Emollient Use Reduces Atopic Eczema Symptoms in Infants
Emollient Use Reduces Atopic Eczema Symptoms in Infants
Atopic eczema (synonym atopic dermatitis) in children is unpredictable in its course and may have a profound impact on the quality of life of patients and their family, as well as being time-consuming for healthcare professionals to manage. However, the primary care setting is not often well equipped for patient education and support. Twenty years ago, in 1993 a survey of members of the National Eczema Society asked what members wanted healthcare professionals to do to improve the control of childhood atopic eczema. The majority wanted more time to be spent explaining the nature of eczema and advice about how to use the treatments prescribed. In 83% of consultations with general practitioners (GPs) and 74% of first consultations with a dermatologist, the expectations of parents/patients had been only partially met or not met at all.
Education of parents and children with atopic eczema is now recognised as one of the most important interventions in the management of atopic eczema. The largest RCT of an education programme was conducted in Germany, including 823 children or adolescents with atopic eczema and their families. A six-week education programme for the management of moderate to severe atopic eczema was evaluated, with dermatological, nutritional and psychological facets; it was delivered as a two hour, once-weekly session by a multi-professional team. At one year, improvement in the severity of atopic eczema (SCORAD) in children who received the education programme was significantly greater than in the control group. There were also significant improvements in subjective assessments of severity, itching behaviour and emotional coping in the group receiving education compared to control.
A cost-effectiveness analysis was performed using the data from the German trial as part of the NICE guidelines for treatment of atopic eczema. This demonstrated that if an atopic eczema education programme, similar to that detailed in the German RCT could be provided at less than about £800 per child, then it would be highly likely to be cost effective. NICE also concluded that if a less-resource intensive (and less effective) programme could be implemented in the NHS then this was also likely to be cost-effective.
The impact of specialist dermatology nurse-led education has been evaluated in children with mild/moderate atopic eczema. These studies showed a significant improvement in the control of atopic eczema in children receiving education. For example Cork and colleagues found that 24% of children with atopic eczema were receiving no emollient treatment, with an average use of emollient of just 54 g per week. Dermatology clinic-based specialist nurse-led educational intervention resulted in an 800% increase in the use of emollients with a corresponding 89% reduction in the severity of the atopic eczema. Although much less resource intensive than the German RCT, these studies were in populations of children with less severe, mild/moderate atopic eczema.
There have been no comparisons of different education programmes for atopic eczema in children apart from a recent comparison of face-to-face care and an e-health intervention. Children (with their parents) and adults with moderate severity atopic eczema attended for a first consultation with a dermatologist and specialist dermatology nurse. Subsequently, they were randomised to face-to-face follow-up treatment in the dermatology department or to internet-guided monitoring and on-line self-management training. There were no significant differences in severity of the atopic eczema, quality of life and intensity of itching between the two groups. Compared to routine care, the e-health intervention led to non-significant changes in health and broader societal costs although estimates were imprecise.
Atopic eczema arises as a result of gene-environment interactions leading to a defective skin barrier. Thus, emollient creams, ointments and wash products are the first line treatment to repair the skin. In mild atopic eczema, effective management consists of complete emollient therapy plus occasional treatment of flares with mild potency topical corticosteroids. Educational interventions for atopic eczema are provided most commonly in the secondary care hospital setting, while the large majority of children have mild atopic eczema and are treated in primary care. Guidelines emphasize the importance of using sufficient emollient: 250 to 500 grams per week, the more emollient being used the less the need for mild potency topical corticosteroids. However, the actual use of emollients in the UK is far less than this recommended amount.
Rather than designing an intervention that influenced the selection of prescribed products, we designed a study to assess and improve emollient use and outcomes in children who had currently been prescribed a proprietary emollient, E45 Cream (Reckitt Benckiser Healthcare, UK). Using this design, the amount of emollient could be tracked, along with co-treatment over a 3-month period, allowing the support programme to be assessed. The support programme used a multifaceted approach since evidence from a number of fields supports an integrated, supportive approach for patients as more effective than single or simple measures in achieving behavioural change.
