Effectiveness of a nurse-led one-to-one education programme in addition to standard care in children with atopic dermatitis: a multicentre randomized control trial.

BACKGROUND: Therapeutic patient education (TPE) is recommended for children with atopic dermatitis (AD), but no consensus has been reached on the optimal tailoring of delivery. While repeated multidisciplinary group education sessions have shown effectiveness, the benefits of one-on-one educational interventions led by nurses for children with AD have not yet been assessed. OBJECTIVES: To assess the benefits of additional, well-structured, 1-h nurse-led individual TPE interventions in children with AD and their families compared with standard care alone. METHODS: Children with moderate-to-severe AD and their parents were randomized to receive a 1-h nurse-led education session in addition to standard care vs. standard care alone. The primary outcome was the area under the curve (AUC) of the SCORing of Atopic Dermatitis index (SCORAD) from baseline to week 24 (lower AUC values represent better long-term control of the disease). RESULTS: In our study, 176 patients were randomized across 11 centres, and 153 were included in the full analysis set. The mean (SD) age was 4.47 (4.57) years. By week 24, there were no significant differences in the AUCs of the SCORAD between the two groups (P = 0.3). Secondary outcomes including patient-reported severity and quality of life [AUCs of the patient-oriented SCORAD (PO-SCORAD) and Infants' Dermatitis Quality of Life Index (IDLQI), Children's Dermatitis Quality of Life Index (CDLQI) and Family Dermatitis Quality of Life Index (FDLQI)] were not significantly different between the two groups. The only significant change observed in the intervention group, when compared with the one receiving standard care, was a decrease in topical steroid phobia, as assessed by the topical corticosteroid phobia (TOPICOP) score. Prespecified subgroup analyses showed that disease severity in the intervention group was significantly lower throughout the study, compared with the standard-care group when participants had moderate AD at baseline (n = 47); while participants with severe AD at baseline (n = 106) did not show benefit from the intervention. Participants showed no additional benefit from the intervention regardless of age group. CONCLUSIONS: This study did not show any additional effectiveness, in long-term severity control, of a 1-h nurse-led TPE intervention in children with AD treated with standard care, compared with those treated with standard care alone. However, it should be noted that the intervention reduced the fear of using topical steroids and may be beneficial for patients in the subgroup with moderate AD.

Atopic dermatitis (AD), also known as atopic eczema, is a chronic relapsing disease that affects 7­15% of children worldwide. Therapeutic patient education (TPE) is recommended for children with AD, but no agreement has been reached on the best way to tailor delivery. While repeated multidisciplinary group education sessions in a hospital setting have been found effective, this type of intervention requires a lot of resources and is time-consuming. To assess the benefits of TPE in children with AD, researchers in France carried out this study with children with moderate-to-severe AD, to compare a 1-hour nurse-led education session in addition to standard care vs. standard care alone. The main aim of this research was to assess the effectiveness of a TPE intervention over a period of 6 months, using a measurement tool called the SCORAD (SCORing of Atopic Dermatitis index). We found no additional benefits in terms of long-term severity control and quality of life at 6 months of a 1-hour nurse-led education intervention in children with AD treated with standard care. However, it should be noted that the intervention reduced the fear of using topical steroids and may be beneficial for people in the moderate AD subgroup.

When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council.

BACKGROUND: Although most patients with atopic dermatitis (AD) are effectively managed with topical medication, a significant minority require systemic therapy. Guidelines for decision making about advancement to systemic therapy are lacking. OBJECTIVE: To guide those considering use of systemic therapy in AD and provide a framework for evaluation before making this therapeutic decision with the patient. METHODS: A subgroup of the International Eczema Council determined aspects to consider before prescribing systemic therapy. Topics were assigned to expert reviewers who performed a topic-specific literature review, referred to guidelines when available, and provided interpretation and expert opinion. RESULTS: We recommend a systematic and holistic approach to assess patients with severe signs and symptoms of AD and impact on quality of life before systemic therapy. Steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. LIMITATIONS: Our work is a consensus statement, not a systematic review. CONCLUSION: The decision to start systemic medication should include assessment of severity and quality of life while considering the individual's general health status, psychologic needs, and personal attitudes toward systemic therapies.

