Global Skin Disease Morbidity and Mortality
An Update From the Global Burden of Disease Study 2013
Chante Karimkhani, MD; Robert P. Dellavalle, MD, PhD, MSPH; Luc E. Coffeng, MD, PhD; Carsten Flohr, MD, MSc, PhD, FRCP;
Roderick J. Hay, DM, FRCP; Sinéad M. Langan, MSc, PhD; Elaine O. Nsoesie, PhD; Alize J. Ferrari, PhD; Holly E. Erskine, PhD;
Jonathan I. Silverberg, MD, PhD, MPH; Theo Vos, MD, Msc, PhD; Mohsen Naghavi, MD, PhD
IMPORTANCE
Disability secondary to skin conditions is substantial worldwide. The Global
Burden of Disease Study 2013 includes estimates of global morbidity and mortality due to
skin diseases.
OBJECTIVE To measure the burden of skin diseases worldwide.
DATA SOURCES For nonfatal estimates, data were found by literature search using PubMed
and Google Scholar in English and Spanish for years 1980 through 2013 and by accessing
administrative data on hospital inpatient and outpatient episodes. Data for fatal estimates
were based on vital registration and verbal autopsy data.
STUDY SELECTION Skin disease data were extracted from more than 4000 sources including
systematic reviews, surveys, population-based disease registries, hospital inpatient data,
outpatient data, cohort studies, and autopsy data. Data metric s included incidence,
prevalence, remission, duration, severity, deaths, and mor tality risk.
DATA EXTRACTION AND SYNTHESIS Data were extracted by age, time period, case definitions,
and other study characteristics. Data points were modeled with Bayesian meta-regression to
generate estimates of morbidity and mortality metrics for skin diseases. All estimates were
made with 95% uncertainty intervals.
MAIN OUTCOMES AND MEASURES Disability-adjusted life years (DALYs), years lived with
disability, and years of life lost from 15 skin conditions in 188 countries.
RESULTS Skin conditions contributed 1.79% to the global burden of disease measured in
DALYs from 306 diseases and injuries in 2013. Individual skin diseases varied in size from
0.38% of total burden for dermatitis (atopic, contact, and seborrheic dermatitis), 0.29% for
acne vulgaris, 0.19% for psoriasis, 0.19% for urticaria, 0.16% for viral skin diseases, 0.15% for
fungal skin diseases, 0.07% for scabies, 0.06% for malignant skin melanoma, 0.05% for
pyoderma, 0.04% for cellulitis, 0.03% for keratinocyte carcinoma, 0.03% for decubitus ulcer,
and 0.01% for alopecia areata. All other skin and subcutaneous diseases composed 0.12% of
total DALYs.
CONCLUSIONS AND RELEVANCE Skin and subcutaneous diseases were the 18th leading cause
of global DALYs in Global Burden of Disease 2013. Excluding mortality, skin diseases were the
fourth leading cause of disability worldwide.
JAMA Dermatol. 2017;153(5):406-412. doi:10.1001/jamadermatol.2016.5538
Published online March 1, 2017. Last corrected on May 10, 2017.
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Author Affiliations: Author
affiliations are listed at the end of this
article.
Corresponding Author: Chante
Karimkhani, MD, University Hospitals
Case Western Medical Center, 408 W
St Clair Ave, Unit 317, Cleveland, OH
44113 (ck2525@caa.columbia.edu).
Research
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G
lobal disability and mortality due to skin disease has
been investigated by the Global Burden of Disease
(GBD) 2013 Study. The GBD is a collaboration of more
than 1000 experts worldwide, aiming to create a systematic,
quantified, and internally consistent source of health
information.
1
Based at the Institute for Health Metrics and
Evaluation and funded by the Bill and Melinda Gates Founda-
tion, GBD 2013 provides disability and mortality metrics for
diseases, injuries, and risk factors stratified by age, sex, loca-
tion, and time.
2,3
Disease burden was estimated using the
metric of disability-adjusted life year (DALY), which is the sum
of years of life lost to a disease (YLLs) plus years lived with
disability (YLDs). One DALY is equivalent to 1 year of healthy
life lost.
