Global, Regional, and National Burdens of Viral Skin Diseases from 1990 to 2021: A Cross-Sectional and Time-Series Analyses

Abstract

Background: Viral skin diseases, particularly those caused by human papillomavirus (HPV), represent a major component of the global burden of infectious dermatoses. However, long-term global trends and socioeconomic inequalities remain insufficiently characterized.

Methods: Data were obtained from the Global Burden of Disease Study 2021, covering approximately 7.97 billion individuals. Incidence, prevalence, disability-adjusted life years (DALYs), and years lived with disability (YLDs) were analyzed. Age-standardized rates were calculated, and temporal trends were assessed using Joinpoint regression to estimate average annual percentage changes (AAPCs). Socioeconomic inequality was evaluated using the Slope Index of Inequality (SII) and Concentration Index (CI). Analyses were stratified by age, sex, country, region, and Socio-Demographic Index (SDI).

Results: Between 1990 and 2021, the global incidence, prevalence, and DALYs of viral skin diseases increased by 32.27%, 36.29%, and 35.81%, respectively. The age-standardized incidence rate declined slightly from 1134.3 to 1126.3 per 100,000. Increased age-specific incidence was observed among children < 15 years and adults aged 50–65 and 85–95 years, with consistently higher rates in males. Geographically, incidence and prevalence were highest in Germany and lowest in Israel. Burden indicators were generally greater in high-SDI regions, whereas lower-middle SDI regions showed continued growth. Projections indicate stable age-standardized incidence through 2046, with case numbers rising until around 2030 before plateauing.

Discussion: The increasing absolute burden despite stable standardized rates reflects population growth and aging. Disparities across SDI regions highlight the roles of socioeconomic factors and healthcare access. Although vaccination and antiviral advances have improved viral disease control in high-SDI regions, limited resources and healthcare disruptions constrain progress in low- and middle-SDI regions, underscoring the need for targeted, equitable interventions.

Conclusions: Viral skin diseases remain a substantial and evolving global health burden. Persistent age-, sex-, and socioeconomic-related disparities highlight the need for targeted prevention strategies and strengthened public health policies.

Graphical abstract

Keywords

viral skin diseases / human papillomavirus / Global Burden of Disease / health inequality / epidemiology

Introduction

Viral skin diseases are conditions affecting the skin and mucosa caused by viral infections, typically presenting with specific lesions such as vesicular, papular, nodular, or wart-like eruptions[1,2]. Susceptible populations span all age groups, from children to the elderly, with children being particularly vulnerable, making viral infections a leading cause of pediatric rashes. These skin and mucosal lesions are primarily attributed to infections caused by viruses such as human papillomavirus (HPV), herpesviruses, and enteroviruses. Viral skin diseases, exemplified by HPV-related conditions, pose a significant global public health burden, impacting patients’ quality of life and imposing substantial strain on healthcare resources and socio-economic systems[3,4].

Herpes simplex virus (HSV) includes two types, HSV-1 and HSV-2[5], both of which can cause skin and mucosal damage and establish latent infections within sensory ganglia[6]. Rubella virus infection during early pregnancy may lead to congenital rubella syndrome (CRS), which carries severe consequences, with approximately 100,000 CRS cases reported globally each year[7]. Viral warts, caused by HPV, result in proliferative skin lesions[8–10]. β-HPV, γ-HPV strains, and certain α-HPV types are linked to the development of viral skin diseases[11]. Clinically, these warts are classified into three main forms: common warts, plantar warts, and flat warts.

Previous studies have highlighted the significant global health burden posed by viral skin diseases. A 2013 study identified skin and subcutaneous diseases as the 18th leading cause of disability worldwide. Among skin diseases, viral skin conditions accounted for 1.79% of disability-adjusted life years (DALYs), representing 0.16% of the global disease burden and ranking sixth among all skin diseases[12]. A 2019 study further demonstrated an increase in the incidence and DALYs of viral skin diseases globally since 1990, with a disproportionate burden observed in younger populations and significant geographical disparities in disease burden[13]. Statistics indicate that over 67% of the global population are infected with HSV-1[14]. The prevalence of HSV-2 is also high among adults, particularly within sexually active populations[15]. HPV, one of the most common sexually transmitted viruses, is estimated by the World Health Organization (WHO) to infect more than 50% of sexually active individuals at some point in their lives[16].

To effectively prevent and treat these diseases, countries must develop tailored public health policies based on disease distribution patterns. Vaccination has proven to be an effective preventive measure against certain viral skin diseases, such as those caused by HPV[17]. Furthermore, enhanced surveillance and data collection are critical for designing effective investigation, prevention, and treatment programs. Public health policies should also adapt to shifting disease trends to alleviate the global burden of viral skin diseases.

