The Global Psoriasis Atlas (GPA) is a joint project of the ILDS (International League of Dermatological Societies), IFPA (International Federation of Psoriasis Associations), and IPC (International Psoriasis Council) delivered by staff based at the University of Manchester. Its goal is to provide the benchmark on the burden of psoriasis in all countries and regions throughout the world using comprehensive epidemiological data to inform research, policy, and healthcare.
Previous limited literature implied that psoriasis is a rare condition in the indigenous Inuit people of the Arctic regions, however personal observations by colleagues at the University of Copenhagen contradicted these findings. In part to address this discrepancy and to further our knowledge of the prevalence of psoriasis and access of patients to dermatological care, we undertook a pilot field study to examine the prevalence of skin diseases in East Greenland. This was in collaboration with colleagues from the Universities of Copenhagen, Zurich, Manchester and King’s College London. The intention for the preliminary study was to inform and link with the national population health survey that will take place in Greenland in 2023.
Greenland is the world’s largest island, three-quarters of which is covered by permanent ice sheet. The country has a population of 56,000 concentrated in the capital Nuuk, on the West coast, and smaller towns and settlements scattered along the coastline. Transportation is mainly by small flights, helicopter or boat as there are no connecting roads between towns or settlements. We visited Tasiilaq (formerly known as Ammassalik), the most populous community on the eastern coast of Greenland between 1st to 12th May 2022. Previous work by the University of Copenhagen colleagues on atopic dermatitis had facilitated contacts with the Tasiilaq community. The township is particularly difficult to access, even in early summer, requiring helicopter transportation from Kulusuk island further to the East. Tasiilaq has a population of 1931 people, a third of whom are under the age of 181.
The team gained ethical approval to promote study recruitment prior to our arrival through the local newspaper, radio station, posters and social media. A skin survey clinic for all adults with or without any skin complaints was established in the town community centre with separate areas for consent, examination and consultation. The study was supported by the local district hospital and a team of translators fluent in Danish and/or Greenlandic. Demographic and consultation information were entered into encrypted portable tablet devices. If the participant required treatment, a letter was dictated, and prescription arranged to be transported to the local dispensary situated in the town’s small hospital.
The team* reviewed a total of 295 participants, including 16 with psoriasis. 90% of the population are of Inuit background with public jobs or hunting and fishing as the main way of life for many inhabitants. Initial impressions are that psoriasis is present in the Inuit people, but its phenotype is different compared to the European population with thinner plaques, milder disease severity and a sebopsoriasis distribution. Interestingly, the individuals with psoriasis did not appear to have any associated comorbidities. There was a high prevalence of hand eczema, discoid eczema and lichen simplex chronicus. Rare skin disorders, including pustulosis, annular lichen planus and actinic prurigo were also seen.
The field study enabled the team to gain a deeper understanding of the presentation of skin diseases, comorbidities and treatments available in remote East Greenland. A particular challenge is the provision of medications and long-term follow-up. As there are no pharmacies in Greenland, drugs for each patient are dispensed free of charge by the local district hospitals. The list of drugs kept in stock is very limited and many topical treatments require shipping from Denmark. Furthermore, emollient and moisturiser availability are also limited and expensive to purchase as supplies by ships are only possible during the summer months when the sea ice melts, and the iceberg risk is at its lowest. Follow-up is invariably intermittent and access to specialist care is limited as there are no dermatologists in Greenland and the service is provided by tele-dermatology and 2-week consultation tours distributed between towns up to twice a year.
The GPA team will use the methodological knowledge and networking gained during the visit to design future research studies and to advocate for outreach engagement particularly in underserved populations and regions. The shared experience and important data collected will be submitted for presentation and journal publications. Ultimately, the aim is to ensure that every person will have access to the best available care for their skin, a key goal of the World Health Organization.
Manchester: Chris Griffiths, Rebekah Swan and Jingyuan Xu
King’s College London: Carsten Flohr and Su Lwin
Zurich: Julia-Tatjana Maul
Copenhagen: Morten Bahrt Haulrig, Tove Agner, Jacob Thyssen and Claus Zachariae
Nuuk: Lone Storgaard Hove