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Three Part Question

IN [children with atopic eczema] DOES [an educational intervention] IMPROVE [compliance and reduce relapses]?

Clinical Scenario

A child attends the Paediatric Emergency Department with an exacerbation of atopic eczema. You ask the mother about their current medications and usage. You find that the mother is confused as to what the diagnosis means and is struggling to comply with the emollient regimes. She has frequently been to the GP who alters the lotions and indicates that the instructions are labelled.

You are very busy in the Emergency department and try to impart some knowledge with regards to the condition and the treatment regime before discharging them. You wonder if a educational session would help improve the situation.

Search Strategy

Cochrane, OVID Medline <1950 to June Week 2 2010, EMBASE <1980 to 2010 Week 23, CINAHL.
Cochrane: 'atopic dermatitis' OR 'eczema'.
OVID Medline/EMBASE/CINAHL: (exp dermatitis,atopic OR exp eczema) AND (exp education OR exp health education) LIMIT to child < 18 years AND human AND english language.

Search Outcome

Cochrane: 37 found. 1 relevant.
OVID Medline: 227 found. 4 relevant.
EMBASE: 0 found.
CINAHL: 222 found. 0 relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Moore et al May 2009 Australia	112 children aged from 0-16 years were recruited from new referrals of atopic dermatitis to the Dermatology department.	Randomised controlled trial. Children were randomised to either a standard dermatologist-led clinic (40 mins) or a nurse practitioner-led clinic (90 mins).	Reduction in symptoms and signs of eczema including itching, sleep loss and body area coverage (health practitioner using SCORAD index, max. 103)	Difference of 9.93 points (p < 0.001) when workshop clinic compared to standard dermatology clinc.	Sample size not established. Blinding was not performed (difficult to achieve in this setting).
Shaw et al January-February 2008 United States	106 children aged 0-18 years with atopic dermatitis were recruited from dermatology clinics at a North Carolina hospital.	Randomised controlled trial. Interventional group received 15 minutes with an educator after initial visit to clinic.	No significant difference in SCORAD index (health practitioner)	P = 0.27 when comparing interventional group to control.	There was a large variation in the follow-up time ranging from 1-3 months. At 1 month patients may not have seen many benefits when compared to 3 months due to the chronic nature of the condition. Using only the SCORAD index did not take into account anxiety levels or patient satisfaction with the service. Dermatologists gave educational advice to most children within their clinics during the period which may not give a true good comparison with normal practice. There was a high drop out rate (30%) of children. Caregivers varied between visits so educational input may not have been as successful as specifically targeting the primary caregiver.
Ersser et al 2007 United Kingdom	Randomised controlled trials looking at psychological or educational interventions for children from 0 to 18 years with atopic eczema.	Systematic review (data searched up to September 2005). 5 randomised controlled trials evaluated.	Four studies looking at parental intervention	Data was non-comparable	Majority of data was non-comparable, models were too different to allow comparison. No meta-analysis included. The study included only randomised controlled trials in an area where cohort or qualitative data may be just as relevant when looking at quality of life, patient satisfaction and long-term outcomes.
			Three educational studies identified	Improvements in disease severity (p < 0.05)
			One study evaluating long-term outcomes identified	Significant improvements in disease severity and parental quality of life (p < 0.05)
Grillo et al September-October 2006 Australia	61 children aged 0 to 16 years with atopic eczema recruited from Adelaide.	Randomised controlled trial. The interventional group were given a 2 hour workshop in addition to standard management.	Improvement in the SCORAD index (patient or primary caregiver score depending on age)	Mean inprovement in SCORAD score of 27.45 in the interventional group compared to only 7.52 in the control group by week 12 (p < 0.005)	The methods were not justified in terms of previous study designs and outcomes.
			Improvement in quality of life (QoL index depending on age)	78.39% showed an improvement in quality of life in interventional group by week 12 compared to 26.93% in the control group.

Comment(s)

The papers included are those of good quality following critical appraisal. The studies varied in their approach and methods of evaluating educational interventions. There were improvements in disease severity and patient quality of life amongst other measures. The studies who included a substantial session length, practical demonstration and group sessions showed the best results.

Clinical Bottom Line

Educational interventions should be considered in those with poor compliance and recurrent relapses of atopic dermatitis.

References

1. Moore EJ, Williams A, Manias E, Varigos G and Donath S. Eczema workshops reduce severity of childhood atopic eczema. Australian Journal of Dermatology. May 2009;50(2):100-6.
2. Shaw M, Morrell DS and Goldsmith LA. A Study of Targeted Enhanced Patient Care for Paediatric Atopic Dermatitis (STEP PAD) Paediatric Dermatology January-February 2008;25(1):19-24.
3. Ersser SJ, Latter S, Sibley A, Satherley PA, Welbourne S. Psychological and educational interventions for atopic eczema in children. Cochrane Database of Systematic Reviews. 2007;(3):CD004054.
4. Grillo M, Gassner L, Marshman G, Dunn S and Hudson P Pediatric atopic eczema: the impact of an educational intervention Pediatric Dermatology September-October 2006;23(5):428-36.