Quality of life in children with Quality of life in children with juvenile plantar dermatosis in juvenile plantar dermatosis in

primary care settingsprimary care settings

Antonio An Tung ChuhAntonio An Tung ChuhMD(HK) MRCP(UK) FRCP(Irel) MRCPCH FRACGPMD(HK) MRCP(UK) FRCP(Irel) MRCPCH FRACGP

General practitioner in private practice in Hong KongGeneral practitioner in private practice in Hong Kong

Part-time Clinical Associate ProfessorPart-time Clinical Associate Professor

Department of Community and Family MedicineDepartment of Community and Family Medicine

Chinese University of Hong KongChinese University of Hong Kong

Background – juvenile plantar Background – juvenile plantar dermatosisdermatosis

Juvenile plantar dermatosis (JPD) is a common dermatosis affecting children and adolescents.

Previous clinical descriptions were from dermatologists in specialist settings.

Whether such applies to children with JPD in the community and the effect of JPD on the quality of life (QOL) are unknown.

Background – treatment of juvenile Background – treatment of juvenile plantar dermatosisplantar dermatosis

Various treatments were employed empirically for JPD.

Whether treatment has significant impact on QOL is also unknown.

Background – Children’s Background – Children’s Dermatology Life Quality IndexDermatology Life Quality Index

The Children’s Dermatology Life Quality Index (CDLQI)© questionnaire is designed for use in children aged 5-16.

Lewis-Jones MS, Finlay AY. The Children's Dermatology Life Quality Index (CDLQI): Initial validation and practical use. Br J Dermatol 1995; 132: 942-9.

© M.S. Lewis-Jones, A.Y. Finlay, May 1993

Background – Children’s Background – Children’s Dermatology Life Quality IndexDermatology Life Quality Index

Self explanatory, can be simply handed to the child

Child’s parent or guardian may help.

Usually completed in 1-2 minutes.

Translation of CDLQI into CantoneseTranslation of CDLQI into Cantonese

Obtained written permission from copyright owners of the CDLQI to translate such into the Cantonese dialect of Chinese, and to apply CDLQI in this study.

The translation work was arranged by the Department of Linguistics, University of Hong Kong.

Translation of CDLQI into CantoneseTranslation of CDLQI into Cantonese

Two independent translators translated CDLQI into the Cantonese. They then discussed and agreed on a joint second Cantonese version.

Two further translators then back translated the questionnaire to English.

The discrepancies from the original English version were noted, and modifications with further checking and by further back translation.

Translation of CDLQI into CantoneseTranslation of CDLQI into Cantonese

I then requested five children with skin problems to complete this third Cantonese version.

These five patients were interviewed with respect to comprehensibility, ambiguity of the items and relevance to their social context.

Validation of Cantonese CDLQIValidation of Cantonese CDLQI

I requested 30 children with skin problems (18 males and 12 females, mean age = 9.5 years) and 30 children consulting for problems unrelated to the skin (17 males and 13 females, mean age = 8.9 years) in a primary care setting to complete the Cantonese CDLQI questionnaire before their consultation.

I assessed the severity of the skin problem with a scale of 1 to 5 (1: mildest, 5: most severe). I had no knowledge of their CDLQI scores during the assessment.

Validation of Cantonese CDLQIValidation of Cantonese CDLQI

The CDLQI scores were positively correlated with physician-rated disease severity, such correlation being strong (s = +0.850) and

significant (p < 0.01).

For individual diseases, results of the Cantonese CDLQI were similar to those of the English version (Lewis-Jones MS and Finlay AY, 1995).

Validation of Cantonese CDLQIValidation of Cantonese CDLQI

Item-scale correlations were all greater or equal to 0.40.

Validation of Cantonese CDLQI – Validation of Cantonese CDLQI – reliability and internal consistencyreliability and internal consistency

Nine children with skin problems and seven children with problems unrelated to the skin completed the Cantonese CDLQI again seven days later.

The single measure intra-class correlation coefficient of test and retest results was 0.94 (95% CI: 0.84 – 0.98).

The test-retest score differences were statistically insignificant (two-tailed p = 0.817).

Cronbach’s was +0.83 for collective analysis of scores of all ten questions.

ObjectivesObjectives

To investigate:

Effects on QOL in children with JPD, and

Whether treatment has significant impact on QOL.

MethodMethod

Between 1 October 2003 and 31 March 2004 (six months), all children aged between 5-16 diagnosed to have JPD in a primary care setting were invited to join the study.

The diagnoses were made clinically by a physician with training and qualifications in paediatrics and dermatology.

MethodMethod

Our diagnostic criteria was “persistent erythema of feet with scaling and/or cracking at the pressure bearing areas”.

Dermatophyte infection was excluded by skin scraping for fungal smear and culture.

MethodMethod

JPD is often associated with atopic dermatitis.

For the purpose of this study, children with JPD and atopic dermatitis were excluded.

MethodMethod

For each child diagnosed with JPD, the next child of the same sex and comparable age ( two years) consulting us for atopic dermatitis was recruited as the first group of controls.We adopted the diagnostic criteria of the United Kingdom Working Party.Similarly, the next child of the same sex and comparable age consulting us for conditions unrelated to the skin was recruited as the second group of controls.

