feature article atopic eczema and evidence-based...

FEATURE ARTICLE

Atopic Eczema andEvidence-Based Care

Sandra Lawton

ABSTRACT: Dermatology nursing research and theinvolvement of nurses in evidence-based care for theirpatients has been transformed over the last decade.Many nurses in the United Kingdom see patients fromreferral to discharge and need both clinical andtheoretical skills in order to do this. This paper willsummarize the current evidence base and resourcesavailable for nurses caring for children and theirfamilies with atopic eczema.Key words: Atopic Eczema, Evidence-Based Care,Pediatrics

Dermatology nursing research and the in-volvement of nurses in evidence-based carefor their patients have been transformedover the last decade. Back in the late 1990s,dermatology nursing research was sparseand the focus of dermatology nursing research wasdriven by a national U.K. project summarizing dermato-logical nursing literature (Ersser, 1998). Nurses are nowactively becoming involved in dermatological researcharound the United Kingdom, working either collabora-tively or independently (Lawton, 2006). This article willsummarize the current evidence base and resources avail-able for nurses caring for children and their families withatopic eczema.

ATOPIC ECZEMA

PrevalenceAtopic eczema is the commonest inflammatory skin dis-ease of childhood, affecting 15%Y20% of children inthe United Kingdom at any one time. The epidemic ofeczema seems to be leveling or decreasing in some coun-tries with previously high prevalence rates such as theUnited Kingdom. The picture elsewhere is mixed withmany developing countries formerly with low prevalenceexperiencing substantial increases, especially in theyounger age groups (Williams et al., 2008).

Eczema Care in the United KingdomIn theUnitedKingdom, eczemaaccounts for 30%of derma-tological consultations in general practice and 10%Y20%of all referrals to dermatologists (Cork et al., 2003; Hoareet al., 2000). In the U.K. healthcare system, children andtheir families receive care from a variety of settings (home,local healthcare services [doctors, health visitors, practicenurses, school nurses, and pharmacists], and specialist ec-zema teams [nurses and doctors]). This often results ina minefield of confusion and misinformation for thesechildren and their families.

ImpactAlthough a common condition, it is still often seen astrivial and unimportant to many. This is far from thetruth with the impact eczema can have on the qualityof life for the child and his or her family. The extremeitch associated with eczema usually results in sleepdisturbance and leads to irritable behavior and reduc-tion in concentration at school. A study by Beattie andLewis-Jones (2006) showed that skin diseases such asatopic eczema, although not life-shortening in the waythat serious conditions such as cystic fibrosis are, causedchildren as much or more distress in their everyday life.Parents reported that the impact on the children’s qualityof life of chronic skin diseases, such as eczema, equatedto that of other chronic diseases, for example, epilepsyand asthma, although the long-term implications of skindiseases may be less severe.

VOLUME 3 | NUMBER 3 | MAY/JUNE 2011 131

Sandra Lawton, RN, OND, RN Diploma (Child) ENB 393, MSc,QN Nurse Consultant Dermatology, Queen’s Medical Centre,Nottingham University Hospitals NHS Trust, Nottingham, UnitedKingdom.

Correspondence concerning this article should be addressed toSandra Lawton, RN, OND, RN Diploma (Child) ENB 393, MSc,QN Nurse Consultant Dermatology, Queen’s Medical Centre,Nottingham University Hospitals NHS Trust, Nottingham, UnitedKingdom.E-mail: [email protected]

This report/article presents independent research commissioned bythe National Institute for Health Research (NIHR). The views ex-pressed in this publication are those of the author(s) and notnecessarily those of theNHS, theNIHRor theDepartment ofHealth.

