|Year : 2022 | Volume
| Issue : 1 | Page : 3-7
Counseling strategies in atopic dermatitis: How best can they be integrated in dermatological practice?
Soumya Jagadeesan1, Deepak Parikh2, Sandipan Dhar3
1 Department of Dermatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
2 Department of Pediatric Dermatology, Wadia Children Hospital, Mumbai, Maharashtra, India
3 Department of Pediatric Dermatology, Institute of Child Health, Kolkata, West Bengal, India
|Date of Submission||02-Jul-2021|
|Date of Decision||05-Sep-2021|
|Date of Acceptance||14-Sep-2021|
|Date of Web Publication||31-Dec-2021|
Department of Dermatology, Amrita Institute of Medical Sciences, Ponekkara, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
The time-centered routine consultations have been shown to be inadequate in imparting the necessary knowledge and practical skills for the children and the family suffering from atopic dermatitis. There is a need to complement medical treatment with adequate counseling or focused psychological and educational interventions, directed at the patient and the parents. The authors discuss the various approaches in “counseling” that has been used worldwide and propose a practical approach for the same in the Indian scenario.
Keywords: Atopic dermatitis, counseling, educational interventions, psychological interventions
|How to cite this article:|
Jagadeesan S, Parikh D, Dhar S. Counseling strategies in atopic dermatitis: How best can they be integrated in dermatological practice?. Indian J Paediatr Dermatol 2022;23:3-7
|How to cite this URL:|
Jagadeesan S, Parikh D, Dhar S. Counseling strategies in atopic dermatitis: How best can they be integrated in dermatological practice?. Indian J Paediatr Dermatol [serial online] 2022 [cited 2022 Jan 20];23:3-7. Available from: https://www.ijpd.in/text.asp?2022/23/1/3/334659
| Introduction|| |
Atopic dermatitis (AD), represents a unique dermatological disease entity in terms of the age-group affected, the chronicity, the relapsing and remitting course, psychological impact, and the impact on the overall quality of life of the patient and the family. Children with moderate-severe disease often have a low self-esteem and poor self-image. They are frequently ridiculed by their peers for the appearance of their skin and the frequent scratching. Together with the sleep disturbances, these further add to the stress and affect their scholastic performance. Furthermore, as the caregivers are required to administer the treatment to the child, their understanding, ability, and outlook determine the success and adherence to the treatment schedule. There is a need, therefore, to complement medical treatment in AD with adequate counseling or focused psychological and educational interventions, directed at the patient and the parents.
| What is Counseling?|| |
The word “counseling” itself can often be confusing, as it means different things for different people, in different contexts. The Concise Oxford Dictionary (9th edition) gives 2 definitions to the term “counseling” which adds to the confusion:
“Give advice to (a person) on social or personal problems, especially professionally” and “Assisting and guiding clients, especially by a trained person professionally, to resolve especially personal, social, or psychological problems and difficulties.”
The New Consensus Definition of Counseling 2020–21, which is accepted by 29 organizations worldwide, gives a studied definition-“Counseling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.”
Therefore, by strict definition, counseling perhaps constitutes only a minor part of the many psychological interventions in AD. However, in this article, in line with the popular usage, the term “counseling” will be used to indicate the whole spectrum of psychological and educational interventions in AD.
| Why Counseling?|| |
The dermatologists, both academics and private practitioners, face manifold demands on their time while communicating with the patient and the family in the outpatient department. The time-centered routine consultations have been shown to be inadequate in imparting the necessary knowledge and practical skills for the children and the family in managing the finer nuances of AD including the right way to apply the topical medications, discern the changes to make the necessary adjustments in treatment, etc. The patients and their family also need help and support to develop the resilience needed in managing the complexities of the fluctuating disease course and adhering to long-term treatment.,
A variety of focused interventions have been studied worldwide as an adjuvant to medical therapy to improve the treatment adherence and outcomes in AD. These may be directed at the child or the parents; the type and appropriateness of the intervention depend on the age and developmental stage of the child.,
| Educational Interventions in Atopic Dermatitis Worldwide|| |
Numerous groups across Europe and North America have developed structured educational programs such as “eczema centers” or “atopic schools.”,, In countries like UK, nurse-led clinics deliver focused interventions. The eczema school multidisciplinary model is more established in countries like Germany. Both the content of learning and the most effective process (who is best placed to educate, using what educational technology, at what frequency and duration) require careful consideration.