4(pp6-7)
This measurement unit allows for cross-
comparison of diverse disease states. The goal of GBD is to pro-
duce the highest-quality epidemiologic data by ensuring trans-
parent analytic strategies that include uncertainty distributions,
promote internal consistency, and allow iterative revisions over
time. Each GBD iteration incorporates new studies and im-
proved methodology, creating a “living” database to inform
clinical, research-oriented, and policy-making decisions. This
rolling design of the data set allows for the addition of new data
sources and improvements to the methods of estimation.
Global Burden of Disease 2013 made estimates for 306 dis-
eases and injuries in 188 countries. As GBD researchers and col-
laborators, we present results for 15 dermatologic conditions.
Methods
The analyses were carried out by the team members of the
Institute of Health Metrics and international skin experts with
an interest in dermatoepidemiology. The following skin con-
ditions were selected based on available data, standardized
disease definitions, and prevalence: dermatitis (including the
common varieties of eczema: atopic, seborrheic, and contact
dermatitis), psoriasis, cellulitis, pyoderma, scabies, fungal skin
diseases, viral skin diseases, acne vulgaris, alopecia areata, pru-
ritus, urticaria, decubitus ulcer, malignant skin melanoma, and
keratinocyte carcinoma (including basal and squamous cell car-
cinomas). An additional category, “other skin and subcutane-
ous diseases,” encompasses the remainder of miscellaneous
skin conditions.
5
International Classification of Diseases, Ninth
Revision (ICD-9) and ICD-10 codes were used to define each of
the 15 skin disease categories (eTable 1 in the Supplement).
The initial step in the GBD estimation strategy was a thor-
ough investigation of the world literature using PubMed and
Google Scholar for data on the incidence, prevalence, remis-
sion, duration, severity, and mortality risk (only applicable for
selected skin diseases) of the 15 skin conditions. Data were ex-
tracted by age, time period, and with information defining
uncertainty (standard error, confidence interval, or numerator/
denominator). Searches were performed in English and Span-
ish languages for the years 1980 through 2013. Data were ex-
tracted from more than 4000 sources including systematic
reviews, surveys, population-based disease registries, hospi-
tal inpatient data, outpatient data, and cohort studies. Most
incidence data for certain skin diseases were obtained from 3
medical record sources: (1) inpatient data from Europe, Latin
America, and the United States, (2) outpatient data predomi-
nantly from the United States, and (3) in the case of basal cell
and squamous cell carcinoma of the skin, registry data where
it included keratinocyte carcinoma, for example, Northern
Ireland Cancer Registry, 2010 (see eTable 2 in the Supplement
for all GBD 2013 skin disease data sources).
Data points from the aforementioned literature search were
analyzed in a Bayesian meta-regression modeling tool,
DisMod-MR 2.0, to yield prevalence estimates that are con-
sistent with the other available epidemiological parameters for
each of the skin conditions. All estimates were generated with
1000 draws from the posterior distribution of the quantity of
interest, which allows for generation of 95% uncertainty
intervals. Compared with the previous GBD 2010 study,
DisMod-MR was recoded and optimized to run up to 50 times
faster and shifted from a negative binomial to an offset log-
normal model.
6
The literature search for GBD 2013 compared with GBD
2010 doubled the data set for psoriasis with an additional 30
prevalence and 5 incidence studies. Psoriasis was also mod-
eled with a smaller remission assumption (0.05-0.15 remit-
ted cases per case per year), better reflecting a chronic dis-
ease pattern. Of note, the GBD definition of remission is the
rate at which cases stop fulfilling the case definition, that is,
cure. For cellulitis, 13 191 incidence data points from both in-
patient and outpatient samples were added. No additional data
sources were added for pyoderma in GBD 2013. However, du-
ration of disease was decreased from approximately 1 year in
GBD 2010 to between 2 weeks for treated disease to 4 weeks
for untreated disease in GBD 2013. For fungal skin diseases,
prevalence was estimated separately for tinea capitis and “other
fungal skin diseases.” Similarly, prevalences of viral warts and
molluscum contagiosum were modeled separately and then
summarized as “viral skin diseases.” In GBD 2010, studies for
“itch” were used as prevalence of pruritus, which inaccu-
rately included cases of pruritic skin and nonskin conditions.
