Abstract
Background
Daily skin care using appropriate detergents and moisturizers is essential in the management of pediatric atopic dermatitis (AD). Despite guideline recommendations, real-life adherence and caregiver practices vary widely. Therapeutic education is considered a key tool to improve awareness and optimize disease management. The aim of this study is to evaluate the use of detergents, moisturizers, and the experience with therapeutic education among a large cohort of Italian children with AD.
Methods
An observational multicenter study was conducted on 529 pediatric patients aged ≤ 18 year with a physician-confirmed diagnosis of AD, who were evaluated between June 2020 and December 2021 across seven specialized centers in Italy. Clinical and demographic data was collected through physician interviews. Patients’ skin care routines, including cleansing practices and moisturizer use, were analyzed alongside reported therapeutic education experiences. Categorical variables were analyzed using the chi-squared test or Fisher’s exact test; continuous variables were compared using Student’s t-test or the Wilcoxon-Mann-Whitney test, depending on distribution. Normality was assessed with the Kolmogorov-Smirnov test. Statistical significance was set at p-value ≤ 0.05.
Results
Overall, 73.9% of patients used lukewarm water for bathing and 74.4% dried their skin by tamponing. Specific detergents were used by 56.0% of participants, most commonly during both flare-ups and remission. A moderate correlation was found between detergent use (ml/week) and body surface area (BSA) (r = 0.300, p-value < 0.0001). Specific moisturizers were used by 65.4% of patients; 73.0% applied them in both acute and remission phases, mainly after bathing. No significant correlation was found between moisturizer volume and BSA (r = 0.087, p-value = 0.085). Therapeutic education was received by 69.0% of families, mainly through physician counseling. Educational exposure was significantly associated with better adherence to recommended practices, including higher usage of specific detergents and moisturizers, more appropriate bathing techniques, and broader product application. Families who received physician-led education also reported significantly greater confidence (p-value < 0.0001) and satisfaction (p-value = 0.007) in managing AD care.
Conclusions
This study highlights significant variability in general washing and moisturizing practices among Italian pediatric AD patients and underlines the potential key role of therapeutic education in improving adherence to skin care, along with greater caregiver confidence and satisfaction. These findings support the implementation of structured, multidisciplinary educational programs to enhance disease management and patient outcomes.
Keywords: Atopic dermatitis, Children, Detergents, Moisturizers, Therapeutic education, Skin care
Introduction
Atopic dermatitis (AD) is a common inflammatory disease of the skin, characterized by persistent skin dryness, itching and eczematous lesion with chronic and recurrent relapses [1, 2].
The global prevalence of AD in pediatric population ranges from 2.7% to 20.1% across different countries [3]. AD is characterized by impaired epidermal barrier integrity, compromising the skin’s natural function as a barrier to the outside environment.
Both genetic and acquired factors are involved in the pathogenic mechanism leading to AD. Among the main genetic factors, filaggrin deficiency alters the structure of corneocytes and facilitates the penetration of exogenous molecules such as toxins, bacterial and allergens [4].
The outermost layer of the skin, known as the stratum corneum, consists of keratinocytes and an extracellular matrix. The extracellular spaces of the stratum corneum are composed of lipids that form stacked layers called lamellar bilayers. These lipids, which constitute about 10% of the mass of the stratum corneum in normal skin, play a crucial role in maintaining the integrity of the skin barrier. In AD, there is a reduction in extracellular lipids content, resulting in a leaky extracellular matrix. This condition leads to increased transepidermal water loss (TEWL), causing a partial alteration of the skin barrier. The compromised barrier function contributes to the increased permeability of the skin, which allows for the penetration of microbial pathogens and allergens [5]. Keratinocytes play a significant role in this barrier dysfunction. They exhibit structural and functional abnormalities that contribute to increased TEWL, and decreased production of essential lipids required for skin integrity [6].
In AD, keratinocytes also display aberrant immune activation, characterized by increased production of pro-inflammatory cytokines such as interleukin (IL)-1β, IL-6, IL-8, IL-18, IL-25 and chemokines such as thymus and activation-regulated chemokine, cutaneous T cell attracting chemokine, and monocyte derived chemokine in skin inflammation [7, 8].
This overproduction of cytokines and chemokines leads to elevated levels of inflammatory mediators and promotes the infiltration and accumulation of lymphocytes, macrophages, mast cells, eosinophils, and dendritic cells within the epidermis, thereby contributing to the progression of AD [9–11].
Furthermore, keratinocytes possess innate antimicrobial properties and serve as a crucial line of defence against invading pathogens. They produce antimicrobial peptides, including cathelicidins and defensins, which help control microbial colonization and infection on the skin surface. However, in AD, keratinocytes’ alterations can lead to an increased susceptibility to skin infections [12].
