Forty-four interviews with parents were undertaken between 21 February 2018 and 17 September 2019: 20 at Week 4 and 24 at Week 16. These included five parents, interviewed twice at Week 4 and Week 16, who had expressed an interest in undertaking follow-up interviews and whose children’s characteristics aligned with the sampling criteria. The characteristics of the children are shown in Table 1. Twenty-four children participated in the interviews with their parents. Interviews lasted between 15 and 61 minutes (mean = 28 minutes). Eighteen interviews were face-to-face and 26 were by phone. Only 10 parents of children from non-White backgrounds were recruited, and as such it was not possible to fully explore the experiences of people with a range of skin types. This reflected the number (n = 77/550, 14%) of non-White participants recruited to the wider BEE trial.
• effectiveness and acceptability (how well the emollients worked for participants and how they found using and integrating them into everyday life);
• balancing choice between effectiveness and acceptability (the value placed on different aspects of the emollients and how this shaped their decisions on future emollient use); and
• study participation and the use of emollients (how study engagement and supporting materials affected emollient application routines and practices).
Quotes are tagged by ‘study ID’ and ‘child’ if drawn from children’s data, eczema severity, age of child, and assigned emollient.
While ‘cream’ is a type of emollient, the term ‘cream’ or ‘moisturising cream’ was also used by parents/carers and children to describe emollients and moisturisers generically. When used in this way, the term [generic] has been added in the data after ‘cream’. Where ‘cream’ appears without [generic], this references ‘cream’ as an emollient type.
Emollient effectiveness and acceptability
Emollient effectiveness
A clear theme identified in relation to effectiveness was the variation of experience within each emollient type. All four types were associated with both positive (stabilisation or improvement) and negative (adverse reactions or worsening) experiences.
Participants identified their experience of an emollient’s effectiveness in positive terms if it stabilised and/or improved their child’s eczema.
For the former, the key aspect was that the emollient reduced or stopped disease flares, and in doing so reduced the need for parents to use a topical corticosteroid:
‘ [The emollient] doesn’t always necessarily get rid of the eczema but sometimes it just stops it getting any worse, stops her getting any flare ups.’
(N6, mild, aged 6 months, lotion)
For some parents the effect of their study emollient was more beneficial, leading to an improvement in their child’s signs and symptoms:
‘We’ve tried a few different ones and ‘cos we’d got used to [a lotion] , I was a bit worried about changing it but it changed for the positive actually.’
(S7, moderate, aged 7 years, cream)
‘We currently use [the study ointment] and we have used it and since then it has cleared up beautifully, like round her neck and on her arms you can barely tell she’s [got eczema].’
(B11, moderate, aged 8 years, ointment)
However, there were negative experiences across all emollient types. These ranged from skin irritation to worsening of eczema and flares, which often led to parents changing to an alternative or reverting to their pre-study emollient:
‘By the end of that day it was red and really bad, and within a couple of days she was screaming and crying in pain whenever we were putting [the gel] on her … so we were probably only on it three or four days I think.’
(B7, severe, aged 3 years, gel)
‘I think within two or three weeks his skin was worse than it had ever been … the [cream] obviously wasn’t good enough to then control it and it went nuts … ’
(S8, mild, aged 1 year, cream)
Effectiveness and emollient thickness
In describing why an emollient did or did not work for them, a common theme was the thickness of an emollient, which was linked to its moisturising and protective qualities:
‘I think it’s better than some of the things we’ve used in the past ‘cos of its consistency and it has kept the dryness at bay.’
(S5, moderate, aged 4 years, cream)
‘ [The lotion] was so thin and watery, it had no effect whatsoever and we had to go, can’t remember if we went to the doctors and got a different like better emollient ‘cos it just wasn’t effective.’
(B16, moderate, aged 7 years, lotion)
For others, it was the ability of a thinner emollient to absorb into the skin that was seen as the effective attribute. The following participant stopped using their study ointment and reverted to thinner emollients they had previously used:
‘I like it to soak in. I think when you’ve got one of these gels, like on the skin’s really greasy, I don’t think it’s nice for anybody. So I think, like I say, that it soaks in and then obviously that it has an effect.’