DOI: 10.1097/JDN.0b013e31821c0b59

Copyright @ 201 Dermatology Nurses' Association. Unauthorized reproduction of this article is prohibited.1

Economic BurdenSuch disability also imposes a significant economic bur-den. This is reflected in direct medical costs associatedwith the use of health service, direct cost to the fami-lies, indirect costs associated with loss of productivity, andintangible costs associated with the psychological effectsof the disease (Emerson et al., 2001). A study in theUnited States, which focused on all types of eczema andspanned all ages, also showed that the annual cost ofeczema was similar to those of other diseases such asemphysema, psoriasis, and epilepsy (Ellis et al., 2002).

DERMATOLOGY NURSING EVIDENCEWithin dermatology nursing, there have been few formalstudies looking specifically at nursing interventions in themanagement of chronic conditions such as atopic eczemain children. Chinn et al. (2002) looked at the impact adermatology nurse in primary care (community setting)had on the quality of life of children with atopic eczema.This study randomized controlled trial (RCT) was un-dertaken over 1 year and looked at a variety of quality oflife indices. It showed marginal improvements in scores asmost children seen hadmilder disease that had less impacton their quality of life. Other outcome measures, such asdisease severity, medication use, and patient satisfaction,might have been appropriate for this study, and furtherrecommendations were made in relation to sample sizeand these additional outcome measures.

Cork et al. (2003) undertook a study to determine theeffect of education and demonstration of topical therapiesby specialist dermatology nurses on therapy utilization andseverity of atopic eczema. Children (n = 51) attending achildren’s dermatology clinic (hospital based) were fol-lowed up for 1 year, and at each visit, the parent’s knowl-edge about atopic eczema, treatment, and therapy use wasrecorded. The severity of the eczema and parental assess-ment of itch, sleep disturbance, and irritability were re-corded. At the first visit, the nurse explained and showedhow to use all the topical therapies. This was then repeatedat subsequent visits, depending on the knowledge of theparent. There was an 89% reduction in disease severity,an 800% increase in the use of emollients, and no overallincrease in the use of topical steroids. This study showedthat the most important interventions in the managementof atopic eczema are to spend time to listen and explainits causes and to demonstrate how to apply topical ther-apies and use adequate amounts (emollients and topicalsteroids).

What parents want and an important considerationwhen providing care is access to good quality, relevantinformation on the seriousness of atopic eczema, theproblems that are likely to occur during the illness, andhow these may affect the child and his or her family’severyday life (Lawton et al., 2005; National Institute forHealth and Clinical Excellence (NICE), 2007; Table 1).

More recently, a study (RCT) compared the level ofcare by nurse practitioners with that of dermatologistsin children with eczema. The level of care provided bya nurse practitioner in terms of the improvement in theeczema severity and the quality of life outcomes werecompared with that provided by a dermatologist, andthe parents were more satisfied with the care that wasprovided by the nurse (Schuttelaar et al., 2009). Similarfindings were also found in a study (RCT) specificallylooking at adult patients, which showed that dermatol-ogy nurses can add to a dermatology consultation andprovide effective patient education and support in man-aging a skin condition (Gradwell et al., 2002).

CONCLUSIONSThe most effective way to manage atopic eczema is to pro-vide adequate time for education and demonstration oftreatments, which can be achieved through nurse-led clin-ics, which will impact on and reduce the severity of eczemain children (Moore et al., 2006). This nurse-led care, how-ever, should not be viewed in isolation; to achieve the bestfor our patients, it requires a multidisciplinary approach.To achieve this, our interventions and treatment decisionsshould be based on available evidence. The next section ofthis article will show the resources to which nurses com-monly refer to obtain that evidence and Table 2 showssome key areas that have influenced my clinical practice.

ECZEMA RESEARCH RESOURCES

The Centre of Evidence-Based DermatologyThe Centre of Evidence-Based Der-matology (CEBD) is based in Not-tingham; the United Kingdom hasan international reputation for skinresearch and evidence-based prac-tice. It is the editorial base for theCochrane SkinGroup and the coor-dinating center for the U.K. Dermatology Clinical TrialsNetwork (UK DCTN) and National Health Service (NHS)

TABLE 1. Education and Adherence toTherapy (NICE, 2007)

Healthcare professionals should spend time educatingchildren with atopic eczema and their parents or carersabout atopic eczema and its treatment. They shouldprovide information in verbal and written forms, withpractical demonstrations, and should cover

Y how much of the treatments to use

Y how often to apply the treatments

Y when and how to step treatment up or down

Y how to treat infected atopic eczema.