Additionally, keratinocytes participate in the sensitization process to allergens in AD. They uptake and process allergenic proteins, presenting allergen fragments to immune cells, thus initiating an immune response [13]. This sensitization process contributes to the development of allergic reactions and the chronic inflammation observed in AD [13].
Overall, the abnormalities in keratinocytes’ structure, function, immune activation, and antimicrobial defence contribute to the impaired skin barrier and the inflammatory responses observed in AD.
Topical treatments, including the use of detergents and moisturizers, are considered the main therapeutic options for managing AD in children [14].
The aim of this study was to describe real-life cleansing habits and the use of detergents and moisturizers among a large cohort of Italian pediatric patients with AD. We also evaluated the association between therapeutic education and adherence to recommended skin care practices.
Methods
We carried out a multicenter observational study conducted at the Comano Thermal Spring Water Center (Comano, Italy), Allergy and Dermatology Units of the Meyer Children’s Hospital IRCCS (Florence, Italy), Pediatric Allergy Clinic and Pediatric Dermatology Clinic of the University Hospital of Bologna (Bologna, Italy), Pediatric Unit of the University Hospital of Pisa (Pisa, Italy) and Pediatric Allergy Unit of the “San Pietro Fatebenefratelli” Hospital of Rome (Italy). Pediatric Patients aged ≤ 18 years who underwent a specialist visit from 28th June 2020 to 13th December 2021, with previous physician confirmed diagnosis of AD using the criteria of Hanifin and Rajka [15], were included in the study. During the admission visits to the Comano Thermal Spring Water Center, as required by the principles of good clinical practice in thermal medicine and by the institute’s policy [16], we considered any coexisting systemic pathology (e.g., infections, heart diseases, immunodeficiencies or malignancies) or cutaneous disease (e.g., viral, bacterial or fungal infections, skin cancer or ulcers) as exclusion criteria for the study. The same inclusion and exclusion criteria were applied uniformly across all participating centers. An informed, written consent was obtained from all parents/guardians before including the patients in the study. During the admission visits to the Comano Thermal Spring Water Center and the other centers in Florence, Bologna, Pisa and Rome demographic and clinical data were collected through a physician interview. Additionally, during the physician interview at the first visit, caregivers were asked whether they had previously received therapeutic education for AD regarding the use of detergents and moisturizers, and, if so, about the modality through which it had been provided (verbal, written, or combined) and the healthcare professional who delivered it. Caregivers were also asked to rate their current level of satisfaction with the therapeutic education received and their self-confidence in managing the use of detergents and moisturizers, using a numerical scale from 1 to 10.
Qualitative data was presented as frequency tables (number of observations or percentages) and/or through histograms, while quantitative data was expressed as number of observations, mean and standard deviation (SD). Chi-squared test with Yates correction or Fisher exact test was used to evaluate associations between qualitative variables. The Kolmogorov-Smirnov test was used to verify the normality of distributions. If normally distributed, Student’s t-test for two independent samples was used to compare quantitative measures. When normal distribution was not found, the non-parametric Wilcoxon-Mann-Whitney test was used. The differences were considered statistically significant if p-value ≤ 0.05. Statistical data analysis was carried out using Statistical Analysis System (SAS) software (SAS Institute, Cary, North Carolina, United States of America).
Results were divided into three main sections based on the outcome examined: cleansing habits and use of detergents, use of moisturizers and therapeutic education.
Results
Sample
The analysed sample includes 529 children recruited from the seven participating centres, with a geographical representation that covers 18 out of 21 Italian regions: mostly of the patients were from Tuscany (44.3%), Emilia Romagna (14.8%), Lombardia (12.5%), Trentino Alto Adige (8.7%), Lazio (6.7%), Veneto (5.5%). The mean age was 6.5 years (standard deviation, SD = 4.6 years and range 0–18). The mean age at onset was 1.6 years (SD = 2.5 years and range 0–16). The mean height of the children was 118.2 cm (SD = 31.0 cm), the mean weight was 27.8 kg (SD = 17.8 kg), and the mean Body Surface Area was 0.9 m2 (SD = 0.4 m2). The overall male-to-female ratio was 1.12:1 (Table 1).
Table 1.
