FormalPara Key Summary Points

Multinational cross-sectional surveys were conducted among patients with atopic dermatitis (AD) and dermatologists to compare their perspectives toward AD management and communication.

Both patients and dermatologists were largely aligned in their top treatment goals in AD management, but there was some discordance in how goals were prioritized.

The prevention of exacerbations and minimization of treatment adverse effects were prioritized by patients but less so by dermatologists.

Although patient–clinician communication was observed to be good for most aspects, clinicians tend to report better communication, compared with patients.

There are potential areas in communication that could be improved to increase patient satisfaction and enhance patient-centered care in Asia.

Introduction

Atopic dermatitis (AD) is a chronic inflammatory condition that manifests predominantly in the skin and is characterized by intense pruritus and eczematous lesions [1]. With an estimated global prevalence of 230 million, it is the top global contributor to skin-related burden of disease [1,2,3]. The prevalence of AD continues to rise, especially in the Asia–Pacific region [4]. Past research conducted in Asia observed that about four in ten adult patients with AD suffer moderate-to-severe symptoms [5,6,7]. The burden associated with moderate-to-severe AD is significant and includes not only comorbidities [8] but also psychological [9,10,11], social, and financial costs.

Once thought to be primarily an allergic disease, AD is now recognized as a complex condition with diverse clinical features caused by a combination of immunological dysregulation, poor skin barrier function, genetic predisposition, and environmental factors [4]. Recent advancements in medicine, particularly the development of biologics and Janus kinase inhibitors (e.g., dupilumab) for the treatment of AD [12,13,14], have revolutionized the management of AD. To manage moderate-to-severe AD, a multistep long-term approach, which includes medications and interventions aimed to strengthen the skin barrier, minimize triggers, restore normal skin dysbiosis, and reduce inflammation, are crucial [15]. Given the multifactorial pathogenesis of AD and the complex nature of its management, an individualized and patient-centered approach is especially important to achieve good patient outcomes [16].

Patient-centered communication typically entails the physician and patient reaching a consensus on treatment-related issues that are important to the patient. Effective patient-centered communication and shared treatment goals are associated with improved patient adherence to treatment [17,18,19], better treatment outcomes [16], and increased patient satisfaction [20]. Previous studies revealed that patient–clinician interactions in Asia are typically doctor-centered, which is contrary to patient-centered care [21,22,23]. It is worth noting, however, that these studies did not specifically investigate patient–clinician interactions in the management of AD. Hence, it remains unclear how patients with AD and clinicians in Asia perceive such interactions and if there are potential lapses in communication. There are also no Asian studies conducted to compare treatment objectives of patients and clinicians in AD management.

Given the research gaps identified, this study aims to compare perspectives between patients with AD and dermatologists regarding communication and treatment expectations in Asia. Results from this study can be used to improve the level of patient-centered care in the management of AD.

Methods

Setting

Patients with moderate-to-severe AD and practicing dermatologists were recruited from eight Asia–Pacific territories, including Mainland China, Hong Kong, India, Japan, Singapore, South Korea, Taiwan, and Thailand. Ethical approval was received from the following institutional review boards (IRBs): Korea University Ansan Hospital, Chulalongkorn University, Father Muller Hospital, NPO MINS, National Taiwan University Hospital, Hong Kong Doctor Union, and Sir Run Run Shaw Hospital. The Parkway Independent Ethics Committee granted an exemption from review. The study was conducted in accordance with the protocol, Guidelines for Good Pharmacoepidemiology Practices, and the Declaration of Helsinki. All participants provided informed consent.

Study Participants

An online screener was sent to registered members of a commercial panel. Patients were recruited if they satisfied the following criteria: (1) legal adult age in the respective territory, (2) diagnosis of AD by a physician (self-reported), (3) fulfilled at least three major criteria of Hanifin–Rajka, (4) received medical care for AD symptoms in the past 3 months, and (5) experienced moderate or severe AD symptoms during the latest flare episode within the last 3 months (self-reported using the Patient Global Impression of Severity scale [24]). Participants without internet access to participate in the online survey or who are working in market research, advertising, healthcare, or pharmaceutical companies were excluded from the study.

Potential clinicians were identified through physician panels, contact lists, and other relevant directories/databases in each territory of interest. Clinicians were enrolled if they satisfy the following criteria: (1) board-certified dermatologist with at least 2 years of experience, (2) treat an average of ≥ 2 adult patients with moderate-to-severe AD per month, and (3) spend at least 60% of their work time in direct patient care.