This should be reinforced at every consultation,addressing factors that affect adherence.

132 Journal of the Dermatology Nurses’ Association


Evidence Y SkinDisorders. The research strategyof theCEBDis based on the concept of three interdependent research cogs:

� Systematic reviews are used to review the existingevidence and to generate research questions.

� UK DCTN and other noncommercial clinical trialsare used.

� The resulting guidance and evidence base is thendisseminated through NHS Evidence Y Skin Disor-ders and through patient support groups.

Cochrane Skin Group (http://www.csg.cochrane.org)The Cochrane Skin Group is a network ofpeople from all over the world committedto producing and updating systematicreviews of trials relating to skin condi-tions. The editorial base of the CochraneSkin Group is located at the CEBD atNottingham, where its output regularly informs otherstrands of work such as the need for new trials and thebest design of new trials. The scope of the group is wideand includes any skin problem that leads an individual toseek help from a healthcare provider. The group also con-

siders evidence about skin treatments that are sold overthe counter or are widely available.

UK DCTN (http://www.ukdctn.org)TheUKDCTN is a dermatologyclinical trials network open toanyone with an interest in ap-plied dermatological research(membership is free). The net-work was developed in 2002 by Professor HywelWilliams and a group of academic and clinical colleaguesin response to the growing need for high-quality evidenceto inform dermatology clinical practice. The UK DCTNhas now developed into a collaborative, national networkofdermatologists, nurses, health service researchers, andpa-tient representatives. The aim of the network is to conductindependent, high-quality, randomized, controlled multi-center clinical trials for the treatment or prevention of skindisease. Priority is given to trials that address questions ofimportance to clinicians, patients, and the NHS. The UKDCTN is a registered charity with the main infrastructurebeing coordinated fromCEBD.All trial suggestions are sub-mitted by the network members and then put through apredefined trial development process, and a crucial role of

TABLE 2. Some of the Key Evidence-Based Sources That Have Influenced my Clinical Practice1. Diagnostic

criteria& Williams, H. C., Burney, P. G., Pembroke, A. C., Hay, R. J. (1994). The U.K.Working Party’s diagnostic criteriafor atopic dermatitis: III. Independent hospital validation. British Journal of Dermatology, 131, 406Y416.

& Brenninkmeijer, E. E. A., Schram, M. E, Leeflang, M. M. G., et al. (2008). Diagnostic criteria for atopicdermatitis: A systematic review. British Journal of Dermatology, 158, 754Y765.

2. POEM Score & Charman, C. R., Venn, A. J., & Williams, H. C. (2004). The patient-oriented eczema measure:Development and initial validation of a new tool for measuring atopic eczema severity from thepatients’ perspective. Archives of Dermatology, 140, 1513Y1519.

& Charman, C. R., Venn, A. J., Williams, H. C., & Bigby, M. (2005). Measuring atopic eczema severityvisually: Which variables are most important to patients? Archives of Dermatology, 141, 1146Y1151.

3. ClinicalGuidelines

& Hoare, C., Li Wan Po, A., & Williams, H. C. (2000). Systematic review of treatments for atopiceczema. Health Technol Assess, 4(37), 25Y28.

& National Institute for Health and Clinical Excellence. (2007). Atopic eczema in children:Management of atopic eczema in children from birth up to the age of 12 years. London: NICE:http://www.nice.org.uk/CG057

4. Triggers orcauses offlares

& Langan, S. M., Thomas, K. S., & Williams, H. C. (2006). What is meant by a ‘‘flare’’ in atopicdermatitis? A systematic review and proposal. Archives of Dermatology, 142(9):1190Y1196.

