The considerable inequality between countries as a result of wars and large percentages of some populations living below the poverty line has led to increases in migratory flows across borders. European countries have received large numbers of immigrants in recent years and Spain is no exception. As a result, the composition of our population has changed considerably with the arrival of immigrants from Africa, Asia, Latin America, and Eastern Europe.

The resulting sociodemographic changes call for a reanalysis of needs and priorities in all health care areas.1 Several studies have analyzed the sociodemographic characteristics and specific and general health care needs of the immigrant population in Spain.2,3

Few studies, however, have been conducted in dermatology,4 although there have been isolated reports of skin diseases in immigrant patients.5–7 A number of Spanish studies have also analyzed the peculiarities of skin disorders in dark-skinned individuals and shown that certain conditions are difficult to diagnose in these patients.8,9

In view of the growth of the immigrant population in Spain and the lack of studies on skin disorders in this population from the perspective of the health care system, we decided to analyze and compare the frequency of dermatology consultations and the prevalence of skin disorders in immigrant and nonimmigrant patients in Spain.

We conducted a prospective, descriptive, and analytical study of immigrant patients treated at any of the dermatology units in health care district number 19 in Alicante, Spain between February 1, 2005 and February 1, 2006. We analyzed the frequency of and reasons for consultation in this group and also designed a cross-sectional substudy of skin complaints diagnosed in Spanish patients to compare the prevalence of skin disorders in immigrant and nonimmigrant patients.

For the purpose of this study, we considered an economic immigrant to be someone who had been born outside the European Union (EU-25) or in a country that had a lower per capita gross domestic product than Spain in January 2005. This excluded immigrants from the United States, Switzerland, Norway, Canada, Japan, Iceland, Kuwait, and Israel. We also included children of immigrants, even if they had been born in Spain, and adopted children if they had been in Spain for fewer than 6 years.

The growing influx of immigrants in Spain has increased demands on the Spanish health care system. According to a study conducted in Zaragoza in 2004, immigrants accounted for 4% of all dermatology patients, while studies of demand for specialist outpatient care in the autonomous community of Madrid reported that immigrants accounted for 3.2% of all patients requiring nonurgent psychiatric care2 and 4.1% of those requiring neurological care.3 The Madrid studies were conducted in 2001 and 2002, a time when the immigrant population in the area accounted for 10% of the total population of the community. In our health district, consultations by immigrant patients accounted for 4.1% of all dermatology consultations in the study period, at a time when the immigrant population accounted for 11% of the population in Alicante and 8.2% of the overall Spanish population.

Like other authors, we found that immigrant patients are young (mean age, 29 years) and mostly female. National statistics for 2006, however, show that there were slightly more immigrant men than women in the country.11 The fact that we detected more women than men in our group might be because the majority of patients were from Latin America, and women outnumbered men in this subpopulation.11

It is important to study the characteristics of dermatology patients from other countries because, among other reasons, some patients in this population have skin types that are different from those of Spanish patients. Accordingly the frequency and form of presentation of certain diseases may vary. Furthermore, immigrants constitute a heterogeneous group of individuals from different geographic regions with specific sociodemographic characteristics that may also influence the prevalence of certain skin disorders.

The most common skin disorders detected in our study were eczema, nongenital warts, and acne. Only 1 other Spanish study to date has analyzed skin disorders in the immigrant population.4 In that study, the authors reported that infections in general, and fungal infections in particular, were the most common skin conditions in immigrant patients in Zaragoza. Our results are not directly comparable to theirs, however, as the Zaragoza study treated eczema and atopic dermatitis as separate entities. If the authors had considered atopic dermatitis to be a form of eczema, this would have been the most prevalent skin disorder among the immigrant patients they studied. Viral infections, including warts, made up the second most common group of skin diseases. Finally, the third most prevalent skin condition, acne, was also the third most frequent in our immigrant population.

In studies of immigrant populations outside Spain, Halder and Nootheti12 (Washington DC, USA), Taylor13 (New York, USA), and Child et al.14 (London, UK) have reported that acne and eczema, in that order, were the most common skin disorders in immigrants. In a study of Latin American immigrants in New York, the results of Sánchez15 coincided with ours in that the most common skin disorders were eczema, warts, and acne.

Eczema, which was the most frequent reason for consultation by immigrants in our study, encompasses a range of conditions, but the most prevalent ones were atopic dermatitis and chronic eczema. We think that skin type might favor the development of atopic dermatitis. The presentation of this condition is different in individuals with more highly pigmented skin, in which it takes on a color that is more violaceous than red, possibly making it more difficult to diagnose in primary care and leading to more referrals to the dermatologist. Occupation, as well as skin type, might play a role in the persistence of the condition as immigrants are often domestic workers or employed in building or hotel and restaurant trades.

