Dermatology nursing research and the involvement of nurses in evidence-based care for their patients have been transformed over the last decade. Back in the late 1990s, dermatology nursing research was sparse and the focus of dermatology nursing research was driven by a national U.K. project summarizing dermatological nursing literature (Ersser, 1998). Nurses are now actively becoming involved in dermatological research around the United Kingdom, working either collaboratively or independently (Lawton, 2006). This article will summarize the current evidence base and resources available for nurses caring for children and their families with atopic eczema.
Atopic eczema is the commonest inflammatory skin disease of childhood, affecting 15%-20% of children in the United Kingdom at any one time. The epidemic of eczema seems to be leveling or decreasing in some countries with previously high prevalence rates such as the United Kingdom. The picture elsewhere is mixed with many developing countries formerly with low prevalence experiencing substantial increases, especially in the younger age groups (Williams et al., 2008).
Eczema Care in the United Kingdom
In the United Kingdom, eczema accounts for 30% of dermatological consultations in general practice and 10%-20% of all referrals to dermatologists (Cork et al., 2003; Hoare et al., 2000). In the U.K. healthcare system, children and their families receive care from a variety of settings (home, local healthcare services [doctors, health visitors, practice nurses, school nurses, and pharmacists], and specialist eczema teams [nurses and doctors]). This often results in a minefield of confusion and misinformation for these children and their families.
Although a common condition, it is still often seen as trivial and unimportant to many. This is far from the truth with the impact eczema can have on the quality of life for the child and his or her family. The extreme itch associated with eczema usually results in sleep disturbance and leads to irritable behavior and reduction in concentration at school. A study by Beattie and Lewis-Jones (2006) showed that skin diseases such as atopic eczema, although not life-shortening in the way that serious conditions such as cystic fibrosis are, caused children as much or more distress in their everyday life. Parents reported that the impact on the children's quality of life of chronic skin diseases, such as eczema, equated to that of other chronic diseases, for example, epilepsy and asthma, although the long-term implications of skin diseases may be less severe.
Such disability also imposes a significant economic burden. This is reflected in direct medical costs associated with the use of health service, direct cost to the families, indirect costs associated with loss of productivity, and intangible costs associated with the psychological effects of the disease (Emerson et al., 2001). A study in the United States, which focused on all types of eczema and spanned all ages, also showed that the annual cost of eczema was similar to those of other diseases such as emphysema, psoriasis, and epilepsy (Ellis et al., 2002).
DERMATOLOGY NURSING EVIDENCE
Within dermatology nursing, there have been few formal studies looking specifically at nursing interventions in the management of chronic conditions such as atopic eczema in children. Chinn et al. (2002) looked at the impact a dermatology nurse in primary care (community setting) had on the quality of life of children with atopic eczema. This study randomized controlled trial (RCT) was undertaken over 1 year and looked at a variety of quality of life indices. It showed marginal improvements in scores as most children seen had milder disease that had less impact on their quality of life. Other outcome measures, such as disease severity, medication use, and patient satisfaction, might have been appropriate for this study, and further recommendations were made in relation to sample size and these additional outcome measures.
Cork et al. (2003) undertook a study to determine the effect of education and demonstration of topical therapies by specialist dermatology nurses on therapy utilization and severity of atopic eczema. Children (n = 51) attending a children's dermatology clinic (hospital based) were followed up for 1 year, and at each visit, the parent's knowledge about atopic eczema, treatment, and therapy use was recorded. The severity of the eczema and parental assessment of itch, sleep disturbance, and irritability were recorded. At the first visit, the nurse explained and showed how to use all the topical therapies. This was then repeated at subsequent visits, depending on the knowledge of the parent. There was an 89% reduction in disease severity, an 800% increase in the use of emollients, and no overall increase in the use of topical steroids. This study showed that the most important interventions in the management of atopic eczema are to spend time to listen and explain its causes and to demonstrate how to apply topical therapies and use adequate amounts (emollients and topical steroids).