Informed consent was obtained from all eligible participants at enrollment. Patients and clinicians who did not complete the survey were considered to have withdrawn consent and were excluded from the study. Participants who completed the survey also received compensation for their time spent. This study was approved by the institutional review board in each of the eight territories.

Online Surveys

For the purpose of this study, two structured questionnaires were developed in English. One questionnaire was designed for patients (patient survey), while the other was for dermatologists (clinician survey). To ensure the validity and relevance of the surveys, they were reviewed by a steering committee (StC), which comprised of an expert in dermatology from each territory (eight experts in total). The clarity, comprehensibility, and clinical relevance of the questionnaires were improved over multiple online meetings involving the StC and study team. The final English version of the study materials were translated into the respective local language of each territory by a professional translation agency before they were submitted for IRB review. After IRB approval was obtained, the patient survey was piloted among two patients in each territory, while the physician survey was pilot tested with 2 dermatologists (one StC member and one eligible dermatologist) from each territory. The pilot tests were designed to validate the language and survey programming before launching the surveys to a wider population. The final translated versions of the patient questionnaire were administered online, while the clinician questionnaire was administered either online or over the telephone.

To compare patients’ and clinicians’ expectations regarding AD treatment, both parties were instructed to select their top three goals for AD management from a list specified in the questionnaire. The goals included the reduction of eczema and pruritis, prevention of exacerbations, minimization of treatment adverse effects, improvement of sleep, increase in productivity, and improvement in mental health. Minimization of non-adherence was included as an additional goal in the list for clinicians. Patients’ expectations on the length of treatment before satisfactory response were also elicited. Satisfaction based on patients’ expectations was assessed using two additional items, including satisfaction of their treatment experience for their latest flare episode and whether they required additional treatment on top of what was prescribed.

To compare the perceived level of patient–clinician communication, all participants completed a ten-item questionnaire (Supplementary Table 1, Supplementary Materials) assessing patient–clinician communication. Since the study was conducted during the coronavirus disease 2019 (COVID-19) pandemic, two of the included items were related to the communication on how AD or AD treatment may impact the risk and severity of COVID-19 infection. Items assessing communication were scored using a 4-point Likert scale (“strongly agree,” “agree,” “disagree,” and “strongly disagree”).

Demographic information of patients, including age, gender, education level, employment status, and self-reported AD severity, were collected. Clinicians self-reported their years of experience treating AD, average number of moderate-to severe patients with AD treated monthly, and the location in which they practiced.

Statistical Analysis

Summary statistics of patient responses, in terms of frequency and percentage for categorical variables or median and interquartile range (IQR) for continuous variables were juxtaposed with that of responses from clinicians.

Results

A total of 1103 patients with AD completed the questionnaire over the span of 3 months (Table 1). The median age of patients was 41.0 years (IQR 16.0). The majority of the patients were male (51.9%), with an undergraduate degree (54.6%), and were employed (92.1%) at the time of survey participation.

Table 1 Demographics of recruited patients with atopic dermatitis
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Among the invited clinicians, 271 eligible dermatologists completed the questionnaire (Table 2). The majority of the dermatologists recruited in this study reported having more than 10 years of experience in managing and treating AD (59.0%) and were working in university hospitals or academic institutions (32.8%). The dermatologists saw a median of 30.0 (IQR 50.0) moderate-to-severe patients with AD monthly.

Table 2 Characteristics of recruited dermatologists
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Expectations from AD Treatment

Overall, patients and clinicians were generally aligned in their top treatment goals. The reduction of AD symptoms (or healing of skin lesions) and the prevention of exacerbations were indicated by both parties as their most important goals in AD treatment (Fig. 1). Although preventing exacerbations was identified as one of the top three priorities, it was nominated by a considerably higher proportion of patients (78.0%) than clinicians (47.2%). There were also relatively lower proportions of patients and clinicians who chose improvement in sleep (44.1% and 39.6%, respectively) and higher productivity in daily activities (30.3% and 40.4%, respectively). Notably, while 46.4% of patients selected the minimization of treatment adverse effects as one of their top three goals, only 9.1% of clinicians concurred with this. Furthermore, 16.0% of patients identified improvement of mental health as a priority in AD treatment, but only 4.9% of clinicians did the same.