Significant differences were found between immigrant and Spanish patients in the prevalence of certain skin disorders. These differences can be attributed to various factors. As mentioned, eczema is probably more common in immigrants because of their skin type and occupation. Skin type might also favor the development of xerosis in darker-skinned individuals, as might a lower use of moisturizing products, which might not be considered an essential item by immigrants, who tend to have fewer resources.Certain types of alopecia are common in black patients16 and this might partly explain why we observed more cases in immigrants than in Spanish patients. On the other hand, no cases of alopecia were observed in sub-Saharan immigrants, most of whom were black. The difference thus might be due to the fact that Latin American women consult more about hair loss. The lower prevalence of melanocytic nevi detected in the immigrant group can probably be explained by the fact that most of the patients analyzed had highly pigmented skin as melanocytic nevi are reported to be less common in individuals with a dark complexion.17–20

Similarly, the lower frequency of squamous cell carcinoma, actinic keratosis, and melanoma in the immigrant group would be attributable to skin type and younger age. Skin cancer is less common in individuals with darkly pigmented skin13,16,21,22 as melanin content and melanosome dispersion exert a protective effect.16 Furthermore, even though we only considered Spanish patients younger than 60 years in the comparison of skin disorder prevalence, the mean age of the Spanish patients was still higher than that of the immigrants and both squamous cell carcinoma and actinic keratosis are more common in older patients.23,24

A higher prevalence of lupus has been reported in black individuals than white individuals, although similar rates have been described in Latin Americans and whites.25 Because our immigrant group mostly consisted of Latin Americans, we expected to find a similar frequency of lupus in immigrant and nonimmigrant patients. However, this disease was actually more common in the Spanish group, possibly because this chronic condition requires many follow-up visits, increasing the number of consultations related to this diagnosis in the Spanish group.

We detected a higher frequency of pigmentation disorders in the immigrant group; this was to be expected as these disorders are more common in black, Latin American, and Asian individuals.12,13,15

The significantly higher frequency of infectious diseases we detected in immigrants coincides with the findings of Porta et al.,4 who reported higher rates of onychomycosis, tinea, genital warts, syphilis, and scabies in this population. In our study, only tinea, scabies, and herpes simplex infection were significantly more common in immigrants than in nonimmigrants; the higher percentages of molluscum contagiosum, onychomycosis, and pityriasis versicolor in immigrants, however, were not significantly different. In our study, immigrants had a higher frequency of scabies and tinea than Spanish patients, possibly because they live in more crowded living conditions with worse hygiene and sanitation.26 The higher prevalence of herpes simplex infection in the immigrant group might also be due to crowded living conditions, which facilitate the spread of disease, or indeed to stress, which is common among immigrants and can contribute to viral reactivation. Nongenital warts are very common in both immigrants and nonimmigrants. We believe that the higher frequency of warts detected in the Spanish patients in our series can be attributed to immigrants’ lower rate of consultation about this disease (due to greater health care access difficulties) rather than to a truly lower incidence in the immigrant population.

We would like to stress that we observed no cases of leprosy in any of the immigrant patients seen by the dermatology units during the study period (1 year). Even though leprosy is now typically associated with immigration, our findings indicate that this disease is not common in immigrants, and indeed, very few cases have been reported in Spain.27,28 Dermatologists should, nonetheless, remain alert to the possibility of leprosy in the immigrant population as an early diagnosis can prevent disabilities and the spread of disease.

The immigrant population in Spain is highly heterogeneous and includes individuals from countries with a very high prevalence of sexually transmitted diseases (STDs). Immigrants are considered to be at high risk of acquiring STDs for numerous reasons, including conditions associated with immigration, such as human trafficking, in addition to precarious social and economic conditions, and less stable partnerships.29,30 Nonetheless, we observed very few cases of STD in our immigrant population; there were just 14 cases of genital warts, which accounted for 1.1% of all the diagnoses in this group. This finding can be attributed to the fact that most STDs are treated at a specialist clinic in our area; this clinic guarantees anonymity and is easily accessible for immigrants as a national health service access card is not required.

Clinical research may have limitations related to study design, procedures, and data analysis. Our study has a number of limitations that may have influenced results. The cross-sectional design meant that we were unable to follow patients over time. Consequently, changes in disease activity were not recorded, and we might have missed certain diagnoses. For example, we observed no cases of rare tropical diseases such as onchocerciasis or leprosy. Additionally, because the data were collected by different dermatologists, our results might also have been influenced by interobserver variability; however, considering the organization of the Spanish health care system, it would have been practically impossible to have had all the immigrants seen by a single dermatologist. Finally, differences in the prevalence of certain disorders between immigrant and Spanish patients may have failed to reach statistical significance because of the small numbers of immigrants from certain geographic regions and the low frequency of certain disorders.

In conclusion, the most common reasons for consultation by immigrants in our health care district are eczema, nongenital warts, and acne. Furthermore, because the infections diagnosed most frequently in the immigrant group (nongenital warts, molluscum contagiosum, onychomycosis, scabies, and tinea) are common in many countries, it can be concluded that immigration in Spain does not pose a significant risk for the spread of imported skin diseases from tropical countries.

The authors declare that they have no conflicts of interest.