Psychological and educational interventions for atopic eczema in children
Editorial Group: Cochrane Skin Group
Published Online: 7 JAN 2014
Assessed as up-to-date: 17 JAN 2013
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Ersser SJ, Cowdell F, Latter S, Gardiner E, Flohr C, Thompson AR, Jackson K, Farasat H, Ware F, Drury A. Psychological and educational interventions for atopic eczema in children. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD004054. DOI: 10.1002/14651858.CD004054.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 7 JAN 2014
Psychological and educational interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. This is an update of the original Cochrane review.
To assess the effect of psychological and educational interventions for atopic eczema in children.
We updated our searches of the following databases to January 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 12), MEDLINE (from 1946), EMBASE (from 1974), OpenGrey, and PsycINFO (from 1806). We also searched six trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs).
Randomised controlled trials of psychological or educational interventions, or both, used to assist children and their carers in managing atopic eczema.
Data collection and analysis
Three authors independently applied eligibility criteria, assessed trial quality, and extracted data. A lack of comparable data prevented data synthesis, and we were unable to conduct meta-analysis because there were insufficient data.
We included 10 RCTs, of which 5 were new to this update; all interventions were adjuncts to conventional therapy and were delivered in primary- and secondary-care settings. There were 2003 participants in the 9 educational interventions and 44 participants in the 1 psychological study. Some included studies had methodological weaknesses; for example, we judged four studies to have high risk of detection bias, attrition bias, or other bias. Our primary outcomes were participant-rated global assessment, reduction in disease severity (reported as objective SCORAD (SCORing Atopic Dermatitis)), and improvement in sleep and quality of life. No study reported participant-rated global assessment or improvement of sleep.
The largest and most robust study (n = 992) demonstrated significant reduction in disease severity and improvement in quality of life, in both nurse- and dermatologist-led intervention groups. It provided six standardised, age-appropriate group education sessions. Statistically significant improvements in objective severity using the SCORAD clinical tool were recorded for all intervention groups when compared with controls. Improvements in objective severity (intervention minus no intervention) by age group were as follows: age 3 months to 7 years = 4.2, 95% confidence interval (CI) 1.7 to 6.8; age 8 to 12 years = 6.7, 95% CI 2.1 to 11.2; and age 13 to 18 years = 9.9, 95% CI 4.3 to 15.5. In three of five studies, which could not be combined because of their heterogeneity, the objective SCORAD measure was statistically significantly better in the intervention group compared with the usual care groups. However, in all of the above studies, the confidence interval limits do not exceed the minimum clinically important difference of 8.2 for objective SCORAD.
The largest study measured quality of life using the German 'Quality of life in parents of children with atopic dermatitis' questionnaire, a validated tool with five subscales. Parents of children under seven years had significantly better improvements in the intervention group on all five subscales. Parents of children aged 8 to 12 years experienced significantly better improvements in the intervention group on 3 of the 5 subscales.
This update has incorporated five new RCTs using educational interventions as an adjunct to conventional treatment for children with atopic eczema. We did not identify any further studies using psychological interventions. The inclusion of new studies has not substantially altered the conclusions from the original review. The educational studies in both the original review and this update lack detail about intervention design and do not use a complex interventions framework. Few use an explicit theoretical base, and the components of each intervention are not sufficiently well described to allow replication. A relative lack of rigorously designed trials provides limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of atopic eczema in children. However, there is some evidence from included paediatric studies using different educational intervention delivery models (multiprofessional eczema interventions and nurse-led clinics) that these may lead to improvements in disease severity and quality of life. Educational and psychological interventions require further development using a complex interventions framework. Comparative evaluation is needed to examine their impact on eczema severity, quality of life, psychological distress, and cost-effectiveness. There is also a need for comparison of educational interventions with stand-alone psychosocial self-help.
Plain language summary
Psychological and educational interventions for atopic eczema in children
Atopic eczema is an itchy, inflammatory skin condition, which affects the quality of life of children with eczema and their parents or carers. It affects large and increasing numbers of children worldwide. Psychological and educational approaches have been used to complement medication in managing eczema, for example, by using simple psychological techniques to manage itching and scratching or sleep disturbance. Educational interventions, provided to individuals and groups by nurses or teams of specialists in hospital or community settings, have been used to help parents and children to understand the condition and their role in managing it successfully. However, the effect of these approaches has not been systematically measured.
We included 10 studies in this review: 5 were in the original review, and 5 were newly incorporated in this update.
Nine studies were educational and predominantly parent-focused (total number of participants n = 2003), and the tenth was a child-centred psychological intervention (n = 44).
The main finding of this review is that there is currently only limited research evidence about the effect of educational and psychological approaches when used alongside medicines for the treatment of childhood eczema. Included studies provided a range of interventions, from a single 15-minute consultation to a comprehensive series of sessions delivered to groups of parents over a period of 12 hours. Details of the interventions used and the educational theory base are generally poorly described. Outcome measures varied between studies.
Although it is not possible to draw definitive conclusions from this review, several studies using educational interventions demonstrated improvements in eczema severity and quality of life for both children and families. In particular, two studies showed promise. One large study (n = 992) using a multi-disciplinary group education intervention in a hospital setting showed modest improvements in disease severity and quality of life. The single study using psychological approaches indicated that relaxation methods reduced the severity of eczema when compared to discussion only.
There is a need for further research into this subject, and priority should be given to comparing the relative cost effectiveness of health professionals educating parents either in teams or by nurses alone. There is also a need for comparison with stand-alone self-help. The most appropriate timeframe for evaluating the effect of interventions should be considered.