Fig. 1
figure 1

Top 3 treatment goals in atopic dermatitis management

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Even though expectations regarding length of treatment before satisfactory response varied across patients, they largely (45.0%) expected treatment response between 4 and 8 weeks (Table 3). Based on their expectations of AD treatment, a total of 61.3% of patients indicated that they were either “very satisfied” or “satisfied” with their latest acute AD treatment. However, a majority of patients (65.5%) indicated that they needed more treatment on top of what was prescribed for their latest acute AD flare-up.

Table 3 Patients’ expectations and satisfaction with atopic dermatitis treatment
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Perceived Patient–Clinician Communication

In general, the majority of patients indicated “agree” to all ten items, while the majority of clinicians indicated “strongly agree” to most of the items assessing patient–clinician communication (Table 4). Except for items related to COVID-19, there were consistently higher proportions of patients who indicated either “disagree” or “strongly disagree,” compared with clinicians. Notably, while 17.4% of patients disagreed or strongly disagreed that their clinicians provided opportunities for them to discuss issues about their condition, only 3.7% of the clinicians indicated similarly. In addition, 18.7% of patients (compared with 2.6% of clinicians) disagreed or strongly disagreed with having discussed the side effects of medications during consultation. Relative to the other items, higher proportions of both patients and clinicians also disagreed or strongly disagreed with having discussed the effect of AD (33.1% and 42.8%, respectively), and AD treatment (16.6% and 38.3%, respectively) on the risk and severity of COVID-19 infection.

Table 4 Communication between patients and clinicians
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Discussion

Perspectives from patients with AD and dermatologists regarding communication and treatment expectations were obtained from two cross-sectional surveys conducted across eight Asia–Pacific territories, and subsequently compared in this study. Results from our study indicated that patients with AD and dermatologists were generally aligned in terms of treatment goals and agreed that there was good patient–clinician communication in most aspects. Although results looked promising, this study also highlights some potential areas for improvement, including communication about side effects of medications and how AD or its treatment may affect COVID-19 infection.

While patients with AD and dermatologists shared similar treatment goals in our study, the three most striking differences were for the prevention of exacerbation, minimization of treatment adverse effects, and the improvement of mental health. To improve patient-centered care and satisfaction, dermatologists can pay more attention to patient’s needs and priorities, while at the same time communicating realistic expectations regarding time to treatment response, disease remission, and future flare prevention. When managing acute AD flares, it is plausible that dermatologists are primarily focused on treating current symptoms and may not always consider the need to prevent future flares. This finding could explain why even though the majority of patients with AD reported being very satisfied or satisfied with their treatment for acute AD, about two-thirds of patients also expressed a desire for additional treatment beyond what was prescribed, possibly to reduce the occurrence of future flares. Considering that AD is a chronic relapsing disease, a key treatment goal for clinicians is the long-term maintenance of remission [15]. However, similar to proactive therapy, effective maintenance therapy to control residual subclinical inflammation after an acute flare has also been proven to be a valid strategy to prevent future flares [25]. The rationale of maintenance therapy could be better communicated to patients to better align treatment goal for the prevention of future flares. Importantly, for patients seeking more aggressive treatment for faster recovery, dermatologists should also caution them about the higher risk of adverse effects associated with such a treatment approach [26]. In addition, a larger proportion of patients reported improvement of mental health as a top treatment goal in our study. This finding suggests that many patients could have mental health issues due to their AD condition. For instance, depression and anxiety are commonly experienced by patients with AD [27]. However, due to limited time in each consultation, dermatologists often prioritize skin-related health and symptom relief over other aspects of care. Given the well-established association between AD and psychological issues [9,10,11], dermatologists should allocate some time to assess the mental health of their patients, and refer them to seek further medical care if necessary. As the prevention of AD recurrence may also improve the mental health of patients with AD, clinicians can consider communicating this benefit of AD recurrence prevention to patients. Such efforts to enhance communication and treatment goal alignment between dermatologists and patients with AD will be beneficial for improving outcomes and patient satisfaction [16, 20].

