Developing a written action plan for children with eczema: a qualitative study

Supporting children, young people and families to self-manage atopic eczema

Atopic eczema is common in childhood and can continue into adulthood. Adherence to treatment is a significant factor in its effective management, but the complexity of treatment regimens can make adherence challenging. Additionally, living with the condition can have adverse psychosocial consequences for young people in particular. This article discusses treatment regimens for moderate-to-severe atopic eczema and some of the challenges encountered by children, young people and families in self-managing the condition. The authors discuss strategies that can support families to achieve optimal self-management, namely online support tools, written action plans and nurse-led eczema clinics.

Atopic eczema and the barriers to treatment adherence for children: a literature review

Atopic eczema is a chronic, non-contagious, relapsing inflammatory skin condition commonly seen in children and adults. Children with atopic eczema often endure complex skincare regimens that can keep the condition under control when managed effectively. Nonadherence, particularly to topical treatments, is one of the most common causes of treatment failure in atopic eczema. This literature review aimed to explore the barriers that influence treatment adherence in children and young people with atopic eczema and identify recommendations for practice. Six studies were included in the literature review and three themes were identified: relationships, medicines concerns and information deficits. Healthcare professionals should strive to develop trusting relationships with parents and understand the barriers to treatment adherence. Individualised conversations and education about medicines concerns, understanding the psychosocial effects of atopic eczema on children and families, and providing clear, consistent advice can be beneficial.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Perceptions on Management of Atopic Dermatitis in Children Under 2 Years by Community Pediatricians: A Focus Group Study

Atopic dermatitis (AD) is a common skin condition and is undertreated in children under 2 years, whom there are no specific guidelines for. We sought to understand barriers to AD treatment and primary care pediatricians' (PCPs) suggested solutions. We conducted semi-structured focus groups (n = 5) with PCPs (n = 17) on how the undertreatment of AD can be addressed. Data were analyzed using an inductive qualitative approach. Participants noted that the perceived undertreatment of AD in children under 2 years could be explained by topical corticosteroid (TCS) use hesitancy, lack of caregiver adherence to PCP recommendations, and under-documentation of AD in the electronic medical record (EMR). Proposed suggestions for improving AD management included caregiver and PCP education on TCS safety; stepwise management guidelines for this age group; and EMR aids to help document and manage AD. Research is warranted to create and disseminate clinician-friendly AD management guidelines for this age group.

Where and how have written action plans for atopic eczema/dermatitis been developed and evaluated? Systematic review

Background

Atopic eczema/dermatitis is a common inflammatory condition which affects 15%-30% of children and 2%-10% of adults. It can have a significant impact and its management can be challenging. It is important for patients, parents, and caregivers to know how to look after their skin.

Objectives

To identify and review written eczema action plans (WAPs) that are available internationally for use by patients, parents, and caregivers.

Methods

We followed Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. We searched relevant databases (MEDLINE, Embase, COCHRANE) from inception until March 2022. We sought grey literature via Google searches and professional networks. Database search results were independently reviewed by two different reviewers. With identified WAPs, we assessed length, appearance, content, how it was developed and whether it had been evaluated.

Results

From 312 abstracts, supplemented by other searches, we identified 20 unique eczema WAPs. From nine countries, all were written in English with 18 were designed for children. For the majority, it was unclear whether any development work preceded their creation or the intended clinical setting for use. Nineteen had a stepwise approach, 17 advised when to seek help, 6 were visually appealing and 6 had a rationale behind treatment documented in the WAP. Only three had been evaluated in clinical trials.

Conclusion

Further evaluation is needed to assess the effectiveness of the WAPs that currently exist, prior to creating further WAPs. Patient and caregiver involvement is needed in any future work.

