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Sach TH, Lartey ST, Davies C, Chalmers JR, Haines RH, Bradshaw LE, Montgomery AA, Thomas KS, Brown SJ, Ridd MJ, Lawton S, Cork MJ, Flohr C, Mitchell E, Swinden R, Wyatt L, Tarr S, Davies-Jones S, Jay N, Kelleher MM, Perkin MR, Boyle RJ, Williams HC. Emollients for preventing atopic eczema: Cost-effectiveness analysis of the BEEP trial. Clin Exp Allergy 2023; 53:1011-1019. [PMID: 37574761 DOI: 10.1111/cea.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/19/2023] [Accepted: 06/28/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Recent discoveries have led to the suggestion that enhancing skin barrier from birth might prevent eczema and food allergy. OBJECTIVE To determine the cost-effectiveness of daily all-over-body application of emollient during the first year of life for preventing atopic eczema in high-risk children at 2 years from a health service perspective. We also considered a 5-year time horizon as a sensitivity analysis. METHODS A within-trial economic evaluation using data on health resource use and quality of life captured as part of the BEEP trial alongside the trial data. Parents/carers of 1394 infants born to families at high risk of atopic disease were randomised 1:1 to the emollient group, which were advised to apply emollient (Doublebase Gel or Diprobase Cream) to their child at least once daily to the whole body during the first year of life or usual care. Both groups received advice on general skin care. The main economic outcomes were incremental cost-effectiveness ratio (ICER), defined as incremental cost per percentage decrease in risk of eczema in the primary cost-effectiveness analysis. Secondary analysis, undertaken as a cost-utility analysis, reports incremental cost per Quality-Adjusted Life Year (QALY) where child utility was elicited using the proxy CHU-9D at 2 years. RESULTS At 2 years, the adjusted incremental cost was £87.45 (95% CI -54.31, 229.27) per participant, whilst the adjusted proportion without eczema was 0.0164 (95% CI -0.0329, 0.0656). The ICER was £5337 per percentage decrease in risk of eczema. Adjusted incremental QALYs were very slightly improved in the emollient group, 0.0010 (95% CI -0.0069, 0.0089). At 5 years, adjusted incremental costs were lower for the emollient group, -£106.89 (95% CI -354.66, 140.88) and the proportion without eczema was -0.0329 (95% CI -0.0659, 0.0002). The 5-year ICER was £3201 per percentage decrease in risk of eczema. However, when inpatient costs due to wheezing were excluded, incremental costs were lower and incremental effects greater in the usual care group. CONCLUSIONS In line with effectiveness endpoints, advice given in the BEEP trial to apply daily emollient during infancy for eczema prevention in high-risk children does not appear cost-effective.
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Affiliation(s)
- Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Charlotte Davies
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Mike J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Laura Wyatt
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's University of London, London, UK
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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2
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Leshem YA, Chalmers JR, Apfelbacher C, Katoh N, Gerbens LAA, Schmitt J, Spuls PI, Thomas KS, Howells L, Williams HC, Simpson EL. Measuring Atopic Eczema Control and Itch Intensity in Clinical Practice: A Consensus Statement From the Harmonising Outcome Measures for Eczema in Clinical Practice (HOME-CP) Initiative. JAMA Dermatol 2022; 158:1429-1435. [PMID: 36223090 DOI: 10.1001/jamadermatol.2022.4211] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Measuring outcomes in clinical practice can aid patient care, quality improvement, and real-world evidence generation. The Harmonising Outcome Measures for Eczema (HOME) Clinical Practice initiative is developing a list of validated, feasible instruments to measure atopic eczema in clinical care. Prior work identified symptoms and long-term control as the most important domains to measure in clinical practice. The Patient-Oriented Eczema Measure (POEM) and the Patient-Oriented Scoring Atopic Dermatitis Index (PO-SCORAD) were recommended by consensus to measure symptoms in clinical practice, but a need for instruments to measure itch intensity specifically was recognized. The HOME group also previously decided that long-term control should be captured by repeated measurements of eczema control. Recommended instruments to measure eczema control in clinical practice have not been defined. Objective To recommend instruments to measure eczema control and itch intensity in patients with atopic eczema in clinical practice. Evidence Review Available instruments to measure eczema control and itch intensity were identified through systematic reviews, informing a consensus process held at the HOME VIII virtual online meeting (October 6 and October 9, 2020). Feasibility aspects were highlighted to optimize instrument selection for the clinical practice. Consensus on an instrument was reached if fewer than 30% of the voters disagreed. Findings Of 7 identified instruments, the Recap of Atopic Eczema (RECAP) and Atopic Dermatitis Control Tool (ADCT) were the recommended instruments to measure eczema control (3 of 63 [5%] and 7 of 69 [10%] of voters disagreed, respectively). A single-question patient global assessment garnered support, but the current available instrument did not reach consensus. Six available itch-intensity instruments were identified. Of them, 3 instruments were recommended by consensus: a peak 24-hour numeric rating scale (NRS)-itch, and 1-week NRS-itch instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) Itch Questionnaire, measuring average and peak itch (11 of 63 [17%], 14 of 63 [22%], and 16 of 59 [27%] voters disagreed, respectively). Conclusions and Relevance Clinicians and patients are encouraged to incorporate these well-validated, quick-to-perform, and easy-to-use instruments into their clinic, selecting the instruments that best fit their need. These assessments are meant to enhance, not replace, the patient-clinician encounter, and to support real-world research and health care improvement.
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Affiliation(s)
- Yael A Leshem
- Division of Dermatology, Rabin Medical Center, Petach-Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Christian Apfelbacher
- Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany.,Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore
| | - Norito Katoh
- Department of Dermatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, TU Dresden, Germany
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Laura Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon
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3
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Bradshaw LE, Wyatt LA, Brown SJ, Haines RH, Montgomery AA, Perkin MR, Lawton S, Sach TH, Chalmers JR, Ridd MJ, Flohr C, Brooks J, Swinden R, Mitchell EJ, Tarr S, Jay N, Thomas KS, Allen H, Cork MJ, Kelleher MM, Simpson EL, Lartey ST, Davies-Jones S, Boyle RJ, Williams HC. Emollients for prevention of atopic dermatitis; 5-year findings from the BEEP randomised trial. Allergy 2022; 78:995-1006. [PMID: 36263451 DOI: 10.1111/all.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/14/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effectiveness of emollients for preventing atopic dermatitis/eczema is controversial. The Barrier Enhancement for Eczema Prevention trial evaluated the effects of daily emollients during the first year of life on atopic dermatitis and atopic conditions to age 5 years. METHODS 1394 term infants with a family history of atopic disease were randomised (1:1) to daily emollient plus standard skin-care advice (693 emollient group) or standard skin-care advice alone (701 controls). Long-term follow-up at ages 3, 4 and 5 years was via parental questionnaires. Main outcomes were parental report of a clinical diagnosis of atopic dermatitis and food allergy. RESULTS Parents reported more frequent moisturiser application in the emollient group through to 5 years. A clinical diagnosis of atopic dermatitis between 12 and 60 months was reported for 188/608 (31%) in the emollient group and 178/631 (28%) in the control group (adjusted relative risk 1.10, 95% confidence interval 0.93 to 1.30). Although more parents in the emollient group reported food reactions in the previous year at 3 and 4 years, cumulative incidence of doctor diagnosed food allergy by 5 years was similar between groups (92/609 (15%) emollients and 87/632 (14%) controls, adjusted relative risk 1.11, 95% confidence interval 0.84 to 1.45). Findings were similar for cumulative incidence of asthma and hay fever. CONCLUSIONS Daily emollient application during the first year of life does not prevent atopic dermatitis, food allergy, asthma or hay fever.
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Affiliation(s)
- Lucy E Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Laura A Wyatt
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK.,Department of Dermatology, Ninewells Hospital and Medical School, Dundee.,Centre for Genomic and Experimental Medicine, University of Edinburgh, Edinburgh, UK.,Department of Dermatology, NHS Lothian, Edinburgh, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael R Perkin
- Population Health Research Institute, St. George's, University of London, London, UK
| | | | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, UK
| | - Joanne Brooks
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hilary Allen
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Stella T Lartey
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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4
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Sivyer K, Teasdale E, Greenwell K, Steele M, Ghio D, Ridd MJ, Roberts A, Chalmers JR, Lawton S, Langan SM, Cowdell F, Le Roux E, Wilczynska S, Williams HC, Thomas KS, Yardley L, Santer M, Muller I. Supporting families managing childhood eczema: developing and optimising eczema care online using qualitative research. Br J Gen Pract 2022; 72:e378-e389. [PMID: 35577586 PMCID: PMC9119812 DOI: 10.3399/bjgp.2021.0503] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/01/2022] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Katy Sivyer
- Department of Psychology, University of Southampton, Southampton; lecturer, University of Portsmouth, Portsmouth
| | | | | | | | - Daniela Ghio
- University of Manchester, Manchester; research fellow, University of Southampton, Southampton
| | | | | | | | | | | | | | | | | | | | | | - Lucy Yardley
- University of Bristol, Bristol; professor of health psychology, University of Southampton, Southampton
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5
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Greenwell K, Ghio D, Sivyer K, Steele M, Teasdale E, Ridd MJ, Roberts A, Chalmers JR, Lawton S, Langan S, Cowdell F, Le Roux E, Wilczynska S, Jones H, Whittaker E, Williams HC, Thomas KS, Yardley L, Santer M, Muller I. Eczema Care Online: development and qualitative optimisation of an online behavioural intervention to support self-management in young people with eczema. BMJ Open 2022; 12:e056867. [PMID: 35443955 PMCID: PMC9021764 DOI: 10.1136/bmjopen-2021-056867] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To describe the development of Eczema Care Online (ECO), an online behaviour change intervention for young people with eczema (phase I); and explore and optimise the acceptability of ECO among this target group using think-aloud interviews (phase II). METHODS Theory-based, evidence-based and person-based approaches to intervention development were used. In phase I, a qualitative systematic review and qualitative interviews developed an in-depth understanding of the needs and challenges of young people with eczema. Guiding principles highlighted key intervention design objectives and features to address the needs of this target group to maximise user engagement. Behavioural analysis and logic modelling developed ECO's hypothesised programme theory. In phase II, qualitative think-aloud interviews were carried out with 28 young people with eczema and the intervention was optimised based on their feedback. RESULTS The final intervention aimed to reduce eczema severity by supporting treatment use (emollients, topical corticosteroids/topical calcineurin inhibitors), management of irritants/triggers, emotional management and reducing scratching. Generally, young people expressed positive views of intervention content and design in think-aloud interviews. Quotes and stories from other young people with eczema and ECO's focus on living with eczema (not just topical treatments) were valuable for normalising eczema. Young people believed ECO addressed knowledge gaps they had from childhood and the safety information about topical corticosteroids was reassuring. Negative feedback was used to modify ECO. CONCLUSIONS A prototype of the ECO intervention was developed using rigorous and complementary intervention development approaches. Subsequent think-aloud interviews helped optimise the intervention, demonstrated ECO is likely to be acceptable to this target group, and provided support for our guiding principles including key design objectives and features to consider when developing interventions for this population. A randomised controlled trial and process evaluation of the intervention is underway to assess effectiveness and explore user engagement with the intervention's behavioural goals.
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Affiliation(s)
- Kate Greenwell
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Daniela Ghio
- Division of Psychology & Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Katy Sivyer
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Department of Psychology, Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Mary Steele
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Emma Teasdale
- School of Primary Care, Population Health and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sandra Lawton
- Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinead Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Emma Le Roux
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Sylvia Wilczynska
- School of Primary Care, Population Health and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Hannah Jones
- Faculty of Medicine, University of Southampton, Southampton, UK
| | | | - H C Williams
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Kim Suzanne Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
- Centre for Academic Primary Care, School of Psychological Science, University of Bristol, Bristol, UK
| | - Miriam Santer
- School of Primary Care, Population Health and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ingrid Muller
- School of Primary Care, Population Health and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
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Leighton P, Chalmers JR, Batchelor JM, Rogers A, Perways A, Haines RH, Meakin GD, White J, Ravenscroft JC, Sach TH, Santer M, Whitton ME, Eleftheriadou V, Thomas KS. Prescribing and using vitiligo treatments - lessons from a nested Process Evaluation within the HI-Light Vitiligo Randomised Controlled Trial. Clin Exp Dermatol 2022; 47:1480-1489. [PMID: 35340044 PMCID: PMC9544377 DOI: 10.1111/ced.15193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/20/2022] [Accepted: 03/23/2022] [Indexed: 12/01/2022]
Abstract
Background The HI‐Light Trial demonstrated that for active, limited vitiligo, combination treatment with potent topical corticosteroid (TCS) and handheld narrowband ultraviolet B offers a better treatment response than potent TCS alone. However, it is unclear how to implement these findings. Aim We sought to answer three questions: (i) Can combination treatment be used safely and effectively by people with vitiligo?; (ii) Should combination treatment be made available as routine clinical care?; and (iii) Can combination treatment be integrated within current healthcare provision? Methods This was a mixed‐methods process evaluation, including semi‐structured interviews with a purposive sample of trial participants, structured interviews with commissioners, and an online survey and focus groups with trial staff. Transcripts were coded by framework analysis, with thematic development by multiple researchers. Results Participants found individual treatments easy to use, but the combination treatment was complicated and required nurse support. Both participants and site investigators felt that combination treatment should be made available, although commissioners were less certain. There was support for the development of services offering combination treatment, although this might not be prioritized above treatment for other conditions. A ‘mixed economy’ model was suggested, involving patients purchasing their own devices, although concerns regarding the safe use of treatments mean that training, monitoring and ongoing support are essential. The need for medical physics support may mean that a regional service is more practical. Conclusion Combination treatment should be made available for people seeking treatment for vitiligo, but services require partnership with medical physics and ongoing training and support for patients.
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Affiliation(s)
- Paul Leighton
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | - Jonathan M Batchelor
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | - Andy Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Akram Perways
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Garry D Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Jennifer White
- Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Jane C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tracey H Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Maxine E Whitton
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
| | | | - Kim S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, UK
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7
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Lax SJ, Harvey J, Axon E, Howells L, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Ming LC, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS, Chalmers JR. Strategies for using topical corticosteroids in children and adults with eczema. Cochrane Database Syst Rev 2022; 3:CD013356. [PMID: 35275399 PMCID: PMC8916090 DOI: 10.1002/14651858.cd013356.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eczema is a common skin condition. Although topical corticosteroids have been a first-line treatment for eczema for decades, there are uncertainties over their optimal use. OBJECTIVES To establish the effectiveness and safety of different ways of using topical corticosteroids for treating eczema. SEARCH METHODS We searched databases to January 2021 (Cochrane Skin Specialised Register; CENTRAL; MEDLINE; Embase; GREAT) and five clinical trials registers. We checked bibliographies from included trials to identify further trials. SELECTION CRITERIA Randomised controlled trials in adults and children with eczema that compared at least two strategies of topical corticosteroid use. We excluded placebo comparisons, other than for trials that evaluated proactive versus reactive treatment. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods, with GRADE certainty of evidence for key findings. Primary outcomes were changes in clinician-reported signs and relevant local adverse events. Secondary outcomes were patient-reported symptoms and relevant systemic adverse events. For local adverse events, we prioritised abnormal skin thinning as a key area of concern for healthcare professionals and patients. MAIN RESULTS We included 104 trials (8443 participants). Most trials were conducted in high-income countries (81/104), most likely in outpatient or other hospital settings. We judged only one trial to be low risk of bias across all domains. Fifty-five trials had high risk of bias in at least one domain, mostly due to lack of blinding or missing outcome data. Stronger-potency versus weaker-potency topical corticosteroids Sixty-three trials compared different potencies of topical corticosteroids: 12 moderate versus mild, 22 potent versus mild, 25 potent versus moderate, and 6 very potent versus potent. Trials were usually in children with moderate or severe eczema, where specified, lasting one to five weeks. The most reported outcome was Investigator Global Assessment (IGA) of clinician-reported signs of eczema. We pooled four trials that compared moderate- versus mild-potency topical corticosteroids (420 participants). Moderate-potency topical corticosteroids probably result in more participants achieving treatment success, defined as cleared or marked improvement on IGA (52% versus 34%; odds ratio (OR) 2.07, 95% confidence interval (CI) 1.41 to 3.04; moderate-certainty evidence). We pooled nine trials that compared potent versus mild-potency topical corticosteroids (392 participants). Potent topical corticosteroids probably result in a large increase in number achieving treatment success (70% versus 39%; OR 3.71, 95% CI 2.04 to 6.72; moderate-certainty evidence). We pooled 15 trials that compared potent versus moderate-potency topical corticosteroids (1053 participants). There was insufficient evidence of a benefit of potent topical corticosteroids compared to moderate topical corticosteroids (OR 1.33, 95% CI 0.93 to 1.89; moderate-certainty evidence). We pooled three trials that compared very potent versus potent topical corticosteroids (216 participants). The evidence is uncertain with a wide confidence interval (OR 0.53, 95% CI 0.13 to 2.09; low-certainty evidence). Twice daily or more versus once daily application We pooled 15 of 25 trials in this comparison (1821 participants, all reported IGA). The trials usually assessed adults and children with moderate or severe eczema, where specified, using potent topical corticosteroids, lasting two to six weeks. Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application (OR 0.97, 95% CI 0.68 to 1.38; 15 trials, 1821 participants; moderate-certainty evidence). Local adverse events Within the trials that tested 'treating eczema flare-up' strategies, we identified only 26 cases of abnormal skin thinning from 2266 participants (1% across 22 trials). Most cases were from the use of higher-potency topical corticosteroids (16 with very potent, 6 with potent, 2 with moderate and 2 with mild). We assessed this evidence as low certainty, except for very potent versus potent topical corticosteroids, which was very low-certainty evidence. Longer versus shorter-term duration of application for induction of remission No trials were identified. Twice weekly application (weekend, or 'proactive therapy') to prevent relapse (flare-ups) versus no topical corticosteroids/reactive application Nine trials assessed this comparison, generally lasting 16 to 20 weeks. We pooled seven trials that compared weekend (proactive) topical corticosteroids therapy versus no topical corticosteroids (1179 participants, children and adults with a range of eczema severities, though mainly moderate or severe). Weekend (proactive) therapy probably results in a large decrease in likelihood of a relapse from 58% to 25% (risk ratio (RR) 0.43, 95% CI 0.32 to 0.57; 7 trials, 1149 participants; moderate-certainty evidence). Local adverse events We did not identify any cases of abnormal skin thinning in seven trials that assessed skin thinning (1050 participants) at the end of treatment. We assessed this evidence as low certainty. Other comparisons Other comparisons included newer versus older preparations of topical corticosteroids (15 trials), cream versus ointment (7 trials), topical corticosteroids with wet wrap versus no wet wrap (6 trials), number of days per week applied (4 trials), different concentrations of the same topical corticosteroids (2 trials), time of day applied (2 trials), topical corticosteroids alternating with topical calcineurin inhibitors versus topical corticosteroids alone (1 trial), application to wet versus dry skin (1 trial) and application before versus after emollient (1 trial). No trials compared branded versus generic topical corticosteroids and time between application of emollient and topical corticosteroids. AUTHORS' CONCLUSIONS Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema; however, there is uncertain evidence to support any advantage of very potent over potent topical corticosteroids. Effectiveness is similar between once daily and twice daily (or more) frequent use of potent topical corticosteroids to treat eczema flare-ups, and topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups). Adverse events were not well reported and came largely from low- or very low-certainty, short-term trials. In trials that reported abnormal skin thinning, frequency was low overall and increased with increasing potency. We found no trials on the optimum duration of treatment of a flare, branded versus generic topical corticosteroids, and time to leave between application of topical corticosteroids and emollient. There is a need for longer-term trials, in people with mild eczema.
