Behavioural treatment of scratching in patients with atopic dermatitis

Are behavioral interventions a better choice for atopic dermatitis patients? A meta-analysis of 6 randomized controlled trials

BACKGROUND

The treatment for atopic dermatitis (AD) has been the focus of clinical research, and behavioral intervention is considered an indispensable treatment method. To our knowledge, no relevant meta-analysis has evaluated the effects of behavioral interventions on atopic dermatitis.

OBJECTIVES

To evaluate the effects of behavioral interventions on atopic dermatitis.

METHODS

The authors searched PubMed, EMBASE, and Cochrane CENTRAL to retrieve relevant RCTs (up to Feb 2022). The search strategy involved a combination of related keywords. The Cochrane Q and I2 statistics were used to assess heterogeneity.

RESULTS

Six RCTs involving seven reports with 246 patients were included. The results suggested that behavioral interventions could relieve eczema severity (correlation coefficient [r = -0.39]; p < 0.001) and scratching severity significantly (r = -0.19; p = 0.017), while not affect itching intensity (r = -0.02; p = 0.840). A sensitivity analysis confirmed the robustness of the results.

STUDY LIMITATIONS

An important limitation of this study was the insufficient number of RCTs and the limited sample size. In addition, the study lacked a control group receiving a type of intervention other than the experimental protocol. Another limitation was the short duration of follow-up.

CONCLUSIONS

This study suggests that behavioral interventions could be effective in treating atopic dermatitis by reducing eczema and scratching severity. Additionally, habit-reversal behavioral therapy may be more effective for treating atopic dermatitis.

Electroacupuncture for relieving itching in atopic eczema: study protocol for a multicenter, randomized, sham-controlled trial

Background

Atopic eczema (AE) is a common atopic inflammatory skin disease affecting 2.1-4.9% of the population in different countries. Pruritus, one of the most burdensome symptoms, is often underestimated for the problems it can cause, creating a vicious loop of itching, scratching, and lichenification. Therefore, further research into practical and safe treatments that relieve itchy symptoms and enhance skin protection is key to overcoming AE. Acupuncture, with or without electrical stimulation, is one of the most commonly used therapeutic measures to treat AE. This trial aimed to objectively evaluate the efficacy and safety of the electroacupuncture (EA) antipruritic technique in AE pruritus and obtain high-level clinical evidence for the popularization and application of EA for AE.

Methods and analysis

This multicenter, single-blinded, randomized controlled trial is planned to transpire from April 15, 2023, to June 30, 2025. We will recruit 132 participants with AE (44 per group). Participants will be assigned randomly to three equal-sized groups: EA, sham electroacupuncture, and sham acupuncture. Treatment will be administered three times a week during the 2-week intervention phase. The primary outcome measure is the Visual Analog Scale, with a numeric rating scale to evaluate pruritus. Secondary outcome measures include the Eczema Area and Severity Index and Dermatology Life Quality Index. Other outcome measures include physical examination, serum IgE, and safety evaluation. The number, nature, and severity of adverse events will be carefully recorded.

Trial registration

ClinicalTrials.gov, 22Y11922200. Registered 3 September 2022, https://register.clinicaltrials.gov.

Cognitive behavior therapy as dermatological treatment: a narrative review

Cognitive behavior therapy (CBT) is efficacious in treating numerous psychological disorders. It is also effective in combination with medication for chronic pain, diabetes, and other diseases. Patients with skin disease report high levels of stress, anxiety, and negative feelings.

Objective

To summarize the findings on the utility of CBT for the improvement of skin status and quality of life in patients with dermatological conditions.

Methods

PubMed and Google Scholar databases were searched for relevant articles from database inception to the time of search (October 20, 2021). A total of 30 included studies featured 10 on psoriasis, 11 on atopic dermatitis, 4 on vitiligo, 4 on acne, and 1 study on alopecia areata.

Results

Several studies, including randomized controlled trials with large study samples, support the effectiveness of CBT and Internet CBT for a number of dermatological conditions. Patients who completed CBT courses were less likely to rely on dermatological healthcare during follow-up.

Limitations

There are a limited number of studies discussing the implementation of CBT for alopecia, acne, and vitiligo.

Conclusion

Patients who underwent CBT or Internet CBT in addition to skin care demonstrated improvement with quality of life and severity of skin disease as compared to controls only receiving standard of care treatment.

Psychological Therapies and Mind-Body Techniques in the Management of Dermatologic Diseases: A Systematic Review

BACKGROUND

There is a clear link between skin disease and psychological factors and this relationship works both ways: skin diseases can cause psychological distress and psychological issues can worsen skin disease. There are a number of therapies that approach this problem from the psychological side and may be useful, especially as adjunctive therapies in select patients.

OBJECTIVE

The aim of this review was to determine the efficacy of various psychological therapies and mind-body techniques in the management of common dermatologic diseases in individuals of all ages.

METHODS

A systematic review of PubMed, Elsevier, and Wiley was performed for studies investigating psychological and mind-body interventions in the management of various skin diseases. Both physical and non-physical treatment outcomes were considered. Studies were evaluated for both risk of bias and overall quality of evidence.

RESULTS

A total of 40 articles studying unique sets of dermatological patients receiving psychological therapies or mind-body interventions were identified. Of the 40 included articles encompassing 3112 patients, 18 investigated these interventions in psoriasis management while 15 focused on atopic dermatitis. The remaining studies investigated vitiligo (2), pruritus (2), acne vulgaris (2), and acne excoriée (1).

CONCLUSIONS

Based on the analysis of included studies and an assessment of their quality of evidence, the most promising interventions are cognitive behavioral therapy, mindfulness-based interventions, and habit reversal therapy.