Current Utilization of Qualitative Methodologies in Dermatology: A Scoping Review

The focus of this review was to determine how qualitative methods are used in dermatology research and whether published manuscripts meet current standards for qualitative research. A scoping review of manuscripts published in English between January 1, 2016 and September 22, 2021 was conducted. A coding document was developed to collect information on authors, methodology, participants, research theme, and the presence of quality criteria as outlined by the Standards for Reporting Qualitative Research. Manuscripts were included if they described original qualitative research about dermatologic conditions or topics of primary interest to dermatology. An adjacency search yielded 372 manuscripts, and after screening, 134 met the inclusion criteria. Most studies utilized interviews or focus groups, and researchers predominantly selected participants on the basis of disease status, including over 30 common and rare dermatologic conditions. Research themes frequently included patient experience of disease, development of patient-reported outcomes, and descriptions of provider and caregiver experiences. Although most authors explained their analysis and sampling strategy and included empirical data, few referenced qualitative data reporting standards. Missed opportunities for qualitative methods in dermatology include examination of health disparities, exploration of surgical and cosmetic dermatology experiences, and determination of the lived experience of and provider attitudes toward diverse patient populations.

Needs and preferences of patients regarding atopic dermatitis care in the era of new therapeutic options: a qualitative study

To optimally tailor atopic dermatitis (AD) care to patients' needs, especially considering the many emerging therapeutic options, insight into patients' needs and preferences regarding AD care is needed. To explore patients' needs and preferences regarding AD care, a qualitative study consisting of three focus groups with a total of 20 adult AD patients was conducted. All sessions were transcribed verbatim and inductively analyzed using several phases of coding to create an overview of patients' needs and preferences. AD patients emphasized the need for a patient-tailored approach in all identified aspects of AD care. With regard to consultations, patients stressed the need for a personal approach and increased recognition of the disease impact, which should mainly be determined by patients. With regard to the organization of AD care, the need for psychosocial and medical supportive care as well as quick access to health-care providers during disease flares was emphasized. Within the decision-making process, patients indicated that the provided information, the role of the patient and physician, whether or not treatment goals should be set, and decisive factors for indication and feasibility of novel therapies should be patient dependent. AD care should be patient tailored with increased attention for the psychosocial burden, as well as better access to health care during disease flares. To provide patient-tailored care, the personal situation, needs, and preferences of the patient should be taken into account in the therapeutic decision-making process, with respect for the autonomy of the patient.

Supporting families managing childhood eczema: developing and optimising eczema care online using qualitative research

BACKGROUND

Childhood eczema is often poorly controlled owing to underuse of emollients and topical corticosteroids (TCS). Parents/carers report practical and psychosocial barriers to managing their child's eczema, including child resistance. Online interventions could potentially support parents/carers; however, rigorous research developing such interventions has been limited.

AIM

To develop an online behavioural intervention to help parents/carers manage and co-manage their child's eczema.

DESIGN AND SETTING

Intervention development using a theory-, evidence-, and person-based approach (PBA) with qualitative research.

METHOD

A systematic review and qualitative synthesis of studies (n = 32) and interviews with parents/carers (n = 30) were used to identify barriers and facilitators to effective eczema management, and a prototype intervention was developed. Think-aloud interviews with parents/carers (n = 25) were then used to optimise the intervention to increase its acceptability and feasibility.

RESULTS

Qualitative research identified that parents/carers had concerns about using emollients and TCS, incomplete knowledge and skills around managing eczema, and reluctance to transitioning to co-managing eczema with their child. Think-aloud interviews highlighted that, while experienced parents/carers felt they knew how to manage eczema, some information about how to use treatments was still new. Techniques for addressing barriers included providing a rationale explaining how emollients and TCS work, demonstrating how to use treatments, and highlighting that the intervention provided new, up-to-date information.

CONCLUSION

Parents/carers need support in effectively managing and co-managing their child's eczema. The key output of this research is Eczema Care Online for Families, an online intervention for parents/carers of children with eczema, which is being evaluated in a randomised trial.

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND

Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current 'trial and error' approach to find suitable emollients can be frustrating for parents, children, and clinicians.