To the best of our knowledge, no previous studies have examined the long-term global epidemiological trends of viral skin diseases, especially those caused by HPV. The 2021 Global Burden of Disease (GBD) study highlighted both emerging and persistent health threats across 204 countries and territories. Using these data, this study reports the burden of viral skin diseases in terms of incidence, prevalence, DALYs, and years lived with disability (YLDs), with both crude counts and age-standardized rates. The burden was analyzed by age and Socio-Demographic Index (SDI). Key trends were identified and discussed through frontier analysis and cross-national health inequality assessments, offering insights into global burden trends from 1990 to 2021. The objective was to summarize the current burden of viral skin diseases and assist healthcare providers and policymakers in developing effective risk-reduction strategies.

Methods

Overview and data source

This study used data from GBD 2021[18], which provides estimates for 204 countries and territories, grouped into 21 regions, assessing the burden of 371 diseases and injuries and 87 risk factors from 1990 onward. According to the ICD-10 classification system[19], the GBD database lists major viral skin diseases including herpes simplex (B00), rubella (B06), viral warts (B07), other viral infections characterized by skin and mucous membrane lesions, not elsewhere classified (B08), and unspecified viral infection characterized by skin and mucous membrane lesions (B09). Our study relied on secondary data from GBD 2021 without direct interaction with participants. Patients were not involved in formulating research questions, determining outcome measures, or designing and implementing the study.

For this analysis, data related to viral skin diseases from 1990 to 2021 were extracted, including incidence, prevalence, DALYs and YLDs. A combined cross-sectional and time-series analysis was performed using linear regression to calculate average annual percentage changes (AAPCs) and annual percentage changes (APCs) to assess disease burden trends. Additionally, a log age-period-cohort model was applied to forecast case numbers and incidence rates for 2046. All steps in our analysis adhere to the STROBE statement, with a completed STROBE checklist provided in Table S1.

Socio-demographic index

SDI is a composite measure reflecting a country’s development level, based on fertility rates, education years, and per capita income, ranging from 0 to 1. Higher SDI values indicate greater socioeconomic development[20]. Using the SDI stratifications in the GBD dataset, we compared health metrics for viral skin diseases across countries and regions. This study analyzed the relationship between SDI and health indicators, exploring how development levels affect disease burden of viral skin diseases.

Statistical analysis

The primary indicators used to describe the burden of viral skin diseases included incidence, prevalence, DALYs, YLDs, and their corresponding absolute values. Rates were reported per 100,000 population with 95% uncertainty intervals (UIs), according to GBD methodology.

Temporal trends were analyzed using Joinpoint regression to calculate AAPCs and APCs. The dynamics of viral skin diseases were assessed to determine temporal trends and concentrated distributions. AAPCs and their 95% UIs were calculated using linear modeling on a logarithmic scale. The declining trend was indicated if both the AAPC and the upper bound of its 95% UI were below zero, while an increasing trend was indicated otherwise.

Health inequality related to the socioeconomic burden was assessed using the slope index of inequality (SII) and the concentration index (CI), calculated through linear regression models and Lorenz curves as recommended by the WHO[21]. SII represents the slope of the regression line between disease burden and the weighted ranking of SDI regions, while CI assesses the inequality of disease distribution across socioeconomic groups. The positive values indicate a concentration of disease burden in high SDI regions and negative values indicate the opposite.

Additionally, the minimum achievable burden based on development levels was assessed by frontier analysis. A non-linear boundary was established to represent the minimum achievable burden based on development levels. Non-parametric data envelopment analysis was applied, following the methods described in previous studies[22,23]. The deviation between disease burden and its frontier boundary was considered as effective differences, representing unrealized health gains based on the current development level of the country or region.

For predictive modeling, the Nordpred model was employed, a specialized time-series forecasting tool designed to model future trends based on historical data. This approach is particularly suitable for capturing long-term trends and changes in complex datasets[24].

All analyses were conducted using GraphPad Prism 10, RStudio (v4.2.1), and the Joinpoint Regression Program (v4.9.1.0). Statistical significance was determined using two-sided tests, and P < 0.05 was considered statistically significant.

Results

Burden of viral skin diseases: global trends

This study included 7.97 billion individuals, with 50.18% male and 49.82% female. The burden of mucocutaneous infectious diseases increased annually. Incidence was dominated by fungal infections, followed by bacterial and viral infections (from 4% to 3.1%). Viral infections had the highest proportion of fatality and disability burden, contributing 46.4% to 42.4% of total fatality burden and 57.9% to 52.7% of disability burden (Figures S1–S4).

Incidence

From 1990 to 2021, global viral skin disease cases rose by 32.27%, from 64,056,940 to 84,730,445. The age-standardized incidence rate (ASIR) decreased slightly from 1134.3 to 1126.3 (AAPC = –0.02) (Table 1). Figure 1 shows the temporal trends. From 2015 to 2018, ASIR showed a slight rise (APC = 0.02) (Figure 1A). During this period, the incidence of viral skin diseases among children under 15 years increased, with the most significant rise of 44.2% observed in children under 5 years old. Men aged 50–65 and 85–95 also showed an increase. Children aged 5–9 had the highest incidence in both 1990 and 2021 (2767.38 and 2836.71, respectively). Figure 2 presents the sex-specific incidence patterns. Across all years, males had higher incidence rates than females, although girls under 10 years had higher incidence than boys (Figure 2A).

