# Bridging Primary and Specialist Care in Atopic Dermatitis: Outcomes of an Interregional Referral Protocol in Portugal

## TL;DR

A referral protocol in Portugal improved atopic dermatitis care by identifying patients needing specialist attention and streamlining their access to hospital services.

## Contribution

The study introduces and evaluates a structured referral protocol to bridge primary and specialist care for atopic dermatitis patients in Portugal.

## Key findings

- 78.7% of assessed patients had mild or well-controlled atopic dermatitis.
- 22.3% of patients required specialist care due to moderate-to-severe disease burden.

## Abstract

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a significant impact on quality of life and healthcare systems. In Portugal, access to specialist care remains limited, particularly for patients requiring advanced therapies available only in hospital settings. This study aimed to implement and evaluate a structured referral protocol between primary and hospital dermatology services to improve AD management.

Between April 2024 and February 2025, adult patients (≥18 years) coded with AD were identified at the USF Planície primary care center and assessed using a structured telephone questionnaire evaluating disease severity (Patient-Oriented Eczema Measure (POEM)), pruritus (Itch Numeric Rating Scale (INRS)), and sleep disturbance (Sleep Numeric Rating Scale (SNRS)).

Of 213 identified patients, 119 (55.8%) were excluded - 94 (44.1%) could not be contacted; 19 (8.9%) denied the diagnosis; and 6 (2.8%) refused to participate - and 94 (44.1%) completed the assessment. Among these patients, 74 (78.7%) had mild or well-controlled disease, whereas 21 (22.3%) presented with moderate-to-severe AD. Patients with moderate-to-severe POEM showed a higher disease burden, with INRS ≥ 5 in 17 patients (85.0%), SNRS ≥ 5 in 5 patients (25.0%), and involvement of high-impact areas in 15 patients (75.0%), whereas in mild POEM, most patients had INRS < 5 (71, 95.9%), SNRS < 5 (74, 100%), and limited involvement of high-impact areas (16, 21.6%).

This protocol demonstrated feasibility and clinical relevance, improving patient stratification and facilitating timely referral for specialist evaluation.