Psychological Interventions Are More Effective Than Educational Interventions at Improving Atopic Dermatitis Severity: A Systematic Review

ABSTRACT

We determined which educational and/or psychological interventions were most effective in atopic dermatitis (AD). A systematic review of published studies evaluated the effectiveness of educational and/or psychological interventions in MEDLINE, Embase, SCOPUS, LILACS, Cochrane, China National Knowledge Infrastructure, Taiwan Electronic Periodical Services, and CiNii. Two reviewers conducted title/abstract, full-text review, and data extraction. Twenty-four prospective studies were included, including 20 randomized controlled trials. Educational (4/7 studies) and combined educational and psychological (5/6 studies) interventions reduced AD severity; psychological (10/11 studies) interventions showed the greatest benefit. The most commonly studied psychological intervention was habit reversal training (8/11 studies), which was most frequently incorporated in studies that reduced AD severity (8/10 studies). The most commonly studied educational interventions were education on AD triggers (7/7 studies) and skin care (7/7 studies); they were incorporated in all studies that reduced AD severity. Different psychological and/or educational interventions successfully reduced AD severity, especially habit reversal training.

Itch: Pathogenesis and treatment

Itch pathogenesis is broadly characterized into histaminergic and nonhistaminergic pathways and transmitted via 2 main receptor families: G protein-coupled receptors and transient receptor potential channels. In the skin, itch is primarily transmitted by unmyelinated type C and thinly myelinated type Aδ nerve fibers. Crosstalk between the immune and neural systems modulates itch transmission at the skin, spinal cord, and brain. Among the many known pruritogens, Th2 cytokines, such as interleukin-4, interleukin-13, interleukin-31, and thymic stromal lymphopoietin, are particularly important mediators that signal through shared Janus kinase pathways, representing novel targets for novel itch therapeutics. Emerging evidence has also revealed that the opioidergic system is a potent modulator of itch transmission, with increased μ-opioid activity and decreased κ-opioid activity contributing to itch pathogenesis. Optimal management of itch requires that treatment approaches be tailored to specific etiologic itch subtypes. When the etiology is unknown and patients are given a diagnosis of chronic pruritus of unknown origin, treatment should be guided by the presence of Th2 polarization, often reflected by increased blood eosinophils. In the second article of this 2-part series, we outline our current understanding of itch pathogenesis and discuss available and emerging treatments for itch.

Experiences with the first eczema school in the United States

Patient education programs are beneficial in the treatment of chronic diseases. In Germany, France, and other countries worldwide, educating children, adolescents, and adults plus the parents of children with atopic dermatitis (AD) leads to better coping with the skin disease, as well as to a reduction in the severity of the skin symptoms and signs. The results in Europe led to the idea to also establish an eczema school in the United States. In the style of the German eczema school, an eczema school was founded in 2014 at Temple University, Philadelphia, PA. Since then, a team consisting of a dermatologist, psychologist, nutritionist, and nurse practitioner has offered an eczema school to interested patients with AD and their families three times a year. This patient education program consists of three weekly 2-hour sessions, which address proper skin care, the itch-scratch cycle, healthy nutrition, and the role of stress in AD. The current review summarizes the first experiences with the education program in the United States.

Therapeutic patient education in children with moderate to severe atopic dermatitis: A multicenter randomized controlled trial in China

BACKGROUND

Therapeutic patient education is a continuous, systematic, patient-centered learning process to help patients and their families acquire and maintain the skills they need to manage their lives with a chronic disease. It has been proven effective in increasing treatment adherence and improving quality of life for patients with atopic dermatitis (AD) in Western countries. We introduce the first multicenter, randomized controlled clinical trial of therapeutic patient education in Chinese children with AD.

OBJECTIVES

To evaluate the effects of therapeutic patient education on the severity of AD, quality of life, and understanding and successful use of emollients in Chinese children with eczema.

METHODS

We recruited 580 children, ages 2-14 years, with moderate to severe AD from six hospitals in China. Participants were randomized (1:1) to an intervention (n = 293) or control (n = 249) group. In addition to the severity of AD, data on quality of life and a questionnaire on family and patient knowledge of emollients were evaluated at the 6-month follow-up.

RESULTS

On study completion, we found that the intervention group showed a significantly greater reduction in mean SCORing Atopic Dermatitis (P < .001) and Infant's Dermatology Life Quality Index (P = .030) scores than the control group. In addition, knowledge about the use of emollients improved significantly in the intervention group. There was no significant difference between groups in Children's Dermatology Life Quality Index scores.

CONCLUSIONS

The first randomized controlled trial of a therapeutic patient education program in China had positive long-term effects on decreasing eczema severity and improvement of quality of life in children 2-4 years of age with AD, as well as in promoting greater understanding of the use of emollients.

The positive effects of habit reversal treatment of scratching in children with atopic dermatitis: a randomized controlled study

BACKGROUND

Scratching and itch are common clinical signs of atopic dermatitis (AD). Studies of adult patients have shown that a decrease in scratching behaviour results in regression of inflammation and improved healing of the skin.

OBJECTIVES

To investigate whether a modified habit reversal (HR) treatment protocol could be used for the treatment of scratching in children to improve skin status.

METHODS

The study is a single-blind, randomized controlled trial of 39 patients who started with registration a week before randomization into one of two groups (intervention or control). The participants in the intervention group received a habit-breaking therapy of their scratching behaviour (i.e. HR) in addition to a potent steroid (mometasone furoate), whereas the patients in the control group received the steroid alone. The patients were assessed by an independent dermatologist after the first week of registration (baseline assessment) and then after 3 and 8 weeks of treatment. The primary efficacy variable was a change in objective Scoring Atopic Dermatitis (SCORAD).

RESULTS

At the end of the 3-week treatment period, the change in mean objective SCORAD was significantly (P = 0·027) higher in the intervention group (-31·9 ± 9·5) than in the control group (-23·8 ± 10·1). After the 8-week follow-up, the change in mean objective SCORAD was significantly (P = 0·0038) higher in the intervention group (-31·7 ± 10·4) than in the control group (-19·7 ± 9·4).

CONCLUSIONS

The treatment of scratching with the HR method in combination with a potent steroid was found to improve skin status significantly after 3 and 11 weeks.

