Summary
The Severe Eczema Clinic (SEC) at St John’s Institute of Dermatology, Guy’s & St Thomas’ NHS Foundation Trust, is a unique, multidisciplinary service for children and young people on systemic medication. Led by Professor Flohr since 2014, the SEC receives referrals from across the country. It comprises outpatient clinics and multidisciplinary team (MDT) meetings and includes consultant dermatologists, speciality registrars, clinical fellows, clinical nurse specialists, a clinical psychologist, research practitioners and paediatric dermatology pharmacists. The wider SEC MDT includes paediatric allergy, respiratory medicine, immunology, sleep medicine and ophthalmology. The team delivers high quality care, which goes beyond the clinic. It also runs national educational programmes for patients, carers and colleagues.
Method
The clinical nurse specialists operate a direct patient helpline, supported by doctors. There is also an in-clinic pharmacist, who is a biologics prescriber, overseeing the safe prescribing of systemic therapies. The MDT paediatric clinical psychologist provides in-clinic support to address mental health concerns and has developed a habit reversal programme, as well as a stepped care model to enable patients to access input (eg self-help booklets) and individual therapy sessions, supporting patients to manage the impact of living with eczema. The research practitioners recruit patients into systemic therapy trials, and the SEC is the coordinating centre of the UK-Irish Atopic eczema Systemic TherApy Register (A-STAR). Clear referral pathways have been established with paediatric allergy, immunology and sleep medicine colleagues, running joint consultations when required, including a monthly joint paediatric allergy and dermatology clinic. In addition, there is a well-established transition pathway for adolescent patients.
Results
About 800 eczema patients are cared for on systemic therapies per year – the largest paediatric cohort on biologics in the UK. Validated disease severity and quality-of-life scores are reviewed on every visit to monitor progress. There are paediatric-specific guidelines for all systemic therapies and quality improvement projects are conducted regularly. The specific needs of adolescents and their transition into adult care are recognised. MDT members regularly present on the research and care models at national and international conferences. In addition to nurse-led patient education sessions, national courses are held – one on Paediatric Dermatology and an ‘Allergy and the Skin’ study day – both attended by around 250 colleagues annually. Prof Flohr works with the National Eczema Society and Eczema Outreach Support charities, running patient webinars. The clear treatment pathways and guidelines have been adopted by other departments. National educational activities ensure positive outcomes for patients in the clinic and beyond. Senior consultant Dr Howard led the development of a service to optimise delivery of developmentally appropriate care for adolescent patients and their transition pathway through to the adult services. This was co-created with adolescent patients and the hospital transformation team. A mobile app has been developed to track patient progress through disease severity, quality of life and psychological co-morbidity questionnaires (DrDoctor platform). Individual psychology sessions, mindfulness workshops and habit reversal groups have received positive feedback from patients and parents, as well as reducing mood scores. The clinic-embedded research team recruits patients into the national A-STAR registry and identifies patients for novel systemic therapy trials, as well as the SEC’s Medical Research Foundation-funded ‘Mind & Skin’ study.
Sustainability and Spread
The SEC led the largest worldwide clinical trial with conventional systemic medication in children with severe eczema (TREAT). The findings resulted in a shift in systemic prescribing internationally, favouring methotrexate over ciclosporin. Furthermore, the team presented its integrated care model and outcome data at British Society of Paediatric and Adolescent Dermatology and Psychodermatology UK events. A teaching seminar was run on Paediatric Psychodermatology and had an outstanding feedback rating (4.8/5), increasing physicians’ confidence in managing paediatric patients’ psychological needs. Habit reversal materials have been developed in collaboration with families for the Kids in Control project, funded by the UK Dermatology Clinical Trials Network. The aim is to integrate the scheme into existing clinical care pathways and ultimately test it in a clinical trial. The MDT regularly contributes to national webinar events, while the annual DermAcademy webinars, held in collaboration with the National Eczema Society, have improved understanding and management of eczema for patients and families.
Dermatology Team of the Year
The Paediatric Severe Eczema Clinic
by St John’s Institute of Dermatology, Guy’s & St Thomas’ NHS Foundation Trust
