A Review of Multidisciplinary Interventions in Atopic Dermatitis

Multidisciplinary atopic dermatitis program: A novel approach to managing difficult-to-control atopic dermatitis patients

BACKGROUND/OBJECTIVES

Disease improvement for difficult-to-control pediatric atopic dermatitis may be more challenging to achieve when directed by single specialties due to disjointed and conflicting dialogue with patients.

METHODS

The Multidisciplinary Atopic Dermatitis Program (MADP) was developed through collaborations with the Rady Children's Hospital and UC San Diego Health Divisions of Dermatology, Allergy & Immunology and Clinical Pharmacy, to create team-based evaluation and management of children and adolescents with atopic dermatitis (AD). The MADP allows concurrent, comprehensive evaluations by multiple specialists to develop treatment plans. The program includes extensive patient education to support shared decision making, incorporating patient and family's perspectives along with those of clinical experts into their care. Objective severity measures and patient reported outcome data were collected, along with assessment of patient and family satisfaction with the MADP.

RESULTS

Data showed significant improvement in AD severity as assessed by providers, patients and families by the first follow-up visit. BSA mean percentage decreased by up to 56% by the 7th visit, and pruritus (NRS), CLDQI and POEM mean scores decreased by more than 4 points, 12 points, and over 11 points, respectively. After management was initiated in the MADP, 72.73% of patients achieved an EASI 50 and 47.73% achieved an EASI 75 from a baseline mean of 21.7. Patients who continued in clinic beyond the second visit showed further clinically significant decreases in disease measures.

CONCLUSIONS

The multidisciplinary approach shows success in the treatment of difficult-to-control AD patients with improvements in clinician and patient reported outcome measures.

Itch: from the skin to the brain - peripheral and central neural sensitization in chronic itch

Similar to chronic pain, chronic itch is frequently linked to neural sensitization, a phenomenon wherein the nervous system becomes hypersensitive to stimuli. This process of neural sensitization of chronic itch is orchestrated by various signaling pathways and mediators in both the peripheral and central nervous systems. At the level of the peripheral nervous system, inflammation and neuroimmune interactions induce plastic changes to peripheral nerve fibers, thereby amplifying the transmission of itch signaling. Neural sensitization in the central nervous system occurs at both the spinal cord and brain levels. At the level of the spinal cord, it involves hyperactivity of itch-activating spinal pathways, dysfunction of spinal inhibitory circuits, and attenuation of descending supraspinal inhibitory pathways. In the brain, neural sensitization manifests as structural and functional changes to itch-associated brain areas and networks. Currently, we have a diverse array of neuroimmune-modulating therapies targeting itch neural sensitization mechanisms to help with providing relief to patients with chronic itch. Itch research is a dynamic and continually evolving field, and as we grow in our understanding of chronic itch mechanisms, so will our therapeutic toolbox. Further studies exploring the peripheral and central neural sensitization mechanisms in the context of chronic itch are needed.

Atopic Dermatitis: Disease Features, Therapeutic Options, and a Multidisciplinary Approach

The latest findings regarding AD pathogenesis point to an impaired function of the epidermal barrier, changed immune response, colonization of the skin by microorganisms, and certain psychological factors among other causes/triggers. The inflammatory response of AD patients is mainly associated with the activation of T cells (Th2 cells predominate), dendritic cells, macrophages, keratinocytes, mast cells, and eosinophils. Therapy usually involves medical evaluations and adequate management including treatment of concomitant diseases (e.g., allergies and infections), patient education and nursing care, psychological support, and nutritional consultations, which are organized through specific programs and structured educational groups. Systemic AD therapy includes conventional systemic treatment (cyclosporine, methotrexate, azathioprine) and new, specific drugs, interleukin inhibitors (e.g., dupilumab) and JAK inhibitors (baricitinib, abrocitinib, upadacitinib, etc.). Since many AD patients are affected by various psychological factors and comorbidities, they should be assessed and managed through a multidisciplinary approach, involving different professions (psychologists, ear-nose-throat specialists, pulmonologists, allergologists, immunologists, nutritionists, pediatricians, gastroenterologists, psychiatrists (when necessary), and others). A multidisciplinary approach provides better coping strategies and improves control over the disease, patient adherence to therapy, and quality of life. It also has a positive influence on family quality of life while at the same time making more efficient use of dermatology healthcare resources, reducing the economic burden on both patients and society.