Our study shows that patients and dermatologists generally “agreed” or “strongly agreed” to items assessing patient–clinician communication, indicating a satisfactory level of communication. However, dermatologists consistently reported better communication than patients (a higher proportion of “strongly agree” by dermatologists). Furthermore, there was a relatively higher proportion of patients with AD (compared with dermatologists) who indicated that they were unsatisfied with the level of patient–clinician communication. For example, their dermatologists may not have adequately explained the side effects of medications or provided them with opportunities to discuss their condition. These findings suggest that although there was satisfactory patient–clinician communication in general, dermatologists could have perceived their communication with patients to be better than in reality. Our results are consistent with previous studies showing that communication in an Asian clinic setting is typically doctor centric [21,22,23]. While doctor-centric communication involves doctors being the dominant communicator in a doctor–patient relationship and making all decisions on behalf of patients [28], patient-centered communication involves both doctors and patients engaging in active communication, where patients highlight their needs and doctors provide more personalized medical care in response [29]. Cultural, religious, social, and philosophical differences, as well as language barriers, were identified as possible reasons for the lack of patient-centered communication in Asia [22]. To optimally tailor AD care, it is essential for dermatologists to use a patient-centered approach in communication that takes into account the unique needs, preferences, and circumstances of each patient before decision making [30]. The communication skills required to achieve this include eliciting the patient’s needs and preferences with open-ended questions, showing empathy, not interrupting the patient, and practicing focused active listening [31].

Compared with other items on communication, this study found that higher proportions of patients with AD and dermatologists disagreed on having discussed the effect of AD or AD treatment on the risk and severity of COVID-19 infection. This finding is worrisome, considering that patients with AD could have a higher risk of more severe COVID-19 infection due to their concomitant medical conditions and long-term use of immunosuppressive medications [32, 33]. Furthermore, a previous study highlighted that patients believed that AD symptoms increase the likelihood of being infected with COVID-19 and were worried about the availability of dermatological treatment during the pandemic [34]. Changes in lifestyle and forced quarantine were also found to be associated with worse AD symptoms [35]. The lack of communication on COVID-19 during routine consultations may be due to two reasons. Dermatologists may be focused on treating conditions pertaining to the skin and may not have time to address patients’ concerns about COVID-19. During the pandemic, there could also be limited information published in the scientific literature or clinical guidelines on the relationship between COVID-19 and AD, as well as how certain treatments may influence COVID-19 infection. In recent developments, some recommendations for guiding the treatment of AD have been published. These include advising patients on using gentle cleansers and hand sanitizers, discontinuing the use of dupilumab in the presence of an upper respiratory tract viral infection, and providing patients with access to telehealth services to ensure continued care [33, 36]. The need for regular hand sanitization during the pandemic could have resulted in constant exposure to harsh chemicals in soaps or sanitizers, resulting in the worsening of AD symptoms. Some patients may also stop their AD treatment over fears that the medications increase their susceptibility to infections. Dermatologists have an important role in dispelling myths, promoting medication adherence, and recommending alternative therapies so as to balance the need to reduce skin inflammation with the risk of infection. Even when limited information is available, improved communication can still be beneficial, as it enables discussion between the physician and patient, allowing for informed decision making and making trade-offs, which respect the patient’s autonomy. In the event that there is another pandemic, physicians should be better equipped to understand patients’ needs, make timely changes to their treatment plans, and ensure patients remain adherent to their prescribed therapy.

We acknowledge that there are some limitations to this study. First, this study involved self-reported data from surveys, which could be influenced by recall bias. Second, the patient survey excluded patients without internet access. As it is possible that these patients have lower income and education levels [37], our study findings may not be generalizable to them. In addition, they typically experience more barriers in communication with clinicians and may report lower satisfaction with AD management. Third, this study collected unpaired data (i.e., recruited dermatologists might not necessarily be those managing the patients with AD who participated in our study); hence, the experiences of these two groups may vary. Lastly, as the physician survey may be conducted over the telephone, this could result in social desirability bias among some dermatologists, potentially causing them to over report their communication with patients.

Conclusion

This multinational study found that patients with AD and dermatologists were generally aligned in treatment goals, and there was satisfactory patient–clinician communication in Asia. However, improving patient-centered communication can help identify possible mental health issues, align expectations on effectiveness and side effects of treatment, and respect patients’ autonomy when making decisions that involve trade-offs. Hence, it is important for physicians to recognize the potential drawbacks of a doctor-centric communication approach and be more receptive toward engaging in two-way communication with their patients. Future studies can explore barriers in patient-centric communication and evaluate strategies to prevent or mitigate them.