Key messages
• Face-to-face education for individuals and groups may reduce eczema severity. Using technology to deliver education, such as the internet, may have little or no effect on disease severity.
• Using nurse practitioners instead of dermatologists to deliver group education may have lower costs and be similarly effective.
• People's circumstances vary and this will affect delivery of, and and how they receive information. Educational and psychological interventions for people with eczema should be developed based on patient and carer preferences, so that they will be used. Study participants should be followed over the (very) long term, remembering that 'long term' could be a lifetime for someone with eczema, not just the length of a research study.
What is eczema?
Eczema (also known as atopic dermatitis) is an uncomfortable, itchy, visible skin condition. Many different things can make eczema worse, such as foods, pollen, dust mites, stress, seasonal changes and pollution. Scratching the itch can make the skin itchier, reduce the chances of treatment being successful, and damage the skin.
How is eczema treated?
It is a complicated business living with eczema. It is usually treated by avoiding 'triggers' and irritants, and applying moisturising (emollients) or medicated (topical corticosteroids or clacineurin inhibitors) creams and lotions. Education and psychological techniques can give people information to manage the impact of eczema.
Education can be provided in different ways, such as one-on-one or group sessions, led by either doctors or patients themselves. These sessions can be in-person or online. They can vary in length and often include follow-ups. Follow-ups are important because benefitting from educational and psychological material usually takes some time and requires some support. Methods to help change behaviour are also often used during educational sessions.
Stress and coping behaviours can make eczema worse. Therapy that focuses on changing habits or distracting from scratching can help, and we have grouped these as 'psychological interventions'. Counselling may be a cost-effective option. Techniques like mindfulness and relaxation can also help reduce itching. Some methods, like guided imagery and virtual reality, can divert attention away from itching. Virtual reality, although not widely studied for eczema, has been used for anxiety and pain, which are related to itching. However, not all places offer these therapies consistently.
What did we want to find out?
We investigated the usefulness of educational and psychological techniques to help anybody with eczema. That might be to reduce eczema symptoms or the costs of treating eczema.
What did we do?
We searched for studies that investigated educational or psychological approaches to improve eczema. Improvement could be measured by reduction in symptoms, as reported by people with eczema or their carers, or improvement in quality of life, for example. We also looked for other improvements: long‐term control of eczema symptoms, psychological well‐being, and using medication appropriately. We wondered if there were unwanted effects from the information given.
What did we find?
We found 37 studies that included 6170 adults and children. Most studies took place in hospitals in high-income countries. The majority of participants were children and adolescents. People in the studies had a mix of eczema severity. We found little information about cost-effectiveness and no useful information about self-help, psychological therapy, or printed educational materials.
The results below are for educational or psychological methods compared with standard eczema care.
• Individual education may reduce short-term disease severity (1 study, 30 participants).
• Group education probably reduces eczema severity (9 studies, 2426 participants).
• We are unable to comment on whether education delivered using technology (for example online education) reduces disease severity as measured by clinical signs. It may have little or no effect on eczema severity as reported by patients but probably slightly improves long-term control of eczema symptoms (5 studies, 654 participants).
• Treatment to change habits may reduce disease severity but probably has little or no effect on improvement of quality of life (1 study, 33 participants).
• Therapies to reduce stress or anxiety such as mindfulness, meditation and relaxation techniques (arousal reduction therapies) may make little or no difference in improvement in quality of life (3 studies, 33 participants).
No studies provided useful information about improvement in long-term control of eczema symptoms, improvement in following standard treatment, or unwanted effects.
What are the limitations of the evidence?
Where we found evidence, our confidence in it is only moderate because of concerns that the included studies used different ways of delivering educational or psychological treatments. The studies were very small and most did not the best design to give conclusive results.
Most studies were in high-income countries, so our review does not report on whether some of these educational and psychological methods might work better in some cultures or for people in low- or middle-income countries.
How up to date is this evidence?
The evidence is current up to March 2023.
In-person, individual education, as an adjunct to conventional topical therapy, may reduce short-term eczema signs compared to standard care, but there is no information on eczema symptoms, quality of life or long-term outcomes. Group education probably reduces eczema signs and 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 minimal 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.
