Pacific people living in New Zealand are most commonly referred with eczema to dermatologists

There is a lack of research regarding dermatological conditions affecting Pacific people in the Pacific Islands.¹ In New Zealand, Pacific people, made up of 17 ethnic groups, accounted for 8% of the population in 2018,² and 5.4% in our district.³ In existing literature, Māori and Pacific patients have been grouped as one ethnic group.^4,5 

Eczema, pityriasis versicolor and tinea are the three most common reasons for seeking specialist dermatology care in the Pacific Islands.^1,6 In Samoa, one-quarter of 75 patients presenting to a 4-day clinic were diagnosed with eczema.¹ In a series of dermatology clinics in Samoa and Vanuatu assessing 1,072 patients, 21% were diagnosed with eczema.⁶ One cross-sectional United States study found that Asians/Pacific Islanders visited physicians for atopic dermatitis six times more often than Caucasians with white skin.⁷

In New Zealand, eczema is known to affect Pacific children more frequently than children of other ethnicities.⁸ In a survey involving more than 11,000 children and adolescents conducted in five New Zealand regions from 2001 to 2003, eczema was estimated to affect 16% of Pacific children, compared to 10% of other ethnicities.⁸ Skin infection disproportionately affects Pacific children living in New Zealand, who have a higher rate of hospitalisation for severe skin infection compared with other ethnic groups, with Pacific children being 4.5 times more likely to be hospitalised for skin infection.⁹

Less is known about other dermatological conditions among Pacific adults in New Zealand. Māori/Pacific people have 2.47 times increased relative risk of all types of cutaneous lupus compared to those of European ancestry.⁵ Pacific adults are disproportionately hospitalised for severe skin infection (cellulitis) compared to the total New Zealand population,¹⁰ and may have increased rates of psoriasis.⁴ In a 2016 study of 145 patients with cutaneous lupus, it was found that Māori/Pacific adults have a high relative risk of all types of lupus compared to Europeans, and Māori/Pacific children have a higher incidence of systemic lupus erythematosus compared to European children.⁵ Patients of Māori and Pacific ethnicity were over-represented in an audit of ethnicities of psoriasis patients treated in the Auckland District Health Board from 2009 to 2014.⁴

Method

We conducted an observational study of ethnicity data in electronic referrals to dermatology in the Waikato Region from January 2016 to May 2022. Referrals included suspected skin cancer and general skin condition referrals. Ethnicity was recorded according to the Stats NZ Ethnicity Data Protocols 2017.¹¹ Diagnoses made by the responding dermatologist were extracted from the electronic medical record for patients of Pacific ethnicity and recorded using ICD-10 coding. Simple statistical analyses were performed, with patient ethnicity and rates of dermatological diagnoses reported as a percentage. Ethics approval for the project was granted by the Health and Disability Ethics Committee (21/NTB/82).

View Figure 1–2, Table 1.

Results

Pacific ethnicity was recorded for 530 patients (1.7% of 30,769 referrals). Thirty-six percent of patients had eczema, 11% had benign skin lesions, 8.3% had an infection and 8.1% had psoriasiform disorder (Figure 2). No diagnosis was recorded for 3.9% of patients. Reasons for not receiving a diagnosis included the condition being undiagnosed, the referral being declined with further advice or the referrer providing insufficient information. Neoplasm was the least common reason for referral, with 2.2% of cases diagnosed as malignancy (Table 1). Malignant skin lesions included histology-confirmed basal cell carcinoma (0.8%), malignant neoplasm of unknown behaviour (0.4%), melanoma/melanoma in situ (0.6%) and squamous cell carcinoma/intra-epidermal carcinoma (0.4%).

The most common subtypes of eczema were atopic dermatitis, dermatitis not otherwise specified and discoid eczema. Dermatophyte infection was the most common subtype of infection, followed by bacterial infection. Twelve cases of cutaneous lupus erythematosus were referred to dermatology.

Discussion

There is a lack of research concerning dermatological conditions affecting people of Pacific ethnicity. In this observational study, Pacific people were under-represented (1.7%) compared to the district's population (5.4%).³ Pacific people are reported to present for general practitioner appointments at higher rates but receive fewer referrals (20% of Pacific people receive referrals to specialists versus the national average of 30%).¹² The impact of the inclusion of suspected skin cancer referrals on the total number of Pacific people referred is not known.

Various kinds of eczema were the most common reasons for referral, not unexpectedly. The percentage of referrals for eczema (36%) is higher than reported in the Pacific Islands (25.6%¹ and 21%⁶). Environmental or socio-economic factors may contribute to this. It is known that Pacific children in New Zealand have higher rates of eczema compared to children of other ethnicities.⁸ Further research should investigate rates of eczema among Pacific adults living in New Zealand compared to other ethnicities.

Limitations

The study was a snapshot of skin diseases and conditions in referrals of Pacific people.

• We did not analyse the referral population by age group nor evaluate the age groups of the whole referral database; the low referral rate may reflect the younger local Pacific population compared to other ethnicities.
• Our results may not reflect the incidence or prevalence of skin diseases in the population or patients presenting to primary care. The relatively high proportion of referrals for eczema in our study may reflect the recognition and treatment of common skin infections in primary care.
• No attempt was made to compare diagnoses made in referrals of patients with other ethnicities.