BackgroundEczema is common among children, and in the UK the majority are managed by GPs. The most common cause of poor disease control is incorrect use of topical treatments. There is a lack of research into the challenges faced by GPs in diagnosing and managing this condition.AimTo explore the experiences of GPs in assessing and managing children with eczema.Design and settingQualitative study in primary care in England.MethodSemi-structured interviews with 15 GPs were audiorecorded, transcribed verbatim, and analysed thematically using the framework method.ResultsGPs described a paucity of dermatology training. Although most GPs were confident diagnosing uncomplicated eczema, they reported using a trial-and-error approach to prescribing emollients, and were uncertain about quantities of topical treatments to issue. Mild and moderate potency topical corticosteroids (TCS) were commonly used, but most GPs lacked confidence in recommending potent TCS, and viewed parents or carers to be fearful of using all strengths of TCS. GPs perceived adherence to treatments to be low, but provision of information to support self-care was variable. Routine review of medication use or disease control was uncommon, which GPs attributed to service constraints. Participants’ views on the causes and management of eczema were perceived to be at odds with parents and carers, who were said to be overly focused on an underlying cause, such as allergy.ConclusionGP uncertainty in managing eczema, lack of routine information and review, and perceived dissonance with parents around causation and management may be contributing to low concordance with treatments.

ObjectivesTo compare parents’ and clinicians’ perspectives on the assessment and treatment of children with eczema in primary care.DesignQualitative interview study with purposive and snowball sampling and thematic analysis.Setting14 general practices in the UK.Participants11 parents of children with eczema and 15 general practitioners (GPs) took part in semistructured individual interviews.ResultsWe identified several areas of dissonance between parents and GPs. First, parents sought a ‘cause’ of eczema, such as an underlying allergy, whereas GPs looked to manage the symptoms of an incurable condition. Second, parents often judged eczema severity in terms of psychosocial impact, while GPs tended to focus on the appearance of the child’s skin. Third, parents sought ‘more natural’ over-the-counter treatments or complementary medicine, which GPs felt unable to endorse because of their unknown effectiveness and potential harm. Fourth, GPs linked poor outcomes to unrealistic expectations of treatment and low adherence to topical therapy, whereas parents reported persisting with treatment and despondency with its ineffectiveness. Consultations were commonly described by parents as being dominated by the GP, with a lack of involvement in treatment decisions. GPs’ management of divergent views varied, but avoidance strategies were often employed.ConclusionsDivergent views between parents and clinicians regarding the cause and treatment of childhood eczema can probably only be bridged by clinicians actively seeking out opinions and sharing rationale for their approach to treatment. Together with assessing the psychosocial as well as the physical impact of eczema, asking about current or intended use of complementary therapy and involving parents in treatment decisions, the management of eczema and patient outcomes could be improved.

BackgroundEczema is common in children but adherence to treatments is poor. Written action plans (WAPs) have been shown to help in asthma but the potential value, format, and content of an eczema WAP is unknown.AimTo explore the potential role of an eczema WAP, and to design an eczema-specific WAP.Design and settingA qualitative study of parents of children with eczema, primary and secondary care health professionals, and other stakeholders.MethodA total of 41 semi-structured one-to-one interviews and two focus groups were audiorecorded, transcribed, and analysed thematically.ResultsReported challenges of managing eczema included: parental confusion about treatment application; lack of verbal and written advice from GPs; differing beliefs about the cause and management of eczema; re-prescribing of failed treatments; and parents feeling unsupported by their GP. An eczema WAP was viewed as an educational tool that could help address these problems. Participants expressed a preference for a WAP that gives clear, individualised guidance on treatment use, presented in a step-up/step-down approach. Participants also wanted more general information about eczema, its potential triggers, and how to manage problem symptoms.ConclusionAn eczema WAP may help overcome some of the difficulties of managing eczema, and support families and clinicians in the management of the condition. Further evaluation is needed to determine if the eczema WAP the authors have developed is both acceptable and improves the outcomes for affected children and their families.

ObjectivesTo determine the feasibility of a randomised controlled trial of ‘leave on’ emollients for children with eczema.DesignSingle-centre, pragmatic, 4-arm, observer-blinded, parallel, randomised feasibility trial.SettingGeneral practices in the UK.ParticipantsChildren with eczema aged 1 month to <5 years.Outcome measuresPrimary outcome—proportion of parents who reported use of the allocated study emollient every day for the duration of follow-up (12 weeks). Other feasibility outcomes—participant recruitment and retention, data collection and completeness and blinding of observers to allocation.InterventionsAveeno lotion, Diprobase cream, Doublebase gel, Hydromol ointment.Results197 children were recruited—107 by self-referral (mainly via practice mail-outs) and 90 by inconsultation (clinician consenting and randomising) pathways. Participants recruited inconsultation were younger, had more severe Patient-Oriented Eczema Measure scores and were more likely to withdraw than self-referrals. Parents of 20 (10%) of all the randomised participants reported using the allocated emollient daily for 84 days. The use of other non-study emollients was common. Completeness of data collected by parent-held daily diaries and at monthly study visits was good. Daily diaries were liked (81%) but mainly completed on paper rather than via electronic (‘app’) form. Major costs drivers were general practitioner consultations and eczema-related prescriptions. Observer unblinding was infrequent, and occurred at the baseline or first follow-up visit through accidental disclosure.ConclusionsIt is feasible in a primary care setting to recruit and randomise young children with eczema to emollients, follow them up and collect relevant trial data, while keeping observers blinded to their allocation. However, reported use of emollients (study and others) has design implications for future trials.Trial registration numberISRCTN21828118/EudraCT2013-003001-26.

Objectives: Nearly 40% of care home residents who are living with dementia also have symptoms of disturbed sleep. However, the impact of these disturbances is relatively unknown and is needed to indicate whether interventions are warranted; therefore, we aimed to investigate the impact. Design: One-to-one semi-structured interviews. Settings: Four UK care homes. Participants: We interviewed 18 nurses and care assistants about residents with sleep disturbances. Measurements: We used a topic guide to explore staff experience of sleep disturbance in residents with dementia. The interviews were audio recorded and transcribed and then analyzed thematically by two researchers independently. Results: Staff described that sleep disturbances in most, but not all, residents impacted negatively on the resident, other residents, staff, and relatives. Residents became more irritable or agitated if they had slept badly. They slept in the daytime after a bad night, which then increased their chances of being awake the following night. For some, being sleepy in the day led to falls, missing medication, drinks, and meals. Staff perceived hypnotics as having low efficacy, but increasing the risk of falls and drowsiness. Other residents were disturbed by noise, and staff described stress when several residents had sleep disturbance. Some of the strategies reported by staff to deal with sleep disturbances such as feeding or providing caffeinated tea at night might be counterproductive. Conclusions: Sleep disturbances in care home residents living with dementia negatively affect their physical and psychological well-being. These disturbances also disturb other residents and increase stress in staff.