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Affiliation(s)
- Stephanie J Lax
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jane Harvey
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Emma Axon
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Laura Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | | | - Sandra Lawton
- Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinéad Langan
- London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema, Nottingham, UK
| | - Amina Ahmed
- c/o Cochrane Skin Group, University of Nottingham, Nottingham, UK
| | - Ingrid Muller
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Long Chiau Ming
- PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Gadong, Brunei Darussalam
| | - Saumya Panda
- Department of Dermatology, KPC Medical College and Hospital, Kolkata, India
| | - Pavel Chernyshov
- Department of Dermatology and Venereology, National Medical University, Kiev, Ukraine
| | - Ben Carter
- Biostatistics and Health Informatics, King's College London; Institute of Psychiatry, Psychology & Neuroscience, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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8
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Williams HC, Schmitt J, Thomas KS, Spuls PI, Simpson EL, Apfelbacher CJ, Chalmers JR, Furue M, Katoh N, Gerbens LAA, Leshem YA, Howells L, Singh JA, Boers M. The HOME Core outcome set for clinical trials of atopic dermatitis. J Allergy Clin Immunol 2022; 149:1899-1911. [DOI: 10.1016/j.jaci.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/21/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
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9
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Jabbar-Lopez ZK, Ezzamouri B, Briley A, Greenblatt D, Gurung N, Chalmers JR, Thomas KS, Frost T, Kezic S, Common JEA, Danby S, Cork MJ, Peacock JL, Flohr C. Randomized controlled pilot trial with ion-exchange water softeners to prevent eczema (SOFTER trial). Clin Exp Allergy 2021; 52:405-415. [PMID: 34854157 DOI: 10.1111/cea.14071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Observational studies suggest an increased risk of eczema in children living in hard versus soft water areas, and there is, therefore, an interest in knowing whether softening water may prevent eczema. We evaluated the feasibility of a parallel-group assessor-blinded pilot randomized controlled trial to test whether installing a domestic ion-exchange water softener before birth in hard water areas reduces the risk of eczema in infants with a family history of atopy. METHODS Pregnant women living in hard water areas (>250 mg/L calcium carbonate) in and around London UK, were randomized 1:1 antenatally to either have an ion-exchange water softener installed in their home or not (ie to continue to receive usual domestic hard water). Infants were assessed at birth and followed up for 6 months. The main end-points were around feasibility, the primary end-point being the proportion of eligible families screened who were willing and able to be randomized. Clinical end-points were evaluated including frequency of parent-reported doctor-diagnosed eczema and visible eczema on skin examination. Descriptive analyses were conducted, and no statistical testing was performed as this was a pilot study. RESULTS One hundred and forty-nine families screened were eligible antenatally and 28% (41/149) could not have a water softener installed due to technical reasons or lack of landlord approval. Eighty of 149 (54%) were randomized, the primary end-point. Two participants withdrew immediately after randomization, leaving 39 participants in each arm (78 total). Attrition was 15% (12/78) by 6 months postpartum. All respondents (n = 69) to the study acceptability questionnaire reported that the study was acceptable. Fifty-six of 708 (7.9%) water samples in the water softener arm were above the hard water threshold of 20 mg/L CaCO3 . At 6 months of age 27/67 infants (40%) developed visible eczema, 12/36 (33%) vs. 15/31 (48%) in the water softener and control groups, respectively, difference -15% (95% CI -38, 8.3%), with most assessments (≥96%) remaining blinded. Similarly, a lower proportion of infants in the water softener arm had parent-reported, doctor-diagnosed eczema by 6 months compared to the control arm, 6/17 (35%) versus 9/19 (47%), difference -12% (95% CI -44, 20%). CONCLUSION A randomized controlled trial of water softeners for the prevention of atopic eczema in high-risk infants is feasible and acceptable.
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Affiliation(s)
- Z K Jabbar-Lopez
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - B Ezzamouri
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Briley
- Women's Health, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK.,Caring Futures Institute, Flinders University, Adelaide, South Australia, Australia
| | - D Greenblatt
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Gurung
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - J R Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - K S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - T Frost
- Aqua Focus Ltd., Shrewsbury, UK
| | - S Kezic
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - J E A Common
- Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
| | - S Danby
- Department of Infection, Sheffield Dermatology Research, Immunity & Cardiovascular Diseases, The University of Sheffield Medical School, Sheffield, UK
| | - M J Cork
- Department of Infection, Sheffield Dermatology Research, Immunity & Cardiovascular Diseases, The University of Sheffield Medical School, Sheffield, UK
| | - J L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK.,Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, New Hampshire, USA
| | - C Flohr
- Unit for Population-Based Dermatology, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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10
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Bradshaw LE, Haines RH, Thomas KS, Chalmers JR, Irvine AD, Williams HC, Brown SJ. Clinical examination for hyperlinear palms to determine filaggrin genotype: A diagnostic test accuracy study. Clin Exp Allergy 2021; 51:1421-1428. [PMID: 34608691 DOI: 10.1111/cea.14025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/20/2021] [Accepted: 09/22/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Palmar hyperlinearity is a feature of ichthyosis vulgaris, the monogenic skin disorder caused by FLG loss-of-function mutations. OBJECTIVE To investigate how well the presence or absence of hyperlinear palms (HLP) detect FLG genotype in children. METHODS STARD criteria are used to report this diagnostic accuracy study. Phenotype and genotype data (four most prevalent FLG null mutations) were obtained from a total of 3656 children in three studies: the UK CLOTHES trial (children 1-5 years with moderate-severe atopic eczema); UK BEEP trial (2 year olds at high risk of developing atopic eczema); UK-Irish eczema case collection (0-16 year olds with atopic eczema). All participants included in analyses of HLP as the index test and FLG genotype as the reference were of white European ancestry. RESULTS Thirty-two percent of participants (1159/3656) had FLG null mutation(s) and 37% (1347/3656) had HLP. In 13% (464/3656), HLP was recorded as 'unsure' or not recorded. The sensitivity and specificity of HLP for detecting FLG mutations in each of the studies was: 67% (95% CI 55-78%) and 75% (67-82%) in CLOTHES; 46% (36-55%) and 89% (86-91%) in BEEP; 72% (68-75%) and 60% (57-62%) in the UK-Irish case collection. Positive and negative likelihood ratios were: 2.73 (1.95-3.81) and 0.44 (0.31-0.62) in CLOTHES; 4.02 (2.99-5.40) and 0.61 (0.52-0.73) in BEEP; 1.79 (1.66-1.93) and 0.47 (0.42-0.53) in the UK-Irish collection. DISCUSSION Trained observers were able to define palmar hyperlinearity in the majority (3191/3656, 87%) of cases. The presence of HLP is not a reliable sign to detect FLG mutations, but the absence of HLP excludes FLG null genotype with a reasonable degree of certainty.
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Affiliation(s)
- Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Alan D Irvine
- Clinical Medicine, Trinity College Dublin, Dublin, Ireland
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
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11
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Axon E, Chalmers JR, Santer M, Ridd MJ, Lawton S, Langan SM, Grindlay DJC, Muller I, Roberts A, Ahmed A, Williams HC, Thomas KS. Safety of topical corticosteroids in atopic eczema: an umbrella review. BMJ Open 2021; 11:e046476. [PMID: 34233978 PMCID: PMC8264889 DOI: 10.1136/bmjopen-2020-046476] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/20/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE An umbrella review summarising all safety data from systematic reviews of topical corticosteroids (TCS) in adults and children with atopic eczema. METHODS Embase, MEDLINE, PubMed, Cochrane Database of Systematic Reviews and the Centre of Evidence Based Dermatology map of eczema systematic reviews were searched until 7 November 2018 and Epistemonikos until 2 March 2021. Reviews were included if they assessed the safety of TCS in atopic eczema and searched >1 database using a reproducible search strategy. Review quality was assessed using version 2 of 'A MeaSurement Tool to Assess systematic Reviews' (AMSTAR 2 tool). RESULTS 38 systematic reviews included, 34 low/critically low quality. Treatment and follow-up were usually short (2-4 weeks). KEY FINDINGS TCS versus emollient/vehicle: No meta-analyses identified for skin-thinning. Two 2-week randomised controlled trials (RCTs) found no significant increased risk with very potent TCS (0/196 TCS vs 0/33 vehicle in children and 6/109 TCS vs 2/50 vehicle, age unknown). Biochemical adrenal suppression (cortisol) was 3.8% (95% CI 2.4% to 5.8%) in a meta-analysis of 11 uncontrolled observational studies (any potency TCS, 522 children). Effects reversed when treatment ceased.TCS versus topical calcineurin inhibitors: Meta-analysis showed higher relative risk of skin thinning with TCS (4.86, 95% CI 1.06 to 22.28, n=4128, four RCTs, including one 5-year RCT). Eight cases in 2068 participants, 7 using potent TCS. No evidence of growth suppression.Once daily versus more frequent TCS: No meta-analyses identified. No skin-thinning in one RCT (3 weeks potent TCS, n=94) or biochemical adrenal suppression in two RCTs (up to 2 weeks very potent/moderate TCS, n=129).TCS twice/week to prevent flares ('weekend therapy') versus vehicle: No meta-analyses identified. No evidence of skin thinning in five RCTs. One RCT found biochemical adrenal suppression (2/44 children, potent TCS). CONCLUSIONS W e found no evidence of harm when TCS were used intermittently 'as required' to treat flares or 'weekend therapy' to prevent flares. However, long-term safety data were limited. PROSPERO REGISTRATION NUMBER CRD42018079409.
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Affiliation(s)
- Emma Axon
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Primary Care & Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Sandra Lawton
- Dermatology Department, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Sinead M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ingrid Muller
- Primary Care & Population Sciences, University of Southampton, Southampton, Hampshire, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Amina Ahmed
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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12
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Stuart BL, Howells L, Pattinson RL, Chalmers JR, Grindlay D, Rogers NK, Grinich E, Pawlitschek T, Simpson EL, Thomas KS. Measurement properties of patient-reported outcome measures for eczema control: a systematic review. J Eur Acad Dermatol Venereol 2021; 35:1987-1993. [PMID: 33977561 DOI: 10.1111/jdv.17335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 04/23/2021] [Indexed: 12/20/2022]
Abstract
Atopic eczema (herein referred to as 'eczema') is a skin disease characterized by remitting and relapsing symptoms. The Harmonising Outcome Measures for Eczema (HOME) initiative was developed to establish a core outcome set (COS) for eczema to be measured for all future eczema trials. The core outcome set for atopic eczema clinical trials includes the domain for patient-reported eczema control, but a review of the validation of available eczema control instruments was lacking. We aimed to review the literature and systematically assess the measurement properties of validated patient-reported outcome instruments that capture eczema control. PubMed and Ovid EMBASE were searched up to 24 January 2020 for any study that reported on PROM instrument development or validation. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria were used to assess the quality of eligible studies. We screened 12 036 titles and abstracts and 58 full texts. A total of 12 papers were included, reporting on seven PROMS. These were assessed with respect to development, reliability, construct validity and responsiveness. Two instruments, Recap of Atopic Eczema (RECAP) and the Atopic Dermatitis Control Tool (ADCT), have been developed and validated to a sufficient standard to support their recommendation as patient-reported outcome instruments for measuring control of atopic eczema as part of the HOME Core Outcome Set.
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Affiliation(s)
- B L Stuart
- Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - L Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - R L Pattinson
- College of Biomedical and Life Sciences, School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - D Grindlay
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - N K Rogers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - E Grinich
- Oregon Health and Science University, Portland, OR, USA
| | - T Pawlitschek
- Oregon Health and Science University, Portland, OR, USA
| | - E L Simpson
- Oregon Health and Science University, Portland, OR, USA
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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13
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Perkin MR, Logan K, Marrs T, Radulovic S, Craven J, Boyle RJ, Chalmers JR, Williams HC, Versteeg SA, van Ree R, Lack G, Flohr C. Association of frequent moisturizer use in early infancy with the development of food allergy. J Allergy Clin Immunol 2021; 147:967-976.e1. [PMID: 33678253 PMCID: PMC9393761 DOI: 10.1016/j.jaci.2020.10.044] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
Background Objectives Methods Results Conclusions
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Affiliation(s)
- Michael R Perkin
- Population Health Research Institute, St George's, University of London, London, United Kingdom.
| | - Kirsty Logan
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Tom Marrs
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Suzana Radulovic
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Joanna Craven
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Robert J Boyle
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, United Kingdom
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, United Kingdom
| | - Serge A Versteeg
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ronald van Ree
- Department of Experimental Immunology, Academic Medical Center, Amsterdam, The Netherlands; Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
| | - Gideon Lack
- Paediatric Allergy Research Group, Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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14
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Kelleher MM, Cro S, Van Vogt E, Cornelius V, Lodrup Carlsen KC, Ove Skjerven H, Rehbinder EM, Lowe A, Dissanayake E, Shimojo N, Yonezawa K, Ohya Y, Yamamoto‐Hanada K, Morita K, Cork M, Cooke A, Simpson EL, McClanahan D, Weidinger S, Schmitt J, Axon E, Tran L, Surber C, Askie LM, Duley L, Chalmers JR, Williams HC, Boyle RJ. Skincare interventions in infants for preventing eczema and food allergy: A cochrane systematic review and individual participant data meta‐analysis. Clin Exp Allergy 2021; 51:402-418. [DOI: 10.1111/cea.13847] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | - Suzie Cro
- Imperial Clinical Trials Unit Imperial College London London UK
| | | | | | - Karin C. Lodrup Carlsen
- Division of Paediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Håvard Ove Skjerven
- Division of Paediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
| | - Eva Maria Rehbinder
- Faculty of Medicine Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Dermatology Oslo University Hospital Oslo Norway
| | - Adrian Lowe
- Allergy and Lung Health Unit Melbourne School of Population and Global Health University of Melbourne Melbourne VIC Australia
| | - Eishika Dissanayake
- Department of Pediatrics School of Medicine and Public Health University of Wisconsin Madison WI USA
| | - Naoki Shimojo
- Center for Preventive Medical Sciences Chiba University Chiba Japan
| | - Kaori Yonezawa
- Department of Midwifery and Women's Health Graduate School of Medicine The University of Tokyo Tokyo Japan
| | - Yukihiro Ohya
- Allergy Center National Center for Child Health and Development Tokyo Japan
| | | | - Kumiko Morita
- Department of Pediatrics Keio University School of Medicine Tokyo Japan
| | - Michael Cork
- Sheffield Dermatology Research Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield Sheffield UK
| | - Alison Cooke
- Division of Nursing, Midwifery and Social Work School of Health Sciences The University of Manchester Manchester UK
| | | | | | - Stephan Weidinger
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Campus Kiel Kiel Germany
| | - Jochen Schmitt
- Centre for Evidence‐Based Healthcare Medizinische Fakultät Carl Gustav Carus, TU Dresden Dresden Germany
| | - Emma Axon
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Lien Tran
- Imperial Clinical Trials Unit Imperial College London London UK
| | - Christian Surber
- Department of Dermatology University Hospital Zurich Zurich Switzerland
- Department of Dermatology University Hospital Basel Basel Switzerland
| | - Lisa M. Askie
- NHMRC Clinical Trials Centre University of Sydney Camperdown NSW Australia
| | - Lelia Duley
- Nottingham Clinical Trials Unit Nottingham Health Science Partners Nottingham UK
| | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Robert J. Boyle
- National Heart and Lung InstituteImperial College London London UK
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
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15
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Thomas KS, Apfelbacher CA, Chalmers JR, Simpson E, Spuls PI, Gerbens LAA, Williams HC, Schmitt J, Gabes M, Howells L, Stuart BL, Grinich E, Pawlitschek T, Burton T, Howie L, Gadkari A, Eckert L, Ebata T, Boers M, Saeki H, Nakahara T, Katoh N. Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting. Br J Dermatol 2021; 185:139-146. [PMID: 33393074 PMCID: PMC8359383 DOI: 10.1111/bjd.19751] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2020] [Indexed: 12/18/2022]
Abstract
Background The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema (AE) clinical trials. Previous consensus meetings have agreed on preferred instruments for clinician‐reported signs (Eczema Area and Severity Index, EASI) and patient‐reported symptoms (Patient‐Oriented Eczema Measure, POEM). This paper reports consensus decisions from the HOME VII meeting. Objectives To complete the core outcome set for AE by agreeing on core outcome instruments for the domains of quality of life (QoL), long‐term control and itch intensity. Methods A face‐to‐face consensus meeting was held in Tokyo, Japan (8–10 April 2019) including 75 participants (49 healthcare professionals/methodologists, 14 patients, 12 industry representatives) from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using predefined consensus rules. Results It was agreed by consensus that QoL should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children’s Dermatology Life Quality Index (CDLQI) for children and the Infant’s Dermatology Quality of Life Index (IDQoL) for infants. For long‐term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long‐term control. The peak itch numerical rating scale (NRS)‐11 past 24 h was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum. Conclusions For now, the core outcome set for clinical trials in AE is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.
