This is a 4 post series centered on ‘The Combined Approach’ that is explained in the ‘Atopic Skin Disease’, a manual for practitioners authored by Christopher Bridgett, Peter Noren and Richard Staughton (copy of book viewable by joining here). The Combined Approach uses habit reversal to stop habitual scratching in atopic eczema. Dr Christopher Bridgett has previously helped in Friday Doctor Q&A from November 2011 to February 2012 and MarcieMom has invited him to share more about the Combined Approach.
Why is it a Combined Approach?
The Combined Approach is about using conventional topical treatment (steroids and moisturizers) together with the elimination of self-damaging behavior using habit reversal techniques. ‘Atopic Skin Disease’ was published in 1996 as there was much success using The Combined Approach, which was reported at the European Congresses on Dermatology and Psychiatry in 1991 and 1995.
MarcieMom: Dr Bridgett, can you briefly explain the difference between The Combined Approach versus an eczema patient using his/her own ways to divert attention from scratching? Also, if an eczema patient or parent of eczema child comes to know of your approach, can he/she simply pass your manual to a dermatologist that he/she is seeing?
Dr Bridgett: The Combined Approach is an exercise in behavioral medicine, and has two elements combined:
1. Optimized conventional treatment (emollients and topical steroids usually) : this is an important part of the approach, and cannot be overlooked!
2. Habit reversal: a formal behaviour modification technique: it requires, when offered to Adults and Older Children, first a period of registration using a hand tally counter – this is continued, as habit reversal is introduced. The inventiveness of the eczema patient is very useful in introducing new successful habit reversal behaviours, but some structure, discipline and supervision is linked to the success reported by many patients, and this requires reference to written material, and is often usefully supported by contact with others.
The manual is available for anyone to consult and follow if they wish, and both nurse practitioners and medical practitioners are successfully using The Combined Approach. An important alternative is to use the self help format set out in the book The Eczema Solution by Sue Armstrong-Brown.
When is Habit Reversal Most Effective?
The main idea is that scratching can often become a habit – that is, the adult or child with eczema then scratches not only because of itch. It is mentioned that adults with severe eczema can benefit most from The Combined Approach. Why is this so? Can you share with us pictures of before and after eczema and what was the habit that was eliminated that led to an improvement?
Dr Bridgett: Habit reversal is most effective
- in combination with optimized conventional treatment, and
- when there is evidence of chronic eczema – in adults or children – that is to say, the thickened skin called lichenification, which is due to regular rubbing and scratching that has become a habit, complicating atopic eczema. Any rubbing and scratching of the skin can become a habit, but each person can have their own particular problem.
In the first pictures below the patient was habitually picking the skin of her forehead when watching TV, resulting in chronic eczema. When habit reversal was added to optimized topical treatment the skin healed very quickly.
In the next pictures, the patient had developed a habit of using the rivets on her jeans to scratch against:
Not Neglecting Topical Treatment
I note that The Combined Approach does start with understanding and explaining the importance of topical treatment, as eliminating scratching is not a stand-alone treatment. Would explaining the structure of the skin and how a weak skin barrier is prone to water loss be important in the first visit? If yes, could you do a quick introduction for our parents to understand?
Dr Bridgett: Yes, The Combined Approach always covers the importance of skin as a barrier, and the importance of optimal topical treatment.
The skin has two layers, epidermis and dermis. The outer epidermis, which carefully replaces itself every four weeks, is important in preventing water getting out from inside, and irritation and infection getting in from outside.
Acute eczema involves inflammation of the epidermis. It’s structure then becomes weakened, allowing excessive water to escape. Extra moisturizers are then needed to stop excessive water loss, and anti-inflammatory topical steroids are also needed. And that’s not the whole story: the inflammation releases itchy substances that cause scratching – and this scratching stimulates over-activity of the epidermal cells. If the emollients and topical steroids are used correctly the situation quickly returns to normal. If not, the scratching continues, becomes a habit and the damaged and sensitive skin of chronic eczema is the result.
For more on skin structure, acute and chronic eczema see http://atopicskindisease.com/articles/FF3
MarcieMom: Thank you Dr Christopher Bridgett for giving us an understanding of the Combined Approach and showed us some of the successful cases. In our next post, we will understand more on the use of moisturizers and steroids as explained in the manual ‘Atopic Skin Disease’.