NHS England consultation: Items which should not routinely be prescribed in primary care: an update and a consultation on further guidance for CCGs

Official response from the British Association of Dermatologists’ Officers and Therapy & Guidelines sub-committee

Preliminary questions

A. Do you feel there are any groups, protected by the Equality Act 2010, likely to be disproportionately affected by this work?

– No (tick box)

B. Do you feel there is any further evidence we should consider in our proposals on the potential impact on health inequalities experience by certain groups e.g. people on low incomes; people from black and minority ethnic (BME) communities?

– Yes (tick box)

Please provide further information on why you think this might be the case.

– People from lower socioeconomic background will be deprived of the choice of certain products (see our response for bath and shower preparations) which might lead to worsening of their condition and escalation to more expensive NHS treatment.

C. How do you feel about the proposed process for identification of items for possible addition to the guidance or indeed possible removal, from the guidance?

– Agree (tick box)

Minocycline for acne

1. Advise CCGs that prescribers in primary care should not initiate minocycline for any new patient.

– Agree (tick box)

2. Advise CCGs to support prescribers in deprescribing minocycline in all patients and, where appropriate, ensure the availability of relevant services to facilitate this change

– Agree (tick box)

If needed, please provide further information.

– The BAD would like to stress the importance of appropriate wording in the final guidance produced (e.g. specify in this wording “all patients with acne”), as minocycline is prescribed for certain skin infections (e.g. nocardiosis, Lyme disease, atypical TB, etc.). Any potential misinterpretation by CCGs leading to blanket-banning minocycline prescription must be avoided. Clinicians must still be able to prescribe minocycline for people who require it.

Silk garments

1. Advise CCGs that prescribers in primary care should not initiate silk garments for any
new patient.

– Agree (tick box)

2. Advise CCGs to support prescribers in deprescribing silk garments in all patients and,
where appropriate, ensure the availability of relevant services to facilitate this
change.

– Agree (tick box)

If needed, please provide further information.

– The BAD would like to stress the importance of appropriate wording in the final
guidance produced, as silk garments have a place in managing other (non-selflimiting)
skin conditions, e.g. ichthyosis and other genetic skin disorders. Any
potential misinterpretation by CCGs in blanket-banning silk garment prescription
must be avoided. Clinicians must still be able to prescribe silk garments if people
would benefit from them, including severe cases of eczema.

Bath and shower preparations

1. Advise CCGs that prescribers in primary care should not initiate bath and shower
preparations for any new patient.

– Disagree (tick box)

2. Advise CCGs to support prescribers in deprescribing bath and shower preparations in
this category and substitute with “leave-on” emollients and, where appropriate, to
ensure the availability of relevant services to facilitate this change.

– Disagree (tick box)

If needed, please provide further information.

– The rationale for this recommendation is based on a misinterpretation of the
results of a clinical trial (BATHE) which did not set out to compare the
effectiveness of bath/shower preparations with leave-on emollients in all people
with eczema. The BATHE trial involved only children under the age of 12 who
mostly had mild-to-moderate disease (a subgroup of people with eczema) and
concluded no additional benefit of adding bath/shower preparations to standard
eczema care (which was the use of leave-on emollient as a soap substitute in
both groups in the trial). The BAD supports the objection submitted by the
investigators of the BATHE trial in using the misinterpreted results of their study
as the rationale for this recommendation.

– There is no evidence of a difference in effectiveness between leave-on
emollients used as a wash product and bath/shower preparations in people with
eczema.

– There is no difference in cost between leave-on emollients used as a wash
product and bath/shower preparations in people with eczema.

– The step-wise approach for the management of eczema in NICE guideline CG57
involves emollients, then topical steroids, followed by topical calcineurin
inhibitors, and finally systemics (including biologics such as dupilumab). The cost
of managing eczema is much lower at the bottom rung of the treatment ladder
and it is imperative that eczema is controlled appropriately at this level.

– Correct use and application of emollients (of any preparation), to support best
eczema care, reduces the need for treatment escalation to systemic/biologic
therapies. Conversely, limiting access to emollients will lead to unnecessary use
of expensive biologics.

– NICE guideline CG57 mandates patient choice and the proposed NHSE
recommendation limits the breadth of available products. Individuals have
widely varying tolerance of different emollients. By not allowing routine
prescribing of bath/shower preparations, an entire type of emollient preparation
is being restricted in people with eczema – this is different from
removing/streamlining different formulations/products within a type of
emollient preparation.

– Many people with eczema may become allergic to specific different components
of emollients. For these people, many brands may be contraindicated and will
worsen their eczema. The ability to choose from a range of differently
formulated products or preparations is important in these cases.

– The patient support group, National Eczema Society, worked with NICE in
ensuring that people with eczema were given the choice on emollient
preparations due to lack of evidence that one (e.g. leave-on) is better than
another (e.g. bath/shower preparations). Therefore, the BAD supports the
notion that the selection of emollient wash products should be based on patient
choice as this will enhance compliance / concordance / adherence (NICE
guideline CG57), reducing the need for treatment escalation to more expensive
products.

– Children, young people and adults with eczema from lower socioeconomic
background, who do not have financial resources to self-purchase their required
treatment, may be the most affected if access is restricted. This might worsen
their condition and require NHS escalation to more expensive treatment.

– The BAD considers this apparently cost-saving NHSE recommendation to be a
false economy, based on the misinterpretation of one clinical study, and
recommend removing it completely from the final commissioning guidance
when it is issued. Optimising choice of emollients and bath/shower
preparations, with consideration of cost-effectiveness, is important but should
be based on health economic evidence. Any prescribing for people with chronic
disease should be integrated so that primary and secondary care work together
to optimise patient care.