Factors facilitating shared decision making in eczema: Met and unmet needs from the patient perspective

Background

Research has shown that eczema patients prefer some degree of shared control over treatment decisions, but little is known about factors perceived to be important to facilitate shared decision making (SDM).

Objective

To determine factors eczema patients and caregivers consider to be important for SDM, and how often they experience them with their eczema healthcare provider (HCP).

Methods

A cross-sectional survey study (64 questions) was conducted, which included factors related to SDM rated by respondents on a Likert scale for importance, and how often these factors were true with their current eczema HCP.

Results

Respondents (840, response rate 62.4%) most frequently rated their health literacy and communication skills as important for SDM. Factors which indicated a strong provider-patient relationship, and HCPs who initiate treatment conversations were also deemed beneficial. Low importance was placed on concordant HCP race/ethnicity, however, of those who did rate it as important, 53/91 identified as Black (half of all Black respondents).

Limitations

A high proportion of respondents were aware of the term SDM prior to the survey.

Conclusions

SDM is more likely to be facilitated when patient education and empowerment are coupled with HCPs who initiate treatment discussions, maintain compassion resilience, and listen to patient perspectives.

Engagement, Retention and Acceptability in a Digital Health Program for Atopic Dermatitis: Prospective Interventional Study

BACKGROUND

Patients with Atopic Dermatitis (AD) can experience chronic eczema with pruritus, skin pain, sleep problems, anxiety, and other problems that reduce their quality of life (QoL). Current treatments aim to improve these symptoms and reduce inflammation, but poor treatment adherence and disease understanding are key concerns in the long-term management of AD. Digital therapeutics can help with these, and support patients towards a healthier lifestyle to improve their overall QoL.

OBJECTIVE

To test the feasibility of a digital health program tailored for AD through program engagement, retention and acceptability.

METHODS

Adults with AD were recruited in Iceland for a six-week digital health program delivered through a smartphone app. Key components of the digital program were disease and trigger education, medication reminders, patient-reported outcomes (PROs) on energy levels, stress levels, and quality of sleep (referred to as QoL PROs), AD symptom PROs, guided meditation, and healthy lifestyle coaching. The primary outcome was program feasibility, as assessed by in-app retention and engagement. User satisfaction was assessed by the mHealth App Usability Questionnaire (MAUQ).

RESULTS

Twenty-one patients were recruited (17 female, mean age: 31 years); 20 (95%) completed the program. On average, users were active in the app 6.5 days per week and completed 8.2 missions per day. The education content, medication reminders, and PROs had high user engagement and retention; all users who were exposed to the QoL PROs (n=17) interacted with these, and 20/21 (95%) users continuously engaged with the education missions, medication missions, and symptom PROs. Continued engagement with the step counter and mind missions among exposed users was lower (17/21 and 13/20 participants respectively). Medication reminder and education task completion remained high over time (at least 18/20, 90%), but weekly interactions declined. All assigned users completed AD symptom PROs on weeks 1-5 and only one did not do so on week 6; the reported number and total severity of AD symptoms reduced during the program. Regarding the QoL PROs, 16/17 (94%) and 14/17 (82%) users interacted with these at least 3 times in the first and last week of the program respectively, and all reported improvements over time. User satisfaction was high, with a total score of 6.2/7.

CONCLUSIONS

We found high overall engagement and retention in a targeted digital health program among patients with AD, as well as high compliance with missions relating to medication reminders, patient education, and PROs. Symptom number and severity was reduced and QoL PROs improved over time. We conclude that a digital health program is feasible and may provide added benefits for patients with AD, including the tracking and improvement of AD symptoms.