Comparatively, GBD 2013 included only outpatient data from
Norway and the United States and several data points from the
literature of patients with a diagnosis of pruritus (excluding
known causes of itch). While no additional data sources were
Key Points
Question What is the burden of skin disease worldwide?
Findings In this observational study, skin diseases contributed
1.79% to the global burden of disease measured in
disability-adjusted life years (DALYs). Skin diseases arranged in
order of decreasing global DALYs are as follows: dermatitis (atopic,
contact, seborrheic), acne vulgaris, urticaria, psoriasis, viral skin
diseases, fungal skin diseases, scabies, melanoma, pyoderma,
cellulitis, keratinocyte carcinoma, decubitus ulcer, and alopecia
areata.
Meaning Skin diseases remain a major cause of disability
worldwide. An objective measure of burden, such as the DALY,
allows for comparison of diverse diseases across geography and
time.
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added, acne vulgaris modeling in GBD 2013 no longer as-
sumes that reported data include asymptomatic cases be-
cause most data points were based on examination and there-
fore would reflect symptomatic cases. For alopecia areata, GBD
2013 applied lower estimates from the largest data source (out-
patient data from the United States). No new data sources for
urticaria were added; however, similarly to the case for acne
vulgaris, GBD 2013 urticaria data points reflect solely symp-
tomatic cases. For decubitus ulcer, input data were incidence
from hospital admission and outpatient data. In GBD 2010, im-
plausible duration estimates led to an overestimate of preva-
lence, which has been corrected in GBD 2013. Global Burden
of Disease 2013 set bounds on the remission rate from 0.5 to 6
corresponding to duration range of 2 months to 2 years.
Years lived with disability due to skin cancers were esti-
mated for 4 different sequelae: (1) diagnosis and treatment,
(2) remission, (3) metastatic disease, and (4) terminal dis-
ease. The survival timeframe was extended from 5 to 10 years.
The duration of diagnosis and treatment for keratinocyte car-
cinoma was taken as the same as for melanoma from Neal
et al
7
(duration until diagnosis plus 2 months for treatment).
As defined by Neal et al,
7
duration until diagnosis included days
from first presentation in general practice (GP) to referral or
GP biopsy, days from referral to first seen in clinic, days from
first seen in clinic to biopsy/wide local excision for GP exci-
sions, and days from presentation to biopsy/wide local exci-
sion for GP excisions. Duration of the remission sequela is based
on time until death or 5 years for survivors minus duration of
the other sequelae. Duration of disseminated disease was based
on Nolan et al
8
for lethal keratinocyte skin cancers and on
Surveillance, Epidemiology, and End Results
9
analysis of
median survival for patients with stage IV melanoma.
Prevalence estimates from the estimation strategy were
combined with disability weights to yield skin disease mor-
bidity, expressed in YLDs, for each age-sex-country-year
group. Disability weights, which range from 0 to 1 for each
condition, were derived from 4 population-based European
surveys (30 660 respondents) and the GBD 2010 disability
weight surveys (30 230 respondents) eliciting response to
the question “who is the healthier?” for randomly chosen
pairs of health states. Health states were presented with a
short lay description. For parsimony, a smaller number (235)
of health states were designed to cover the spectrum of dis-
ability across all 2337 disease sequelae. The most commonly
used health states for skin disease were 3 levels of severity of
disfigurement with or without itch and/or pain.
10
The lay
descriptions for disfigurement assessed in the disability
weight surveys include psychological morbidity attributable
to each skin disease. The mild infectious disease health state
was also used for bacterial, fungal, and viral skin diseases.
See Table 1 for descriptions of health states used to generate
disability weights for skin diseases.
