Abstract

Background

Atopic dermatitis (eczema), can have a significant impact on well‐being and quality of life for affected people and their families. Standard treatment is avoidance of triggers or irritants and regular application of emollients and topical steroids or calcineurin inhibitors. Thorough physical and psychological assessment is central to good‐quality treatment. Overcoming barriers to provision of holistic treatment in dermatological practice is dependent on evaluation of the efficacy and economics of both psychological and educational interventions in this participant group. This review is based on a previous Cochrane review published in 2014, and now includes adults as well as children.

Objectives

To assess the clinical outcomes of educational and psychological interventions in children and adults with atopic dermatitis (eczema) and to summarise the availability and principal findings of relevant economic evaluations.

Search methods

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, APA PsycINFO and two trials registers up to March 2023. We checked the reference lists of included studies and related systematic reviews for further references to relevant randomised controlled trials (RCTs) and contacted experts in the field to identify additional studies. We searched NHS Economic Evaluation Database, MEDLINE and Embase for economic evaluations on 8 June 2022.

Selection criteria

Randomised, cluster‐randomised and cross‐over RCTs that assess educational and psychological interventions for treating eczema in children and adults.

Data collection and analysis

We used standard Cochrane methods, with GRADE to assess the certainty of the evidence for each outcome. Primary outcomes were reduction in disease severity, as measured by clinical signs, patient‐reported symptoms and improvement in health‐related quality‐of‐life (HRQoL) measures. Secondary outcomes were improvement in long‐term control of symptoms, improvement in psychological well‐being, improvement in standard treatment concordance and adverse events. We assessed short‐ (up to 16 weeks after treatment) and long‐term time points (more than 16 weeks).

Main results

We included 37 trials (6170 participants). Most trials were conducted in high‐income countries (34/37), in outpatient settings (25/37). We judged three trials to be low risk of bias across all domains. Fifteen trials had a high risk of bias in at least one domain, mostly due to bias in measurement of the outcome. Trials assessed interventions compared to standard care.

Individual educational interventions may reduce short‐term clinical signs (measured by SCORing Atopic Dermatitis (SCORAD); mean difference (MD) −5.70, 95% confidence interval (CI) −9.39 to −2.01; 1 trial, 30 participants; low‐certainty evidence) but patient‐reported symptoms, HRQoL, long‐term eczema control and psychological well‐being were not reported.

Group education interventions probably reduce clinical signs (SCORAD) both in the short term (MD −9.66, 95% CI −19.04 to −0.29; 3 studies, 731 participants; moderate‐certainty evidence) and the long term (MD −7.22, 95% CI −11.01 to −3.43; 3 studies, 1424 participants; moderate‐certainty evidence) and probably reduce long‐term patient‐reported symptoms (SMD −0.47 95% CI −0.60 to −0.33; 2 studies, 908 participants; moderate‐certainty evidence). They may slightly improve short‐term HRQoL (SMD −0.19, 95% CI −0.36 to −0.01; 4 studies, 746 participants; low‐certainty evidence), but may make little or no difference to short‐term psychological well‐being (Perceived Stress Scale (PSS); MD −2.47, 95% CI −5.16 to 0.22; 1 study, 80 participants; low‐certainty evidence). Long‐term eczema control was not reported.

We don't know whether technology‐mediated educational interventions could improve short‐term clinical signs (SCORAD; 1 study; 29 participants; very low‐certainty evidence). They may have little or no effect on short‐term patient‐reported symptoms (Patient Oriented Eczema Measure (POEM); MD −0.76, 95% CI −1.84 to 0.33; 2 studies; 195 participants; low‐certainty evidence) and probably have little or no effect on short‐term HRQoL (MD 0, 95% CI −0.03 to 0.03; 2 studies, 430 participants; moderate‐certainty evidence). Technology‐mediated education interventions probably slightly improve long‐term eczema control (Recap of atopic eczema (RECAP); MD −1.5, 95% CI −3.13 to 0.13; 1 study, 232 participants; moderate‐certainty evidence), and may improve short‐term psychological well‐being (MD −1.78, 95% CI −2.13 to −1.43; 1 study, 24 participants; low‐certainty evidence).