| Therapeutic Patient Education|| |
In 1998, a WHO working group defined therapeutic patient education (TPE) as a “process that would enable patients to acquire and maintain skills that optimize management of their lives with their disease;” TPE has been used extensively in several chronic diseases outside the field of dermatology. The German Atopic Dermatitis Intervention Study, a multicentric randomized control trial was the first to demonstrate the efficacy of age-related, structured TPE in the long-term management of moderate to severe AD using evidence-based criteria.
The survey conducted by Oriented Patient Education Network in Dermatology (OPENED) looked at TPE experiences of 23 centers across 11 countries. They found that the target population mainly comprised of children and adolescents and only a few centers focused on adults (7/23). The type of educative approach was either “individual” or “collective.” The individual sessions were handled by a physician or a nurse, the average duration of which was 45 min. The advantages of this approach are the relative ease to plan and execute, the quick rapport established with the patient and family, better identification of their needs and expectations, and the opportunity to set goals in terms of the skills they have to acquire and the behavioral modifications needed (written action plan).
Collective sessions on the other hand lasted for an average duration of around 2 h and were organized either in groups of 10 similarly aged patients or as mixed population groups of 100 or more. This is a useful method to disseminate information to large groups of people and get them interested in more structured programs later., The Berlin Parent Education Program developed in Germany provided a structured education program to a small group of parents with the help of a multidisciplinary team and has been emulated elsewhere.
The composition of the TPE team was multidisciplinary constituting physicians (dermatologists/pediatricians/allergists), nurses, dietitians, and psychologists., The content of the programs varied; most dealt with epidemiology, pathogenesis, course of the disease, trigger factors; imparted practical skills information regarding treatment; discussed aspects of living with the disease, communicating disease to others, asking for help during a flare-up, etc. Most centers used information handouts; some gave online support and offered interactive sessions. The patient's progress was monitored using clinical scores and quality of life scores. The OPENED expert's consensus opined that TPE must be integrated with the conventional patient-centered medical care.
Ersser et al. in their Cochrane review endorsed that there is scope for both multidisciplinary teams and individual clinicians to deliver educational interventions in AD as an adjuvant to medical treatment.
To summarize, Lee et al. identified 4 central themes in the various studies conducted focusing on educational interventions in AD:
- The “learners” are children of all age and severity and their caregivers
Age-appropriate care, tailored as per the severity and delivering a patient-centered and family-centered approach are the common features.
- The “educators” are well trained (underwent a training workshop for AD) and family preferred health professionals from various disciplines, namely dermatologists or pediatricians, psychologists, dieticians, specialist dermatology, or pediatric nurses
- Long-term follow-up (1–24 months) with diverse interventions as educational activities is delivered. Diverse interventions are in the form of:
- Online consultations or
- Group educational activities such as group discussions and lecture, eczema school, community-based workshops, structured playful activity or
- Individual educational interventions such as face-to-face education, E-mail based or telephonic advice, feedback, and support
- The educational interventions are aimed at improving the quality of life of the child, the parents, and the whole family and focused on emotional support.
| Psychological Interventions in Atopic Dermatitis|| |
Epidemiological studies have proven the role of psychosocial stressors such as personality types, poor family relationships, caregiver stress, and negative life events on the disease severity. As per Chida et al., the psychological interventions in AD may be justified and classified based on these rationales.
- Aggravation of AD is known to be induced by perceived stressors, justifying the use of psychotherapy including cognitive therapy, brief dynamic psychotherapy, etc., Psychological therapies focused on internal processes are also sometimes referred to as “talking therapies,” they focus on raising insight. Ehlers et al. described a cognitive therapy which dealt with everyday problem-solving strategies and improving the patient's communication and interpersonal skills. Psychodynamic therapy on the other hand places stress on unconscious motives; recognizes unhelpful defenses; and links these to underlying conflicts. The focus is on AD perception and AD-related conflicts such as depressive feelings of learning to live with AD, handling rejection from others, anxiety or aggression related to itch–scratch patterns, etc. Counseling (nondirective, nonjudgmental, empathetic, and supportive) and family therapy are the other methods used.
