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Meta-Analysis
. 2024 Aug 12;8(8):CD014932.
doi: 10.1002/14651858.CD014932.pub2.

Educational and psychological interventions for managing atopic dermatitis (eczema)

Heidi Singleton  1 , Andrew Hodder  2   3 , Orouba Almilaji  4 , Steven J Ersser  1 , Vanessa Heaslip  5 , Susan O'Meara  6 , Dwayne Boyers  7 , Amanda Roberts  8 , Helen Scott  9 , Julie Van Onselen  10   11 , Liz Doney  12 , Robert J Boyle  13 , Andrew R Thompson  14
Affiliations
Meta-Analysis

Educational and psychological interventions for managing atopic dermatitis (eczema)

Heidi Singleton et al. Cochrane Database Syst Rev. .

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.

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Conflict of interest statement

Singleton H: none known. Heidi works as a Senior Lecturer at Bournemouth University, is currently the Programme Lead for Children and Young People's Nursing and is on the Nursing and Midwifery Council register.

Hodder A reports receiving support for attending meetings or travel as part of an Associate Fellowship with the UK Dermatology Clinical Trials Network (personal payment). AH works for University Hospitals Dorset NHS Trust as a Locum Consultant, and formerly the Royal Cornwall Hospitals NHS Trust as an Associate Specialist undertaking NHS clinical work in dermatology (treating patients with eczema).

Almilaji O: none known. Orouba works in the Department of Health Service Research and Policy within the Faculty of Public Health and Policy at LSHTM as a full‐time Research Fellow in Medical Statistics/Data Science at The London School of Hygiene and Tropical Medicine.

Ersser SJ declared that they have no conflict of interest. SJE works for Bournemouth University as the Head of The Centre for Wellbeing and Long‐Term Health and Professor of Nursing & Dermatology Care teaching Dermatology, and is on the Nursing and Midwifery Council register (as a Registered General Nurse and non‐medical prescriber).

Heaslip V: none known. Vanessa is a Professor of Nursing and Healthcare Equity at Salford University

Boyle RJ reports income from private practice at several clinics, including eczema management (personal payment). RB has received consulting fees as a Cochrane Senior Editor (personal payment). RB works as a paediatric allergist at Imperial College Healthcare NHS Trust (treating patients with eczema). RB is a Joint Co‐ordinating Editor for Cochrane Skin and was not involved in the editorial process for this review.

O'Meara S: none known. Susan works for Kleijnen Systematic Reviews Ltd.

Boyers D: none known. Dwayne is a senior research fellow at the University of Aberdeen.

Roberts A: none known. Amanda is an active member of the Nottingham Support Group for Carers of Children with Eczema.

Scott H: none known. Helen works for Centre of Evidence Based Dermatology at the University of Nottingham.

Van Onselen J reports income from dermatology education projects and consultancy for the NHS, pharmaceutical and patient groups, all received into her business, Dermatology Education Partnership Ltd, of which she is a Director (VAT registered, corporation and personal tax paid; accounts audited). This includes participation in advisory boards regarding childhood atopic eczema and adult eczema management for AbbVie; pharmacist education on eczema management for Morph; an eczema article on prescribing update for Mark Allen Publishing; webinars on eczema management for Thornton & Ross; webinars on eczema management, sponsored by Dermal, for Mark Allen Publishing; educational online modules and eczema articles and a virtual conference presentation for Nursing in Practice; and consultancy for the Eczema mindlines project from University of Birmingham. JVO has received a personal payment from AbbVie for a delegate fee for attending an European Academy of Dermatology and Venereology (EADV) virtual meeting. JVO does skin cancer assessment and dermoscopy work one day per week for a private diagnostic company, Check4Cancer Ltd; and works two days per month in an NHS primary care dermatology clinic for SDSmyhealthcare Healthcare Federation, South Birmingham and Solihull Clinical Commissioning Group. Julie has caried out some work for companies (including L'Oreal) over the last three years, including leading a GP lunchtime education session on eczema, a Black Friday Campaign for two days (November 2023), which involved a ‘helpline concept’, speaking to the public about skin concerns for general advice and on three occasions worked for a Cerave project talking to the public about skin health and sun protection. All these projects had other HCPs involved, and were based around public education and support. This work was carried out in Julie’s self employed time. JVO works 0.5 days per week as a nurse advisor on the National Eczema Society helpline and advises/writes public information on eczema for them.

Doney L: none known. Liz is a Senior Information Specialist at Nottinghamshire Healthcare NHS Foundation Trust

Thompson AR reports no specific conflict of interest. AT works as a Professor of Clinical Psychology and Consultant Clinical Psychologist for Cardiff and Vale University Health Board. He is Programme Director for the South Wales Clinical Psychology Programme based at Cardiff University. AT reports receipt of industry funding for presenting at dermatology educational events (UCB UK, Sanofi) and support with collaboration with dermatology research activity (not related to eczema: Pfizer; Incyte).