Prevalence

From 1990 to 2019, global viral skin disease cases increased by 36.29%, from 100,377,653 to 136,807,659. The age-standardized prevalence rate (ASPR) decreased from 1813 to 1781.3 (AAPC = –0.06). Between 2015 and 2018, the ASPR showed a slight rise (APC = 0.04) (Figure 1B). The prevalence of viral skin diseases among children under 15 increased, with the most significant rise of 13.9% observed in children under 5 years old. The prevalence also rose among men aged 75 and older. Children aged 5–9 had the highest prevalence in both 1990 and 2021 (3368.29 and 3671.01, respectively). Across all years, males had higher prevalence rates than females (Figure 2B).

DALYs

From 1990 to 2021, DALYs related to viral skin diseases increased by 35.81%, from 3,091,683 to 4,199,075. The age-standardized DALY rate (ASDAR) decreased from 55.6 to 54.8 (AAPC = –0.05) (Table S2). Between 2015 and 2019, ASDAR rose modestly (APC = 0.04) (Figure 1C). Children under 15 experienced a significant DALY increase, especially a 14.5% rise observed in those under under 5 years old. The DALYs rate also rose among men aged 75 and older. Children aged 5–9 had the highest DALY rates in both 1990 and 2021 (105.24 and 114.98, respectively). Males consistently had higher DALYs than females (Figure 2C).

Burden of viral skin diseases: SDI regional trends

Incidence

From 1990 to 2021, high-middle-SDI regions exhibited the most significant increase in incidence rates (AAPC = 0.12), while high SDI regions showed a slight decline (AAPC = –0.02). Throughout the period, high SDI regions maintained the highest incidence at 1566 in 1990 and 1559.4 in 2021, while low-middle SDI regions had the lowest incidence, at 973.3 in 1990 and 994.5 in 2021 (Table 1). Joinpoint regression analysis showed a decline in the high SDI region before 2014, but the incidence began to rise after 2014, reaching its peak between 2019 and 2021 (APC = 0.35). In other regions, incidence rates generally rose, with significant increases in high-middle SDI and low SDI regions between 2019 and 2021 (Figure 1A).

Prevalence

Between 1990 and 2021, low-middle SDI regions recorded the most substantial increase in prevalence rates (AAPC = 0.26), while High SDI regions remained stable (AAPC = 0). During the period, high SDI regions consistently had the highest prevalence at 3374.4 in 1990 and 3370.2 in 2021. In contrast, low-middle SDI regions had the lowest prevalence, at 1202.6 in 1990 and 1305.3 in 2021 (Table 1). Joinpoint regression analysis showed notable fluctuations in high SDI regions, with the most significant decrease from 1990 to 1993 (APC = –0.15) and the sharpest rise from 2010 to 2019 (APC = 0.05). Middle SDI regions experienced a decline before 2001 and followed by growth after 2006. The other regions exhibited overall upward trends, with all regions showing stable or slowed prevalence growth from 2019 to 2021 (Figure 1B).

DALYs

Regarding DALYs, low-middle SDI regions showed the largest increase (AAPC = 0.28), while high SDI regions saw the greatest decline (AAPC = –0.01). High SDI regions maintained the highest ASDAR at 103.8 in 1990 and 103.5 in 2021, while low-middle SDI regions reported the lowest (36.9 in 1990 and 40.2 in 2021) (Table 1). Joinpoint regression analysis revealed fluctuations in High SDI regions, with a decline from 1990 to 1993 (APC = –0.14) and an increase from 2010 to 2019 (APC = 0.04). Other regions showed slower DALY growth from 2019 to 2021 (Figure 1C).

Burden of viral skin diseases: geographic regional trends

Incidence

Western Sub-Saharan Africa showed the largest increase in incidence rates (AAPC = 0.14), while Western Europe and High-income North America experienced declines (AAPC = –0.04) (Figure S5). High-income North America maintained the highest ASIR at 1817.4 in 1990 and 1804.1 in 2021, while Central Sub-Saharan Africa had the lowest at 855.9 in 1990 and 889 in 2021 (Table 1). Cluster analysis of AAPC across 31 regions identified four patterns: 14 regions, including Eastern Europe, showed stable trends; 4 regions, such as high SDI regions, experienced slight declines; 5 regions, including Western Sub-Saharan Africa, exhibited significant increases; and 8 regions, such as Southeast Asia, showed modest increases (Figure S6).

