Does it work and is it safe? Parents' perspectives on adherence to medication for atopic dermatitis

General practitioner prescription patterns for atopic eczema in children-Are they affected by telemedicine advice?

Traditionally, patients presenting to primary care with severe eczema would be referred to a dermatology clinic for an in-person specialist appointment. With the rise of teledermatology, dermatologists are instead dispensing tailored written advice based on information provided in the referral. However, there is currently minimal literature assessing whether this advice translates into relevant prescriptions. This clinical audit examines GP prescribing practices and how they correlate to dermatologist recommendations with the objective of assessing whether this form of teledermatology is a viable method of providing care to paediatric eczema patients.

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

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

Atopic Dermatitis in Children in the General Population: Baseline Characteristics, Medication Use, and Severity Measures in the Rotterdam Eczema Study

Background: Real-life data on severity and treatments in children with atopic dermatitis (AD) are needed to evaluate self-management. Objectives: To determine severity and use of topical treatments in children with AD in the general population. Furthermore, we aim to determine agreement and correlation between objective and subjective AD severity measures. Methods: Data were used from the Rotterdam Eczema Study, an observational prospective cohort study with an embedded pragmatic open-label randomized controlled trial. Descriptive statistics were used for baseline characteristics, medication use, and severity. Strength of agreement and correlation were determined using kappa analysis and Pearson correlation. Results: In total, 367 children (mean age 5.7 years) were recruited. The mean eczema area and severity index (EASI) score was 2.1 (±3.2) and mean patient-oriented eczema measure (POEM) score was 10.3 (±6.1). The majority applied emollients on a daily basis (54.9%) and had not used topical corticosteroids (TCSs) over the past week (51%). Based on severity banding of POEM and EASI, 49.9% and 24.9% of the children were undertreated, respectively. No evidence was found for an agreement between EASI and POEM (kappa 0.028, n = 178, P = 0.451). A moderate correlation between POEM, EASI, infants' dermatitis quality of life index, and children's dermatology life quality index was found. POEM showed higher correlation with quality of life (QoL) than EASI. Conclusion: Emollients were used sufficiently in the study population. Based on signs or symptoms, 24.9% and 49.9% of children are undertreated, respectively. POEM scores correlated better with QoL than with EASI scores. We argue that EASI underestimates severity of AD, and treatment based on EASI scores may lead to undertreatment of AD. Treating physicians should be aware of suboptimal use of TCSs.

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

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

The characteristics and efficacy of educational nurse-led interventions in the management of children with atopic dermatitis - An integrative review

OBJECTIVE

This integrative review investigates the modalities, characteristics, and efficacy of educational nurse-led interventions for parents of children with atopic dermatitis (AD).

METHODS

We conducted an integrative review with the following inclusion criteria: Quantitative, qualitative and mixed-method studies written in English or German and published between 1 January 2000 and 31 December 2021. We searched for entirely nurse-led interventions.

RESULTS

Four RCTs, three pre-post studies without control groups, and one post-test study without control group met the inclusion criteria. Nurse-led interventions were found to have medium to large positive effect sizes on disease severity, and none to large positive effects on quality of life. There was significant heterogeneity across study designs with a wide variety in educational interventions and outcome measures used. The quality of most included studies was low.

CONCLUSION

Nurse-led educational interventions for parents of children with AD are beneficial in reducing disease severity. However, it remains unclear, which main components of the nurse-led intervention are most effective.

PRACTICE IMPLICATIONS

Based on the results of this review, we think that trained and qualified nurses who are part of the entire treatment of children with AD and do as well educational interventions have the greatest potential to improve outcomes.

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

Background

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

Objective

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

Design

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

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

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

Interventions

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

Main outcome measures

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Trial registration

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

Funding

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

Video-Based Education with Storytelling Reduces Parents' Fear of Topical Corticosteroid Use in Children with Atopic Dermatitis: A Randomized Controlled Trial (The EduDerm Study Part II)

OBJECTIVE

To investigate the efficacy of educational videos using storytelling to reduce parents' fear of topical corticosteroid (TCS) use in children affected by atopic dermatitis (AD).

METHODS

Children aged 0 to 5 years who had AD were included. The primary outcome measures were parental fear of TCSs, as determined by Topical Corticosteroid Phobia score, and quality of life according to the Family Dermatology Life Quality Index. Disease severity, assessed by the Scoring Atopic Dermatitis tool, served as a secondary outcome measure. Assessments were performed at baseline (T1), 1 to 4 weeks later (T2), and at 3-month follow-up (T3). The intervention group was exposed to the videos between baseline and T2.

RESULTS

Forty patients were recruited: 21 in the intervention group and 19 in the control group. A statistically significant decrease in parental TCS fear was found in the intervention group at T2 after video education as compared with the control group (P < .0001); this was maintained at T3 (P = .001). The groups did not significantly differ in FDLQI or SCORAD scores at any point.

CONCLUSIONS

These findings suggest that video education based on the method of storytelling is effective in reducing TCS fear. Although the education did not impact disease severity or quality of life, effectively reducing TCS fear remains an important aspect for AD management.