Psychological and Educational Interventions for Atopic Dermatitis in Adults: A Systematic Review and Meta-Analysis

Psychological and educational interventions are valuable adjuncts in the management of adult atopic dermatitis. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) of the efficacy of these interventions. Twelve articles published between 1986 and 2013 were identified through electronic searches. The methodological quality was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.1 (Higgins & Green, 2015). A random-effects model was used to estimate the standardised mean difference (SMD). No significant difference was found in eczema severity determined in three RCTs (124 participants; SMD, -0.29; 95% CI [-0.64, 0.07]) and dropout rate in five RCTs (198 participants; relative risk, 0.66; 95% CI [0.20, 2.17]). Education via online video was significantly superior to handouts in ameliorating eczema severity in one RCT (80 participants). We conclude that, rather than a combination of these interventions with conventional therapy being of no value, the data did not have sufficient power to provide evidence-based conclusions.

Pharmacological interventions for pruritus in adult palliative care patients

BACKGROUND

This is an update of the original Cochrane review published in 2013 (Issue 6). Pruritus occurs in patients with disparate underlying diseases and is caused by different pathologic mechanisms. In palliative care patients, pruritus is not the most prevalent but is one of the most puzzling symptoms. It can cause considerable discomfort and affects patients' quality of life.

OBJECTIVES

To assess the effects of different pharmacological treatments for preventing or treating pruritus in adult palliative care patients.

SEARCH METHODS

For this update, we searched CENTRAL (the Cochrane Library), and MEDLINE (OVID) up to 9 June 2016 and Embase (OVID) up to 7 June 2016. In addition, we searched trial registries and checked the reference lists of all relevant studies, key textbooks, reviews and websites, and we contacted investigators and specialists in pruritus and palliative care regarding unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of different pharmacological treatments, compared with a placebo, no treatment, or an alternative treatment, for preventing or treating pruritus in palliative care patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the identified titles and abstracts, performed data extraction and assessed the risk of bias and methodological quality. We summarised the results descriptively and quantitatively (meta-analyses) according to the different pharmacological interventions and the diseases associated with pruritus. We assessed the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation) and created 10 'Summary of findings' tables.

MAIN RESULTS

In total, we included 50 studies and 1916 participants in the review. We added 10 studies with 627 participants for this update. Altogether, we included 39 different treatments for pruritus in four different patient groups.The overall risk of bias profile was heterogeneous and ranged from high to low risk. However, 48 studies (96%) had a high risk of bias due to low sample size (i.e. fewer than 50 participants per treatment arm). Using GRADE criteria, we downgraded our judgement on the quality of evidence to moderate in seven and to low in three comparisons for our primary outcome (pruritus), mainly due to imprecision and risk of bias.In palliative care participants with pruritus of different nature, the treatment with the drug paroxetine, a selective serotonin reuptake inhibitor, reduced pruritus by 0.78 points (numerical analogue scale from 0 to 10; 95% confidence interval (CI) -1.19 to -0.37; one RCT, N = 48, quality of evidence: moderate) compared to placebo.For participants suffering from uraemic pruritus (UP), gabapentin was more effective than placebo (visual analogue scale (VAS): 0 to 10), mean difference (MD) -5.91, 95% CI -6.87 to -4.96; two RCTs, N = 118, quality of evidence: moderate). The κ-opioid receptor agonist nalfurafine showed amelioration of UP (VAS 0 to 10, MD -0.95, 95% CI -1.32 to -0.58; three RCTs, N = 422, quality of evidence: moderate) and only few adverse events. Moreover, cromolyn sodium relieved UP participants from pruritus by 2.94 points on the VAS (0 to 10) (95% CI -4.04 to -1.83; two RCTs, N = 100, quality of evidence: moderate) compared to placebo.In participants with cholestatic pruritus (CP), data favoured rifampin (VAS: 0 to 100, MD -24.64, 95% CI -31.08 to -18.21; two RCTs, N = 42, quality of evidence: low) and flumecinol (RR > 1 favours treatment group; RR 1.89, 95% CI 1.05 to 3.39; two RCTs, N = 69, quality of evidence: low) and showed a low incidence of adverse events in comparison with placebo. The opioid antagonist naltrexone reduced pruritus for participants with CP (VAS: 0 to 10, MD -2.26, 95% CI -3.19 to -1.33; two RCTs, N = 52, quality of evidence: moderate) compared to placebo. However, effects in participants with UP were inconclusive (percentage difference -12.30%, 95% CI -25.82% to 1.22%, one RCT, N = 32). Furthermore, large doses of opioid antagonists (e.g. naltrexone) could be inappropriate in palliative care patients because of the risk of reducing analgesia.For participants with HIV-associated pruritus, it is uncertain whether drug treatment with hydroxyzine hydrochloride, pentoxifylline, triamcinolone or indomethacin reduces pruritus because the evidence was of very low quality (e.g. small sample size, lack of blinding).

AUTHORS' CONCLUSIONS

Different interventions tended to be effective for CP and UP. However, therapies for patients with malignancies are still lacking. Due to the small sample sizes in most meta-analyses and the heterogeneous methodological quality of the included trials, the results should be interpreted cautiously in terms of generalisability.

Contagious itch: what we know and what we would like to know

All humans experience itch in the course of their life. Even a discussion on the topic of itch or seeing people scratch can evoke the desire to scratch. These events are coined “contagious itch” and are very common. We and others have shown that videos showing people scratching and pictures of affected skin or insects can induce itch in healthy persons and chronic itch patients. In our studies, patients with atopic dermatitis (AD) were more susceptible to visual itch cues than healthy. Also, personality traits like agreeableness and public self-consciousness were associated with induced scratching in skin patients, while neuroticism correlated with induced itch in healthy subjects. The underlying course of contagious itch is not yet fully understood. It is hypothesized that there are human mirror neurons that are active when we imitate actions and/or negative affect. Until now, there has been only limited data on the mechanisms of brain activation in contagious itch though. We have barely begun to understand the underlying physiological reactions and the triggering factors of this phenomenon. We summarize what we currently know about contagious itch and provide some suggestions what future research should focus on.