Prevalence

Central Latin America displayed the most significant increase in prevalence (AAPC = 0.36), while High-income North America experienced the largest declines (AAPC = –0.05) (Figure S7). High-income North America maintained the highest ASPR at 4281.7 in 1990 and 4207.3 in 2021. In contrast, Central Latin America recorded the lowest ASPR at 835.2 in 1990, while Central Sub-Saharan Africa had the lowest ASPR at 920.1 in 2021 (Table S2). Cluster analysis of AAPC for prevalence showed that 6 regions, including high SDI regions, were largely stable with slight declines; 12 regions, such as Western Sub-Saharan Africa, exhibited modest increases; 11 regions, including Southeast Asia, showed significant increases; and 2 regions, such as Central Latin America, demonstrated the most notable growth (Figure S8).

DALYs

Central Latin America had the largest increase (AAPC = 0.36), while High-income North America had the largest decrease (AAPC = –0.07) (Figure S9). High-income North America reported the highest ASDAR at 131.4 in 1990 and 128.6 in 2021, while Central Latin America had the lowest at 25.8 in 1990 and Central Sub-Saharan Africa at 28.3 in 2021 (Table S3). Cluster analysis of AAPC for DALY rates identified four patterns: 5 regions, including Western Europe, were stable with slight declines; 13 regions, such as Oceania, experienced modest increases; 7 regions, including Southeast Asia, showed significant growth; and 6 regions, such as Central Latin America, demonstrated the sharpest increases (Figure S10).

Burden of viral skin diseases: global trends

Incidence

Between 1990 and 2021, Germany had the highest ASIR, declining slightly from 2442.13 in 1990 to 2436.84 in 2021, a 0.22% decrease in ASIR and a 1.71% reduction in the number of cases (Figures S11–S85). Conversely, Israel consistently recorded the lowest ASIR, increasing from 655.59 in 1990 to 662.45 in 2021, a 1.04% rise in ASIR and an 81.02% increase in case numbers. In 2021, 168 out of 204 countries and territories had ASIR below the global average, compared to 151 countries in 1990. Only 14 countries showed a decreasing trend in ASIR (AAPC < 0) (Table S4).

Prevalence

Germany also recorded the highest ASPR during this period, rising from 4421.50 in 1990 to 4469.80 in 2021, an increase of 1.09% in ASPR and 25.50% in the number of cases (Figures S11–S85). The lowest ASPR were observed in Guatemala in 1990 (809.22) and the Central African Republic in 2021 (886.99). By 2021, 149 countries had ASPR below the global average, compared to 151 countries in 1990. Only 2 countries showed a decreasing trend in ASPR (AAPC < 0) (Table S5).

DALYs

In terms of disease burden, Germany had the highest ASDAR, with a slight increase from 136.01 in 1990 to 137.48 in 2021 (Figures S11–S85). The lowest ASDAR was recorded in Guatemala in 1990 (24.77) and the Central African Republic in 2021 (27.19). In both 1990 and 2021, 166 out of 204 countries and territories had ASDARs below the global average. Only 2 countries showed a decreasing trend in ASDAR (AAPC < 0) (Table S6).

Burden of viral skin diseases: SDI-related analysis

The burden of health losses caused by viral skin diseases was primarily concentrated in relatively developed groups. In 1990, the SII was 18.98, and the CI was 0.27. By 2021, the SII and CI changed to 21.51 and 0.25, respectively (Table S7). While absolute health inequality grew, relative inequality declined, suggesting a widening gap between groups but a shift in the burden toward lower socioeconomic status (Figures 3A and 4B). For prevalence, the SII rose from 604.29 in 1990 to 690.32 in 2021, while the CI decreased from 0.26 to 0.25 (Table S7). Similar trends in health inequality were observed, with a widening gap in burden and a shift toward lower socioeconomic status (Figures 3C and 4D).

Similarly, the incidence burden of viral skin diseases was concentrated in more developed groups. The SII and CI were 134.90 and 0.19, respectively, in 1990, decreasing to 110.84 and 0.17, respectively, in 2021 (Table S7). Both absolute and relative measures of health inequality for incidence showed improvement, indicating reduced health disparities (Figures 3E and 4F).

The age-standardized incidence, prevalence, and DALY rates by region and SDI are shown in Figures S5–S7. These rates were generally higher in high-SDI regions than in low-SDI regions, with the top three being High-income North America, High-income Asia Pacific, and Australasia. For DALYs, the top three were High-income North America, High-income Asia Pacific, and Southern Latin America. Notably, Eastern Sub-Saharan Africa, a low-SDI region, had unusually higher incidence, prevalence, and DALY rates compared to other low-SDI regions.

Burden of viral skin diseases: frontier analysis

From 1990 to 2021, unrealized health gains in 204 countries and territories generally increased with SDI, indicating that higher SDI countries have greater potential to reduce disease burden (Figure 4). Germany, the United States, and Canada had the highest potential for improvement.