What is already known about this topic?
Core outcomes sets improve the design and reporting of clinical trials, reduce selective outcome reporting bias and facilitate meta‐analysis of results in systematic reviews. The HOME core outcome set for eczema recommends the inclusion of four core domains in all atopic eczema trials: clinician‐reported signs, patient‐reported symptoms, health‐related quality of life (HrQoL) and long‐term control. Clinician‐reported signs should be captured using the Eczema Area and Severity Index (EASI) and patient‐reported symptoms using the Patient‐Oriented Eczema Measure (POEM).
What does this study add?
The HOME core outcome set is now complete and recommended core outcome instruments have been agreed on for all four domains. Core outcome instruments for HrQoL: Dermatology Life Quality Index (DLQI) for adults, Children’s Dermatology Life Quality Index (CDLQI) for children and Infant’s Dermatology Quality of Life Index (IDQoL) for infants. Core outcome instruments for long‐term control: either the Recap of Atopic Eczema (RECAP) or the Atopic Dermatitis Control Test (ADCT). In addition, itch intensity should be measured using the peak NRS‐11 past 24 h for trials including older children and adults.
What are the clinical implications of this work?
If all future trials of eczema treatments include the HOME core outcome instruments, then trial results will be more readily incorporated into meta‐analyses in systematic reviews and clinical care will be informed by the best available evidence.
Linked Comment: D.F. Murrell and C.F. Paul. Br J Dermatol 2021; 185:13–14.
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Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, Nottingham, UK
| | - C A Apfelbacher
- Institute of Social Medicine and Health Systems Research (ISMHSR), Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - J R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, Nottingham, UK
| | - E Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, OR, USA
| | - P I Spuls
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L A A Gerbens
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H C Williams
- Centre of Evidence Based Dermatology, School of Medicine, Nottingham, UK
| | - J Schmitt
- Center for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - M Gabes
- Medical Sociology, Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - L Howells
- Centre of Evidence Based Dermatology, School of Medicine, Nottingham, UK
| | - B L Stuart
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - E Grinich
- School of Medicine (Department of Dermatology), Oregon Health & Science University, Portland, OR, USA
| | - T Pawlitschek
- School of Medicine (Department of Dermatology), Oregon Health & Science University, Portland, OR, USA
| | - T Burton
- Patient representative (independent), Nottingham, UK
| | - L Howie
- Global Parents for Eczema Research, Brisbane, Australia
| | - A Gadkari
- Health Economics and Outcomes Research, Boehringer Ingelheim Inc., Ingelheim, Rheinland-Pfalz, Germany
| | - L Eckert
- Global Dupixent Business Partner, sanofi GHEVA, 1 av. Pierre Brossolette, Chilly-Mazarin, 91380, France
| | - T Ebata
- Chitofuna Dermatology Clinic, Tokyo, Japan
| | - M Boers
- Department of Epidemiology and Data Science, Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - H Saeki
- Department of Dermatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - T Nakahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Katoh
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Muller I, Stuart B, Sach T, Hooper J, Wilczynska S, Steele M, Greenwell K, Sivyer K, Yardley L, Williams HC, Chalmers JR, Leighton P, Howells LM, Ridd MJ, Lawton S, Griffiths G, Nuttall J, Langan SM, Roberts A, Ahmed A, Kirk H, Becque T, Little P, Thomas KS, Santer M. Supporting self-care for eczema: protocol for two randomised controlled trials of ECO (Eczema Care Online) interventions for young people and parents/carers. BMJ Open 2021; 11:e045583. [PMID: 33550268 PMCID: PMC7925854 DOI: 10.1136/bmjopen-2020-045583] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/22/2020] [Accepted: 01/20/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Eczema care requires management of triggers and various treatments. We developed two online behavioural interventions to support eczema care called ECO (Eczema Care Online) for young people and ECO for families. This protocol describes two randomised controlled trials (RCTs) aimed to evaluate clinical and cost-effectiveness of the two interventions. METHODS AND ANALYSIS: Design: Two independent, pragmatic, unmasked, parallel group RCTs with internal pilots and nested health economic and process evaluation studies. Setting: Participants will be recruited from general practitioner practices in England. Participants: Young people aged 13-25 years with eczema and parents and carers of children aged 0-12 years with eczema, excluding inactive or very mild eczema (five or less on Patient-Oriented Eczema Measure (POEM)). Interventions: Participants will be randomised to online intervention plus usual care or to usual eczema care alone. Outcome measures: Primary outcome is eczema severity over 24 weeks measured by POEM. Secondary outcomes include POEM 4-weekly for 52 weeks, quality of life, eczema control, itch intensity (young people only), patient enablement, health service and treatment use. Process measures include treatment adherence, barriers to adherence and intervention usage. Our sample sizes of 303 participants per trial are powered to detect a group difference of 2.5 (SD 6.5) in monthly POEM scores over 24 weeks (significance 0.05, power 0.9), allowing for 20% loss to follow-up. Cost-effectiveness analysis will be from a National Health Service and personal social service perspective. Qualitative and quantitative process evaluation will help understand the mechanisms of action and participant experiences and inform implementation. ETHICS AND DISSEMINATION The study has been approved by South Central Oxford A Research Ethics Committee (19/SC/0351). Recruitment is ongoing, and follow-up will be completed by mid-2022. Findings will be disseminated to participants, the public, dermatology and primary care journals, and policy makers. TRIAL REGISTRATION NUMBER ISRCTN79282252.
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Affiliation(s)
- Ingrid Muller
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Beth Stuart
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Tracey Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Julie Hooper
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Sylvia Wilczynska
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Mary Steele
- Department of Psychology, University of Southampton, Southampton, UK
| | - Kate Greenwell
- Department of Psychology, University of Southampton, Southampton, UK
| | - Katy Sivyer
- Department of Psychology, University of Southampton, Southampton, UK
- Department of Psychology, University of Portsmouth, Portsmouth, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
- School of Experimental Psychology, University of Bristol, Bristol, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Paul Leighton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Laura M Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol Faculty of Health Sciences, Bristol, UK
| | - Sandra Lawton
- Department of Dermatology, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Jacqui Nuttall
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | - Sinead M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Roberts
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Amina Ahmed
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hayden Kirk
- Neurological Rehabilitation, Solent NHS Trust, Southampton, UK
| | - Taeko Becque
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Paul Little
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
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Kelleher MM, Cro S, Cornelius V, Lodrup Carlsen KC, Skjerven HO, Rehbinder EM, Lowe AJ, Dissanayake E, Shimojo N, Yonezawa K, Ohya Y, Yamamoto-Hanada K, Morita K, Axon E, Surber C, Cork M, Cooke A, Tran L, Van Vogt E, Schmitt J, Weidinger S, McClanahan D, Simpson E, Duley L, Askie LM, Chalmers JR, Williams HC, Boyle RJ. Skin care interventions in infants for preventing eczema and food allergy. Cochrane Database Syst Rev 2021; 2:CD013534. [PMID: 33545739 PMCID: PMC8094581 DOI: 10.1002/14651858.cd013534.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eczema and food allergy are common health conditions that usually begin in early childhood and often occur together in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective in preventing eczema or food allergy. OBJECTIVES Primary objective To assess effects of skin care interventions, such as emollients, for primary prevention of eczema and food allergy in infants Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy. SEARCH METHODS We searched the following databases up to July 2020: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. We searched two trials registers and checked reference lists of included studies and relevant systematic reviews for further references to relevant randomised controlled trials (RCTs). We contacted field experts to identify planned trials and to seek information about unpublished or incomplete trials. SELECTION CRITERIA RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (0 to 12 months) without pre-existing diagnosis of eczema, food allergy, or other skin condition were included. Comparison was standard care in the locality or no treatment. Types of skin care interventions included moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required. DATA COLLECTION AND ANALYSIS This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured by the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen. MAIN RESULTS This review identified 33 RCTs, comprising 25,827 participants. A total of 17 studies, randomising 5823 participants, reported information on one or more outcomes specified in this review. Eleven studies randomising 5217 participants, with 10 of these studies providing IPD, were included in one or more meta-analysis (range 2 to 9 studies per individual meta-analysis). Most studies were conducted at children's hospitals. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported our outcomes, 13 assessed emollients. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to two years. We assessed most of this review's evidence as low certainty or had some concerns of risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. Evidence for the primary food allergy outcome was rated as high risk of bias due to inclusion of only one trial where findings varied when different assumptions were made about missing data. Skin care interventions during infancy probably do not change risk of eczema by one to two years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; moderate-certainty evidence; 3075 participants, 7 trials) nor time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). It is unclear whether skin care interventions during infancy change risk of IgE-mediated food allergy by one to two years of age (RR 2.53, 95% CI 0.99 to 6.47; 996 participants, 1 trial) or allergic sensitisation to a food allergen at age one to two years (RR 0.86, 95% CI 0.28 to 2.69; 1055 participants, 2 trials) due to very low-certainty evidence for these outcomes. Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial). However, this was only seen for cow's milk, and may be unreliable due to significant over-reporting of cow's milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.34, 95% CI 1.02 to 1.77; moderate-certainty evidence; 2728 participants, 6 trials) and may increase risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) or stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although confidence intervals for slippages and stinging/allergic reactions are wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses show that effects of interventions were not influenced by age, duration of intervention, hereditary risk, FLG mutation, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and risk of developing eczema or food allergy. AUTHORS' CONCLUSIONS Skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema, and probably increase risk of skin infection. Effects of skin care interventions on risk of food allergy are uncertain. Further work is needed to understand whether different approaches to infant skin care might promote or prevent eczema and to evaluate effects on food allergy based on robust outcome assessments.
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Affiliation(s)
- Maeve M Kelleher
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
| | - Suzie Cro
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | | | - Karin C Lodrup Carlsen
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Håvard O Skjerven
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Eva M Rehbinder
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
| | - Adrian J Lowe
- Allergy and Lung Health Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Eishika Dissanayake
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Naoki Shimojo
- Center for Preventive Medical Sciences, Chiba University, Chiba, Japan
| | - Kaori Yonezawa
- Department of Midwifery and Women's Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | | | - Kumiko Morita
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Emma Axon
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Christian Surber
- Department of Dermatology, University Hospital Zurich, Zurich, Switzerland
- Department of Dermatology, University Hospital Basel, Basel, Switzerland
| | - Michael Cork
- Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Alison Cooke
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Lien Tran
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Eleanor Van Vogt
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technischen Universität (TU) Dresden, Dresden, Germany
| | - Stephan Weidinger
- Department of Dermatology and Allergy, University Hospital Scheswig-Holstein, Kiel, Germany
| | - Danielle McClanahan
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Eric Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, Australia
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- National Heart & Lung Institute, Section of Inflammation and Repair, Imperial College London, London, UK
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Persson MSM, Harman KE, Thomas KS, Chalmers JR, Vinogradova Y, Langan SM, Hippisley-Cox J, Gran S. Using electronic health records to inform trial feasibility in a rare autoimmune blistering skin disease in England. BMC Med Res Methodol 2021; 21:22. [PMID: 33541270 PMCID: PMC7863423 DOI: 10.1186/s12874-021-01212-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background Trials of novel agents are required to improve the care of patients with rare diseases, but trial feasibility may be uncertain due to concerns over insufficient patient numbers. We aimed to determine the size of the pool of potential participants in England 2015–2017 for trials in the autoimmune blistering skin disease bullous pemphigoid. Methods The size of the pool of potential participants was estimated using routinely collected healthcare data from linked primary care (Clinical Practice Research Datalink; CPRD) and secondary care (Hospital Episode Statistics; HES) databases. Thirteen consultant dermatologists were surveyed to determine the likelihood that a patient would be eligible for a trial based on the presence of cautions or contra-indications to prednisolone use. These criteria were applied to determine how they influenced the potential pool of participants. Results Extrapolated to the population of England, we would expect approximately 10,800 (point estimate 10,747; 95% CI 7191 to 17,239) new cases of bullous pemphigoid to be identified in a three-year period. For a future trial involving oral prednisolone (standard care), the application of cautions to its use as exclusion criteria would result in approximately 365 potential participants unlikely to be recruited, a further 5332 could be recruited with caution, and 5104 in whom recruitment is still possible. 11–17% of potential participants may have pre-existing dementia and require an alternative consent process. Conclusions Routinely collected electronic health records can be used to inform the feasibility of clinical trials in rare diseases, such as whether recruitment is feasible nationally and how long recruitment might take to meet recruitment targets. Future trials of bullous pemphigoid in England may use the data presented to inform trial design, including eligibility criteria and consent processes for enrolling people with dementia. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01212-1.
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Affiliation(s)
- M S M Persson
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K E Harman
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Y Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - S M Langan
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - J Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - S Gran
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, UK.
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Ridd MJ, Webb D, Roberts K, Santer M, Chalmers JR, Gilbertson A, Marriage D, Blair PS, Turner NL, Garfield K, Coast J, Selman LE, Clement C, Shaw ARG, Muller I, Waddell L, Angier E, Taylor J, Kai J, Boyle RJ. Test-guided dietary management of eczema in children: A randomized controlled feasibility trial (TEST). Clin Exp Allergy 2021; 51:452-462. [PMID: 33386634 DOI: 10.1111/cea.13816] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 12/14/2020] [Accepted: 12/27/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Parents commonly ask about food allergy tests, to find a cause for their child's eczema, yet the value of routine testing is uncertain. OBJECTIVE To determine whether a clinical trial comparing test-guided dietary advice versus usual care, for the management of eczema, is feasible. METHODS Children (>3 months and <5 years) with mild-to-severe eczema, recruited via primary care, were individually randomized (1:1) to intervention or usual care. Intervention participants underwent structured allergy history and skin prick tests (SPT) with dietary advice for cow's milk, hen's egg, wheat, peanut, cashew and codfish. All participants were followed up for 24 weeks. A sample of doctors and parents was interviewed. Registration ISRCTN15397185. RESULTS From 1059 invitation letters sent to carers of potentially eligible children, 84 were randomized (42 per group) with mean age of 32.4 months (SD 13.9) and POEM of 8.7 (4.8). Of the 42, 6 (14%) intervention participants were advised to exclude one or more foods, most commonly egg, peanut or milk. By participant, 1/6 had an oral food challenge (negative); 3/6 were told to exclude until review in allergy clinic; and 6/6 advised a home dietary trial (exclusion and reintroduction of food over 4-6 weeks) - with 1/6 partially completing it. Participant retention (four withdrawals) and data completeness (74%-100%) were acceptable and contamination low (two usual care participants had allergy tests). There were three minor SPT-related adverse events. During follow-up, 12 intervention and 8 usual care participants had minor, unrelated adverse events plus one unrelated hospital admission. CONCLUSIONS It is possible to recruit, randomize and retain children with eczema from primary care into a trial of food allergy screening and to collect the outcomes of interest. Changes to recruitment and inclusion criteria are needed in a definitive trial, to ensure inclusion of younger children from more diverse backgrounds.
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Affiliation(s)
- Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Douglas Webb
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Kirsty Roberts
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Miriam Santer
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Anna Gilbertson
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Deb Marriage
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Peter S Blair
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Nicholas L Turner
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Kirsty Garfield
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK.,Health Economics Bristol, Population Health Sciences, University of Bristol, Bristol, UK
| | - Joanna Coast
- Health Economics Bristol, Population Health Sciences, University of Bristol, Bristol, UK
| | - Lucy E Selman
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Alison R G Shaw
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Ingrid Muller
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Lisa Waddell
- Nottingham City Care Partnership, Nottingham, UK
| | - Elizabeth Angier
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jodi Taylor
- Bristol Randomised Trials Collaboration, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Joe Kai
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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Thomas KS, Batchelor JM, Akram P, Chalmers JR, Haines RH, Meakin GD, Duley L, Ravenscroft JC, Rogers A, Sach TH, Santer M, Tan W, White J, Whitton ME, Williams HC, Cheung ST, Hamad H, Wright A, Ingram JR, Levell NJ, Goulding JMR, Makrygeorgou A, Bewley A, Ogboli M, Stainforth J, Ferguson A, Laguda B, Wahie S, Ellis R, Azad J, Rajasekaran A, Eleftheriadou V, Montgomery AA. Randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo: results of the HI-Light Vitiligo Trial. Br J Dermatol 2020; 184:828-839. [PMID: 33006767 DOI: 10.1111/bjd.19592] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence for the effectiveness of vitiligo treatments is limited. OBJECTIVES To determine the effectiveness of (i) handheld narrowband UVB (NB-UVB) and (ii) a combination of potent topical corticosteroid (TCS) and NB-UVB, compared with TCS alone, for localized vitiligo. METHODS A pragmatic, three-arm, placebo-controlled randomized controlled trial (9-month treatment, 12-month follow-up). Adults and children, recruited from secondary care and the community, aged ≥ 5 years and with active vitiligo affecting < 10% of skin, were randomized 1 : 1 : 1 to receive TCS (mometasone furoate 0·1% ointment + dummy NB-UVB), NB-UVB (NB-UVB + placebo TCS) or a combination (TCS + NB-UVB). TCS was applied once daily on alternating weeks; NB-UVB was administered on alternate days in escalating doses, adjusted for erythema. The primary outcome was treatment success at 9 months at a target patch assessed using the participant-reported Vitiligo Noticeability Scale, with multiple imputation for missing data. The trial was registered with number ISRCTN17160087 on 8 January 2015. RESULTS In total 517 participants were randomized to TCS (n = 173), NB-UVB (n = 169) and combination (n = 175). Primary outcome data were available for 370 (72%) participants. The proportions with target patch treatment success were 17% (TCS), 22% (NB-UVB) and 27% (combination). Combination treatment was superior to TCS: adjusted between-group difference 10·9% (95% confidence interval 1·0%-20·9%; P = 0·032; number needed to treat = 10). NB-UVB alone was not superior to TCS: adjusted between-group difference 5·2% (95% CI - 4·4% to 14·9%; P = 0·29; number needed to treat = 19). Participants using interventions with ≥ 75% expected adherence were more likely to achieve treatment success, but the effects were lost once treatment stopped. Localized grade 3 or 4 erythema was reported in 62 (12%) participants (including three with dummy light). Skin thinning was reported in 13 (2·5%) participants (including one with placebo ointment). CONCLUSIONS Combination treatment with home-based handheld NB-UVB plus TCS is likely to be superior to TCS alone for treatment of localized vitiligo. Combination treatment was relatively safe and well tolerated but was successful in only around one-quarter of participants.