Recommendations from a European Roundtable Meeting on Best Practice Healthy Infant Skin Care.

BACKGROUND: European roundtable meeting recommendations on bathing and cleansing of infants were published in 2009; a second meeting was held to update and expand these recommendations in light of new evidence and the continued need to address uncertainty surrounding this aspect of routine care. METHODS: The previous roundtable recommendations concerning infant cleansing, bathing, and use of liquid cleansers were critically reviewed and updated and the quality of evidence was evaluated using the Grading of Recommendation Assessment, Development and Evaluation system. New recommendations were developed to provide guidance on diaper care and the use of emollients. A series of recommendations was formulated to characterize the attributes of ideal liquid cleansers, wipes, and emollients. RESULTS: Newborn bathing can be performed without harming the infant, provided basic safety procedures are followed. Water alone or appropriately designed liquid cleansers can be used during bathing without impairing the skin maturation process. The diaper area should be kept clean and dry; from birth, the diaper area may be gently cleansed with cotton balls/squares and water or by using appropriately designed wipes. Appropriately formulated emollients can be used to maintain and enhance skin barrier function. Appropriately formulated baby oils can be applied for physiologic (transitory) skin dryness and in small quantities to the bath. Baby products that are left on should be formulated to buffer and maintain babies' skin surface at approximately pH 5.5, and the formulations and their constituent ingredients should have undergone an extensive program of safety testing. Formulations should be effectively preserved; products containing harsh surfactants, such as sodium lauryl sulfate, should be avoided. CONCLUSION: Health care professionals can use these recommendations as the basis of their advice to parents.

Outpatient Home-based Wet Wrap Dressings with Topical Steroids with Children with Severe Recalcitrant Atopic Dermatitis: A Feasibility Pilot Study.

Wet wrapping (WW) appears to be effective in severe atopic dermatitis (AD) in children resistant to topical treatment. Seventeen children were included and were directed to use WW every night (≥6 hr) until lesions disappeared, followed by maintenance treatment of two to three treatments per week. The mean Scoring Atopic Dermatitis (SCORAD) score at baseline was 48.9. After 1 month of treatment the mean SCORAD score was 18.9, and efficacy was maintained after 3 months of treatment. The majority of patients were satisfied (91.7%) with the WW treatment; 92% considered it to be much more effective than the previous treatments received. WW was easy to perform for 75% of patients, 83% of patients stated that it was better tolerated, and 17% considered it to be tolerated equally to dermatologic corticosteroids without WW. The home WW program was continued on a maintenance basis for 75% of patients. This open-label study showed that this program was a feasible and well-tolerated alternative for the treatment of severe, refractory AD in children and adolescents.

Analysis of correlations between patient-oriented SCORAD (PO-SCORAD) and other assessment scores of atopic dermatitis severity and quality of life.

OBJECTIVE: Self-assessment scores such as the Patient-Oriented Scoring of Atopic Dermatitis (PO-SCORAD) index being recommended by public health authorities for chronic disease management, we aimed at analysing correlations between PO-SCORAD and physician and patient assessment scores of atopic dermatitis (AD) severity and quality of life. METHODS: We perfomed an observational study conducted in 12 European countries in 4,222 atopic patients aged ≥1 month and prescribed Exomega® emollient cream. AD severity was measured by the SCORAD index, PO-SCORAD, Patient-Oriented Eczema Measure (POEM) and Self-Administered Eczema Area and Severity Index (SA-EASI) scales, and patient and family quality of life by the Dermatology Life Quality Index (DLQI) and Dermatitis Family Questionnaire Impact (DFQI) scales, respectively. Their correlations were analysed. RESULTS: PO-SCORAD was the only self-assessment score to be highly correlated with the SCORAD index and POEM (r ≥ 0.70). It was also the best correlated with the DLQI (r = 0.67) and DFQI (r = 0.56). After a 5-week treatment, SCORAD index and PO-SCORAD severity scores had decreased significantly by 60 and 56% (p < 0.0001), and quality of life had improved. CONCLUSION: PO-SCORAD is better correlated with quality of life scales than other self-assessment scores.