CLINICALTRIAL

Impact of a Digital Atopic Dermatitis Educational Intervention on Hispanic Patients and Family Members

With the increasing incidence of atopic dermatitis (AD) in the U.S., the highest prevalence of AD being found in Hispanic countries, and the rising Hispanic-American population, educational resources on eczema focused on Spanish-speaking populations are needed more than ever. As such, the primary goal of this project was to assess the beneficial impact of an educational intervention conducted through a virtual platform for Hispanic individuals living with atopic dermatitis. Utilizing WhatsApp, the study enrolled 55 participants diagnosed with AD and/or parents of children diagnosed with AD. Participants were enrolled in a seven-day educational module with daily topics on AD health knowledge. A health knowledge survey was administered before the educational program, upon completion of the program, and one month after completion. The program found a 14% increase in AD health knowledge upon completion of the program (p < 0.001). Most importantly, there was no significant difference found between the health knowledge survey submitted at program completion and one month after completion, signaling that health knowledge taught through the course was successfully retained by participants (p = 0.29). Qualitative themes involving atopic disease were additionally explored through group discussions, including mental health and peer stigma. This study is the first of its kind in dermatology utilizing the WhatsApp format. The success of retained health knowledge regarding AD demonstrates that future virtual endeavors can be effective and accessible methods of patient education overall for populations that might not have ease of access to major medical centers.

Unmet Medical Needs and Early Referral of Pediatric Atopic Dermatitis: An Expert Modified Delphi Consensus from Saudi Arabia

Atopic dermatitis (AD) is a chronic skin disease with increasing prevalence worldwide. It is characterized by pruritic eczematous lesions, affecting up to 20% of the children and negatively impacting their quality of life. Guidelines for AD management are available worldwide, but specific guidelines for pediatric AD in Saudi Arabia are lacking. This consensus document aims to identify the needs for the diagnosis and management of pediatric AD in Saudi Arabia by gathering the opinions and recommendations of key experts. We conducted a three-step modified Delphi method to develop the present consensus. The experts agreed that pediatricians and dermatologists commonly encounter AD; however, it is still under-recognized in its early stage in Saudi Arabia. The family physicians should be involved in assessing suspected children with a family history of atopy, particularly in patients with isolated lesions. Further, the experts confirmed that AD diagnosis should be documented, showing assessment criteria used, key morphological characteristics, and features used to ascertain the severity of the disease. There is still a need for simple validated diagnostic criteria suitable for daily practice for pediatric AD. The experts highlighted several medical conditions that pertain to the diagnosis and management of AD in Saudi Arabia.

Pioneering Global Best Practices in Atopic Dermatitis: Results from the Atopic Dermatitis Quality of Care Initiative

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by unrelenting pruritus and recurrent eczematous lesions. It affects up to 15% of children and adolescents and up to 5% of adults and confers a high and multifactorial burden to patients, families, and society. With increasing awareness of this substantial burden, AD has become a priority for healthcare systems.

OBJECTIVE

The Atopic Dermatitis Quality of Care (ADQoC) Initiative set out to describe good practices for addressing the challenges that impede the management of AD.

METHODS

The Initiative carried out a literature review and surveyed 32 expert care centres, catalogued findings, and analysed and elucidated global challenges to AD care along with good practice implementations that can address them.

RESULTS

The four challenges to quality care for AD are: misconceptions about AD; delayed referral and access to AD specialists; poor patient access to AD treatments and poor adherence to medications; and managing the complexity of atopic dermatitis and its comorbidities. The Initiative highlighted five of ten good practice implementations as high priority for any AD care centre to focus: clinical assessment and diagnosis; a structured multidisciplinary care team; monitoring and evaluating care quality; patient education and communication; and collaboration and exchange with patient groups.

CONCLUSIONS

These implementations can provide benefits for patients, healthcare providers, and the healthcare system. They directly contribute to the efficacy of treatment; improved healthcare provider efficiency; improved education; and improved costs to healthcare systems. The Initiative was launched on https://atopicdermatitiscare.kpmg.co.uk/ to provide an easy-to-use educational platform.

