# The burden of skin disease in Europe

Myrto Trakatelli, Marie-aleth Richard, Anna Rouillard, Carle Paul, Martin Röcken, Alexander Stratigos

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Myrto Trakatelli, Marie-aleth Richard, Anna Rouillard, Carle Paul, Martin Röcken, et al.. The burden of skin disease in Europe. Journal of the European Academy of Dermatology and Venereology, 2023, 37 (S7), pp.3 - 5. 10.1111/jdv.19390. hal-04988175

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# The burden of skin disease in Europe

The term ‘Burden of disease’ was conceived to describe the total, cumulative repercussions of a specific disease or a range of harmful diseases with respect to disabilities in a community. These repercussions include health, social aspects and costs to society.

The Global Burden of Disease study, which sets out trends in global health, ranked skin diseases as the fourth leading cause of disability worldwide.¹

With a view to gaining detailed insights into the burden of skin diseases in Europe, the European Academy of Dermatology and Venereology (EADV) conducted recently a population-based study on a representative adult population in 27 European countries.

This represents the largest-ever epidemiological study undertaken in Europe to assess the prevalence and burden of skin diseases.

The Burden of Skin Disease Survey reveals the important impact that skin diseases have on human well-being and the limitations in access to care for patients. These data are important to create awareness and establish the setting for the management of skin diseases. As part of EADV's nascent advocacy programme, it is timely to publish the results in a JEADV supplement that groups vital information on important aspects of the impact of skin diseases.

Addressing skin diseases is vital to achieve the United National Sustainable Development Goals (SDGs).² Understanding the impact of these diseases on individuals, as well as the needs of patients within the healthcare systems, are fundamental efforts to support healthy lives and well-being.

Skin diseases range from mild to severe, and some are life-threatening. Dermatologists are responsible for diagnosing and treating over 3000 skin diseases. This spectrum includes a large number of rare diseases, many causing severe morbidity. They need to be highly skilled and require, in addition, a large spectrum of competencies. Impressive progress has been made in the field of dermatology over the past two decades. The discoveries and advances made in dermatology have successfully been translated into almost all other fields of medicine such as gastroenterology, neurology, rheumatology, otorhinolaryngology, pneumonology and, almost all fields of oncology including lung and breast cancers, gastrointestinal and hepatic cancers, urogenital cancers and others.

This revolutionized the role of dermatologists who have to understand and master the use of innovative drugs such

as biologics and targeted therapies, as well as the short and long-term side effects. This revolution also includes new molecular diagnostics and complex surgical procedures combined with systemic therapies, due to the increasing number of diseases in immune-compromised patient.

This supplement, which analyses data from representative European citizens, reflects the lived experience of people with skin diseases and underscores the crucial role of dermatologists in taking care of a large spectrum of skin diseases with a large range of severity, from mild to severe mutilating and deadly diseases.

The Burden of Skin Disease survey's prevalence data show that 43.35% of responding persons reported having had at least one skin disease in the past 12 months. Projecting this figure to the general population, more than 185 million adults in the 27 countries surveyedª are potentially affected by a skin disease within 1 year.³

An overview of the patient journey from first consultation to diagnosis by Richard et al.⁴ shows that ‘medical avoidance’ is common amongst individuals with skin diseases, in particular those suffering from acne, alopecia and fungal infection as well as many with atopic dermatitis, psoriasis and sexually transmitted infections. By nature—most diseases are mild, and have a spectrum from almost undetectable to very severe. This was recently exemplified by the COVID pandemic. In some individuals, the infection caused either no or only very mild disease, while it was deadly in up to 10% in some populations. Skin diseases are very frequent. The visible benign courses are frequently generalized, while severe course, including skin cancers, are often hidden from the public and even cause medical avoidance. Therefore, policymakers and healthcare authorities are not really aware neither of the impact of skin diseases on normal life nor of the impact of novel therapies on disease outcomes. Delayed access to appropriate dermatological care results in severe disease courses that strongly increase treatment costs, may be mutilating, and even be deadly. Furthermore, skin diseases are often associated with significant co-morbidities, underscoring the need for patients to be treated in a holistic way. The use of guidelines may aid in improving the patient journey. Yet, guidelines are boundaries and not dogmas; in consequence, treating dermatologist have to take the responsibility for the correct diagnosis and the individually adapted therapy.