Habit reversal treatment may reduce short‐term clinical signs (SCORAD; MD −6.57, 95% CI −13.04 to −0.1; 1 study, 33 participants; low‐certainty evidence) but we are uncertain about any effects on short‐term HRQoL (Children's Dermatology Life Quality Index (CDLQI); 1 study, 30 participants; very low‐certainty evidence). Patient‐reported symptoms, long‐term eczema control and psychological well‐being were not reported.

We are uncertain whether arousal reduction therapy interventions could improve short‐term clinical signs (Eczema Area and Severity Index (EASI); 1 study, 24 participants; very low‐certainty evidence) or patient‐reported symptoms (visual analogue scale (VAS); 1 study, 18 participants; very low‐certainty evidence). Arousal reduction therapy may improve short‐term HRQoL (Dermatitis Family Impact (DFI); MD −2.1, 95% CI −4.41 to 0.21; 1 study, 91 participants; low‐certainty evidence) and psychological well‐being (PSS; MD −1.2, 95% CI −3.38 to 0.98; 1 study, 91 participants; low‐certainty evidence). Long‐term eczema control was not reported.

No studies reported standard care compared with self‐help psychological interventions, psychological therapies or printed education; or adverse events.

We identified two health economic studies. One found that a 12‐week, technology‐mediated, educational‐support programme may be cost neutral. The other found that a nurse practitioner group‐education intervention may have lower costs than standard care provided by a dermatologist, with comparable effectiveness.

Authors' conclusions

In‐person, individual education, as an adjunct to conventional topical therapy, may reduce short‐term eczema signs compared to standard care, but there is no information on eczema symptoms, quality of life or long‐term outcomes. Group education probably reduces eczema signs and symptoms in the long term and may also improve quality of life in the short term. Favourable effects were also reported for technology‐mediated education, habit reversal treatment and arousal reduction therapy. All favourable effects are of uncertain clinical significance, since they may not exceed the minimal clinically important difference (MCID) for the outcome measures used (MCID 8.7 points for SCORAD, 3.4 points for POEM). We found no trials of self‐help psychological interventions, psychological therapies or printed education. Future trials should include more diverse populations, address shared priorities, evaluate long‐term outcomes and ensure patients are involved in trial design.

Author(s)

Heidi Singleton, Andrew Hodder, Orouba Almilaji, Steven J Ersser, Vanessa Heaslip, Susan O'Meara, Dwayne Boyers, Amanda Roberts, Helen Scott, Julie Van Onselen, Liz Doney, Robert J Boyle, Andrew R Thompson

Abstract

Plain language summary

Are education and psychological therapies effective for managing eczema?

Key messages

• Face‐to‐face education for individuals and groups may reduce eczema severity. Using technology to deliver education, such as the internet, may have little or no effect on disease severity.

• Using nurse practitioners instead of dermatologists to deliver group education may have lower costs and be similarly effective.

• People's circumstances vary and this will affect delivery of, and and how they receive information. Educational and psychological interventions for people with eczema should be developed based on patient and carer preferences, so that they will be used. Study participants should be followed over the (very) long term, remembering that 'long term' could be a lifetime for someone with eczema, not just the length of a research study.

What is eczema?

Eczema (also known as atopic dermatitis) is an uncomfortable, itchy, visible skin condition. Many different things can make eczema worse, such as foods, pollen, dust mites, stress, seasonal changes and pollution. Scratching the itch can make the skin itchier, reduce the chances of treatment being successful, and damage the skin.

How is eczema treated?

It is a complicated business living with eczema. It is usually treated by avoiding 'triggers' and irritants, and applying moisturising (emollients) or medicated (topical corticosteroids or clacineurin inhibitors) creams and lotions. Education and psychological techniques can give people information to manage the impact of eczema.