AIM

To identify how parents and children experience and evaluate emollients.

DESIGN AND SETTING

Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial).

METHOD

Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity.

RESULTS

Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration.

CONCLUSION

There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them.

Quality of Life for Children with Allergic Skin Diseases

Allergic skin diseases are highly prevalent among children. Patients with allergic skin diseases experience sociopsychological and quality-of-life (QoL) burdens in excess of those in the general population. Children and their caregivers are especially vulnerable to the burden of many of the common allergic skin diseases. In the past few decades, researchers have developed a number of disease-specific scores and indices for the measurement of QoL for childhood skin diseases. Most of the research in this area has focused on atopic eczema and urticaria and less so on allergic contact dermatitis. We provide an overview of QoL and its assessment for these dermatologic conditions.

Pearls for Managing Atopic Dermatitis in Patients With Low Socioeconomic Status

Atopic dermatitis (AD) is a chronic inflammatory dermatosis presenting with inflamed and itchy skin. Recent studies have shown an inverse relationship between socioeconomic status and the severity of AD. Low socioeconomic status (LSES) individuals with AD face specific barriers that may impede management. These include forgoing doctor's appointments due to transportation costs, inability to take time off from work, and lack of affordable childcare services. Unaffordable medications and over-the-counter products for managing AD further present as significant challenges for LSES patients. This article aims to offer practical and affordable recommendations to help mitigate the challenges faced by LSES patients with AD and thereby alleviate disease burden and improve treatment outcomes.

A labelling system improves parental comfort and willingness to use topical corticosteroids for paediatric atopic dermatitis

Objectives

In the United Kingdom, atopic dermatitis (AD) affects 20% of children and topical corticosteroids (TCS) are a mainstay of AD treatment regimes. Many TCS have similar packaging despite significant differences in potency frequently leading to confusion, and along with misinformation and steroid phobia, potentially reducing treatment adherence. We aimed to evaluate parents' knowledge/concerns regarding TCS and explore benefits of/preference for a TCS‐labelling system.

Method

Hundred parents of children with AD attending paediatric dermatology and/or allergy appointments completed mixed‐methodology Survey 1 (knowledge‐quiz, TCS‐labelling options, feedback on what supports AD‐care). Thirty parents, adolescents, and healthcare professionals completed Survey 2. Qualitative/quantitative data was thematically/statistically analysed (SPSS v25) respectively.

Results

Parents preferred the traffic light system (green = mild, yellow = moderate, red = potent; n = 71/100) and reported significantly increased willingness and comfort in using TCS if a labelling system was used p ≤ 0.001). Knowledge regarding TCS potency was lacking: 62% (n = 46/74) of mild TCS‐users overestimated potency; 51% (n = 67/131) of potent TCS‐users underestimated potency. Common concerns were TCS‐related skin thinning, long‐term side effects and themes for improved AD‐care/support included: better information, written plans, access to advice, involvement of certain staff. Parents wanted accessible information in various formats: verbally, electronic resources, leaflets, and education sessions.

Conclusions

Parents of children with AD confirmed significant concerns and demonstrated poor knowledge regarding TCS use. Our findings suggest that a simple labelling system may improve TCS adherence. Future work to test refined label prototypes and evaluating their impact on adherence and correct use is needed.

Children's Views and Experiences of Treatment Adherence and Parent/Child Co-Management in Eczema: A Qualitative Study

Eczema affects one in five children and can have a substantial impact on quality of life. This qualitative study aimed to explore children's views and experiences of eczema and what may affect treatment adherence from their perspective. We conducted semi-structured, face-to-face interviews with children with eczema aged 6-12 years from March to July 2018. Interviews were transcribed verbatim and analysed using inductive thematic analysis. We found that children do not typically view eczema as a long-term condition, and topical treatments (predominately emollients) were seen to provide effective symptom relief. Uncertainty around co-managing at home was expressed as children typically felt that parental reminders and assistance with applying different types of topical treatments were still needed. For some children, eczema can be difficult to manage at school due to a lack of convenient access and appropriate spaces to apply creams and psychosocial consequences such as attracting unwanted attention from peers and feeling self-conscious. Treatment adherence could be supported by reinforcing that eczema is a long-term episodic condition, providing clear information about regular emollient use, practical advice such as setting reminders to support co-management at home, and working with schools to facilitate topical treatment use when necessary.