Incidence

The top 10 countries with the largest effective difference from the frontier (1786.73–997.79) were Germany, USA, Canada, Greenland, Japan, New Zealand, South Korea, Singapore, Australia, and Brunei (Table S8). These countries had disproportionately higher incidence rates with similar sociodemographic resources. Low-SDI countries with low effective differences included Somalia, Niger, and the Central African Republic. High-SDI countries with low effective differences included Poland, Latvia, Estonia, Lithuania, and Czechia (Figure 4B).

Prevalence

The top 10 countries with the largest effective difference from the frontier (3659.34–3082.91) were Germany, USA, Canada, Greenland, South Korea, Singapore, Australia, Japan, New Zealand, and Brunei (Table S8). These had disproportionately higher DALY rates. Low-SDI countries with low effective differences included Somalia, Niger, and the Central African Republic. High-SDI countries with low effective differences included Poland, Bermuda, United States Virgin Islands, and Puerto Rico (Figure 4D).

DALYs

The top 10 countries with the largest effective difference from the frontier (112.70–94.75) were Germany, USA, Canada, Greenland, South Korea, Singapore, Japan, Australia, Brunei, and New Zealand (Table S8). These had disproportionately higher DALY rates. Low-SDI countries with low effective differences included Somalia, Niger, and the Central African Republic. High-SDI countries with low effective differences included Poland, United States Virgin Islands, Puerto Rico, Bermuda, Latvia, and Estonia (Figure 4F).

Burden of viral skin diseases: predicted trends

From 1992 to 2030, the ASIR of viral skin diseases remained stable, with a trough around 2015 at 936.85 (Figure 5A). Between 2019 and 2021, the increase in ASIR began to slow. Projections show slight fluctuations from 2022 to 2044, with a gradual increase expected to reach 940.66 by 2046. The number of cases is expected to rise by 28.36% from 1990 to 2046, with the sharpest growth occurring between 2006 and 2020 (Table S9).

From 1992 to 2030, the ASPR of viral skin diseases remained stable, with a trough around 2016 at 1594.32 (Figure 5B). Projections show slight fluctuations from 2019 to 2046,with a gradual increase expected to reach 1609.74 by 2046. The number of cases is expected to rise by 49.58% (Table S10).

From 1992 to 2030,the ASDAR of viral skin diseases remained stable, with a trough around 2024 at 48.58 (Figure 5C). Projections show slight fluctuations from 2024 to 2046,with a gradual increase expected to reach 49.27 by 2046. The number of cases is expected to rise by 48.19% (Table S11).

Discussion

Viral skin diseases, caused by viral infections, significantly impact global health, particularly among children under 15 years. This study analyzed epidemiological trends from 1990 to 2021 across all GBD regions and age groups. The findings highlight changes in the prevalence, incidence, and societal costs associated with these diseases, emphasizing the urgent need for targeted prevention and management strategies to inform global policies and clinical practices.

Over the past three decades, the ASPR, ASIR, and ASDAR associated with viral skin diseases have declined in high SDI regions. However, ASPR and ASIR increased in all other SDI regions. Middle and low-middle SDI regions, such as Central Latin America and Western Sub-Saharan Africa, experienced the largest increases in incidence and DALYs from 1990 to 2021.

Despite these trends, the burden remains the highest in high SDI regions. In 2021, High-income North America accounted for the largest share of incidence and DALYs. For instance, the United States of America consistently reported the highest prevalence and disease burden, with prevalence decreasing slightly from 4104.99 in 1990 to 3935.39 in 2021 and DALYs dropping from 125.35 to 117.53 during the same period. Meanwhile, incidence rates were most prominent in the Federal Republic of Germany, decreasing from 2079.92 in 1990 to 1914.19 in 2021. These patterns underscore the critical role of socioeconomic factors in disease distribution and the need for region-specific public health interventions to address disparities in the burden of viral skin diseases.

Despite advancements in control measures, immuno-compromised children and the elderly remain highly susceptible to viral skin diseases, bearing a significant burden globally. Among children under 15, particularly those aged 5–9, the impact is especially pronounced. Over the past three decades, incidence and prevalence in this group have consistently increased, with a 44.2% rise in incidence among children under 5. Children are notably vulnerable to infections such as HPV and rubella due to immature immune systems and weaker skin barriers[7,25,26].

Cross-sectional studies reveal a high prevalence of viral skin diseases in children. One study analyzing 1465 children aged 4–15 found that 33% were affected by HPV-induced skin lesions, with prevalence rising from 15% at age 4 to 44% at age 11[27]. This trend may result from the underdeveloped immune responses and skin barrier functions in children[28]. As children enter adolescence, lack of knowledge about sexual health and personal hygiene increases their risk of HPV infection via sexual or other transmission routes. In adults, HPV-related skin diseases are less common[29], though some individuals, particularly women, may experience persistent lesions or prolonged disease, significantly impacting quality of life[30]. Approximately 10%–20% of viral skin diseases, including stubborn warts, epidermodysplasia verruciformis, and Tree-Man Syndrome, can become chronic or treatment-resistant[31,32].

