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On Thursday 28th March 2017 at The Medical Society of London there was an afternoon multidisciplinary meeting to consider the current position of the behaviour modification technique habit reversal in the treatment of atopic eczema.
The eighty attendees included dermatologists, psychiatrists, psychologists, general practitioners, nurses and, most important of all, patients.
The full programme below has links to each of the nine short slideshow presentations, followed by an edited written account of the discussion that followed the presentations.
1. Dr Christopher Bridgett & Dr Richard Staughton
2. Dr Christopher Bridgett, Consultant Psychiatrist, Chelsea & Westminster Hospital, London
Habit Reversal & Atopic Eczema
3. Dr Richard Staughton, Consultant Dermatologist, The Lister Hospital, London
Results with Adults
4. Dr Peter Norén, Consultant Dermatologist, Uppsala, Sweden
Working with Children
5. Dr Jon Goulding Consultant Dermatologist, Solihull Hospital
Habit reversal: a non-toxic, cost-effective intervention for chronic eczema
6. Dr Pixie McKenna General Practitioner, The London Clinic
Habit reversal for eczema: simple to use, in both primary care and secondary care
7. Jill Peters Dermatology Nurse Practitioner, Ipswich Hospital
The Combined Approach to atopic eczema and the Nurse Practitioner
8. Dr Reena Shah Chartered Senior Clinical Psychologist, CNWL NHS Foundation Trust
Motivation, and success with habit reversal
9. Sue Armstrong-Brown Author “The Eczema Solution”
Self-help and the importance of professional support
[Scroll down, or click on a listed topic, to go to it in the discussion below the list]
- Working with children
- Non-itch scratching and atopic eczema
- Habit reversal and hypnotherapy
- Three additional dimensions to The Combined Approach
- Saying "Don't Scratch!"
- Biological therapies
- Promoting habit reversal
- Those who benefit most from habit reversal
- Important components of habit reversal treatment
- Reluctance to use topical steroids
- Group therapy & Habit Reversal
- Habit reversal for other skin conditions
- The self-help book
- The website www.atopicskindisease.com
- What patients achieve on their own
- Soap substitutes
- Self assessment
- Planning the treatment programme
The discussion started with a question from the floor asking about working with children - from what age could one expect success? Dr Bridgett pointed out that the programme for younger children and their parents is set out in Chapter 5 of the practitioner’s manual Atopic Skin Disease, and working with infants can certainly be very successful - the younger the patient, perhaps the more quickly habit reversal can take effect. Jill Peters spoke about working with older children, and how attitude, and motivation to change, is important. Dr Hogarth asked if starting effective treatment really early could prevent habitual scratching starting and therefore prevent chronic eczema becoming established. Dr Staughton said this was his opinion - early diagnosis and firm, confident topical treatment, also part of The Combined Approach - can mean that habit reversal is not required, if then chronic eczema does not become an issue.
Dr Sarkany asked about non-itch scratching and atopic eczema: what drives it - was it habit, or was it stress? An adult eczema sufferer had described to him how on occasions she had an intense need to scratch her eczema, despite there being no itch at all - for example, after a stressful day at work. Sue Armstrong-Brown confirmed this had been part of her previous experience. It seemed that violent scratching induced a drug-like effect, a deep release, a calm, good feeling - despite her skin being scratched to shreds. She thought this scratching may not be anything primarily to do with the skin. Dr Norén agreed. Patients reported to him getting home from work, undressing quickly inside the door, and starting to scratch. When this is known, it can be planned for, in advance - and instead, on opening the door, a new skin-safe behaviour can be agreed as a good alternative to scratching - "playing the trombone" for example, he suggested - and this new safe behaviour is then practised consistently for long enough to change matters. He pointed out we can change habits quickly with dogs by working with their owners. For him it is the same when helping small children, working with their parents. It works, but you have to be consistent. Dr Bridgett remarked habit-scratching is a common self-grooming behaviour that reflected a variety of mental states and associated circumstances. Talking about these patterns of behaviour and responses exposed the secrets of living with atopic eczema - and led to successful treatment, and living without eczema.
Dr Baron thought, perhaps more for some adults than for most children, scratching of eczema was sometimes a "coping mechanism", perhaps like deliberate self harm, and with significant secondary gain - as also could be skin-picking and hair-pulling. It was not easy to help those who did not want to help themselves. With very young children it was important for parents to learn to treat acute atopic eczema early and aggressively, and to use distraction techniques to counter scratching - else by 3 or 4 years chronic eczema becomes established and can become difficult to deal with. She incorporated habit reversal with hypnotherapy, which is also effective in tackling habits. Dr Staughton remembered a hypnotherapist sitting in with Chris, and when asked afterwards if hypnotherapy could add something to habit reversal, replied that he had seen that Chris was already successfully using hypnotherapy with all his patients. Dr Bridgett explained that in some schools of hypnosis the process is seen as akin to establishing a full clinical engagement and positive rapport with the patient. In addition to the three levels of treatment of The Combined Approach there are three important additional dimensions - coping with stress, attitudes of the patient, and attitudes of others, all having an effect in managing atopic eczema. And if we have a positive attitude, it can be important - attitudes are contagious.