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Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J M Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - P Akram
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - R H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - G D Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - L Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - T H Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - M Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - W Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J White
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - M E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S T Cheung
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - H Hamad
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Wright
- St Luke's Hospital, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - J R Ingram
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - N J Levell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - J M R Goulding
- Solihull Hospital, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Makrygeorgou
- West Glasgow Ambulatory Care Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - A Bewley
- Barts Health NHS Trust and Queen Mary University London, London, UK
| | - M Ogboli
- Birmingham Children's Hospital, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Stainforth
- York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - A Ferguson
- Royal Derby Hospital and the London Road Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - B Laguda
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - S Wahie
- University Hospital of North Durham, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - R Ellis
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - J Azad
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - A Rajasekaran
- Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - A A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Williams HC, Rogers NK, Chalmers JR, Thomas KS. Scoping the international impact from four independent national dermatology trials. Clin Exp Dermatol 2020; 46:657-662. [PMID: 33179251 DOI: 10.1111/ced.14506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Research impact describes whether and how research results in wider benefits to society beyond academic publication. Little is known about translation of clinical trial research into dermatological practice. AIM We scoped international impact from four independently funded clinical trials published by our group over the past 10 years. METHODS This was a scoping survey of 35 international colleagues from 22 countries followed by a narrative summary of emergent themes. RESULTS All recipients kindly responded to the survey. At least 20 emergent themes were identified, which broadly included: (i) interest and enthusiasm in the concept of trying to document clinical trial impact; (ii) direct impacts such as adoption of the drug as tested and recommended from the trial results, including more confidence using the drug in slightly different ways for the same condition; (iii) the finding that trial impact was dependent on factors such as drug availability and country-specific disease patterns; and (iv) the educational value of good trial design for journal club discussions and improving future clinical trial designs in dermatology. Our survey suggests that uptake into clinical practice was surprisingly rapid and widespread. CONCLUSION Clinical trial research is of little use unless findings are translated into clinical practice for patient benefit. Our international scoping survey suggests that independent clinical trials that address important questions identified by the dermatology community have substantial, diverse and far-reaching impacts on dermatological practice.
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Affiliation(s)
- H C Williams
- Centre of Evidence Based Dermatology, School of Medicine, King's Meadow Campus, The University of Nottingham, Nottingham, UK
| | - N K Rogers
- Centre of Evidence Based Dermatology, School of Medicine, King's Meadow Campus, The University of Nottingham, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, King's Meadow Campus, The University of Nottingham, Nottingham, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, King's Meadow Campus, The University of Nottingham, Nottingham, UK
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Thomas KS, Apfelbacher CA, Chalmers JR, Simpson E, Spuls PI, Gerbens LAA, Williams HC, Schmitt J, Gabes M, Howells L, Stuart BL, Grinich E, Pawlitschek T, Burton T, Howie L, Gadkari A, Eckert L, Ebata T, Boers M, Saeki H, Nakahara T, Katoh N. Recommended core outcome instruments for health-related quality of life, long-term control and itch intensity in atopic eczema trials: results of the HOME VII consensus meeting. Br J Dermatol 2020:bjd.19673. [PMID: 33179283 DOI: 10.1111/bjd.19673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Harmonising Outcome Measures for Eczema (HOME) initiative has established a core outcome set of domains for atopic eczema clinical trials. Previous consensus meetings have agreed upon preferred instruments for clinician-reported signs (Eczema Area and Severity Index - EASI) and patient-reported symptoms (Patient-Oriented Eczema Measure - POEM). This paper reports consensus decisions from the HOME VII meeting. OBJECTIVE To complete the core outcome set for atopic eczema by agreeing upon core outcome instruments for the domains of quality of life, long-term control and itch intensity. METHODS Face-to-face consensus meeting held in Tokyo, Japan (8th to 10th April, 2019) including 74 participants (47 healthcare professionals/methodologists, 14 patients, 13 industry representatives), from 16 countries. Consensus decisions were made by presentations of evidence, followed by whole and small group discussions and anonymous voting using pre-defined consensus rules. RESULTS It was agreed by consensus that quality of life should be measured using the Dermatology Life Quality Index (DLQI) for adults, the Children's Dermatology Life Quality Index (CDLQI) for children, and the Infant's Dermatology Quality of Life Index (IDQoL) for infants. For long-term control, the Recap of Atopic Eczema (RECAP) instrument or the Atopic Dermatitis Control Test (ADCT) should be used. Consensus was not reached over the frequency of data collection for long-term control. The peak itch numerical rating scale(NRS)-11 past 24 hours was recommended as an additional instrument for the symptom domain in trials of older children and adults. Agreement was reached that all core outcome instruments should be captured at baseline and at the time of primary outcome assessment as a minimum. CONCLUSIONS For now, the core outcome set for clinical trials in atopic eczema is complete. The specified domains and instruments should be used in all new clinical trials and systematic reviews of eczema treatments.
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Affiliation(s)
- K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - C A Apfelbacher
- Institute of Social Medicine and Health Systems Research (ISMHSR), Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - E Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - P I Spuls
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - L A A Gerbens
- Department of Dermatology, Amsterdam Public Health, Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J Schmitt
- Center for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - M Gabes
- Medical Sociology, Department of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - L Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - B L Stuart
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - E Grinich
- School of Medicine, Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - T Pawlitschek
- School of Medicine, Department of Dermatology, Oregon Health & Science University, Portland, Oregon, USA
| | - T Burton
- Patient Representative (independent), Nottingham, United Kingdom
| | - L Howie
- Global Parents for Eczema Research, Brisbane, Australia
| | - A Gadkari
- Health Economics and Outcomes Research, Boehringer Ingelheim Inc, Germany
| | - L Eckert
- Global Dupixent Business Partner, sanofi GHEVA, 1 av. Pierre Brossolette, 91 380, Chilly Mazatin, France
| | - T Ebata
- Chitofuna Dermatology Clinic, Tokyo, Japan
| | - M Boers
- Department of Epidemiology and data Science; Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - H Saeki
- Department of Dermatology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan
| | - T Nakahara
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - N Katoh
- Department of Dermatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Sach TH, Thomas KS, Batchelor JM, Perways A, Chalmers JR, Haines RH, Meakin GD, Duley L, Ravenscroft JC, Rogers A, Santer M, Tan W, White J, Whitton ME, Williams HC, Cheung ST, Hamad H, Wright A, Ingram JR, Levell N, Goulding JMR, Makrygeorgou A, Bewley A, Ogboli M, Stainforth J, Ferguson A, Laguda B, Wahie S, Ellis R, Azad J, Rajasekaran A, Eleftheriadou V, Montgomery AA. An economic evaluation of the randomized controlled trial of topical corticosteroid and home-based narrowband ultraviolet B for active and limited vitiligo (the HI-Light Vitiligo Trial). Br J Dermatol 2020; 184:840-848. [PMID: 32920824 DOI: 10.1111/bjd.19554] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Economic evidence for vitiligo treatments is absent. OBJECTIVES To determine the cost-effectiveness of (i) handheld narrowband ultraviolet B (NB-UVB) and (ii) a combination of topical corticosteroid (TCS) and NB-UVB compared with TCS alone for localized vitiligo. METHODS Cost-effectiveness analysis alongside a pragmatic, three-arm, placebo-controlled randomized controlled trial with 9 months' treatment. In total 517 adults and children (aged ≥ 5 years) with active vitiligo affecting < 10% of skin were recruited from secondary care and the community and were randomized 1: 1: 1 to receive TCS, NB-UVB or both. Cost per successful treatment (measured on the Vitiligo Noticeability Scale) was estimated. Secondary cost-utility analyses measured quality-adjusted life-years using the EuroQol 5 Dimensions 5 Levels for those aged ≥ 11 years and the Child Health Utility 9D for those aged 5 to < 18 years. The trial was registered with number ISRCTN17160087 on 8 January 2015. RESULTS The mean ± SD cost per participant was £775 ± 83·7 for NB-UVB, £813 ± 111.4 for combination treatment and £600 ± 96·2 for TCS. In analyses adjusted for age and target patch location, the incremental difference in cost for combination treatment compared with TCS was £211 (95% confidence interval 188-235), corresponding to a risk difference of 10·9% (number needed to treat = 9). The incremental cost was £1932 per successful treatment. The incremental difference in cost for NB-UVB compared with TCS was £173 (95% confidence interval 151-196), with a risk difference of 5·2% (number needed to treat = 19). The incremental cost was £3336 per successful treatment. CONCLUSIONS Combination treatment, compared with TCS alone, has a lower incremental cost per additional successful treatment than NB-UVB only. Combination treatment would be considered cost-effective if decision makers are willing to pay £1932 per additional treatment success.
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Affiliation(s)
- T H Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J M Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A Perways
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - R H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - G D Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - L Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M Santer
- Primary Care, Population Sciences & Medical Education, University of Southampton, Southampton, UK
| | - W Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - J White
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - M E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S T Cheung
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - H Hamad
- Cannock Chase Hospital and New Cross Hospital, The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - A Wright
- St Luke's Hospital, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - J R Ingram
- Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - N Levell
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - J M R Goulding
- Solihull Hospital, University Hospitals of Birmingham NHS Foundation Trust, Birmingham, UK
| | - A Makrygeorgou
- West Glasgow Ambulatory Care Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - A Bewley
- Whipps Cross Hospital and The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - M Ogboli
- Birmingham Children's Hospital, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - J Stainforth
- York Hospital, York Teaching Hospital NHS Foundation Trust, York, UK
| | - A Ferguson
- Royal Derby Hospital and the London Road Community Hospital, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - B Laguda
- Chelsea and Westminster Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - S Wahie
- University Hospital of North Durham, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - R Ellis
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - J Azad
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - A Rajasekaran
- Birmingham City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - A A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Batchelor JM, Thomas KS, Akram P, Azad J, Bewley A, Chalmers JR, Cheung ST, Duley L, Eleftheriadou V, Ellis R, Ferguson A, Goulding JM, Haines RH, Hamad H, Ingram JR, Laguda B, Leighton P, Levell N, Makrygeorgou A, Meakin GD, Millington A, Ogboli M, Rajasekaran A, Ravenscroft JC, Rogers A, Sach TH, Santer M, Stainforth J, Tan W, Wahie S, White J, Whitton ME, Williams HC, Wright A, Montgomery AA. Home-based narrowband UVB, topical corticosteroid or combination for children and adults with vitiligo: HI-Light Vitiligo three-arm RCT. Health Technol Assess 2020; 24:1-128. [PMID: 33245043 PMCID: PMC7750863 DOI: 10.3310/hta24640] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Systematic reviews suggest that narrowband ultraviolet B light combined with treatments such as topical corticosteroids may be more effective than monotherapy for vitiligo. OBJECTIVE To explore the clinical effectiveness and cost-effectiveness of topical corticosteroid monotherapy compared with (1) hand-held narrowband ultraviolet B light monotherapy and (2) hand-held narrowband ultraviolet B light/topical corticosteroid combination treatment for localised vitiligo. DESIGN Pragmatic, three-arm, randomised controlled trial with 9 months of treatment and a 12-month follow-up. SETTING Sixteen UK hospitals - participants were recruited from primary and secondary care and the community. PARTICIPANTS Adults and children (aged ≥ 5 years) with active non-segmental vitiligo affecting ≤ 10% of their body area. INTERVENTIONS Topical corticosteroids [mometasone furoate 0.1% (Elocon®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) plus dummy narrowband ultraviolet B light]; narrowband ultraviolet B light (narrowband ultraviolet B light plus placebo topical corticosteroids); or combination (topical corticosteroids plus narrowband ultraviolet B light). Topical corticosteroids were applied once daily on alternate weeks and narrowband ultraviolet B light was administered every other day in escalating doses, with a dose adjustment for erythema. All treatments were home based. MAIN OUTCOME MEASURES The primary outcome was self-assessed treatment success for a chosen target patch after 9 months of treatment ('a lot less noticeable' or 'no longer noticeable' on the Vitiligo Noticeability Scale). Secondary outcomes included blinded assessment of primary outcome and percentage repigmentation, onset and maintenance of treatment response, quality of life, side effects, treatment burden and cost-effectiveness (cost per additional successful treatment). RESULTS In total, 517 participants were randomised (adults, n = 398; and children, n = 119; 52% male; 57% paler skin types I-III, 43% darker skin types IV-VI). At the end of 9 months of treatment, 370 (72%) participants provided primary outcome data. The median percentage of narrowband ultraviolet B light treatment-days (actual/allocated) was 81% for topical corticosteroids, 77% for narrowband ultraviolet B light and 74% for combination groups; and for ointment was 79% for topical corticosteroids, 83% for narrowband ultraviolet B light and 77% for combination. Target patch location was head and neck (31%), hands and feet (32%), and rest of the body (37%). Target patch treatment 'success' was 20 out of 119 (17%) for topical corticosteroids, 27 out of 123 (22%) for narrowband ultraviolet B light and 34 out of 128 (27%) for combination. Combination treatment was superior to topical corticosteroids (adjusted risk difference 10.9%, 95% confidence interval 1.0% to 20.9%; p = 0.032; number needed to treat = 10). Narrowband ultraviolet B light was not superior to topical corticosteroids (adjusted risk difference 5.2%, 95% confidence interval -4.4% to 14.9%; p = 0.290; number needed to treat = 19). The secondary outcomes supported the primary analysis. Quality of life did not differ between the groups. Participants who adhered to the interventions for > 75% of the expected treatment protocol were more likely to achieve treatment success. Over 40% of participants had lost treatment response after 1 year with no treatment. Grade 3 or 4 erythema was experienced by 62 participants (12%) (three of whom were using the dummy) and transient skin thinning by 13 participants (2.5%) (two of whom were using the placebo). We observed no serious adverse treatment effects. For combination treatment compared with topical corticosteroids, the unadjusted incremental cost-effectiveness ratio was £2328.56 (adjusted £1932) per additional successful treatment (from an NHS perspective). LIMITATIONS Relatively high loss to follow-up limits the interpretation of the trial findings, especially during the post-intervention follow-up phase. CONCLUSION Hand-held narrowband ultraviolet B light plus topical corticosteroid combination treatment is superior to topical corticosteroids alone for treatment of localised vitiligo. Combination treatment was relatively safe and well tolerated, but was effective in around one-quarter of participants only. Whether or not combination treatment is cost-effective depends on how much decision-makers are willing to pay for the benefits observed. FUTURE WORK Development and testing of new vitiligo treatments with a greater treatment response and longer-lasting effects are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN17160087. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 64. See the NIHR Journals Library website for further project information.
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Bradshaw LE, Montgomery AA, Williams HC, Chalmers JR, Haines RH. Two-by-two factorial randomised study within a trial (SWAT) to evaluate strategies for follow-up in a randomised prevention trial. Trials 2020; 21:529. [PMID: 32546180 PMCID: PMC7296963 DOI: 10.1186/s13063-020-04373-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 05/05/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Failure to collect outcome data in randomised trials can result in bias and loss of statistical power. Further evaluations of strategies to increase retention are required. We assessed the effectiveness of two strategies for retention in a randomised prevention trial using a two-by-two factorial randomised study within a trial (SWAT). METHODS Parents of babies included in the host trial were randomised to (1) short message service (SMS) notification prior to sending questionnaires at 3, 6, 12 and 18 months versus no SMS notification and (2) a £10 voucher sent with the invitation letter for the primary follow-up visit at 24 months or given at the visit. The two co-primary outcomes were collection of host trial (1) questionnaire data at interim follow-up times and (2) primary outcome at 24 months during a home/clinic visit with a research nurse. RESULTS Between November 2014 and November 2016, 1394 participants were randomised: 350 to no SMS + voucher at visit, 345 to SMS + voucher at visit, 352 to no SMS + voucher before visit and 347 to SMS + voucher before visit. Overall questionnaire data was collected at interim follow-up times for 75% in both the group allocated to the prior SMS notification and the group allocated to no SMS notification (odds ratio (OR) SMS versus none 1.02, 95% CI 0.83 to 1.25). Host trial primary outcome data was collected at a visit for 557 (80%) allocated to the voucher before the visit in the invitation letter and for 566 (81%) whose parents were allocated to receive the voucher at the visit (OR before versus at visit 0.89, 95% CI 0.69 to 1.17). CONCLUSION There was no evidence of a difference in retention according to SMS notification or voucher timing. Future synthesis of SWAT results is required to be able to detect small but important incremental effects of retention strategies. TRIAL REGISTRATION ISRCTN registry, ID: ISRCTN21528841. Registered on 25 July 2014. SWAT Repository Store ID 25.