Figures

1
1
Figure 1. Prisma flow diagram showing identification and screening process
1.1
1.1. Analysis
Comparison 1: Individual educational interventions versus standard care only, Outcome 1: Reduction in disease severity, as measured by clinical signs (SCORAD)
2.1
2.1. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 1: Long‐term reduction in disease severity, as measured by clinical signs (SCORAD) across all age groups
2.2
2.2. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 2: Short‐term reduction in disease severity, as measured by clinical signs (SCORAD)
2.3
2.3. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 3: Reduction in disease severity, as measured by patient‐reported symptoms
2.4
2.4. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 4: Improvement in quality‐of‐life measures (DLQI): all scales, infants, children, and family
2.5
2.5. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 5: Improvement in quality‐of‐life measures: family impact
2.6
2.6. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 6: Improvement in psychological well‐being measures
2.7
2.7. Analysis
Comparison 2: Group educational interventions versus standard care only, Outcome 7: Change in concordance with standard treatment: Parents’ Self‐Efficacy with Eczema Care Index
3.1
3.1. Analysis
Comparison 3: Technology‐mediated educational interventions versus standard care only, Outcome 1: Reduction in disease severity, as measured by clinical signs (SCORAD)
3.2
3.2. Analysis
Comparison 3: Technology‐mediated educational interventions versus standard care only, Outcome 2: Reduction in disease severity, as measured by patient‐reported symptoms (POEM)
3.3
3.3. Analysis
Comparison 3: Technology‐mediated educational interventions versus standard care only, Outcome 3: Improvement in quality‐of‐life measures
3.4
3.4. Analysis
Comparison 3: Technology‐mediated educational interventions versus standard care only, Outcome 4: Improvement in long‐term control of eczema symptoms (RECAP)
3.5
3.5. Analysis
Comparison 3: Technology‐mediated educational interventions versus standard care only, Outcome 5: Improvement in psychological well‐being measures: one‐item overall stress‐rating scale
4.1
4.1. Analysis
Comparison 4: Habit reversal versus standard care only, Outcome 1: Reduction in disease severity, as measured by clinical signs (SCORAD)
4.2
4.2. Analysis
Comparison 4: Habit reversal versus standard care only, Outcome 2: Improvement in quality‐of‐life measures: children (CDLQI)
5.1
5.1. Analysis
Comparison 5: Arousal reduction therapy: individual progressive muscle relaxation versus standard care, Outcome 1: Reduction in disease severity, as measured by clinical signs (EASI)
5.2
5.2. Analysis
Comparison 5: Arousal reduction therapy: individual progressive muscle relaxation versus standard care, Outcome 2: Improvement in psychological measures: State Anxiety
6.1
6.1. Analysis
Comparison 6: Arousal reduction therapy: individual relaxation imagery versus standard care, Outcome 1: Improvement in psychological well‐being measures: State Anxiety
6.2
6.2. Analysis
Comparison 6: Arousal reduction therapy: individual relaxation imagery versus standard care, Outcome 2: Reduction in disease severity, as measured by patient‐reported symptoms (VAS)
7.1
7.1. Analysis
Comparison 7: Arousal reduction therapy: group integrated Body‐Mind‐Spirit versus standard care, Outcome 1: Improvement in quality‐of‐life measures (DFI)
7.2
7.2. Analysis
Comparison 7: Arousal reduction therapy: group integrated Body‐Mind‐Spirit versus standard care, Outcome 2: Improvement in psychological well‐being measures
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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Liang 2017 {published data only}
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Linnet 2001 {published data only}
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Moore 2009 {published data only}
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Morawska 2016 {published data only}
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Niebel 1999 {published data only}
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Noren 2018 {published data only}
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Pustisek 2016 {published data only}
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Rea 2018 {published data only}
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Ryu 2015 {published data only}
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Santer 2014 {published data only}
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Santer 2022 {published data only}
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Shaw 2008 {published data only}
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Singer 2018 {published data only}
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Staab 2006 {published data only}
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References to studies excluded from this review

Anderson 2000 {published data only}
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Armstrong 2014 {published data only}
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Bashyam 2020 {published data only}
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Bergmo 2009 {published data only}
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Dahiya 2011 {published data only}
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Ersser 2013 {published data only}
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Guido 2020 {published data only}
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Haubrock 2009 {published data only}
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Hedman‐Lagerlof 2019 {published data only}
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Jordan 1974 {published data only}
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Jung 2020 {published data only}
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Klinger 2007 {published data only}
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References to studies awaiting assessment

NCT04174651 {published data only}
    1. NCT04174651. Stress-induced scratching in healthy and AD. clinicaltrials.gov/ct2/show/NCT04174651 (first received 22 November 2019).
NCT04633616 {published data only}
    1. NCT04633616. Tailored Patient-Provider Communication (TPPC): evaluating the impact of TPPC in dermatology patients. clinicaltrials.gov/ct2/show/NCT04633616 (first received 18 November 2020).

References to ongoing studies

ACTRN12618000940279 {published data only}
    1. ACTRN12618000940279. Determining the effect of early eczema education, in the form of a series of video's and pamphlet, on eczema severity in children < 6 years of age. trialsearch.who.int/Trial2.aspx?TrialID=ACTRN12618000940279 (first received 4 June 2018).
NCT03664271 {published data only}
    1. NCT03664271. Educational eczema video intervention. clinicaltrials.gov/ct2/show/NCT03664271 (first received 10 September 2018).
NCT04352270 {published data only}
    1. NCT04352270. Clinic-based atopic dermatitis therapeutic patient education. clinicaltrials.gov/ct2/show/NCT04352270 (first received 20 April 2020).
NCT04919330 {published data only}
    1. NCT04919330. Acceptance and Commitment Therapy-based eczema management programme (ACTeczema). clinicaltrials.gov/ct2/show/NCT04919330 (first received 9 June 2021).
NCT05502848 {published data only}
    1. NCT05502848. The effect of intervention and mechanism of ICBT on chronic itching in patients with atopic dermatitis. clinicaltrials.gov/ct2/show/NCT05502848 (first received 16 August 2022).

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References to other published versions of this review

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