Response from the authors of ‘Weekly versus daily bathing for people with eczema: results of the Eczema Bathing online randomized controlled trial’ to ‘Translating the Eczema Bathing Study: why context and infection burden matter’, by Ng et al.

Background Effective communication during consultations is facilitated by clinical empathy and realistic optimism, and can enhance patient satisfaction with care, alleviate symptoms, and improve quality of life. However, primary care systems are under significant strain and changing rapidly, which may affect practitioners' ability to communicate empathically and convey realistic optimism, with implications for the patient-practitioner relationship and patient outcomes. Understanding patients' perspectives of healthcare communication in the current clinical context is therefore important. We aimed to explore patients' experiences and perceptions of communication in UK primary care consultations, focussing on the communication of clinical empathy and realistic optimism. Methods A qualitative interview study was conducted as part of a multi-centre cluster-randomised trial of EMPathicO, a brief e-learning package for Primary Care Practitioners (PCPs) on communicating clinical empathy and realistic optimism. Participants were not aware whether their general practice had access to EMPathicO or not. Interviews were conducted within 7-14 days of participants' consultations, explored their views and experiences of clinical empathy and realistic optimism, and were transcribed verbatim. Interviews were analysed using Ritchie and Spencer's Framework Method. Results We conducted semi-structured audio-recorded qualitative telephone interviews with 71 participants from 29 primary care practices taking part in the EMPathicO trial. Following comprehensive mapping of data to the framework derived following initial analysis, four themes were agreed. Overall, most participants described positive empathic consultations with their PCPs, however, participants' experiences were shaped by wider systemic and contextual factors. They described a stretched and inefficient primary care system impacting empathy and optimism; the impact of PCP 'preparedness' as a marker for empathy; how consultation modality (i.e. in-person or telephone) shaped perceptions of empathy, and how PCPs sharing next steps in participants' treatment and management could foster realistic optimism. Conclusions While clinical empathy and realistic optimism may be experienced by patients during consultations with practitioners, the wider contextual challenges of accessing and navigating primary care systems can threaten overall perceptions of feeling cared for. Future primary care policy and workforce training must consider these system pressures to preserve effective communication in consultations and positive patient-practitioner encounters.

Summary Box Maternal dietary changes influenced by allergy during breastfeeding are not well evidenced or informed. This mixed‐methods study aims to estimate the prevalence and impact of maternal dietary changes during breastfeeding.

Summary Real‐world topical eczema treatment in children is highly variable and declines over time. Specialist care uses more frequent and higher‐potency topical therapies than generalist settings.

BACKGROUND:Acne vulgaris is a common chronic skin disease amongst young people. Effective, early management improves outcomes and reduces risk of long-term impacts such as scarring. However, little is known about how young people seek information, treatment and product advice, or the role of parents in acne management. OBJECTIVES:To explore the views and experiences of young people and parent and child dyads about their perceptions of living with and managing acne, particularly in relation to treatment, advice and information seeking. METHODS:Qualitative semi-structured interviews with 13-25 year-olds with acne and their parents sought their views and experiences of acne management. Participants were recruited via social media. Purposeful sampling sought diverse participant characteristics. Transcripts were analysed using inductive thematic analysis. Interviews were conducted between July and September 2022 with young people and their parents from across England. RESULTS:We carried out interviews with 21 young people with acne, 5 parents plus three pairs of parents and young people. Participants discussed seeking trustworthy information and advice about acne (e.g. NHS website). However, other online information, particularly via social media, was commonly used to identify products, despite recognition this can be untrustworthy. Learning about experiences of others with acne was highly valued and relied upon for selecting products, as was perceived familiarity of products. Parents' role in acne management varied. Some helped with costs of products or as gatekeepers for seeking professional advice, especially during early stages of acne. Both parents and young people lacked awareness of effective treatments for acne, which seemed a barrier to effective self-management. CONCLUSIONS:Online information, from varying sources, is very important to young people with acne and, although aware of potential misinformation, they still value its accessibility. Parents appear to have a strong role in supporting young people through formal healthcare seeking but are less involved in making sense of online information which young people tend to use independently. Reliable information resources for acne management should be targeted at both young people and parents. Clinicians need to be aware of patients' reliance on online information and signpost towards evidence-based resources.