Parents and GPs' understandings and beliefs about food allergy testing in children with eczema: qualitative interview study within the Trial of Eczema allergy Screening Tests (TEST) feasibility trial

AIM

To explore parent and general practitioner (GP) understanding and beliefs about food allergy testing for children with eczema.

DESIGN AND SETTING

Qualitative interview study in UK primary care within the Trial of Eczema allergy Screening Tests feasibility trial.

PARTICIPANTS

Semi-structured interviews with parents of children with eczema taking part in the feasibility study and GPs at practices hosting the study.

RESULTS

21 parents and 11 GPs were interviewed. Parents discussed a range of potential causes for eczema, including a role for food allergy. They believed allergy testing to be beneficial as it could potentially identify a cure or help reduce symptoms and they found negative tests reassuring, suggesting to them that no dietary changes were needed. GPs reported limited experience and uncertainty regarding food allergy in children with eczema. While some GPs believed referral for allergy testing could be appropriate, most were unclear about its utility. They thought it should be reserved for children with severe eczema or complex problems but wanted more information to advise parents and help guide decision making.

CONCLUSIONS

Parents' motivations for allergy testing are driven by the desire to improve their child's condition and exclude food allergy as a possible cause of symptoms. GPs are uncertain about the role of allergy testing and want more information about its usefulness to support parents and help inform decision making.

TRIAL REGISTRATION NUMBER

ISRCTN15397185.

The role of the nurse in the care and management of patients with atopic dermatitis

BACKGROUND

The purpose of this paper is to provide an overview of key aspects of specialised dermatology nursing practice in the management of patients with moderate to severe atopic dermatitis. The role of dermatology nurse specialists in supporting patients and promoting disease understanding, education and treatment adherence continues to evolve. As features of specialised nursing care can also inform other nursing staff in a wide range of care settings, an overview of key components is examined. Observations presented are from a pan-European perspective and represent the collected view of a group of dermatology nurse specialists, dermatologists and patient advocates following two round-table discussions.

MAIN BODY

Atopic dermatitis is a common, chronic, inflammatory disease characterised by erythematous/scaling skin lesions, with often intense pruritus. Disease course is cyclic with periodic disease flares of varying intensity, presenting management challenges to patients and families. Dermatology nurse specialists play a key role in providing education and substantial patient support to improve treatment outcomes and quality of life to patients and their family, delivered within a multidisciplinary team framework. Nurse-led education and 'eczema schools' are of benefit in reducing disease severity and improving quality of life by enhancing self-management, adherence and patient engagement. eHealth tools, such as patient portals or online training platforms, can provide online learning, individualised education, and help to improve engagement. These and other initiatives, such as written action plans, are all essential to improve or maintain treatment adherence, self-management and quality of life.

CONCLUSIONS

Dermatology nurse specialists play a central role in the assessment and management of moderate to severe atopic dermatitis patients and families. This places them in an ideal position to build strong and often long-term relationships with patients and parents. Such engagement promotes trust, assists in setting realistic expectations of treatment and outcomes, and enhances self-management and engagement in their own care. Providing emotional support, as well as formal and systematic education (including individualised practical advice) all contribute to improved treatment adherence and can enhance the quality of life of patients and their families throughout the course of this long-term condition.

The content and conduct of GP consultations for dermatology problems: a cross-sectional study

Background

Skin complaints are common in primary care, and poor outcomes in long-term conditions are often due to low adherence to treatment. Shared decision making and self-management support may help, yet there is little understanding of patient involvement or the support provided by GPs.

