A Randomized Controlled Trial of an Eczema Care Plan

Assessment and Management of Atopic Dermatitis in Primary Care Settings: A Systematic Review

Atopic dermatitis is a complex, recurrent, chronic inflammatory skin condition. It frequently begins to manifest in early childhood and may last throughout adulthood. The need for clinical practice guidelines that are based on evidence is critical for efficient and secure care. Little is known about how primary care providers (PCPs) should handle pediatric and adult atopic dermatitis cases and whether they should follow national recommendations. Our systemic review aimed to examine management strategies for treating adult and pediatric (family) atopic dermatitis, including topical calcineurin inhibitors (TCIs), topical corticosteroids (TCS), skin emollients, oral antihistamines, and diet. Data sources were PubMed (MEDLINE) and Embase. Our review investigated English-language articles from 2014 to 2023 that studied the management of adult and children atopic dermatitis. Overall, there were 15 articles included. Surveys and analyses of national databases were the most widely used methods (n=7). The use of TCS by PCPs was common, but they also overprescribed nonsedating antihistamines, favored low-potency drugs, and avoided TCIs. Most studies relied on healthcare personnel reporting their typical behaviors rather than looking at specific patient encounters and it is considered a limitation. Finally, there are gaps in knowledge and management of critical topics such as prescribing TCIs and understanding the safety profiles of TCS, when it comes to treating adult and pediatric atopic dermatitis. Future research in this area is urgently needed because the current systemic assessment is mostly restricted to small studies that assess prescribing behaviors with scant information describing nonmedication management.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Management of Pediatric Atopic Dermatitis by Primary Care Providers: A Systematic Review

BACKGROUND

Primary care providers (PCPs), including pediatricians and general practitioners, are often the first to see children with eczema/atopic dermatitis (AD). Little is known about management of pediatric AD by PCPs and adherence to national guidelines.

OBJECTIVE

To review existing literature examining management components of pediatric AD (topical corticosteroids [TCS], topical calcineurin inhibitors [TCIs], antihistamines, bathing, emollients, and diet) by PCPs.

DATA SOURCES

PubMed/Medline and Embase.

STUDY ELIGIBILITY CRITERIA

English-language articles dated 2015 to 2020 reporting outcomes addressing management of pediatric AD by PCPs.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened titles/abstracts, reviewed full-text articles, extracted relevant data, and evaluated study quality. Disagreements were resolved by a third author.

RESULTS

Twenty articles were included. Surveys and national database analyses were the most common methodologies (n = 7 each). PCPs commonly prescribed TCS but had a preference for low-potency agents, overprescribed nonsedating antihistamines, and avoided TCIs. PCPs commonly recommended emollients, although this was not universal. Data characterizing nonmedication management were limited.

LIMITATIONS

Most studies did not examine individual patient encounters, but rather relied on providers reporting their general behaviors. Provider behavior may vary based on country of practice.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Knowledge and management gaps exist among PCPs in treating pediatric AD in key areas including knowledge of TCS safety profiles and prescribing of TCIs. The current literature is largely limited to small studies that evaluate prescribing behaviors with limited data characterizing nonmedication management, highlighting the need for future research in this area.

Interventions to improve primary care provider management of atopic dermatitis: A systematic review

Most atopic dermatitis (AD) patients are managed by primary care providers (PCPs). PCP discomfort diagnosing and managing AD leads to suboptimal patient outcomes. In order to determine the efficacy of interventions aimed at improving PCP management of AD, a systematic literature review was performed for interventions to improve primary care management of AD. PubMed, MEDLINE, Embase, Scopus, LILACS, Cochrane, GREAT, and CINAHL were searched from database origin to February 24, 2020. Two reviewers independently performed the title/abstract and full-text review, and data extraction. Overall, 3009 non-duplicate articles were screened; 145 full-text articles were assessed. Thirteen studies met inclusion criteria, including 8 randomized controlled trials, 2 cohorts, 2 qualitative studies, and 1 unspecified design. Seven interventions (53.8%) significantly improved PCP knowledge/ability and/or a patient outcome, including patients consulting with a dermatology-trained nurse, pairing clinical education with expert consultation, pairing trainees with clinical mentors, giving clinicians a treatment guide, pairing clinical education with a treatment guide, and providing an eczema action plan. Studies had moderate-high risk-of-bias, moderate quality, and heterogeneous designs. There are few studies published and little evidence supporting the efficacy of interventions aimed at improving primary care management of AD. Further research is required to develop and implement effective interventions to improve primary care management of AD.

An Innovative Model for Providing Dermatology Services Within Primary Care

OBJECTIVE

Dermatologic complaints are common in outpatient pediatrics. However, pediatric dermatology specialty care can be difficult to access. We aimed to test the feasibility of co-locating dermatology services within primary care and increase the proportion of patients treated for basic skin complaints within the medical home while decreasing wait times.

METHODS

The Rapid Assessment of Skin Health (RASH) clinic was created within a hospital-based primary care clinic in 11/2013. The clinic was staffed by 2 pediatricians trained in the dermatology department and supported with specialist advice as needed. Referral volume and wait times to dermatology and RASH clinic were tracked for visits between 11/1/12 and 10/31/18. A chart review was also conducted on a subset of RASH clinic visits. Primary care providers (PCPs) were surveyed about their experiences.

RESULTS

Fifty-eight percent of patients referred for a dermatologic complaint were scheduled in RASH clinic. Wait times for new patient appointments in RASH clinic were significantly shorter than for new dermatology appointments in the previous 12 months (mean 36 days vs 65 days, P < .001). The monthly number of referrals to dermatology also decreased significantly after the RASH clinic opened (24/month vs 12/month, P < .001). Ten percent of RASH patients were referred on to dermatology. In a survey of PCPs (N = 67), 76% said the RASH clinic was "extremely/very helpful."

CONCLUSIONS

Providing dermatologic care to low or moderate complexity patients within the medical home is feasible and leads to better access to care. This innovative model could be spread to other clinics and subspecialties.