Education can be provided in different ways, such as one‐on‐one or group sessions, led by either doctors or patients themselves. These sessions can be in‐person or online. They can vary in length and often include follow‐ups. Follow‐ups are important because benefitting from educational and psychological material usually takes some time and requires some support. Methods to help change behaviour are also often used during educational sessions.

Stress and coping behaviours can make eczema worse. Therapy that focuses on changing habits or distracting from scratching can help, and we have grouped these as 'psychological interventions'. Counselling may be a cost‐effective option. Techniques like mindfulness and relaxation can also help reduce itching. Some methods, like guided imagery and virtual reality, can divert attention away from itching. Virtual reality, although not widely studied for eczema, has been used for anxiety and pain, which are related to itching. However, not all places offer these therapies consistently.

What did we want to find out?

We investigated the usefulness of educational and psychological techniques to help anybody with eczema. That might be to reduce eczema symptoms or the costs of treating eczema.

What did we do?

We searched for studies that investigated educational or psychological approaches to improve eczema. Improvement could be measured by reduction in symptoms, as reported by people with eczema or their carers, or improvement in quality of life, for example. We also looked for other improvements: long‐term control of eczema symptoms, psychological well‐being, and using medication appropriately. We wondered if there were unwanted effects from the information given.

What did we find?

We found 37 studies that included 6170 adults and children. Most studies took place in hospitals in high‐income countries. The majority of participants were children and adolescents. People in the studies had a mix of eczema severity. We found little information about cost‐effectiveness and no useful information about self‐help, psychological therapy, or printed educational materials.

The results below are for educational or psychological methods compared with standard eczema care.

• Individual education may reduce short‐term disease severity (1 study, 30 participants).

• Group education probably reduces eczema severity (9 studies, 2426 participants).

• We are unable to comment on whether education delivered using technology (for example online education) reduces disease severity as measured by clinical signs. It may have little or no effect on eczema severity as reported by patients but probably slightly improves long‐term control of eczema symptoms (5 studies, 654 participants).

• Treatment to change habits may reduce disease severity but probably has little or no effect on improvement of quality of life (1 study, 33 participants).

• Therapies to reduce stress or anxiety such as mindfulness, meditation and relaxation techniques (arousal reduction therapies) may make little or no difference in improvement in quality of life (3 studies, 33 participants).

No studies provided useful information about improvement in long‐term control of eczema symptoms, improvement in following standard treatment, or unwanted effects.

What are the limitations of the evidence?

Where we found evidence, our confidence in it is only moderate because of concerns that the included studies used different ways of delivering educational or psychological treatments. The studies were very small and most did not the best design to give conclusive results.

Most studies were in high‐income countries, so our review does not report on whether some of these educational and psychological methods might work better in some cultures or for people in low‐ or middle‐income countries.

How up to date is this evidence?

The evidence is current up to March 2023.

Author(s)

Heidi Singleton, Andrew Hodder, Orouba Almilaji, Steven J Ersser, Vanessa Heaslip, Susan O'Meara, Dwayne Boyers, Amanda Roberts, Helen Scott, Julie Van Onselen, Liz Doney, Robert J Boyle, Andrew R Thompson

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

The purpose of this review was to summarise all the available evidence on the relative effectiveness of educational and psychological interventions for adults and children to inform practice, accompanied by a health economic evaluation to aid decision‐making.

Face‐to‐face education, delivered to the individual, as an adjunct to conventional topical therapy, may reduce short‐term disease severity as determined by clinical signs. Direct education delivered to groups (across all age groups), probably reduces disease severity as determined by both clinical signs in the long term and the short term, and results in a reduction in participant‐reported symptoms in the long term. The favourable effects seen for individual face‐to‐face or group face‐to‐face education are of uncertain clinical significance because the confidence intervals for the estimates include effect sizes that are less than the minimal clinically important difference (MCID). Despite not reaching the MCID threshold, long‐term reduction in disease severity (measured by POEM), relating to group education, will be of particular interest to people with eczema and their carers. When mediated via technology, educational interventions probably slightly improve long‐term control of eczema symptoms. These data suggest that educational interventions may be relevant additions to conventional topical treatment for eczema.