Aim

To describe the content of primary care consultations for skin problems, including shared decision making practice, delivery of self-management advice, and follow-up.

Design and setting

Cross-sectional study of video-recorded UK adult GP consultations and linked data.

Method

A coding tool was developed and applied to all consultations with skin problems. Shared decision making was assessed using the observer OPTION⁵ scale.

Results

A total of 45/318 consultations (14.2%) related to one or more skin problems, which were discussed alongside other problems in 71.1% (32/45) of consultations. Of the 100 different problems discussed in these consultations, 51 were dermatological. The mean amount of time spent on skin problems in the consultations was 4 minutes 16 seconds. Medication was recommended for 66.7% (34/51) of skin problems, with low shared decision making (mean OPTION⁵ score = 10.7). Self-management advice (verbal only) was given for 47.1% (24/51) of skin problems. Most skin problems (84.3%; 43/51) were not referred to secondary care; 32.6% (14/43) of the skin problems not referred were seen again in primary care within 12 weeks, of which 35.7% (5/14) follow-up appointments were not planned.

Conclusion

In this study, skin problems were usually presented alongside other complaints and resulted in a medication recommendation. Shared decision making was uncommon and self-management advice not consistently given, with re-attendance for the same problem common. GPs’ training should reflect how frequently skin problems are seen and seek to improve patient involvement in decision making and support self-management.

Self-perceived disease control in childhood eczema

BACKGROUND

Atopic eczema (AE) is a common relapsing inflammatory skin disease in children which is often associated with chronicity and poor quality of life. Unlike atopic asthma, control of AE is seldom assessed in therapeutics.

AIM

To investigate the utility of a Traffic Light Control (TLC) system as a measurement/assessment of self-perceived eczema control.

METHODS

This is a prospectively study of all Chinese children (aged 6 to 18 years old) with eczema attending the paediatric dermatology clinic of a tertiary hospital from Jan to June 2020. Eczema control, eczema severity, quality of life and biophysical skin condition of consecutive patients at the paediatric dermatology clinic of a teaching hospital were evaluated with the validated Chinese versions of Depressive, Anxiety, Stress Scales (DASS-21), Patient Oriented Eczema Measure (POEM), transepidermal water loss (TEWL), and stratum corneum skin hydration (SH), respectively. With a visual TLC analogy, patients were asked if their eczema is under control (green light), worsening (yellow) or in flare-up (red light).

RESULTS

Among AE patients (n = 36), self-perceived TLC as green (under control), amber (worsening) and red (flare up) reflected acute and chronic severity (SCORAD, NESS, POEM) and quality of life (CDLQI) (p< 0.0001), but not SH, TEWL or Depression, anxiety and stress.

CONCLUSIONS

Eczema control can be semi-quantified with a child-friendly TLC self-assessment system. AE patients reporting worse eczema control have worse acute and chronic eczema severity, more impairment of quality of life; but not the psychologic symptoms of depression, anxiety and stress or skin hydration or transepidermal water loss. TLC can be linked to an eczema action plan to guide patient management.

Action plans into action - An electronic action plan generation tool at a paediatric centre

BACKGROUND

Individualised Action Plans (APs) are a key management tool for paediatric asthma, allergy, anaphylaxis and eczema. They provide salient care instructions for patients and caregivers and are thought to improve disease outcomes, albeit with minimal supporting evidence. Whilst the provision of an AP has become a widely measured healthcare quality marker, the content of the plans provided has been relatively neglected. The Royal Children's Hospital, Melbourne (RCH) implemented an AP generation tool integrated within its Electronic Medical Record (EMR) in 2017. This case study aims to exhibit the potential benefits of a hospital-wide integrated AP tool, assess its uptake and usage at our institution and demonstrate quality and user interface issues detected through audit of APs provided.

METHODS

A retrospective observational analysis of all APs created within the RCH EMR for patients aged 0-18 years between January 1 and December 31, 2018 was conducted. For each AP, automatically populated and clinician entered fields were extracted and analysed.

