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Figure. Children's Hospital Boston blank eczema action plan (EAP). Each child received a personalized EAP at the baseline visit.

Figure. Children's Hospital Boston blank eczema action plan (EAP). Each child received a personalized EAP at the baseline visit.

Table. Demographics of Study Population
Table. Demographics of Study Population
1.
Krejci-Manwaring J, Tusa MG, Carroll C,  et al.  Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.  J Am Acad Dermatol. 2007;56(2):211-216PubMedArticle
2.
Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma.  Arch Pediatr Adolesc Med. 2002;156(6):562-567PubMedArticle
3.
Lwebuga-Mukasa J, Dunn-Georgiou E. A school-based asthma intervention program in the Buffalo, New York, schools.  J Sch Health. 2002;72(1):27-32PubMedArticle
4.
Ntuen E, Taylor SL, Kinney M, O ’Neill JL, Krowchuk DP, Feldman SR. Physicians' perceptions of an eczema action plan for atopic dermatitis.  J Dermatolog Treat. 2010;21(1):28-33PubMedArticle
5.
Chisolm SS, Taylor SL, Balkrishnan R, Feldman SR. Written action plans: potential for improving outcomes in children with atopic dermatitis.  J Am Acad Dermatol. 2008;59(4):677-683PubMedArticle
6.
Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M.EASI Evaluator Group.  The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis.  Exp Dermatol. 2001;10(1):11-18PubMedArticle
Research Letter
Mar 2012

Parental Response to Written Eczema Action Plans in Children With Eczema

Author Affiliations

Author Affiliations: Harvard Medical School (Ms Rork) and Children's Hospital Boston, Harvard Medical School (Drs Sheehan, Gaffin, Schneider, and Phipatanakul and Ms Timmons); and Seattle Children's Hospital, Seattle, Washington (Dr Sidbury).

Arch Dermatol. 2012;148(3):391-392. doi:10.1001/archdermatol.2011.2267

The treatment of eczema in the pediatric population can be a complex and dynamic process. A typical care plan may include over-the-counter and prescription topical agents, oral medications, as well as bathing and dietary recommendations. Inevitable disease fluctuations demand treatment modification, and thus parental and patient confusion can easily occur. Not surprisingly, adherence in eczema management is poor and has been reported to be as low as 32% with simple regimens.1

Similar to eczema, asthma is a fluctuating disease with evolving treatment plans. To address this, written asthma action plans provide an educational framework for disease self-management and are effective at improving adherence and decreasing exacerbations.2,3 Previous studies have suggested that an individualized written eczema action plan (EAP) has the potential to serve as a specific treatment guideline that addresses each patient's fluctuating treatment regimen.4,5 In this quality-improvement study, we hypothesize that EAPs would be well received by parents and would improve their treatment confidence, particularly when managing eczema flares.

Methods

During clinic appointments at our tertiary allergy program, children with eczema treatment regimens requiring multiple topical and/or oral medications were approached by their providers to participate in the study and were given an individualized EAP (Figure) similar to a previously published eczema action plan.5 Parents completed a baseline survey addressing parents' perceived severity of their child's eczema, treatment comfort level, and whether they had previously received a written eczema care plan. Parents were contacted via telephone between 3 and 12 months later to complete a follow-up survey regarding the severity of their child's eczema and the utility of the EAP, specifically if it clarified which medications to use during an eczema flare. This study was approved by the Children's Hospital, Boston investigational review board (committee on clinical investigation). Descriptive statistics were used to explore the characteristics of the study population, and statistical significance was determined by the McNemar test for paired data.

Results

Thirty-five children with a diagnosis of eczema were included in the study; all 35 (100%) completed baseline and follow-up surveys. The subjects' ages ranged from 4 months to 17 years; 63% (22 of 35) were boys (Table).

At baseline, 80% of parents (28 of 35) reported having never received a written, individualized eczema care plan. Of the 35 subjects, 51% of parents (18 of 35) self-rated their child's skin as severe, and 46% (16 of 35) as moderate. All subjects completed a follow-up survey via telephone between 3 and 12 months after the clinic encounter (median follow-up time, 3.9 months). At the time of follow-up, 80% of the parents (28 of 35) rated their child's eczema on a lower severity scale: 57% mild (20 of 35); 40% moderate (14 of 35); and 3% severe (1 of 35). Parental comfort level of skin care improved from a baseline 57% (20 of 35) to 86% (30 of 35) after receiving the EAP (P  =  .02).

