# Introduction

The use of digital technology in dermatology is revolutionizing the field by transforming traditional practices into a modern, digitized approach [1]. This shift, driven by the increasing accessibility and efficiency of digital platforms, is reshaping how dermatologists diagnose and treat skin conditions [2–5]. One of the most significant advancements in this domain is the rise of store-and-forward teledermatology (SFTD) [1–5]. SFTD allows healthcare providers to capture and transmit high-quality images and patient information to dermatologists for subsequent evaluation [1–3]. At a time where access to dermatologists is becoming more difficult, SFTD has demonstrated high efficacy and reliability in the management of skin conditions [6]. In France, as of March 2022, tele-expertise is covered by French Social Security for all patients, and all medical situations can be addressed via tele-expertise. In this context, our objective was to conduct a national study in France to assess the propensity of the French population to accept SFTD.

# Materials and methods

The survey was conducted between June and October 2022. A representative sample of the French population, consisting of 15,050 individuals aged 18 and over, was selected using the quota method [sex, age, region of residence, and socio-professional category]. These quotas were based on data provided by the National Institute of Statistics and Economic Studies (INSEE), Table 1
                     , which allow extrapolation of results to the entire French population. Selected participants were contacted by personal email inviting them to take part in a survey, without specifying the subject of the survey. This prevented any self‐selection bias since participants with a skin disease might have been more likely to participate in the study if its purpose had been disclosed. Where contact was not successfully established, a different potential participant having the same sociodemographic characteristics was randomly selected. To ensure the robustness of the data collected, individuals failing to complete the entire survey were excluded.

The question asked was kept simple to ensure it was readily understood by everyone: “If you had a skin problem and your general physician or pharmacist offered to seek the opinion of a dermatologist based on a photo taken by them, what would your reaction be?” To avoid hasty responses, three possible answers were offered: (1) “You would refuse, preferring to see your dermatologist”; (2) “You would accept only if the cost was covered by French social security”; (3) “You would agree because it would be faster than making an appointment with a dermatologist”. Qualitative and ordinal variables were described in terms of number and frequency. Quantitative variables were described in terms of mean value, standard deviation, median, and distribution. In each country, the total population of individuals was calculated by direct extrapolation of the proportions from the proportionally stratified sample in each country. We compared the responses according to age groups (18–24; 25–34; 35–45; 55–65 and >65 years old), residency area, and income (≤18,000; 18–47,000 and >47,000 euros). Moreover, we asked participants whether they had a skin condition and compared the responses in both groups.

Multivariate logistic regression was performed to evaluate the relationship between reluctance to undergo tele-expertise (TLX) and several variables: gender [female/male], age, declared annual income [less than 18 k euros, between 18 k and 47 k euros, more than 47 k euros], educational level [no diploma, secondary diploma, university diploma], presence of a skin disease, presence or absence of a child aged under 18 years in the household, whether or not the person has a health app on their phone, and whether or not they have confidence in innovation. The multicollinearity of the data was checked using the Belsley-Kuh-Welsch technique. The heteroscedasticity and normality of the residuals were assessed using White's test and the Lilliefors test, respectively. A p-value of 0.05 was considered statistically significant. Patients with missing data were excluded from the analysis. The statistical analysis was performed using EasyMedStat software (version 3.35; https://www.easymedstat.com).