Cognitive Behavioural Stress Management as Treatment of Atopic Dermatitis: A Case Study

A 37-year-old male with a 13-year history of atopic dermatitis (AD) was treated with cognitive behavioural stress management. Self-rated stress and extent of AD rash decreased from baseline to the end of treatment, and gains were maintained at follow-up. A significant correlation between stress and extent of AD rash was observed. Discussion focused on the possible role of stress induced immunosuppression on exacerbations of AD, and the need for controlled trials evaluating the treatment procedures used in the current study.

Psychological management of wound pruritus

OBJECTIVE

To explore the psychological treatment options for pruritus in patients with wounds.

METHOD

This study employed a narrative design with a search being completed using the databases Academic Search Complete, Google Scholar, PsycInfo, PsycARTICLES, Medline and CINAHL Plus. All articles between 1980-2013 that included the following search terms: [pruritus OR itch OR itching] AND [management OR psychological interventions OR treatment] AND [wounds OR burns OR wounds burns] were included in the review.

RESULTS

A number of psychological treatments options emerged from the literature search that were suggested to be effective for treating itching. These included methods such as habit reversal, suggestions, relaxation, massage and itch-coping programmes. Each of these methods showed potential for improving the patient experience by reducing itching, although the research evidence is currently somewhat limited.

CONCLUSION

Although itching is a common symptom in wounds, the use of psychological treatments for this may be rather limited. The treatments discussed show promise and their use should be a welcome addition to the healthcare professional's armoury for working with people with wounds.

DECLARATION OF INTEREST

There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

Non-pharmacologic therapies for atopic dermatitis

Atopic dermatitis (AD) continues to present significant therapeutic challenges, especially in severe cases. Navigating the line between risk and benefit can be difficult for more powerful medications such as immunosuppressants, but non-pharmacologic treatments are often overlooked and underutilized. Creative application of these more physical therapies can serve to minimize the pharmacologic treatments and their side effects, and possibly even create synergy between modalities, to maximize benefit to the patient.

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. This is an update of the original Cochrane review.

OBJECTIVES

To assess the effect of psychological and educational interventions for atopic eczema in children.

SEARCH METHODS

We updated our searches of the following databases to January 2013: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2012, Issue 12), MEDLINE (from 1946), EMBASE (from 1974), OpenGrey, and PsycINFO (from 1806). We also searched six trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

Randomised controlled trials of psychological or educational interventions, or both, used to assist children and their carers in managing atopic eczema.

DATA COLLECTION AND ANALYSIS

Three authors independently applied eligibility criteria, assessed trial quality, and extracted data. A lack of comparable data prevented data synthesis, and we were unable to conduct meta-analysis because there were insufficient data.

MAIN RESULTS

We included 10 RCTs, of which 5 were new to this update; all interventions were adjuncts to conventional therapy and were delivered in primary- and secondary-care settings. There were 2003 participants in the 9 educational interventions and 44 participants in the 1 psychological study. Some included studies had methodological weaknesses; for example, we judged four studies to have high risk of detection bias, attrition bias, or other bias. Our primary outcomes were participant-rated global assessment, reduction in disease severity (reported as objective SCORAD (SCORing Atopic Dermatitis)), and improvement in sleep and quality of life. No study reported participant-rated global assessment or improvement of sleep.The largest and most robust study (n = 992) demonstrated significant reduction in disease severity and improvement in quality of life, in both nurse- and dermatologist-led intervention groups. It provided six standardised, age-appropriate group education sessions. Statistically significant improvements in objective severity using the SCORAD clinical tool were recorded for all intervention groups when compared with controls. Improvements in objective severity (intervention minus no intervention) by age group were as follows: age 3 months to 7 years = 4.2, 95% confidence interval (CI) 1.7 to 6.8; age 8 to 12 years = 6.7, 95% CI 2.1 to 11.2; and age 13 to 18 years = 9.9, 95% CI 4.3 to 15.5. In three of five studies, which could not be combined because of their heterogeneity, the objective SCORAD measure was statistically significantly better in the intervention group compared with the usual care groups. However, in all of the above studies, the confidence interval limits do not exceed the minimum clinically important difference of 8.2 for objective SCORAD.The largest study measured quality of life using the German 'Quality of life in parents of children with atopic dermatitis' questionnaire, a validated tool with five subscales. Parents of children under seven years had significantly better improvements in the intervention group on all five subscales. Parents of children aged 8 to 12 years experienced significantly better improvements in the intervention group on 3 of the 5 subscales.

AUTHORS' CONCLUSIONS

This update has incorporated five new RCTs using educational interventions as an adjunct to conventional treatment for children with atopic eczema. We did not identify any further studies using psychological interventions. The inclusion of new studies has not substantially altered the conclusions from the original review. The educational studies in both the original review and this update lack detail about intervention design and do not use a complex interventions framework. Few use an explicit theoretical base, and the components of each intervention are not sufficiently well described to allow replication. A relative lack of rigorously designed trials provides limited evidence of the effectiveness of educational and psychological interventions in helping to manage the condition of atopic eczema in children. However, there is some evidence from included paediatric studies using different educational intervention delivery models (multiprofessional eczema interventions and nurse-led clinics) that these may lead to improvements in disease severity and quality of life. Educational and psychological interventions require further development using a complex interventions framework. Comparative evaluation is needed to examine their impact on eczema severity, quality of life, psychological distress, and cost-effectiveness. There is also a need for comparison of educational interventions with stand-alone psychosocial self-help.  