With educational interventions, there is a varied array of configurations of different components of these interventions that are complex in nature. This includes the active component of the mode of educational delivery, such as direct didactic teaching, the use of aids or not, and the extent to which health professionals promote active participation of the patient or carer within the educational process. Healthcare professionals involved in the delivery also varied, including dermatologists, nurses, psychologists, and multidisciplinary groups. Another dimension of the 'dose effect' of such intervention is their frequency of delivery and its duration. Frequency varied from a single session up to 10 educational sessions, and duration varied from 10 minutes to six hours within a single clinic; education was sustained over a longer period of a month up to 10 months. Consideration should also be given to the preferences of people with eczema (children, parents, and adults) for individual versus group delivery, such as the desire to receive group education or individual delivery alongside another group of people with eczema.

Within resource‐constrained health systems, the health economic appraisal of group versus individual delivery is an important consideration as well as a logistical or organisational consideration, in bringing together a team of health professionals to deliver an educational programme. The limited health economic evidence for educational interventions is based on one trial in which there was a combination of individual and group education. It was targeted at children under 16, delivered by a nurse practitioner, and compared to standard dermatologist care. It suggests that the costs of care provided by the nurse practioners were lower than care provided by the dermatologists, yet with comparable effectiveness. Further research will hopefully guide how best to deliver educational interventions for eczema in the most efficient and cost‐effective way, considering which people with eczema are most likely to benefit from such interventions.

In this review, nine of the 37 included trials assessed psychological interventions. These ranged from watching a humorous video, cognitive behavioural stress management, individual hypnotherapy, habit reversal, brief dynamic psychotherapy, and group relaxation sessions. We did not find any trials that could be considered to be self‐help psychological interventions or counselling.

In relation to the mode of delivery of the interventions, only one intervention was technology‐mediated (a cognitive behavioural internet intervention delivered over 12 weeks), whilst the other eight trials were face‐to‐face. The majority (6/9) of interventions were group‐based rather than delivered to individuals. Again, this should be a consideration for clinical psychologists when deciding how to structure their treatments, balancing resourcing, cost and time pressures for people with eczema and their family preferences.

Relating to the dose effect, the duration of the intervention ranged from a single group session or video viewing to 15.5 individual sessions (on average) over six months. The duration of follow‐up ranged from one to 12 months. We could not make any conclusions about optimal dose effect, but this would be an important factor for psychologists and would have cost and time resource implications. Clinical psychology remains a limited resource in health systems due to variable resource constraints and specifically, the availability of appropriately trained clinical psychologists. It is therefore important to consider which patient groups will benefit most from specialist psychological intervention and whether the impact of these interventions can be widened through the use of group interventions, web‐based interventions (as reviewed in Hedman‐Lagerlof 2021), and possibly lower‐grade interventions that can be delivered by healthcare professionals other than fully trained clinical psychologists.

The finding that habit reversal treatment may reduce disease severity as measured by clinical signs (SCORing Atopic Dermatitis (SCORAD)) makes it a potential option for psychologists treating children and adults with eczema, though it made little or no improvement in the quality of life of children with eczema. In the relevant trial included in this review, clenching the fists, pinching or pressing the itchy area with a nail were used until the itching caused by eczema stopped. This was repeated several times a day to reverse the scratching habit. Instructions were given to children that were child‐friendly and included them in the treatment process. Although the participants were children, it seems reasonable to think that this would also be effective with adults with eczema.

We were uncertain whether arousal reduction interventions, including relaxation, and body, mind and spirit interventions, could reduce disease severity as measured by clinical signs using Eczema Area and Severity Index (EASI) or reduce disease severity as measured by visual analogue scales. Both relevant trials included were conducted with adult participants. We would expect a similar inconclusive finding for child participants. Arousal reduction interventions may have little or no improvement in quality of life. However, the relevant trials involved children and families; these interventions might be more effective for improving quality of life in adult populations.