# Results

The sample of 15,050 individuals was representative of the French population (Table 1). Of these, 24.7% reported having a skin disease confirmed by a doctor. Among French people, 81% said they would agree to SFTD (81.2% of men vs 80.8% of women, non-significant difference), 33.6% would agree on condition that the consultation was covered by social security, and 47.4% would agree since it was faster than making an appointment with a dermatologist. Only 19.01% of French people stated that they would refuse, preferring to consult a dermatologist in person. Table 2
                      regarding age, the most reluctant were the youngest (29.3% among 18–24-year-olds, 20.7% among 25–34 year-olds) and those aged over 65 years, 20.3% of whom would refuse, preferring to see their dermatologist. The youngest were also the most likely to accept the idea only if social security reimbursement was provided (40.17%), versus 26.5% of those aged over 65 years. In terms of geographical location, Île-de-France and Occitanie (South of France) were the most reluctant, with 22.9% and 21.2% respectively opposed to SFTD. The least reluctant were the inhabitants of the Pays de la Loire region, where only 15.4% were opposed to SFTD. It is interesting to note that according to official data (source: INSEE as of 23/1/23), the first two regions have a higher medical density (Île-de-France: 383/100,000, Occitanie: 350/100,000) than the Pays de la Loire region (256/100,000). The rate of reluctance increased with agglomeration size: 15.92% in rural areas, 17.44% in medium-sized cities, 20.12% in large cities, and 23.74% in the Paris metropolitan area. Among French subjects who declared an annual income of less than 18,000 euros, 23.26% were reluctant, compared with 18.17% among those with an income between 18,001 and 47,000 euros, and 15.68% among those with annual incomes above 47,000 euros. Those with a skin disease were significantly more reluctant than those who did not [23.3% vs. 17.6%, p < 0.001].

In the multivariate analysis (Table 3
                     ), the absence of a diploma (odds ratio (OR) = 1.21, 95% confidence interval (95%CI) [1.06; 1.38], p = 0.0035), a declared annual income below 18,000 euros (OR = 1.18, 95%CI [1.06; 1.32], p = 0.0028), residence in an urban area (OR = 1.31, 95%CI [1.19; 1.43], p < 0.0001), the presence of a skin disease (OR = 1.34, 95%CI [1.21; 1.47], p < 0.0001), lack of trust in innovation (OR = 1.77, 95%CI [1.59; 1.97], p < 0.0001), being aged 55 and over (OR = 1.34, 95%CI [1.2; 1.51], p < 0.0001) or under 30 (OR = 1.62, 95%CI [1.44; 1.82], p < 0.0001), were associated with higher expression of reluctance to SFTD. Gender or the presence of a dependent child were not associated with expressing refusal of TD.

# Discussion

The shift from conventional to digital dermatology, epitomized by store-and-forward techniques, is not merely a trend but a permanent progression [1–7]. Thanks to detailed image analysis, this approach can accelerate diagnosis, allow for comprehensive record-keeping, and facilitate better follow-up care. It can also broaden access to dermatological expertise, especially in underserved areas where immediate consultation with a specialist might not be feasible [2,3]. Several studies report that patients are generally satisfied, or extremely satisfied, with teledermatology (TD). Between 38% and 86% of patients prefer SFTD, and while one study reported slightly higher satisfaction with conventional in-person care, 76% of patients preferred TD over waiting or traveling long distances to see a dermatologist [8]. General physicians also report an overall positive experience with TD once they have tried it, particularly in the field of skin cancer. TD facilitates communication between consultants and medical reference sites and reduces hospitalizations. It is a useful tool for triaging patients seeking primary care and for referring those requiring an in-person specialist consultation to a dermatologist.