RESULTS

2637 APs were completed during the study period. The most used AP was for asthma. Omission rates of critical information were low but could be improved. Depending on clinical condition, there was variation in both the location of completion (ED vs clinic/hospital visit) and role of clinician completing the AP (consultant vs junior medical staff).

CONCLUSION

There was considerable uptake of an EMR-integrated AP tool across our institution. An electronic AP allowed for qualitative evaluation of usage and audit of AP content and will guide further system and user interface improvements to improve AP quality.

Knowledge mobilisation: an ethnographic study of the influence of practitioner mindlines on atopic eczema self-management in primary care in the UK

OBJECTIVE

To explore how atopic eczema specific mindlines are developed by primary care practitioners.

DESIGN

Ethnographic study.

SETTING

One large, urban general practice in central England.

PARTICIPANTS

In observation, all practitioners and support staff in the practice and in interviews a diverse group of practitioners (n=16).

RESULTS

Observation of over 250 hours and interview data were combined and analysed using an ethnographic approach through the lenses of mindlines and self-management. Three themes were identified: beliefs about eczema, eczema knowledge and approaches to self-management. Eczema mindlines are set against a backdrop of it being a low priority and not managed as a long-term condition. Practitioners believed that eczema is simple to manage with little change in treatments available and prescribing limited by local formularies. Practice is largely based on tacit knowledge and experience. Self-management is expected but not often explicitly facilitated. Clinical decisions are made from knowledge accumulated over time. Societal and technological developments have altered the way in which practitioner mindlines are developed; in eczema, for most, they are relatively static.

CONCLUSIONS

The outstanding challenge is to find novel, profession and context-specific, simple, pragmatic strategies to revise or modify practitioner mindlines by adding reliable and useful knowledge and by erasing outdated or inaccurate information thus potentially improve quality of eczema care.

'Hope you find your 'eureka' moment soon': a qualitative study of parents/carers' online discussions around allergy, allergy tests and eczema

OBJECTIVES

To explore understandings and concerns surrounding allergy, food intolerances and their potential impact on eczema among parents and carers of children with eczema who had posted messages in online forums.

METHODS

We conducted a scoping review for active UK-based discussion forums that did not require password/registration to view posts and identified two parenting discussion forums with high activity and frequent use. We used their internal search functions to identify and export discussion threads relating to allergy and allergy testing for eczema from 2011 to 2016. We carried out an inductive thematic analysis of the 120 exported discussion threads.

RESULTS

246 pages of text were analysed. Analysis led to three main themes: (1) confusion over the language surrounding 'allergy' and 'intolerance'; (2) diverse beliefs about allergy testing in relation to eczema and (3) parents' frustrations with perceptions of health professionals as uninterested and unhelpful about allergy testing. Forum users were concerned about immediate and delayed-type allergies but showed confusion in how terms were used, as well as different approaches to testing. Parents sought experiences of others, seeking social support as well as practical guidance.

CONCLUSIONS

The confusion around allergy-related terminology and its possible relationship with eczema means that it is essential healthcare professionals are able to signpost parents to accurate, accessible information. The lack of consistent information currently available means parents may use online discussion forums as an important source of information. This study suggests that the confused nature of discussions on these forums is inaccurate at best, and detrimental at worst.

Emollient prescribing formularies in England and Wales: a cross-sectional study

OBJECTIVE

To identify and compare emollient formularies across all clinical commissioning groups (CCGs) and local health boards (LHBs) in England and Wales.

DESIGN

Formularies were retrieved via CCG/LHB websites or Google search (October 2016-February 2017). Data on structure and content were extracted, and descriptive analyses were undertaken.

SETTING

209 English CCGs and 7 Welsh LHBs.

MAIN OUTCOME MEASURES

Number and structure of formularies; number, type and name of emollients and bath additive recommendedandnot recommended; and any rationale given.

