Dermatology is blemished by inequality: The poor have more skin in the game

As long as monetary incentives remain with urban centres, cosmetics and surgical procedures, it is hard to imagine the inequality that underpins dermatology will be fixed in the near future.

As applications open up for the next intake of dermatology registrars, hopeful doctors will attempt to land one of the 20-25 positions made available by the Australasian College of Dermatologists (ACD) nationwide. With two in three Australians experiencing skin cancer at some point in their life, those fortunate enough to be accepted into the programme will go on to administer a crucial public service to their patients for decades to come. Assuming, of course, that those patients live in a major city.

In almost all cases, as the distance between you and a major city increases, the quality of your healthcare decreases. Compared to people living in major cities, rural inhabitants are six times more likely to report not having a GP nearby and nearly ten times more likely to report not having a specialist nearby. A key area of study here pertains to hospitalisations for preventable diseases, where remoteness is the best predictor of suffering in almost all cases.

Dermatology is worthy of particular criticism because the conditions that plague rural communities are incredibly dangerous yet eminently treatable. Remote Aboriginal communities, for example, are the worst sufferers of skin sores worldwide, and when left untreated they can trigger further, and often lethal, complications such as renal failure or rheumatic heart disease. Scabies, an itchy and contagious rash that causes skin sores, is found in 35% of children and 25% of adults in remote northern Australia. It can also be cured within two weeks if a patient is given access to the appropriate treatment. In many cases however, Australians living in remote and rural areas are simply not able to get access to it.

The root cause of this is the relative concentration of dermatologists in urban areas. In Australia in 2021, only six accredited dermatologists out of 591 worked permanently in rural areas. Meanwhile, in Bondi Junction, there are nine dermatologists operating out of the same building

On 6 March, the Grattan Institute released a report into out-of-pocket healthcare expenses, listing dermatology as a specialty of particular concern. This is because the structure of the Australian medical system effectively rewards dermatologists for going into lucrative private practices in major urban centres.

The report identified that over 60% of dermatologists charge more than double the schedule fee of $90. In Sydney, consultation costs are routinely more than triple the schedule fee. Of the 20 practices I contacted, the cheapest appointment was $240, the most expensive was $331, and the average was $290. 

Australian citizens can, of course, access the public health system, but there are wait times of up to 600 days for those seeking routine first appointments. With government messaging suggesting a skin check annually, people at risk for skin cancer are essentially forced into the private system. So too are sufferers of psoriasis (2.3-6.6% of Australians), severe cystic acne (~5%) and eczema (10-15%), for whom effective treatment can only be legally prescribed by a dermatologist. Such skin diseases can be incurable and debilitating without lifelong treatment, leaving patients with no choice but to reluctantly incur the costs of a private practice.

Underpinning issues of unequal access and inflated prices is a more sinister social trend. In urban centres such as Sydney, dermatologists focus much of their practice on less-severe cosmetic issues than more debilitating diseases suffered by rural inhabitants. While it is difficult to sustain this thesis with substantive data, surveying dermatologist clinic websites in wealthy areas is telling. As just one of numerous examples, Complete Dermatology in Bondi dedicates an entire section of its website to cosmetic treatments such as botox, face lifts and anti-ageing treatments. When compared to the struggle of rural inhabitants to access specialist services for treatable diseases, this focus on superficial cosmetic treatments appears vain. As a public good, dermatologists such as those in Bondi could be better served helping those in remote areas. 

The problem is, for those doctors more interested in profits than community service, dermatology has been corrupted by the marketing divisions of skincare companies intent on redefining skin health as an aesthetic judgement, rather than skin that is disease-free.

One such metric that indicates a growing focus on aesthetic dermatology is the emergence of cosmeceutical specialists. Cosmeceuticals are therapeutic products that are intended to have a beneficial effect on skin health and beauty, but their effectiveness is contested because they are unregulated. Across Australia, there are three times as many dermatologists interested in cosmeceuticals as there are in rural outreach clinics (use the “Filter by specialty” tool to see for yourself).

One prominent Australian dermatologist sells her own line of cosmeceutical products, advertised as ‘skincare backed by science’. One of her products – purportedly designed for skin care and the treatment of acne – is available on her website for $315. For a similar price, one could consult a dermatologist, receive a prescription for Isotretinoin (the most effective acne treatment) and pick it up from their local pharmacy. I hope this doctor has never specifically recommended her products to her patients, as that would likely constitute a breach of Section 3 of the ACD Professional Code of Ethics – “clinical decisions will not be influenced by personal gain”.

Dermatology is not necessarily unique in that the concentration of money in urban centres is leaving rural inhabitants without necessary medical services. Indeed, analogies can be drawn to the growth of cosmetic surgery – another potentially lucrative industry that draws medical professionals away from serving the public good. 

The issues surrounding unequal access to dermatologists are known to the ACD, and they have made changes to the training programme selection criteria in the hopes of amending them.

According to its website, the ACD “encourages applicants with a desire to practice in rural and regional areas to apply”. It also advertises pathways for Aboriginal and Torres Strait Islander people to get into the training programme, however at the time of publication, the link associated with this pathway does not work.

Sydney medical student Daniel* feels the current incentives for rural medical placements simply don’t work for dermatology specialists. “Derm is different because it is not a hospital thing. There is a high demand for dermatologists, so patients will just come to you. The only people who seem interested in working in rural areas are the people who were born there,” he said.

As long as monetary incentives remain with urban centres, cosmetics and surgical procedures, it is hard to imagine the inequality that underpins dermatology will be fixed in the near future. In its current form, the dermatology specialty is a blemish on the Australian medical system.

*Note: Names have been changed.