Pharmacological interventions for pruritus in adult palliative care patients

BACKGROUND

Pruritus is not the most prevalent but one of the most puzzling symptoms in palliative care patients. It can cause considerable discomfort and has a major impact on patients' quality of life. In the field of palliative care, pruritus is a symptom occurring in patients with disparate underlying diseases and based on different pathologic mechanisms but ending in the same phenomenon. The pathogenesis of pruritus is complex and not fully elucidated. Thus, it is still very difficult to treat pruritus effectively. Evidence-based treatment approaches are needed.

OBJECTIVES

The objective was to evaluate the efficacy of different pharmacological treatments for preventing or treating pruritus in adult palliative care patients.

SEARCH METHODS

A systematic literature search up to January 2012 was performed and it was updated in August 2012. The following databases were searched: The Cochrane Library (CENTRAL, DARE, CDSR) (2012, issue 8 of 12); MEDLINE (1950 to August 2012); EMBASE (1980 to August 2012) and three other databases. In addition, we searched trials registries and checked the reference lists of all relevant studies, key textbooks, reviews, and websites, and contacted investigators and specialists in pruritus and palliative care regarding unpublished data.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of different pharmacological treatments on preventing or treating pruritus in palliative care patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified titles and abstracts. Three independent review authors performed assessment of all potentially relevant studies, data extraction, assessment of risk of bias and methodological quality. Results were summarised descriptively according to the different pharmacological interventions and the type of underlying pruritus. Where possible, results were presented in meta-analyses.

MAIN RESULTS

In total, 38 reports comprising 40 studies and 1286 participants were included in the review. Altogether, 30 different treatments for pruritus in four different patient groups were included.The findings of this review indicated that the treatment of pruritus for palliative care patients is challenging and requires an individualistic approach. Results showed that effective therapeutic choices have to be guided by the pathophysiology of the pruritus. Various forms of pruritus occur, especially in the field of palliative care, and sometimes the origin of the pruritus is difficult to determine. Therefore, identifying the underlying cause of pruritus is of prime importance in order to develop tailored treatment plans, even if in palliative care the treatment is focused towards the symptom and not necessarily the underlying disease.Results show that in palliative care patients with pruritus of different natures, treatment with the drug paroxetine, a selective serotonin reuptake inhibitor, may be beneficial. For patients suffering from pruritus associated with HIV infection, indomethacin was described as the most effective drug, although the evidence was weak. For patients suffering from chronic kidney disease-associated pruritus, gabapentin may be an option. An alternative treatment for this patient group seems to be the κ-opioid receptor agonist nalfurafine, which has shown significant amelioration of pruritus and acceptable adverse effects. As they have exhibited a low incidence of adverse effects, rifampicin and flumecinol may be recommended for patients with cholestatic pruritus. The opioid antagonist naltrexone has been shown to offer a therapeutic alternative for patients suffering from uraemic or cholestatic pruritus. However, these drugs are often inappropriate in the palliative population because of the risk of reducing analgesia when giving high doses of naltrexone.

AUTHORS' CONCLUSIONS

The findings of this review indicate that the number of systemic and topical drugs used for the different subforms of pruritus is increasing. Different interventions have been shown to be effective in the treatment of pruritus of different origins. Nevertheless, an optimal therapy for pruritus is constrained due to the limited understanding of crucial itch mediators and receptors in the various subforms of itch. Ideal antipruritic therapies are still lacking, especially for palliative care patients.This systematic review also indicates that there is insufficient evidence to give any concrete recommendations regarding treatment of pruritus in palliative care patients. Due to the very small sample sizes and poor methodological quality of the majority of studies that were included, the results of this review need to be interpreted with caution. Furthermore, the generalizability is questionable. Additional studies, and particularly carefully designed treatment trials, are needed to provide valid evidence for adequate treatment of pruritus in palliative care patients.

Psychoneuroimmunology of psychological stress and atopic dermatitis: pathophysiologic and therapeutic updates

Atopic dermatitis is a chronic inflammatory skin disease characterized by impaired epidermal barrier function, inflammatory infiltration, extensive pruritus and a clinical course defined by symptomatic flares and remissions. The mechanisms of disease exacerbation are still poorly understood. Clinical occurrence of atopic dermatitis is often associated with psychological stress. In response to stress, upregulation of neuropeptide mediators in the brain, endocrine organs, and peripheral nervous system directly affect immune and resident cells in the skin. Lesional and non-lesional skin of patients with atopic dermatitis demonstrates increased mast cells and mast cell-nerve fiber contacts. In the setting of stress, sensory nerves release neuromediators that regulate inflammatory and immune responses, as well as barrier function. Progress towards elucidating these neuroimmune connections will refine our understanding of how emotional stress influences atopic dermatitis. Moreover, psychopharmacologic agents that modulate neuronal receptors or the amplification circuits of inflammation are attractive options for the treatment of not only atopic dermatitis, but also other stress-mediated inflammatory skin diseases.

Management of itch in atopic dermatitis

Atopic dermatitis is a common, pruritic, inflammatory skin disorder. Chronic, localized, or even generalized pruritus is the diagnostic hallmark of atopic dermatitis, and its management remains a challenge for physicians. The threshold for itch and alloknesis is markedly reduced in these patients, and infections can promote exacerbation and thereby increase the itch. Modern management consists of anti-inflammatory, occasionally antiseptic, as well as antipruritic therapies to address the epidermal barrier as well as immunomodulation or infection. Mild forms of atopic dermatitis may be controlled with topical therapies, but moderate-to-severe forms often require a combination of systemic treatments consisting of antipruritic and immunosuppressive drugs, phototherapy, and topical compounds. In addition, patient education and a therapeutic regimen to help the patient cope with the itch and eczema are important adjuvant strategies for optimized long-term management. This review highlights various topical, systemic, and complementary and alternative therapies, as well as provide a therapeutic ladder for optimized long-term control of itch in atopic dermatitis.