BACKGROUND:Questions about washing are a high priority for people with eczema (also known as atopic dermatitis and atopic eczema), but they are rarely the focus of randomized controlled trials (RCTs). OBJECTIVES:To assess the impact of weekly vs. daily bathing in people with eczema in the first of a series of eczema citizen science online trials in the UK. METHODS:This was a pragmatic two-arm parallel-group superiority RCT. People with self-reported eczema aged ≥ 1 years were eligible, excluding those with very mild eczema [Patient Orientated Eczema Measure (POEM) score ≤ 2]. Participants were allocated (1 : 1) using minimization, balancing on eczema severity (POEM), age and usual method of bathing to either the weekly bathing group (bath or shower once or twice weekly) or the daily bathing group (bath or shower ≥ 6 times weekly) for 4 weeks. Participants were not blinded to their allocation. The primary outcome was participant-reported eczema symptoms collected weekly over 4 weeks using POEM (range 0-28, where higher scores indicate more severe eczema). The trial was registered with ISRCTN on 22 November 2023 (https://www.isrctn.com/ISRCTN12016473). RESULTS:In total, 438 people with eczema (108 of whom were aged < 16 years) were randomized between 29 January and 8 July 2024: 218 to daily bathing and 220 to weekly bathing. The primary analysis included 195 participants (89.4%) allocated to daily bathing and 193 (87.7%) to weekly bathing who completed at least one follow-up questionnaire. Mean (SD) POEM scores at baseline and at 1, 2, 3 and 4 weeks were 14.5 (5.7), 11.7 (5.9), 12.2 (5.9), 11.7 (6.7) and 11.6 (6.5), respectively, in the daily bathing group and 14.9 (6.3), 12.1 (6.8), 11.3 (6.7), 10.5 (7.0) and 10.6 (7.2), respectively, in the weekly bathing group. The adjusted difference in mean POEM score over 4 weeks for weekly vs. daily bathing was -0.4 (95% confidence interval -1.3 to 0.4; P = 0.30). Process evaluation data highlighted participants' experiences of making changes to bathing routines, including barriers to following the allocated routine. No serious unintended effects or harms were reported. CONCLUSIONS:The trial found no evidence of a difference in eczema symptoms between bathing or showering weekly vs. daily. These results are helpful for people with eczema, giving them the freedom to choose what suits them best.

Background Inflammatory dermatoses have a varied prevalence and appearance in diverse skin tones. The underrepresentation of people with skin of colour in medical education and clinical trials is widely acknowledged. However, there has been limited research on experiences from a patient perspective. Aim To explore the experiences of eczema, acne, and psoriasis in adults with skin of colour in the UK. Design and setting This was a qualitative study of 20 people in the UK with eczema, acne, and psoriasis and skin of colour, recruited using online methods. Method Participants took part in online, one-to-one, semi-structured interviews. NVivo qualitative data analysis software was used to code and organise the data. Reflexive thematic analysis was used to generate themes using an iterative approach. Results Participants were mostly female (65%, 13/20), Asian/Asian British ethnicity (45%, 9/20), and had eczema (55%, 11/20). We identified eight themes: delayed or missed diagnosis; preferences regarding healthcare professionals; lack of online information and social media use; misunderstanding in cultural communities; concerns about treatment and lack of research in skin of colour; complementary medicine use; experiences and impact of dyspigmentation; and challenges with structural racism. Conclusion The themes generated highlight the unique experiences and challenges faced by UK adults with eczema, acne, and psoriasis. The findings can help guide diagnostic approaches, culturally sensitive communication, and treatment discussions for patients with skin of colour. Further research is needed in this underrepresented group.