What parents want and an important consideration when providing care is access to good quality, relevant information on the seriousness of atopic eczema, the problems that are likely to occur during the illness, and how these may affect the child and his or her family's everyday life (Lawton et al., 2005; National Institute for Health and Clinical Excellence (NICE), 2007; Table 1).
More recently, a study (RCT) compared the level of care by nurse practitioners with that of dermatologists in children with eczema. The level of care provided by a nurse practitioner in terms of the improvement in the eczema severity and the quality of life outcomes were compared with that provided by a dermatologist, and the parents were more satisfied with the care that was provided by the nurse (Schuttelaar et al., 2009). Similar findings were also found in a study (RCT) specifically looking at adult patients, which showed that dermatology nurses can add to a dermatology consultation and provide effective patient education and support in managing a skin condition (Gradwell et al., 2002).
The most effective way to manage atopic eczema is to provide adequate time for education and demonstration of treatments, which can be achieved through nurse-led clinics, which will impact on and reduce the severity of eczema in children (Moore et al., 2006). This nurse-led care, however, should not be viewed in isolation; to achieve the best for our patients, it requires a multidisciplinary approach. To achieve this, our interventions and treatment decisions should be based on available evidence. The next section of this article will show the resources to which nurses commonly refer to obtain that evidence and Table 2 shows some key areas that have influenced my clinical practice.
ECZEMA RESEARCH RESOURCES
The Centre of Evidence-Based Dermatology
The Centre of Evidence-Based Dermatology (CEBD) is based in Nottingham; the United Kingdom has an international reputation for skin research and evidence-based practice. It is the editorial base for the Cochrane Skin Group and the coordinating center for the U.K. Dermatology Clinical Trials Network (UK DCTN) and National Health Service (NHS) Evidence - Skin Disorders. The research strategy of the CEBD is based on the concept of three interdependent research cogs:
* Systematic reviews are used to review the existing evidence and to generate research questions.
* UK DCTN and other noncommercial clinical trials are used.
* The resulting guidance and evidence base is then disseminated through NHS Evidence - Skin Disorders and through patient support groups.
The Cochrane Skin Group is a network of people from all over the world committed to producing and updating systematic reviews of trials relating to skin conditions. The editorial base of the Cochrane Skin Group is located at the CEBD at Nottingham, where its output regularly informs other strands of work such as the need for new trials and the best design of new trials. The scope of the group is wide and includes any skin problem that leads an individual to seek help from a healthcare provider. The group also considers evidence about skin treatments that are sold over the counter or are widely available.
The UK DCTN is a dermatology clinical trials network open to anyone with an interest in applied dermatological research (membership is free). The network was developed in 2002 by Professor Hywel Williams and a group of academic and clinical colleagues in response to the growing need for high-quality evidence to inform dermatology clinical practice. The UK DCTN has now developed into a collaborative, national network of dermatologists, nurses, health service researchers, and patient representatives. The aim of the network is to conduct independent, high-quality, randomized, controlled multicenter clinical trials for the treatment or prevention of skin disease. Priority is given to trials that address questions of importance to clinicians, patients, and the NHS. The UK DCTN is a registered charity with the main infrastructure being coordinated from CEBD. All trial suggestions are submitted by the network members and then put through a predefined trial development process, and a crucial role of the coordinating center is to support this process. Funding for individual trials then comes from National Institute for Health Research (NIHR) funding streams and partner bodies including medical research charities.
National Health Service Evidence - Skin Disorders, formerly the NLH Skin Disorders Specialist Library, is intended to be a one-stop shop for quality, evidence-based information on skin disorders and their treatment for NHS health professionals. It brings together all the relevant U.K. guidelines, systematic reviews, policy documents, and other relevant information resources in an organized, easily accessible, and up-to-date electronic collection. NHS Evidence - Skin Disorders is 1 of 33 specialist collections funded by NHS Evidence, part of the NICE. As well as maintaining the main collection, an important part of the work of NHS Evidence - Skin Disorders is the annual evidence updates (Batchelor & Williams, 2009), annual searches for new evidence in the form of guidelines, and systematic reviews published over the last year on a given disease topic:
* Williams, H. C., & Grindlay, D. J. (2010). What's new in atopic eczema? An analysis of systematic reviews published in 2007 and 2008: Part 1. Definitions, causes and consequences of eczema. Clinical and Experimental Dermatology, 35(1), 12-15.