Sample characteristics (Bologna Dermatology n = 25; Bologna Pediatrics n = 20; Comano n = 214; Florence Allergy n = 119; Florence Dermatology n = 82; Pisa n = 37; Rome n = 32)
| Study population number | Male to female ratio | Mean age (years) | Mean age of onset (years) | Mean height (cm) | Mean weight (kg) | Mean BSA (m2) |
|---|---|---|---|---|---|---|
| 529 | 1.12 | 6.5 | 1.6 | 118.2 | 27.8 | 0.9 |
BSA: body surface area
Regarding the comorbidities, 56.5% of children did not present comorbidities, but at least one allergological comorbidity was observed in 43.5% of the sample. There was a higher proportion of allergic rhinitis alone (18.7%), 10.4% of the sample had food allergy. The presence of allergic rhinitis associated with allergic asthma was then recorded in 5.1% of cases, only 3.4% of patients had a food allergy, allergic rhinitis and asthma and very few patients had an association with food allergies and allergic rhinitis or asthma (respectively 1.7% and 0.4%).
Cleansing and detergents
Regarding the cleansing aspects, the water temperature for the bath appeared to be lukewarm in 73.9% of the cases, hot in 23.8% and cold in the remaining 2.3%. The washing duration was between 5 and 10 min in 48.4% of cases, more than 10 min in 36.1% and less than 5 min in 15.5%.
Skin drying occurred in 74.4% by tamponing the skin, while in the remaining 25.6% by rubbing it. Only 10.6% of respondents reported using sodium hypochlorite and/or antiseptic detergents for bathing. Among them, 9.5% used only antiseptic detergents, 0.8% used only sodium hypochlorite, and 0.4% used both. The remaining 89.4% did not use either product.
Moreover, 56.0% of respondents stated that they use specific detergents for atopy. Among those who use detergents, 90.6% use them in the acute phase and in remission, 6.1% only in the acute phase, while the remaining 3.3% only in remission. The correlation between quantity (ml/week) in detergent consumption and the body surface area (BSA) was calculated with the Spearman correlation coefficient (r = 0.300 p-value < 0.0001), which indicates a fair correlation between the two variables (Fig. 1).
Fig. 1.
Correlation between quantity in detergent consumption and BSA. BSA: body surface area. Spearman correlation coefficient r = 0.300, p-value < 0.0001
Notably, 45.6% reported not adjusting the frequency of detergent use depending on specific conditions, while 15.7% modified it according to climatic conditions and seasonal changes, 14.0% based it on skin dryness, 8.9% based on both climatic conditions and season and sporting activity, 8.1% only based on sporting activity.
Finally, when asked where the detergent is applied, 95.5% of respondents said they apply it all over the body, 2.7% only on the areas affected by eczema and only 1.8% in other particular locations (e.g., trunk, limbs).
Moisturizers
The use of specific moisturizers was reported by 65.4% of the sample. Among the children who use moisturizers, 73.0% used them in the acute phase and in remission, 24.5% only in the acute phase, while the remaining 2.5% only in remission. Moreover, 37.6% reported no variation in the frequency of moisturizer use, while 41.2% adjusted it based on skin dryness, 10.2% based on both skin dryness, climatic conditions and season, 5.5% only based on climatic conditions and season. Regarding the use of different moisturizer formulations (e.g., creams, ointments, lotions), 64.1% of participants reported no variation in formulation. In contrast, 22.9% varied the formulation based on skin dryness, 7.4% based on climatic conditions and season, and 3.6% based on both skin dryness and climatic conditions and season.
In 79.6% of cases, the moisturizer was applied after the bath (on damp skin), in 13.8% at specific times (e.g., in the morning, in the evening, as needed), 3.7% before and after the bath, 2.9% only before bathing (on dry skin).
Unlike detergents, there was no correlation observed between BSA and quantity (ml/week) of moisturizers consumption when calculated with the Spearman correlation coefficient (r = 0.087, p-value = 0.085) (Fig. 2). Finally, 68.9% of respondents who use moisturizers applied it to the whole body, 28.9% applied it to the areas affected by eczema, and 2.2% applied it only in specific locations (e.g., trunk, limbs).
Fig. 2.
Correlation between quantity in moisturizer consumption and BSA. BSA: body surface area. Spearman correlation coefficient r = 0.087, p-value = 0.085
Therapeutic education
At the first visit the patients were asked if they had a previous educational therapy about how to treat AD. 69% of the patients declared to have been educated about how to use moisturizers and detergents. In 87.0% of the cases the therapeutic education was done by the physician during the visit, in 0.6% by both the physician and by the nurse and in 1.7% by both the physician and by another medical figure. Only few cases reported to have learned it by other parents with atopic children (2.5%) or by both the physician and other parents (4.7%). More than half of the patients declared to have had a verbal education (57.9%), 23.0% verbal and written indications, 12.8% only written. Only 6.3% of patients declared to have had an education in a group or with a practical demonstration.
We have represented the independent variables in relation to the outcome “therapeutic education”, respectively for cleansing and detergents (Table 2), and for moisturizers (Table 3).