Abstract Background In 2024, one-third of GP appointments in England were conducted by telephone. What happens during these consultations is largely unknown. Aim To test the feasibility of collecting recorded GP telephone consultations with linked data and consent for future research use. Design and setting Retrospective observational study in seven practices in South West England. Method Adults who had a telephone consultation at practices that routinely record calls were invited to consent to retrieval of call audio, a 4-month electronic health record (EHR) extract and a post-consultation patient questionnaire. Practice-level consent rates were analysed using regression models. Results Of 28 clinicians recruited, 19 GPs had consultations with patients whose recordings were retrievable, usable, and consented for future research. Of 2,053 invitations, 123 patients consented (6.0%). Consent was lower in more deprived practices (IMD 1–2 vs 9–10: OR=0.22, 95CI=0.09–0.54). Of 101 recordings retrieved, 96 were usable and 91 had consent for future research. 86/91 were linked to EHRs and 89/91 to post-consultation patient questionnaires. Mean consultation duration was 7 minutes 13 seconds; audible typing was heard in 69% (63/91). 161 problems were discussed (mean 1.77 per consultation). Most patients were happy their consultation was by telephone (96/117, 82%), although the majority reported usually preferring face-to-face appointments (68/115, 59%). Conclusion It is feasible to assemble a reusable archive of GP telephone consultations with linked data. However, recruitment was low using retrospective remote consent. Future work should test alternative recruitment approaches, particularly to improve patient engagement at practices serving deprived populations. How this fits in Telephone consultations now account for approximately one-third of GP appointments in England, yet the interactional detail of these calls remains under-described. This study establishes the One in a Million Telesafe archive: 91 recorded GP telephone consultations from seven practices, linked to EHR and patient-and clinician-reported data, with permissions for research re-use. Feasibility was demonstrated, but retrospective, remote consent produced low participation (6%) with lower responses in more deprived practices, limiting generalisability of estimates from this dataset. The archive offers a platform to examine communication quality and documentation, informing service design for safe, person-centred remote primary care.

Lower urinary tract symptoms (LUTS) affect up to 90% of men aged >50 yrs, but few (around 10%) receive appropriate treatment. Research indicates that men with LUTS are mostly poorly informed about their urinary symptoms and view LUTS as largely unworthy of clinical attention. As a result, many men endure symptoms for lengthy periods without seeking support. In this uninformed and untreated context, men with LUTS are susceptible to anxiety about prostate cancer, fueled by widespread misconceptions about the association between prostate cancer and LUTS. Prostate cancer fear drives a sizeable proportion of male LUTS primary care consultations. This mini review examines the hitherto largely unrecognized “PSA test loop”—whereby over time, men with LUTS undergo repeated cycles of prostate-specific antigen (PSA) testing with negative results, but do not receive clinically recommended information or guidance within primary care to support their urinary symptoms. This concept arose through qualitative research, which was part of a large UK randomized controlled trial of conservative management for male LUTS [TRIUMPH study: ISRCTN11669964]. The PSA test loop is set in motion when men with LUTS attend primary care with a focus on prostate cancer and PSA testing, and when general practitioner (GP) attention subsequently shifts away from urinary symptoms and the provision of appropriate information, guidance and treatment to support male LUTS. The effect is compounded by GP consultation time constraints and by limitations in GPs’ attitudes and knowledge in relation to the self-management of male LUTS. The PSA test loop is activated when men with LUTS receive negative PSA results, often by telephone, and experience relief in relation to their prostate cancer concerns, leading them to exit primary care—without follow-up and without receiving guidance to support their untreated urinary symptoms. Over time, as symptoms persist and prostate cancer fears resurface, the cycle repeats. The TRIUMPH study has demonstrated that a structured and tailored self-management intervention can be effectively delivered in primary care, outside of GP consultation time (eg, by trained health care assistants or nurses), and can provide information, guidance, reassurance and symptom relief. We propose prioritizing self-management guidance for men with LUTS in primary care, especially following negative PSA testing, to better inform men, to alleviate untreated urinary symptoms and associated prostate cancer concerns, and to deactivate the PSA test loop cycle. Patient summary Older men with urinary symptoms can become trapped in cycles of prostate cancer testing (prostate-specific antigen - or 'PSA' - tests), without receiving proper advice to help relieve their symptoms. We explain how this can happen and propose offering men who receive negative PSA results a follow-up appointment in primary care with a trained nurse or health care assistant. The follow-up appointment would be an opportunity to provide men with up-to-date information on their urinary symptoms and tailored guidance, based on clinically trialed and recommended self-help techniques, to help men manage their urinary symptoms.

