelter sites and within the local community.12 Active surveillance and case finding should be boosted via telemedicine and training of healthcare providers in early detection of skin manifestations of measles, varicella and rubella. COVID-19 dermatological presentations13 and cutaneous reactions after mRNA COVID-19 vaccines14 should also be included as topics because of the differential diagnosis for common skin diseases in refugees and displaced people, such as morbilliform rashes, chilblains, pernio-like lesions, urticarial rashes and macular erythema.
The COVID-19 pandemic and the war have escalated food insecurity in the country. This may have long-lasting consequences on the nutritional status and more generally on the health of displaced people. Malnutrition lowers immunity leading to increased vulnerability to communicable diseases and triggers reactivation of latent infections, such as tuberculosis. Cutaneous abnormalities involving the skin, hair and nails are commonly seen in patients with micronutrient deficiencies15 and often provide clues to the underlying deficiency. Therefore, healthcare providers in host countries should be acquainted with the skin manifestations of malnutrition in order to make an early diagnosis followed by adequate nutrient supplementation.
Lack of access to barrier contraception and increased risk of sexual and gender-based violence increase the risk of sexually transmitted infections and HIV in refugees. Moreover, long-term disruption to treatment for HIV may result in the development of drug resistance and poor disease outcomes. Assuring refugees’ access to skin and sexual health services in neighbouring countries is therefore paramount.
As the conflict continues, the risk of development or exacerbation of mental health problems including anxiety, post-traumatic stress disorder and depression rises. Mental health issues can in turn exacerbate long-term skin conditions, particularly when patients’ regular care is unavailable.
What can be done to provide assistance? The Migrant Health Dermatology Working Group of the International Foundation for Dermatology has brought together dermatology specialists from around the world to discuss the most pressing skin health issues facing migrants and refugees. The group advocates for improved skin health provision for refugees and internally displaced people in Ukraine and neighbouring countries via training of health workers and adequate supply of a dermatological formulary to treat skin conditions including eczema, frostbite injuries, burns and infected wounds. Moreover, the implementation of teledermatology services in countries neighbouring Ukraine may contribute to reducing the burden on national healthcare systems by providing e-platforms for surveillance, consultation and monitoring of patients’ skincare with local and international colleagues. This will help strengthen dermatology training, and permit assessment of dermatology-specific needs, with the ultimate goal of ‘leaving no one behind’.