Therapeutic patient education in atopic dermatitis: worldwide experiences.

Therapeutic patient education (TPE) has proven effective in increasing treatment adherence and improving quality of life (QoL) for patients with numerous chronic diseases, especially atopic dermatitis (AD). This study was undertaken to identify worldwide TPE experiences in AD treatment. Experts from 23 hospitals, located in 11 countries, responded to a questionnaire on 10 major items. Patients in TPE programs were mainly children and adolescents with moderate to severe AD or markedly affected QoL. Individual and collective approaches were used. Depending on the center, the number of sessions varied from one to six (corresponding to 2 to 12 hours of education), and 20 to 200 patients were followed each year. Each center's education team comprised multidisciplinary professionals (e.g., doctors, nurses, psychologists). Evaluations were based on clinical assessment, QoL, a satisfaction index, or some combination of the three. When funding was obtained, it came from regional health authorities (France), insurance companies (Germany), donations (United States), or pharmaceutical firms (Japan, Italy). The role of patient associations was always highlighted, but their involvement in the TPE process varied from one country to another. Despite the nonexhaustive approach, our findings demonstrate the increasing interest in TPE for managing individuals with AD. In spite of the cultural and financial differences between countries, there is a consensus among experts to integrate education into the treatment of eczema.

Therapeutic patient education in children with atopic dermatitis: position paper on objectives and recommendations.

Poor adherence is frequent in patients with atopic dermatitis (AD), leading to therapeutic failure. Therapeutic patient education (TPE) helps patients with chronic disease to acquire or maintain the skills they need to manage their chronic disease. After a review of the literature, a group of multispecialty physicians, nurses, psychologists, and patients worked together during two international workshops to develop common recommendations for TPE in AD. These recommendations were structured as answers to nine frequently asked questions about TPE in AD: What is TPE and what are its underlying principles? Why use TPE in the management of AD? Who should benefit from TPE in AD? How can TPE be organized for AD? What is the assessment process for TPE in AD? What is the evidence of the benefit of TPE in AD? Who are the people involved in TPE? How should TPE be funded in dermatology? What are the limits of the TPE process?

[Atopic dermatitis of the child]. / Dermatite atopique de l'enfant.

Atopic dermatitis is a chronic inflammatory skin disease characterized by episodes of acute eczema alternating with periods of remission. It is a common disease, Its prevalence is estimated to be between 10 and 15 %. The affected areas change depending on the age of the child. Treatment consists of topical corticosteroids for which safety for the prescribed doses is now established. We distinguish the initial treatment and maintenance treatment. Investigation for a food allergy or contact allergy is reported as a second-line after failure of local treatment or in the presence of other suggestive symptoms.

Towards global consensus on outcome measures for atopic eczema research: results of the HOME II meeting.

The use of nonstandardized and inadequately validated outcome measures in atopic eczema trials is a major obstacle to practising evidence-based dermatology. The Harmonising Outcome Measures for Eczema (HOME) initiative is an international multiprofessional group dedicated to atopic eczema outcomes research. In June 2011, the HOME initiative conducted a consensus study involving 43 individuals from 10 countries, representing different stakeholders (patients, clinicians, methodologists, pharmaceutical industry) to determine core outcome domains for atopic eczema trials, to define quality criteria for atopic eczema outcome measures and to prioritize topics for atopic eczema outcomes research. Delegates were given evidence-based information, followed by structured group discussion and anonymous consensus voting. Consensus was achieved to include clinical signs, symptoms, long-term control of flares and quality of life into the core set of outcome domains for atopic eczema trials. The HOME initiative strongly recommends including and reporting these core outcome domains as primary or secondary endpoints in all future atopic eczema trials. Measures of these core outcome domains need to be valid, sensitive to change and feasible. Prioritized topics of the HOME initiative are the identification/development of the most appropriate instruments for the four core outcome domains. HOME is open to anyone with an interest in atopic eczema outcomes research.

