Skin Deep

Jen is a pleasant 68 year-old homeless woman who frequents the day shelter and shelter clinic.  She is familiar face to the Women of Means staff and has regular follow-up with one of our nurses for supplies.  Two weeks ago, as I was talking with another shelter guest, I noticed that Jen had a large 3inch x 3inch piece of gauze covering the left posterior-lateral region of her neck.  Concerned, I asked her if there was anything wrong and she informed me that she yet another methicillin-resistance Staph. aureus (MRSA) abscess for which she was being treated with the oral antibiotic Bactrim (trimethoprim-sulfamethoxazole).  Today, she approaches me to tell me that her neck infection has cleared up, but expresses extreme concern that “this just keeps happening over and over again” and asks me why and how she can make it stop.

MRSA is a strain of bacteria that is highly resistant to antibiotics, and therefore, very difficult to treat.  Jen has had multiple infections with this nasty bug over the 9 months, which include cellulitis (an infection of the superficial layers of the skin) of her left lower leg and a right groin abscess that have each taken over a month to resolve.  Last winter, she had multiple bouts of bronchitis, and one episode of pneumonia for which she had to be hospitalized. On top of this, Jen has a complex medical history that includes poorly-controlled hypertension currently being treated with clonidine (a antihypertensive drug), hypothyroidism on levothyroxine (thyroid replacement hormone), and eczema currently being treated with topical steroids. 

Jen is embarrassed by her continued MRSA infections, as she considers herself a clean person despite living in a shelter.  She describes to me her nightly routine of using hand sanitizer to wipe down her mattress – however, she has been unable to do so over the last 2-3 weeks due to the outbreaks of Norovirus in her shelter.  To compensate, she has been washing her hands more frequently, but this in turn, exacerbates her eczema and dry skin, now with multiple cracks in them.

Jen’s situation is an example of the web of medical complexities that many homeless women live in. While homeless individuals tend to have similar chronic medical problems as the general population, they are also plagued with additional dermatiologic disorders due to their living conditions.  This ranges from infestations by lice, bed bugs, and scabies to dermatitis from cold or chemical exposure.  Not only does Jen’s prior skin infectious predispose her to further skin infectious, her eczema and dry skin provide the small sites for bacteria innoculate an infection.  Jen’s question is a good one – with her living situation and skin condition, preventing further infections is a difficult task.  The best thing I can offer her today is my support and empathy, and together we agree to start with some baby steps – education and some lotion/hand sanitizer – to improve her health.