BACKGROUND:In countries with well-resourced primary care, most children with eczema are managed by their general practitioner, but we know little about how often they are seen or how they are treated. OBJECTIVES:To describe patterns of consultations and prescribing by eczema severity for children with eczema. METHODS:Analysis of electronic medical record data from 422 participants in the BATHE study. We used descriptive statistics to compare participants' characteristics, consultation and prescribing patterns. We explored associations with eczema severity [Patient-Oriented Eczema Measure (POEM)], age and sex using Poisson and linear regression models. RESULTS:Mean age 4.8 (SD 2.9) years and POEM 10.0 (SD 5.8). Over 12 months, 386 children had a median of 4.0 (interquartile range 2.0-7.0) consultations. Of 2049 encounters, 1421 (69.4%) were for an eczema flare. Emollients were the most commonly prescribed item, with a mean of 4.6 (SD 4.5) prescriptions (median total quantity 1500 g or mL) per child over 12 months, yet 32.2% (136/422) were not prescribed any. On average, children were prescribed 1.3 (SD 0.5) different emollient types, with cream being most common [74.3% (211/284) children, 59.8% (778/1300) prescriptions]. In total, 51.7% (218/422) were prescribed a topical corticosteroid (TCS) with a mean of 2.8 (SD 2.5) prescriptions (90 g or mL) per child over 12 months and a mean of 1.4 (SD 0.6) different TCS potency types [mild being the most common 71.6% (151/211) children, 54.2% (316/583) prescriptions]. The number of consultations, but not the quantity of emollients and TCS prescribed, was associated with age and eczema severity. CONCLUSIONS:Children with eczema are seen frequently in primary care but are prescribed less emollient and TCS than might be appropriate for age and severity.

The Finger-tip Unit (FTU) has guided topical corticosteroid dosing in eczema since 1991, but does it work in practice? Drawing on published research and parent lived-experience, we highlight confusion around FTU-based guidance, from inconsistent prescribing outcomes to variability in finger size and nozzle standards. We argue the FTU is better suited to clinicians than patients, and call for research comparing it against simpler advice like "apply a thin layer."

BACKGROUND:Informed self-management is the first-line treatment for male lower urinary tract symptoms (LUTS), although the extent of delivery in primary care is unclear. The TReating Urinary symptoms in Men in Primary Health care (TRIUMPH) cluster randomised controlled trial (reference: ISRCTN11669964) compared a structured self-management intervention with usual care for men with LUTS. We report on embedded qualitative interviews. AIM:To investigate men's experiences of LUTS, engagement with primary care, and responses to a self-management intervention, along with the perspectives of primary care clinicians in order to inform the delivery of self-management guidance in primary care. DESIGN & SETTING:Qualitative interview study embedded in the TRIUMPH trial, which was conducted across 30 general practice sites in the South West of England. METHOD:Semi-structured interviews were conducted with 58 men with LUTS (selected purposively from the TRIUMPH trial population) and 14 treating clinicians (recruited from the TRIUMPH trial primary care sites), then analysed using thematic analysis. RESULTS:Men with LUTS were characterised as 'languishing', poorly informed, discounting symptoms as 'just old men's problems', and experiencing prostate-specific antigen (PSA) testing cycles that did not resolve their LUTS. GPs described a focus on LUTS self-management being restricted by clinical pressures and attending to prostate cancer concerns. The TRIUMPH self-help intervention booklet was strongly valued by men: many reported that it gave them a greater understanding of their symptoms and self-management options, reduced anxiety, and that using it improved their LUTS and quality of life. A few men, however, found the intervention unrewarding. CONCLUSION:Explanations and tailored self-management support were liked and found useful by many men with LUTS. Recommendations for clinical practice include: avoiding the expression 'old men's problems', ensuring LUTS follow-up after PSA testing, focusing on symptoms and self-management approaches, and distributing the TRIUMPH booklet widely.