<footnote>ªNorway, EU (24), UK and Switzerland.</footnote>
It is well-known that many skin diseases exert a signifi-
cant impact on patients' quality of life, and this is corrobo-
rated by Gisondi et al.⁵ who describe a high impact of skin
diseases on the life of affected people, with individuals ex-
periencing embarrassment, anxiety or depression, stigmati-
zation, sleep disturbance, as well as negative impacts on the
patient's profession. Stigmatization significantly contributes
to reduced quality of life, and amongst those suffering from
skin diseases, up to 20 per cent with of those affected by hi-
dradenitis suppurativa, acne, vitiligo, rosacea or psoriasis
suffer from their stigmatization. The WHO strongly urges
member states to take measures against the stigmatization
of skin diseases and the findings of this study highlight the
ongoing need for to protect patients with skin diseases from
stigmatization.

The perception of dermatologists amongst the general public influences where, when and how patients with skin diseases search help. Richard et al.⁶ provide novel insights on the frequency and reasons for consulting a dermatologist and other healthcare professionals. The data confirm the leading role of dermatologists in providing care for skin diseases, and patients' satisfaction with the care received. She also found, telemedicine was generally considered as an acceptable mode to contact patients, and this field will rapidly develop in the future. While popular, this risks to transform internet offers into a self-service business, that underestimates the role of the holistic approach to skin diseases and the important interaction between dermatologist and the patient—as mentioned above, patients tend to hide their diseases even from the treating dermatologist.

Importantly, only a small proportion of dermatology con-
sultations documented in the study were for cosmetic rea-
sons, emphasizing the medical-focused role of dermatology.

In parallel to EADV's Burden of Skin Disease survey, GlobalSkin, the International Alliance of Dermatology Patient Organizations, has conducted a European Delphi study to better understand the main impacts of skin diseases from the patient's perspective. Trialonis-Suthakharan et al.⁷ highlight the significant psychological impacts of skin diseases on patients and point to the need for a new approach to assess the impact of skin diseases, which measures the whole person impact, including broader psychological and social aspects, disability and threats, including threat of dying.

Overall, this supplement's articles provide important in-
formation for future health policymaking and raise general
awareness about skin diseases and the role of dermatologists
in managing them.

The coronavirus (COVID-19) pandemic has high-
lighted a diversity of public health challenges and oppor-
tunities, not least with regards to strengthening health
systems resilience. The dermatology community contrib-
utes important expertise and advice in the post-pandemic
rebuilding of Europe's health systems and in the design
and implementation of strategies to provide appropriate
care for skin diseases, which have hitherto been largely
under-prioritized.

Addressing the burden of skin disease in Europe requires a multi-stakeholder approach. In this spirit, the EADV has launched a series of multi-stakeholder Policy Roundtables, aimed at fostering discussion on the policies and partnerships needed to create appropriate awareness for skin diseases in Europe. Contributors have included the European Commission, European Parliament, members of the World Health Organization, healthcare professionals, patient's organizations, and other relevant stakeholders. Besides the studies in this supplement, various stakeholders and experts were invited to comment on the different scientific articles thus already providing feedback and holistic viewing on the various issues raised.

The EADV looks forward to collaborate with medical and patient associations to aid that policies on the EU's agenda deliver impactful results for the significant number of citizens living in Europe with skin diseases. Horizontal actions, improving the lives of EU citizens could be conducted at an EU level, such as collection of concerted data on skin cancer, psoriasis, lupus erythematosus, other non-transmittable and transmittable diseases, including sexually transmitted infections. This will help to create better awareness of the impact of many severe skin diseases and to include them in EU and WHO strategic plans.