Deaths and YLLs were estimated for the following 6 skin
categories: malignant skin melanoma, keratinocyte carci-
noma, cellulitis, pyoderma, decubitus ulcer, and other skin and
subcutaneous diseases. The Cause of Death Ensemble Model
(CODEm) tool was used to produce mortality estimates based
on data on causes of death from the extensive GBD collection
of vital registration and verbal autopsy data.
11
The CODEm strat-
egy uses a range of plausible models and predictive covari-
ates for each cause and chooses the best-performing models
to yield predictions for cause-specific death estimates with
uncertainty intervals. The YLLs for each age-sex-country group
are the multiplication of death counts at the age at death by
remaining life expectancy from the GBD standard life table that
is applied equally to all countries and periods.
2
Mortality from
the remaining skin conditions was assumed to be 0.
Morbidity (YLD) and mortality (YLL) estimates were added
for each age-country-sex group to yield DALYs, which are re-
ported as numbers, percent of total DALYs from all condi-
tions studied by GBD, and the DALY rate per 100 000 per-
sons. Estimates were made for both sexes and 21 age groups
ranging from the first week of life to older than 80 years, as
well as age-standardized estimates. Age standardization was
applied based on the standard population structure of popu-
lation in 2010 through 2035 as estimated for GBD 2013 based
on the most recent World Population Prospects by the United
Nations Population Division.
11,12
Finally, the GBD analysis was
computed for 188 countries grouped into 21 GBD world
regions.
13
The Global Burden of Disease Study has institu-
tional review board approval through March 25, 2018, from the
University of Washington.
Table 1. Skin Disease Disfigurement Health States and Disability Weights
Disfigurement
Health State Description
Disability Weight Value
(95% CI)
Disfigurement, level 1 This person has a slight, visible physical deformity that others notice, which causes
some worry and discomfort.
0.011 (0.005-0.021)
Disfigurement, level 2 This person has a visible physical deformity that causes others to stare and comment.
As a result, the person is worried and has trouble sleeping and concentrating.
0.067 (0.044-0.096)
Disfigurement, level 3 This person has an obvious physical deformity that makes others uncomfortable, which
causes the person to avoid social contact, feel worried, sleep poorly, and think about suicide.
0.405 (0.275-0.546)
Disfigurement,
level 1 with itch/pain
This person has a slight, visible physical deformity that is sometimes sore or itchy.
Others notice the deformity, which causes some worry and discomfort.
0.027 (0.015-0.042)
Disfigurement,
level 2, with itch/pain
This person has a visible physical deformity that is sore and itchy. Other people stare
and comment, which causes the person to worry. The person has trouble sleeping and
concentrating.
0.188 (0.125-0.267)
Disfigurement,
level 3, with itch/pain
This person has an obvious physical deformity that is very painful and itchy. The physical
deformity makes others uncomfortable, which causes the person to avoid social contact,
feel worried, sleep poorly, and think about suicide.
0.576 (0.401-0.731)
Infectious disease,
acute episode, mild
This person has a low fever and mild discomfort, but no difficulty with daily activities. 0.006 (0.002-0.017)
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Results
Skin and subcutaneous diseases were responsible for 41.6 mil-
lion DALYs and 39.0 million YLDs in 2013. The age-standardized
percent change in DALY rate from 2005 to 2013 was 0.1%. Table 2
lists age-standardized DALY rates per 100 000 persons, percent
change in DALY rates from 2005 to 2013, and all-age DALYs for
the 14 skin conditions and the other skin and subcutaneous dis-
eases category. Results are presentedin orderof decreasing DALY
rate. Dermatitis, which includes estimates for atopic, seborrheic,
and contact dermatitis, is responsible for the largest global bur-
den of DALYs and YLDs. While cellulitis causes an intermediate
global burden compared with the other skin conditions, it expe-
rienced the greatest decline from 2005 to 2013 and was the only
skin condition with a significant change. This change was due
to a decrease in death estimates.
