A skin problem can begin with something familiar. An itch that persists. A rash that returns. A patch that looks different from the rest of the skin. What happens next often depends on where a person lives and whether appropriate care is within reach.
The Global Access to Skin Health Observatory is a landmark global study led by Esther Freeman in collaboration with the International League of Dermatological Societies (ILDS) and L’Oréal Dermatological Beauty. Published in JAMA Dermatology, it brings together data from 158 countries representing 97% of the world’s population.
For India, the findings raise questions about where specialists practise, how patients reach them and what happens when treatment is delayed.
What the numbers miss
The study proposes a benchmark of 5.63 per lakh, derived from countries reporting adequate access to dermatological care. This, however, is a reference point, rather than a universal staffing prescription. Dr. Freeman, who is associate professor of dermatology at Harvard Medical School and director of global health dermatology at Massachusetts General Hospital, places India’s dermatologist density well below the benchmark at around 0.5 to 1 per lakh people.
Ramesh Bhat, the Indian co-author of the study and professor at Father Muller Medical College and head of research at Father Muller Research Centre, Mangalore, cautions against directly comparing India with Europe or the Americas, because their health systems differ. What surprises Prof Bhat is that shortages persist despite the number of postgraduate dermatology training seats. He points to the urban-rural divide, with a concentration of specialists in urban areas, and in many cities in southern India, while rural communities face a different reality, where access even to a doctor may be limited.
The study reports that, globally, 79% of dermatologists practise in urban areas. National averages can therefore conceal substantial local gaps. “Dermatologist density gives us an important starting point, but it does not tell us whether a patient can actually receive care,” Dr. Freeman says.
When care is delayed
For Prof Bhat, the consequences are visible in clinical practice. He identifies “delay in diagnosis, wrong treatment, steroid abuse” among the problems arising when appropriate care is unavailable. He singles out leprosy as a condition where delayed diagnosis has implications beyond the individual patient. His concern brings the discussion back to what happens before someone reaches a specialist and whether the treatment they receive along the way is appropriate.
Dr Freeman emphasises the breadth of skin disease, from common infections to chronic inflammatory conditions and neglected tropical diseases. She argues that skin health must be recognised as an essential part of healthcare, with investment directed towards services that already reach communities.
The question is, how to make those services capable of recognising and managing skin disease safely.
Bringing expertise closer
“We need more dermatologists, but we cannot train our way out of this problem with specialists alone,” Dr Freeman says. Primary-care physicians and health officers already manage substantial amounts of skin disease. She advocates practical training, essential medicines and clear referral pathways, allowing common conditions to be treated locally while complex disease and uncertain diagnoses reach specialists.
Prof Bhat also proposes that medical colleges adopt villages, strengthening their links with surrounding communities. He also sees a role for the district residency programme, which takes residents into district settings, and for health camps in reaching rural and tribal populations.
These approaches sit alongside his call for rural specialist clinics and teledermatology. His emphasis is on extending the reach of existing teaching institutions and services, while giving residents the training needed to work effectively beyond major urban centres.
Making remote advice useful
“Teledermatology can be implemented,” Prof Bhat says. But he cautions that training healthcare workers must not result in unqualified practice or drug misuse. Expanding access requires clarity about who can manage a condition and when specialist assessment is necessary.
Dr. Freeman makes a related point. Teledermatology and Artificial Intelligence use need trained frontline providers, available treatment, and reliable referral arrangements. A patient requiring a biopsy, urgent assessment or specialist therapy must still be able to obtain it. “The goal is not to replace dermatologists, but to make their expertise reach much further,” she says.
A remote consultation needs to connect with treatment and follow-up. Advice alone cannot resolve the practical difficulties of obtaining medicines or reaching a referral centre.
What progress should look like
In 2025, the World Health Assembly recognised skin diseases as a global public-health priority. The next step is translating that recognition into national funding and delivery plans.
Prof Bhat’s priorities include an adequate health budget and insurance coverage for dermatological medicines such as biologics and for procedures. He also calls for better training of dermatology residents and dermatology nursing as a separate speciality within nursing education. These proposals bring together workforce development, treatment affordability and rural services, addressing several barriers to appropriate dermatological care.
Measuring progress will require listening more closely to patients. Dr. Freeman acknowledges that the Observatory relied on national leaders and health-system informants, rather than patients directly. Future work should examine waiting times, travel, affordability and diagnostic delays, alongside outcomes and quality of life.
Her planned next phase will examine selected countries more closely to understand where clinicians choose to train and practise, what retains them in underserved areas and which models improve access in different settings. “Five years from now, success should not simply mean there are more dermatologists,” she says. “It should mean that where someone lives is less predictive of whether they can get appropriate care for their skin disease.”
For India, that would mean earlier recognition, appropriate treatment and dependable referral, with fewer patients left to navigate the gaps themselves.
(Dr. Monisha Madhumita is assistant professor, department of dermatology, Saveetha Medical College and Hospitals, Chennai. mail.monisha.m@gmail.com)
Published – October 12, 2026 07:00 pm IST