Secondary and Tertiary Prevention: Medical Rehabilitation

Allergies are a major public health burden, and targeted measures are required in terms of prevention and treatment. The most common allergic conditions encompass atopic dermatitis (AD), food allergy (FA), allergic asthma (AA), and allergic rhino-conjunctivitis (AR). Primary prevention aims at preventing the onset of allergic disease, before the disease process begins. Secondary prevention aims at preventing progression and exacerbation of allergic disease whereas tertiary prevention aims at reducing disease burden in patients with established disease, by allergen immunotherapy (AIT) or medical rehabilitation. Rehabilitation programs are used for treatment of AA and AD and usually consist of extensive patient assessment, optimization of treatment management, patient education, and behavioral interventions, ideally involving a multidisciplinary treatment team and sometimes provided in a specific climate, usually alpine or maritime. Similarly, prevention of occupational skin diseases requires interdisciplinary approaches on the level of secondary and tertiary preventive intervention; if this is provided, then prevention programs have proven highly (cost-) effective. Unfortunately, the recently published Minimal Standards of Prevention of these dermatoses, underlining especially the importance of meticulous allergological diagnosis and subsequent multidisciplinary patient education, are so far being adhered to only in very few European countries.

Effects of a self-efficacy theory-based parental education program on eczema control and parental outcomes

BACKGROUND

Eczema is the most common childhood skin problem worldwide. Education that enhances parental self-efficacy in carrying out appropriate eczema management is crucial to controlling eczema symptoms of their children. However, the lack of such a structured education program hinders everyday lives of eczematous children and their families. This study evaluated the effects of a self-efficacy theory-based parental eczema education program in controlling eczema of Chinese children at three months after commencement of intervention.

METHODS

An assessor-blind, 2-arm, randomized controlled trial was conducted at an outpatient clinic of a regional hospital. One hundred and thirty-six Chinese children aged 3 months to 12 years with physician-diagnosed eczema, and their parents were recruited. The intervention was underpinned by the Social Cognitive Theory. Children's disease severity, parental self-efficacy, treatment adherence, and quality of life of family members were assessed by validated tools. Generalized estimating equation model was employed to compare differential change in each outcome across time between different groups.

RESULTS

Eczema severity of children and parental self-efficacy in the intervention group were found to show greater improvement at 3-month follow-up with regression coefficient (β) -16.98 (95% CI, -21.04 to -12.92; P < .001) and β 29.39 (95% CI, 22.64-36.14; P < .001), respectively. Nearly all parents (97%) receiving the intervention rated this program as useful and helpful.

CONCLUSIONS

This program is effective in enhancing parents' self-efficacy in managing their children's eczema and improving their adherence to eczema treatment and quality of life.

The role of the nurse in the care and management of patients with atopic dermatitis

BACKGROUND

The purpose of this paper is to provide an overview of key aspects of specialised dermatology nursing practice in the management of patients with moderate to severe atopic dermatitis. The role of dermatology nurse specialists in supporting patients and promoting disease understanding, education and treatment adherence continues to evolve. As features of specialised nursing care can also inform other nursing staff in a wide range of care settings, an overview of key components is examined. Observations presented are from a pan-European perspective and represent the collected view of a group of dermatology nurse specialists, dermatologists and patient advocates following two round-table discussions.

MAIN BODY

Atopic dermatitis is a common, chronic, inflammatory disease characterised by erythematous/scaling skin lesions, with often intense pruritus. Disease course is cyclic with periodic disease flares of varying intensity, presenting management challenges to patients and families. Dermatology nurse specialists play a key role in providing education and substantial patient support to improve treatment outcomes and quality of life to patients and their family, delivered within a multidisciplinary team framework. Nurse-led education and 'eczema schools' are of benefit in reducing disease severity and improving quality of life by enhancing self-management, adherence and patient engagement. eHealth tools, such as patient portals or online training platforms, can provide online learning, individualised education, and help to improve engagement. These and other initiatives, such as written action plans, are all essential to improve or maintain treatment adherence, self-management and quality of life.

CONCLUSIONS

Dermatology nurse specialists play a central role in the assessment and management of moderate to severe atopic dermatitis patients and families. This places them in an ideal position to build strong and often long-term relationships with patients and parents. Such engagement promotes trust, assists in setting realistic expectations of treatment and outcomes, and enhances self-management and engagement in their own care. Providing emotional support, as well as formal and systematic education (including individualised practical advice) all contribute to improved treatment adherence and can enhance the quality of life of patients and their families throughout the course of this long-term condition.