* Williams, H. C., & Grindlay, D. J. (2010). What's new in atopic eczema? An analysis of systematic reviews published in 2007 and 2008: Part 2. Disease prevention and treatment. Clinical and Experimental Dermatology, 35(3), 223-227.
* Williams, H. C., & Grindlay, D. J. (2008). What's new in atopic eczema? An analysis of the clinical significance of systematic reviews on atopic eczema published in 2006 and 2007. Clinical and Experimental Dermatology, 33(6), 685-688.
NHS Evidence - Skin Disorders fits in with the other "cogs" of the CEBD as a means of disseminating systematic reviews and other researches carried out by the center, in particular, through the monthly e-mail updates sent out to over 600 dermatology health professionals. It also acts as an information resource to support the CEBD activities. From Spring 2011 this will be known as NHS Evidence and the specialist Skin Disorders resource will be available form there: http://www.evidence.nhs.uk/aboutus/Pages/AboutSpecialistCollections.aspx.
NICE produces four types of guidance and referral advice:
1. technology appraisals that provide guidance on the use of new or existing medicines and treatments within the NHS in England and Wales; currently, there are two completed appraisals for atopic eczema:
* atopic dermatitis (eczema) - topical steroids (No. 81; http://www.nice.org.uk/guidance/TA81) and
* atopic dermatitis (eczema) - pimecrolimus and tacrolimus (No. 82; http://guidance.nice.org.uk/TA82);
2. clinical guidelines on the appropriate treatment and care of people with specific diseases and conditions within the NHS in England and Wales: management of atopic eczema in children from birth up to the age of 12 years (http://www.nice.org.uk/guidance/);
3. guidance on whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use;
4. referral advice for conditions such as atopic eczema, acne, and psoriasis.
The NHS Clinical Knowledge Summaries are a reliable source of evidence-based information and practical "know how" about the common conditions managed in primary (community) care. It has primarily been designed for use by patients and primary healthcare professionals and to support nonmedical prescribers.
National Institute for Health Research (NIHR) (http://www.nihr.ac.uk/)
The Health Technology Assessment program is part of the NIHR. It produces independent research information about the effectiveness, costs, and broader impact of healthcare treatments and tests for those who plan, provide, or receive care in the NHS:
* Hoare, C., Li Wan Po, A., & Williams, H. C. (2000). Systematic review of treatments for atopic eczema. Health Technology Assessment, 4(37), 1-191. http://www.hta.ac.uk/execsumm/summ437.shtml
Current research supported by the Health Technology Assessment/NIHR are as follows:
* Softened Water Eczema Trial (http://www.swet-trial.co.uk/), a clinical trial to see if water softeners help children with eczema, showed no benefit from using a water softener for the treatment of childhood eczema.
* SPRUSD (Setting Priorities and Reducing Uncertainties for People With Skin Disease).
The CEBD has received funding from the NIHR for 5 years to conduct research into several skin diseases, including eczema:
* The previous systematic review of clinical trials (Hoare et al., 2000), which covers all treatments for atopic eczema, has been updated. The Global Resource of Eczema Trials (GREAT) database holds records, including the full citation, for all randomised controlled trials on eczema treatment from the year 2000 and will be regularly updated. The database can be accessed free of charge at http://www.greatdatabase.org.uk.
* A James Lind Alliance (http://www.lindalliance.org) prioritization exercise for eczema treatment, which aims to collect as many of the unanswered questions about the treatment of eczema as possible from patients, consumers, clinicians, health professionals, and carers, is to be done. These unanswered questions will be prioritized by representatives from all the interested parties to produce a list of the top 10 unanswered questions about eczema treatment. This will then help to direct future eczema research.
