Educational interventions to support eczema management

Educational interventions have also been used to bring about behavioural change through health/patient education or patient teaching for those with eczema (Niebel et al., 2000). These are important since chronic disease management requires a degree of self-management (or caregiver/ parental support) and therefore education and behavioural change (Holman and Lorig, 2000). A limited number of evaluative studies have examined the impact of parental education on the management of children with atopic eczema (e.g. Niebel et al., 2000), although some studies have examined the impact of education on adults with eczema; these studies are informative (e.g. Ehlers et al., 1995). The basis for education is highlighted throughout this content, highlighting, for example, key aspects of Emollients on emollient therapy, understanding treatments for eczema – as outlined in this section and developing strategies to help patients make the most of their treatment (Helping patients make the most of their treatment). These emphasise the need to involve the patient in education, assess educational need systematically and provide education in a planned manner.

A recent systematic review has been undertaken to examine the effectiveness of educational and psychological interventions in changing outcomes for children with atopic eczema (Ersser et al., 2007). This review was published at the time of the production of the NICE (2007) guidance on atopic eczema in children, but provides a more extensive account of the evidence available, information on the typical service delivery models in use and an extensive critique of the evidence available.

Up to this stage the most recent systematic review of the treatments for atopic eczema was a generic review of treatments for atopic eczema (Hoare et al., 2000). Ersser et al.’s Cochrane review identified that such interventions have been used as an adjunct to conventional therapy for children with atopic eczema to enhance the effectiveness of topical therapy. The selection criteria for the review included randomised controlled trials (RCTs) of such interventions used to manage children with atopic eczema. Eligibility to enter the trail, assess trial quality and extract data was independently assessed by two reviewers and revealed a limited number of studies that met the quality criteria for inclusion (n = 5) and a lack of comparable data prevented data synthesis. Some included that studies required clearer reporting of trial procedures. Rigorous established outcome measures were not always used.

The main results are that five studies (RCTs) met the inclusion criteria; all interventions were adjuncts to conventional therapy, four related to educational intervention (Niebel et al., 2000; Chinn et al., 2002; Staab et al., 2002, 2006). 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 (Sokel et al., 1993) examined the effect of relaxation techniques (hypnotherapy and biofeedback) on severity. Some educational studies identified significant improvements in disease severity between intervention groups. The largest trial to date, conducted in Germany (Staab et al., 2006) evaluated long-term outcomes and found significant improvements in both disease severity at 1 year (3 months to 7 years, p = 0.0002; 8–12 years, p = 0.003; 13–18 years, p = 0.0001) and parental quality of life (3 months to 7 years, p = 0.0001; 8–12 years, p = 0.002), for children with atopic eczema. One study by Niebel et al. (2002) found that video-based education was more effective in improving severity than direct education and the control (discussion) (p < 0.001). The single psychological study found that relaxation techniques improved clinical severity as compared to the control at 20 weeks (t = 2.13) but of borderline significance (p = 0.042) (Sokel et al., 1993).

In conclusion, the lack of rigorously designed trials (excluding the study by Staab et al., 2006) 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 and adult studies (e.g. Ehlers et al., 1995; Gradwell et al., 2002) indicated that different service delivery models were in operation, including multiprofessional eczema schools, which were more common in countries such as Germany and the nurse-led clinic model, which was utilised in the UK. These different models of service delivery require further and comparative evaluation to examine their cost-effectiveness and suitability for different health systems.


Drawing on these two reviews there are indications that there may be considerable scope for developing nurse-led dermatology services, especially targeted at groups such as those with atopic eczema requiring educational support. Indeed the National Eczema Society has issued guidance on developing such clinics (Penzer, 2003). The systematic review by Hoare et al. (2000) of treatments for atopic eczema identified the role of specialist nurses as an urgent research priority. An important feature in the development of dermatology services over recent years has been the expansion of nurse-led services. Evidence from a survey conducted of BAD consultants for the BAD Therapy Guidelines and Audit Committee has indicated that there has been a major expansion of nurse-led services in Britain; 69% (n = 183) of consultants had nurse-led clinics, which they anticipated to rise by 91% (Cox, 1999); although more recent data is limited in proving new information, the anecdotal evidence on the UK suggests that these have expanded considerably. These developments are consistent with government nursing strategy to identify where the nursing service can expand its role and enhance its contribution to service delivery where health needs are inadequately or poorly addressed (Department of Health, 2000, 2008). Indeed, the NHS plan policy document highlights nurse-led clinics in dermatology as one of ‘10 key roles for nurses’ in the new NHS (Department of Health 2000, p. 83). Despite the rapid expansion of dermatology services over recent years, the evaluation programme for the expansion of these services has fallen behind, especially in settings such as dermatology. There is also limited knowledge of the precise nature of many of these services and their therapeutic impact.