Multidisciplinary management of chronic atopic dermatitis in children and adolescents: a prospective pilot study

Background: Atopic dermatitis (AD) is a chronic, pruritic disorder affecting 10-20% of children and is associated with psychological issues and impaired quality of life (QoL). The role of psychosocial support in the treatment of AD is increasingly important. We studied the impact of a multidisciplinary clinic (MDC) in the management of AD in a tertiary children's hospital in Singapore.Methods: We performed a prospective pilot interventional study on 34 pediatric patients with AD and concomitant psychosocial impairment. Patients were recruited into an MDC, comprising a dermatologist, clinical psychologist and medical social worker. AD severity was scored using Scoring Atopic Dermatitis (SCORAD), while QoL was assessed using the Children's Dermatology Life Quality Index Questionnaire (CDLQI) and Family Dermatology Life Quality Index Questionnaire (FDLQI). Biopsychosocial assessments and interventions were also performed. Eighty-three percent of patients received cognitive behavioral therapy, while 40% received social work intervention.Results: There was an overall improvement in mean SCORAD, CDLQI, and FDLQI scores across MDC visits. A correlation between AD severity and QoL was established. A patient satisfaction survey showed improvement in severity, understanding, and control of the disease.Conclusion: Our study suggests the effectiveness of a multidisciplinary approach in managing pediatric AD patients with psychosocial co-morbidities.

Depressive Symptoms and Sleep Disturbance in Female Nurses with Atopic Dermatitis: The Korea Nurses' Health Study

Although the prevalence of atopic dermatitis is high in nurses, there is a lack of research on the relationship between atopic dermatitis and depressive symptoms and sleep disturbance among female nurses. This study aimed to determine the effects of atopic dermatitis on depressive symptoms and sleep disturbance in female nurses. We analyzed the data of the Korea Nurses’ Health Study, a large-scale prospective cohort study. A total of 20,613 female hospital nurses aged 20–45 years who participated in the Module 1 of Korea Nurses’ Health Study between July 2013 and November 2014 were included. The chi-square test, t-test, and multivariate ordinal logistic regression analysis were conducted for statistical analysis. The prevalence of atopic dermatitis among female nurses was 11.6%. The levels of depressive symptoms and sleep disturbance were higher in nurses with atopic dermatitis than those without atopic dermatitis. Nurses with atopic dermatitis were 1.16 times more likely to have depressive symptoms and 1.35 times more likely to have sleep disturbance than those without atopic dermatitis after adjusting for confounding variables. The results of this study suggest that additional support should be considered for nurses with atopic dermatitis to improve the occupational environment for managing and preventing the exacerbation of symptoms.

What is new in the psychology of chronic itch?

Itch is often regarded as unpleasant or bothersome and is accompanied by symptoms of distress and impairments in daily life. The biopsychosocial model of chronic itch describes how psychological factors can contribute to the improvement or exacerbation of chronic itch and related scratching behaviour. Recent research underlines the important role of cognitive-affective information processing, such as attention, affect and expectancies. This may not only play a role for acute itch states, but may particularly apply to the process of itch chronification, for example, due to the vicious cycle in which these factors shape the experience of itch. The present paper focuses on new insights into the relation between itch and the cognitive-affective factors of attention, affect and expectancies. These factors are thought to play a possible aggravating role in itch in the long term and have received increasing attention in the recent empirical literature on maintaining and exacerbating factors for chronic physical symptoms. Possible psychophysiological and neurobiological pathways regarding these factors are discussed, as well as possible intervention methods.

Effectiveness of alpine climate treatment for children with difficult to treat atopic dermatitis: Results of a pragmatic randomized controlled trial (DAVOS trial)

BACKGROUND

Alpine climate treatment has historically been used in Europe to treat atopic dermatitis (AD), but no randomized trials have been conducted to provide evidence for its effectiveness.

OBJECTIVE

To investigate the long-term effectiveness of alpine climate treatment for children with difficult to treat AD.