Among the elderly, particularly males aged 50–65 and 85–95, the incidence of viral skin diseases has risen significantly. This is attributed to aging-related declines in immune function, particularly weakened cellular immunity, making older adults more susceptible to viral infections and reactivations[33–35]. Additionally, chronic diseases common in older adults may serve as triggers for viral skin conditions[36]. From 1990 to 2021, men consistently showed higher incidence rates than women, likely due to greater participation in high-risk behaviors such as unprotected sexual activity[37,38] and less robust personal hygiene practices. These findings highlight the critical role of age and gender in shaping screening and management strategies for viral skin diseases. Tailored interventions addressing these factors could significantly reduce disease burden and improve outcomes.

Antiviral therapies, widespread vaccination, and improved public health infrastructure have significantly contributed to reducing the transmission and burden of viral skin diseases[39]. In high SDI regions, access to healthcare resources and vaccination is higher, and public health policies are more systematic, leading to a notable reduction in disease prevalence and associated health losses[39]. Conversely, in low SDI regions, limited resources have resulted in slower increases in burden, but the total number of cases continues to accumulate. This trend underscores the need for equitable resource allocation in global public health policies to mitigate growing health disparities in these regions[40].

During the COVID-19 pandemic, isolation policies and public facility closures unexpectedly slowed the growth of ASPR and ASDAR across several regions, despite increases in ASIR among certain SDI groups. Conversely, incidence rose in high, high-middle, and low SDI regions, potentially reflecting variations in the implementation of public health measures such as quarantine and social distancing[41]. These divergent patterns may also indicate disruptions in healthcare access and reporting systems; however, causal interpretations warrant caution. Regional disparities in vaccination rates also influenced disease control, with lower vaccination coverage leading to higher transmission and incidence of viral skin diseases[42]. This highlights the critical need for maintaining continuous healthcare services during public health crises.

High SDI countries have achieved significant success in preventing and managing viral skin diseases, particularly by raising public awareness and promoting early detection[43,44]. However, challenges remain, such as demographic changes, necessitating the development of comprehensive management strategies. These efforts should prioritize sustaining progress while addressing emerging challenges to ensure effective long-term control of viral skin diseases.

Children under 15, especially those aged 5–9, face significant challenges in managing viral skin diseases, influenced by socioeconomic status, access to healthcare, and risk behaviors. Families with lower socioeconomic status often lack resources to afford medical care, and unequal healthcare access prevents timely interventions[45,46]. As children grow older, some may engage in risky behaviors such as unprotected sexual activity, increasing their susceptibility to sexually transmitted viruses like HPV[47]. Expanding access to affordable antiviral treatments and enhancing awareness among children and parents are crucial for controlling disease spread and reducing the burden in this vulnerable age group.

Despite a global decline in incidence rates, this trend is primarily driven by reductions in highly developed countries such as the United States, where baseline burdens were high. In contrast, more than 180 countries continue to experience rising incidence rates (AAPC > 0). Addressing these disparities requires targeted interventions and public health policies tailored to specific viral skin diseases. Effective strategies should focus on reducing the burden of disease and associated disability[48]. Public awareness campaigns and education initiatives are critical for high-burden, rapidly growing regions to improve public health systems and enhance disease management capabilities[40].

Limitations

This study has several limitations. First, as mentioned by the GBD capstone study[49–51], the quality and completeness of disease-related data collection vary substantially across countries and regions, which may affect the robustness of the findings. As the originating country of the GBD initiative, the United States achieved a relatively high level of disease data collection in the early stages and has maintained more comprehensive coverage to date; in contrast, data collection in other regions may be less complete under similar conditions. Second, ecological fallacy should be considered, as this study is based on aggregated data, and associations observed at the population level may not be applicable at the individual level. Third, the lack of specificity in case definitions represents an important limitation, as different viral etiologies cannot be distinguished. In addition, viral skin diseases, particularly in resource-limited settings, may be underestimated if affected individuals do not seek medical care, a factor that may not be fully captured by GBD modeling approaches.

Conclusion

From 1990 to 2021, the burden of viral skin diseases remains a significant global health issue. While some progress has been made in prevention and treatment, the burden continues to grow rapidly outside high SDI regions, especially among children under 15. Targeted interventions focusing on vulnerable populations and low SDI regions are urgently needed to reduce the health and societal impacts of disease transmission and address global health inequities effectively.

References

[1] Ramdass P, Mullick S, Farber HF. Viral skin diseases. Prim Care. 2015;42(4):517-567.

[2] Keighley CL, Saunderson RB, Kok J, Dwyer DE. Viral exanthems. Curr Opin Infect Dis. 2015;28(2):139-150.

