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Three levels... and three dimensions.
The Combined Approach to atopic eczema combines optimal topical treatment - Level 1: Emollients, and Level 2: Topical Steroids - with Habit Reversal, for habitual scratching, at Level 3.
As well as these three important levels, there are a further three dimensions to consider. The first is Stress, and its management; the second and third relate to Attitudes, of the patient, and of others.
For the practitioner, the relevance of stress in understanding the atopic eczema of a particular patient needs keeping in mind throughout The Combined Approach - from initial assessment to follow-up advice. The referral process to the practitioner may often be related to emotional factors, directly or indirectly. Thus a particularly troublesome period with atopic eczema may be associated with stressful life events. Then an associated increase in habitual scratching can exacerbate and maintain the eczema, regardless of topical treatment, and referral for a novel treatment approach is precipitated. At assessment the relevance of stress as a precipitating factor should always be asked about. During treatment with habit reversal, after two weeks the relationship between stress and habitual scratching may have become especially evident, and stress management tactics can be usefully reviewed. At follow-up, stress as a factor that can precipitate acute relapses needs consideration: at this stage the patient is in control and managing their skin well, and a review of what can be done to keep things that way is particularly useful.
For the patient, the relevance of stress in understanding both acute and chronic eczema varies from person to person. Acute relapse can be triggered by a stressful life event, as it can by exposure to a paticular allergen. Sometimes it seems that both these factors are relevant, and others too - an acute relapse is not due to one factor operating on its own. Chronic eczema is particularly associated with habitual scratching - this is the target phenomenon that habit reversal is aimed at - and a certain proportion of habitual scratching is stress related. Stress related habitual scratching is linked to both personality and circumstantial factors. The Combined Approach to atopic eczema should offer all patients an opportunity for understanding stress and its general management. A few people with atopic eczema also benfit from further specific psychological help. How this can be best arranged should be discussed with a professional. Reading more about stress and its management can be important.
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