MATERIALS & METHODS

A pragmatic, open, randomized controlled trial was conducted. Children diagnosed with AD that was considered difficult to treat, aged between 8 and 18 years and willing to be treated in Switzerland were randomized to a six-week personalized integrative multidisciplinary treatment period in a clinical setting in the alpine climate (Switzerland) or an outpatient setting in moderate maritime climate (Netherlands). Study assessments were conducted at the Wilhelmina Children's Hospital; an electronic portal was used for the collection of questionnaire data. Primary outcomes were disease activity (SAEASI), quality of life (CDLQI) and catastrophizing thoughts (JUCKKI/JU) 6 months after intervention. Other assessments were immediately and 6 weeks after intervention. Subgroup analyses concerned asthma-related outcomes. Children were randomly assigned to either the intervention or control group using a covariate adaptive randomization method, taking age and asthma diagnosis into account. Children, parents and healthcare professionals involved in treatment were not blinded to group assignment. Data were analysed according to intention-to-treat with linear mixed-effects models for continuous outcomes. The trial is registered at Current Controlled Trials ISCRTN88136485.

RESULTS

Between 14 September 2010 and 30 September 2014, 88 children were enrolled in the trial, 84 children were randomized (41 assigned to intervention, 43 to control) of whom 77 completed the intervention (38 of 41 (93%) intervention, 39 of 43 (91%) control) and 74 completed follow-up (38 of 41 (93%) intervention, 36 of 43 (84%) control). Six months after intervention there were no significant differences between the groups on disease activity (SAEASI mean difference -3.4 (95%CI -8.5 to 1.7)), quality of life (CDLQI mean difference -0.3 (95%CI -2.0 to 1.4)) and catastrophizing thoughts (JUCCKI/JU subscale mean difference -0.7 (95%CI -1.4 to -0.0)). Immediately and 6 weeks after intervention, disease activity and quality of life were significantly different in favour of alpine climate treatment. Mean differences on SAEASI were -10.1 (95%CI -14.5 to -5.8) and -8.4 (95%CI -12.2 to -4.6) and on CDLQI -1.9 (95%CI -3.3 to -0.5) and -1.5 (95%CI -2.8 to -0.3) immediately and 6 weeks after the intervention, respectively. There were no long-term differences on asthma-related outcomes. Five serious adverse events occurred during the study period, which were not thought to be related to the treatment.

CONCLUSIONS & CLINICAL RELEVANCE

For children with difficult to treat AD, there was no additional long-term benefit of alpine climate treatment, in contrast to the short-term, compared to an outpatient treatment programme in moderate maritime climate, using a personalized integrative multidisciplinary treatment approach.

Frequency and Management of Sleep Disturbance in Adults with Atopic Dermatitis: A Systematic Review

Introduction

Intense nocturnal pruritus as well as the complex pathophysiology of atopic dermatitis (AD) can severely affect sleep and become a major factor in negatively impacting quality of life in adults. However, much of the literature on sleep disturbance in AD patients is on the pediatric population, and it is not well studied in adults. Furthermore, limited studies are available to guide effective management of sleep disturbance in AD in general. We review the literature to present the studies that have investigated the relationship between AD and its effect on sleep in adults and provide an approach for clinicians caring for this population.

Methods

A systematic literature search was conducted through the PubMed and EMBASE databases using the search terms “atopic dermatitis” OR “eczema” AND “sleep.” The articles generated by the search and their references were reviewed.

Results

A high prevalence of sleep disturbance is experienced by adults with AD. The likelihood of sleep disturbance is much higher in patients with AD compared to those without AD. Sleep disturbance appears to worsen with AD severity. Pruritus and scratching appear to be large contributors to sleep disturbance in adult patients with AD.

Conclusion

It is important that clinicians evaluate the severity of AD and ask general questions about itching, sleep, impact on daily activities, and persistence of disease during each patient visit and follow-up with the complaint of sleep disturbance. Management of sleep disturbance in AD should focus on adequate disease control of AD as well as possible medical interventions to help improve sleep. The pathophysiology of sleep disturbance in AD is extremely complex, and further research is needed to better understand the interplay of the immune system, circadian rhythm, and environmental factors implicated in both AD and sleep.