How and what adverse events are reported and captured in randomized control trials of emollients in the treatment of eczema?

BACKGROUND

Emollients are universally recommended for atopic dermatitis/eczema ('eczema'), to improve the skin barrier and reduce symptoms. However, our knowledge of the frequency and nature of adverse effects associated with their use is limited.

OBJECTIVES

We sought to determine how well adverse events are reported in randomized controlled trials (RCTs) of emollients for eczema.

METHODS

MEDLINE was searched from inception (1946) to May 2022. Inclusion criteria were RCTs of moisturizers or emollients used as a leave-on treatment (as the intervention or control) in adults or children with eczema. Exclusion criteria were non-RCTs; patients with other diagnoses included; use of emollient as bath additives, soap substitutes or as preventative; and not published in English. References of eligible papers were reviewed for any additional, relevant research. Data were extracted into an Excel spreadsheet and analysed descriptively. An assessment of study quality was carried out using the Joanna Briggs Institute tool for RCTs.

RESULTS

From 369 potential papers, 35 papers (reporting on 34 studies) were included. Most research was conducted in research centres or hospitals (unclear in 34%). In total, 89% reported collecting data on adverse events related to emollient treatment use but the methods used were poorly reported (40% unclear). Four papers used patient questionnaires/diaries. However, it was unclear how and what was collected as only two studies showed the questionnaires used.

CONCLUSIONS

Reporting of adverse events related to emollient use in trials of patients with eczema is poor and inconsistent. Agreement should be reached on how and what adverse events should be collected, to standardize reporting across studies.

Antibiotic perceptions, adherence, and disposal practices among parents of pediatric patients

Antibiotics are frequently prescribed for children in the outpatient setting. Although sometimes necessary, antibiotic use is associated with important downstream effects including the development of antimicrobial resistance among human and environmental microorganisms. Current outpatient stewardship efforts focus on guiding appropriate antibiotic prescribing practices among providers, but little is known about parents' understanding of antibiotics and appropriate disposal of leftover antibiotics. To help bridge this gap, we conducted a qualitative study to assess parental understanding of their children's antibiotics, their adherence to antibiotic instructions, and their disposal practices. We conducted a semi-structured interview with parents of 13 children diagnosed with acute respiratory illnesses and prescribed antibiotics in an urban outpatient clinic. We found that parents had limited understanding of how antibiotics work. Although they received instructions about antibiotic use during the healthcare visit, adherence to the prescription and appropriate disposal of antibiotics was suboptimal. Limited baseline understanding of antibiotics, their prior experiences with antibiotics, perceptions about their social networks' antibiotic use, and information provided to them by healthcare providers may influence these behaviors. Our findings can inform educational efforts of outpatient stewardship programs to help optimize parental understanding of how to use and dispose of their children's antibiotics.

Cancer risk with topical calcineurin inhibitors, pimecrolimus and tacrolimus, for atopic dermatitis: a systematic review and meta-analysis

BACKGROUND

Atopic dermatitis is a prevalent condition in children and can be effectively managed with medications such as topical calcineurin inhibitors (pimecrolimus or tacrolimus). A key unresolved safety concern is whether use of topical calcineurin inhibitors is associated with cancer. We systematically reviewed the risk of cancer in patients with atopic dermatitis exposed to topical calcineurin inhibitors.

METHODS

As part of the 2022 American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters atopic dermatitis guidelines, we searched MEDLINE, Embase, the Latin American and Caribbean Health Sciences Literature database, the Índice Bibliográfico Espanhol de Ciências da Saúde database, the Global Resource of Eczema Trials database, WHO's International Clinical Trials Registry Platform, the US Food and Drug Administration database, the European Medicines Agency database, company registers, and relevant citations from inception to June 6, 2022. We included randomised controlled trials and comparative and non-comparative non-randomised studies in any language addressing cancer risk in patients with atopic dermatitis using topical calcineurin inhibitors. We excluded split-body studies and studies with less than 3 weeks of follow-up. Paired reviewers independently screened records, extracted data, and assessed risk of bias in duplicate. We used Bayesian models to estimate the probability for cancer due to topical calcineurin inhibitor exposure and the GRADE approach to determine the certainty of the evidence. Patients, advocacy groups, and care providers set a priori thresholds of important effects. This study is registered with Open Science Framework, https://osf.io/v4bfc.

FINDINGS

We identified and analysed 110 unique studies (52 randomised controlled trials and 69 non-randomised studies [11 were non-randomised study extensions of randomised controlled trials]) including 3·4 million patients followed up for a mean of 11 months (range 0·7-120). The absolute risk of any cancer with topical calcineurin inhibitor exposure was not different from controls (absolute risk 4·70 per 1000 with topical calcineurin inhibitors vs 4·56 per 1000 without; odds ratio 1·03 [95% credible interval 0·94-1·11]; moderate certainty). For all age groups and using data from observational studies and randomised controlled trials, the use of pimecrolimus (OR 1·05 [95% credible interval 0·94-1·15]) or tacrolimus (0·99 [0·89-1·09]) is likely to have had little to no association with cancer compared with no topical calcineurin inhibitor exposure. For pimecrolimus versus tacrolimus, the finding was similar (0·95 [95% credible interval 0·83-1·07]). Findings were similar in infants, children, and adults, and robust to trial sequential, subgroup, and sensitivity analyses.

