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Behavioral Strategies to Address AD

In this podcast, Ramiz Hamid, MD, discusses behavioral strategies that help improve adherence and quality of life among patients with atopic dermatitis.

Dr Hamid is a resident physician in the Department of Dermatology at Wake Forest School of Medicine.


Melissa: Hello, everyone. Today, I’ll be speaking with Dr Ramiz Hamid, resident physician in the Department of Dermatology at Wake Forest School of Medicine. We will be discussing different behavioral strategies that can be used to help patients with atopic dermatitis.

Thank you so much for joining us today, Dr Hamid.

Dr Ramiz Hamid: Thanks for having me, Melissa.

Melissa: Let’s get started. Could you discuss the foundations behind different behavioral strategies for addressing atopic dermatitis and why they are important to incorporate in clinical practice?

Dr Hamid: Sure. We know that atopic dermatitis is a highly prevalent disorder, affects up to 20% of kids, 3% of adults. The most troublesome symptom for patients across the board is the itch. Itch is such a horrid sensation that people will do anything for even a moment’s relief. Some patients will just scratch, and scratch, and scratch, until they bleed. Even if they know it’s worsening their disease.

This repetitive scratching really traumatizes the skin and causes more inflammation, which leads to even more itch and pain. This is why eczema’s been called the itch that rashes. Unfortunately, we don’t have a magic pill to cure these patients, so achieving control of atopic dermatitis takes a lot of work.

That’s a really big burden on patients, both financially and emotionally. One of my mentors, Dr Jorizzo likes to say, “You don’t treat eczema with a tube.” If you can’t get patients to buy into the program and overcome the itch‑scratch cycle, no matter how many pounds of triamcinolone you throw at them, it won’t be successful.

Behavioral strategies can act as a supplement to medical therapy. Particularly, in cases where there are pathologic scratching behaviors, adherence issues, or resulting stress or depression that’s associated with the eczema.

Melissa: What strategies are effective for managing itching patients with atopic dermatitis?

Dr Hamid: Different causes of itch call for different forms of management. In atopic dermatitis, the skin barrier is impaired. That leads to increased water loss through the epidermis and dry, scaly skin. This type of skin is easily irritated, and patients can develop chronic inflammation at affected sites that often manifest as itch.

The steps in management of itch are similar for all atopic dermatitis patients, but the strategies really have to be tailored based on their age and each individual patient. Some of the steps that go into this process would be, first of all, identifying and eliminating trigger factors. Soaps, perfumes, cosmetics, certain types of clothing. Some patients are very sensitive to cold, dry air, or certain bacteria. Sometimes anxiety and stress can set off the itch. Really detailed history‑taking and some investigative testing can help illicit these factors.

The second step would be maintaining the skin barrier through emollients. Too often I ask eczema patients what moisturizer they’re using, and the reply that I get is the prescription cream that the doctor gave them. We really need to emphasize moisturization. Ideally, with clear products applied over the top of prescription creams and reapplied several times a day to keep that barrier intact.

Third, targeting inflammation through the use of our medications. Topical medications, sometimes systemic medications, or phototherapy. Adherence to topical medications is terrible, especially when large areas of the body are involved. There’s different strategies for different age groups that can be more effective.

For kids, something as simple as sticker charts to track adherence and a reward system can be a really strong motivator. For adolescence, it’s going to be more difficult. Sometimes, you can use the principle of loss aversion to warn them about potential scarring of their beautiful skin, which might be something that they care about, or tell them which medication’s the most popular with other people their age.

Then providing reminders can be effective for teenagers, but you want to make sure that you don’t cross over to the nagging territory because they’re very resistant to that. For adults, helping them create routines to remember to apply the medications. Like, maybe leaving the creams on top of their shoes so they remember to apply before leaving the house.

The next step would be symptomatic management of the itch with treatments that aren’t those prescription medications. Sometimes topical anesthetics and other cooling agents can be helpful, antihistamines. Then encouraging patients to even just trim their fingernails so when they scratch they’re not causing as much trauma to their skin.

Then addressing the psychological and behavioral components is, of course, important as well. You have to meet the child at their level of development and get involved in their skincare. Address the barriers to adherence, break that itch‑scratch cycle, look for behavioral alternatives to scratching, distraction, or strategies for relaxation, or stress management.

Managing the sleep disruption is also really important and addressing the impact of the atopic dermatitis on their mood and their self‑esteem. Children especially are at increased risk for experiencing or developing behavioral and emotional difficulties, especially the ones with severe disease.

Melissa: Are there any other strategies that are different between counseling patients who are younger versus those who are teenagers or adults?

Dr Hamid: Some of the things that I mentioned, the first important point is to empower patients, even young patients, to be involved in their care. Really put them in charge because, in the end, even if young patients are there with their parents, if the parents are the ones driving the ship in terms of management of the eczema, oftentimes, children can develop resistant behaviors.

It’ll just become a real struggle to even take baths or apply their creams. That can just create a lot of stress in the household and decrease the quality‑of‑life for the patient and the parent.

I think sometimes creating a written action plan for children who are a little older and able to really comprehend and participate in that, with escalation of interventions based on the severity, can be really helpful because then kids will know what to expect.

