When Dr. Rachel Asiniwasis returned to the prairies after her dermatology residency in Toronto, she noticed a pattern among many of her pediatric patients.

Hundreds of them were coming to her with itchy, raw patches of skin, the result of atopic dermatitis — eczema.

“One of the biggest frustrations for me is when people say ‘oh, it’s just a skin problem’,” said Asiniwasis. “Itching in many ways is just as impactful as chronic pain,”

Atopic dermatitis is the most common chronic skin inflammatory disease. The vast majority of cases start in children under the age of five. At least one in every ten Indigenous children in Canada has some form of eczema. That figure rises to one in every four children in some Arctic communities.

Asiniwasis said the itch and pain -- amongst other signs and symptoms in moderate to severe cases -- can lead to depression, ADHD, anxiety, and an increased risk of suicide.

Two years ago, she conducted a survey of 50 dermatologists, nurses and family physicians who work in Indigenous communities across Canada. Atopic dermatitis was the most common skin disease reported by their patients, followed by bacterial infections. 

Working with medical leaders in five southern Saskatchewan Indigenous communities, Asiniwasis was also granted permission and ethics board approval to perform a confidential chart review for hundreds of pediatric patients with atopic dermatitis. A number of those patients saw their uncontrolled atopic dermatitis devolve into secondary infections, often leading to hospital visits and multiple courses of antibiotics.

"The literature's also showing high rates of bacterial skin infections, which is another part of the scoping review,” she said. “We're also seeing problems with chronic impetigo, boils, MRSA, all of these types of bacterial skin infections in those with uncontrolled eczema in rural and indigenous children, across all fronts.”

She’s seen a number of patients with skin lichenification: something she refers to as ‘elephant skin’. 

“It comes to a point where often our first line topical therapies don't penetrate and treat it, or it can take months,” she said. “We have to escalate therapy in these patients, so that can put them at risk for other side effects. We need to prescribe things like immunosuppressants, like methotrexate, or biologic targeted therapy if it's all over the skin. They can't be put in creams everywhere."

After Asiniwasis asked her young patients and their caregivers to describe barriers to healing their skin, they spoke of long wait times to see dermatologists, often travelling hundreds of kilometres at their own cost to seek care. 

They also described the cost of skin care products in northern communities as ‘hyper-inflated’. Her patients and their families also face a sharp learning curve, as they adhere to strict bathing regimens, moisturizing, recognizing signs of infection, and learning to use topical ointments effectively. 

Asiniwasis said resources in rural and northern communities for follow-up care are often limited. 

“We can really tell someone a a lot about someone's health by looking at their skin.”