& Langan, S. M. & Williams, H. C. (2006). What causes worsening of eczema? A systematic review.British Journal of Dermatology, 155(3):504Y514.

& Langan, S. M., Silcocks, P., & Williams, H. C. (2009). What causes flares of eczema in children? BritishJournal of Dermatology, 161, 640Y646.

5. TopicalTherapies

& Thomas, K. S., Armstrong, S., Avery, A., Li Wan Po, A., O’Neill, C., Young, S., et al. (2002). Randomisedcontrolled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mildpreparation for children with mild or moderate atopic eczema. BMJ, 324, 768Y771.

& Beattie, P. E., & Lewis-Jones, S. M. (2003). Parental knowledge of topical therapies in the treatmentof childhood atopic dermatitis. Clinical and Experimental Dermatology, 28(5), 549Y553.

Note. POEM = Patient Oriented Eczema Measure (Appendix A).



the coordinating center is to support this process. Fundingfor individual trials then comes from National Institutefor Health Research (NIHR) funding streams and partnerbodies including medical research charities.

National Health Service Evidence Y Skin Disorders(http://www.library.nhs.uk/skin/)National Health Service Evidence Y Skin Disorders, for-merly the NLH Skin Disorders Specialist Library, is in-tended to be a one-stop shop for quality, evidence-basedinformation on skin disorders and their treatment for NHShealth professionals. It brings together all the relevant U.K.guidelines, systematic reviews, policy documents, and otherrelevant information resources in an organized, easily acces-sible, and up-to-date electronic collection. NHS Evidence YSkin Disorders is 1 of 33 specialist collections funded byNHS Evidence, part of the NICE. As well as maintainingthe main collection, an important part of the work of NHSEvidence Y Skin Disorders is the annual evidence updates(Batchelor &Williams, 2009), annual searches for new evi-dence in the form of guidelines, and systematic reviewspublished over the last year on a given disease topic:

� Williams, H. C., & Grindlay, D. J. (2010). What’snew in atopic eczema? An analysis of systematicreviews published in 2007 and 2008: Part 1. Defi-nitions, causes and consequences of eczema. Clini-cal and Experimental Dermatology, 35(1), 12Y15.

� Williams, H. C., & Grindlay, D. J. (2010). What’snew in atopic eczema? An analysis of systematicreviews published in 2007 and 2008: Part 2. Dise-ase prevention and treatment. Clinical and Experi-mental Dermatology, 35(3), 223Y227.

� Williams, H. C., & Grindlay, D. J. (2008). What’snew in atopic eczema? An analysis of the clinicalsignificance of systematic reviews on atopic eczemapublished in 2006 and 2007. Clinical and Experi-mental Dermatology, 33(6), 685Y688.

NHS Evidence Y Skin Disorders fits in with the other‘‘cogs’’ of the CEBD as a means of disseminating sys-tematic reviews and other researches carried out by thecenter, in particular, through the monthly e-mail updatessent out to over 600 dermatology health professionals.It also acts as an information resource to support theCEBD activities. From Spring 2011 this will be knownas NHS Evidence and the specialist Skin Disorders re-source will be available form there: http://www.evidence.nhs.uk/aboutus/Pages/AboutSpecialistCollections.aspx.

NICE (http://www.nice.org.uk)NICE produces four types of guidance and referral advice:

1. technology appraisals that provide guidance on theuse of new or existing medicines and treatmentswithin the NHS in England and Wales; currently,there are two completed appraisals for atopic eczema:

� atopic dermatitis (eczema) Y topical steroids (No.81; http://www.nice.org.uk/guidance/TA81) and

� atopic dermatitis (eczema) Y pimecrolimus andtacrolimus (No. 82; http://guidance.nice.org.uk/TA82);

2. clinical guidelines on the appropriate treatmentand care of people with specific diseases and con-ditions within the NHS in England andWales: man-agement of atopic eczema in children from birthup to the age of 12 years (http://www.nice.org.uk/guidance/);

3. guidance on whether interventional procedures usedfor diagnosis or treatment are safe enough and workwell enough for routine use;

4. referral advice for conditions such as atopic eczema,acne, and psoriasis.