Pathophysiology and therapy of pruritus in allergic and atopic diseases

Pruritus (itch) is a major characteristic and one of the most debilitating symptoms in allergic and atopic diseases and the diagnostic hallmark of atopic dermatitis. Pruritus is regularly defined as an unpleasant sensation provoking the desire to scratch. Although we achieved rather good knowledge about certain inducers of itch such as neuropeptides, amines, mu-opioids, cytokines and proteases, for example, less is known about the pathophysiological specifities among the different diseases, and the therapeutic consequences which may derive thereoff. This review dissects the role of mediators, receptors and itch inhibitors on peripheral nerve endings, dorsal root ganglia, the spinal cord and the CNS leading to the amplification or - vice versa - suppression of pruritus. As the treatment of pruritus in allergic and atopic skin disease is still not satisfactory, knowing these pathways and mechanisms may lead to novel therapeutic approaches against this frequently encountered skin symptom.

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.

The Effects of Psychological Intervention on Atopic Dermatitis

BACKGROUND

Psychological interventions may be valuable in atopic dermatitis. We systematically reviewed and carried out a meta-analysis of randomized controlled trials of psychological interventions.

METHODS

Electronic searches and manual journal searches were carried out. Two coders independently coded study designs, participants, treatments and outcome characteristics of the studies meeting the selection criteria.

RESULTS

Eight journal articles published between 1986 and 2006 were included. Eight types of intervention were tested: aromatherapy, autogenic training, brief dynamic psychotherapy, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, habit reversal behavioral therapy, a stress management program, and structured educational programs. Effect sizes were computed as correlation coefficient (r), and random effects models were used in the analysis. For eczema severity, the average effect size for the 8 trials including 8 interventions was -0.367 [chi(2)(1) = 7.452, p = 0.006; 95% CI -0.579 to -0.108]. The average effect sizes on itching intensity (5 trials with 5 interventions) and scratching (5 trials with 4 interventions) were -0.805 [chi(2)(1) = 4.719, p = 0.030; 95% CI -0.971 to -0.108] and -0.620 [chi(2)(1) = 24.24, p < 0.0001; 95% CI -0.767 to -0.410], respectively.

CONCLUSIONS

Although the present meta-analysis revealed that psychological interventions had a significant ameliorating effect on eczema severity, itching intensity and scratching in atopic dermatitis patients, a definite conclusion about their effectiveness seems premature. Accordingly, future studies should involve more sophisticated methodologies, use established measures of outcome variables, adjust for possible confounders between the intervention and control groups, and provide sufficient data to calculate the effect sizes for future meta-analyses.

Psychosomatic cofactors and psychiatric comorbidity in patients with chronic itch

BACKGROUND

While psychosomatic factors may be involved in eliciting as well as coping with chronic itch, psychiatric comorbidity often goes unrecognized in dermatological patients.

AIM

To record psychiatric illness, psychiatric and psychotherapeutic pretreatment, and psychotherapy indication in dermatology inpatients with pruritus.

METHODS

A consecutive sample of 109 dermatology inpatients with the symptom of pruritus were examined by interviews with consecutive ratings by experts (using psychiatric ICD-10 diagnoses, the Global Assessment of Functioning Scale and the Impairment Score) and self-assessment using the the Eppendorf Itch Questionnaire.

RESULTS

In > 70% of the pruritus patients, 1-6 psychiatric diagnoses could be demonstrated. In > 60%, psychotherapeutic or psychiatric treatment was recommended. In contrast, almost 90% of the patients had had no previous psychotherapeutic experience.

CONCLUSION

As psychiatric comorbidity in dermatology inpatients suffering from chronic itch is high, dermatology departments should aim for an improvement of their psychosomatic consultation and liaison services.

Development of a psychological treatment service for pruritic skin conditions

The role of psychological contributions to common dermatological disease is increasingly recognized. It is often a challenge to find suitable psychological services to complement dermatological treatment. This paper describes the development of a psychological treatment service to reduce scratching behaviour found in common pruritic skin conditions. Our Department of Dermatology together with a consultation-liaison psychiatrist designed a four-session outpatient treatment programme incorporating psychiatric assessment, psychoeducation about the itch-scratch cycle, behavioural analysis, habit reversal techniques and between-session tasks for the patient to complete. This programme is actively modified in consultation with patients and their therapists to suit each patient's individual needs. Formal investigation is required to determine if this psychological treatment adds benefit in overall symptom control beyond dermatological treatment alone.

Psychological factors in prurigo nodularis in comparison with psoriasis vulgaris: results of a case-control study

BACKGROUND

It has been suggested that psychological factors such as repressing anger and altruistic interpersonal behaviour may play a role in the aetiology of chronic itching in prurigo nodularis (PN). Whether these issues are specific for PN or are also common in other chronic skin diseases, e.g. psoriasis, has not been investigated until now.

OBJECTIVES

To investigate psychosomatic problem areas and psychiatric comorbidity in patients with PN in comparison with patients with psoriasis.

METHODS

Ninety-four patients with PN and 91 patients with psoriasis were administered the Hospital Anxiety and Depression Scale, Toronto Alexithymia Scale, State-Trait Anger Expression Inventory, Inventory of Interpersonal Problems, Screening for Somatoform Disorders and the Whiteley Index for hypochondriasis.

RESULTS

After Bonferroni post hoc adjustment, the metrical scales demonstrated no significant differences between patients with PN and those with psoriasis. There was only a tendency to less 'anger-out' and to less autocratic/dominant and more insecure/submissive behaviour in the patients with PN. Patients with PN were, in general, comparable with those with psoriasis with regard to alexithymia, somatization symptoms, hypochondriasis, anxiety and depression, with 18% cases of anxiety and 22% cases of depression.

CONCLUSIONS

The hypotheses formulated in the literature on the specific aetiology of PN could not be proven for the majority of patients with PN in our study. Concerning their psychopathology, patients with PN were comparable with those with psoriasis. Therefore the clinical management of PN should include psychosomatic assessment.