Table 2.
Cleansing habits and detergent use: association with therapeutic education
| Variable | Therapeutic education | p-value* | ||
|---|---|---|---|---|
| Yes | No | |||
| Water temperature for the bath [n (%)] | Hot | 81 (22.4) | 44 (27.3) | 0.043 |
| Cold | 5 (1.4) | 7 (4.4) | ||
| Lukewarm | 275 (76.2) | 110 (68.3) | ||
|
Washing duration in minutes [n %)] |
< 5 | 59 (16.5) | 22 (13.8) | 0.230 |
| 5–10 | 179 (50.0) | 72 (45.0) | ||
| > 10 | 120 (33.5) | 66 (41.2) | ||
| Skin drying [n (%)] | Tamponing | 280 (78.2) | 106 (65.4) | 0.002 |
| Rubbing | 78 (21.8) | 56 (34.6) | ||
| Use of additives for the bath [n (%)] | sodium hypochlorite | 4 (1.1) | 0 (0.0) | 0.369 |
| antiseptic detergents | 32 (8.9) | 16 (9.9) | ||
| sodium hypochlorite + antiseptic detergents | 1 (0.3) | 1 (0.6) | ||
| None of them | 324 (89.8) | 145 (89.5) | ||
| Use of specific detergents [n (%)] | Yes | 217 (60.1) | 76 (46.9) | 0.003 |
| No (other) | 144 (39.9) | 86 (53.1) | ||
|
Number of times per week of use of detergent [Mean (SD), Median (IQR)] |
4.8 (2.3) 4.0 (4.0) |
4.2 (2.4) 4.0 (4.5) |
0.001 | |
|
Detergent use phase [n (%)] |
Only in the acute phase | 23 (6.8) | 6 (4.1) | 0.513 |
| Only in remission | 11 (3.2) | 5 (3.4) | ||
| In the acute phase and in remission | 305 (90.0) | 136 (92.5) | ||
|
Detergent usage frequency variation [n (%)] |
No | 164 (45.4) | 75 (46.3) | 0.944 |
| Skin dryness | 48 (13.3) | 25 (15.4) | ||
| Climatic condition and season | 57 (15.8) | 25 (15.4) | ||
| Sporting activity | 28 (7.8) | 15 (9.3) | ||
| Skin dryness + climatic condition and season | 15 (4.2) | 4 (2.5) | ||
| Skin dryness + climatic condition and season + sporting activity | 13 (3.6) | 4 (2.5) | ||
| Skin dryness + sporting activity | 2 (0.6) | 1 (0.6) | ||
| Climatic condition and season + sporting activity | 34 (9.4) | 13 (8.0) | ||
|
Detergent usage quantity variation [n (%)] |
No | 253 (70.1) | 98 (60.5) | 0.334 |
| acute phase/remission | 21 (5.8) | 13 (8.0) | ||
| Skin dryness | 28 (7.8) | 21 (13.0) | ||
| Climatic condition and season | 20 (5.5) | 13 (8.0) | ||
| Sporting activity | 14 (3.9) | 10 (6.2) | ||
| Acute phase/remission + skin dryness | 7 (1.9) | 2 (1.2) | ||
| Acute phase/remission + skin dryness + climatic condition and season | 4 (1.1) | 0 (0.0) | ||
| Acute phase/remission + skin dryness + climatic condition and season + sporting activity | 2 (0.6) | 0 (0.0) | ||
| acute phase/remission + climatic condition and season | 3 (0.8) | 0 (0.0) | ||
| acute phase/remission + climatic condition and season + sporting activity | 1 (0.3) | 0 (0.0) | ||
| Skin dryness + climatic condition and season | 2 (0.6) | 3 (1.9) | ||
| Skin dryness + climatic condition and season + sporting activity | 1 (0.3) | 0 (0.0) | ||
| climatic condition and season + sporting activity | 5 (1.4) | 2 (1.2) | ||
|
Consumption of the detergent (ml / week) [Mean (SD), Median (IQR)] |
55.2 (41.2) 50.0 (50.0) |
60.0 (46.6) 50.0 (70.0) |
0.269 | |
| Where the detergent is applied [n (%)] | Whole body | 336 (95.7) | 149 (95.5) | 0.901 |
| Areas affected by eczema | 10 (2.9) | 4 (2.6) | ||
| Particular locations (including limbs. trunk) | 5 (1.4) | 3 (1.9) | ||
IQR: interquartile range; SD: standard deviation
*p-value refers to the Student t-test or Wilcoxon-Mann-Whitney test in case of quantitative independent variables, to the exact Fisher or Chi-squared test, in case of qualitative variables
Table 3.
