It has been postulated that scratching becomes a habit in atopic eczema, and that it is detrimental because it damages the skin further. Habit-reversal is a modified behavioural technique which teaches patients to recognise the habit and then to progressively train them to develop a "competing response practice" such as simply touching, squeezing or tapping the itching area or to develop other ways of moving their hands away from the itching area.37 The technique has been described in two RCTs38,39 conducted by the same team from Sweden and compared against topical cortiscosteroids. A further RCT evaluated the potential benefit of three psychological approaches versus dermatological education in the prevention of relapse in atopic eczema.40
In the first habit-reversal study,3817 patients with atopic eczema aged 19-41 years were randomised into two groups. The interventions consisted of hydrocortisone cream plus two sessions of habit-reversal treatment, received during week 1, (active-treatment group) or hydrocortisone cream alone (comparator group). The study was unblinded and of 28 days duration. At the end of the assessment period the mean reduction in global eczema score was 67% in the active-treatment group compared with 37% in the comparator group (P<0-05). Total score of self-assessed annoyance was also markedly reduced in the active versus comparator groups. Mean percentage reduction of scratching episodes per day was 79% in the active-treatment group compared with 49% in the comparator group (P<0-01).
In the later study conducted by the same team39 45 patients were randomised to four groups for a period of 5 weeks. One group applied hydrocortisone cream for the entire 5-week period, another group applied betamethasone valerate (a strong topical steroid) for 3 weeks followed by hydrocortisone for the remaining 2 weeks. Another group applied hydrocortisone plus habit-reversal for the 5-week period and another group, betamethasone plus habit-reversal for the first 3 weeks followed by hydrocortisone plus habit-reversal for the remaining 2 weeks. The study was unblinded. Significant differences were reported between the behavioural-therapy groups and those taking steroids alone for total skin status. Scratching was reduced by 65% in the hydrocortisone-only group, 74% in the betamethasone followed by hydrocortisone group, 88% in the hydrocortisone plus habit-reversal group, and 90% in the betamethasone plus hydrocortisone plus habit-reversal group.
The study by Ehlers and colleagues in 199540 evaluated the use of an autogenic training programme (ATP) as a form of relaxation therapy versus a cognitive-behavioural treatment (BT), versus a standard dermatological educational programme (DE) versus combined DE and BT
(DEBT). A total of 113 secondary-care patients were randomised to these four groups and were also compared with an additional standard medical treatment group who were not part of the random assignment. Investigators were blinded to the group allocation. The intervention was for 3 months and patients were followed up for 1 year. At the end of 1 year, mean skin severity lesion score dropped from 29-5 to 28-8 in the DE group, from 33-7 to 19-8 in the ATP group, from 31-0 to 20-7 in the BT group and from 35-4 to 25-8 in the DEBT group. There were no significant differences in mean severity of itching between the four groups. The DEBT treatment led to significantly greater improvement in global skin severity than intensive education (DE) alone and this was also accompanied by significant reductions in topical steroid use.
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