Quality of life of parents living with a child suffering from atopic dermatitis before and after a 3-month treatment with an emollient.

Atopic dermatitis (AD) can be extremely disabling and may cause psychological problems for affected children and their families. Moisturizers and emollients are important in the baseline daily skin care of patients with AD. To assess the effect of a 3-month, twice-daily treatment with an emollient on the quality of life (QoL) of parents with a child with mild to moderate AD (SCORing Atopic Dermatitis [SCORAD] ≤ 30, a multicenter open trial was performed by eight dermatologists on 191 volunteers. Evaluation by the dermatologist of the child's clinical condition (SCORAD) and of the efficacy and overall safety of the treatment was associated with a QoL questionnaire completed by one parent of the atopic child. A self-assessment of the global QoL and of the efficacy and overall safety was also performed. During the study, mean SCORAD dropped from 28 to 12 (p < 0.001), with good improvement in skin dryness and pruritus criteria. At the same time, the self-assessment of the global parent QoL scores dropped from 4.4 to 2.1 (p < 0.001) with 60%, 48% and 79% favorable parent opinions regarding wellbeing or improvement of the health condition, quality of sleep, and efficacy of the emollient, respectively. This trial revealed the efficacy of the product in improving parent QoL (85% of parents noted improvement in QoL), and its global safety was considered to be very good or good, with 80% favorable opinions in parents' declarative judgements and dermatologists' assessments. The emollient evaluated improves the course of AD and can improve the QoL of patients and their families.

EczemaPred: A computational framework for personalised prediction of eczema severity dynamics.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory skin disease leading to substantial quality of life impairment with heterogeneous treatment responses. People with AD would benefit from personalised treatment strategies, whose design requires predicting how AD severity evolves for each individual. OBJECTIVE: This study aims to develop a computational framework for personalised prediction of AD severity dynamics. METHODS: We introduced EczemaPred, a computational framework to predict patient-dependent dynamic evolution of AD severity using Bayesian state-space models that describe latent dynamics of AD severity items and how they are measured. We used EczemaPred to predict the dynamic evolution of validated patient-oriented scoring atopic dermatitis (PO-SCORAD) by combining predictions from the models for the nine severity items of PO-SCORAD (six intensity signs, extent of eczema, and two subjective symptoms). We validated this approach using longitudinal data from two independent studies: a published clinical study in which PO-SCORAD was measured twice weekly for 347 AD patients over 17 weeks, and another one in which PO-SCORAD was recorded daily by 16 AD patients for 12 weeks. RESULTS: EczemaPred achieved good performance for personalised predictions of PO-SCORAD and its severity items daily to weekly. EczemaPred outperformed standard time-series forecasting models such as a mixed effect autoregressive model. The uncertainty in predicting PO-SCORAD was mainly attributed to that in predicting intensity signs (75% of the overall uncertainty). CONCLUSIONS: EczemaPred serves as a computational framework to make a personalised prediction of AD severity dynamics relevant to clinical practice. EczemaPred is available as an R package.

Propranolol for treatment of ulcerated infantile hemangiomas.