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Affiliation(s)
- Lucy E. Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Alan A. Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, NG7 2RD UK
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Vincent R, Chalmers JR, McWilliams C, Thomas KS, Dodd S, Rogers N, Ridd MJ, Schmitt J, Kirkham JJ. Assessing uptake of the Harmonising Outcome Measures for Eczema (HOME) Core Outcome Set and recommended instruments. Br J Dermatol 2020; 183:566-568. [PMID: 32167583 DOI: 10.1111/bjd.19030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- R Vincent
- University Hospital Bristol NHS Foundation Trust, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - C McWilliams
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S Dodd
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - N Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - M J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | - J Schmitt
- Center for Evidence-based Healthcare, Medizinische Fakultät, Technische Universität Dresden, Dresden, Germany
| | - J J Kirkham
- Centre for Biostatistics, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
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Chalmers JR, Haines RH, Bradshaw LE, Montgomery AA, Thomas KS, Brown SJ, Ridd MJ, Lawton S, Simpson EL, Cork MJ, Sach TH, Flohr C, Mitchell EJ, Swinden R, Tarr S, Davies-Jones S, Jay N, Kelleher MM, Perkin MR, Boyle RJ, Williams HC. Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial. Lancet 2020; 395:962-972. [PMID: 32087126 PMCID: PMC7086156 DOI: 10.1016/s0140-6736(19)32984-8] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Skin barrier dysfunction precedes eczema development. We tested whether daily use of emollient in the first year could prevent eczema in high-risk children. METHODS We did a multicentre, pragmatic, parallel-group, randomised controlled trial in 12 hospitals and four primary care sites across the UK. Families were approached via antenatal or postnatal services for recruitment of term infants (at least 37 weeks' gestation) at high risk of developing eczema (ie, at least one first-degree relative with parent-reported eczema, allergic rhinitis, or asthma, diagnosed by a doctor). Term newborns with a family history of atopic disease were randomly assigned (1:1) to application of emollient daily (either Diprobase cream or DoubleBase gel) for the first year plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). The randomisation schedule was created using computer-generated code (stratified by recruiting centre and number of first-degree relatives with atopic disease) and participants were assigned to groups using an internet-based randomisation system. The primary outcome was eczema at age 2 years (defined by UK working party criteria) with analysis as randomised regardless of adherence to allocation for participants with outcome data collected, and adjusting for stratification variables. This trial is registered with ISRCTN, ISRCTN21528841. Data collection for long-term follow-up is ongoing, but the trial is closed to recruitment. FINDINGS 1394 newborns were randomly assigned to study groups between Nov 19, 2014, and Nov 18, 2016; 693 were assigned to the emollient group and 701 to the control group. Adherence in the emollient group was 88% (466 of 532) at 3 months, 82% (427 of 519) at 6 months, and 74% (375 of 506) at 12 months in those with complete questionnaire data. At age 2 years, eczema was present in 139 (23%) of 598 infants with outcome data collected in the emollient group and 150 (25%) of 612 infants in the control group (adjusted relative risk 0·95 [95% CI 0·78 to 1·16], p=0·61; adjusted risk difference -1·2% [-5·9 to 3·6]). Other eczema definitions supported the results of the primary analysis. Mean number of skin infections per child in year 1 was 0·23 (SD 0·68) in the emollient group versus 0·15 (0·46) in the control group; adjusted incidence rate ratio 1·55 (95% CI 1·15 to 2·09). INTERPRETATION We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children and some evidence to suggest an increased risk of skin infections. Our study shows that families with eczema, asthma, or allergic rhinitis should not use daily emollients to try and prevent eczema in their newborn. FUNDING National Institute for Health Research Health Technology Assessment.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK; Department of Dermatology, Ninewells Hospital and Medical School, Dundee, UK
| | - Matthew J Ridd
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
| | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, Guy's & St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Richard Swinden
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Stella Tarr
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Davies-Jones
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital, Sheffield, UK
| | - Maeve M Kelleher
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Robert J Boyle
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
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Howells LM, Chalmers JR, Gran S, Ahmed A, Apfelbacher C, Burton T, Howie L, Lawton S, Ridd MJ, Rogers NK, Sears AV, Spuls P, von Kobyletzki L, Thomas KS. Development and initial testing of a new instrument to measure the experience of eczema control in adults and children: Recap of atopic eczema (RECAP). Br J Dermatol 2020; 183:524-536. [PMID: 31794074 PMCID: PMC7496132 DOI: 10.1111/bjd.18780] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2019] [Indexed: 02/01/2023]
Abstract
Background Eczema control has been identified as an important outcome by key stakeholders in eczema research (including patients, carers, healthcare professionals and researchers) but no validated instruments for the domain have been identified. Objectives To develop a measurement instrument to capture a patient's perspective of eczema control that is suitable for use in eczema clinical trials. Methods Best practice for the development of a patient‐reported outcome was followed. A mixed‐methods approach was used to develop and refine a conceptual framework, generate, refine and select items and to test the distribution and construct validity of the final scale. The mixed‐methods approach involved expert panel meetings (including patient representatives, healthcare professionals and methodologists), and data collection using a focus group, cognitive interviews and an online survey with people with eczema and caregivers. Multivariable linear regression was used in the item selection process. Results Fourteen expert panel members co‐produced the instrument, with input from people with eczema and caregivers via a focus group (n = 6), cognitive interviews (n = 13) and an online survey (n = 330). The resulting instrument, Recap of atopic eczema (RECAP), is a seven‐item questionnaire that captures eczema control via self or caregiver report. The development process aimed to ensure good content validity and feasibility. Initial testing suggested no floor or ceiling effects and good construct validity. Hypothesized correlation with the Patient‐Oriented Eczema Measure was confirmed [r(258) = 0·83, P < 0·001]. Conclusions RECAP has the potential to improve reporting of eczema control in research and clinical practice. Further exploration of measurement properties is required. Linked Comment: Pattinson and Bundy. Br J Dermatol 2020; 183:418–419. What's already known about this topic? Eczema control has been identified as an important outcome by key stakeholders in eczema research (including patients, carers, healthcare professionals and researchers). Qualitative studies suggest eczema control is a multifaceted and individual experience and no instrument has been identified that captures eczema control in this way.
What does this study add? We have developed Recap of atopic eczema (RECAP), a seven‐item questionnaire to capture the experience of eczema control in all ages and eczema severities; there are two versions: a self‐reported version for adults and older children with eczema, and a caregiver‐reported version for younger children with eczema. Designed with input from people with eczema, caregivers and healthcare professionals to ensure good content validity. Initial testing of score distributions and construct validity suggests good measurement properties.
What are the clinical implications of the work? The RECAP instrument is appropriate and feasible for measuring eczema control in clinical trials and may also be useful in routine practice.
Linked Comment: Pattinson and Bundy. Br J Dermatol 2020; 183:418–419. Plain language summary available online
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Affiliation(s)
- L M Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - S Gran
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A Ahmed
- Patient representative, Nottingham, UK
| | - C Apfelbacher
- Department of Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany.,Institute of Social Medicine and Health Economics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - T Burton
- Patient representative, Nottingham, UK
| | - L Howie
- Patient representative, Brisbane, Australia
| | - S Lawton
- Rotherham NHS Foundation Trust, Rotherham, UK
| | - M J Ridd
- Department of Population Health Science, University of Bristol, Bristol, UK
| | - N K Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A V Sears
- St John's Institute of Dermatology and Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, UK
| | - P Spuls
- Department of Dermatology, Amsterdam University Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - L von Kobyletzki
- Centre for Clinical Research, Malmö, Lund University, Sweden.,Centre for Clinical Research, Örebro University, Sweden
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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29
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Kelleher MM, Jay N, Perkin MR, Haines RH, Batt R, Bradshaw LE, Montgomery AA, Chalmers JR, Williams HC, Boyle RJ. An algorithm for diagnosing IgE‐mediated food allergy in study participants who do not undergo food challenge. Clin Exp Allergy 2020; 50:334-342. [DOI: 10.1111/cea.13577] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/11/2020] [Accepted: 01/27/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Maeve M. Kelleher
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
| | - Nicola Jay
- Children’s Allergy Dept. Sheffield Children’s NHS Foundation Trust Sheffield UK
| | - Michael R. Perkin
- Population Health Research Institute St George's University of London London UK
| | - Rachel H. Haines
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | - Rebecca Batt
- Children’s Allergy Service Evelina Children’s Hospital London London UK
| | - Lucy E. Bradshaw
- Nottingham Clinical Trials Unit University of Nottingham Nottingham UK
| | | | - Joanne R. Chalmers
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Hywel C. Williams
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
| | - Robert J. Boyle
- Section of Inflammation, Repair & Development National Heart & Lung Institute Imperial College London London UK
- Centre of Evidence Based Dermatology University of Nottingham Nottingham UK
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30
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Kelleher MM, Cro S, Cornelius V, Axon E, Lodrup Carlsen KC, Skjerven HO, Rehbinder EM, Lowe A, Dissanayake E, Shimojo N, Yonezawa K, Ohya Y, Yamamoto-Hanada K, Morita K, Surber C, Cork M, Cooke A, Tran L, Askie LM, Duley L, Chalmers JR, Williams HC, Boyle RJ. Skincare interventions in infants for preventing eczema and food allergy. Cochrane Database Syst Rev 2020. [DOI: 10.1002/14651858.cd013534] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Maeve M Kelleher
- Imperial College London; Department of Medicine, Section of Paediatrics; St Mary's Campus London UK
| | - Suzie Cro
- Imperial College London; Imperial Clinical Trials Unit; 1st Floor, Stadium House 68 Wood Lane London UK W12 7RH
| | - Victoria Cornelius
- Imperial College London; Imperial Clinical Trials Unit; 1st Floor, Stadium House 68 Wood Lane London UK W12 7RH
| | - Emma Axon
- University of Nottingham; Centre of Evidence Based Dermatology; King's Meadow Campus Nottingham UK NG7 2NR
| | - Karin C Lodrup Carlsen
- Oslo University Hospital; Division of Paediatric and Adolescent Medicine; Oslo Norway NO-0424
- University of Oslo; Faculty of Medicine, Institute of Clinical Medicine; PO Box 4956 Nydalen Oslo Norway NO-0424
| | - Håvard Ove Skjerven
- Oslo University Hospital; Division of Paediatric and Adolescent Medicine; Oslo Norway NO-0424
| | - Eva Maria Rehbinder
- University of Oslo; Faculty of Medicine, Institute of Clinical Medicine; PO Box 4956 Nydalen Oslo Norway NO-0424
- Oslo University Hospital; Department of Dermatology; Oslo Norway
| | - Adrian Lowe
- University of Melbourne; Allergy and Lung Health Unit, Melbourne School of Population and Global Health; Melbourne Victoria Australia 3053
| | - Eishika Dissanayake
- University of Wisconsin School of Medicine and Public Health; Department of Pediatrics; Madison Wisconsin USA
| | - Naoki Shimojo
- Graduate School of Medicine, Chiba University; Department of Pediatrics; 1-8-1 Inohana Chuo-Ku Chiba Japan 260-8670
| | - Kaori Yonezawa
- Graduate School of Medicine, The University of Tokyo; Department of Midwifery and Women's Health; Tokyo Japan
| | - Yukihiro Ohya
- National Center for Child Health and Development; Allergy Center; Tokyo Japan 157-8535
| | | | - Kumiko Morita
- Keio University School of Medicine; Department of Pediatrics; Tokyo Japan
| | - Christian Surber
- University Hospital Zurich; Department of Dermatology; Gloriastrasse 31 Zurich Switzerland 8091
- University Hospital Basel; Department of Dermatology; Petersgraben 4 Basel Switzerland 4031
| | - Michael Cork
- The University of Sheffield; Sheffield Dermatology Research, Department of Infection, Immunity & Cardiovascular Disease; Beech Hill Road Sheffield UK S10 2RX
| | - Alison Cooke
- The University of Manchester; Division of Nursing, Midwifery and Social Work, School of Health Sciences; Room 4.338, Jean McFarlane Building, Oxford Road Manchester UK M13 9PL
| | - Lien Tran
- Imperial College London; Imperial Clinical Trials Unit; 1st Floor, Stadium House 68 Wood Lane London UK W12 7RH
| | - Lisa M Askie
- University of Sydney; NHMRC Clinical Trials Centre; Locked Bag 77 Camperdown NSW Australia 2050
| | - Lelia Duley
- Nottingham Health Science Partners; Nottingham Clinical Trials Unit; C Floor, South Block Queen's Medical Centre Nottingham UK NG7 2UH
| | - Joanne R Chalmers
- University of Nottingham; Centre of Evidence Based Dermatology; King's Meadow Campus Nottingham UK NG7 2NR
| | - Hywel C Williams
- University of Nottingham; Centre of Evidence Based Dermatology; King's Meadow Campus Nottingham UK NG7 2NR
| | - Robert J Boyle
- Imperial College London; Department of Medicine, Section of Paediatrics; St Mary's Campus London UK
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31
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Leshem YA, Chalmers JR, Apfelbacher C, Furue M, Gerbens LAA, Prinsen CAC, Schmitt J, Spuls PI, Thomas KS, Williams HC, Simpson EL. Measuring atopic eczema symptoms in clinical practice: The first consensus statement from the Harmonising Outcome Measures for Eczema in clinical practice initiative. J Am Acad Dermatol 2020; 82:1181-1186. [PMID: 31926221 DOI: 10.1016/j.jaad.2019.12.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 12/19/2019] [Accepted: 12/25/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Measuring patient-centered outcomes in clinical practice is valuable for monitoring patients and advancing real-world research. A new initiative from the Harmonising Outcome Measures for Eczema (HOME) group aims to recommend what might be recorded for atopic eczema patients in routine clinical care. OBJECTIVES Prioritize outcome domains to measure atopic eczema in clinical practice and select valid and practical outcome measurement instruments for the highest-priority domain. METHODS An online survey of HOME members identified and ranked 21 possible health domains. Suitable instruments were then selected for the top-prioritized domain at the HOME VI meeting, using established consensus processes informed by systematic reviews of instrument quality. RESULTS Patient-reported symptoms was the top-prioritized domain. In accordance with psychometric properties and feasibility, there was consensus that the recommended instruments to measure atopic eczema symptoms in clinical practice are the POEM, the PO-SCORAD index, or both. The numeric rating scale for itch received support pending definition and validation in atopic eczema. CONCLUSION Following the first step of the HOME Clinical Practice initiative, we endorse using the POEM, the PO-SCORAD index, or both for measuring atopic eczema symptoms in clinical practice. Additional high-priority domains for clinical practice will be assessed at subsequent HOME meetings.
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Affiliation(s)
- Yael A Leshem
- Divison of Dermatology, Rabin Medical Center, Petach-Tikva, Israel; Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.
| | - Joanne R Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Christian Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany; Institute of Social Medicine and Health Systems Research, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Masutaka Furue
- Department of Dermatology, Kyushu University, Fukuoka, Japan
| | - Louise A A Gerbens
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Cecilia A C Prinsen
- Amsterdam UMC, VU University, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Phyllis I Spuls
- Department of Dermatology, Amsterdam UMC, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health, Infection and Immunity, Amsterdam, the Netherlands
| | - Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
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Jabbar-Lopez ZK, Gurung N, Greenblatt D, Briley A, Chalmers JR, Thomas KS, Frost T, Kezic S, Common JEA, Kong HH, Segre JA, Danby S, Cork MJ, Peacock JL, Flohr C. Protocol for an outcome assessor-blinded pilot randomised controlled trial of an ion-exchange water softener for the prevention of atopic eczema in neonates, with an embedded mechanistic study: the Softened Water for Eczema Prevention (SOFTER) trial. BMJ Open 2019; 9:e027168. [PMID: 31434765 PMCID: PMC6707708 DOI: 10.1136/bmjopen-2018-027168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Atopic eczema affects 20% of UK children, and environmental factors are important in its aetiology. Several observational studies suggest an increased risk of atopic eczema in children living in hard water areas. The Softened Water for Eczema Prevention pilot trial tests the feasibility of installing domestic ion-exchange water softeners around the time of birth to reduce the risk of atopic eczema in children with a family history of atopy. A further aim is to explore the pathophysiological mechanisms for this in an embedded mechanistic study. METHODS AND ANALYSIS Multicentre parallel group assessor-blinded randomised controlled pilot trial. Participants are newborn babies (n=80) living in a hard water (>250 mg/L calcium carbonate) area at risk of developing atopic eczema because of a family history of atopy. Participants will be randomised prior to birth in a 1:1 ratio. The intervention group will have an ion-exchange water softener installed prior to birth. The control group will receive their usual domestic hard water supply. Follow-up will be until 6 months of age. Data will be collected at birth (baseline), 1, 3 and 6 months of age. The main outcome is the proportion of eligible families screened who are willing and able to be randomised. Several secondary feasibility and clinical endpoints will also be evaluated, alongside mechanistic outcomes. Data will be analysed on an intention-to-treat basis. There will be no hypothesis testing for the clinical outcomes. Study acceptability will be evaluated through semistructured interviews. ETHICS AND DISSEMINATION This study has been reviewed and given a favourable opinion by the North West-Liverpool East Research Ethics Committee (Ref: 17/NW/0661). The results of the study will be reported at international conferences and in peer-reviewed scientific journals. We will send participating families a summary of the pilot trial results. TRIAL REGISTRATION NUMBER NCT03270566.