Background A systematic review of international guidelines for eczema (syn. atopic dermatitis) highlighted variable recommendations for using topical corticosteroid (TCS), reflecting limited randomised controlled trial (RCT) evidence to inform practice. The Rapid Eczema Trials project is a novel programme delivering multiple online RCTs working with members of the public to co-design studies that answer questions of importance to them. The Keep Control of Eczema Study evaluates whether providing specific advice on how long to apply TCS for during an eczema flare-up improves eczema control compared to usual care, over 16 weeks. Methods This is an online, two-arm, parallel-group superiority RCT. Individuals are eligible if aged ≥1 year, live in the UK, have used TCS on at least three days for eczema flares in the past 8 weeks, and are willing to change how they use their TCS. Participants are excluded if using a TCS preparation with antibiotics/antifungal, unlikely to have atopic eczema, eczema only present on the scalp and/or sensitive body sites, and using very strong TCS. Participants are randomised 1:1 to either: 1) specific advice to treat eczema flares for slightly longer or 2) treat as usual. Those allocated to the treat for longer group are asked to use TCS for 2 days after the skin looks/feels eczema-free. Primary outcome is eczema control measured by Recap of atopic eczema (RECAP) assessed weekly over 16 weeks. Secondary outcomes: Patient Oriented Eczema Measure (POEM), days of TCS use and skin specific quality of life, number of weeks when TCS not used, number of well controlled weeks, global change in eczema and safety outcomes. Some participants will be invited to a semi-structured interview to discuss their experience. The primary analysis will be conducted according to randomised allocation regardless of adherence to allocated TCS strategy during a flare-up. Trial registration: Prospectively registered with the International Standard Randomised Controlled Trial Number (ISRCTN) 29214215. DOI: https://doi.org/10.1186/ISRCTN29214215

Background A systematic review of international guidelines for eczema (syn. atopic dermatitis) highlighted variable recommendations for using topical corticosteroid (TCS), reflecting limited randomised controlled trial (RCT) evidence to inform practice. The Rapid Eczema Trials project is a novel programme delivering multiple online RCTs working with members of the public to co-design studies that answer questions of importance to them. The Keep Control of Eczema Study evaluates whether providing specific advice on how long to apply TCS for during an eczema flare-up improves eczema control compared to usual care, over 16 weeks. Methods This is an online, two-arm, parallel-group superiority RCT. Individuals are eligible if aged ≥1 year, live in the UK, have used TCS on at least three days for eczema flares in the past 8 weeks, and are willing to change how they use their TCS. Participants are excluded if using a TCS preparation with antibiotics/antifungal, unlikely to have atopic eczema, eczema only present on the scalp and/or sensitive body sites, and using very strong TCS. Participants are randomised 1:1 to either: 1) specific advice to treat eczema flares for slightly longer or 2) treat as usual. Those allocated to the treat for longer group are asked to use TCS for 2 days after the skin looks/feels eczema-free. Primary outcome is eczema control measured by Recap of atopic eczema (RECAP) assessed weekly over 16 weeks. Secondary outcomes: Patient Oriented Eczema Measure (POEM), days of TCS use and skin specific quality of life, number of weeks when TCS not used, number of well controlled weeks, global change in eczema and safety outcomes. Some participants will be invited to a semi-structured interview to discuss their experience. The primary analysis will be conducted according to randomised allocation regardless of adherence to allocated TCS strategy during a flare-up. Trial registration: Prospectively registered with the International Standard Randomised Controlled Trial Number (ISRCTN) 29214215. DOI: https://doi.org/10.1186/ISRCTN29214215

Background Acne is common with substantial impact on quality of life and health care costs. Antibiotics are frequently prescribed, leading to antibiotic resistance. Guidelines recommend topical treatments as first-line therapy, but they are under-used due to low awareness, avoidable side effects or delayed onset of action. AcneCareOnline, an online behavioural intervention, was developed to support self-management for young people with acne. Methods Multi-centre 1:1 randomized controlled trial with economic evaluation and process evaluation of AcneCareOnline. The trial will recruit people aged 13–25 years with self-defined acne and active lesions (on self-assessment scale). Participants will be recruited through English general practices, community pharmacies, schools/colleges, community and social media advertising. Intervention group receive access to AcneCareOnline. Control group are signposted to NHS advice and given access to the intervention after follow-up. Both groups have access to usual care. Follow-up is for 52 weeks. Target sample size is 908 participants. Outcomes Primary outcome is acne severity at 12 weeks, measured using Acne-QoL symptoms subscale. Secondary outcomes include; acne severity evaluated over 12 months (Acne-QoL symptoms subscale), other Acne-QoL subscales; self-reported treatment use, Patient Enablement Instrument, Brief Illness Perceptions Questionnaire, Patient Health Questionnaire, EQ-5D-5L, Short Warwick Edinburgh Mental Well-being Scale, and resource use. Process evaluation includes qualitative interviews to explore trial participants’ engagement with the intervention and quantitative examination of potential moderator effects on intervention engagement. Economic evaluation includes cost utility analyses to estimate the cost-effectiveness of the online intervention compared to usual care alone from NHS and participant perspectives.

