The Effects of Psychological Intervention on Atopic Dermatitis

Introduction

Historically, many physicians have considered allergic diseases to be "psychosomatic". Indeed, before the inflammatory basis of allergy was discovered, allergic diseases were among the disorders thought to be of purely psychogenic origin. In 1950, Alexander mentioned atopic dermatitis (AD) and bronchial asthma among the classic psychosomatic disorders. Moreover, recent epidemiological studies have demonstrated a detrimental effect of various psychosocial stresses, such as caregiver stress, certain personality types, poor family relationships, and negative life events, on the symptoms of allergic disease. Interestingly, a retrospective study conducted in Kobe, Japan, found that AD in refugees experiencing severe psychological stress due to a natural disaster, the Great Hanshin-Awaji Earthquake, worsened.

AD is a major public health problem worldwide with a prevalence of 10-20% in children and 1-3% in adults. The prevalence has steadily increased by 2-3 times over the past three decades in industrialized countries. AD is persistent and chronic in nature, and long-term pharmacological therapies have potential side effects. Given the close association of psychosocial factors with allergic disease, one might expect that effective management of AD would involve a multi-faceted approach, including psychological intervention as well as conventional physical therapies such as skin care, identification and elimination of exacerbating factors, and anti-inflammatory medicine.

There has been much discussion about the effectiveness of psychological interventions in the management of AD, but there is little scientific evidence. Therefore, the purpose of this study was to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) on psychological interventions in AD.

‍

Study Methods

Inclusion Criteria

The criteria for inclusion were as follows: (1) random assignment of subjects; (2) AD diagnosed by a physician; (3) appropriate control group (i.e., usual medical care, waiting list, attentive placebo); (4) Full publication in English in a peer-reviewed journal; (5) active treatment that included some psychological/psychosocial components beyond simply providing information (e.g., brief patient education) about the disease; (6) if samples overlapped between articles, the article with the smaller sample size was excluded; (7) if more than one type of intervention was employed in an article, the samples were included separately.

‍

Study Results

The outcome variables and effect sizes are summarized as follows:

Severity of Eczema

All 8 psychological interventions in 7 clinical studies presented eczema severity as an outcome variable. Methods for measuring this severity included the Atopic Dermatitis Severity Index (SCORAD) score in 3/8 studies, a modified SCORAD index in 1/8 studies, an Atopic Dermatitis Assessment Measure (ADAM) in 1/8 studies, and original scoring methods by the authors in 3/8 studies. Of the interventions, 5 (autogenic training, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, behavioral therapy for habit reversal, and structured educational programs) showed a significant reduction in eczema severity, while 3 did not (aromatherapy, brief dynamic psychotherapy, and stress management program).

Itching

Five types of intervention (autogenic training, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, behavioral therapy for habit reversal, and stress management program) in 3 studies assessed the effect on itch intensity. In all cases, itching was measured using a subjective Likert-type scale. Four types of intervention (autogenic training, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, and stress management program) showed a significant decrease in itching, and only 1 did not (behavioral therapy for habit reversal).

Scratching

‍Four types of intervention (autogenic training, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, and behavioral therapy for habit reversal) in 3 studies assessed the effect on scratching intensity and all demonstrated significant improvement.

Psychological Effects

‍A wide range of psychological effects was examined, including anxiety, depression, anger, annoyance, daytime irritation, nighttime disturbances, quality of life, coping skills, and catastrophization and management of itch. Anxiety, depression, anger, and coping skills were assessed using self-administered questionnaires, including the State-Trait Anxiety Inventory (STAI), the Center for Epidemiological Studies Depression Scale (CES-D), the Positive and Negative Affect Scales (PANAS), the Self-Consciousness Scale, the State-Trait Anger Expression Inventory (STAXI), and the Trier Coping Scales. The STAI is a self-administered 40-item questionnaire, divided into 20 items concerning state anxiety and 20 on trait anxiety. "State anxiety" refers to the level of anxiety currently felt, while "trait anxiety" refers to the anxiety generally experienced by the person. The CES-D is a 20-item tool that assesses the level of depressed mood, with higher scores indicating greater depression. The PANAS consists of 20 mood-related adjectives, 10 assessing positive affect and 10 negative affect. The Self-Consciousness Scale includes 22 items designed to help understand how individuals think and feel in social situations. The STAXI measures the experience of anger and the expression of state and trait anger. This scale consists of 44 items that form 6 scales (state anger, trait anger, anger in, anger out, anger control, and anger expression) and 2 subscales (trait of angry temperament and trait of angry reaction). The Trier Coping Scales are a questionnaire with 37 items in 5 dimensions: rumination, seeking information about the illness, seeking social support, minimizing the threat related to the illness, and seeking support in religion. Three types of intervention (behavioral therapy for habit reversal, stress management program, and structured educational programs) had a positive effect on social anxiety, annoyance, quality of life, coping abilities, or catastrophization and management of itch, while others did not significantly improve psychological discomfort.

Therapeutic Behavior

‍Using topical steroids, medical compliance, and treatment cost were examined as outcome variables. Four types of intervention (autogenic training, cognitive-behavioral therapy, dermatological education and cognitive-behavioral therapy, and structured educational programs) significantly reduced the use of topical steroids, and the structured educational programs significantly reduced costs. Behavioral therapy for habit reversal failed to improve medical compliance. Overall, since both psychological effects and treatment behavior were inconsistently assessed as outcome variables, we were unable to evaluate them through meta-analysis.

‍

Conclusion

In conclusion, the current meta-analysis has revealed that psychological intervention has a beneficial effect on AD. However, given some of the limitations mentioned above, this review should be considered as a starting point for future updates. Further research is needed to clarify which psychological interventions (or combinations thereof) are most effective and which specific characteristics of AD patients respond to these interventions, and to examine whether such treatments can reduce reliance on pharmacological therapies.