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Affiliation(s)
- Zarif K Jabbar-Lopez
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nikeeta Gurung
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Danielle Greenblatt
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Joanne R Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | - Kim Suzanne Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Sanja Kezic
- Coronel Institute of Occupational Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John E A Common
- Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
| | - Heidi H Kong
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Julie A Segre
- Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Simon Danby
- Sheffield Dermatology Research, Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Michael J Cork
- Sheffield Dermatology Research, Department of Infection, Immunity and Cardiovascular Diseases, University of Sheffield Medical School, Sheffield, UK
| | - Janet L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Carsten Flohr
- Unit for Population-Based Dermatology Research, St John's Institute of Dermatology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
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Chalmers JR, Axon E, Harvey J, Santer M, Ridd MJ, Lawton S, Langan S, Roberts A, Ahmed A, Muller I, Long CM, Panda S, Chernyshov P, Carter B, Williams HC, Thomas KS. Different strategies for using topical corticosteroids in people with eczema. Hippokratia 2019. [DOI: 10.1002/14651858.cd013356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Joanne R Chalmers
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Emma Axon
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Jane Harvey
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Miriam Santer
- University of Southampton; Department of Primary Care and Population Sciences; Aldermoor Health Centre, Aldermoor Close Southampton UK SO16 5ST
| | - Matthew J Ridd
- University of Bristol; 25-27 Belgrave Road Bristol UK BS8 2AA
| | - Sandra Lawton
- Rotherham NHS Foundation Trust; Department of Dermatology; Moorgate Road Rotherham UK S60 2UD
| | - Sinéad Langan
- London School of Hygiene and Tropical Medicine; Keppel Street London UK WC1E 7HT
| | - Amanda Roberts
- Nottingham Support Group for Carers of Children with Eczema; Nottingham UK NG5 4FG
| | - Amina Ahmed
- University of Nottingham; c/o Cochrane Skin Group; King's Meadow Campus Nottingham UK NG7 2NR
| | - Ingrid Muller
- University of Southampton; Department of Primary Care and Population Sciences; Aldermoor Health Centre, Aldermoor Close Southampton UK SO16 5ST
| | - Chiau Ming Long
- School of Medicine, University of Tasmania; Department of Pharmacy; Hobart Australia
| | - Saumya Panda
- KPC Medical College and Hospital; Department of Dermatology; 18D/11, Anupama Housing Complex Phase I Kolkata India 700052
| | - Pavel Chernyshov
- National Medical University; Department of Dermatology and Venereology; Bulvar Shevchenko, 13 Kiev Ukraine 01601
| | - Ben Carter
- King's College London; Institute of Psychiatry, Psychology & Neuroscience; Biostatistics and Health Informatics; Denmark Hill London UK
| | - Hywel C Williams
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
| | - Kim S Thomas
- University of Nottingham; Centre of Evidence Based Dermatology; Room A103, King’s Meadow Campus, Lenton Lane Nottingham UK NG7 2NR
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34
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Ridd MJ, Edwards L, Santer M, Chalmers JR, Waddell L, Marriage D, Muller I, Roberts K, Garfield K, Coast J, Selman L, Clement C, Shaw ARG, Angier E, Blair PS, Turner NL, Taylor J, Kai J, Boyle RJ. TEST (Trial of Eczema allergy Screening Tests): protocol for feasibility randomised controlled trial of allergy tests in children with eczema, including economic scoping and nested qualitative study. BMJ Open 2019; 9:e028428. [PMID: 31076476 PMCID: PMC6527983 DOI: 10.1136/bmjopen-2018-028428] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Early onset eczema is associated with food allergy, and allergic reactions to foods can cause acute exacerbations of eczema. Parents often pursue dietary restrictions as a way of managing eczema and seek allergy testing for their children to guide dietary management. However, it is unclear whether test-guided dietary management improves eczema symptoms, and whether the practice causes harm through reduced use of conventional eczema treatment or unnecessary dietary restrictions. The aim of the Trial of Eczema allergy Screening Tests Study is to determine the feasibility of conducting a trial comparing food allergy testing and dietary advice versus usual care, for the management of eczema in children. METHODS AND ANALYSIS Design: A single centre, two-group, individually randomised, feasibility randomised controlled trial (RCT) with economic scoping and a nested qualitative study. SETTING General Practioner (GP) surgeries in the west of England. PARTICIPANTS children aged over 3 months and less than 5 years with mild to severe eczema. INTERVENTIONS allergy testing (structured allergy history and skin prick tests) or usual care. Sample size and outcome measures: we aim to recruit 80 participants and follow them up using 4-weekly questionnaires for 24 weeks. Nested qualitative study: We will conduct ~20 interviews with parents of participating children, 5-8 interviews with parents who decline or withdraw from the trial and ~10 interviews with participating GPs. Economic scoping: We will gather data on key costs and outcomes to assess the feasibility of carrying out a cost-effectiveness analysis in a future definitive trial. ETHICS AND DISSEMINATION The study has been reviewed by the Health Research Authority and given a favourable opinion by the NHS REC (West Midlands - South Birmingham Research Ethics Committee, Reference Number 18/WM/0124). Findings will be submitted for presentation at conferences and written up for publication in peer-reviewed journals, which may include mixed-method triangulation and integration of the quantitative and qualitative findings. TRIAL REGISTRATION ISRCTN15397185; Pre-results.
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Affiliation(s)
| | - Louisa Edwards
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Joanne R Chalmers
- Centre for Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | | | - Ingrid Muller
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | | | - Kirsty Garfield
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Joanna Coast
- Health Economics at Bristol, University of Bristol, Bristol, UK
| | - Lucy Selman
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Clare Clement
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | | | - Elizabeth Angier
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Peter S Blair
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | | | - Jodi Taylor
- Bristol Randomised Trials Collaboration, University of Bristol, Bristol, UK
| | - Joe Kai
- Division of Primary Care, University of Nottingham, Nottingham, UK
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Howells L, Thomas KS, Sears AV, Nasr I, Wollenberg A, Schuttelaar MLA, Romeijn GLE, Paller AS, Mueller K, Doytcheva K, Kataoka Y, Daguze J, Barbarot S, von Kobyletzki LB, Beckman L, Ratib S, Cowdell F, Santer M, Chalmers JR. Defining and measuring 'eczema control': an international qualitative study to explore the views of those living with and treating atopic eczema. J Eur Acad Dermatol Venereol 2019; 33:1124-1132. [PMID: 30720903 PMCID: PMC6594222 DOI: 10.1111/jdv.15475] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 12/19/2018] [Indexed: 11/30/2022]
Abstract
Background Atopic eczema (also known as eczema) is a chronic, inflammatory skin condition that often afflicts patients’ health and well‐being. The Harmonising Outcome Measures for Eczema (HOME) initiative recommends that ‘long‐term control of eczema’ is measured in all clinical trials 3 months or longer in duration. However, little has been published on what eczema control means to those living with or treating atopic eczema. Objectives To (i) develop understanding of what eczema control means to patients, carers and clinicians and (ii) explore the feasibility and acceptability of different ways of measuring eczema control in the long term. Methods Online focus groups explored patients/carers experiences in the UK, the United States, the Netherlands, France, Sweden and Japan, and an international online survey gathered views of clinicians. The framework method was used to analyse the focus groups, and thematic analysis was used to analyse survey data. All findings were integrated into a theoretical framework to create overarching themes that cut across these diverse groups. Results Eight focus groups with patients (16 years+) and eight groups with carers of children took place (N = 97). Sixty‐two people took part in the survey. Eczema control was described as a multifaceted construct involving changes in disease activity, the treatment and management of the condition and psychological, social and physical functioning. Patient/carer measurement allows personal accounts and frequent measurement, whilst clinician measurement was deemed less subjective. The burden on patients/carers and issues for analysing and interpreting data should be considered. Conclusions This study formed the basis of judging the content validity and feasibility of measurement instruments/methods to assess control of eczema in clinical trials. This online approach to an international qualitative study is an example of how core outcome set developers with limited resources can engage with multiple stakeholder groups on an international basis to inform consensus meeting discussions.
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Affiliation(s)
- L Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - A V Sears
- St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Immunology and Microbial Sciences, King's College London, London, UK
| | | | - A Wollenberg
- Department of Dermatology and Allergy, Ludwig Maximilian University, Munich, Germany.,Klinik Thalkirchner Straße, Munich, Germany
| | - M L A Schuttelaar
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - G L E Romeijn
- Department of Dermatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A S Paller
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Mueller
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - K Doytcheva
- Department of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Y Kataoka
- Department of Dermatology, Osaka Habikino Medical Center, Osaka, Japan
| | - J Daguze
- Department of Dermatology, CHU Nantes, Nantes, France
| | - S Barbarot
- Department of Dermatology, CHU Nantes, Nantes, France
| | | | - L Beckman
- Department of Public Health Science, Karlstad University, Karlstad, Sweden
| | - S Ratib
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - F Cowdell
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - M Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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36
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Prinsen CAC, Spuls PI, Kottner J, Thomas KS, Apfelbacher C, Chalmers JR, Deckert S, Furue M, Gerbens L, Kirkham J, Simpson EL, Alam M, Balzer K, Beeckman D, Eleftheriadou V, Ezzedine K, Horbach SER, Ingram JR, Layton AM, Weller K, Wild T, Wolkerstorfer A, Williams HC, Schmitt J. Navigating the landscape of core outcome set development in dermatology. J Am Acad Dermatol 2019; 81:297-305. [PMID: 30878565 DOI: 10.1016/j.jaad.2019.03.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/30/2019] [Accepted: 03/04/2019] [Indexed: 12/23/2022]
Abstract
The development of core outcome sets (COSs; ie, a minimum set of core outcomes that should be measured and reported in all trials or in clinical practice for a specific condition) in dermatology is increasing in pace. A total of 44 dermatology-related COS projects have been registered in the online Core Outcome Measures in Effectiveness Trials database (http://www.comet-initiative.org/studies/search) and include studies on 26 different skin diseases. With the increasing number of COSs in dermatology, care is needed to ensure the delivery of high-quality COSs that meet quality standards when using state-of-the-art methods. In 2015, the Cochrane Skin-Core Outcome Set Initiative (CS-COUSIN) was established. CS-COUSIN is an international, multidisciplinary working group aiming to improve the development and implementation of COSs in dermatology. CS-COUSIN has developed guidance on how to develop high-quality COSs for skin diseases and supports dermatology-specific COS initiatives. Currently, 17 COS development groups are affiliated with CS-COUSIN and following standardized COS development processes. To ensure successful uptake of COSs in dermatology, researchers, clinicians, systematic reviewers, guideline developers, and other stakeholders should use existing COSs in their work.
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Affiliation(s)
- Cecilia A C Prinsen
- Amsterdam UMC, Department of Epidemiology and Biostatistics, Vrije Universiteit University Medical Center, Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Phyllis I Spuls
- Amsterdam UMC, Department of Dermatology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Kottner
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany; University Centre for Nursing and Midwifery, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Kim S Thomas
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Christian Apfelbacher
- Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - Joanne R Chalmers
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Stefanie Deckert
- Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Masutaka Furue
- Department of Dermatology, Kyushu University, Fukuoka, Japan
| | - Louise Gerbens
- Amsterdam UMC, Department of Dermatology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Jamie Kirkham
- Medical Research Council North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Eric L Simpson
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Murad Alam
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Katrin Balzer
- Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
| | - Dimitri Beeckman
- University Centre for Nursing and Midwifery, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Viktoria Eleftheriadou
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Khaled Ezzedine
- Department of Dermatology and Evaluation of Therapeutics, EA7379, Paris-Est University, University Paris Est Créteil, University Hospital Departments Viruses, Immunity, and Cancer, Créteil, France
| | - Sophie E R Horbach
- Amsterdam UMC, Department of Plastic, Reconstructive, and Hand Surgery, University of Amsterdam, Amsterdam, the Netherlands
| | - John R Ingram
- Division of Infection and Immunity, University Hospital of Wales, Cardiff University, Cardiff, United Kingdom
| | - Alison M Layton
- Hull York Medical School, University of York, York, United Kingdom; Harrogate and District National Health Service Foundation Trust, Harrogate, United Kingdom
| | - Karsten Weller
- Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Wild
- Department of Plastic, Aesthetic, and Hand Surgery, Interdisciplinary Center for Treatment of Chronic Wounds, Dessau Medical Center, Dessau, Germany; Department of Dermatology, Venereology, Allergology, and Immunology, Dessau Medical Center, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany; Institut of Applied Bio-Sciences and Process Management, University of Applied Science Anhalt, Koethen, Germany
| | - Albert Wolkerstorfer
- Amsterdam UMC, Department of Dermatology, Amsterdam Public Health Research Institute, University of Amsterdam, Amsterdam, the Netherlands
| | - Hywel C Williams
- Centre of Evidence-Based Dermatology, University of Nottingham, Nottingham, United Kingdom
| | - Jochen Schmitt
- Center for Evidence-Based Healthcare, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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Al-Naqeeb J, Danner S, Fagnan LJ, Ramsey K, Michaels L, Mitchell J, Branca K, Morris C, Nease DE, Zittleman L, Levy B, Daly J, Hahn D, Dolor RJ, Williams HC, Chalmers JR, Hanifin J, Tofte S, Zuckerman KE, Hansis K, Gundersen M, Block J, Karr F, Dunbrasky S, Siebe K, Dillon K, Cibotti R, Lapidus J, Simpson EL. The Burden of Childhood Atopic Dermatitis in the Primary Care Setting: A Report from the Meta-LARC Consortium. J Am Board Fam Med 2019; 32:191-200. [PMID: 30850455 DOI: 10.3122/jabfm.2019.02.180225] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/14/2018] [Accepted: 11/20/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Little is known about the burden of atopic dermatitis (AD) encountered in US primary care practices and the frequency and type of skin care practices routinely used in children. OBJECTIVE To estimate the prevalence of AD in children 0 to 5 years attending primary care practices in the United States and to describe routine skin care practices used in this population. DESIGN A cross-sectional survey study of a convenience sample of children under the age of 5 attending primary care practices for any reason. SETTING Ten primary care practices in 5 US states. RESULTS Among 652 children attending primary care practices, the estimated prevalence of ever having AD was 24% (95% CI, 21-28) ranging from 15% among those under the age of 1 to 38% among those aged 4 to 5 years. The prevalence of comorbid asthma was higher among AD participants compared to those with no AD, namely, 12% and 4%, respectively (P < .001). Moisturizers with high water:oil ratios were most commonly used (ie, lotions) in the non-AD population, whereas moisturizers with low water:oil content (ie, ointments) were most common when AD was present. CONCLUSIONS Our study found a large burden of AD in the primary care practice setting in the US. The majority of households reported skin care practices that may be detrimental to the skin barrier, such as frequent bathing and the routine use of moisturizers with high water: oil ratios. Clinical trials are needed to identify which skin care practices are optimal for reducing the significant burden of AD in the community.
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Affiliation(s)
- Jinan Al-Naqeeb
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Sankirtana Danner
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Lyle J Fagnan
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Katrina Ramsey
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - LeAnn Michaels
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Julie Mitchell
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Kelsey Branca
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Cynthia Morris
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Donald E Nease
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Linda Zittleman
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Barcey Levy
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Jeanette Daly
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - David Hahn
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Rowena J Dolor
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Hywel C Williams
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Joanne R Chalmers
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Jon Hanifin
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Susan Tofte
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Katharine E Zuckerman
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Karen Hansis
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Mollie Gundersen
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Julie Block
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Francie Karr
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Sandra Dunbrasky
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Kathy Siebe
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Kristen Dillon
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Ricardo Cibotti
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Jodi Lapidus
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC)
| | - Eric L Simpson
- From Department of Dermatology, Oregon Health and Science University, Portland (JA, JH, ST, ELS); Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland (SD, LJF, LM, KB, KD); Public Health and Preventive Medicine, Oregon Health and Science University, Portland (KR, KEZ, JL); Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland (JM, CM); High Plains Research Network, University of Colorado, Denver (DEN, LZ); Iowa Research Network, University of Iowa, Iowa City (BL, JD); Wisconsin Research and Education Network, University of Wisconsin, Madison (DH); Primary Care Research Consortium, Duke University, Durham, North Carolina (RD); Centre of Evidence-Based Dermatology, University of Nottingham, England (HCW, JRC); Division of General Pediatrics, Oregon Health and Science University, Portland (KEZ); Patient Advocate (KH, MG); National Eczema Association, San Rafael, CA (JB); Mid-Columbia Medical Center, The Dalles, OR (FK); Treasure Valley Pediatric Clinic, Ontario (SD); Winding Waters Clinic, Enterprise (KS); National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institute of Health, Bethesda, MD (RC).
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Chalmers JR, Danby S. Towards a better understanding of outcome measurement instruments for atopic eczema. Br J Dermatol 2018; 179:246-247. [PMID: 30141558 DOI: 10.1111/bjd.16827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- J R Chalmers
- Centre of Evidence-based Dermatology, University of Nottingham, Nottingham, U.K
| | - S Danby
- Academic Unit of Dermatology, the University of Sheffield, Sheffield, U.K
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Chalmers JR, Thomas KS, Apfelbacher C, Williams HC, Prinsen CA, Spuls PI, Simpson E, Gerbens LAA, Boers M, Barbarot S, Stalder JF, Abuabara K, Aoki V, Ardeleanu M, Armstrong J, Bang B, Berents TL, Burton T, Butler L, Chubachi T, Cresswell-Melville A, DeLozier A, Eckert L, Eichenfield L, Flohr C, Futamura M, Gadkari A, Gjerde ES, van Halewijn KF, Hawkes C, Howells L, Howie L, Humphreys R, Ishii HA, Kataoka Y, Katayama I, Kouwenhoven W, Langan SM, Leshem YA, Merhand S, Mina-Osorio P, Murota H, Nakahara T, Nunes FP, Nygaard U, Nygårdas M, Ohya Y, Ono E, Rehbinder E, Rogers NK, Romeijn GLE, Schuttelaar MLA, Sears AV, Simpson MA, Singh JA, Srour J, Stuart B, Svensson Å, Talmo G, Talmo H, Teixeira HD, Thyssen JP, Todd G, Torchet F, Volke A, von Kobyletzki L, Weisshaar E, Wollenberg A, Zaniboni M. Report from the fifth international consensus meeting to harmonize core outcome measures for atopic eczema/dermatitis clinical trials (HOME initiative). Br J Dermatol 2018; 178:e332-e341. [PMID: 29672835 DOI: 10.1111/bjd.16543] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2018] [Indexed: 12/11/2022]
Abstract
This is the report from the fifth meeting of the Harmonising Outcome Measures for Eczema initiative (HOME V). The meeting was held on 12-14 June 2017 in Nantes, France, with 81 participants. The main aims of the meeting were (i) to achieve consensus over the definition of the core domain of long-term control and how to measure it and (ii) to prioritize future areas of research for the measurement of the core domain of quality of life (QoL) in children. Moderated whole-group and small-group consensus discussions were informed by presentations of qualitative studies, systematic reviews and validation studies. Small-group allocations were performed a priori to ensure that each group included different stakeholders from a variety of geographical regions. Anonymous whole-group voting was carried out using handheld electronic voting pads according to predefined consensus rules. It was agreed by consensus that the long-term control domain should include signs, symptoms, quality of life and a patient global instrument. The group agreed that itch intensity should be measured when assessing long-term control of eczema in addition to the frequency of itch captured by the symptoms domain. There was no recommendation of an instrument for the core outcome domain of quality of life in children, but existing instruments were assessed for face validity and feasibility, and future work that will facilitate the recommendation of an instrument was agreed upon.