[3] Serrano B, Brotons M, Bosch FX, Bruni L. Epidemiology and burden of HPV-related disease. Best Pract Res Clin Obstet Gynaecol. 2018;47:14-26.

[4] Largeron N, Petry KU, Jacob J, Bianic F, Anger D, Uhart M. An estimate of the public health impact and cost-effectiveness of universal vaccination with a 9-valent HPV vaccine in Germany. Expert Rev Pharmacoecon Outcomes Res. 2017;17(1):85-98.

[5] Tognarelli EI, Palomino TF, Corrales N, Bueno SM, Kalergis AM, González PA. Herpes simplex virus evasion of early host antiviral responses. Front Cell Infect Microbiol. 2019;9:127.

[6] Duarte LF, Reyes A, Farías MA, et al. Crosstalk between epithelial cells, neurons and immune mediators in HSV-1 skin infection. Front Immunol. 2021;12:662234.

[7] Winter AK, Moss WJ. Rubella. Lancet. 2022;399(10332):1336-1346.

[8] Bruggink SC, Gussekloo J, de Koning MN, et al. HPV type in plantar warts influences natural course and treatment response: secondary analysis of a randomised controlled trial. J Clin Virol. 2013;57(3):227-232.

[9] Shimizu A, Yamaguchi R, Kuriyama Y. Recent advances in cutaneous HPV infection. J Dermatol. 2023;50(3):290-298.

[10] Skubic L, Breznik V, Poljak M. Different skin wart types, different human papillomavirus types? a narrative review. Acta Dermatovenerol Alp Pannonica Adriat. 2023;32(4):165-171.

[11] Antonsson A, Forslund O, Ekberg H, Sterner G, Hansson BG. The ubiquity and impressive genomic diversity of human skin papillomaviruses suggest a commensalic nature of these viruses. J Virol. 2000;74(24):11636-11641.

[12] Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the Global Burden of Disease Study 2013. JAMA Dermatol. 2017;153(5):406-412.

[13] Yakupu A, Aimaier R, Yuan B, et al. The burden of skin and subcutaneous diseases: findings from the Global Burden of Disease Study 2019. Front Public Health. 2023;11:1145513.

[14] Looker KJ, Magaret AS, May MT, et al. Global and regional estimates of prevalent and incident herpes simplex virus type 1 infections in 2012. PLoS One. 2015;10(10):e0140765.

[15] Looker KJ, Magaret AS, Turner KM, Vickerman P, Gottlieb SL, Newman LM. Global estimates of prevalent and incident herpes simplex virus type 2 infections in 2012. PLoS One. 2015;10(1):e114989.

[16] Bruni L, Albero G, Rowley J, et al. Global and regional estimates of genital human papillomavirus prevalence among men: a systematic review and meta-analysis. Lancet Glob Health. 2023;11(9):e1345-e1362.

[17] Ntanasis-Stathopoulos I, Kyriazoglou A, Liontos M, A Dimopoulos M, Gavriatopoulou M. Current trends in the management and prevention of human papillomavirus (HPV) infection. J BUON. 2020;25(3):1281-1285.

[18] Institute for Health Metrics and Evaluation (IHME): GBD Results. Seattle, WA: IHME, University of Washington, 2021.

[19] Tzitzivacos D. International classification of diseases 10th edition (ICD-10). CME. 2007;25(1):8-10.

[20] Ordunez P, Martinez R, Soliz P, Giraldo G, Mujica OJ, Nordet P. Rheumatic heart disease burden, trends, and inequalities in the Americas, 1990-2017: a population-based study. Lancet Glob Health. 2019;7(10):e1388-e1397.

[21] World Health Organization. Handbook on health inequality monitoring: with a special focus on low-and middle-income countries. World Health Organization; 2013.

[22] Pan H, Zhao Z, Deng Y, et al. The global, regional, and national early-onset colorectal cancer burden and trends from 1990 to 2019: results from the Global Burden of Disease Study 2019. BMC Public Health. 2022;22(1):1896.

[23] GBD 2015 Healthcare Access and Quality Collaborators. Healthcare access and quality index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015: a novel analysis from the Global Burden of Disease Study 2015. Lancet. 2017;390(10091):231-266.

[24] Li DP, Han YX, He YS, et al. A global assessment of incidence trends of autoimmune diseases from 1990 to 2019 and predicted changes to 2040. Autoimmun Rev. 2023;22(10):103407.

[25] Knöpfel N, Noguera-Morel L, Latour I, Torrelo A. Viral exanthems in children: a great imitator. Clin Dermatol. 2019;37(3):213-226.

[26] Lipke MM. An armamentarium of wart treatments. Clin Med Res. 2006;4(4):273-293.

[27] Bristow I. Paediatric cutaneous warts and verrucae: an update. Int J Environ Res Public Health. 2022;19(24):16400.