Background
Atopic eczema (synonym atopic dermatitis) in children is unpredictable in its course and may have a profound impact on the quality of life of patients and their family, as well as being time-consuming for healthcare professionals to manage. However, the primary care setting is not often well equipped for patient education and support. Twenty years ago, in 1993 a survey of members of the National Eczema Society asked what members wanted healthcare professionals to do to improve the control of childhood atopic eczema. The majority wanted more time to be spent explaining the nature of eczema and advice about how to use the treatments prescribed. In 83% of consultations with general practitioners (GPs) and 74% of first consultations with a dermatologist, the expectations of parents/patients had been only partially met or not met at all.
Education of parents and children with atopic eczema is now recognised as one of the most important interventions in the management of atopic eczema. The largest RCT of an education programme was conducted in Germany, including 823 children or adolescents with atopic eczema and their families. A six-week education programme for the management of moderate to severe atopic eczema was evaluated, with dermatological, nutritional and psychological facets; it was delivered as a two hour, once-weekly session by a multi-professional team. At one year, improvement in the severity of atopic eczema (SCORAD) in children who received the education programme was significantly greater than in the control group. There were also significant improvements in subjective assessments of severity, itching behaviour and emotional coping in the group receiving education compared to control.
A cost-effectiveness analysis was performed using the data from the German trial as part of the NICE guidelines for treatment of atopic eczema. This demonstrated that if an atopic eczema education programme, similar to that detailed in the German RCT could be provided at less than about £800 per child, then it would be highly likely to be cost effective. NICE also concluded that if a less-resource intensive (and less effective) programme could be implemented in the NHS then this was also likely to be cost-effective.
The impact of specialist dermatology nurse-led education has been evaluated in children with mild/moderate atopic eczema. These studies showed a significant improvement in the control of atopic eczema in children receiving education. For example Cork and colleagues found that 24% of children with atopic eczema were receiving no emollient treatment, with an average use of emollient of just 54 g per week. Dermatology clinic-based specialist nurse-led educational intervention resulted in an 800% increase in the use of emollients with a corresponding 89% reduction in the severity of the atopic eczema. Although much less resource intensive than the German RCT, these studies were in populations of children with less severe, mild/moderate atopic eczema.
There have been no comparisons of different education programmes for atopic eczema in children apart from a recent comparison of face-to-face care and an e-health intervention. Children (with their parents) and adults with moderate severity atopic eczema attended for a first consultation with a dermatologist and specialist dermatology nurse. Subsequently, they were randomised to face-to-face follow-up treatment in the dermatology department or to internet-guided monitoring and on-line self-management training. There were no significant differences in severity of the atopic eczema, quality of life and intensity of itching between the two groups. Compared to routine care, the e-health intervention led to non-significant changes in health and broader societal costs although estimates were imprecise.
Atopic eczema arises as a result of gene-environment interactions leading to a defective skin barrier. Thus, emollient creams, ointments and wash products are the first line treatment to repair the skin. In mild atopic eczema, effective management consists of complete emollient therapy plus occasional treatment of flares with mild potency topical corticosteroids. Educational interventions for atopic eczema are provided most commonly in the secondary care hospital setting, while the large majority of children have mild atopic eczema and are treated in primary care. Guidelines emphasize the importance of using sufficient emollient: 250 to 500 grams per week, the more emollient being used the less the need for mild potency topical corticosteroids. However, the actual use of emollients in the UK is far less than this recommended amount.
Rather than designing an intervention that influenced the selection of prescribed products, we designed a study to assess and improve emollient use and outcomes in children who had currently been prescribed a proprietary emollient, E45 Cream (Reckitt Benckiser Healthcare, UK). Using this design, the amount of emollient could be tracked, along with co-treatment over a 3-month period, allowing the support programme to be assessed. The support programme used a multifaceted approach since evidence from a number of fields supports an integrated, supportive approach for patients as more effective than single or simple measures in achieving behavioural change.