Moisturizers use: association with therapeutic education
| Variable | Therapeutic education | p-value* | ||
|---|---|---|---|---|
| Yes | No | |||
| Use of specific moisturizer [n (%)] | Yes | 250 (69.3) | 94 (58.0) | 0.009 |
| No (other) | 111 (30.7) | 68 (42.0) | ||
|
Moisturizer use phase [n (%)] |
Only in the acute phase | 74 (21.9) | 44 (31.6) | 0.034 |
| Only in remission | 7 (2.1) | 5 (3.6) | ||
| In the acute phase and in remission | 257 (76.0) | 90 (64.8) | ||
| Moisturizer usage frequency variation [n (%)] | No | 135 (37.4) | 61 (37.7) | 0.357 |
| Skin dryness | 142 (39.3) | 75 (46.3) | ||
| Climatic condition and season | 19 (5.3) | 9 (5.6) | ||
| Sporting activity | 4 (1.1) | 2 (1.2) | ||
| Skin dryness + climatic condition and season | 45 (12.5) | 9 (5.6) | ||
| Skin dryness + climatic condition and season + sporting activity | 10 (2.8) | 5 (3.1) | ||
| Skin dryness + sporting activity | 2 (0.6) | 0 (0.0) | ||
| Climatic condition and season + sporting activity | 4 (1.1) | 1 (0.6) | ||
|
Consumption of the moisturizer (ml / week) [Mean (SD), Median (IQR)] |
57.0 (62.1) 40.0 (40.0) |
69.9 (71.0) 50.0 (80.0) |
0.049 | |
|
Moisturizer usage quantity variation [n (%)] |
No | 139 (38.5) | 66 (40.7) | 0.636 |
| Acute phase/remission | 60 (16.6) | 33 (20.4) | ||
| Skin dryness | 66 (18.3) | 33 (20.4) | ||
| Climatic condition and season | 12 (3.3) | 4 (2.5) | ||
| Sporting activity | 3 (0.83) | 0 (0.0) | ||
| Acute phase/remission + skin dryness | 51 (14.1) | 16 (9.9) | ||
| Acute phase/remission + skin dryness + climatic condition and season | 14 (3.9) | 3 (1.9) | ||
| Acute phase/remission + skin dryness + climatic condition and season + sporting activity | 5 (1.4) | 1 (0.6) | ||
| Acute phase/remission + climatic condition and season | 3 (0.8) | 2 (1.2) | ||
| skin dryness + climatic condition and season | 6 (1.7) | 4 (2.5) | ||
| skin dryness + sporting activity | 2 (0.6) | 0 (0.0) | ||
| Where the moisturizer is applied [n (%)] | Whole body | 246 (70.9) | 91 (63.6) | 0.049 |
| Areas affected by eczema | 91 (26.2) | 51 (35.7) | ||
| Particular locations (including limbs. trunk) | 10 (2.9) | 1 (0.7) | ||
| Number of times per week of use of moisturizer [Mean (SD), Median (IQR)] |
6.8 (4.5) 7.0 (3.0) |
5.7 (4.0) 6.0 (4.0) |
0.008 | |
| Moisturizer different formulation usage [n (%)] | No | 232 (64.3) | 103 (63.6) | 0.850 |
| Skin dryness | 83 (22.9) | 38 (23.5) | ||
| Climatic conditions and season | 23 (6.4) | 15 (9.3) | ||
| Sporting activity | 2 (0.6) | 1 (0.6) | ||
| Skin dryness + climatic conditions and season | 15 (4.2) | 4 (2.5) | ||
| Skin dryness + climatic conditions and season + sporting activity | 4 (1.1) | 1 (0.6) | ||
| Skin dryness + sporting activity | 1 (0.3) | 0 (0.0) | ||
| climatic conditions and season + sporting activity | 1 (0.3) | 0 (0.0) | ||
| When moisturizer is applied [n (%)] | After bath (damp skin) | 272 (79.3) | 112 (80.6) | 0.839 |
| Specific times | 50 (14.6) | 17 (12.2) | ||
| Before and after bath | 12 (3.5) | 5 (3.6) | ||
| Before bath (dry skin) | 9 (2.6) | 5 (3.6) | ||
IQR: interquartile range; SD: standard deviation
*p-value refers to the Student t-test or Wilcoxon-Mann-Whitney test in case of quantitative independent variables, to the exact Fisher or Chi-squared test, in case of qualitative variables
In detail the mean number of weekly detergents application was higher among those who received therapeutic education compared to those who did not (4.8 vs. 4.2 times per week, p-value = 0.001). Similarly, the mean weekly use of moisturizers was greater in the educated group (6.8 vs. 5.7 times per week, p-value = 0.008).