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Affiliation(s)
- J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - C Apfelbacher
- Medical Sociology, Institute of Epidemiology and Preventive Medicine, University of Regensburg, Regensburg, Germany
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - C A Prinsen
- Department of Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands
| | - P I Spuls
- Department of Dermatology, Academic Medical Center, Amsterdam, the Netherlands
| | - E Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, U.S.A
| | - L A A Gerbens
- Department of Dermatology, Academic Medical Center, Amsterdam, the Netherlands
| | - M Boers
- VU University Medical Center, Amsterdam, the Netherlands
| | - S Barbarot
- Department of Dermatology, Nantes University Hospital (CHU de Nantes), France
| | - J F Stalder
- Department of Dermatology, Nantes University Hospital (CHU de Nantes), France
| | - K Abuabara
- Department of Dermatology, University of California San Francisco, San Francisco, CA, U.S.A
| | - V Aoki
- University of São Paulo Medical School, São Paulo, Brazil
| | - M Ardeleanu
- Regeneron Pharmaceuticals, Tarrytown, NY, U.S.A
| | | | - B Bang
- LEO Pharma, Ballerup, Denmark
| | | | | | - L Butler
- National Eczema Association, San Rafael, CA, U.S.A
| | - T Chubachi
- GlaxoSmithKline, Research Triangle Park, NC, U.S.A
| | | | - A DeLozier
- Eli Lilly and Company, Indianapolis, IN, U.S.A
| | | | - L Eichenfield
- Rady Children's Hospital, University of California San Francisco, San Diego, CA, U.S.A
| | - C Flohr
- St John's Institute of Dermatology, St Thomas' Hospital, London, U.K
| | | | - A Gadkari
- Regeneron Pharmaceuticals, Tarrytown, NY, U.S.A
| | - E S Gjerde
- The Psoriasis and Eczema Association of Norway, Oslo, Norway
| | - K F van Halewijn
- Erasmus MC, University Medical Centre, Rotterdam, the Netherlands
| | | | - L Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - L Howie
- Global Parents for Eczema Research, Brisbane, Australia
| | | | - H A Ishii
- Brazilian Atopic Dermatitis Association (AADA), São Paulo, Brazil
| | - Y Kataoka
- Osaka Prefectural Medical Center for Respiratory and Allergic Disease, Osaka, Japan
| | | | - W Kouwenhoven
- Dutch Association for People with Atopic Dermatitis, Nijkerk, the Netherlands
| | - S M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, U.K
| | - Y A Leshem
- Beilinson Hospital and Tel Aviv University, Petah Tikva and Tel Aviv, Israel
| | - S Merhand
- Association Française de l'Eczéma, Redon, France
| | | | - H Murota
- Department of Dermatology, Osaka University, Suita, Japan
| | - T Nakahara
- Department of Dermatology, Kyushu University, Fukuoka, Japan
| | - F P Nunes
- Eli Lilly and Company, Indianapolis, IN, U.S.A
| | - U Nygaard
- Eli Lilly and Company, Indianapolis, IN, U.S.A
| | | | - Y Ohya
- National Centre for Child Health and Development, Tokyo, Japan
| | - E Ono
- Osaka University, Osaka, Japan
| | - E Rehbinder
- Department of Dermatology, Oslo University Hospital, Oslo, Norway
| | - N K Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - G L E Romeijn
- Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - M L A Schuttelaar
- Department of Dermatology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - A V Sears
- St John's Institute of Dermatology, St Thomas' Hospital, London, U.K
| | | | - J A Singh
- Department of Medicine, University of Alabama at Birmingham and Birmingham Veterans Affairs Medical Center, Birmingham, AL, U.S.A
| | - J Srour
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU - München, Munich, Germany
| | - B Stuart
- Primary Care and Population Sciences Division, University of Southampton, Southampton, U.K
| | - Å Svensson
- Department of Dermatology and Venereology, Lund University, Malmö, Sweden
| | - G Talmo
- The Psoriasis and Eczema Association of Norway, Haugesund, Norway
| | - H Talmo
- The Psoriasis and Eczema Association of Norway, Haugesund, Norway
| | | | - J P Thyssen
- Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Hellerup, Denmark
| | - G Todd
- University of Cape Town, Cape Town, South Africa
| | - F Torchet
- Association Française de l'Eczéma, Redon, France
| | - A Volke
- Department of Dermatology, University of Tartu, Tartu, Estonia
| | - L von Kobyletzki
- Department of Dermatology, Lund University, Skåne University Hospital, Malmö, Sweden.,Department of Public Health Sciences, Karlstad University, Karlstad, Sweden.,CF Wahlgren, Dermatology Unit, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden.,Department of Dermatology, Venereology and Allergy University Hospital Schleswig-Holstein, Kiel, Germany
| | - E Weisshaar
- Department of Social Medicine, Occupational and Environmental Dermatology, Ruprecht Karls University, Heidelberg, Germany
| | | | - M Zaniboni
- University of São Paulo, Campinas, Brazil
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Howells L, Ratib S, Chalmers JR, Bradshaw L, Thomas KS. How should minimally important change scores for the Patient-Oriented Eczema Measure be interpreted? A validation using varied methods. Br J Dermatol 2018; 178:1135-1142. [PMID: 29355894 PMCID: PMC6001667 DOI: 10.1111/bjd.16367] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/28/2022]
Abstract
Background The Patient‐Oriented Eczema Measure (POEM), scored 0–28, is the core outcome instrument recommended for measuring patient‐reported atopic eczema symptoms in clinical trials. To date, two published studies have broadly concurred that the minimally important change (MIC) of the POEM is three points. Further assessment of the MIC of POEM in different populations, and using a variety of methods, will improve interpretability of the POEM in research and clinical practice. Objectives To calculate the smallest detectable change in the POEM and estimate the MIC of the POEM using a variety of methods in a trial dataset of children with moderate‐to‐severe atopic eczema. Methods This study used distribution‐based and anchor‐based methods to calculate the MIC of the POEM in children with moderate‐to‐severe eczema. Results Data were collected from 300 children. The smallest detectable change was 2·13. The MIC estimates were 1·07 (using 0·2 SD of baseline POEM scores) and 2·68 (using 0·5 SD of baseline POEM scores) based on distribution‐based methods; were 3·09–6·13 based on patient‐/parent‐reported anchor‐based methods; and were 3·23–5·38 based on investigator‐reported anchor‐based methods. Conclusions We recommend the following thresholds be used to interpret changes in POEM scores: ≤ 2, unlikely to be a change beyond measurement error; 2·1–2·9, a small change detected that is likely to be beyond measurement error but may not be clinically important; 3–3·9, probably a clinically important change; ≥ 4, very likely to be a clinically important change. What's already known about this topic? The Patient‐Oriented Eczema Measure (POEM) is recommended as the core outcome instrument for measuring patient‐reported symptoms in eczema clinical trials. Two previous studies have examined the minimally important change (MIC) of the POEM; one in children with mild eczema and another in adults with very severe eczema. These previous studies both concluded that the MIC in POEM is around three points.
What does this study add? This study explored the impact of different methodologies for calculating the MIC of the POEM in children with moderate‐to‐severe eczema. A change in POEM of less than two points is likely to be below the smallest detectable change (i.e. below measurement error) for the scale. The MIC varied considerably depending on the method used, but a change in POEM score below three points is unlikely to be a clinically important change.
What are the clinical implications of this work? This study aids sample size calculations for clinical trials and helps researchers, clinicians and patients to interpret changes in POEM scores in clinical trials and routine monitoring of eczema in clinical practice.
https://doi.org/10.1111/bjd.16611 available online https://goo.gl/Uqv3dl
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Affiliation(s)
- L Howells
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, U.K
| | - S Ratib
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, U.K
| | - J R Chalmers
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, U.K
| | - L Bradshaw
- Nottingham Clinical Trials Unit, School of Medicine, University of Nottingham, Nottingham, U.K
| | - K S Thomas
- Centre of Evidence Based Dermatology, School of Medicine, University of Nottingham, Nottingham, U.K
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Haines RH, Thomas KS, Montgomery AA, Ravenscroft JC, Akram P, Chalmers JR, Whitham D, Duley L, Eleftheriadou V, Meakin G, Mitchell EJ, White J, Rogers A, Sach T, Santer M, Tan W, Hepburn T, Williams HC, Batchelor J. Home interventions and light therapy for the treatment of vitiligo (HI-Light Vitiligo Trial): study protocol for a randomised controlled trial. BMJ Open 2018; 8:e018649. [PMID: 29615444 PMCID: PMC5893933 DOI: 10.1136/bmjopen-2017-018649] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Vitiligo is a condition resulting in white patches on the skin. People with vitiligo can suffer from low self-esteem, psychological disturbance and diminished quality of life. Vitiligo is often poorly managed, partly due to lack of high-quality evidence to inform clinical care. We describe here a large, independent, randomised controlled trial (RCT) assessing the comparative effectiveness of potent topical corticosteroid, home-based hand-held narrowband ultraviolet B-light (NB-UVB) or combination of the two, for the management of vitiligo. METHODS AND ANALYSIS The HI-Light Vitiligo Trial is a multicentre, three-arm, parallel group, pragmatic, placebo-controlled RCT. 516 adults and children with actively spreading, but limited, vitiligo are randomised (1:1:1) to one of three groups: mometasone furoate 0.1% ointment plus dummy NB-UVB light, vehicle ointment plus NB-UVB light or mometasone furoate 0.1% ointment plus NB-UVB light. Treatment of up to three patches of vitiligo is continued for up to 9 months with clinic visits at baseline, 3, 6 and 9 months and four post-treatment questionnaires.The HI-Light Vitiligo Trial assesses outcomes included in the vitiligo core outcome set and places emphasis on participants' views of treatment success. The primary outcome is proportion of participants achieving treatment success (patient-rated Vitiligo Noticeability Scale) for a target patch of vitiligo at 9 months with further independent blinded assessment using digital images of the target lesion before and after treatment. Secondary outcomes include time to onset of treatment response, treatment success by body region, percentage repigmentation, quality of life, time-burden of treatment, maintenance of response, safety and within-trial cost-effectiveness. ETHICS AND DISSEMINATION Approvals were granted by East Midlands-Derby Research Ethics Committee (14/EM/1173) and the MHRA (EudraCT 2014-003473-42). The trial was registered 8 January 2015 ISRCTN (17160087). Results will be published in full as open access in the NIHR Journal library and elsewhere. TRIAL REGISTRATION NUMBER ISRCTN17160087.
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Affiliation(s)
- Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Jane C Ravenscroft
- Department of Paediatric Dermatology, Nottingham Children's Hospital, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Perways Akram
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | | | - Garry Meakin
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Jennifer White
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Andy Rogers
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tracey Sach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Wei Tan
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Trish Hepburn
- Nottingham Clinical Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jonathan Batchelor
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Mason JM, Chalmers JR, Godec T, Nunn AJ, Kirtschig G, Wojnarowska F, Childs M, Whitham D, Schmidt E, Harman K, Walton S, Chapman A, Williams HC. Doxycycline compared with prednisolone therapy for patients with bullous pemphigoid: cost-effectiveness analysis of the BLISTER trial. Br J Dermatol 2018; 178:415-423. [PMID: 28940316 DOI: 10.1111/bjd.16006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder associated with significant morbidity and mortality. Doxycycline and prednisolone to treat bullous pemphigoid were compared within a randomized controlled trial (RCT). OBJECTIVES To compare the cost-effectiveness of doxycycline-initiated and prednisolone-initiated treatment for patients with BP. METHODS Quality-of-life (EuroQoL-5D-3L) and resource data were collected as part of the BLISTER trial: a multicentre, parallel-group, investigator-blinded RCT. Within-trial analysis was performed using bivariate regression of costs and quality-adjusted life-years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost-effectiveness from a health service perspective. RESULTS In the base case, there was no robust difference in costs or QALYs per patient at 1 year comparing doxycycline- with prednisolone-initiated therapy [net cost £959, 95% confidence interval (CI) -£24 to £1941; net QALYs -0·024, 95% CI -0·088 to 0·041]. However, the findings varied by baseline blister severity. For patients with mild or moderate blistering (≤ 30 blisters) net costs and outcomes were similar. For patients with severe blistering (> 30 blisters) net costs were higher (£2558, 95% CI -£82 to £5198) and quality of life poorer (-0·090 QALYs, 95% CI -0·22 to 0·042) for patients starting on doxycycline. The probability that doxycycline would be cost-effective for those with severe pemphigoid was 1·5% at a willingness to pay of £20 000 per QALY. CONCLUSIONS Consistently with the clinical findings of the BLISTER trial, patients with mild or moderate blistering should receive treatment guided by the safety and effectiveness of the drugs and patient preference - neither strategy is clearly a preferred use of National Health Service resources. However, prednisolone-initiated treatment may be more cost-effective for patients with severe blistering.
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Affiliation(s)
- J M Mason
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, U.K
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - T Godec
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - A J Nunn
- MRC Clinical Trials Unit at UCL, Aviation House, 125 Kingsway, London, WC2B 6NH, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, U.K
| | - M Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, QMC, Nottingham, NG7 2UH, U.K
| | - E Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - K Harman
- Dermatology Department, Leicester Royal Infirmary, University Hospitals Leicester, Leicester, LE1 5WW, U.K
| | - S Walton
- Castle Hill Hospital, Castle Road, Cottingham, Hull, HU16 5JQ, U.K
| | - A Chapman
- Queen Elizabeth Hospital, Greenwich, London, SE18 4QH, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, NG7 2NR, U.K
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Howells LM, Chalmers JR, Cowdell F, Ratib S, Santer M, Thomas KS. 'When it goes back to my normal I suppose': a qualitative study using online focus groups to explore perceptions of 'control' among people with eczema and parents of children with eczema in the UK. BMJ Open 2017; 7:e017731. [PMID: 29146642 PMCID: PMC5695402 DOI: 10.1136/bmjopen-2017-017731] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To inform the development of a core outcome set for eczema by engaging with people with eczema and parents of children with eczema to understand their experiences and understanding of the concept 'eczema control'. DESIGN 37 participants took part in a total of six semi-structured online focus groups held in a typed chatroom with 5-7 participants per group. Three groups involved adults with eczema and three groups involved parents of children with eczema. Framework analysis was used for data analysis. SETTING A community-based sample was recruited from across the UK via social media and email. PARTICIPANTS 19 adults aged 17-61 years (15/19 female, 16/19 white) and 18 parents of children with eczema aged 9 months-17 years (9/18 female, 18/19 white). RESULTS Four main themes were identified:(1) 'Commonalities and differences in the experiences of control': a reduction in symptoms such as itch and sleep loss characterised eczema control, but what level was acceptable differed across participants;(2) 'Eczema control goes beyond the skin': psychological factors, social factors, the constant scratching and the impact on everyday activities are a variety of ways an individual can be impacted;(3) 'Stepping up and down of treatment': participants' stepped-up treatment in response to loss of control, but several factors complicated this behaviour. Control needed to be maintained after stepped-up treatment ended to be acceptable; and (4) 'How to measure control': self-report was generally preferred to allow frequent measurements and to capture unobservable features. Although most thought their eczema needed to be measured frequently, many also felt that this was not always realistic or desirable. CONCLUSIONS 'Eczema control' is a complex experience for people with eczema and parents of children with the condition. These experiences could have important implications on how long-term control should be measured in eczema clinical trials and clinical practice.
