General practitioner prescription patterns for atopic eczema in children—Are they affected by telemedicine advice?

Traditionally, patients presenting to primary care with severe eczema would be referred to a dermatology clinic for an in‐person specialist appointment. With the rise of teledermatology, dermatologists are instead dispensing tailored written advice based on information provided in the referral. However, there is currently minimal literature assessing whether this advice translates into relevant prescriptions. This clinical audit examines GP prescribing practices and how they correlate to dermatologist recommendations with the objective of assessing whether this form of teledermatology is a viable method of providing care to paediatric eczema patients.


INTRODUCTION
Eczema is a common skin condition estimated to affect up to 20% of children worldwide. 1,2][4] Furthermore, many GPs lack the confidence to manage severe paediatric eczema and are hesitant to follow local guidelines. 5eledermatology refers to the remote assessment of dermatological conditions through technology without seeing patients in person.This is an area that has greatly increased in popularity given the decrease in the availability of in-person appointments.Instead of seeing referred patients in the clinic, dermatologists can offer tailored treatment advice based on information provided by the GP including history, photos, examination findings and current treatment regime.As there is no direct interaction between the dermatologist and the patient, it is the responsibility of the GP to incorporate this advice and dispense care accordingly to the patient.
A potential limitation of this process is the translation of specialist advice by the treating GP into actual prescribing.This study aims to assess whether specialist advice results in a relevant change in subsequent GP prescribing practices.
Medications of interest include topical corticosteroids (TCS), moisturisers, antimicrobials, combination topical corticosteroids/antimicrobials, antihistamines, antibiotics, systemic corticosteroids and calcineurin inhibitors as these are all commonly prescribed eczema medications in primary care. 6

METHODS
A retrospective review of data from Te Whatu Ora Waikato Dermatology Department's telemedicine advice service was performed.The study population included all paediatric patients (patients aged 15 years or less) referred to Waikato's Dermatology Department for telemedicine consultation regarding eczema from 1 July 2020 to 31 June 2022.Exclusion criteria included duplicate referrals, patients who were seen in person within 6 months of initial advice, and referrals that were declined.Data were collected from the electronic referral system, business analytical data and electronic medical records.Ethics approval was not required to perform this audit.
All eczema medications prescribed to these patients 6 months before and after the telemedicine consultation were recorded from the New Zealand e-prescribing system (an online record of all prescribed medications).This was expressed as the number of patients that received each medication at least once during these periods.The McNemar chi-squared test was then used to assess whether there was any statistically significant shift in GP prescription patterns as a result of the telemedicine advice.
Prescribing recommendations made by dermatologists were also recorded and compared to the prescriptions received by patients in the 6 months following the telemedicine consultation.The frequency with which GP prescriptions corresponded to dermatologist recommendations was expressed as a percentage.The prescribed medication had to be identical to the recommended medication in both content and formulation to be accepted.The frequency with which GP prescriptions deviated from advice given was also calculated and expressed as a percentage.

RESULTS
A total of 162 patients were included in the study.There were 83 males and 79 females with an average age of 62 months.Of the 162 patients, 130 had eczema affecting the body and 100 had eczema affecting the face.
There was a significant change in the prescribing patterns of several medications following dermatology specialist advice (Table 1).The proportion of patients receiving a mild or moderate TCS for the face increased by 133% (p < 0.05), while the proportion of patients receiving a moderate or potent TCS for the body increased by 168% (p < 0.001).Dermatologist-approved moisturiser use was increased by 87.2% (p < 0.001).There was a decrease of 40.8% (p < 0.05) and 64.3% (p < 0.001) in the number of patients receiving an antimicrobial and combination topical antimicrobial/corticosteroid respectively.No statistically significant change was seen in the proportion of people who were prescribed each of the remaining classes of medication.
Comparing advice given in the telemedicine consultation to prescriptions received by the patient in the 6 months following the advice showed generally low levels of correlation.Overall, 51.2% of TCS and 51.9% of topical calcineurin inhibitors recommended by dermatologists were prescribed.Advice to prescribe emollients and antibacterials was followed more frequently at 65.5% and 63.6% respectively.
Our study also shows that many non-recommended products were prescribed during the follow-up period (Table 2).Of the 4 patients who were recommended combination topical antimicrobial/corticosteroids, only one patient received this product during the follow-up period with a further 19 patients receiving them inappropriately (95% discordance).This was followed by antibacterials (80.6%), ketoconazole shampoo (63.6%) and TCS (48.3%).The majority of emollient and calcineurin inhibitor prescriptions were in accordance with advice, with 23.9% and 22.2% of prescriptions, respectively, not having been advised.