Moreover, those who received therapeutic education had a higher probability of using lukewarm water for the bath (76.2% vs. 68.3%, p-value = 0.043), of tamponing the skin (78.2% vs. 65.4%, p-value = 0.002) and of using specific detergents (60.1% vs. 46.9%, p-value = 0.003). As reported, we observed a fair correlation, calculated with the Spearman correlation coefficient (r = 0.300), between quantity (ml/week) of detergent consumption and BSA in the entire sample; notably, the correlation remained significant even within the group that received therapeutic education (r = 0.320, p-value < 0.0001).
Additionally, those who received therapeutic education have a higher probability of using specific moisturizers (69.3% vs. 58.0%, p-value = 0.009), of using moisturizers in acute phase and in remission (76.0% vs. 64.8%, p-value = 0.034) and of applying moisturizers throughout the whole body (70.9% vs. 63.6%, p-value = 0.049).
We also noticed that the quantity in median consumption of moisturizers in a week, in millilitres was lower among those who received therapeutic education (40.0 vs. 50.0 median consumption ml/week, p-value = 0.049), while for detergents there was no significant difference.
The analysis showed no correlation between quantity (ml/week) of moisturizer consumption and BSA in the entire sample (Spearman correlation coefficient r = 0.087), similarly no correlation was found between the two variables even in the subgroup that received therapeutic education (r = 0.013, p-value = 0.831).
We also evaluated the families’ level of satisfaction with the therapeutic education received, as well as their self-confidence in using detergents and moisturizers, using a rating scale from 1 to 10.
Parents’ assessment of satisfaction about therapeutic education received showed that 64.2% had a positive evaluation (score between 7 and 10), 15.3% felt sufficiently satisfied (score 6), and 20.5% referred to feel not satisfied (score between 1 and 5).
Moreover, parents’ assessment of how confident they feel about using detergents and moisturizers as part of AD therapy indicated that 59.9% of respondents scored between 7 and 10 (positive evaluation), 14.0% scored as sufficient (score 6), but 26.1% proved to be insecure (score between 1 and 5) in the management of the use of detergents and moisturizers.
The latest analyses display the differences in self-confidence and satisfaction scores (on a scale of 1 to 10) between those families who have had therapeutic education from the physician versus those who have not received it or received it from someone else. The median value of self-confidence among those who received therapeutic education from the physician is significantly higher than those who received the education elsewhere (8.0 vs. 6.0, p-value < 0.0001). Also, the degree of satisfaction is significantly higher (7.0 vs. 6.0, p-value = 0.007).
Discussion
In our study we described the application of cleansing, the use of detergents and moisturizers as baseline therapy in a pediatric population of Italian patients with AD.
Additionally, the study highlights how a therapeutic education program plays a key role in increasing families’ awareness and confidence in the daily management of the disease. Current recommendations for the therapeutic management of AD emphasize the importance of regular bathing with lukewarm water and the use of mild detergents, such as amphoteric or oil-based formulations, to prevent skin dehydration [17, 18].
Regular application of moisturizers is also shown to play a key role in the management of cutaneous manifestations, (xerosis and pruritus), by restoring the skin barrier function and improving epidermal hydration [19]. The long-term use of moisturizers may also prolong the duration of flare free intervals and reduce the use of topical steroids [1, 14].
Emollients usually contain a humectant such as urea or glycerol. A Cochrane review [20] comparing moisturizers versus no moisturizer found that the former were more effective in reducing investigator-reported severity, frequency of flares up and in decreasing the need for corticosteroids.
Adequate adherence to prescribed treatment regimens can help to interrupt the cycle of treatment failure, disease evolution and subsequent treatment escalation, especially given that suboptimal adherence remains a major barrier to achieve optimal therapeutic outcomes [21].
To ensure proper and consistent implementation of moisturizing therapy, it is crucial to effectively convey its importance to parents. Evidence indicates that adherence to chronic disease management, including topical treatments, is suboptimal, with the World Health Organization reporting an average adherence rate of 50% as early as 2003. Moreover, the adherence rate tends to be even lower for topical treatments due to the additional time required and potential confusion associated with their application [22].
Non-adherence may partly depend on unclear skin care instructions and confusion due to the wide range of non-prescription products available [23]. Additionally, the cost of high-quality emollient therapies can be a limiting factor, as these are not covered by prescriptions and often need to be used in large quantities, making them less accessible for regular use [17]. In the Italian National Health System emollients and other non-drug medications for atopic dermatitis are fully paid by patients [24].
