PD07: Prescribing and using vitiligo treatments for limited active vitiligo: lessons from a nested process evaluation within the HI‐Light Vitiligo randomized controlled trial

Abstract

Prescribing and using vitiligo treatments for limited active vitiligo: lessons from a nested process evaluation within the HI-Light Vitiligo randomized controlled trial J. Batchelor, J. Chalmers, P. Leighton, V. Eleftheriadou, J. Ravenscroft, M. Santer, R. Haines, G. Meakin and K. Thomas University of Nottingham, Nottingham, UK; Nottingham University Hospitals NHS Trust, Nottingham, UK; and University of Southampton, Southampton, UK In the UK, people with vitiligo have mixed experiences of obtaining treatment, even with commonly used treatments such as topical corticosteroids (TCS). Narrowband ultraviolet B (NB-UVB) treatment is usually reserved for people with extensive vitiligo and given in hospital settings; the provision of home-based handheld NB-UVB is rare. The HI-Light Vitiligo Trial was a randomized controlled trial involving children (> 5 years) and adults with active vitiligo affecting < 10% of the skin. Participants were randomized to 9 months of treatment with either combination treatment with potent TCS + homebased handheld NB-UVB; TCS + dummy NB-UVB; or NB-UVB + dummy TCS. Combination treatment gave a better treatment response than potent TCS alone and was better value for money than NB-UVB or potent TCS used in isolation in the treatment of limited vitiligo. However, there are uncertainties in how best to implement this treatment combination in clinical practice. We report the findings of a process evaluation nested within the HI-Light Trial, aimed at addressing three questions: (i) Can combination treatment (potent TCS + handheld NBUVB) be used safely and effectively by people with vitiligo? (ii) Do stakeholders (people with vitiligo, parents of children with vitiligo, health service commissioners, healthcare professionals) feel that such combination treatment should be made available as routine clinical care? (iii) Do stakeholders feel that combination treatment for vitiligo could be integrated within current healthcare provision? This was a mixed-methods process evaluation, which included 25 semi-structured interviews with trial participants, commissioners and prescribers, and an online survey and focus groups involving trial staff. All recorded data were transcribed and coded following the conventions of framework analysis. Trial participants and healthcare professionals agreed that combination treatment should be made available to people with limited active vitiligo. Some participants found combination treatment quite complicated, but it was not always possible to predict who was more likely to struggle. We identified potential barriers to the commissioning of new services providing home-based handheld NB-UVB for vitiligo, including perceived lack of demand for treatment, or views that vitiligo is mainly a cosmetic problem. Concerns regarding the safe use of combination treatment mean that careful selection of suitable recipients, followed by adequate training and support, are essential. Medical physics services need to be closely involved in the provision of home-based handheld NB-UVB, to ensure that devices are properly checked and maintained. This may mean that regional, rather than local, provision is more practical.