Educational and psychological interventions for managing atopic dermatitis.

Abstract

Background Atopic dermatitis can have a significant impact on well-being and quality of life for affected people and their families. Standard treatment is with trigger/irritant avoidance and regular application of emollients and topical steroids or calcineurin inhibitors. Thorough physical and psychological assessment is central to informing about 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. Objectives 1. To assess the clinical outcomes of educational and psychological interventions in children and adults with atopic dermatitis 2. To summarise the availability and principal findings of relevant economic evaluations Search Methods The Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, APA PsycINFO and two trials registers were searched 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. NHS EED, MEDLINE and Embase were searched for economic evaluations on 8 June 2022. Selection criteria Randomised, cluster‐randomised and crossover randomised controlled trials that assess educational and psychological interventions for treating atopic dermatitis in children and adults. Data collection and Analysis We used standard Cochrane methods, with GRADE to assess the quality of the evidence for each outcome. Primary outcomes were reduction in disease severity, as measured by clinical signs, patient‐reported symptoms and improvement in quality‐of‐life measures. Secondary outcomes were improvement in long‐term control of atopic dermatitis symptoms, improvement in psychological well‐being, improvement in standard treatment concordance and adverse events. Time points assessed were short term (up to 16 weeks after treatment) and long term (>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. Interventions were assessed compared to standard care. Individual educational interventions may reduce short-term clinical signs (SCORAD) (mean difference (MD) -5.70, 95% confidence interval (CI) -9.39 to -2.01; 1 study, 30 participants; low‐certainty of evidence) but patient reported symptoms, quality of life, long-term atopic dermatitis 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 of evidence) and the long term (MD -7.22, 95% CI -11.01 to -3.43; 3 studies, 1424 participants; moderate-certainty of evidence). Group education interventions reduce long-term patient reported symptoms (SMD -0.47 95% CI -0.60 to -0.33; 2 studies, 908 participants; moderate-certainty of evidence). Group education may slightly improve short-term quality of life (SMD -0.19, 95% CI -0.36 to -0.01; 4 studies, 746 participants; low certainty of evidence), but may make little or no difference to short-term psychological well-being (PSS) (MD -2.47, 95% CI -5.16 to 0.22; 1 study, 80 participants; low certainty of evidence). Long-term atopic dermatitis control was not reported. We are unable to comment on whether technology-mediated educational interventions could change short-term clinical signs (SCORAD) (1 study; 29 participants; very low certainty of evidence). Technology mediated education interventions may have little or no effect on short-term patient reported symptoms (POEM) (MD: -0.76, 95% CI: -1.84 to 0.33; 2 studies; 195 participants; low certainty of evidence) and probably have little or no effect on short-term quality of life (HRQoL) (MD: 0, 95% CI -0.03 to 0.03; 2 studies, 430 participants; moderate certainty of evidence). Technology-mediated education interventions probably slightly improve long-term atopic dermatitis control (RECAP) (MD -1.5, 95% CI -3.13 to 0.13; 1 study, 232 participants; moderate certainty), 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 of evidence) but we are uncertain about any effects on short-term quality of life (CDLQI) (1 study, 30 participants; very low certainty of evidence). Patient reported symptoms, long-term atopic dermatitis control and psychological well-being were not reported. We were uncertain whether arousal reduction therapy interventions could change short-term clinical signs (EASI) (1 study, 24 participants; very low certainty of evidence) or patient reported symptoms (VAS) (1 study; 18 participants; very low certainty of evidence). Arousal reduction therapy may improve short-term quality of life (DFI) (MD: -2.1, 95% CI: -4.41 to 0.21; 1 study, 91 participants; low certainty of evidence) and psychological well-being (PSS) (MD -1.2, 95% CI -3.38 to 0.98; 1 study, 91 participants; low certainty of evidence). Long-term atopic dermatitis control was not reported. No studies reported comparisons of standard care with self-help psychological interventions, psychological therapies or printed education. No adverse events were reported in any of the studies. Two health economic studies were identified. One found a 12-week technology-mediated educational support programme may be cost neutral. The other study found a nurse practitioner group education intervention may have lower costs than standard care provided by a dermatologist, with comparable effectiveness. Author's conclusions In person, individual education, as an adjunct to conventional topical therapy, may reduce short-term atopic dermatitis signs compared to standard care, but there is no information on atopic dermatitis symptoms, quality of life or long-term outcomes. Group education probably reduces atopic dermatitis signs and atopic dermatitis 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 minimally 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.