Two-Thirds of Appalachian Counties Have No Dermatologist, Registry Analysis Finds

A sweeping new analysis of physician records has revealed a stark picture of skin care access in one of America’s most medically underserved regions. Researchers combing through the National Plan and Provider Enumeration System, the federal registry that assigns unique National Provider Identifier numbers to every health care professional in the United States, found that 65.5 percent of Appalachian counties have no dermatologist at all. Of the 423 counties spread across 13 states that make up the Appalachian region as defined by the Appalachian Regional Commission, only a minority can claim even a single skin specialist, leaving millions of residents potentially hours away from the nearest expert in diagnosing skin cancer, psoriasis, or blistering autoimmune disease.

The study, published as a short report in Archives of Dermatological Research, was conducted by a team from Northeast Ohio Medical University led by medical students Jacob Fay and Natasha Salmen, with dermatologist Eliot Mostow serving as principal investigator. Their approach was elegantly simple: they queried the NPPES registry for providers listing a dermatology taxonomy code and matched each provider’s primary address zip code to the Appalachian Regional Commission’s interactive mapping tool, which delineates the region’s county boundaries. This cross-sectional methodology allowed them to generate a county-by-county census of dermatologists without relying on surveys or voluntary self-reporting, two approaches that often undercount or skew physician workforce data.

The numbers they assembled are striking in their unevenness. In total, 870 dermatologists were identified across the entire 205,000-square-mile region, a stretch that runs from southern New York to northeastern Mississippi. Pennsylvania reported the highest count at 238 dermatologists, while Mississippi reported the lowest at just 10 spread across 24 Appalachian counties. The median county density was 0.00 dermatologists per 100,000 residents, a figure that technically means more than half of all Appalachian counties contain no dermatologist whatsoever. The interquartile range of 0.00 to 2.01 per 100,000 underscores how compressed the distribution is: even among counties that do have specialists, most have only a handful.

Concentration is the defining feature of the data. The ten counties with the most dermatologists collectively accounted for 409 of the 870 providers, or 47.0 percent of the entire regional workforce. In other words, fewer than 2.4 percent of Appalachian counties host nearly half of the region’s skin specialists. This pattern mirrors a well-documented national trend. Previous research published in JAMA Dermatology has shown that dermatologist density in the United States is strongly correlated with urbanization, with rural counties consistently falling below urban ones in specialists per capita. The Appalachian analysis extends that finding into a region where rurality, mountainous terrain, and economic hardship compound one another.

To capture that variation, the researchers turned to the Appalachian Regional Commission’s own subregional framework, which divides the region into five zones: North, North Central, South, South Central, and Central Appalachia. Aggregated dermatologist density ranged from a high of 4.27 per 100,000 residents in South Central Appalachia to a low of 1.41 per 100,000 in Central Appalachia, the subregion that includes eastern Kentucky and southern West Virginia. Even the best-performing subregion falls short of densities reported in major metropolitan areas nationally, and the gap between the highest and lowest subregions is roughly threefold, suggesting that scarcity is not evenly shared even within this already disadvantaged region.

Perhaps the most sobering finding emerged when the researchers cross-referenced dermatologist presence with the Appalachian Regional Commission’s county economic classification system, which grades counties from distressed to attainment based on unemployment, income, and poverty metrics. Distressed counties, the most economically struggling tier, lacked a dermatologist in 70 of 77 cases, a rate of 90.9 percent. By contrast, competitive counties lacked one in only 28.6 percent of cases, and attainment counties, the strongest economic tier, had a dermatologist in every single one of the three counties so classified. The gradient is nearly monotonic: as economic status improves, the probability of having local skin care access rises sharply, a correlation that hints at the self-reinforcing nature of regional health disadvantage.

The clinical stakes of this shortage are considerable. Dermatology is a visually diagnostic specialty, and conditions such as melanoma depend heavily on early detection for favorable outcomes. Melanoma mortality in rural America has been rising even as urban rates stabilize, and delayed diagnosis of skin cancers, infections, and inflammatory diseases is a plausible downstream consequence of specialist scarcity. Patients without a local dermatologist must weigh long drives over mountain roads, lost wages, and childcare against the perceived urgency of a suspicious mole or a worsening rash, and many simply defer care until disease progresses. The study’s authors note that limited dermatologic care in these areas may contribute to the poor health outcomes that have long characterized the region.

The researchers are candid about the limitations of their method. The NPPES registry records a provider’s primary practice address, which may not reflect where the clinician actually sees patients; some dermatologists listed in urban-adjacent counties may hold outreach clinics elsewhere, while others may have retired or changed specialties without updating their registry information. The cross-sectional design also captures only a single moment in time, so it cannot track whether the workforce is growing or shrinking. Taxonomy-based identification may likewise miss physicians who perform dermatologic procedures under different designations. These caveats mean the true picture could be somewhat better or worse than the snapshot suggests, though the authors argue the overall pattern of severe maldistribution is robust.

What emerges from the data is a roadmap for intervention. The authors point to expanded service models, most notably teledermatology, in which store-and-forward imaging or live video consultations connect primary care providers in underserved counties with board-certified dermatologists elsewhere. Teledermatology has shown strong diagnostic concordance with in-person evaluation for many conditions and could dramatically shrink the effective distance between Appalachian patients and specialist expertise. They also advocate targeted workforce planning aimed at the persistently underserved counties identified in the analysis, alongside outreach clinics and mobile services that bring periodic specialist care into communities that would otherwise never see it. Because the study pinpoints exactly which counties lack providers, it offers policymakers a concrete prioritization list rather than a vague call for attention.

Beyond its immediate findings, the study demonstrates the power of publicly available administrative data to illuminate health care deserts with remarkable granularity. The NPPES registry is free, comprehensive, and updated continuously, making it a reusable surveillance tool for any specialty or region. As the United States grapples with a projected physician shortage and widening rural-urban health gaps, this kind of registry-driven mapping offers a low-cost way to direct resources where they are needed most. For the residents of the 277 Appalachian counties without a single dermatologist, the hope is that precise data will translate into political will, and that the next census of the region’s skin specialists will find far fewer empty counties on the map.

Subject of Research: Geographic distribution of dermatologists and dermatologic care access across the Appalachian region

Article Title: A cross-sectional analysis of the distribution of dermatologists in the appalachian region using the national plan and provider enumeration system national provider identifier registry

Article References: A cross-sectional analysis of the distribution of dermatologists in the appalachian region using the national plan and provider enumeration system national provider identifier registry. (n.d.). https://doi.org/10.1007/s00403-026-04903-1

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04903-1

Keywords: dermatology, Appalachia, physician distribution, health disparities, NPPES registry, rural health, teledermatology, workforce shortage, skin cancer, health care access, Appalachian Regional Commission, cross-sectional study