Skin health in people experiencing homelessness

Introduction

People experiencing homelessness (PEH) are individuals who lack the legal right to occupy any accommodation or whose accommodation is unsuitable for habitation.

Skin disease disproportionately affects PEH, in particular: ectoparasitic infestations, cutaneous infections, and skin cancer.

Though data is limited, one study in the United States found that the prevalence of dermatoses such as eczema, psoriasis, and seborrheic dermatitis in a shelter-based population was similar to that of the general population.

Understanding homelessness

There are four types of homelessness:

1. Rough sleeping (‘street homeless’)
Unsheltered individuals residing in places not intended for habitation eg, doorways, cars, parks, abandoned buildings, and transportation stations.

2. Temporary accommodation (‘shelter homeless’)
Residents of designated facilities, including emergency shelters, women’s refuges, or provisional accommodations.

3. Statutory homelessness
Individuals or households recognised by local authorities as being in priority need of assistance due to a current or imminent lack of accommodation.

4. Hidden homelessness
The largest group, comprising individuals whose homelessness is not visible or captured in statistics. This includes people ‘sofa surfing’ with friends or relatives, squatters, and those in severely overcrowded households.

Why is homelessness a risk factor for skin problems?

Multiple factors increase the risk of skin disease among PEH, including:

• Socioeconomic deprivation and limited access to health services
• Malnutrition
• Overcrowding
• Inappropriate footwear
• Neglect of skincare, including the feet
• Increased exposure to injury
• Exposure to extreme weather eg, cold, heavy or prolonged rain, and heatwaves
• Alcohol and/or substance misuse
• Higher rates of chronic health conditions and comorbidities with numerous skin manifestations eg, peripheral vascular disease, hepatitis C, HIV
• Skin cancer risk factors eg, chronic sun exposure, limited education on risk reduction, lack of photoprotective resources
• Sexually transmitted infection risk factors eg, intimate partner violence, substance use, and incarceration.

How do you identify skin problems in people experiencing homelessness?

A regular full skin examination should be performed by a healthcare professional, with special attention given to the feet.

How do you prevent skin problems in people experiencing homelessness?

• General skincare and hygiene, with an emphasis on foot care eg, appropriate footwear, drying the feet, nail care
• Signposting to local community services
• Active assessment of safeguarding issues (such as abuse or neglect) and social care referrals made when concerns arise
• On a policy level, addressing the upstream structural determinants of health eg, housing access, food security, and income assistance

Skin disorders associated with homelessness

Infections and infestations

Bacterial

• Abscesses, cellulitis, folliculitis, and impetigo — these are common reasons for presenting to emergency departments, particularly in people who inject drugs
• Increased rates of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection
• Higher incidence of invasive Group A Streptococcus outbreaks and infections

Viral

Cutaneous warts

Ectoparasitic

• Scabies
• Fleas
• Ticks
• Pediculosis (lice infestation) — more prevalent among unsheltered individuals; severe infestation can lead to iron deficiency anaemia

Multiple excoriation due to body lice infestation (PL-patient1)

Lice can be identified on the seams of his underwear (PL-patient1)

Skin disorders of the feet

• Leg ulcers
• Corns and calluses
• Environmental exposure-related conditions include ‘immersion foot’ (also known as trench foot), chilblains, and frostbite in winter
• Superficial fungal and bacterial infections:
  • Tinea pedis and onychomycosis, often asymptomatic, can serve as entry points for fungal and bacterial pathogens, leading to more serious infections such as cellulitis or abscesses.
  • Pitted keratolysis may be due to a lack of access to washing facilities and a reluctance or an inability to remove shoes.

Leg ulcers in homeless person 

Skin cancer

Some studies have demonstrated a higher prevalence of precancerous and malignant lesions among PEH.

Malnutrition

• Pellagra (niacin deficiency)
• Vitamin A deficiency
• Scurvy

Corkscrew hairs due to scurvy in a homeless person 

Sexually-transmitted infections

• Gonorrhoea
• Chlamydia
• Herpes
• Genital warts
• Syphilis

Paediatric population

• Skin conditions commonly affect youths experiencing homelessness.
• Young people may be affected by the conditions above, as well as common diseases such as acne and atopic dermatitis.
• The prevalence of child abuse is high among children experiencing homelessness; clinicians should be alert to potential cutaneous manifestations of abuse, including unusual patterns of bruising and scarring.