# Atopic dermatitis: A nationwide study on healthcare pathways and patient satisfaction of disease management in France

Charbel Skayem, Romain Salle, Stéphanie Merhand, Charles Taieb, Delphine Staumont-Salle

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Charbel Skayem, Romain Salle, Stéphanie Merhand, Charles Taieb, Delphine Staumont-Salle. Atopic dermatitis: A nationwide study on healthcare pathways and patient satisfaction of disease management in France. Journal of the European Academy of Dermatology and Venereology, 2023, 37 (8), 10.1111/jdv.19100. hal-04237734

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Submitted on 27 May 2025

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LETTER TO THE EDITOR

# Atopic dermatitis: A nationwide study on healthcare pathways and patient satisfaction of disease management in France

Dear Editor,

Atopic dermatitis (AD) is one of the most common skin disorders in Europe.¹ In the United States, most healthcare visits for AD occur with primary care physicians (PCPs), with fewer visits to dermatologists.² Data on the care pathway patterns in AD patients in France are lacking. In the era of biologics, characterizing the care trajectories of patients and their satisfaction with their disease management are essential to design future patterns for correct referrals and prescriptions. In this context, the aim of our study was to assess the current care pathway and patient satisfaction with AD management in France. The French Eczema Association sent an online survey in 2022 to AD patients over 18 years old with questions regarding symptoms, visited physicians and satisfaction regarding their AD management. The severity of AD was assessed via the Patient-Oriented Eczema Measure (POEM) score.³ Treatment satisfaction (TS) was defined as the proportion of patients who declared being satisfied with their AD management. In total, 1251 patients with AD responded to the survey, of whom 455 (36%) with an additional dermatosis were excluded. Therefore, 796 patients were included in the study. Characteristics of patients are represented in Table 1. The types of healthcare professionals consulted are represented in Table 2. Among the patients consulting a hospital-based dermatologist, 24.2% consulted on their own [27.3% mild AD (MAD) and 22.7% moderate-to-severe AD (MSAD) patients], 50% were referred by a general physician and 25.8% by a dermatologist in private practice (22.7% of MAD and 27.3% of MSAD). The referral purpose was to improve management in 62% of cases (50% of MAD and 67.7% of MSAD) and to change treatments in 32% of cases (43.8% of MAD and 26.5% of MSAD). The mean number of consultations per year with a general physician was 4 ± 2.4, 2.1 ± 2 with a hospital dermatologist and 1.8 ± 1 with a private dermatologist. For patients who declared to have been doctor shopping (n = 501), 54.3% of them declared that it was the dermatologist who prescribed the suitable treatment: hospital dermatologist in 10.8% (7.5% MAD vs. MSAD 13.4%) and private dermatologist in 43.5% (45.1% MAD vs. 42.2% MSAD) of cases. On the contrary, 36.4% of these patients declared that it was the general physician that prescribed the suitable treatment

<table><caption>TABLE 1 Characteristics of patients with atopic dermatitis (AD).</caption><thead><tr><th>Patient characteristics</th><th>n (%), N=796</th></tr></thead><tbody><tr><td>Mean age ± SD</td><td>47.55 ± 14.78</td></tr><tr><td>Female</td><td>553 (69.5)</td></tr><tr><td>Time of diagnosis of AD</td><td></td></tr><tr><td>Adult age</td><td>62.8%</td></tr><tr><td>Before the age of 10</td><td>20.4%</td></tr><tr><td>Severity scores</td><td></td></tr><tr><td>POEM score with corresponding SCORAD score at the time of questionnaire</td><td></td></tr><tr><td>Mild POEM</td><td>408 (51.1)</td></tr><tr><td>Mild SCORAD</td><td>66.1%</td></tr><tr><td>Moderate SCORAD</td><td>32.2%</td></tr><tr><td>Severe SCORAD</td><td>1.7%</td></tr><tr><td>Moderate POEM</td><td>293 (36.8)</td></tr><tr><td>Mild SCORAD</td><td>28.2%</td></tr><tr><td>Moderate SCORAD</td><td>58.5%</td></tr><tr><td>Severe SCORAD</td><td>13.3%</td></tr><tr><td>Severe POEM</td><td>95 (11.9)</td></tr><tr><td>Mild SCORAD</td><td>13.7%</td></tr><tr><td>Moderate SCORAD</td><td>39%</td></tr><tr><td>Severe SCORAD</td><td>47.3%</td></tr><tr><th>Symptoms that bothered patients the most</th><th>Mild AD</th><th>Moderate-to-severe AD</th></tr><tr><td>Pruritus</td><td>251 (62.3)</td><td>259 (66.6)</td></tr><tr><td>Pain</td><td>7 (1.74)</td><td>25 (6.43)</td></tr><tr><td>Visibility of the lesions</td><td>12 (2.98)</td><td>21 (5.4)</td></tr><tr><td>Fatigue</td><td>20 (4.96)</td><td>21 (5.4)</td></tr><tr><td>Erythema</td><td>39 (9.68)</td><td>21 (5.4)</td></tr><tr><td>Localization</td><td>7 (1.74)</td><td>8 (2.06)</td></tr></tbody></table>