Psychoneuroimmunodermatology of atopic dermatitis: from empiric data to the evolutionary hypothesis

Atopic dermatitis is a pruritic skin disease affecting predominantly young people. There is evidence that psychologic stress constitutes an increased risk for atopy and influences the disease's clinical course. This risk is believed mediated by the effects of stress on neuroimmunoregulation, which in turn modulates the hypersensitivity response and involves immunoglobulin E-mediated inflammation, helper T-cell 2 predominance, and eosinophilia. This article examines theoretic perspectives and other behavioral dimensions, such as maternal caring behavior, infant response to stress, temperament, and the so-called "hygiene hypothesis." The Darwinian framework and the mental scenario are examined. These processes may be akin to the generation of antibodies by the immune system.

[Atopic dermatitis and psychological stress]

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease. Its main features are eczematous skin lesions with a typical distribution and severe pruritus. Allergens, skin irritants, systemic or local infections, environmental pollutants and hormonal changes have a role in the pathophysiology of AD. A further important trigger factor for both intrinsic and extrinsic AD is emotional stress. Recently published observations point to direct psychoneuroimmunological and -endocrinological mechanisms: Psychological stress causes a transient increase of peripheral blood eosinophil count and an increase in both CD8+/CD11b+ and CLA+ T-cells. In addition, stress changes the cytokine and the hormone profile with increased levels of IFN-gamma and IL-5, and decreased levels of cortisol in AD patients in contrast to healthy controls. These findings underline the role of immunological changes and a possible suppressed hypothalamic-pituitary-adrenal (HPA) axis closing the loop for the final aggravation of AD.

Endocrine and immune responses to stress in chronic inflammatory skin disorders

Atopy is a genetically and environmentally determined condition predisposing to different forms such as atopic dermatitis (AD) or allergic asthma (AA). Both AD and AA are considered to be multifactorial diseases; however, distinct immunologic abnormalities have been described that play a crucial role. There is growing evidence that immunoglobulin-E hypersecretion and activation of the predominantly T-helper-2 (TH2)-like T cell subset trigger allergic inflammatory processes and cause the disease to become chronic. In the present paper, data suggesting reduced hypothalamic-pituitary-adrenal (HPA) axis responsiveness in patients with AD and AA are summarized, and the potential etiologic significance of a hyporeactive HPA axis is discussed. We propose that because of defective HPA axis, immunoregulation under stressful conditions is ineffective in patients with atopic conditions, leading to aberrant immune responses and subsequent exacerbation of the disease. Further research into the role of the HPA axis in atopy may elucidate the cause of stress-induced exacerbation of atopic symptoms and may be of clinical relevance.

Altered responsiveness of the hypothalamus-pituitary-adrenal axis and the sympathetic adrenomedullary system to stress in patients with atopic dermatitis

A growing number of animal data strongly suggest that a hyporeactive hypothalamus-pituitary adrenal (HPA) axis may be pathologically significant by increasing the susceptibility to chronic inflammation. Following this line of evidence, the specific goal of the present study was to investigate the HPA axis in patients with atopic dermatitis (AD), a chronic allergic inflammatory disease. In addition, the sympathetic adrenomedullary (SAM) system as a second potent immunoregulatory and anti-inflammatory stress-response system has been examined. AD patients (n = 36) and nonatopic control subjects (n = 37) were exposed to a standardized laboratory stressor consisting of a free speech and mental arithmetic task in front of an audience. Cortisol, ACTH, and catecholamine concentrations were assessed before and after the stressor. To investigate feedback sensitivity of the HPA axis, a low dose (0.5 mg) dexamethasone suppression test was also performed. AD patients showed significantly attenuated cortisol and ACTH responses to the stressor, whereas catecholamine levels were significantly elevated in atopic patients. No difference between the experimental groups was found in basal cortisol and ACTH concentrations, whereas basal catecholamine levels were significantly elevated. Analysis of cortisol levels after dexamethasone treatment suggested an intact feedback sensitivity in AD sufferers at the pituitary level. The present findings suggest that patients with AD demonstrate a blunted HPA axis responsiveness with a concurrent overreactivity of the SAM system to psychosocial stress. Considering the important immunoregulatory role of the HPA axis and the SAM system, especially under stressful conditions, an aberrant responsiveness of these neuroendocrine systems may increase the susceptibility to (allergic) inflammation and may be one psychobiological mechanism of stress-related aggravation of the disease.

Stress-induced immunomodulation is altered in patients with atopic dermatitis

Atopic dermatitis (AD) is a chronically relapsing inflammatory skin disease with main symptoms such as eczematous skin lesions and severe pruritus. Although the relevance of stress in the pathology of AD is widely accepted, the underlying biological mechanisms of stress-induced exacerbation of AD symptoms are not fully understood. The specific goal of the present study was to investigate the impact of acute psychosocial stress on atopy-relevant immune functions in AD sufferers. AD patients (n=36) and nonatopic controls (n=37) were exposed to a laboratory stressor including a free speech and mental arithmetic tasks in front of an audience ("Trier Social Stress Test," TSST). Blood samples were collected 10 min before and 1, 10 and 60 min after the stress test as well as 24 h after the experiment at identical time points under resting conditions. Analyses of leukocyte subsets indicated significantly elevated lymphocyte, monocyte, neutrophil and basophil numbers 10 min after the TSST (all p's<0.001) with no significant differences between the two groups. In contrast, eosinophil number was found to be significantly elevated only in AD sufferers, but not subjects (F(3,213)=4.8; p<0.01). Moreover, AD patients but not the control group showed increased IgE levels (F(1,71)=4.4; p<0.05) 24 h after the stress test. Exposure to the TSST resulted in elevation of interferon-gamma (IFN-gamma; F(3,207)=19.55; p<0.001) and, further, in attenuation of interleukin-4 (IL-4; F(3,207)=187.46; p<0.001) concentrations with no significant differences between both groups (all p's>0.05). The present findings suggest that stress may be associated with atopy-relevant immunological changes in AD sufferers, which may be one explanation of the common observation of stress-induced aggravation of symptomatology in this patient group.

