Transcript Quality of life in children with juvenile plantar

Quality of life in children with
juvenile plantar dermatosis in
primary care settings
Antonio An Tung Chuh
MD(HK) MRCP(UK) FRCP(Irel) MRCPCH FRACGP
General practitioner in private practice in Hong Kong
Part-time Clinical Associate Professor
Department of Community and Family Medicine
Chinese University of Hong Kong
Background – juvenile plantar
dermatosis
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
plantar dermatosis
Various treatments were employed empirically for
JPD.
Whether treatment has significant impact on
QOL is also unknown.
Background – Children’s Dermatology
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 Dermatology
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 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 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 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 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 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 CDLQI
Item-scale correlations were all greater or equal
to 0.40.
Validation of Cantonese CDLQI –
reliability 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.
Objectives
To investigate:
Effects on QOL in children with JPD, and
Whether treatment has significant impact on QOL.
Method
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.
Method
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.
Method
JPD is often associated with atopic dermatitis.
For the purpose of this study, children with JPD
and atopic dermatitis were excluded.
Method
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.
Method
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 – 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.
Method
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.
Results
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.
Results
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%.
Results
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).
Treatment
Sleep
Personal
relationships
School or
holidays
Leisure
Symptoms
and feelings
CDLQI parameter scores
JPD before treatment
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Results
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.
Treatment
Sleep
Personal
relationships
School or
holidays
Leisure
Symptoms
and feelings
CDLQI parameter scores
Atopic dermatitis
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Results
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%).
Treatment
Sleep
Personal
relationships
School or
holidays
Leisure
Symptoms
and feelings
CDLQI parameter scores
No skin disease
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Results
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).
CDLQI total scores
10.00
8.00
6.00
4.00
2.00
0.00
JPD
Atopic dermatitis
No skin disease
Results
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).
CDLQI total scores
10.00
8.00
6.00
4.00
2.00
0.00
Atopic
dermatitis
No skin disease
JPD before
treatment
JPD after
treatment
Treatment
Sleep
Personal
relationships
School or
holidays
Leisure
Symptoms
and feelings
CDLQI parameter scores
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Results
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 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 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 conclusions
We have also witnessed some children with JPD
being over-investigated and over-treated by
specialists, particularly dermatologists in private
practice.
Discussion 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 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 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 healthrelated 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.
Acknowledgement
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.