Childhood eczema: paths to optimisation of management

SUPPORTING FAMILIES MANAGING CHILDHOOD ECZEMA

Sivyer et al document the construction and refinement of a complex intervention: an online behavioural programme addressing parents’ and carers’ skill gaps in managing eczema (the Eczema Care Online for Families [ECO for Families] intervention). This was developed using a rigorous theory-, evidence-, and person-based approach with multidisciplinary clinical (plus patient representative) contribution.

The initial construction process involved a systematic review and a qualitative interview study with parents/carers. Guiding principles for the intervention design, key management behaviours to be targeted, and a behaviour change framework to address barriers to these behaviours were established, along with a logic model for the intervention components and outcomes. The prototype intervention (formatted as online modules) was iterated, including by use of ‘think aloud’ interviews with parents/carers.

EVALUATING EMOLLIENTS FOR CHILDHOOD ECZEMA

One of the five behaviours identified in ECO for Families development as targets for eczema care was increased use of emollients to control skin inflammation.¹ Emollients are essential in eczema management but are associated with treatment burden, discomfort, and expense.³ There is a confusing number of different emollients and recommendations for use.⁴ Sutton et al ² explored emollient use, with a qualitative study nested in the ‘Best Emollients for Eczema’ randomised trial of four types of emollient (lotion, cream, gel, and ointment). Interviews were conducted with parent participants in the trial (sometimes together with their child participant). The qualitative study methodology was appropriate and well conducted. The findings are essentially quite straightforward. Emollient thickness and absorbency were issues of importance in use, and acceptability and (especially) effectiveness were considerations in continued use. There was, however, nuance in how the emollients were used in individual cases, including some patients using different types of emollient on different parts of the body (adapting the emollient characteristics to the needs of, for example, face and hand eczema compared to eczema at other sites).

There are issues of note in the work presented in these articles.

It is important that complex interventions are constructed purposively with attention to best practice in the area.^5,6 The ECO for Families intervention was meticulously developed with a solid theoretical basis and sound conduct of all elements of the development process. The authors have acknowledged some potential limitations in external validity of their interviews, but these are unlikely to have had substantive impact.

It is also important that the development process is reported fully so that the rationale for inclusion of the various elements is clear.⁵ This will inform practical implementation of the intervention (for example, taking into account local contexts).⁵ It will also inform process evaluation of the contributions of particular elements of the intervention to its effectiveness (or non-effectiveness)⁵ and to other relevant outcomes,⁶ leading to possible future refinements. Sivyer et al ’s article fulfills these needs for full reporting.¹ Furthermore, evidence from their qualitative study around parents’ and childrens’ co-management of eczema has significance in its own right, addressing a current evidence gap.

The qualitative study by Sutton et al ² will be a valuable adjunct to the quantitative analysis of the trial in which it is nested. Any findings there of differences in efficacy of the four emollient types will be contextualised by this investigation of how children and parents experienced the use of the particular emollients and how they adapted emollient use in response to that experience.