- Stress is shown to directly exacerbate AD by several biological pathways justifying the use of relaxation/arousal reduction techniques. Autogenic training which incorporates relaxation can be specifically adapted and modified for AD. In this technique, the patients learn to focus on specific body parts along with general autosuggestions such as “skin calm and body pleasantly cool” (introduced by Ehlers et al.) or individualized suggestions to control scratching (“I don't need to scratch,” “my skin stays intact”) or coping with itching (“my skin is covered with soft, cool, silk,” “with every breath the itch gets weaker”). Guided imagery, biofeedback, aromatherapy, and hypnotherapy are all other techniques that have been studied in AD,,
- Scratching in itself can exacerbate AD, justifying the use of behavioral therapies such as habit reversal. In this method, the scratching behavior is broken down into two parts movement toward the itching part and the actual scratching. The patient is asked to clench the first for 30 s whenever they get a scratching impulse and if the itch did not vanish in 30 s, pinch or press a fingernail against the itching spot.
A combination of psychotherapy, relaxation techniques, and habit reversal behavior therapies were found to be beneficial in dealing with AD patients and families.,
Although a wide variety of psychological interventions are available, it is unfortunate that they have not been evaluated adequately in AD (limited good quality evidence) or extrapolated from the adult studies to the parents/caregivers of the patients., Individual studies like the one by Ehlers et al. showed that a combined approach with structured educational interventions and cognitive-behavioral treatment shows good benefits than intensive patient education or conventional dermatology treatment.
| Authors' Perspective and a Proposed Indian Working Model|| |
There have not been many studies conducted in India, exploring the impact of counseling/other psychological or educational interventions in AD. With the lack of funding and the time crunch faced by dermatologists, even in academic practice, elaborate structured programs are a rarity in our country. What is practiced generally, is an individual educative approach” where the dermatologist establishes a rapport with the patient and family, explains the details of the disease, imparts information about the course and treatment, listens to their queries, and at times, combines with some amount of hand holding. [Table 1] summarizes the counseling points that could be touched upon while interacting with the family.,
|Table 1: Educative points in counseling of the parents of a child with atopic dermatitis: Indian Scenario|
Click here to view
However, even in a busy pediatric dermatology practice in India, it is possible to create a more significant impact on the disease and the quality of life of the child and the family by making a few focused interventions.
| What do we Propose?|| |
In addition to the consultations with the dermatologist:
- A 15-min individual educative session with a trained nurse/clinic-staff/other health professional every 1–2 months, giving information on the course of the disease, trigger factors; skincare education and demonstration; information on bathing, application of moisturizers, steroids, dosing, and frequency of application; discussion of common concerns, importance of follow-up; discuss queries including on wet-wrap therapy and bleach baths; formulation of an individualized written eczema action plan, etc.
- A group/collective interactive session organized (including 10–100 patients and their family) twice or thrice a year, with a multidisciplinary team including the dermatologist/pediatrician, psychologist and dietician discussing strategies to break the itch-scratch cycle, optimal sleep hygiene, stress management, living with the disease, communicating disease to others, resources for managing food allergy, etc.
- Distribution of printed material/handouts; dissemination of educational videos with information regarding the disease and relevant points in management; sharing links to authentic websites
- Identify the patients who need more focused psychological interventions during the individual or collective sessions and refer them to the concerned specialist.
Streamlining the process, designing the content of the interventions and the training of the resource persons will require some forethought and planning; however, it should not be too difficult for the motivated dermatologist-whether in academics or private practice.
Although as practitioners of medicine, most of us do realize the importance of complementing medical treatment with empathetic listening and nondirective, supportive, and nonjudgmental communications, it is all too easy to get lost in the maze of a busy clinical practice. Building a process and systems in place would definitely be in the best interests of our AD patients and their families. It is important to inject positivity in the minds of socially stigmatized, ostracized children, and their tense parents maintaining a fine balance between practical and practicability.