One of the most significant findings of our analysis highlights the crucial impact of therapeutic education in promoting appropriate and effective use of topical treatments in AD, and in improving adherence to recommended hygiene practices.
Families who underwent specific training showed greater awareness and compliance with preventive measures, including the use of lukewarm water for cleansing (76.2% vs. 68.3%) and gently patting the skin dry (78.2% vs. 65.4%). Moreover, the use of detergents specifically formulated for atopic skin was higher in the educated group compared with non-educated families (60.1% vs. 46.9%), suggesting greater adherence to recommended cleansing products.
In addition, the mean number of weekly detergent applications was significantly higher among families who received therapeutic education, indicating a more structured and regular cleansing routine. A positive correlation was observed between the quantity of detergent used and BSA, reflecting a proportional use of cleansing products according to the child’s size. Notably, this association remained significant within the subgroup of families who received therapeutic education.
Additionally, data from our study indicates that only 65.4% of participants reported using moisturizers specifically formulated for AD. The majority (73%) applied moisturizers during both acute exacerbations and remission phases, with frequency of use primarily influenced by the severity of skin dryness (41.2%).
Families who received therapeutic education demonstrated a higher use of disease-specific moisturizers (69.3% vs. 58%), more frequent weekly application during both remission and flare-ups (76% vs. 64.8%), and broader application over the entire body surface (70.9% vs. 63.6%).
These results suggest that therapeutic education is not only essential for optimal disease management but also plays a pivotal role in reinforcing daily behavioural strategies that reduce the risk of skin barrier damage and subsequent complications.
Guidelines recommend using a proper amount of product quantities (150–200 g/week for children) [14]. The application of moisturisers may follow the fingertip unit (FTU) rule [25]. Our findings revealed no significant correlation between BSA and the weekly quantity of moisturizers applied, suggesting that moisturizers use may not be directly proportional to the extent of skin involvement in AD. In contrast, the significant correlation observed between detergent consumption and BSA may reflect a more proportional use of cleansing products according to the extent of skin surface, as detergents are typically applied uniformly during bathing. Conversely, moisturizer application may be influenced by additional factors such as perceived skin dryness, caregiver habits, cost, or concerns about overuse, rather than being strictly adjusted to body size. Moreover, data indicates that therapeutic education and the implementation of therapeutic standardized procedures (FTU rule) are not fully effective.
These observations highlight the complexity of patient management in AD and the need for comprehensive, individualised educational strategies that address both practical and psycho-social aspects of treatment management.
Our results further emphasized the crucial role of therapeutic education in the management of pediatric AD. Data from family evaluations revealed that 69% of participants had previously received some form of therapeutic education, predominantly delivered by physicians (87%) through individual consultations (57.9%). However, the involvement of other healthcare professionals in the educational process was reported in only a minority of cases, marking a limited implementation of multidisciplinary approaches.
Despite a relatively high rate of prior educational exposure, 26.1% of families still reported uncertainty in managing basic aspects of care, such as the appropriate use of cleansers and moisturizers. Notably, 64.2% of families reported a satisfaction score of 7 or higher, indicating a generally positive evaluation of the therapeutic education received. Families who received therapeutic education from physicians reported significantly higher confidence in treatment management compared to those who received no therapeutic education or were educated by other healthcare providers.
Ideally, a multidisciplinary team should be established to deliver holistic, patient-centered care. Such teams can integrate different professional perspectives and collaborate effectively to address the complex needs of children with AD and their families.
Providing comprehensive information about the importance of treatment adherence, the benefits of the therapy, and the potential long-term cost savings can empower patients to prioritize their AD management despite challenges. Both the 2018 European guidelines [26] and the 2020 Eczema Task Force position paper [27] strongly emphasize that multidisciplinary, age-specific, structured group training programmes (commonly referred to as “eczema schools”) provide the most evidence-based benefits. In line with this, multidisciplinary educational models are under development in several countries to promote comprehensive care and improve long-term outcomes.
For instance, the Berlin model—developed in the early 2000s—features group-based sessions involving pediatricians, dermatologists, psychologists, and dietitians [28].
Similarly, the Atopic Dermatitis Center at Boston Children’s Hospital has implemented a collaborative care model involving pediatric allergists, nurse practitioners, psychologists, and nutritionists. These professionals work together during the patient’s visit to develop a personalized treatment plan [29].
An innovative extension of this approach has been adopted by the Boston Children’s Hospital Dermatology Program, which integrates individual clinical consultations with group-based education and peer support. In this model, nurses play a pivotal role in providing hands-on education about topical treatments and skin care routines, while patients and parents are actively engaged as peer educators within the multidisciplinary team [30].