Implications for research 

There is a clear need for further work to better understand the impact of educational and psychological interventions to support eczema management. Most of the trials included in this review were trials of educational, rather than psychological interventions. We were unable to identify with confidence whether specific approaches provided meaningful improvement in eczema signs, symptoms, or quality of life. However, the findings do suggest that face‐to‐face group education and habit reversal may be of value, and further work is justified to explore these specific approaches. We were unable to make confident conclusions for most other types of interventions, due to low‐certainty, very low‐certainty or absent information.

The domain where we assessed most trials as high risk of bias was the 'Bias in measurement of the outcome' domain, for which there were seven trials (19%), but this may relate somewhat to the nature of the interventions making patient blinding impossible. It may be that cross‐over trials or waiting list designs may reduce this bias. Four trials (11%) were at high risk of bias in the 'Bias due to missing outcome data' domain and four (11%) for the 'Bias in selection of the reported result' domain. We assessed three trials (8%) as being at high risk of bias in the 'Bias arising from the randomisation process' domain, and these may represent poor trial design. There is a requirement for trials designed to minimise bias in the deployment of the outcome measures, ensuring greater completion of data gathering and the use of intention‐to‐treat analysis, addressing the randomisation weaknesses and a clear reporting of the nature and risk of biases. A better trial design would include consideration of the degree and source of risk of bias.

People with eczema

There is an urgent need to explore whether the effectiveness of educational and psychological interventions differs in participants from different settings, especially lower‐income countries and settings. Future trials should aim to include more diverse patient populations and for interventions to be tested in a variety of settings and healthcare systems, including primary care and lower‐income countries. Further subgroup analyses may help to ascertain further which patient groups may benefit most from educational and psychological interventions in health systems where there may be limited resource interventions.

Future trials that compare the effectiveness and cost‐effectiveness of different methods and frequencies and duration of educational and psychological intervention delivery in children and young people with eczema are warranted. When educational and psychological interventions are reported, the frequency and duration of the component elements needs to be clearly specified. Future randomised controlled trials could be designed to assess the efficacy of counselling and psychological self‐help, and printed education interventions.

Comparison

There is scope to undertake comparative trials evaluating the relative effectiveness and cost‐effectiveness of individual versus group educational and psychological interventions. Further research is required in the comparative effectiveness and economic appraisal of nurse‐led delivery of education compared to that by dermatologists. Head‐to‐head trials of face‐to‐face interventions versus technologically mediated interventions showing non‐inferiority would be helpful as technological interventions may be further reaching. It would also be clinically useful to know if interventions for older children and young people are best aimed at the person with eczema, the carer or the family as a unit.

Outcomes

It is important that future research reflects the real gaps in clinical evidence apparent to both people with eczema and clinicians ‐ patient involvement in trial design is paramount. Of note, the Rapid Eczema Trials project is an initiative in place at the time of publishing that involves working with members of the public to prioritise, design and conduct high‐quality online trials for eczema (NIHR203279).

With regard to trials measuring the outcomes of interventions in children, there seems to be a significant variation in the use of outcomes based on the child and those of the parent or the family unit as a whole. It would be useful for future trials to consistently consider measuring outcomes for children, parents and family units.

There is a need for further trials designed using standardised outcome measures such as those recommended by the Harmonising Outcome Measures for Eczema (HOME) initiative. It is encouraging to see more trials using outcomes such as the Patient‐Oriented Eczema Measure (POEM) and the Dermatology Life Quality Index (DLQI), Children’s Dermatology Life Quality Index (CDLQI) and the Infants' Dermatitis Quality of Life Index (IDQOL); though the measures Eczema Area and Severity Index (EASI), Recap of Atopic Eczema (RECAP) and Atopic Dermatitis Control Test (ADCT) need to be employed more frequently. Only six trials measured other outcomes at one year. There is a need for further data to assess the clinical benefit of psychological and educational interventions in the long term.

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