Melissa: Going back to the last point you mentioned, for atopic dermatitis and the comorbidities such as sleep disturbances, what strategies are effective for managing those?

Dr Hamid: Sleep issues are one of the most common complaints from patients with atopic dermatitis, and their parents as well. The first step is to really achieve better disease control. The disease is less active overall, then patients will have less itch and be able to get better sleep at night. Really encouraging adherence to the topicals, which is sometimes easier said than done.

One strategy may be to let the patient choose the vehicle. These steroid medications come in so many different forms and, oftentimes, the teaching that we receive as resident physicians is that ointments are better than creams because of forming a better barrier and better penetration than medication.

Really, I think that the medication that the patient will use is the one that is best. Whether that’s a gel, or a foam, or a spray, or a solution, letting the patient make that choice and finding one that’s best suited to them can really improve adherence.

Then the other thing, and oftentimes, we’ll give patients a pound of cream, say, “Apply this twice a day through your entire body. We’ll see you back in eight weeks.” That’s so difficult to do. Sometimes shorter treatment intervals with close follow‑up can be a lot more effective.

If you tell a patient, “Apply this for three or four days and then we’ll check in either virtually or we’ll schedule you for a follow‑up appointment and see how things are going,” that shorter time interval can provide patients with more motivation to actually use their cream and see some benefit within even a few days to a week. That can really encourage adherence.

For sleep issues, in particular, the type of medication used before bedtime can be important. Sometimes, patients will apply greasy ointments all over their body, and then they’ll lay in bed feeling so gross and won’t be able to fall asleep because of it. Maybe utilizing a spray or other formulation before bedtime.

Also, forming a sleep routine. For patients, who like to take a bath and apply their cream. Have some kind of routine that helps patients get ready for bed and adjust their mind as well to preparing for sleep. Nighttime antihistamines, there are anti‑itch medications like Doxepin, as needed.

Then just having multidisciplinary care, involving different types of specialists such as allergists, dietitians, psychologists and social workers for a really multifaceted approach to controlling the eczema can also help with sleep issues over time.

Melissa: At what point should a dermatologist consider referring a patient with atopic dermatitis to a cognitive‑behavioral therapist?

Dr Hamid: Multidisciplinary interventions can be helpful for many types of patients, but the ones who have severe enough eczema to be causing significant distress or a decrease in their quality‑of‑life would be the ones where I would seriously consider referring a patient for CBT.

For younger patients, for those who have already developed resistant behaviors associated with application of their medication, such as kicking or screaming when the parents are trying to apply them, or really resisting the moisturizers. Where parents feel like they have to adopt coercive parenting strategies or reduce the frequency of therapy to avoid conflicts. Both of those are counterproductive to successful long‑term management of the disease. It can be damaging to the parent‑child relationship as well. In those situations, it’s really important to get patients to a cognitive behavioral therapist who can sometimes teach them to consciously suppress the reflex to scratch through distraction and have reversal techniques. Also, talk about coping mechanisms and stress reduction.

There haven’t been extensive studies on the efficacy of CBT in this area, but early studies have shown improved treatment satisfaction for patients and maybe some improvements in depression, and sleep problems, and quality‑of‑life as well, so I think it’s a really good option.

Melissa: What important considerations should dermatologists keep in mind when counseling patients on behavioral strategies?

Dr Hamid: The first point is really developing the patient‑physician relationship and fostering some trust. One thing that can help with that is, first of all, just normalizing how difficult it is to deal with the disease and to be consistent with adherence to the topical medications. Just the patient having the understanding that the physician knows how much work that entails can be a really big factor in getting them on board with the treatment plan.

Screening for stress and depression associated with the disease is really important as well because sometimes those things are missed.

Then the strategies when it comes to counseling is, first of all, bringing awareness to itching and scratching, because oftentimes, patients may not even realize that the scratching they’re doing is doing so much damage to their skin.

Then identifying quick relief strategies for when itching and scratching are noticed, distraction, or other things like pinching the skin in the area to provide some pain that distracts you from the itch. Then other strategies to refocus the attention away from the itchy skin. Those would be the initial ways to go.

Melissa: What key takeaways do you want to leave dermatologists with?

Dr Hamid: The important points to keep in mind is, first of all, to understand the burden of the disease and just how committed patients have to be to smear cream all over their body twice a day. As dermatologists, we owe it to them to have that same level of commitment to their care.

Making sure we develop a tailored approach for each patient, and understand the unique stresses that they deal with, and the barriers to adherence for them. As the saying goes, treat the patient, not the disease. Then also, considering behavioral strategies as a supplement to medications, particularly in those patients who have significantly decreased quality‑of‑life. As I mentioned before, screening for stress and depression in patients with severe disease. Those are some of the important takeaways.

For those who have further interest in this topic, I’d recommend a book. It’s called Practical Ways to Improve Adherence by Daniel Lewis and Dr Steve Feldman here at Wake Forest. It has lots of psychological and behavioral strategies to encourage patient adherence. I found it very helpful for my practice.

Melissa: Thank you so much for joining us today, Dr Hamid.

Dr Hamid: Thank you so much for having me.

Melissa: If you have any questions or comments, please submit them in the feedback box below. We really enjoy your feedback. Thank you so much for listening.

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