Title: Developing and testing an online intervention to support self-management, improve outcomes and reduce antibiotic use in acne
Funder: Department of Health and Social Care

Abstract: Background Acne is common and can cause significant psychosocial impact, permanent scarring and/or disfiguring pigment change. Topical treatments for acne are effective but not well-used and long courses of oral antibiotics are common, making a major contribution to antibiotic use and resistance. People with acne often purchase ineffective cosmetic products rather than effective pharmaceutical treatments. They also become keen for oral antibiotics, which are (often incorrectly) perceived to be more effective than topical treatments. Aim To improve outcomes for acne by promoting the use of appropriate treatments and reducing overuse of long-term oral antibiotics through an online intervention to support acne self-management. Objectives Develop an online intervention for people with acne to support effective self-management Examine effectiveness of the intervention in a randomised controlled trial Explore mechanisms underlying effectiveness of the intervention through process evaluation Develop and undertake an economic evaluation to estimate cost-effectiveness of the intervention compared with usual care from NHS and patient perspectives Identify and utilise catalysts to support implementation and dissemination Methods Workstream 1 Develop an online behavioural intervention to support acne self-management, particularly through the promotion of evidence-based treatments and adherence to topical treatments. To prepare for intervention development we will: (1) build stakeholder groups including young people with acne, parents/carers, and health professionals; (2) update our systematic review of qualitative studies in acne and expand to include quantitative research on acne treatment adherence; (2) carry out a qualitative interview study. Intervention development will use the Person-based Approach and include an iterative approach with involvement from public contributors as well as think-aloud interviews with draft intervention materials. Workstream 2 Evaluate the intervention through external feasibility trial and full-scale randomised trial with internal pilot, comparing intervention plus usual care with usual care alone. People with acne aged 13-25 years will be recruited through primary care, community settings and via social media. Primary outcome will be acne-related quality of life at 12 weeks. Secondary outcomes include longer term acne severity, antibiotic and other treatment use. Workstream 3 Process evaluation will explore likely causal mechanisms of the intervention. Workstream 4 Develop resource use data collection tools, test the resource use questionnaires and diaries and compare potential outcome instruments before carrying out a within-trial economic evaluation of the intervention to estimate its cost-effectiveness from NHS and patient perspectives. Workstream 5 Implementation and dissemination workstream will develop pathways to impact via stakeholder engagement throughout the programme. Key outcomes are how to reach people with early acne, promote and endorse use of the intervention amongst young people, encourage health professionals to signpost and embed it within digital care pathways. Timelines for delivery Workstream1: months 0-20; workstream2 months 21-60; workstream3: months 25-60; workstream4 and workstream5: throughout the programme. Anticipated Impact and Dissemination Dissemination: stakeholder workshops, conferences, publications in peer-reviewed journals; professional societies, guideline-developers and patient-information providers; press releases; and social media. Potential benefits for patients include reduced psychosocial burden and reduced risk of severe acne and scarring. Reduced consultations and referrals will benefit the NHS, and antibiotic avoidance is beneficial for society.

Lay abstract: Aim To improve the health of people with acne by increasing use of effective treatments and reducing overuse of long-term oral antibiotics. Background Acne is very common, frequently causes distress, low self-confidence, and may lead to permanent scarring, long-lasting dark marks, and depression. Treatment of acne is a major cause of antibiotic use amongst young people, driving antibiotic resistance. Evidence suggests that topical treatments (treatments applied directly to the skin) should be the main treatments used for mild and moderate acne. Effective topical treatments are available from pharmacies without a prescription, but many people are unaware of these and buy cosmetic products that don t help instead. People often give up with topical treatments because they are not given full advice on how to use them. For example, they don t know how to reduce the risk of stinging and redness and that it takes several weeks for treatments to start working. The main barriers to effective acne treatment are: inaccurate patient beliefs about unproven treatments; low awareness of effective topical treatments resulting in underuse; inadequate support around correct use of topical treatments leading to early discontinuation; delaying contacting health professionals, with increased risk of severe acne and scarring. Methods 1) Develop an online toolkit to support people with acne to obtain and use effective acne treatments, particularly promoting regular use and avoiding side effects with topical treatments 2) Test whether the toolkit improves acne-related quality of life and reduces the use of antibiotics in a randomised trial 3) Explore how the toolkit works, by talking to those that have used it and analysing how they used it 4) Explore the costs to the NHS and for patients of using the toolkit and estimate its value for money Patient and public involvement Two people with extensive experience of managing their own acne are co-applicants and have helped develop this application. A meeting with young people and email discussion group of people with acne have helped develop plans, for instance how to encourage people to take part. Their feedback has informed the emphasis on advice about avoiding side effects from topical treatments and addressing social media quick fix messages. We will continue to work both with public contributor co-applicants and wider public involvement in shaping this research. &ldquo;&hellip; if someone had told me I had to use the creams every day when I was 14, I might not have needed all these other treatments later on.&rdquo; Dissemination We will publish this work in peer-reviewed journals, at conferences and via patient organisations. If effective, we will make the toolkit freely available and ensure widespread uptake by working with young people and health care providers to signpost and endorse its use.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: SKIN