* Patient decision aids should be developed. These can help a patient and clinician (such as a dermatologist) come to a difficult treatment decision based on the current evidence about each treatment option. Plain language summaries of systematic reviews of eczema treatment and prevention will also be written to make them as widely accessible as possible.
* The Barrier Enhancement for Eczema Prevention research study is looking at whether emollients used from birth can prevent or delay the onset of eczema in high-risk babies (http://www.beepstudy.org).
For more information, e-mail email@example.com.
* British Association of Dermatologists: http://www.bad.org.uk
* British Dermatological Nursing Group: http://www.bdng.org.uk
* The International Study of Asthma and Allergies in Childhood: http://www.isaac.auckland.ac.nz/
* National Eczema Society: http://www.eczema.org/
* Nottingham Support Group for Carers of Children With Eczema: http://www.nottinghameczema.org.uk/
I hope this article has illustrated the importance of evidence-based care and the role it has in clinical practice. Applying this to clinical practice influenced the attached record (Appendix B), which provides the team with a comprehensive record that the parents complete prior to their consultation with the eczema team, either a nurse or dermatologist. This has been developed for a number of years, forms part of their medical record, and has been influenced by several factors, evidence-based care, clinical experience, and the views of parents accessing the service in Nottingham.
I count myself extremely fortunate to have worked with my clinical colleagues and the team from the CEBD over a number of years and would like to acknowledge them in the writing of this article: Professor Hywel Williams, Douglas Grindlay, Helen Nankervis, Carron Layfield, Joanne Chalmers, and Kim Thomas.
Beattie, P. E. & Lewis-Jones, M. S. (2006). A comparative study of impairment of quality of life in children with skin disease and children with other chronic childhood diseases. British Journal of Dermatology
Chinn, D. J., Poyner, T., & Sibley, G. (2002). Randomized controlled trial of a single dermatology nurse consultation in primary care on the quality of life of children with atopic eczema. British Journal of Dermatology
Cork, M. J., Britton, J., Butler, L., Young, S., Murphy, R., & Keohane, S. G. (2003). Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse. British Journal of Dermatology
Ellis, C. N., Drake, L. A., Prendergast, M. M., Abramovits, W., Boguniewicz, M., Daniel, C. R., et al. (2002). Cost of atopic dermatitis and eczema in the United States. Journal of American Academy of Dermatology
Emerson, R. M., Williams, H. C., & Allen, B. R. (2001). What is the cost of atopic dermatitis in preschool children? British Journal of Dermatology
Ersser, S. (Ed.) (1998). Annotated bibliography of the dermatological nursing literature
. Oxford, United Kingdom: Oxford Brookes University.
Gradwell, C., Thomas, K. S., English, J. S., & Williams, H. C. (2002). A randomized controlled trial of nurse follow-up clinics: Do they help patients and do they free up consultants' time? British Journal of Dermatology
Hoare, C., Li Wan Po, A., & Williams, H. C. (2000). Systematic review of treatments for atopic eczema. Health Technology Assessment
Lawton, S., Roberts, A., & Gibb, C. (2005). Supporting the parents of children with atopic eczema. British Journal of Nursing
Lawton, S. (2006). Evidence-based care-atopic eczema. British Journal of Dermatology Nursing, 10
Moore, E., Williams, A., Manias, E., & Varigos, G. (2006). Nurse-led clinics reduce severity of childhood atopic eczema: A review of the literature. British Journal of Dermatology
National Institute for Health and Clinical Excellence. (2007). Atopic eczema in children: Management of atopic eczema in children from birth up to the age of 12 years. London: NICE: http://www.nice.org.uk/CG057
Schuttelaar, M. L. A., Vermeulen, K. M., Drukker, N., & Coenraads, P. J. (2009). A randomized controlled trial in children with eczema: Nurse practitioner vs. dermatologist. British Journal of Dermatology
Williams, H., Stewart, A., von Mutius, E., Cookson, B., Anderson, H. R., & the International Study of Asthma and Allergies in Childhood (ISAAC) Phase One and Three Study Groups. (2008). Is eczema really on the increase worldwide? Journal Allergy and Clinical Immunology
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