GPs' experience of diagnosing and managing eczema in children: qualitative study

Problem

Eczema is a common chronic childhood condition, with the majority of children being managed by General Practitioners (GPs). A high level of self-management is needed, but treatment failure in primary care is common, mainly due to poor treatment adherence. While a number of studies have identified the difficulties faced by parents of children with eczema, there has not been research to look at the challenges for GPs in diagnosing and managing this disease. We sought to explore their experiences of, and confidence in, managing children with eczema.

Approach

GPs were recruited across the UK by means of research/professional networks and snowballing. They were sampled across an expressed range of confidence in managing eczema, as well as age, years in role, and socio-economic characteristics of their practice population. Semi-structured in-depth interviews were conducted face-to-face or by telephone, audio-recorded, and transcribed verbatim. A coding frame was developed and refined iteratively with further interviews. Thematic analysis is being undertaken using the principles of Framework Analysis.

Findings

15 GPs were recruited from 14 socio-economically diverse practices in Bristol (7 practices), Gloucestershire (5), Portsmouth (1), and Nottingham (1).

The main emerging problems faced by GPs are: 1) Variable training in Dermatology and dermatological conditions in general were reported to be a low clinical priority in primary care. GPs attended courses or used internet sites rather than using guidelines to inform their knowledge and practice. 2) Diagnostic uncertainty including differentiation of eczema from skin infections, uncertainty around allergies, and eczema skin appearances in different ethnic groups. GPs were unsure how to discuss with patients their commonly reported concerns of underlying allergic aetiology. 3) Treatment uncertainty where GPs reported “Trial and error” was a common approach to prescribing emollients and they were unsure about quantities of treatments to prescribe. GPs also expressed uncertainty about prescribing topical corticosteroids which was compounded by parental fear around this treatment. 4) Low rates of routine review in patients with eczema, to assess treatment acceptability and adherence, which was attributed to pressure on appointments, lack of trained nursing support and no financial incentives.

Consequences

This study identifies gaps in GP confidence, knowledge, and resources to diagnose and manage children with eczema. Evidence from this study along with other published data on the poor management of eczema suggests that more emphasis is needed now on GP dermatology training. Future studies should also look at the development of training resources and support tools which could address the educational needs of both clinicians and patients.