Elizabeth Allen asked if there is evidence that if you tell someone “Don’t scratch” they immediately want to scratch. Dr Bridgett remarked nearly all his eczema patients said that, when scratching, the most likely response from others was “Stop scratching”, while in behaviour therapy it is fundamental that effective advice needs to be positive - what to do, and not what not to do. A psychologist in the audience agreed - if we say “ Don’t forget the bread” - it seems often all that is remembered is “Forget the bread”. If we say “Remember the bread” we can expect better results, and in parenting, it is important to tell the child what to do, rather than what not to do. The child does not know what to do. Maddy Robinson, eczema patient of Dr Staughton and Dr Bridgett said that starting the habit reversal programme and being told for the first registration week to continue scratching, and to use the hand tally counter to record the scratching, was such a great relief and a big weight off her shoulders, as until then her family, her boy-friend - and mostly herself - had always said “Stop scratching”. In the second week, when she started habit reversal, it worked very quickly indeed: exchanging scratching for another behaviour seemed a very powerful thing to do - and she was amazed how simple it was. Asked if she missed scratching, she replied "not at all"!
Dr Daunton had discussed habit reversal for atopic eczema with his colleagues and had been met with considerable scepticism. Treatment of eczema had remained static for several years. Now in the next few years we may have biologic therapies for eczema, perhaps a lot more acceptable to patients than conventional systemic immunosuppressants: what was the panel's view? Would Sue’s eczema have been resolved by an injection of one of these new treatments? Dr Norén remarked they will not change a scratching habit. Dr Staughton added that the new approaches seemed effective in the short term, but then what? Another discussant from the floor added perhaps dermatologists were understandably prone to promote medical treatments. Safer non-medical alternatives are then marginalised. Dr Bridgett remarked that there was a place for a variety of treatments in both dermatology and in psychiatry, but for eczema habit reversal is cost-effective and non-toxic.
To promote the use of habit reversal in chronic atopic eczema it was suggested from the audience that it would be good if the training of dermatologists was further developed to emphasise psychosocial, cost-effective alternatives to narrower biological perspectives. Commissioners of dermatological services had their part to play. It was also suggested that the introduction of the term endogenous with regard to atopic eczema, and the finding of genes that prevent T-cells working and genes for the epidermal barrier not working, has led to a neglect of exogenous factors, both related to allergy, and behaviour. Dr Razzaque agreed on the relevance of the cost-saving implications of the approach, and also how relevant it was to use IT and the social media in promoting the approach.
Regarding the eczema patients that seemed to benefit most from habit reversal Dr Turner reported from his experience those with eczema on exposed and localised areas, such as the face, and the forehead, those with mild to moderate rather than those with very severe eczema, and those with high pre-treatment scratching counts, all seemed to do especially well. Those who believed their condition was actually being caused by their use of topical steroids, and therefore were reluctant to use them, did less well. He agreed with Dr Shah that it was useful to distinguish habitual scratching from emotional and stress-related scratching, where specialist cognitive behaviour therapy techniques might also be useful. Caroline Jee wondered if the effectiveness of habit reversal in atopic eczema depended on certain components of the approach being especially important. For Dr McKenna having the right patient was important, but even more important was having the right therapist: relating to the patient in a positive way was a key factor. In response, Dr Goulding pointed out this generally applied to all treatments, whether psychological or biological - the important components in habit reversal must be more specifically behavioural. There was also the need to address the widespread reluctance to use topical steroids effectively. Dr Staughton agreed: topical steroids had been revolutionary in the treatment of eczema, and as freedom fighters - they should not be seen as terrorists. Dr Heath remarked how the cautious attitudes shown by some pharmacists to prescriptions for topical steroids undermined medical advice. Dr Bridgett saw this as perhaps a reflection of prescriptions being given without follow-up appointments: there was a case for potent topical treatments always being supervised by follow-up. In both primary and secondary care there was a role here for nurse practitioners. Dr Norén added that the use of the mild potency topical steroids like hydrocortisone, bought over the counter, in treating eczema was both ineffective and potentially even indirectly a cause of chronic eczema.