MethodMethod

The study and control subjects were given unlimited time to complete the questionnaire.Parents or guardians were encouraged to assist in the process in a passive manner.They were instructed to only respond to queries raised by the child, and not to intervene otherwise.They may read the questionnaire aloud if necessary, but were explicitly advised not to suggest or amend the responses.

Method – treatmentMethod – treatment

Standard treatment was then advised for the children which is the same as children with JPD not being recruited for study.Such comprises general advice on foot protection (well fitting shoes, cotton socks to reduce friction, avoid walking barefooted) and liberal application of emollients for all children, and topical corticosteroids for acute flare-ups of erythematous and pruritic feet for short durations for some children.

MethodMethod

Children with JPD were requested to complete the questionnaire when they attended follow-up three to six months after the initial consultation.

Informed consent was obtained from parents or legal guardians of all study and control subjects.

ResultsResults

A total of 54 children were recruited, 18 being children with JPD, 18 being age-and-sex-matched control subjects with atopic dermatitis, and 18 being age-and-sex-matched control subjects consulting for conditions unrelated to the skin.

The children with PR were aged between five and 15 years (mean = 12.8 years).

11 (61%) were males and seven (39%) were females.

All had fungal smear and culture negative.

ResultsResults

Parents of all children diagnosed with PR in the recruitment period consented to participate.

All these children and their parents completed the questionnaires.

The response and completion rates were both 100.0%.

ResultsResults

The 18 control subjects with atopic dermatitis were aged between five and 16 years (mean = 12.3 years).

The 18 control subjects consulting for conditions unrelated to the skin were aged between six and 15 years (mean = 12.2 years).

JPD before treatment

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ResultsResults

The total CDLQI scores of children with JPD before our treatment ranged from 0 to 8, the mean total score being 2.06 (95% CI 0.62 to 3.49, SD = 2.88).

Scores in all six parameters were low, with symptoms and feelings (8.0%), leisure (9.3%), and treatment (9.3%) being the highest. Personal relationships (0.0%) had the lowest score.

Atopic dermatitis

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ResultsResults

The total CDLQI scores of control subjects with atopic dermatitis ranged from 4 to 12 (mean = 8.00, 95% CI 6.53 to 9.47, SD = 2.95).

Symptoms and feelings incurred the highest score (45.4%). School or holidays had the lowest score (7.4%).

No skin disease

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ResultsResults

The total CDLQI scores of children consulting for conditions unrelated to the skin ranged from 0 to 2. The mean total score was 0.22 (95% CI -0.05 to 0.44, SD = 0.55).

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ResultsResults

The total CDLQI scores of children with JPD are significantly lower than that of children with atopic dermatitis (p = 0.0008).

The total CDLQI scores of children with JPD are significantly higher than children consulting for conditions unrelated to the skin (p = 0.0178).

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Atopicdermatitis

No skin disease JPD beforetreatment

JPD aftertreatment

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ResultsResults

The total CDLQI score of these children after our treatment ranged from 0 to 8, the mean total score being 1.83 (95% CI 0.52 to 3.15, SD = 2.64).

The mean scores dropped in the three parameters of symptoms and feelings, leisure, and school or holidays. However, the drop was not statistically significant.

The mean scores remained unchanged for personal relationships (0.0%) and sleep (5.6%). The mean scores increased for treatment (from 9.3% to 13.0%). Changes in all parameters were not statistically significant.

Discussion and conclusionsDiscussion and conclusions

Unlike children seen in specialist settings, children with JPD in primary care has QOL affected to a small extent only.

Standard treatment does not have significant impact on QOL.

Discussion and conclusionsDiscussion and conclusions

From our experience, most children with JPD in the community are not bothered by their dermatosis at all.

It is just their parents which are showing concern for the chronic remitting and relapsing nature of the dermatosis, the underlying factors, and whether active investigations and treatments for fungal infections are necessary.

Discussion and conclusionsDiscussion and conclusions

We have also witnessed some children with JPD being over-investigated and over-treated by specialists, particularly dermatologists in private practice.

Discussion and conclusionsDiscussion and conclusions

We are convinced that for most children with JPD, explanation and reassurance by a primary care physicians is adequate to allay the fears and concerns of the parents.

It is likely that in primary care, most children with JPD would not need active pharmacological treatment.

Discussion and conclusionsDiscussion and conclusions

Our results are likely to be different if the study has been conducted at a specialist setting.

We are convinced that primary care represents the closest proxy measure of a common community diagnosis such as JPD.

We emphasised the importance for QOL studies to be performed in primary care settings to avoid referral bias present in specialist settings.

Major messagesMajor messages

While doctors manage the disease, patients experience the illness. There can be huge differences.Organ-specific and disease-specific QOL tools may be more appropriate than generic health-related QOL tools for some conditions.Proper translation and validation of QOL tools are important before clinical application.The assessment of QOL of community-based diagnoses are best performed in the community.

AcknowledgementAcknowledgement

We thank Professor A Finlay, Head, Department of Dermatology, University of Wales College of Medicine, for his permission to use the Cantonese CDLQI in this study, and for his valuable comments on the methodology.