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"Behavioural dermatology - The Combined Approach to atopic eczema"
from exchange National Eczema Society Members' Magazine MARCH 2011 pp20-22
Behavioural medicine - of which behavioural dermatology is a part - links medicine with human behaviour, in order to both improve our understanding of physical illness, and therefore improve its treatment. Behavioural medicine takes account of the behaviour of everyone involved - those in need of care, and also those who provide care, both informally and formally. If behaviour is neglected the results of medical treatment can be less than satisfactory. When behaviour is accounted for, the results of treatment can be optimal.
Behaviour therapy - a form of behaviour modification - is a treatment based on how we learn to do what we do, including how we feel and think, as well as act, in different circumstances. Behaviour therapy works by recognising how some habitual behaviour can be helpful, but also how some can be unhelpful and counterproductive - maladaptive: then, how improved results can be achieved by successfully learning new adaptive behaviour. As therapy, the behavioural approach has much in common with education and training. It is an attractive approach because it is easy to understand. It works by focussing on doing and practicing what is agreed as positive and helpful, rather than dwelling on what is negative and unhelpful. A new way of doing something in a particular context replaces an old way, making the old way impossible to carry out. This produces a desired effect which then reinforces the new behaviour: learning occurs.
The Combined Approach to atopic eczema - is an example of behavioural dermatology. It uses behaviour modifiction to optimise the conventional treatment of atopic eczema. It was originally devised by Dr Peter Norén, Dermatologist in Uppsala, Sweden.
Stage One: The first visit - Assessment
Although the combined approach is suitable for all ages, most of the people we have seen at Chelsea & Westminster Hospital have been either adults or teenagers. All have had atopic eczema for a long time and have been at least moderately affected, including major effects on quality of life and psychological well-being. We believe it is important that this demoralising state of affairs is recognised and taken account of at initial assessment. Active participation in a treatment regime requires a positive attitude, and a commitment to becoming an confident expert at using what is a self-help technique. We have been delighted by our results. It is important and relevant therefore that, right from the start, we share our enthusiasm for the approach with all who come to us for treatment.
The combined approach is an educational programme - a series of four appointments is usually booked. These are supported by a patient handbook. The aim to produce an optimal outcome by first ensuring the nature of the condition and the principles of treatment are properly understood, and then by ensuring the treatment is applied and followed through correctly. There is therefore an important initial discussion on the nature of atopy, on the relationship between eczema and allergy, on the significance of dry skin, and especially on the difference between itching and scratching. Dry skin is a common cause of itch in atopic eczema. Itch leads to scratching, and repetitive scratching leads to habitual scratching, and chronic damage is the undesirable consequence.
These patches of rough thickened skin become resistant to treatment with moisturisers and topical steroids. The combined approach adds to the first two levels of conventional treatment - moisturisers and topical steroids - a third level of treatment to deal with habitual scratching - a behaviour modification technique: habit reversal.
A key initial question is asked: "What percentage of your scratching is due to itch?". In a series of 50 consecutive patients before treatment we found a mean 60% of scratching was attributed to itch: the rest is caused by a variety of issues and factors, including stress, opportunity, boredom, frustration and tiredness - but not itch! Habitual behaviour begins with a specific conscious response to a particular stimulus - at first, the scratching is due to itch. As time passes however and the behaviour continues, it becomes relatively automatic and unconscious, and generalizes from being a specific response to itch to being a general response to a wide range of factors which varies from person to person. Such scratching or self-grooming is normal and instinctive - and often goes unnoticed: it is unconscious. It cannot however be taken for granted, if chronic atopic eczema is going to be successfully treated.
Habitual unconscious scratching must become conscious behaviour before it can be changed. This is achieved by use of a hand tally counter, for just one week, between the first and second clinic visit.
During this time all scratching, rubbing, picking and touching of the skin should continue as before - our advice is : do not stop scratching - instead, register each episode on the counter. If it is agreeable, others around can be asked to help, by prompting the use of the counter when scratching occurs - instead of saying "Stop scratching". It is also important that all circumstances, situations and activities associated with scratching are noted down and reported at the second visit, together with the daily totals.
The reported frequencies range from 100 to 1000 or more episodes per day. First thing in the morning, early evening and last thing at night are the times of most scratching.
Stage Two: The second visit - Starting treatment
With this baseline record achieved, the three levels of the treatment programme are discussed in detail - the Combined Approach:
At level three, habit reversal is explained at the second visit. Its successful use over the next month or so will enable the effectiveness of treatment at levels one and two - hence a combined approach. Fig. 1 above is used to introduce how habitual undesirable behaviour needs to be replaced by a new response to any stimulus that has been associated with the undesirable behaviour. As detailed in Fig. 4, the new, desirable behaviour is best when it makes the old behaviour impossible to carry out. From now on positive advice replaces all negative advice - it's what to do (not what not to do).It is important to review the rationale behind the use of emollients and topical steroids - levels one and two in the diagram, active treatment for dry skin, eczema and itch: these conventional levels of treatment must be optimised, and precise explanation and instructions are given, to ensure this is can be achieved.
All three levels of treatment are now agreed, and carried out for two weeks, with continuing use of the hand-tally counter. Others can be recruited to help, by prompting the new behaviour, or the use of the counter. The treatment is reinforced at a third clinic visit at two weeks, with further habit reversal emphasis: by this time scratching frequency can be as little as 10% of the baseline frequency. At this third visit improvements in the skin condition are often very clear, and are associated with general improvements, such as in quality of sleep.
General measures to aid habit reversal take account of particular circumstances. Thus, planning ahead, doing things quickly, and keeping ones hands busy are all important. Each person has their own behaviour to modify, developing habit reversal principles to suit their own needs.
Stage Three: Follow Up
After another two weeks, the fourth clinic visit provides an opportunity to review the programme, and to make individual adjustments. Usually emollients can now be continued as needed, topical steroids are discontinued at the correct point, and with scratching frequency now less than 10 episodes a day, habit reversal and the use of the tally counter are no longer required. Now it is important to understand how future episodes of acute eczema can be provoked, how they can be recognized, and how they need treating early and vigorously with increased emollient use, and a short course of topical steroids - without habit reversal. This will clear acute eczema in three or four days, the chronic eczema having needed as many weeks - with habit reversal. As the next three months pass, episodes of acute eczema become less severe and less frequent, as the skin recovers further. Our patients now report feeling positive and confident, both regarding the management of their eczema, and regarding life in general.
A follow up audit of 37 patients who followed the combined approach programme enabled us to review outcome after one year, in 26 patients - 76% showed greater than 75% improvement in skin condition, while 81% reported greater than 75% improvement in their quality of life. Achieving treatment goals, with continuing only intermittent use of topical steroids as detailed above, was reported by 70%.
The combined approach to the management of chronic atopic eczema can be successfully offered by nurses and doctors, both in dermatology clinics and in general practice settings. It is also feasible for some as a self-help treatment programme. Sue Armstrong-Brown, one of our patients at Chelsea and Westminster, has written such an account: it contains much more detail of the treatment programme, for those who are interested to know more.
Diagrams are from "Atopic Skin Disease - A Manual for Practitioners"
Sue Armstrong-Brown The Eczema Solution London: Vermillion, 2002
The combined approach to atopic eczema is attractive because it is easy to understand. It is an exercise in guided self-help, involving learning how to optimise conventional treatment and how to eliminate habitual scratching using habit reversal. As a treatment programme it involves a series of steps taken over several weeks,
with positive results within one month.