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.
Three Levels of Treatment
In the manual ‘Atopic Skin Disease’, three levels of treatment are stated, namely:
1. Emollient Therapy
3. Habit reversal
It is advised in your manual that steroid should not be used without follow-up moisturizer but moisturizer can be without steroid application. In the course of recovery, level 3 can be stopped first, followed by 2 and 1. We’ve covered the basics of all three levels in previous posts. There are some further dimensions in the management of eczema as follow:
1. Stress – Stress is one of the possible triggers for eczema. Can you help a parent to identify when a child is stressed and how to see if the child is stressed because of the eczema or because of something else? How can a parent help a child to relax?
Stress can cause emotional upset – unhappiness and apprehensiveness for example – in anyone, young or old. In a child this may include tearfulness, and avoidance behaviour, just as in an adult. Certainly having eczema itself is stressful, for both the child and the parents. Careful observation may clarify if something else is the source of stress: stress comes from common causes, even for the youngest child, and family upsets may be especially important to think about. If there are no other causes and the eczema is troublesome, then adequate treatment of the eczema will be stress relieving – for everyone.
Helping a child to relax usually involves simple acts – giving attention, and comfort, with suitable play, and amusing distraction. Reading a favourite story is a tried and tested bedtime means of inducing relaxation and sleep. But when a child is stressed, enabling relaxation is more difficult, especially if the causes of stress are not identified and dealt with.
2. Attitudes – Positive attitudes are suggested in your manual, such as ‘Manage, Don’t be Managed’ and to be careful so the doctor/nurse does not to ‘spread’ helplessness during a consultation. Should a patient comes across a doctor who is passive about managing the eczema, what can he/she do to change the doctor’s attitude? (Obviously, the other choice is simply switch doctor! But as a service to other patients, someone ought to say something!)
I find myself saying something about this all the time! Of course the responsibility for a successful visit to a doctor rests with all those involved. Each person should consider first what they themselves can do, rather than seeing any problem as caused by someone else. Some really useful ideas about this were covered when Jennifer talked to me: see http://atopicskindisease.com/articles/20111216 This might make a good topic for people reading this post to comment on here: I suggest your readers share their thoughts and experiences with you.
At some health centres and doctors surgeries there are patient discussion groups to allow people to share ideas on how things can be improved. Has anyone had experience of such a group? Does your doctor ever conduct a patient satisfaction survey?
Review of Habit Reversal
In The Combined Approach, follow-up visits include asking the patient or parent their (i) scratching frequency (ii) when there’s most scratching (iii) % of scratching from itch (iv) severity of eczema (v) % new eczema vs old and (vi) where most eczema. If a parent cannot find a doctor or convince their current doctor to implement the Combined Approach, can the parents implement this on their own without a doctor doing the follow-up (i.e. monitoring scratching on their own)?
The questions that you detail are in the first stages of The Combined Approach, during the first 4 to 6 weeks when habit reversal is important. The later part of the programme we call follow-up, and then vigilance for acute flare-up is the important emphasis, with early and energetic treatment with topical treatment being the order of the day. Habit reversal is not important long term. It is optimal topical treatment that is essential to maintain the progress that The Combined Approach achieves.
How to use The Combined Approach depends on the resources available. The clinic-based format is very effective, but if it is not feasible a self-help format is a good alternative, as discussed at http://atopicskindisease.com/categories/20110423_18 (joining is necessary to read this, but joining www.AtopicSkinDisease.com is still free!).
Hopefully blogs like this, and websites like www.AtopicSkinDisease.com will now gradually help everyone everywhere to discover how to treat atopic eczema successfully. There is no need now for anyone to necessarilyLive With Eczema: there is now a possibility to learn how to Live Without Eczema.
MarcieMom: Thank you Dr Christopher Bridgett for taking time to explain The Combined Approach. I’m certainly very glad to collaborate on this series with you. Should there be more questions from parents, I’d certainly invite you for another Friday Doctor Q&A!