Community Dermatology: Necessity or Hype?

Skin diseases are common all over the world with high prevalence in developing countries with significant socioeconomic and behavioral impact. In Nepal it is the fourth leading cause of nonfatal diseases. A community clinic is the term used for a specialist clinic provided in a Primary Care setting. The aim of these clinics in Nepal is to improve access to basic health services including family planning, child health and safe motherhood. But there are no policies for dermatological diseases in the rural communities. As skin diseases do not usually cause mortality, it is often ignored. But the morbidity is often high and the impact on quality of life is also high. Conducting regular skin camps at inaccessible parts of the country is a good way to provide service to the people of the community and due to the fact that most skin conditions can be diagnosed visually, the method of tele-dermatology can be successful.

Skin diseases are common all over the world with high prevalence in developing countries with significant socioeconomic and behavioral impact. In Nepal it is the fourth leading cause of nonfatal diseases. A community clinic is the term used for a specialist clinic provided in a Primary Care setting. The aim of these clinics in Nepal is to improve access to basic health services including family planning, child health and safe motherhood. But there are no policies for dermatological diseases in the rural communities. As skin diseases do not usually cause mortality, it is often ignored. But the morbidity is often high and the impact on quality of life is also high. Conducting regular skin camps at inaccessible parts of the country is a good way to provide service to the people of the community and due to the fact that most skin conditions can be diagnosed visually, the method of tele-dermatology can be successful.

INTRODUCTION
S kin diseases are common all over the world with high prevalence in developing countries with significant socioeconomic and behavioral impact. 1 In European countries, it was reported to be the fourth leading cause of nonfatal diseases 2 , which is similar to that of Nepal. 3 A community clinic is the term used for a specialist clinic provided, usually by a Consultant, in a Primary Care setting. Services provide specialist care and advice to patients referred by General Practitioners (GP's) on a number of non-chronic skin conditions that do not require long-term hospital follow-up or a multidisciplinary or sub-specialist services. 4 There are primary health care outreach facilities in Nepal as well, which was extended to the village level under the National health Policy in 1991 but was limited due to accessibility factors and were therefore initiated in 1994. The aim of these clinics is to improve access to basic health services including family planning, child health and safe motherhood. 5 There are no policies for dermatological diseases in the rural communities of Nepal.

DISCUSSION
I n 2012, Shrestha DP et al conducted a large scale, population based study in 18 wards of 10 villages, in the 3 eco-zones (2 in Dolakha in the mountainous region, 3 each in Makawanpur and Kavre in the hills and 2 in Chitwan in the terai region) of the central development region of Nepal and found that the prevalence of skin diseases was 25%. 6 This study was purely based on dermatology health camps for which the villagers with skin diseases were pre-identified by local health personnel and then examined by the dermatologists during the health camps. Many other published data on skin diseases in rural areas are based on multi-specialty health camps, where the prevalence of skin diseases are much less as compared to the prevalence of proper dermatological health camps. 7,1 In the year 2017/2018, the total number of patients attending dermatology out patient department of Bir Hospital, which is a tertiary referral hospital of Nepal, was 46,250. The number of patients is at an increasing rate as compared to the previous year, which were 43,403. 8 Most of the patients attending here are from very remote areas and of low socio-economic status. So, frequent travelling to Kathmandu is not always feasible for them. Even if they come for check-up, they are not able come for follow-ups. So they continue using the same medicine for a long period of time, which leads to its side-effects. As skin diseases do not usually cause mortality, it is often ignored. But the morbidity is often high and the impact on quality of life is also high. 6 There are around 21 teaching hospitals in Nepal and only few with provision of specialty training programs. The specialty residency-training programs in Nepal are mostly of 3 years duration and during this time, atleast 3 months of community posting is proposed mandatory for the resident doctors. The experience with the community posting has been wonderful both for the resident doctors as well as the residents of the community. We have had great response from the villagers when the residents were posted there. But is it sufficient? It is obvious that the general population would benefit a lot if a dermatologist was available at the district hospital all year round. But due to lack of adequate trained manpower, it does not seem feasible.
The government has made health strategies for the coming year, some of which are establishment of zonal and regional hospitals to provide specialized services related to paediatrics, gynaecology, general surgery, general medicine, eye care, dermatology, orthopaedics and psychiatry with extending specialist curative care services to remote areas, as and when required, through mobile teams. 9

CONCLUSION
In our view, conducting regular skin camps at inaccessible parts of the country is a good way to provide service to the people, as we have seen that the community benefit a lot from these camps.
Also, new concepts like tele-dermatology 10,11 and mobile tele-dermatology 12 are emerging. This method might be of great use in country like ours with so diverse and difficult to access landscapes. Due to the fact that most skin conditions can be diagnosed visually, the method of tele-dermatology can be successful.