Clinical Knowledge Summaries(http://cks.nhs.uk/eczema_atopic)The NHS Clinical Knowledge Summaries are a reliablesource of evidence-based information and practical ‘‘knowhow’’ about the common conditions managed in primary(community) care. It has primarily been designed for useby patients and primary healthcare professionals and tosupport nonmedical prescribers.

National Institute for Health Research (NIHR)(http://www.nihr.ac.uk/)

Health Technology Assessment (http://www.hta.ac.uk/)The Health Technology Assessment program is part ofthe NIHR. It produces independent research informa-tion about the effectiveness, costs, and broader impactof healthcare treatments and tests for those who plan,provide, or receive care in the NHS:

� Hoare, C., Li Wan Po, A., &Williams, H. C. (2000).Systematic review of treatments for atopic eczema.Health Technology Assessment, 4(37), 1Y191. http://www.hta.ac.uk/execsumm/summ437.shtml

Current research supported by the Health TechnologyAssessment/NIHR are as follows:

� SoftenedWater EczemaTrial(http://www.swet-trial.co.uk/),a clinical trial to see if watersofteners help children witheczema, showed no benefit from using a water soft-ener for the treatment of childhood eczema.� SPRUSD (Setting Priorities and Reducing Uncer-tainties for People With Skin Disease).

The CEBD has received funding from the NIHR for5 years to conduct research into several skin diseases,including eczema:

� The previous systematic re-view of clinical trials (Hoareet al., 2000), which covers alltreatments for atopic eczema,



has been updated. The Global Resource of EczemaTrials (GREAT) database holds records, including thefull citation, for all randomised controlled trials oneczema treatment from the year 2000 and will beregularly updated. The database can be accessed freeof charge at http://www.greatdatabase.org.uk.

� A James Lind Alliance (http://www.lindalliance.org)prioritization exercise for eczema treatment, whichaims to collect as many of the unanswered ques-tions about the treatment of eczema as possiblefrom patients, consumers, clinicians, health profes-sionals, and carers, is to be done. These unansweredquestions will be prioritized by representatives fromall the interested parties to produce a list of the top10 unanswered questions about eczema treatment.This will then help to direct future eczema research.

� Patient decision aids should be developed. These canhelp a patient and clinician (such as a dermatologist)come to a difficult treatment decision based on thecurrent evidence about each treatment option. Plainlanguage summaries of systematic reviews of eczematreatment and prevention will also be written tomake them as widely accessible as possible.

� The Barrier Enhancement for Eczema Preventionresearch study is looking at whether emollients usedfrom birth can prevent or delay the onset of eczemain high-risk babies (http://www.beepstudy.org).

Formore information, e-mail [email protected].

ADDITIONAL RESOURCES

� British Association of Dermatologists: http://www.bad.org.uk

� British Dermatological Nursing Group: http://www.bdng.org.uk

� The International Study of Asthma and Allergies inChildhood: http://www.isaac.auckland.ac.nz/

� National Eczema Society: http://www.eczema.org/� Nottingham Support Group for Carers of ChildrenWith Eczema: http://www.nottinghameczema.org.uk/

SUMMARYI hope this article has illustrated the importance ofevidence-based care and the role it has in clinical practice.Applying this to clinical practice influenced the attachedrecord (Appendix B), which provides the team with acomprehensive record that the parents complete prior totheir consultation with the eczema team, either a nurse ordermatologist. This has been developed for a number ofyears, forms part of their medical record, and has beeninfluenced by several factors, evidence-based care, clini-

cal experience, and the views of parents accessing theservice in Nottingham.