The authors feel that the approach toward “counseling” in AD should be scientific, evidence-based, experience-supported, practical, doable, positive, empathetic, humane, and at the same time, protecting your own skin. This will certainly go a long way as far as the “total management” of AD is concerned.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ramirez FD, Chen S, Langan SM, Prather AA, McCulloch CE, Kidd SA, et al.
Association of atopic dermatitis with sleep quality in children. JAMA Pediatr 2019;173:e190025.
Ersser SJ, Cowdell F, Latter S, Gardiner E, Flohr C, Thompson AR, et al.
Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev 2014;7;2014(1):CD004054. doi: 10.1002/14651858.CD004054.pub3. Available from: https://pubmed.ncbi.nlm.nih.gov/24399641
.[Last accessed on 2021 May 31].
Kaplan DM, Tarvydas VM, Gladding ST. 20/20: A vision for the future of counseling: The new consensus definition of counseling. J Couns Dev 2014;92:366-72.
Deb S, Dhar S, Parikh D. The role of patient (parent) education and counseling in pediatric dermatology practice. Indian J Paediatr Dermatol 2015;16:117-21. [Full text]
Thompson DL, Thompson MJ. Knowledge, instruction and behavioural change: Building a framework for effective eczema education in clinical practice. J Adv Nurs 2014;70:2483-94.
Rork JF, Sheehan WJ, Gaffin JM, Timmons KG, Sidbury R, Schneider LC, et al.
Parental response to written eczema action plans in children with eczema. Arch Dermatol 2012;148:391-2.
LeBovidge JS, Elverson W, Timmons KG, Hawryluk EB, Rea C, Lee M, et al
. Multidisciplinary interventions in the management of atopic dermatitis. J Allergy Clin Immunol 2016;138:325-34.
Staab D, Diepgen TL, Fartasch M, Kupfer J, Lob-Corzilius T, Ring J, et al.
Age related, structured educational programmes for the management of atopic dermatitis in children and adolescents: Multicentre, randomised controlled trial. BMJ 2006;332:933-8.
Ersser SJ, Farasat H, Jackson K, Dennis H, Sheppard ZA, More A. A service evaluation of the Eczema Education Programme: An analysis of child, parent and service impact outcomes. Br J Dermatol 2013;169:629-36.
Schuttelaar ML, Vermeulen KM, Drukker N, Coenraads PJ. A randomized controlled trial in children with eczema: Nurse practitioner vs. dermatologist. Br J Dermatol 2010;162:162-70.
Wenninger K, Kehrt R, von Rüden U, Lehmann C, Binder C, Wahn U, et al.
Structured parent education in the management of childhood atopic dermatitis: The Berlin model. Patient Educ Couns 2000;40:253-61.
Stalder JF, Bernier C, Ball A, De Raeve L, Gieler U, Deleuran M, et al.
Therapeutic patient education in atopic dermatitis: Worldwide experiences. Pediatr Dermatol 2013;30:329-34.
Lee Y, Oh J. Educational programs for the management of childhood atopic dermatitis: An integrative review. Asian Nurs Res (Korean Soc Nurs Sci) 2015;9:185-93.
Chida Y, Steptoe A, Hirakawa N, Sudo N, Kubo C. The effects of psychological intervention on atopic dermatitis. A systematic review and meta-analysis. Int Arch Allergy Immunol 2007;144:1-9.
Ehlers A, Stangier U, Gieler U. Treatment of atopic dermatitis: A comparison of psychological and dermatological approaches to relapse prevention. J Consult Clin Psychol 1995;63:624-35.
Hashimoto K, Ogawa Y, Takeshima N, Furukawa TA. Psychological and educational interventions for atopic dermatitis in adults: A systematic review and meta-analysis. Behav Change 2017;34:48-65.
Rajagopalan M, De A, Godse K, Krupa Shankar DS, Zawar V, Sharma N, et al.
Guidelines on management of atopic dermatitis in India: An evidence-based review and an expert consensus. Indian J Dermatol 2019;64:166-81.
] [Full text]
Parikh D, Dhar S, Ramamoorthy R, Srinivas S, Sarkar R, Inamadar A, et al
. Treatment guidelines for atopic dermatitis by ISPD task force 2016. Indian J Paediatr Dermatol 2018;19:108-15. [Full text]