(40.4% MAD vs. 32.2% MSAD). The general satisfaction of AD management is represented in Table 2. In the United States, the most visited physician by AD patients is the general practitioner. This is explained by a long-standing relationship between patients and their PCPs, as well as a

<footnote>This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.</footnote>

<footnote>© 2023 The Authors. *Journal of the European Academy of Dermatology and Venereology* published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.</footnote>
<table><caption>TABLE 2 Healthcare professionals visited by patients with mild and moderate-to-severe atopic dermatitis and general satisfaction of those who have been.</caption><thead><tr><th>Healthcare professional (s) that patients consulted for their AD</th><th>Mild AD, N=408, n (%)</th><th>General satisfaction with this HCP in patients who have been doctor shopping, TS% (N=501), p=0.0003</th><th>Moderate-to-severe AD, N=388, n (%)</th><th>General satisfaction with this HCP in patients who have been doctor shopping, TS% (N=501), p≤0.0001</th></tr></thead><tbody><tr><td>Dermatologist in a hospital setting</td><td>22 (5.4)</td><td>62.5</td><td>44 (11.3)</td><td>61.1</td></tr><tr><td>Dermatologist in private practice</td><td>146 (36.2)</td><td>85.42</td><td>155 (39.9)</td><td>58.4</td></tr><tr><td>General physician</td><td>208 (51.6)</td><td>77.91</td><td>204 (52.4)</td><td>64.04</td></tr><tr><td>Pharmacist</td><td>29 (7.2)</td><td>75</td><td>35 (9)</td><td>52.94</td></tr><tr><td>Other</td><td>9 (2.2)</td><td>71.43</td><td>1 (0.26)</td><td>23.08</td></tr><tr><td>No one (patient manages his AD on his own)</td><td>61 (15.1)</td><td></td><td>46 (11.8)</td><td></td></tr></tbody></table>

shortage of dermatologists in France.⁴ Some studies have suggested that PCPs lack confidence in the diagnosis and management of skin disease.⁵ In fact, dermatology placements are not frequent in junior doctor rotations, and as such, the bulk of dermatology learning takes place in-practice during the postgraduate term.⁶ Therefore, skin disease remains a learning need for PCPs, and it is paramount to ensure that PCPs are able to manage AD within the scope of their practices. For both, MAD and MSAD, the visited dermatologists are mostly those in private practice rather than those in hospitals. For those who have been doctor shopping, the type of visited physician has an impact on MAD and MSAD patients' satisfaction. For MAD, satisfaction is highest with private dermatologists. Surprisingly, for MSAD, it is highest with PCPs. While MSAD patients' needs seem to be met upon consulting PCPs, it is important to highlight that with a breadth of management options available, more complex or problematic AD should seek a specialist's opinion for optimal results. Exploring the AD care pathway and patients' satisfaction in France should promote the reinforcement of PCPs' skills in diagnosing and treating this condition. In France as in the United States, PCPs are allowed to prescribe systemic immunosuppressants⁷ but have a high level of discomfort in doing so in real-life practice. Initiation of systemic immunosuppressants by PCPs can be validated by teledermatologists through tele-expertise, and renewal can subsequently be done under joint supervision. Given the shortfall in dermatology workforce, pathway schemes in atopic dermatitis can rest on the efficacy of teledermatology⁸⁻¹⁰ in designing these models. Finally, European clinical practice guidelines for referral patterns can help optimize patients' access to new biologics when needed.

## ACKNOWLEDGEMENTS

The authors would like to thank Dr Marketa Saint Aroman (Foundation Eczema Pierre Fabre), Dr Claire Thenié (Sanofi) and Dr Jean Michel Joubert (Almirall) for their support in the implementation of this project.

## FUNDING INFORMATION

Almirall, Fondation Eczema Pierre Fabre, Sanofi.

## CONFLICT OF INTEREST STATEMENT

None.

## DATA AVAILABILITY STATEMENT

Data can be provided for valid scientific noncommercial purposes.

Charbel Skayem¹ ID

Romain Salle¹

Stéphanie Merhand²

Charles Taieb³ ID

Delphine Staumont-Salle⁴

¹Department of General and Oncologic Dermatology, EA4340-BECCOH, AP-HP, Ambroise-Paré Hospital, UVSQ, Université Paris-Saclay, Boulogne-Billancourt, France

²Association Française de l'Eczema, Redon, France

³Patients Priority Dpt, European Market Maintenance Assessment, Fontenay-sous-Bois, France

⁴CHU Lille, Service de Dermatologie, Univ Lille, INSERM U1286, Lille Inflammation Translational Research Institute (INFINITE), Lille, France

## Correspondence

Charles Taieb, Patients Priority Dpt, European Market Maintenance Assessment, Fontenay-sous-Bois, France.

Email: charles.taieb@emma.clinic

Charbel Skayem and Romain Salle contributed equally to this study.

## ORCID

Charbel Skayem ID https://orcid.org/0000-0002-4498-0683

Charles Taieb ID https://orcid.org/0000-0002-5142-2479
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