Atopic dermatitis (eczema), can have a significant impact on well-being and quality of life for affected people and their families. Standard treatment is avoidance of triggers or irritants and regular application of emollients and topical steroids or calcineurin inhibitors. Thorough physical and psychological assessment is central to 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. This review is based on a previous Cochrane review published in 2014, and now includes adults as well as children.
To assess the clinical outcomes of educational and psychological interventions in children and adults with atopic dermatitis (eczema) and to summarise the availability and principal findings of relevant economic evaluations.
We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, APA PsycINFO and two trials registers 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. We searched NHS Economic Evaluation Database, MEDLINE and Embase for economic evaluations on 8 June 2022.
Randomised, cluster‐randomised and cross-over RCTs that assess educational and psychological interventions for treating eczema in children and adults.
We used standard Cochrane methods, with GRADE to assess the certainty of the evidence for each outcome. Primary outcomes were reduction in disease severity, as measured by clinical signs, patient‐reported symptoms and improvement in health-related quality‐of‐life (HRQoL) measures. Secondary outcomes were improvement in long‐term control of symptoms, improvement in psychological well‐being, improvement in standard treatment concordance and adverse events. We assessed short- (up to 16 weeks after treatment) and long-term time points (more than 16 weeks).
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. Trials assessed interventions compared to standard care.
Individual educational interventions may reduce short-term clinical signs (measured by SCORing Atopic Dermatitis (SCORAD); mean difference (MD) −5.70, 95% confidence interval (CI) −9.39 to −2.01; 1 trial, 30 participants; low‐certainty evidence) but patient-reported symptoms, HRQoL, long-term eczema 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 evidence) and the long term (MD −7.22, 95% CI −11.01 to −3.43; 3 studies, 1424 participants; moderate-certainty evidence) and probably reduce long-term patient-reported symptoms (SMD −0.47 95% CI −0.60 to −0.33; 2 studies, 908 participants; moderate-certainty evidence). They may slightly improve short-term HRQoL (SMD −0.19, 95% CI −0.36 to −0.01; 4 studies, 746 participants; low-certainty evidence), but may make little or no difference to short-term psychological well-being (Perceived Stress Scale (PSS); MD −2.47, 95% CI −5.16 to 0.22; 1 study, 80 participants; low-certainty evidence). Long-term eczema control was not reported.
We don't know whether technology-mediated educational interventions could improve short-term clinical signs (SCORAD; 1 study; 29 participants; very low-certainty evidence). They may have little or no effect on short-term patient-reported symptoms (Patient Oriented Eczema Measure (POEM); MD −0.76, 95% CI −1.84 to 0.33; 2 studies; 195 participants; low-certainty evidence) and probably have little or no effect on short-term HRQoL (MD 0, 95% CI −0.03 to 0.03; 2 studies, 430 participants; moderate-certainty evidence). Technology-mediated education interventions probably slightly improve long-term eczema control (Recap of atopic eczema (RECAP); MD −1.5, 95% CI −3.13 to 0.13; 1 study, 232 participants; moderate-certainty evidence), 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 evidence) but we are uncertain about any effects on short-term HRQoL (Children's Dermatology Life Quality Index (CDLQI); 1 study, 30 participants; very low-certainty evidence). Patient-reported symptoms, long-term eczema control and psychological well-being were not reported.
We are uncertain whether arousal reduction therapy interventions could improve short-term clinical signs (Eczema Area and Severity Index (EASI); 1 study, 24 participants; very low-certainty evidence) or patient-reported symptoms (visual analogue scale (VAS); 1 study, 18 participants; very low-certainty evidence). Arousal reduction therapy may improve short-term HRQoL (Dermatitis Family Impact (DFI); MD −2.1, 95% CI −4.41 to 0.21; 1 study, 91 participants; low-certainty evidence) and psychological well-being (PSS; MD −1.2, 95% CI −3.38 to 0.98; 1 study, 91 participants; low-certainty evidence). Long-term eczema control was not reported.
No studies reported standard care compared with self-help psychological interventions, psychological therapies or printed education; or adverse events.
We identified two health economic studies. One found that a 12-week, technology-mediated, educational-support programme may be cost neutral. The other found that a nurse practitioner group-education intervention may have lower costs than standard care provided by a dermatologist, with comparable effectiveness.