Psychological and educational interventions for atopic eczema in children.

BACKGROUND Psychological and educational interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. There have been no relevant systematic reviews applicable to children. OBJECTIVES To assess the effectiveness of psychological and educational interventions in changing outcomes for children with atopic eczema. SEARCH STRATEGY We searched the Cochrane Skin Group Specialised Register (to September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2005), MEDLINE (from 1966-2005), EMBASE (from 1980 to week 3, 2005 ), PsycINFO (from 1872 to week 1, 2005). On-line: National Research Register, Meta-register of Controlled Trials, ZETOC alerts, SIGLE (August 2005). SELECTION CRITERIA RCTs of psychological or educational interventions, or both, used to manage children with atopic eczema. DATA COLLECTION AND ANALYSIS Two authors independently applied eligibility criteria, assessed trial quality and extracted data. A lack of comparable data prevented data synthesis. MAIN RESULTS Five RCTs met the inclusion criteria. Some included studies required clearer reporting of trial procedures. Rigorous established outcome measures were not always used. Interventions described in all 5 RCTs were adjuncts to conventional therapy. Four focused on intervention directed towards the parents; data synthesis was not possible. Psychological interventions remain virtually unevaluated by studies of robust design; the only included study examined the effect of relaxation techniques (hypnotherapy and biofeedback) on severity. Three educational studies identified significant improvements in disease severity between intervention groups. A recent German trial evaluated long term outcomes and found significant improvements in both disease severity (3 months to 7 years, p=0.0002, 8 to 12 years, p=0.003, 13 to 18 years, p=0.0001) and parental quality of life (3 months to 7 years, p=0.0001, 8 to 12 years p=0.002), for children with atopic eczema. One study found video-based education more effective in improving severity than direct education and the control (discussion) (p<0.001). The single psychological study found relaxation techniques improved clinical severity as compared to the control at 20 weeks (t=2.13) but this was of borderline significance (p=0.042). AUTHORS' CONCLUSIONS A lack of rigorously designed trials (excluding one recent German study) provides only limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of children with atopic eczema. Evidence from included studies and also adult studies indicates that different service delivery models (multi-professional eczema school and nurse-led clinics) require further and comparative evaluation to examine their cost-effectiveness and suitability for different health systems.