Perceived clinical severity of atopic dermatitis in adolescents: Comparison between patients' and parents' evaluation
Authors: Khaled Ezzedine, Jason Shourick, Stéphanie Merhand, Francesca Sampogna, Charles Taieb
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: In atopic dermatitis (AD), a significant discordance between physician-rated and patient-rated clinical severity has often been observed, probably because patients also include other nonclinical aspects in their evaluation.1Reed B. Blaiss M.S. The burden of atopic dermatitis.Allergy Asthma Proc. 2018; 39: 406-410Crossref PubMed Scopus (33) Google Scholar Although patient-physician agreement has been investigated, patient-caregiver agreement has been rarely studied, and caregivers are burdened with treatment issues and psychosocial consequences of the condition.2Carroll C.L. Balkrishnan R. Feldman S.R. Fleischer A.B. Manuel J.C. The burden of atopic dermatitis: impact on the patient, family, and society.Pediatr Dermatol. 2005; 22: 192-199Crossref PubMed Scopus (380) Google Scholar Balkrishnan et al3Balkrishnan R. Housman T.S. Grummer S. et al.The family impact of atopic dermatitis in children: the role of the parent caregiver.Pediatr Dermatol. 2003; 20: 5-10Crossref PubMed Scopus (41) Google Scholar observed that the family impact of AD increases when the child's disease is perceived as severe. In this context, a representative sample of the adult general French population was recruited by a polling institute (September and October 2019) using a stratified proportional sampling with replacement design. Individuals with children aged 12 to 17 years who were diagnosed with AD by a physician were proposed to participate in the study. Adolescents evaluated their clinical severity on a global assessment (GA) 3-point scale of mild, moderate, or severe. Caregivers evaluated clinical severity using 2 measures: the same GA as their child and the parent version of the self-assessed patient-oriented eczema measure (POEM),4Charman C.R. Venn A.J. Williams H.C. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients' perspective.Arch Dermatol. 2004; 140: 1513-1519Crossref PubMed Scopus (384) Google Scholar whose score was categorized into mild (0-7), moderate (8-16), or severe (17-28). Patient-caregiver agreement was measured using the Cohen κ by comparing: (1) POEM score in 3 categories vs adolescent GA and (2) parent GA vs adolescent GA. A total of 399 parent/adolescent dyads were recruited. Among parents, 67.4% were mothers. Among adolescents, 57.9 were boys, and 50% of them were aged ≥15 years. Severity evaluated by POEM was mild in 57.6%, moderate in 32.8%, and severe in 9.5% of patients. The Cohen κ (Fig 1) for comparisons 1 and 2 was 0.247 and 0.699, respectively. For comparison 1 (Table I), parents underestimated the severity as evaluated by the adolescent in 37.1% of cases and overestimated in 14%, whereas for comparison 2, severity was underestimated by parents only in 12% of cases and overestimated in 6.3%. Thus, patient-caregiver agreement was higher when the same GA measurement scale was used.Table IAgreement between the global assessment (GA) scale of clinical severity by adolescents with atopic dermatitis and their parents' patient-oriented eczema measure (POEM) (categorized in 3 groups), and between adolescent GA and parent GA∗The values in bold indicate the percentage of concordance between the 2 measures.AssessmentAdolescent GAMildModerateSevereNo.%No.%No.%1. Parent POEM Mild10043.512453.962.6 Moderate3526.77859.51813.7 Severe12.62052.61744.72. Parent GA Mild11674.83723.921.3 Moderate188.718086.994.3 Severe25.4513.53081.1∗ The values in bold indicate the percentage of concordance between the 2 measures. Open table in a new tab This means that the POEM and a simple GA question give different information. In fact, POEM questions are focused on symptoms, and thus, they do not capture other factors that patients use to define severity, which may instead be included in an answer to a more general question. To the best of our knowledge, this is the first study to compare patient-caregiver agreement in adolescents' AD severity. For this purpose, the choice of adolescents as target patients was optimal. In fact, they can provide their own evaluation of the disease, and at the same time, their caregivers, like what happens when the patient is a child, are highly involved in treatment and psychosocial issues.2Carroll C.L. Balkrishnan R. Feldman S.R. Fleischer A.B. Manuel J.C. The burden of atopic dermatitis: impact on the patient, family, and society.Pediatr Dermatol. 2005; 22: 192-199Crossref PubMed Scopus (380) Google Scholar,5Marciniak J. Reich A. Szepietowski J.C. Quality of life of parents of children with atopic dermatitis.Acta Derm Venereol. 2017; 97: 711-714Crossref PubMed Scopus (37) Google Scholar We showed that the use of a simple global assessment item may give information on the patient-caregiver agreement about AD clinical severity. A different view of the disease in adolescents with AD and their parents may have consequences on medical care, truancy from work and school, and tension between adolescent and parent. A limitation of the study is that AD was reported and not confirmed by a dermatologist.