The age-stratified breakdown for the skin conditions is
shown in Figure 1. Due to age restrictions, estimates for pa-
tients younger than 1 year were only available for the follow-
ing conditions: cellulitis, pyoderma, scabies, and fungal and
viral skin diseases. In addition, the age categories of 1 to 4, 5
Figure 1. Age Distribution of Skin and Subcutaneous Disease Burden
1200
1000
800
600
400
200
0
DALY Rate per 100
000 Persons
Other skin and
subcutaneous diseases
Decubitus ulcer
Urticaria
Pruritus
Alopecia areata
Acne vulgaris
Viral skin diseases
Fungal skin diseases
Scabies
Pyoderma
Cellulitis
Psoriasis
Dermatitis
Keratinocyte carcinoma
Melanoma
Age
0-6 7-27 28-364 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80
Days Years
This figure shows disability-adjusted life year (DALY) rate per 100 000 persons from 15 skin disease categories throughout the human life span.
Table 2. Age-Standardized Disability-Adjusted Life Year (DALY) Rates per 100 000 Persons, Percent Change in DALY Rate From 2005-2013,
and DALYs for the 15 Skin Conditions
Skin Condition
Age-Standardized DALY Rate
per 100 000 Persons
(95% UI)
Change in DALY Rate
2005-2013,
% (95% UI)
DALYs, Millions
(95% UI)
YLDs
(95% UI)
Dermatitis 128.7 (83.6 to 184.9) 0.1 (−0.4 to 0.6) 9.3 (6.0 to 13.3) 9.3 (6.0 to 13.3)
Acne vulgaris 96.7 (46.4 to 177.8) −0.5 (−6.5 to 7.7) 7.2 (3.4 to 13.2) 7.2 (3.4 to 13.2)
Urticaria 67.0 (43.2 to 95.5) 4.3 (−9.4 to 16.1) 4.7 (3.0 to 6.7) 4.7 (3.0 to 6.7)
Psoriasis 66.8 (46.0 to 93.6) −0.5 (−1.6 to 0.6) 4.7 (3.2 to 6.6) 4.7 (3.2 to 6.6)
Viral skin diseases 54.7 (33.3 to 85.0) −0.6 (−1.5 to 0.3) 4.0 (2.4 to 6.2) 4.0 (2.4 to 6.2)
Fungal skin diseases 54.0 (22.1 to 114.2) 1.0 (0.5 to 1.4) 3.8 (1.6 to 8.1) 3.8 (1.6 to 8.1)
Scabies 23.5 (13.3 to 37.3) −2.8 (−10.2 to 6.7) 1.7 (0.97 to 1.7) 1.7 (0.97 to 1.7)
Melanoma 23.2 (18.1 to 31.1) −6.1 (−13.0 to −0.8) 1.6 (1.2 to 2.1) 0.14 (0.092 to 0.22)
Pyoderma 16.6 (13.0 to 19.3) 6.4 (−7.2 to 21.3) 1.1 (0.89 to 1.3) 0.033 (0.012 to 0.072)
Cellulitis 15.5 (11.8 to 20.2) −13.2 (−21.1 to −1.7) 1.1 (0.81 to 1.4) 0.12 (0.079 to 0.17)
Keratinocyte carcinoma 12.9 (10.8 to 16.3) −6.2 (−10.7 to 0.0) 0.82 (0.68 to 1.0) 0.13 (0.082 to 0.19)
Decubitus ulcer 10.8 (9.1 to 12.7) −0.8 (−5.8 to 4.6) 0.66 (0.55 to 0.78) 0.28 (0.20 to 0.37)
Alopecia areata 4.2 (2.7 to 6.3) −0.1 (−2.9 to 2.7) 0.29 (0.19 to 0.43) 0.29 (0.19 to 0.43)
Pruritus 0.2 (0.1 to 0.3) 0.9 (−6.2 to 8.6) 0.011 (0.0051 to 0.020) 0.0011 (0.0051 to 0.0020)
Other skin and
subcutaneous diseases
44.2 (19.8 to 93.3) 0.4 (−0.7 to 1.6) 3.0 (1.4 to 6.2) 2.9 (1.3 to 6.1)
Abbreviations: UI, uncertainty interval; YLDs, years lived with disability.