Survey questions specifically addressing the EAP revealed that 80% of parents (28 of 35) reported currently having the EAP. Parents found the EAP helpful 86% of the time (30 of 35), and 86% (30 of 35) believed it was helpful in clarifying which medications to use when their children had an exacerbation. Of children whose eczema improved in severity, 68% of parents (19 of 28) attributed the EAP as a contributing factor.

Comment

The results of this study add to the growing body of literature supporting the use of action plans in eczema management. Parents overwhelmingly reported that the EAP was helpful and thought it clarified which medications to use during a flare (86%; 30 of 35). While this study design cannot establish whether the EAP directly contributed to improving eczema, we note that 68% of parents whose child's eczema improved attributed the EAP as a contributing factor (19 of 28).

Limitations to the study include small population size, sampling bias, and that self-report is not a validated measuring instrument. It would be crucial for future studies to evaluate a larger and more clinically diverse group of children not limited to children with treatment regimens requiring multiple medications. A randomized-controlled study with objective measurement of eczema at baseline and follow-up by using a score system such as the Eczema Area and Severity Index (EASI) would further clarify the effectiveness of EAPs in treating eczema.6

In conclusion, our study provides preliminary evidence that EAPs may have clinical utility in managing eczema in the pediatric population. Simple organization helps clarify medications for parents and improves confidence when treating their children.

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Article Information

Correspondence: Dr Phipatanakul, Children's Hospital Boston, Harvard Medical School, Fegan 6, 300 Longwood Ave, Boston, MA 02115 (Wanda.Phipatanakul@childrens.harvard.edu).

Accepted for Publication: October 8, 2011.

Author Contributions: Ms Rork and Dr Sheehan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Sheehan, Timmons, Schneider, and Phipatanakul. Acquisition of data: Rork, Sheehan, Timmons, Schneider, and Phipatanakul. Analysis and interpretation of data: Rork, Sheehan, Gaffin, Sidbury, and Phipatanakul. Drafting of the manuscript: Rork, Sheehan, and Phipatanakul. Critical revision of the manuscript for important intellectual content: Rork, Sheehan, Gaffin, Timmons, Sidbury, Schneider, and Phipatanakul. Statistical analysis: Sheehan and Gaffin. Administrative, technical, and material support: Rork, Sheehan, Timmons, Sidbury, Schneider, and Phipatanakul. Study supervision: Sheehan and Phipatanakul.

Financial Disclosure: Dr Schneider receives research funding from Astellas Pharma US Inc. Dr Phipatanakul receives research grants from Astra Zeneca. Dr Sidbury is involved in a multicenter trial sponsored by Pierre Fabre.

Funding/Support: The study not funded by outside sources, but Dr Phipatanakul receives research support from the National Institutes of Health, grants R01 AI 073964 and R01 AI 073964-02s1.

References
1.
Krejci-Manwaring J, Tusa MG, Carroll C,  et al.  Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis.  J Am Acad Dermatol. 2007;56(2):211-216PubMedArticle
2.
Finkelstein JA, Lozano P, Farber HJ, Miroshnik I, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma.  Arch Pediatr Adolesc Med. 2002;156(6):562-567PubMedArticle
3.
Lwebuga-Mukasa J, Dunn-Georgiou E. A school-based asthma intervention program in the Buffalo, New York, schools.  J Sch Health. 2002;72(1):27-32PubMedArticle
4.
Ntuen E, Taylor SL, Kinney M, O ’Neill JL, Krowchuk DP, Feldman SR. Physicians' perceptions of an eczema action plan for atopic dermatitis.  J Dermatolog Treat. 2010;21(1):28-33PubMedArticle
5.
Chisolm SS, Taylor SL, Balkrishnan R, Feldman SR. Written action plans: potential for improving outcomes in children with atopic dermatitis.  J Am Acad Dermatol. 2008;59(4):677-683PubMedArticle
6.
Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M.EASI Evaluator Group.  The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis.  Exp Dermatol. 2001;10(1):11-18PubMedArticle
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