Evaluation of a parental training program for the management of childhood atopic dermatitis

Atopic dermatitis (AD) in childhood is a common disease with prevalence rates as high as 20%. Its early onset in infancy and its chronic relapsing course puts a special burden on families. Supporting parents in dealing with the management of AD presents a challenge for physicians. The objective of this study was to determine the effect of a structured parental training program on managing AD in children. Two-hundred and four families participated in a prospective, randomized controlled trial. Children (5 months to 12 years in age) had suffered from moderate-to-severe AD for at least 4 months. They were randomly assigned to either the intervention group or a waiting, control group who could participate in the training program 1 year later. The intervention was an inter-disciplinary, structured educational program which covered medical, nutritional, and psychological issues in six group sessions of 2 h each. The families were assessed at the beginning of the study and 1 year later. Main outcome measures were: severity of eczema (SCORAD); treatment habits; treatment costs; quality of life; and coping strategies. Significant effects were shown regarding treatment behavior, such as regular use of emollients, use of antiseptics and topical steroids in the event of exacerbation, and a reduction in the use of unconventional therapies. Satisfaction with medical treatment was improved, and rumination as an ineffective coping strategy was reduced. Finally, significant reduction of treatment costs was achieved. We conclude that structured training programs for parents of children with AD is a helpful adjunct to dermatological treatment.

Structured parent education in the management of childhood atopic dermatitis: the Berlin model

Childhood atopic dermatitis (AD) is a common disease with the prevalence rates increasing. Its chronic course with frequent relapses puts a special burden on both children and their parents. To maximise positive long-term outcome in the management of AD it is important to support parents in dealing with the chronic condition of their child in addition to treating symptoms. In the present article, we describe in detail the goals, structure, and content of the Berlin education program for parents of children with AD. The program aims to contribute towards a comprehensive, family-oriented management of childhood AD. Its objective is to improve parent's self-management skills with regard to their child's disease and to positively impact the course of the disease as well as the family's quality of life. Medical, nutritional and psychological issues are covered in six group sessions which are conducted by a multiprofessional team of paediatricians, psychologists and dieticians. Preliminary data show that the program has a desirable effect on aspects of quality of life and coping.

Itch and atopic dermatitis: an overview

Itching is the hallmark of atopic dermatitis, and a vicious itch-scratch circle is easily established. Itching and scratching are important factors in the maintenance of symptoms and can have a significant impact on the sufferer's quality of life. The pathophysiology of itch in atopic dermatitis is still not understood. Unlike in urticaria, histamine is not considered to be a major pruritogen in atopic dermatitis. In fact, the peripheral pruritogens and their cellular origin(s) still remain to be identified in this disease. Various treatments are used to relieve the skin inflammation, itching, and scratching in patients with atopic dermatitis, but no specific antipruritic therapy is available. However, several nonspecific therapies can effectively break the vicious itch-scratch circle. The use of topical corticosteroids and emollients and the elimination of individual trigger factors are still first-line measures.

The British Association of Dermatologists audit of atopic eczema management in secondary care. Phase 1: audit of service structure

This first comprehensive study of atopic eczema management describes an audit of service structure (phase 1), process (phase 2) and outcome (phase 3) in the U.K. This paper describes the phase 1 results. Service structure was audited by a single-page questionnaire containing 10 questions on outpatient facilities. This was sent to the lead dermatologist at 187 dermatology centres throughout the U.K., and a final response rate of 98% was achieved. Although the percentage of centres reporting the presence of recommended facilities did not reach the 100% working standard for any one specific criterion, about half of the recommended items, such as provision of height and weight measuring facilities, access to a dietician, patch testing and photochemotherapy, was reported in over 90% of centres. Areas of service structure which were infrequently reported to be in place were issuing of new appointment letters asking patients to bring their treatment details to clinic (52% of centres) and access to nurses with dermatology experience on paediatric wards (57% of centres). Some audit measures, e.g. access to counselling services, showed wide regional variation (range 33-94% of centres), and these variations could not be explained simply in terms of provision of specialists. Some of the elements of service structure, such as access to nurses with dermatology experience on paediatric wards, may be difficult to change in the short term because of funding and staffing constraints, but others, such as provision of growth charts, are easy to change at little cost. This preliminary audit serves as a framework for future audits of atopic eczema management.

Clinical psychology in the management of pediatric skin disease

The role of psychological factors in certain dermatological conditions is not disputed; however, these processes have been much more thoroughly explored in adult populations than in pediatric populations. Therefore, this article reviews relevant adult and child studies. This article explores three aspects of psychological functioning as they relate to dermatological conditions and their treatment, specifically stress and emotional regulation, behavioral and environmental issues, and compliance. The goal of this article is to give the practicing dermatologist a working overview of psychological factors in pediatric skin disease which will facilitate good communication with families around these issues and referral for adjunctive psychological treatment as needed.

Altered reactivity of the hypothalamus-pituitary-adrenal axis in patients with atopic dermatitis: pathologic factor or symptom?

Atopic dermatitis (AD) is a chronic inflammatory skin disease with the principal symptoms of dry skin, lichnification, eczematous inflammation, and an intense pruritus. Despite general acceptance that AD is a multifactorial skin disorder, dysregulation of immune functions (e.g., hypersecretion of immunoglobulin-E, altered cytokine profiles) is considered to be mainly involved in AD pathogenesis. Considerable evidence points to an immunoregulatory function for the hypothalamus-pituitary-adrenal (HPA) axis, suggesting that appropriate reactivity of the HPA axis is necessary to prevent the immune system from reaching a level that may be damaging for the host. It is further hypothesized that dysfunctional reactivity of the HPA axis may increase the vulnerability of the organism to immune-related disorders such as inflammatory diseases. In the present paper the role of the HPA axis for the development and chronification of allergic inflammation will be summarized and the potential pathological significance of a dysfunctional HPA axis in AD pathogenesis will be discussed.