In a previous work [31] with the educational approach, particularly interesting and encouraging data was obtained. The interventions consisted in assisting and in coping with the disease and encouraging access to accurate information from reliable sources. In addition, the staff promoted teachings about the application of drugs and promoted discussions about the main concerns of the disease from patients and their parents. Psychological support was also essential to identify children’s emotional triggers related to the disease, and to develop strategies supporting these moments of crisis.
Current literature consistently supports the integration of structured educational interventions as a core component of AD management. Such programmes have demonstrated efficacy in improving disease severity, treatment adherence, and health-related quality of life (QoL). Our findings align with this evidence and further suggest that effective therapeutic education promotes caregiver awareness and families’ self-confidence in managing the pathological condition.
Nonetheless, the implementation of multidisciplinary education models remains limited in the Italian healthcare context. This may be due to practical barriers in integrating such approaches into routine clinical practice, as well as the persistent perception among families that physicians are the unique authoritative figures in therapeutic guidance. Such perception may hinder the broader involvement of other healthcare professionals, such as nurses, psychologists, and dietitians, whose contributions are essential to a comprehensive educational model. Indeed, therapeutic education was heterogeneous across centers and reflected routine clinical practice rather than a standardized program.
However, some limitations of this study should be acknowledged. The observational, cross-sectional design does not allow causal inference between therapeutic education and adherence to skin care practices. Moreover, the absence of longitudinal follow-up prevents evaluation of the impact of therapeutic education on clinical outcomes over time, such as disease severity, frequency of flares, or sustained changes in caregivers’ behaviours. In addition, information on skin care habits and previous therapeutic education was based on self-reported data from caragivers collected during clinician-administered interviews and may therefore be subject to recall or reporting bias. However, interviews were conducted by trained physicians in a specialized clinical setting.
Nevertheless, to our knowledge, this is one of the largest multicenter studies conducted in Italy focusing on daily skin care practices and prior therapeutic education in children with AD. The wide geographic coverage and involvement of multiple specialized centers provide a comprehensive real-world overview of routine clinical practices and caregiver behaviours across different regions.
Conclusion
This study provides an overview of real-world skin care practices among Italian children with AD. Our results highlight an association between therapeutic education and greater caregiver adherence and confidence in managing the disease. Structured, physician-led education programs may enhance adherence to recommended cleansing practice and moisturizer use, supporting better long-term disease management. Future prospective and longitudinal studies are needed to evaluate the long-term impact of therapeutic education on clinical outcomes and disease management in pediatric AD.
Acknowledgements
Not applicable.
Abbreviations
- AD
Atopic dermatitis
- BSA
Body surface area
- FTU
Fingertip unit
- IL
Interleukin
- IQR
Interquartile range
- QoL
Quality of life
- SAS
Statistical Analysis System
- TEWL
Transepidermal water loss
Author contributions
MG conceptualized, designed the work, drafted the initial manuscript and reviewed the manuscript. RP analyzed the data, drafted the initial manuscript and reviewed the manuscript. MP, LT, FP, DP, EG, IN and AG collected the data and reviewed the manuscript. AP, GS drafted the initial manuscript and reviewed the manuscript. DG, EN, GR, SB, FM, CF, TO and GT reviewed the manuscript. EB conceptualized, designed the work, collected the data and reviewed the manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The publication fee was financed by the “Giovan Battista Mattei” Research Institute. However, no significant funding source could have influenced the outcomes of this work.
Data availability
The access to datasets generated and/or analyzed during the current study is not publicly available due to the Centers’ research policies to guarantee the privacy of the participants, whose research data are confidential. Aggregate analyses are however available on reasonable request to the corresponding author.
Declarations
Ethics approval and consent to participate
An informed, written consent was obtained from all parents/guardians prior to including the patients in the study. The study was reviewed and approved by the board of the “Giovan Battista Mattei” Research Institute.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have the following competing interests to disclose in relation to this paper: MG worked as a consultant doctor at Azienda Consorziale Terme di Comano from April to October 2015. MG reports personal fees from Sanofi, Thermo Fisher Scientific. DG worked as a consultant doctor at Azienda Consorziale Terme di Comano from May to September 2016. EB is the president of the “Giovan Battista Mattei” Research Institute. SB declared speaker fees from Nutricia, Sanofi, Firma. However, no significant competing interest could have influenced the outcomes of this work. The other authors declare that they have no conflict of interests to disclose in relation to this paper.
Footnotes
Publisher’s note
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Mattia Giovannini and Riccardo Pertile Joint first co-authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The access to datasets generated and/or analyzed during the current study is not publicly available due to the Centers’ research policies to guarantee the privacy of the participants, whose research data are confidential. Aggregate analyses are however available on reasonable request to the corresponding author.