(N5, moderate, aged 2 years, ointment)
Acceptability, absorption, and emollient thickness
Participants’ accounts of acceptability also varied within and across the emollient types, with no one being clearly more or less acceptable than another. It was also evident that descriptions of what made an emollient acceptable varied between participants.
As with effectiveness, key factors were thickness and absorbency. Some prioritised an emollient that absorbed into the skin quickly, was not sticky, and did not mark clothing, whereas others expressed a need for an emollient that sat more prominently on the skin and provided a ‘protective barrier’; for example, to enable participation in swimming.
For some participants the thinner emollients (lotions) and gels were associated with ease of application. The thinner nature of these emollients meant that they would be absorbed into the skin quicker and not have a negative impact on clothing:
‘I think just the ease of the emollient, you know, being absorbed by the skin is quite helpful because when it’s … just sitting on top is not something very attractive to use.’
(S2, moderate, aged 11 years, gel)
These same qualities were also associated with negative attributes, with some participants feeling the thinner consistency does not give lasting ‘protection’ and the lack of visible presence of the emollient resulting in a perception that more is needed to provide protection, thereby increasing the time spent applying the emollient:
‘I think the lotion that he’s got now soaks in a lot better. Obviously it’s a lot thinner so … I’ll put some on, just a little bit, rub it in and almost make sure it’s soaked in and then I tend to put some more on whereas with the thicker one you could put one lot on, you could kind of see it all and know it was going to stay on.’
(B4, mild, aged 8 years, lotion)
The thicker emollients tended to be described as more challenging to use and as having a greater impact on everyday life, particularly the time spent bathing and dressing:
‘ [The ointment] does absorb into the skin though not as quickly and I found it was particularly difficult because … it was adding extra time … I had to get [my son] up early ‘cos the cream it sunk in, you turn around and its sunk in, the ointment takes what felt like quite a lot longer so I almost had to put a towel, do him head to toe, let him lie on the towel while I was getting … baby ready or whatever and then come back, check, and then if we were putting steroid on then we’ve got to apply the steroids and then go off again and then ok, right, well you can get dressed now.’
(B17, moderate, aged 5 years, ointment)
‘It’s pretty hard to rub in and it takes like three or four minutes to rub in usually.’
(B10, [child] moderate, aged 11 years, cream)
Thickness was also identified as a positive aspect in applying an emollient:
‘It’s better than the old one cos it’s spreadable.’
(B13 [child], mild, aged 8 years, ointment)
Conversely, thicker emollients caused some users discomfort:
‘It’s like clay. I don’t really like the feeling and like what it does to my skin. It kind of makes my skin sticky and then it feels weird, when I put it on my skin, inside my skin it feels like really weird.’
(S4 [child], moderate, aged 8 years, gel)
‘I think the one that we got given for our test is pretty awful, it’s like Vaseline.’
(S9, [child], severe, aged 7 years, ointment)
Emollient containers and dispensers
Acceptability also related to the type of container the study emollient was dispensed from. Containers varied across different emollient types and included pumps, squeezable bottles, tubs, and tubes. Overall, participants were positive about pumps:
‘It’s just so easy. You just leave it on the surface, quick pump and then you’re kind of done … when you’ve got two children with eczema and you’ve got to get everybody ready for bed or ready for school in the morning that kind of thing does make a difference ‘cos it’s just quicker.’
(B14, moderate, aged 8 years, gel)
Participants expressed negative views about tubs, in which all ointments come, and which require a spoon to scoop out the required amount. Participants described this as time consuming, and some used their hands instead (which increases the risk of infection):
‘When I went to see the dermatologist she said that the best way, or what the advice should be that you scoop it out with a spoon … I did use my hands … but I think that adding a spoon to that just … its adding some, you know, it’s another something to do isn’t it, something else to clean up, whereas that pump is so [easy].’