In her presentation Dr Shah had touched on delivering habit reversal as a group therapy. Dr Bridgett pointed out how Sue’s book, The Eczema Solution had drawn on the experiences of fellow patients whom Sue had spoken with in the waiting room at the clinic. Group therapy had partly originated from seeing how patients had benefited from talking to each other in waiting rooms. However group therapy required expert professional support too. He suggested the book could also be used as an aid to training, in addition to being an excellent and inexpensive source of self-help. [See also Getting Training]
Lotte Bateson asked about habit reversal being used for other skin conditions, perhaps psoriasis for example. Dr Bridgett said the focus on atopic eczema reflected the interests of his colleagues Drs Norén & Staughton, but other colleagues interested in other skin conditions like psoriasis found it important to use psychological approaches, such as stress management, alongside effective biological treatments. In his experience habit reversal can be useful when psoriasis was complicated by habitual scratching, but this was much more commonly an issue with atopic eczema. There were also other skin conditions, such as skin picking and hair-pulling, where habit reversal could be helpful.
Dr Parry asked about any evidence being available regarding the effectiveness of the approach when the self-help book was used on its own. Sue Armstrong-Brown thought this was so far only anecdotal. She suggested to get a good result using her book without any professional support at all would require someone to be very single-minded. Kerry Montgomery said that in the management of anxiety and depression self-help has been found to be effective. She and her colleagues are now planning research to examine the effectiveness of the self-help format for habit reversal for atopic eczema. On-line support has been shown to be effective in mental health. For habit reversal and atopic eczema the website atopicskindisease.com was a great resource. Dr Bridgett said the website was due for a face-lift and that now was an ideal time for suggestions for its improvement. Dr Norén agreed that getting good results using a book without additional support would be difficult. Registration of scratching behaviour was essential, and this required self-discipline - and this was difficult to get from a book. Jill Peters thought whether or not using Sue’s book will be effective for a particular patient may be to do with attitude and motivation. Empowering the patient, getting them to believe they could do it, was a key factor for success. Moreover, the approach combines habit reversal with the use of potent topical steroids, and for this professional input is clearly needed. Dr Bridgett remarked that while expert advice is important, what really mattered is what patients achieve on their own, at home, in-between visits to the clinic. Sue’s self-help book emphasises the importance of topical treatment, is cleverly set out as a series of virtual clinic visits, and emphasises the role of the patient’s family doctor.
Dr Taylor said that combining psychological medicine with optimal dermatological treatment was a fundamental for success in psychodermatology. She was introducing habit reversal for atopic eczema in a new psychodermatogy service in East Kent. As well as learning how to offer habit reversal herself, she was considering involving nursing colleagues, both in dermatology, and in liaison psychiatry - where there has recently been an increase in NHS funding. However establishing what are the essential components of the habit reversal approach was clearly important, and the approach should not be watered down.
Dr Staughton added that before referring a patient to Dr Bridgett he explained that water, as a solvent, is the great enemy of atopic skin. He always demonstrated how to choose and use an emollient as a soap substitute, showing the patient how to always apply their preferred emollient to the skin before any contact with water. He did not start a potent topical steroid then himself, but recommended to Dr Bridgett what to use after the first registration week, starting the potent topical steroid alongside habit reversal.
Dr Norén said also he was certain teaching self assessment, by looking at and feeling the skin, was important. Asking if the skin was red, and was it itchy? Was it dry? Is the skin inflamed? The use of optimal topical treatment alongside habit reversal was important to heal chronic eczema, but when the chronic eczema has been successfully treated habit reversal is no longer required, and the regular use of topical treatment is replaced by regular self assessment, and the use of both emollients and topical steroids intermittently, only as required.
Dr Wakelin said she was inclined to jump straight in with treatment: planning the treatment programme is an issue for her. How many days were needed for registration? If first seen on a Monday, and registration started, could the programme be continued on the following Friday? Dr Bridgett said for him it was important to account for the patients previous consultations, and also how the patient had come to be been referred for habit reversal, as these things could indicate both how to plan treatment and measure prognosis. How long is needed for each stage of the treatment programme can be affected by aspects of the patient, aspects of the practitioner, and of aspects of the setting. Clinical experience will be the guide. The main principles of the approach can be adapted to suit, within reason.
Dr Bridgett then closed the meeting, thanking everyone for coming, and encouraging them to get in touch with him with suggestions for future arrangements.
(Other than presenters, & in order of contribution)
Victoria Hogarth Dermatology Kings College Hospital London
Robert Sarkany Dermatology St Thomas’ Hospital London
Susannah Baron Dermatology St Thomas’ Hospital London
Elizabeth Allen Nursing British Association Skin Camouflage
Maddy Robinson Patient London
Adam Daunton Dermatology Salford
Angelika Razzaque General Practice Primary Care Dermatology Society
Mark Turner Psychology Guy’s Hospital London
Caroline Jee Psychology City University, London
Clare Heath General Practice London
Lotte Bateson Researcher Skin Matters, 2017
Eileen Parry Dermatology Lancashire
Kerry Montgomery Psychology Sheffield
Ruth Taylor Psychiatry Bart’s & Royal London Hospitals, London
Sarah Wakelin Dermatology St Mary’s Hospital, London