Does patient education for the management of atopic eczema in children and adolescents help to reduce the severity of atopic eczema, within 12 months?

Written by Amy Brown

  Introduction

Atopic eczema is a common skin disease that is currently on the rise in New Zealand (Clayton, et al., 2013). Atopic eczema affects one in five children and studies show that parents of children with the disease lack knowledge and skills in managing the effects of it (Clayton et al., 2013). Given the considerable underutilization of emollient creams and topical corticosteroids for atopic eczema, effective education in the use of topical therapy is a key issue (Watkins, 2012). There have been many studies undertaken and will be discussed within this paper which indicate that patient education is an effective method in increasing the use of topical therapies and therefore reducing the severity of eczema. Nurses in the primary healthcare setting have a responsibility to provide education to children and their parents and I recommend that they increase the amount of education they give to patients.

  Clinical issue

Atopic eczema or atopic dermatitis is a common chronic inflammatory skin condition, affecting 20% of school-age children (Clayton et al., 2013). It is characterised by an itchy red rash and is a relapsing disease with episodes of exacerbations and remissions (Robinson, 2011). The term eczema describes a skin disorder that is characterised by dry itchy skin, redness, blistering and thickening (Lawton, 2014). ‘Atopic’ describes conditions which often have a genetic basis and may be connected with sensitization to common environmental allergens (Robinson, 2011). These include eczema, hay fever, asthma and seasonal rhinitis. Atopic eczema has a negative impact on the quality of life of children and their families due to the itching and scratching and also as a result of sleep disturbance (Robinson, 2011).

Non-compliance with eczema treatment is a major factor in the increasing prevalence of the disease (Holm, Esmann & Jemec, 2005). Topical corticosteroids have an important role in the treatment of eczema however, many parents have a ‘phobia’ towards them and don’t use them to treat their children’s eczema (Smith, Hong, Fearns, Blaszczynski & Fischer, 2010). Anxiety around the use of corticosteroids is generally due to the possible side effects which are skin thinning, telangiectasia (small dilated blood vessels), striae and local hair growth (Smith et al., 2010). These are however extremely rare and the benefits of it strongly outweigh the risks. Advice to apply steroids sparingly and parents’ uncertainty about the effect on the child’s immune system also contribute to fears relating to topical corticosteroid use (Smith et al., 2010).

Children with atopic eczema are usually seen by health professionals in a primary health care setting in the community such as a General Practice (GP) context. However, this setting is not often well equipped for patient education and support as it is time-consuming and the healthcare professionals’ understanding of eczema may be limited (Lawton, 2014). Surveys taken from parents of children with atopic eczema indicate that they need more time spent explaining to them the nature of the eczema and advice about how to use the prescribed treatments (Lawton, 2014).

I decided to pursue this current issue because it is a significant problem in New Zealand at the moment and I also have eczema myself but have received very little education about the management of it. New Zealand is currently ranked 9th out of 60 countries in the prevalence of eczema among children and studies show the prevalence is increasing (Clayton et al., 2013). New Zealand children and adolescents have high rates of hospital admission for serious skin infection and infected eczema is a modest contributor to this (Clayton et al., 2013). Under-treatment of eczema is a big factor in this as well managed eczema would not normally be followed by hospital admission (Clayton et al., 2013). Anxiety around corticosteroids is a major factor in the under-treatment of eczema in New Zealand and therefore nurses need to educate patients about the management of the disease (Robinson, 2011).

  Evidence and findings

A study was conducted in Germany in 2006 to determine the effects of educational programmes on the management of atopic dermatitis in childhood and adolescence (Staab et al., 2006). The design of the study was a randomised controlled trial with the intervention group receiving an educational programme on the management of eczema and the control group receiving no education (Staab et al., 2006). The participants included three groups of different aged children with atopic dermatitis. The educational programme comprised of six, once weekly sessions, lasting two hours each (Staab et al., 2006). For children who were under 12 years, the parents received the education but the adolescents received the education in their group. The main outcome measure in the study was the difference in the severity of eczema between the start of the study and follow-up after 12 months (Staab et al., 2006). Results showed that at the 12 month follow-up, the severity of eczema had decreased in all groups but the decrease was significantly greater in the intervention groups (Staab et al., 2006). This study therefore shows that giving education to children and their parents on the control of atopic dermatitis is effective in the long-term mangagement of the disease.

Another trial was done in the UK in 2003 with the objective to determine the effect of education and demonstration of topical therapies on therapy utilisation and severity of atopic eczema (Cork et al., 2003). This study used a before and after design with the baseline data used as the control and the education given as the intervention. Participants included fifty-one children with atopic eczema who were followed for up to one year (Cork et al., 2003).  At the first visit, a dermatologist and specialist dermatology nurse gathered baseline information which included the parent’s knowledge about atopic eczema, the severity of the child’s eczema, and treatment that was being used (Cork et al., 2003). The nurse then explained the nature of atopic eczema and possible causes and demonstrated how to use all of the topical treatments (Cork et al., 2003). The child and their parents then had three more visits over 12 months where this education was repeated, depending on their level of knowledge. Results from the study showed that the mean weekly use of emollient increased from 54.3 g at baseline to 426 g at the final visit and there was a decrease in the use of very potent steroids and an increase in the use of mild steroids (Cork et al., 2003). The results also showed a significant reduction in the eczema severity due to the increased dose of emollient used (Cork et al., 2003). The data obtained in this study therefore clearly signifies that the most important interventions in the management of atopic eczema are to spend time educating parents about the disease and to demonstrate how to apply topical therapies.