[28] Visscher MO, Adam R, Brink S, Odio M. Newborn infant skin: physiology, development, and care. Clin Dermatol. 2015;33(3):271-280.

[29] Silverberg JI, Silverberg NB. The U.S. prevalence of common warts in childhood: a population-based study. J Invest Dermatol. 2013;133(12):2788-2790.

[30] Santos BD, Moreira CS, Teixeira-Santos AC, Carvalho E, Pereira MG. HPV-related quality of life in diagnosed women: a longitudinal study. J Health Psychol. 2022;27(13):2982-2996.

[31] Kuwabara AM, Rainer BM, Basdag H, Cohen BA. Children with warts: a retrospective study in an outpatient setting. Pediatr Dermatol. 2015;32(5):679-683.

[32] Béziat V, Rapaport F, Hu J, et al. Humans with inherited T cell CD28 deficiency are susceptible to skin papillomaviruses but are otherwise healthy. Cell. 2021;184(14):3812-3828.e30.

[33] Aw D, Silva AB, Palmer DB. Immunosenescence: emerging challenges for an ageing population. Immunology. 2007;120(4):435-446.

[34] Chen SY, Suaya JA, Li Q, et al. Incidence of herpes zoster in patients with altered immune function. Infection. 2014;42(2):325-334.

[35] Marini A, Hengge UR. Important viral and bacterial infections of the skin and mucous membrane. Internist (Berl). 2009;50(2):160-170.

[36] Marra F, Parhar K, Huang B, Vadlamudi N. Risk factors for herpes zoster infection: a meta-analysis. Open Forum Infect Dis. 2020;7(1):ofaa005.

[37] Palefsky JM, Holly EA, Efirdc JT, et al. Anal intraepithelial neoplasia in the highly active antiretroviral therapy era among HIV-positive men who have sex with men. AIDS. 2005;19(13):1407-1414.

[38] Chin-Hong PV, Vittinghoff E, Cranston RD, et al. Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study. J Natl Cancer Inst. 2005;97(12):896-905.

[39] Shattock AJ, Johnson HC, Sim SY, et al. Contribution of vaccination to improved survival and health: modelling 50 years of the Expanded Programme on Immunization. Lancet. 2024;403(10441):2307-2316.

[40] Hay RJ, Augustin M, Griffiths CEM, Sterry W. The global challenge for skin health. Br J Dermatol. 2015;172(6):1469-1472.

[41] Yan H, Zhu Y, Gu J, et al. Better strategies for containing COVID-19 pandemic: a study of 25 countries via a vSIADR model. Proc Math Phys Eng Sci. 2021;477(2248):20200440.

[42] Saleh R, Nada E, Hamed AF, Hussien WM. Epidemiologic trends of viral skin infections in Egypt: a cross-sectional hospital-based study. Dermatol Res Pract. 2019;2019:5469726.

[43] Bansal R, Tutrone WD, Weinberg JM. Viral skin infections in the elderly: diagnosis and management. Drugs Aging. 2002;19(7):503-514.

[44] Meza-Romero R, Navarrete-Dechent C, Downey C. Molluscum contagiosum: an update and review of new perspectives in etiology, diagnosis, and treatment. Clin Cosmet Investig Dermatol. 2019;12:373-381.

[45] Flores G, Lin H, Walker C, et al. The health and healthcare impact of providing insurance coverage to uninsured children: a prospective observational study. BMC Public Health. 2017;17(1):553.

[46] Jing Z, Li J, Wang Y, Zhou C. Prevalence and trends of sexual behaviors among young adolescents aged 12 years to 15 years in low and middle-income countries: population-based study. JMIR Public Health Surveill. 2023;9:e45236.

[47] Leung J, Lim C, Belete H, Mcclure-Thomas C, Foo S, Chan GCK. Regional and country prevalence estimates of unsafe sex among adolescents in 68 low-income and middle-income countries. Arch Sex Behav. 2024;53(6):2337-2346.

[48] Newton H. Viral infections of the skin: clinical features and treatment options. Nurs Stand. 2013;27(52):43-47.

[49] GBD 2023 Demographics Collaborators. Global age-sex-specific all-cause mortality and life expectancy estimates for 204 countries and territories and 660 subnational locations, 1950–2023: a demographic analysis for the Global Burden of Disease Study 2023. Lancet. 2025;406(10513):1731-1810.

[50] GBD 2023 Causes of Death Collaborators. Global burden of 292 causes of death in 204 countries and territories and 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet. 2025;406(10513):1811-1872.

[51] GBD 2023 Disease and Injury and Risk Factor Collaborators. Burden of 375 diseases and injuries, risk-attributable burden of 88 risk factors, and healthy life expectancy in 204 countries and territories, including 660 subnational locations, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet. 2025;406(10513):1873-1922.

RIGHTS & PERMISSIONS

The Author(s) 2026. This article is published by Higher Education Press on behalf of People’s Medical Publishing House.