INTRODUCTION:Using the James Lind Alliance (JLA) methodology, we established a Priority Setting Partnership (PSP) to identify the most important unanswered research questions in childhood food allergy. This approach places those directly affected, those with food allergy, their parents/carers, and healthcare professionals at the centre of the process. METHODS:A multidisciplinary steering group (n = 19 people) oversaw the PSP. Research uncertainties were collected through a UK-wide online survey distributed to children, young people and adults with food allergy, their parents/carers, and healthcare professionals working in food allergy. A focus group was conducted with seven children aged 8-11 years with food allergy to ensure inclusion of their perspectives. Submitted questions were reviewed, combined into summary questions, and checked against existing evidence to confirm that they represented genuine uncertainties. An interim prioritisation survey was used to rank questions, with equal weighting given to each stakeholder group. A final facilitated workshop used a nominal group technique to agree on the top 10 research priorities. RESULTS:In total, 916 respondents submitted 2563 questions. After removing out-of-scope and already answered questions, an interim prioritisation survey was completed by 1087 participants. The final workshop involved 29 participants, including young people (n = 3), young adults (n = 4), parents (n = 7) and multidisciplinary healthcare professionals (n = 15), who agreed on the top 10 questions. These cover prevention, early diagnosis, treatment, causes, eating out, safety in care settings, impact, emergency treatment, and awareness of food allergy. There was strong consensus from the final workshop across all attendees that prevention should be the number one priority. CONCLUSION:Using a rigorous, transparent, and person-centred approach, we have identified the most important research priorities in childhood food allergy. They highlight the depth and breadth of research required to improve the prevention, diagnosis, treatment, and broader impacts of food allergy on children, families, and carers who live with this condition.

Background In 2024, one-third of NHS GP consultations in England were conducted by telephone. Although remote consulting can be convenient for patients and GPs, it may increase diagnostic uncertainty. Safety-netting advice (guidance on when, and how, patients should seek further medical help) is a tool used to mitigate clinical risk, but its delivery during telephone consultations has not been studied in detail. Aim To evaluate the communication, documentation, and patient recall of safety-netting advice in GP telephone consultations. Design & setting Observational study using data from seven GP practices in south west England. Method Practices routinely recording telephone consultations were invited to participate. Patients with a recent telephone consultation with a participating clinician were invited to consent to consultation recording retrieval, medical record extraction, and completion of a post-consultation questionnaire. Recordings of 96 telephone consultations were obtained and coded using the validated Safety-Netting Coding Tool. Regression models explored factors associated with safety-netting advice. Patient recall was assessed using post-consultation questionnaires. Results There were 93 instances of safety-netting advice, delivered in 60.4% (n = 58) of 96 consultations applying to 43.4% (n = 72) of 166 identified problems. Instances of safety-netting advice were mostly GP initiated (95.7%, n = 89), delivered during treatment planning (66.7%, n = 62), and included specific elements (64.5%, n = 60). Delivered safety-netting advice was documented in 64.2% (n = 34) of 53 consultations with notes that were available. Written advice was rarely used: only four out of 96 consultations contained written advice, which was delivered via text message. Patients correctly recalled the presence of safety-netting advice in two-thirds of consultations when it was given. Safety-netting advice was more likely to be provided by younger GPs (aged <45 years; odds ratio 5.09, P = 0.011). Conclusion Safety-netting advice was commonly delivered during GP telephone consultations, but its delivery, documentation, and recall were inconsistent. Opportunities exist to improve the consistency, documentation, and use of written advice to support patient understanding, recall, and safety in remote care.