However, it is essential to consider whether this reliance supports or fosters dependency. Ideally, TD should assist general practitioners in making complex decisions rather than leading to a pattern of systematic requests for all dermatological issues. Our study indicates that most adult French people (extrapolated figure: 39 million) are willing to seek a dermatologist’s opinion via TD. However, this acceptance varies according to several factors. For example, just under one-fifth of respondents would still prefer to consult a dermatologist in person, while one-third would only accept remote advice if it were covered by health insurance. This might be an important factor in France, where almost every aspect of medical care is reimbursed by Social Security. The reluctance among young people can be explained by their fear of not being reimbursed by Social Security, while among older individuals, it may result from less familiarity with digital medicine. In the Île-de-France region, where access to healthcare is generally better, residents are more reluctant because they believe they can obtain an in-person appointment more easily, in contrast with rural areas, where finding a dermatologist is often challenging. Regarding income, those earning more are less reluctant. This could be explained by a greater ability to pay for consultations in the private sector, if necessary, as well as greater knowledge and use of available digital health services. Reluctance among people with a skin disease could be explained by a preference for personalized follow-up and concerns about data confidentiality and security. However, SFTD remains a tool that has demonstrated its ability to modify management plans and resolve issues for a large majority of dermatology patients without in-person evaluation [8–10]. Triage allows for allocating in-person visits to patients with the most urgent problems, reducing appointment waiting times for high-risk patients, and expanding access to dermatological consultations for hospitalized patients [11–13]. It is essential that patients with skin disease be informed about the efficacy of SFTD, especially in terms of triage, which is one of the major issues in countries like France, where access to dermatologists is becoming increasingly difficult [14]. The observation that patients with a known dermatological condition exhibit greater hesitancy regarding TD warrants further exploration. It would be useful to investigate whether these patients have prior experience with TD, as such experience may influence their perceptions and satisfaction with remote consultations. For instance, individuals who have lived with a dermatological disease may feel a stronger need for in-person evaluations, leading to increased dissatisfaction with virtual consultations. Furthermore, it is concerning that those who could genuinely benefit from TD are often less inclined to utilize it compared to the general population, who might not fully grasp the complexities of living with a dermatological condition. Understanding these dynamics could provide insights on how to enhance the adoption of TD among patients who need it most.

While this study provides valuable insights into acceptance by the French population of diagnosis through SFTD, it is important to place these findings in context within the broader landscape of international studies. Research from the Netherlands and the United States suggests that the demographics of individuals benefiting from TD often include those on lower incomes, such as those under Medicaid or Medicare, as well as individuals with limited education [15–23]. Interestingly, these studies also indicate that younger patients with less severe skin conditions are generally more willing to utilize TD, likely due to their ease with technology. This contrasts with our findings, which may reflect unique aspects of the French healthcare system, including comprehensive reimbursement for TD services and the requirement that TD consultations be linked to primary care providers' requests. Moreover, it is crucial to recognize that patients inclined to use TD might face greater barriers to access in traditional care settings, potentially leading to resignation regarding their options. The timing of our study, which was conducted shortly after the implementation of TD reimbursement, may also have influenced patients' acceptance levels, as early adopters might have a different experience than those who are more set in their care pathways. Lastly, while we acknowledge TD potential for triaging skin conditions, it is essential to address its limitations, particularly concerning fragmented care pathways and patients' existing relationships with dermatologists. Many patients who already have a dermatologist may be reluctant to engage with TD unless it is offered as a means of expediting their care, especially in acute situations. To improve acceptance and implementation of TD, efforts should focus on enhancing primary care providers' knowledge and confidence in utilizing these systems, as well as promoting dermatologists' broader adoption of TD to facilitate access and streamline management for patients.

In conclusion, while SFTD is broadly embraced in France, its acceptance rates vary significantly based on age, geographical location, income, and pre-existing skin conditions. These findings underscore the importance of factoring in these variables when developing and implementing TD networks in order to ensure optimal accessibility and efficacy of dermatological care nationwide. However, it is important to note that a significant portion of SFTD requests still necessitate in-person consultations, indicating that while TD can prioritize cases and reduce unnecessary visits, many patients still require direct interaction with healthcare providers. Furthermore, with a projected reduction in the number of dermatologists by one-third and in light of evidence suggesting that newer practitioners see fewer patients than their predecessors, the overall improvement in access to dermatological care remains uncertain. This is compounded by a shortage of general practitioners, making it increasingly challenging for patients to navigate the system and secure referrals to dermatologists. As healthcare continues to embrace digital transformation, the focus on SFTD exemplifies the broader trend towards digitalization in medicine. This transition reflects a commitment to more efficient, patient-centered care, but it must be approached with caution and awareness of existing challenges. The integration of digital technology in dermatology offers promising opportunities for improved healthcare delivery, yet a multifaceted strategy is essential to ensure that dermatological care remains effective and accessible for all.

# Funding sources

This study was financed by Patient Centricity by Pierre Fabre.

# Patient consent

All individuals gave their consent with the understanding that their information may be made publicly available.