ACKNOWLEDGEMENTS

The authors would like to thank the past and current
Advocacy Working Group members for their support in the
conception and development of this supplement: Jennifer
Austin, Christa De Cuyper, Swen Malte John, Catherine
Van Monfrans, Tiago Matos and Sarah Walsh. The authors
would like to thank the editorial team of JEADV for all the
logistic support on preparing this supplement.

FUNDING INFORMATION

None.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data
were created or analysed in this study.

Myrto Trakatelli<fnref n="1" /> ID

Marie-Aleth Richard² ID

Anna Rouillard³

Carle Paul⁴

Martin Röcken⁵

Alexander Stratigos⁶

<footnote n="1">¹Second Department of Dermatology and Venerology
of Aristotle University School of Medicine,
Papageorgiou Hospital, Thessaloniki, Greece

²Dermatology Department, CEReSS-EA 3279,
Research Centre in Health Services and Quality of Life
Aix Marseille University, University Hospital Timone,</footnote>
Assistance Publique Hôpitaux de Marseille, APHM,
Marseille, France

³Head of Advocacy and EU Public Affairs, European
Academy of Dermatology and Venereology, Lugano,
Switzerland

⁴INSERM Infinity U1291, Université de Toulouse et
CHU, Toulouse, France

⁵Department of Dermatology, Universitäts-Hautklinik,
Tübingen, Germany

⁶Department of Dermatology, Andreas Syggros
Hospital, Medical School, National and Kapodistrian
University of Athens, Athens, Greece

Correspondence

Myrto Trakatelli, Second Department of Dermatology
and Venerology of Aristotle University School of
Medicine, Papageorgiou Hospital, Thessaloniki,
Greece.

Email: mtrakatelli@hotmail.com

Myrto Trakatelli, Marie-Aleth Richard, and Anna
Rouillard contributed equally as the first authors.
Carle Paul, Martin Röcken, and Alexander Stratigos
contributed equally as the final authors.

ORCID

Myrto Trakatelli https://orcid.org/0000-0002-4312-6557

Marie-Aleth Richard https://orcid.
org/0000-0002-0870-9132

REFERENCES

1. Karimkhani C, Dellavalle RP, Coffeng LE, Flohr C, Hay RJ, Langan SM, et al. Global skin disease morbidity and mortality: an update from the global burden of disease study 2013. JAMA Dermatol. 2017;153(5):406-12. https://jamanetwork.com/journals/jamadermatology/article-abstr act/2604831

2. United Nations Sustainable Development Goals website. Available from: https://sdgs.un.org/goals

3. Richard MA, Paul C, Nijsten T, Gisondi P, Salavastru C, Taieb C, et al. Prevalence of most common skin diseases in Europe: a population-based study. J Eur Acad Dermatol Venereol. 2022;36:1088-96.

4. Richard MA, Paul C, Nijsten T, Gisondi, P, Salvalastru C, Taieb, C, et al. The journey of patients with skin conditions from the first consultation to the diagnosis in a representative sample of the European general population from the EADV burden of skin diseases study. J Eur Acad Dermatol Venereol. 2023;37(S7):17-24.

5. Gisondi P, Puig L, Richard MA, Paul C, Nijsten T, Taieb C, et al. Quality of life and stigmatization in people with skin diseases in Europe: a large survey from the 'Burden of Skin Diseases' EADV project. J Eur Acad Dermatol Venereol. 2023;37(S7):6-14.

6. Richard MA, Paul C, Nijsten T, Gisondi P, Salvalastru C, Taieb C, et al. Public perception of dermatologists in Europe: results from a population-based survey. J Eur Acad Dermatol Venereol. 2023;37(S7): 27-37.

7. Trialonis-Suthakharan N, Pattinson R, Tahmasebi Gandomkari N, Austin J, Janus, C, Courtier N, et al. Patient prioritization of impact items to develop the Patient-Reported Impact of Dermatological Diseases (PRIDD) measure: European Delphi data. J Eur Acad Dermatol Venereol. 2023;37(S7):40-50.