RESULTS

102formularies were identified, which named 109 emollients and 24 bath additives. Most were structured in an 'order of preference' (63%) and/or formulation (51%) format. Creams and ointments were the most commonly recommended types of emollients, and three ointments were the most commonly recommended specific emollients (71%-79% of formularies). However, there was poor consensus over which emollient should be used first line and 4 out of 10 of the most recommended lotions and creams contained antimicrobials or urea. Patient preference (60%) and/or cost (58%) were the most common reasons given for the recommendations. Of the 82% of formularies that recommend the use of bath additives, 75% did not give any reasons for their recommendation.

CONCLUSIONS

Emollient formularies in England and Wales vary widely in their structure, recommendations and rationale. The reasons for such inconsistencies are unclear, risk confusion and make for inequitable regional variation. There is poor justification for multiple different, conflicting formularies.

GP and parent dissonance about the assessment and treatment of childhood eczema in primary care: a qualitative study

OBJECTIVES

To compare parents' and clinicians' perspectives on the assessment and treatment of children with eczema in primary care.

DESIGN

Qualitative interview study with purposive and snowball sampling and thematic analysis.

SETTING

14 general practices in the UK.

PARTICIPANTS

11 parents of children with eczema and 15 general practitioners (GPs) took part in semistructured individual interviews.

RESULTS

We identified several areas of dissonance between parents and GPs. First, parents sought a 'cause' of eczema, such as an underlying allergy, whereas GPs looked to manage the symptoms of an incurable condition. Second, parents often judged eczema severity in terms of psychosocial impact, while GPs tended to focus on the appearance of the child's skin. Third, parents sought 'more natural' over-the-counter treatments or complementary medicine, which GPs felt unable to endorse because of their unknown effectiveness and potential harm. Fourth, GPs linked poor outcomes to unrealistic expectations of treatment and low adherence to topical therapy, whereas parents reported persisting with treatment and despondency with its ineffectiveness. Consultations were commonly described by parents as being dominated by the GP, with a lack of involvement in treatment decisions. GPs' management of divergent views varied, but avoidance strategies were often employed.

CONCLUSIONS

Divergent views between parents and clinicians regarding the cause and treatment of childhood eczema can probably only be bridged by clinicians actively seeking out opinions and sharing rationale for their approach to treatment. Together with assessing the psychosocial as well as the physical impact of eczema, asking about current or intended use of complementary therapy and involving parents in treatment decisions, the management of eczema and patient outcomes could be improved.

GPs' experiences of diagnosing and managing childhood eczema: a qualitative study in primary care

BACKGROUND

Eczema is common among children, and in the UK the majority are managed by GPs. The most common cause of poor disease control is incorrect use of topical treatments. There is a lack of research into the challenges faced by GPs in diagnosing and managing this condition.

AIM

To explore the experiences of GPs in assessing and managing children with eczema.

DESIGN AND SETTING

Qualitative study in primary care in England.

METHOD

Semi-structured interviews with 15 GPs were audiorecorded, transcribed verbatim, and analysed thematically using the framework method.

RESULTS

GPs described a paucity of dermatology training. Although most GPs were confident diagnosing uncomplicated eczema, they reported using a trial-and-error approach to prescribing emollients, and were uncertain about quantities of topical treatments to issue. Mild and moderate potency topical corticosteroids (TCS) were commonly used, but most GPs lacked confidence in recommending potent TCS, and viewed parents or carers to be fearful of using all strengths of TCS. GPs perceived adherence to treatments to be low, but provision of information to support self-care was variable. Routine review of medication use or disease control was uncommon, which GPs attributed to service constraints. Participants' views on the causes and management of eczema were perceived to be at odds with parents and carers, who were said to be overly focused on an underlying cause, such as allergy.

CONCLUSION

GP uncertainty in managing eczema, lack of routine information and review, and perceived dissonance with parents around causation and management may be contributing to low concordance with treatments.