ACKNOWLEDGMENTSI count myself extremely fortunate to have worked withmy clinical colleagues and the team from the CEBDover a number of years and would like to acknowledgethem in the writing of this article: Professor HywelWilliams, Douglas Grindlay, Helen Nankervis, CarronLayfield, Joanne Chalmers, and Kim Thomas. h

REFERENCES

Batchelor, J., & Williams, H. C. (2009). Annual evidence update on atopiceczema. ‘‘What’s new?’’Va tour of the 2009 annual evidence updateon atopic eczema with the busy clinician in mind. NHS Evidence - SkinDisorders: http://www.library.nhs.uk/skin/ViewResource.aspx?resID=322682

Beattie, P. E. & Lewis-Jones, M. S. (2006). A comparative study ofimpairment of quality of life in children with skin disease and childrenwith other chronic childhood diseases. British Journal of Dermatology,155, 145Y151.

Chinn, D. J., Poyner, T., & Sibley, G. (2002). Randomized controlled trial ofa single dermatology nurse consultation in primary care on the qualityof life of children with atopic eczema. British Journal of Dermatology,146(3), 432Y439.

Cork, M. J., Britton, J., Butler, L., Young, S., Murphy, R., & Keohane, S. G.(2003). Comparison of parent knowledge, therapy utilization and se-verity of atopic eczema before and after explanation and demonstrationof topical therapies by a specialist dermatology nurse. British Journal ofDermatology, 149(3), 582Y589.

Ellis, C. N., Drake, L. A., Prendergast, M. M., Abramovits, W.,Boguniewicz, M., Daniel, C. R., et al. (2002). Cost of atopic dermatitisand eczema in the United States. Journal of American Academy ofDermatology, 46(3), 361Y370.

Emerson, R. M., Williams, H. C., & Allen, B. R. (2001). What is the costof atopic dermatitis in preschool children? British Journal of Derma-tology, 143, 514Y522.

Ersser, S. (Ed.) (1998). Annotated bibliography of the dermatological nursingliterature. Oxford, United Kingdom: Oxford Brookes University.

Gradwell, C., Thomas, K. S., English, J. S., & Williams, H. C. (2002). Arandomized controlled trial of nurse follow-up clinics: Do they helppatients and do they free up consultants’ time? British Journal ofDermatology, 147(3), 513Y517.

Hoare, C., Li Wan Po, A., & Williams, H. C. (2000). Systematic review oftreatments for atopic eczema.Health Technology Assessment, 4(37), 1Y191.

Lawton, S., Roberts, A., & Gibb, C. (2005). Supporting the parents of childrenwith atopic eczema. British Journal of Nursing, 14(13), 693Y696.

Lawton, S. (2006). Evidence-based careVatopic eczema. British Journal ofDermatology Nursing, 10(1), 14Y15.

Moore, E., Williams, A., Manias, E., & Varigos, G. (2006). Nurse-ledclinics reduce severity of childhood atopic eczema: A review of theliterature. British Journal of Dermatology, 155(6), 1242Y1248.

National Institute for Health and Clinical Excellence. (2007). Atopiceczema in children: Management of atopic eczema in children frombirth up to the age of 12 years. London: NICE: http://www.nice.org.uk/CG057

Schuttelaar, M. L. A., Vermeulen, K. M., Drukker, N., & Coenraads, P. J.(2009). A randomized controlled trial in children with eczema: Nursepractitioner vs. dermatologist. British Journal of Dermatology, 162,162Y170.

Williams, H., Stewart, A., von Mutius, E., Cookson, B., Anderson, H. R.,& the International Study of Asthma and Allergies in Childhood(ISAAC) Phase One and Three Study Groups. (2008). Is eczema reallyon the increase worldwide? Journal Allergy and Clinical Immunology,121(4), 947Y954.

For more than 62 additional continuing education articles related to skin and wound care, go toNursingCenter.com\CE.



APPENDIX A.



APPENDIX B. The atopic eczema record sheet.



APPENDIX B. continued.



feature article atopic eczema and evidence-based...

Documents