Another study was conducted in the UK in 2013 which evaluated the effectiveness of an educational programme as a method of increasing emollient use and reducing atopic eczema in children (Mason et al., 2013). This study also used a before and after design with the intervention being a purpose-designed educational programme for parents of children with atopic eczema (Mason et al., 2013). Participants included 136 children and their parents who were followed-up after 12 weeks. Parents first reported baseline data and then they received a support pack which included an instructional DVD on the use of emollients, online daily diary and telephone helpline. The main baseline and follow-up measures included emollient use (grams per week), severity of eczema and concurrent medication (topical corticosteroid use) (Mason et al., 2013). The severity of eczema was captured using the POEM (Patient Orientated Eczema Measure) which recorded the days in a week that the child was affected by specific signs of eczema (Mason et al., 2013). Results from the study showed that emollient cream use increased significantly with an average daily increase of 87.6 grams. The use of topical corticosteroids also increased from a baseline of 37.8% of patients to 58.6% during the programme. Results also showed that eczema severity reduced significantly with the POEM score reducing 47% from the baseline score (Mason et al., 2013). This study therefore demonstrates that an educational programme that teaches parents the importance of topical therapy in atopic eczema is effective at reducing the severity of eczema in children.

  Implications for practice

There are many benefits in educating patients about the management of atopic eczema including a significant reduction in the severity of eczema and an improved quality of life for both children and their parents (Watkins, 2011). Nurses therefore have a responsibility to educate children and their parents about effective ways of treating atopic eczema (Cork et al., 2003). Treatment will not be successful unless the children and their parents have a clear understanding of the different treatments available and how and when to apply products such as emollients and topical steroids (Cork et al., 2003). An implication for practice is that it has been shown that specialist dermatology nurses have a lot more specific knowledge about eczema and therefore produce better outcomes for their patients than practice nurses (Watkins, 2011). Ideally, specialist dermatology nurses would run nurse-clinics but there can only be so many specialist nurses so many practice nurses would need to do this (Watkins, 2011).

  Recommendations

Based on the evidence I have recommend that nurses:

  • Explain to patients what atopic eczema is and possible causes of it because studies show that this increases the chance of adherence to treatment (Hanifin & Tofte, 1999).
  • Educate patients about the benefits of topical corticosteroids and enforce that mild potencies of it are safe. Studies show that a ‘phobia’ to corticosteroids is a key issue in the under-treatment of atopic eczema in children (Staab et al., 2006).
  • Educate patients about the effectiveness of emollient cream in reducing eczema severity. Many studies have shown that increased use in emollient cream significantly reduces severity of eczema (Mason et al., 2013). 
  • Demonstrate to patients how to apply topical treatments and explain to them when they should be used. This intervention has been shown to improve adherence to, and the outcome of, treatment (Cork et al., 2003).

And nurse –led eczema clinics are started as these have been shown to be effective in educating parents about the management of atopic eczema. They allow more time for education and demonstration of treatments as GP’s and dermatologists only have limited time during a consultation (Watkins, 2011).

  Conclusion

In conclusion, studies have shown that educating children and their parents on the management of atopic eczema does significantly reduce the severity of eczema in children (Cork et al., 2003). Atopic eczema is a significant problem in New Zealand currently and the prevalence of it is increasing (Clayton et al., 2013). Under-treatment of the disease is primarily due to a lack of knowledge in parents about the disease and effective methods of treating it (Cork et al., 2003). In order to try and reduce the increasing prevalence of eczema in New Zealand, I recommend that nurses give a clear explanation of the management of the disease to parents when they visit their GP practice as they have more time than doctors and dermatologists. 

  References

Clayton, T., Asher, M., Crane, J., Ellwood, P., Mackay, R., Mitchell, E., Moyes, C., Pattemore, P., Pearce, N., & Stewart, A. (2013). Time trends, ethnicity and risk factors for eczema in New Zealand children: ISAAC Phase Three. Asia Pacific Allergy, 3(3): 161-178.

Cork, M., Britton, J., Butler, L., Young, S., Murphy, R., & Keohane, S. (2003). Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. British Journal of Dermatology, 149: 582-589.

Hanifin, J., & Tofte, S. (1999). Patient education in the long-term management of atopic dermatitis. Dermatology Nursing, 11(4), 284-289.

Holm, E., Esmann, S., & Jemec, G. (2005). Patient education and morbidity in atopic eczema. Dermatology Nursing, 17(1), 35-45.

Lawton, S. (2014). Managing difficult and severe eczema in children. Nurse Prescribing, 12(1), 26-31.

Mason, J., Carr, J., Buckley, C., Hewitt, S., Berry, P., Taylor, J., & Cork, M. (2013). mproved emollient use reduces atopic eczema symptoms and is cost neutral iinfants: before-and-after evaluation of a multifaceted educational support programme. BMC Dermatology, 13:7

Peate, I. (2011). Eczema: causes, symptoms and treatment in the community. British Journal of Community Nursing, 16(7), 324-331.

Robinson, J. (2011). Assessment and management of atopic eczema in children. Nursing Standard,26(1), 48-56.

Smith, S., Hong, E., Fearns, S., Blaszczynski, A., & Fischer, G. (2010). Corticosteroid phobia and other confounders in the treatment of childhood atopic dermatitis explored using parent focus groups. Australasian Journal of Dermatology, 51:168–174.

Staab, D., Diepgen, T., Fartasch, M., Kupfer, J., Lob-Corzilius, T., Ring, J., Scheewe, S…. Gieler, U. (2006). Age related, structured educational programmes for the management of atopic dermatitis in children and adolescents: multicentre, randomised controlled trial. BMJ, 332:933–938.

Watkins, J. (2011). Eczema diagnosis and management in the community. British Journal of Community Nursing, 16(9), 418-426.

Watkins, J. (2012). Diagnosis and treatment of atopic eczema in children and adults. Practice Nursing, 23(9), 450-458.