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to 9, and 10 to 14 years had no DALY estimates for melanoma
or keratinocyte carcinoma. Dermatitis burden remains rela-
tively consistent throughout all age categories, in compari-
son with acne vulgaris, which causes the greatest burden be-
tween the first and third decades of life. Skin conditions with
the greatest burden in younger ages also include infectious
causes, such as viral skin diseases (mostly viral warts), bacte-
rial skin diseases (pyoderma and cellulitis), and scabies. Bur-
den from psoriasis, alopecia areata, urticaria, fungal skin dis-
eases, and decubitus ulcer is greater in older age categories.
Keratinocyte carcinoma and melanoma burden increase over
the human age-span, with the greatest DALY rates in those older
than 75 years.
Melanoma causes the greatest burden in Australia, fol-
lowed by high-income North America, Western Europe, and
Central Europe (Figure 2). Similarly, keratinocyte carcinoma
causes the greatest burden in Australasia, the Caribbean,
Central Latin America, and tropical Latin America. Dermati-
tis burden follows a similar geographic predominance, with
a high DALY rate in central sub-Saharan Africa. Psoriasis
causes the greatest burden in Australasia, Western Europe,
high-income Asia-Pacific, and southern Latin America.
Burden from acne vulgaris is greatest in Western Europe,
high-income North America, and southern Latin America.
Central, western, and eastern sub-Saharan Africa, along
with Oceania, have the highest DALY rates from cellulitis.
Burden from urticaria is evenly distributed among
world regions. Decubitus ulcer has the greatest DALY rate
in Oceania.
Discussion
The importance of the skin disease global burden can be ap-
preciated by comparing the skin results presented here as
DALYs or YLDs with the 158 disease and injury categories at
level 3 of the GBD 2013 hierarchy.
14,15
Comparing absolute
DALYs and/or YLDs, skin and subcutaneous diseases were the
18th leading cause of global DALYs and the fourth leading cause
of nonfatal burden in GBD 2013. Burden from skin diseases
(41.0 million DALYs) ranked directly behind iron deficiency
anemia (43.7 million DALYs), tuberculosis (49.8 million DALYs),
and sense organ diseases (54.4 million DALYs). As a reference
point, the leading cause of global DALYs over the past decade
has been ischemic heart disease, responsible for 150.2 mil-
lion all-age DALYs in 2013. Excluding mortality, YLDs from skin
diseases (36.4 million) are larger than those caused by diabe-
tes mellitus (29.5 million) and migraines (28.9 million).
A commitment to accurate, transparent, and frequently
updated metrics of disease burden has the potential to affect
diverse levels of health care and further the role of dermatol-
ogy in global health. The objectives of GBD are aligned with
efforts of international organizations such as the World Health
Organization and the United Nations.
16
An example of derma-
tology research and leadership as a global collaboration is the
International Federation of Dermatology Clinical Trials
Network.
17
This organization promotes the development of
standardized and transparent clinical trials in dermatology, in-
dependent of industry. Dermatologists have an important role
Figure 2. Regional Distribution of Skin and Subcutaneous Disease Burden
1200
1000
800
600
400
200
0
DALY Rate per 100
000 Persons
Andean Latin America
Australasia
Caribbean
Central Asia
Central Europe
Central Latin America
Central sub-Saharan Africa
East Asia
Eastern Europe
Other skin and
subcutaneous diseases
Decubitus ulcer
Urticaria
Pruritus
Alopecia areata
Acne vulgaris
Viral skin diseases
Fungal skin diseases
Scabies
Pyoderma
Cellulitis
Psoriasis
Dermatitis
Keratinocyte carcinoma
Melanoma
Eastern sub-Saharan Africa
High-income Asia-Pacific
High-income North America
North Africa and Middle East
Oceania
South Asia
Southeast Asia
Southern Latin America
Southern sub-Saharan Africa
Tropical Latin America
Western Europe
Western sub-Saharan Africa
This figure shows disability-adjusted life year (DALY) rate per 100 000 persons from 15 skin disease categories throughout 21 world regions.
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