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Affiliation(s)
- Laura M Howells
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Fiona Cowdell
- Faculty of Health Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - Sonia Ratib
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Chalmers JR, Wojnarowska F, Kirtschig G, Mason J, Childs M, Whitham D, Harman K, Chapman A, Walton S, Schmidt E, Godec TR, Nunn AJ, Williams HC. A randomised controlled trial to compare the safety, effectiveness and cost-effectiveness of doxycycline (200 mg/day) with that of oral prednisolone (0.5 mg/kg/day) for initial treatment of bullous pemphigoid: the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) trial. Health Technol Assess 2017; 21:1-90. [PMID: 28406394 DOI: 10.3310/hta21100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bullous pemphigoid (BP) is an autoimmune blistering skin disorder with increased morbidity and mortality in the elderly. OBJECTIVES To evaluate the effectiveness, safety and cost-effectiveness of a strategy of initiating BP treatment with oral doxycycline or oral prednisolone. We hypothesised that starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral prednisolone. DESIGN Pragmatic multicentre two-armed parallel-group randomised controlled trial with an economic evaluation. SETTING A total of 54 dermatology secondary care centres in the UK and seven in Germany. PARTICIPANTS Adults with BP [three or more blisters at two sites and positive direct and/or indirect immunofluorescence (immunoglobulin G and/or complement component 3 immunofluorescence at the dermal-epidermal junction)] and able to give informed consent. INTERVENTIONS Participants were allocated using online randomisation to initial doxycycline treatment (200 mg/day) or prednisolone (0.5 mg/kg/day). Up to 30 g/week of potent topical corticosteroids was permitted for weeks 1-3. After 6 weeks, clinicians could switch treatments or alter the prednisolone dose as per normal practice. MAIN OUTCOME MEASURES Primary outcomes: (1) the proportion of participants with three or fewer blisters at 6 weeks (investigator blinded) and (2) the proportion with severe, life-threatening and fatal treatment-related events at 52 weeks. A regression model was used in the analysis adjusting for baseline disease severity, age and Karnofsky score, with missing data imputed. Secondary outcomes included the effectiveness of blister control after 6 weeks, relapses, related adverse events and quality of life. The economic evaluation involved bivariate regression of costs and quality-adjusted life-years (QALYs) from a NHS perspective. RESULTS In total, 132 patients were randomised to doxycycline and 121 to prednisolone. The mean patient age was 77.7 years and baseline severity was as follows: mild 31.6% (three to nine blisters), moderate 39.1% (10-30 blisters) and severe 29.3% (> 30 blisters). For those starting on doxycycline, 83 out of 112 (74.1%) had three or fewer blisters at 6 weeks, whereas for those starting on prednisolone 92 out of 101 (91.1%) had three or fewer blisters at 6 weeks, an adjusted difference of 18.6% in favour of prednisolone [90% confidence interval (CI) 11.1% to 26.1%], using a modified intention-to-treat (mITT) analysis. Per-protocol analysis showed similar results: 74.4% compared with 92.3%, an adjusted difference of 18.7% (90% CI 9.8% to 27.6%). The rate of related severe, life-threatening and fatal events at 52 weeks was 18.2% for those started on doxycycline and 36.6% for those started on prednisolone (mITT analysis), an adjusted difference of 19.0% (95% CI 7.9% to 30.1%; p = 0.001) in favour of doxycycline. Secondary outcomes showed consistent findings. There was no significant difference in costs or QALYs per patient at 1 year between doxycycline-initiated therapy and prednisolone-initiated therapy (incremental cost of doxycycline-initiated therapy £959, 95% CI -£24 to £1941; incremental QALYs of doxycycline-initiated therapy -0.024, 95% CI -0.088 to 0.041). Using a willingness-to-pay criterion of < £20,000 per QALY gained, the net monetary benefit associated with doxycycline-initiated therapy was negative but imprecise (-£1432, 95% CI -£3094 to £230). CONCLUSIONS A strategy of starting BP patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control and considerably safer in the long term. The limitations of the trial were the wide non-inferiority margin, the moderate dropout rate and that serious adverse event collection was unblinded. Future work might include inducing remission with topical or oral corticosteroids and then randomising to doxycycline or prednisolone for maintenance. TRIAL REGISTRATION Current Controlled Trials ISRCTN13704604. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - James Mason
- Durham University, School of Medicine, Pharmacy and Health, Stockton-on-Tees, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Karen Harman
- University Hospitals Leicester, Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | | | | | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Williams HC, Chalmers JR, Nunn AJ, Kirtschig G, Schmidt E. The BLISTER study: possible overestimation of tetracycline efficacy - Authors' reply. Lancet 2017; 390:735-736. [PMID: 28831990 DOI: 10.1016/s0140-6736(17)31790-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 06/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK.
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Gudula Kirtschig
- Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany; Centre of Evidence Based Dermatology, University of Nottingham, Nottingham NG7 2NR, UK
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
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Chalmers JR, Haines RH, Mitchell EJ, Thomas KS, Brown SJ, Ridd M, Lawton S, Simpson EL, Cork MJ, Sach TH, Bradshaw LE, Montgomery AA, Boyle RJ, Williams HC. Effectiveness and cost-effectiveness of daily all-over-body application of emollient during the first year of life for preventing atopic eczema in high-risk children (The BEEP trial): protocol for a randomised controlled trial. Trials 2017; 18:343. [PMID: 28732519 PMCID: PMC5521124 DOI: 10.1186/s13063-017-2031-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 05/29/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Atopic eczema (AE) is a common skin problem that impairs quality of life and is associated with the development of other atopic diseases including asthma, food allergy and allergic rhinitis. AE treatment is a significant cost burden for health care providers. The purpose of the trial is to investigate whether daily application of emollients for the first year of life can prevent AE developing in high-risk infants (first-degree relative with asthma, AE or allergic rhinitis). METHODS This is a protocol for a pragmatic, two-arm, randomised controlled, multicentre trial. Up to 1400 term infants at high risk of developing AE will be recruited through the community, primary and secondary care in England. Participating families will be randomised in a 1:1 ratio to receive general infant skin-care advice, or general skin-care advice plus emollients with advice to apply daily to the infant for the first year of life. Families will not be blinded to treatment allocation. The primary outcome will be a blinded assessment of AE at 24 months of age using the UK Working Party Diagnostic Criteria for Atopic Eczema. Secondary outcomes are other definitions of AE, time to AE onset, severity of AE (EASI and POEM), presence of other allergic diseases including food allergy, asthma and hay fever, allergic sensitisation, quality of life, cost-effectiveness and safety of the emollients. Subgroup analyses are planned for the primary outcome according to filaggrin genotype and the number of first-degree relatives with AE and other atopic diseases. Families will be followed up by online and postal questionnaire at 3, 6, 12 and 18 months with a face-to-face visit at 24 months. Long-term follow-up until 60 months will be via annual questionnaires. DISCUSSION This trial will demonstrate whether skin-barrier enhancement through daily emollient for the first year of life can prevent AE from developing in high-risk infants. If effective, this simple and cheap intervention has the potential to result in significant cost savings for health care providers throughout the world by preventing AE and possibly other associated allergic diseases. TRIAL REGISTRATION ISRCTN registry; ID: ISRCTN21528841 . Registered on 25 July 2014.
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Affiliation(s)
- Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
| | - Rachel H Haines
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sara J Brown
- Skin Research Group, School of Medicine, University of Dundee, Dundee, UK.,Department of Dermatology, Ninewells Hospital and Medical School, Dundee, UK
| | - Matthew Ridd
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sandra Lawton
- The Rotherham NHS Foundation Trust, Moorgate Road, Rotherham, UK
| | - Eric L Simpson
- Department of Dermatology, Oregon Health and Science University, Portland, OR, USA
| | | | - Tracey H Sach
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK
| | - Lucy E Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Robert J Boyle
- Section of Paediatrics, Imperial College London, Wright Fleming Building, London, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Williams HC, Wojnarowska F, Kirtschig G, Mason J, Godec TR, Schmidt E, Chalmers JR, Childs M, Walton S, Harman K, Chapman A, Whitham D, Nunn AJ. Doxycycline versus prednisolone as an initial treatment strategy for bullous pemphigoid: a pragmatic, non-inferiority, randomised controlled trial. Lancet 2017; 389:1630-1638. [PMID: 28279484 PMCID: PMC5400809 DOI: 10.1016/s0140-6736(17)30560-3] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 11/07/2016] [Accepted: 11/22/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Bullous pemphigoid is a blistering skin disorder with increased mortality. We tested whether a strategy of starting treatment with doxycycline gives acceptable short-term blister control while conferring long-term safety advantages over starting treatment with oral corticosteroids. METHODS We did a pragmatic, multicentre, parallel-group randomised controlled trial of adults with bullous pemphigoid (three or more blisters at two or more sites and linear basement membrane IgG or C3). Participants were randomly assigned to doxycycline (200 mg per day) or prednisolone (0·5 mg/kg per day) using random permuted blocks of randomly varying size, and stratified by baseline severity (3-9, 10-30, and >30 blisters for mild, moderate, and severe disease, respectively). Localised adjuvant potent topical corticosteroids (<30 g per week) were permitted during weeks 1-3. The non-inferiority primary effectiveness outcome was the proportion of participants with three or fewer blisters at 6 weeks. We assumed that doxycycline would be 25% less effective than corticosteroids with a 37% acceptable margin of non-inferiority. The primary safety outcome was the proportion with severe, life-threatening, or fatal (grade 3-5) treatment-related adverse events by 52 weeks. Analysis (modified intention to treat [mITT] for the superiority safety analysis and mITT and per protocol for non-inferiority effectiveness analysis) used a regression model adjusting for baseline disease severity, age, and Karnofsky score, with missing data imputed. The trial is registered at ISRCTN, number ISRCTN13704604. FINDINGS Between March 1, 2009, and Oct 31, 2013, 132 patients were randomly assigned to doxycycline and 121 to prednisolone from 54 UK and seven German dermatology centres. Mean age was 77·7 years (SD 9·7) and 173 (68%) of 253 patients had moderate-to-severe baseline disease. For those starting doxycycline, 83 (74%) of 112 patients had three or fewer blisters at 6 weeks compared with 92 (91%) of 101 patients on prednisolone, an adjusted difference of 18·6% (90% CI 11·1-26·1) favouring prednisolone (upper limit of 90% CI, 26·1%, within the predefined 37% margin). Related severe, life-threatening, and fatal events at 52 weeks were 18% (22 of 121) for those starting doxycycline and 36% (41 of 113) for prednisolone (mITT), an adjusted difference of 19·0% (95% CI 7·9-30·1), p=0·001. INTERPRETATION Starting patients on doxycycline is non-inferior to standard treatment with oral prednisolone for short-term blister control in bullous pemphigoid and significantly safer in the long-term. FUNDING NIHR Health Technology Assessment Programme.
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Affiliation(s)
- Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK.
| | | | - Gudula Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK; Institute of General Medicine and Interprofessional Care, University of Tübingen, Tübingen, Germany
| | - James Mason
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Thomas R Godec
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
| | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Margaret Childs
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | | | - Karen Harman
- Dermatology Department, Leicester Royal Infirmary, Leicester, UK
| | - Anna Chapman
- Dermatology Department, Queen Elizabeth Hospital, Greenwich, London, UK
| | - Diane Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Nottingham, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, UK
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von Kobyletzki LB, Thomas KS, Schmitt J, Chalmers JR, Deckert S, Aoki V, Weisshaar E, Ojo JA, Svensson Å. What Factors are Important to Patients when Assessing Treatment Response: An International Cross-sectional Survey. Acta Derm Venereol 2017; 97:86-90. [PMID: 27305646 DOI: 10.2340/00015555-2480] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study investigated the perspective of international patients on individual symptoms of atopic dermatitis (eczema) in determining treatment response. A questionnaire was developed to evaluate the importance of symptoms from the patient's perspective. Patients were asked: "How important are these features in deciding whether or not a treatment is working?", and rated symptoms on a 5-point Likert scale. Patients were approached via Harmonising Outcome Measures for Eczema (HOME) collaborators and self-selected to take part in the on-line survey. Patients from 34 countries (n = 1,111) completed the survey; of these, 423 (38.3%) were parents of children with eczema. Nine items were rated as being "quite important" or "very important" by more than 80% of the respondents: itch, pain/soreness, skin feels hot or inflamed, bleeding, involvement of visible or sensitive body sites, cracks, sleep difficulties, amount of body affected, and weeping/oozing. These results may be of use in determining the face validity of scales from a cross-cultural patients' perspective.
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Affiliation(s)
- Laura B von Kobyletzki
- Department of Dermatology, Lund University, Skåne University Hospital, SE-205 02 Malmö, Sweden.
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Thomas KS, Batchelor JM, Bath-Hextall F, Chalmers JR, Clarke T, Crowe S, Delamere FM, Eleftheriadou V, Evans N, Firkins L, Greenlaw N, Lansbury L, Lawton S, Layfield C, Leonardi-Bee J, Mason J, Mitchell E, Nankervis H, Norrie J, Nunn A, Ormerod AD, Patel R, Perkins W, Ravenscroft JC, Schmitt J, Simpson E, Whitton ME, Williams HC. A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease. Programme Grants Appl Res 2016. [DOI: 10.3310/pgfar04180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BackgroundSkin diseases are very common and can have a large impact on the quality of life of patients and caregivers. This programme addressed four diseases: (1) eczema, (2) vitiligo, (3) squamous cell skin cancer (SCC) and (4) pyoderma gangrenosum (PG).ObjectiveTo set priorities and reduce uncertainties for the treatment and prevention of skin disease in our four chosen diseases.DesignMixed methods including eight systematic reviews, three prioritisation exercises, two pilot randomised controlled trials (RCTs), three feasibility studies, two core outcome initiatives, four funding proposals for national RCTs and one completed national RCT.SettingSecondary care, primary care and the general population.ParticipantsPatients (and their caregivers) with eczema, vitiligo, SCC and PG, plus health-care professionals with an interest in skin disease.InterventionsOur three intervention studies included (1) barrier enhancement using emollients from birth to prevent eczema (pilot RCT); (2) handheld narrowband ultraviolet light B therapy for treating vitiligo (pilot RCT); and (3) oral ciclosporin (Neoral®, Novartis Pharmaceuticals) compared with oral prednisolone for managing PG (pragmatic national RCT).ResultsSystematic reviews included two overarching systematic reviews of RCTs of treatments for eczema and vitiligo, an umbrella review of systematic reviews of interventions for the prevention of eczema, two reviews of treatments for SCC (one included RCTs and the second included observational studies), and three reviews of outcome measures and outcome reporting. Three prioritisation partnership exercises identified 26 priority areas for future research in eczema, vitiligo and SCC. Two international consensus initiatives identified four core domains for future eczema trials and seven core domains for vitiligo trials. Two pilot RCTs and three feasibility studies critically informed development of four trial proposals for external funding, three of which are now funded and one is pending consideration by funders. Our pragmatic RCT tested the two commonly used systemic treatments for PG (prednisolone vs. ciclosporin) and found no difference in their clinical effectiveness or cost-effectiveness. Both drugs showed limited benefit. Only half of the participants’ ulcers had healed by 6 months. For those with healed ulcers, recurrence was common (30%). Different side effect profiles were noted for each drug, which can inform clinical decisions on an individual patient basis. Three researchers were trained to PhD level and a dermatology patient panel was established to ensure patient involvement in all aspects of the programme.ConclusionsFindings from this programme of work have already informed clinical guidelines and patient information resources. Feasibility studies have ensured that large national pragmatic trials will now be conducted on important areas of treatment uncertainty that address the needs of patients and the NHS. There is scope for considerable improvement in terms of trial design, conduct and reporting for RCTs of skin disease, which can be improved through wider collaboration, registration of trial protocols and complete reporting and international consensus over core outcome sets. Three national trials have now been funded as a result of this work. Two international initiatives to establish how best to measure the core outcome domains for eczema and vitiligo are ongoing.Trial registrationCurrent Controlled Trials Barrier Enhancement for Eczema Prevention (BEEP) (ISRCTN84854178 and NCT01142999), Study of Treatments fOr Pyoderma GAngrenosum Patients (STOP GAP) (ISRCTN35898459) and Hand Held NB-UVB for Early or Focal Vitiligo at Home (HI-Light Pilot Trial) (NCT01478945).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kim S Thomas
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | | | - Joanne R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Tessa Clarke
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Finola M Delamere
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | | | - Nicholas Evans
- Trust Headquarters, West Hertfordshire Hospital NHS Trust, Hemel Hempstead, UK
| | - Lester Firkins
- Strategy and Development Group, James Lind Alliance, Oxford, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Louise Lansbury
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Sandra Lawton
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Carron Layfield
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Jo Leonardi-Bee
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - James Mason
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Helen Nankervis
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - John Norrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Andrew Nunn
- Medical Research Council (MRC) Clinical Trials Unit, University College London, London, UK
| | | | - Ramesh Patel
- Radcliffe-on-Trent Health Centre, Nottingham, UK
| | - William Perkins
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jane C Ravenscroft
- Dermatology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jochen Schmitt
- Centre for Evidence-based Healthcare, Medical Faculty Carl Gustav Carus, Dresden, Germany
| | - Eric Simpson
- Oregon Health and Science University, Portland, OR, USA
| | - Maxine E Whitton
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Hywel C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
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Gerbens LAA, Chalmers JR, Rogers NK, Nankervis H, Spuls PI. Reporting of symptoms in randomized controlled trials of atopic eczema treatments: a systematic review. Br J Dermatol 2016; 175:678-86. [PMID: 27012805 DOI: 10.1111/bjd.14588] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2016] [Indexed: 02/04/2023]
Abstract
'Symptoms' is a core outcome domain for atopic eczema (AE) trials, agreed by consensus as part of the Harmonising Outcome Measures for Eczema (HOME) initiative. To standardize and validate the core domain symptoms and symptom instruments for AE trials the HOME roadmap is followed. Its first step is to establish if and how symptoms have been measured in published AE treatment trials. Therefore the Global Resource for Eczema Trials database was used to collect all randomized controlled trials (RCTs) of treatments for AE between January 2000 and April 2014. Study selection and data extraction were performed by three reviewers independently. We identified the use of symptoms in 295 of 378 trials (78%). Symptoms as a primary end point were applied by 147 RCTs (50%). Seventeen different symptoms were measured, but mostly itch and sleep loss. Symptoms were assessed by only 37% of trials by a stand-alone symptom measurement. Overall 63% of RCTs used a composite instrument, and 30 different instruments were identified. The Scoring Atopic Dermatitis (SCORAD) index was the most commonly applied, but only 23% of RCTs reported the SCORAD symptom score separately. This systematic review demonstrates that symptoms, most frequently itch and sleep loss, are commonly reported in AE treatment trials, but are measured using many different instruments. Often symptoms are evaluated as part of a composite instrument, and currently it is not possible to extract symptoms-only data from most published studies. Future trials should report symptom scores to permit meta-analysis of the core outcomes.
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Affiliation(s)
- L A A Gerbens
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
| | - J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - N K Rogers
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - H Nankervis
- Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, U.K
| | - P I Spuls
- Department of Dermatology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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