INTERPRETATION

Among individuals with atopic dermatitis, moderate-certainty evidence shows that topical calcineurin inhibitors do not increase the risk of cancer. These findings support the safe use of topical calcineurin inhibitors in the optimal treatment of patients with atopic dermatitis.

FUNDING

American Academy of Allergy, Asthma and Immunology and American College of Allergy, Asthma and Immunology via the Joint Task Force on Practice Parameters.

Refractory Pediatric Psoriasis and Atopic Dermatitis: The Importance of Therapeutical Adherence and Biological Management

The rates of refractory pediatric psoriasis and atopic dermatitis (AD) have steadily risen over the last few decades, demanding newer and more effective therapies. This review aims to explore the reasons for resistant disease, as well as its management; this includes the indications for, efficacy of, and safety of current therapies for refractory pediatric dermatologic disease. A PubMed search for key phrases was performed. Poor medication adherence is the most common cause of resistant disease and may be managed with techniques such as simplified treatment regimens, more follow-ups and educational workshops, as well as framing and tailoring. Once problems with adherence are ruled out, escalating treatment to stronger biologic therapy may be indicated. Development of anti-drug antibodies (ADAs) can cause patients’ disease to be refractory in the presence of potent biologics, which may be addressed with regular medication use or concomitant methotrexate. If patients with AD fail to respond to biologic therapy, a biopsy to rule out mycosis fungoides, or patch testing to rule out allergic contact dermatitis, may be indicated. A limitation of this study is the absence of more techniques for the management of poor medication adherence. Managing medication adherence, escalating treatment when appropriate, and addressing possible anti-drug antibodies will help assure control and relief for patients with resistant disease.

Improving patient education for atopic dermatitis: A randomized controlled trial of a caregiver handbook

BACKGROUND/OBJECTIVES

Patient education is important to families' ability to manage and cope with pediatric atopic dermatitis (AD). We evaluated whether an educational handbook could improve AD symptoms, caregiver confidence in AD management skills, and AD-related quality of life.

METHODS

Caregivers of children with AD ages 1 month to 16 years were randomly assigned to the intervention arm (handbook in addition to standard AD management) or the control arm (standard management alone). Caregivers completed self-report outcome questionnaires prior to a clinical visit for AD and at 3-month follow-up.

RESULTS

175 caregivers completed questionnaires at baseline and follow-up. AD symptoms measured by the Patient-Oriented Eczema Measure (POEM) improved in both the handbook and control arms. However, the decrease in the mean POEM score in the handbook arm (-4.4, 95% CI [-5.8, -3.0]) did not differ from that in the control arm (-3.4, 95% CI [-4.8, -2.03]; P = .343). Change in quality of life did not differ between study arms. Among caregivers attending a new patient visit for AD, mean confidence scores (measured from 0 to 100) increased more in the handbook arm (67 [95% CI {60, 74}] to 83 [95% CI {77, 88}]) relative to the control arm (74 [95% CI {65, 82}] to 75 [95% CI {67, 83}]; P = .012). The majority of caregivers rated the handbook as helpful in managing the child's AD.

CONCLUSIONS

Despite an adequate sample size, the handbook did not improve AD symptoms more than standard management alone. The handbook improved confidence in management skills for families attending new patient visits for AD.

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

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

Reducing corticosteroid phobia in pharmacy staff and parents of children with atopic dermatitis

Background Besides physicians, pharmacy staff has an important role to inform patients on appropriate medication use. However, they might also experience corticophobia themselves, affecting patient counseling and subsequently patient’s disease management. Objective Implementation of an intervention for pharmacy staff to improve knowledge and stimulate positive perceptions towards TCS use, in order to reduce corticophobia in pharmacy staff and parents of young AD patients. Setting Nine community pharmacies in the Netherlands. Method We developed an intervention consisting of education of pharmacy staff followed by counseling of parents. The intervention was implemented in pharmacies and intervention effectiveness was studied using a pre-post design with an intervention period of 3 months. At baseline and follow-up (3 months), pharmacy staff and parents completed a questionnaire. Main outcome measure Corticophobia, both beliefs and worries, measured with the TOPICOP questionnaire. Higher scores indicate a more negative attitude. Result Baseline and follow-up data were available for 19 pharmacy staff members and 48 parents who attended a counseling session in the pharmacy. In both groups there was as decrease in negative beliefs and worries towards TCS (p < 0.05). Mean total TOPICOP scores decreased from 42 to 35% and from 33 to 25% for parents and pharmacy staff respectively. Conclusion Our results show the prevalence of corticophobia among parents. Education of pharmacy staff and targeted patient counseling seems to be effective in reducing corticophobia.