Comment on ‘The Doctors' Perception of Skin Diseases in General Practice in Denmark, With Emphasis on Atopic Dermatitis—A Descriptive Study’—The Irish Experience

We read with interest the findings of Froelunde et al. and their article entitled ‘The doctors' perception of skin diseases in general practice in Denmark, with emphasis on atopic dermatitis: A descriptive study’ [1].

In Ireland, a significant proportion of the population experience a skin condition in their lifetime, with an estimated 15%−20% of General Practitioner (GP) consultations specifically related to skin. In addition, there has been a well-documented surge in atopic conditions presenting to primary care with good evidence that early intervention can mitigate disease severity and persistence [2] Previous research has demonstrated challenges in the management of patients with atopic dermatitis in primary care, particularly around efficacious use of topical corticosteroids (TCS) and escalation of treatment when needed [3-5]. The National Clinical Programme for Dermatology in Ireland published a ‘Model of Care’ which details the requirement for evidence-based clinical pathways and guidelines with appropriate referral processes in place and sufficient educational supports for GP's in Ireland [2].

The aim of this study is to identify challenges that arise in primary care when managing patients with atopic dermatitis.

This study had a qualitative design and was granted full ethical approval. An anonymous survey was distributed over a 6-week period amongst Registered GP Trainers and Trainees inviting them to participate. Responses from a 5-point Likert Scale were collated and analysed. There were a total of 108 respondents with a 79% completion rate. Forty-five percent (n = 37/84) of respondents were GP Registrar Trainees and 55% GP Trainers. Forty-five percent (n = 39/85) had completed or partially completed a medical or surgical training programme before commencing GP medicine suggesting a varied range of clinical exposure. Eighty-three percent (n = 71/85) reported seeing a patient with a dermatological issue on a weekly basis. Almost 80% (n = 67/85) reported seeing a patient with a new diagnosis of atopic dermatitis at least monthly and just under 85% (n = 72/85) reported seeing a patient with an exacerbation of eczema at least monthly if not more often.

Similar to the findings of Froelunde et al, GP's are more likely to encounter paediatric cases presenting with atopic dermatitis (n = 57/82, 70%). Over 50% (n = 49/85) of respondents are confident in their ability to obtain a focused dermatological history and skin examination and 3/4's (n = 65/85, 76%) of respondents are confident when considering important differential diagnoses and confirming a diagnosis of atopic dermatitis. However, it is important to note that only 29% (n = 25/84) of respondents are confident in their ability to diagnose atopic dermatitis in patients with skin of colour (SOC).

Nearly 2/3's of respondents are confident when prescribing an appropriate strength and duration of TCS. Up to 40% (n = 34/85) highlight that often their patients have concerns regarding overuse of TCS in the management of atopic dermatitis and 43% (37/85) spend time providing patient education focused on the management of atopic dermatitis.

Most respondents (n = 79/85, 94%) decide to escalate a patients management with referral to Dermatology for specialist management approximately 3−4 times per year—the most reported reason for doing so is when a patient presents with clinically severe disease. Whilst over 70% will do so when specifically requested by a patient. Just under 25% will refer for further management when a patient with SOC presents with atopic dermatitis.

A quarter (n = 23/85, 27%) of respondents refer a patient to the Emergency Department for acute inpatient management approximately once a year whilst over half report they have never done so (n = 44/85, 51%).

Free text responses report challenges around availability of TCS in the community due to issues with medicine shortages which can make decisions regarding management more difficult.

This study highlights the high burden of atopic dermatitis in the community managed predominantly by GP's. Our sample size was slightly larger than the study in Denmark (n = 108 vs. 94 respondents) with a similar completed response rate (n = 79% vs. 74%). Both studies report a similar frequency of reviewing a patient with atopic dermatitis at least weekly (Ireland = 40% vs. Denmark = 49%).

The experience and confidence of managing such patients is similar to the findings of our counterparts in Denmark. However, our study highlights particular challenges for GP's in Ireland which include, in particular a lack of confidence when recognising and diagnosing atopic dermatitis in patients with skin of colour. Often disease severity is under-recognised in this patient cohort leading to the potential for mismanagement and an increased risk of disease exacerbation and deterioration.

Froelunde et al comment how GP training within the residency programme in Denmark is a 4-h lecture. In Ireland, current dermatology specific teaching can vary across GP training programmes. These observations are in keeping with global health perspectives. Previous studies describe a heterogenous approach to the management of AD worldwide, identifying Primary Care as essential—yet dermatology teaching for GP's is often poorly supported [6].

It is important to identify areas in which education in Primary Care can be developed to enhance the management of patients with atopic dermatitis in the community. Further studies to compare the experience of GP's in the management of a range of dermatological conditions will be useful to guide GP-focused dermatology curricula in the future.

Anna Wolinska: study administration, data collection, data analysis, write up. Dominic O'Dowd: study administration, data collection, data analysis, write up. Aisling Ní Shúilleabháin: conceptualisation, supervision, editing of final draft. Anne-Marie Tobin: conceptualisation, supervision lead, editing of final draft.

Full ethical approval granted.

The authors declare no conflicts of interest.