Dermatological guidelines for the management of severe atopic eczema in children based on local guidelines 7
T A B L E 1 Number of patients who received each medication before and after telemedicine consultation/advice.While there was a statistically significant increase in the proportion of patients receiving adequate strength and formulation topical corticosteroids, the absolute numbers remained low.As children referred to dermatology generally have more severe eczema, optimal treatment would require the use of moderate or potent topical corticosteroid ointments for the body-which most (54.6%) did not receive-even after receiving specialist input.GPs continued to prescribe their preferred (usually less potent) TCS in 48.3% of TCS prescriptions.

Medication
Dermatologists typically recommend moisturisers such as emulsifying ointment, liquid paraffin 50/50, fatty emulsion cream and white soft paraffin as there is some evidence that suggests thicker ointment-based moisturisers work better than creams/lotions. 9These moisturisers were also poorly prescribed after telemedicine intervention with only 54.3% of patients receiving an appropriate product.
Topical antimicrobial-containing products are another area of concern given the implications for antibiotic resistance. 9Furthermore, topical antimicrobials do not make a difference in comparison to aggressive treatment with TCS and moisturiser. 10As such, they are seldom recommended by dermatologists.It was encouraging to note a statistically significant decrease in the proportion of patients receiving an antimicrobial or combination topical antimicrobial/corticosteroid.Unfortunately, despite this, ongoing prescription of antimicrobial-containing products continues to be an issue especially in the context of poor correlation with dermatologist advice.
Another anomaly noted was the frequency of antihistamine prescribing.Antihistamines are not effective for treating itch caused by eczema, with sedating antihistamines in particular having the potential for serious adverse effects especially in younger children.Likewise, antibiotics and systemic corticosteroids should be generally avoided based on local guidelines. 7Telemedicine advice did little to alter prescriptions for systemic corticosteroids, antihistamines and oral antibiotics.
While our study shows telemedicine advice improved prescribing patterns by GPs, children remain generally undertreated.Only 51.2% of recommended topical corticosteroids and 65.6% of recommended emollients were prescribed to patients.Furthermore, there continues to be a high level of deviation by GPs from dermatologist recommendations especially for antimicrobial-containing products.

CONCLUSION
Overall GP prescriptions did not reflect local guidelines for the management of paediatric eczema, nor specialist advice provided.Less than half the patients received prescriptions which could be considered 'adequate' to manage their eczema.The use of teledermatology advice improved the prescribing of more potent TCS on the body and mild/moderate TCS on the face as well as increasing prescriptions for dermatologist-recommended moisturisers.However, the gap between advice and actual prescribing behaviour remains high.Ongoing use of topical antimicrobials and combination antimicrobials/TCS reflects a lack of prescriber knowledge/insight into overall risks.Teledermatology advice is useful but insufficient to overcome barriers in primary care in embracing paediatric eczema guidelines.Further work is needed to investigate models of care delivery with a scarcity of dermatologists.

and prescribed (no. of times) Recommended but not prescribed (no. of times) Not recommended but prescribed (no. of times) % of dermatology recommendations observed % of prescriptions not recommended
Correlation between medications recommended by dermatologists in telemedicine advice and GP prescribing practices in the subsequent 6 months.
T A B L E 2