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Habit reversal improves skin score by reducing scratching in children with atopic dermatitis
Clinical Question
Does habit reversal training reduce scratching in children with atopic dermatitis?
Bottom line
A previous study showed that habit reversal is effective at reducing scratching and improving outcomes in adults, and this study extends those findings to children. The intervention led to clinically and statistically significant improvements in skin status, which persisted 2 months after the end of the intervention. 1b
Reference
Study design: Randomized controlled trial (single-blinded)
Funding: Self-funded or unfunded
Setting: Population-based
Synopsis
There is a psychological component to itching, and these authors investigated the ability of the habit reversal treatment protocol to reduce scratching in children with atopic dermatitis. This approach helps the patient identify the stimulus that causes the behavior, but then replaces the undesired behavior (scratching) with a more desirable or less harmful behavior (such as pinching or rubbing the skin). In this small study, 39 children (median age of 8 years) with atopic dermatitis were recruited from the community. After a baseline evaluation of the severity of atopic dermatitis using the validated SCORing Atopic Dermatitis (SCORAD) index the kids were randomized to receive habit reversal training or usual care. Children were included in the randomization if they had at least 3 of the following in addition to itch: typical rash distribution, visible eczema, dry skin in the past year, onset before 2 years of age, and a history of asthma and/or hay fever. Children were excluded if they had very mild or very severe disease based on the SCORAD index, signs of infection, or were not between 5 years and 13 years of age. At the first visit, parents were asked to pay attention to when their children were scratching, and which situations seemed to provoke itching and scratching (for example, while using the computer or watching television, or at bedtime). During the second visit all patients were prescribed topical mometasone furoate once daily for 3 weeks. The intervention group also received training in habit reversal from a study nurse, which was repeated during 3 subsequent visits. At each visit the skin was examined by a single dermatologist masked to treatment assignment. The final assessment occurred 8 weeks after the final visit. Although both groups had improvements in their SCORAD assessment, the improvement was larger in the intervention group (32-point vs 20-point improvement at 8 weeks; P < .001).
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
How would this type of training be paid for?
This is interesting and useful. It is known that one activity can substitute for another, already. But the application to atopic eczema as a concept makes total sense. I like the idea. What concerns me is that the process needs to be continuous, for as long as the patient has atopic eczema. A study to that effect would be nice. It would be nice to have this as part of a long-term management programme for patients to confirm its ultimate utility.
A difficult issue if there is poor to zero parent interaction. Single parents a problem
I will pass this study on to parents of the affected four year old. Could there be an overlap between this new information and other skin picking such as trichotillomania I wonder
very short followup
instead of teaching the children to rub their skin,which can also irritate the skin and I have seen them switching to scratching, I teach them to cover the itchy part of skin with a soft tissue and press on the covered area, The softness of the tissue helps to relief the itch to some degree. I also encourage them to carry a small bottle of moisturizing lotion and apply on skin when they feel like scratching, for soothing and distraction. They can apply lotion, cover with tissue and press.