(B16, moderate, aged 7 years, lotion)
Emollient choice: balancing effectiveness and acceptability
This section looks at the choices that families made around emollient use, with a particular focus on intentions after Week 16, when participants could choose to continue with their study emollient or switch to an alternative. In making their choices, participants considered effectiveness and acceptability in assessing an emollient, not necessarily in opposition to each other:
‘It was quite good. It helped [with itching] … but it is quite greasy.’
(S9 [child], severe, aged 7 years, ointment)
For some participants there was a clear improvement, and it was therefore an easy decision for them to carry on using their allocated emollient:
‘The fact that it seems to be helping [was a] good incentive, so we weren’t counting down the weeks until the end of the study, having to decide whether or not it was worth carrying on … there was nothing really to think about.’
(B6, moderate, aged 10 years, lotion)
The data showed effectiveness was the primary driver of decision making. This was evident in cases where parents recognised the improved acceptability of their assigned emollient but were unable to keep using it because it did not control eczema in the way that their previous emollient had done:
‘It went on really nicely and she was quite excited about having this new cream [generic] … It just didn’t solve, yeah, if anything it made it so worse. I think if it had just kept it the same, I would have probably carried on using it but I felt it was making it worse and so couldn’t then carry on.’
(N5, moderate, aged 2 years, ointment)
‘Because it’s so thick and it’s hard to get out ‘cos of how much you get out and it just like stings my body when I put it on … I would have stayed with it because it’s making me better but … it’s not.’
(B10 [child], moderate, aged 11 years, cream)
The data also highlighted the value placed on acceptability by participants, especially when the effectiveness of the emollient was comparable with emollients they had previously used:
‘Actually, there is improvement, not necessarily in his skin but I think like [my son] was saying about it’s easier to apply, I think that’s where the improvement is. It’s easier to apply, it’s not as sticky … and uncomfortable as the other one.’
(B13, mild, aged 8 years, ointment)
There were also instances where participants managed choice going forward by using different emollients for different parts of the body, prioritising effectiveness in badly affected areas and using an emollient that was easier to apply in other areas:
‘We carried on using [the gel] because on the skin that wasn’t broken it was fine and it seems to do a decent enough job. I would say it’s just as good as the [lotion] that we’ve been using. It seems to give the same kind of level of moisturising and it’s kinder to his clothes, it’s not really greasy, it seems to soak in well. So we carried on using it and then just literally would put something else on his face and hands when he needed it.’
(B18, mild, aged 4 years, gel)
Study participation and the use of emollients
As part of the trial, participants were provided with an Emollient Information Sheet about how emollients should be applied. Some parents reported, particularly in the Week 16 interviews, that engaging with the study information had improved their knowledge of eczema management and emollient types, and changed their use of emollients:
‘I’ve only ever had that from the BEE study actually, advice about baths and things like that, about how to put on [emollients]. That’s the first time I’d ever heard of that.’
(S7, moderate, aged 7 years, cream)
As part of the trial, participants were advised to use their study emollient at least twice daily, and the interviews explored whether their daily routines differed to their pre-study practice. Some participants commented that more regular application may have contributed to an improvement in their child’s skin, as before participation they could sometimes be ‘slack’ or ‘lazy’:
‘We probably haven’t been as diligent in terms of applying it on a daily basis as we have been with the study … because we said we would, we’ve probably only used the [pre-study emollient] when we’ve needed to, when he’s had really dry skin.’
(N4, moderate, aged 8 years, gel)
The trial also asked participants to answer questions on a weekly basis about eczema symptoms and treatment use during the first 16 weeks. For some participants, engaging with the study surveys acted as a reminder to apply their emollient regularly, rather than using it to manage an exacerbation of eczema. Participating in the trial had changed some parents’ approach to how long they were willing to persist with an emollient. Committing to an emollient for a sustained period of 16 weeks led some to see benefits in using regularly over a longer period:
‘I don’t think we ever gave it long enough in terms of, you know, we’d get this [emollient] and then we’d go back to the doctors and they’d say oh it’s not really working so change it and I think in hindsight … and also based on this experiment that he’s done with the cream [generic] … we would never have given [an emollient] this long to work.’
(S10, severe, aged 6 years, lotion)