BACKGROUND: Ulcerated infantile hemangiomas (IH) are a therapeutic challenge. Propranolol, a nonselective beta-blocker, was recently introduced as a novel treatment for IH. OBJECTIVE: To evaluate our experience of propranolol in the management of ulcerated IH. METHODS: A national, multicenter, retrospective, observational study was conducted. Data were collected from the medical charts of patients treated from 2008 to 2009 and supplemented by information obtained from parents during targeted telephone interviews. RESULTS: Thirty-three infants with propranolol-treated ulcerated IH were included. The average time to complete ulceration healing was 4.3 weeks in 30 of 33 patients and was significantly faster for head-and-neck locations (P = .0354). The mean time to complete pain control was 14.5 days. Parents rated treatment as very effective for 27 of 31 patients and very well tolerated for 29 of 31 cases. LIMITATIONS: This was a retrospective uncontrolled study. CONCLUSION: Propranolol appears to be an effective and well-tolerated treatment for ulcerated IH.

Therapeutic education in atopic dermatitis: A position paper from the International Eczema Council.

BACKGROUND: Atopic dermatitis (AD) is a chronic, inflammatory skin disease that affects as many as 12.5% of children aged 0-17 years and 3% of the adult population. In the United States, 31.6 million children and adults are estimated to be living with AD. OBJECTIVE: Therapeutic patient education (TPE) has proven its value in the management of chronic diseases for which adherence to therapy is suboptimal. This article explores experts' opinions and treatment practices to determine if TPE is a recommended and effective method for treating AD. METHODS: Forty-two (51%) of 82 Councilors and Associates of the International Eczema Council (IEC), an international group with expertise in AD, responded to an electronic survey on TPE and AD. RESULTS: Most respondents (97.5%) agreed that TPE should play an important role in the management of AD. Many respondents (82.9%) believed that all patients with AD, regardless of disease severity, could benefit from TPE. LIMITATIONS: The International Eczema Council survey lacks specific information on AD severity. CONCLUSIONS: Publications have shown the positive effect of TPE on the course of the disease, the prevention of complications, and the autonomy and quality of patient life. Survey respondents agreed that TPE can improve the quality of patient care and patient satisfaction with care.

Executive dysfunction in children with neurofibromatosis type 1: a study of action planning.

In this study, we tested the hypothesis that action planning is impaired in children with neurofibromatosis type 1 (NF1). Thirty-six children with NF1 were pair-matched to 36 healthy controls (HC) on age (range, 7-12 years), sex, and parental education level, and both groups were administered three action-planning tasks. To examine the relation of task performance to attention deficit hyperactivity disorder (ADHD), the NF1 group was divided into subsets of children who met or did not meet criteria for ADHD. Children with NF1 performed less well than HC on all planning tasks, and differences remained when controlling for IQ or a measure of visuospatial skill. Both the NF1 with ADHD subset and NF1 without ADHD subset performed more poorly than HC on two of the tasks, whereas only the NF1 with ADHD subset performed worse than HC on the third planning task. The results underscore the importance of evaluating executive function in children with NF1 and suggest that deficits in this domain may be only partially related to ADHD. Planning deficits in children with NF1 may be part of their cognitive phenotype. Identifying these deficits is relevant in determining factors contributing to learning problems and in developing appropriate interventions.

Symptomatic acquired zinc deficiency in at-risk premature infants: high dose preventive supplementation is necessary.

Zinc is a cofactor for several enzymes involved in many metabolisms. Zinc deficiency induces various disorders such as acrodermatitis enteropathica, either inherited or acquired. We report three cases of premature infants (24-31 wks gestational age) with low birthweight (650 to 940 g) and enteropathy, two of whom presented with necrotizing enterocolitis. All infants were fed by total parenteral nutrition. At a chronological age ranging from 73 to 80 days, all infants developed a periorificial dermatitis. Before the onset of the first signs, they had received zinc supplementation ranging from 146% to 195% of the recommended dose (400 microg/kg/day). Increased zinc supplementation over a course of 6-18 days induced a complete resolution of symptoms in all cases. No abnormality in the neurologic examination and no recurrence were observed at the end of the zinc treatment. Low birthweight premature infants with enteropathy on total parenteral nutrition are at risk of developing zinc deficiency. The usual recommended zinc supplementation is probably insufficient for those infants. A delay in the diagnosis of zinc deficiency may lead to severe complications.