Factors Influencing Self-Management Behaviors in Patients with Atopic Dermatitis and Intervention Strategies: A Narrative Review

Abstract

Background

Atopic dermatitis (AD), as a chronic, recurrent inflammatory skin disease, relies heavily on patients’ self-management behaviors for long-term effective control. However, clinical practice indicates that patients’ self-management status is generally unsatisfactory and is influenced by the interactive effects of multiple factors, including sociodemographic, disease-related, psychological, and social support factors. In this context, systematically reviewing the factors influencing self-management behaviors and existing intervention strategies is of great significance for optimizing disease control and improving patients’ long-term quality of life and treatment satisfaction. Therefore, this review summarizes the multiple factors affecting self-management behaviors in AD patients and explores the current status and potential of existing interventions.

Methods

Based on inclusion and exclusion criteria, we searched relevant literature in the CNKI, PubMed, and Web of Science databases using keywords including “atopic dermatitis”, “self-management”, “factors influencing self-management”, and “intervention”. A narrative review method was employed to synthesize and analyze the literature on factors influencing self-management behaviors and intervention strategies in patients with atopic dermatitis.

Results

After screening, a total of 11 relevant studies were included. The review found that the level of self-management is influenced by the interaction of multiple factors, including sociodemographic factors, disease-related factors, psychological factors, and social support. Current interventions primarily focus on health education and are gradually incorporating digital health tools and multidisciplinary collaboration models, showing potential in improving medication adherence, skin care practices, and stress management. Despite these advances, the self-management status in clinical practice remains unsatisfactory.

Conclusion

Existing evidence indicates that self-management behaviors in patients with atopic dermatitis remain at a low level and are influenced by multiple complex factors. Future research should prioritize the development of individualized structured education programs and cognitive behavioral interventions to effectively enhance patients’ self-management abilities, thereby optimizing disease control and improving long-term quality of life and treatment satisfaction.

Introduction

Atopic Dermatitis(AD), as a chronic, recurrent, inflammatory skin disease characterized by intense pruritus, eczematous lesions, and skin barrier dysfunction, can occur in all age groups and has become a major challenge in the field of global public health.¹ The prevalence of AD worldwide is approximately 5%–20%, with significant variation across different countries and ethnicities.² According to statistics from the World Allergy Organization(WAO), the prevalence of AD in developed countries is as high as 10% –20%, with over 230 million AD patients globally, and this number continues to increase.³ In recent years, the prevalence of AD has been rising worldwide, with lifetime prevalence exceeding 20% in some developed countries.⁴ AD not only affects children but also significantly impacts adult populations. AD imposes substantial economic and psychological burdens on patients and their families, ranking first in disease burden among non-fatal skin diseases and becoming one of the highest-burden diseases among common non-fatal conditions.⁵ In the Global Burden of Disease Study,⁶ AD was identified as the most disabling skin disease for the population. The US. National Health Survey report⁷ indicates that, among skin diseases, AD has the most significant negative impact on both the Dermatology Life Quality Index and general quality of life scores. Moderate-to-severe AD is associated with a deterioration in quality of life that exceeds that of many common chronic diseases, including heart disease and diabetes.⁸ These data collectively demonstrate that AD has gradually become a public health and social issue requiring ongoing research and societal attention. From a pathogenetic perspective, the core of AD lies in the “Inside-out and Outside-in hypothesis”, see Figure 1:

Figure 1.

Pathogenesis of AD.

On one hand, the “Outside-in” hypothesis emphasizes that skin barrier dysfunction (eg, filaggrin gene mutations) leads to the invasion of external antigens, triggering immune responses; on the other hand, the “Inside-out” hypothesis focuses on systemic immune dysregulation, ie, T-cell-mediated type 2 inflammation resulting in secondary impairment of the skin barrier.^9,10 In fact, these two mechanisms are mutually causal and reinforcing, forming a vicious cycle of”barrier defect—immune activation—further barrier damage. “As a chronic recurrent disease centered on skin barrier defects and immune dysregulation, AD not only presents with intense pruritus and eczematous lesions but also exhibits a cascade of “allergic march” with type 2 inflammatory diseases such as allergic rhinitis and asthma. Its systemic disease characteristics mandate that the management model must transcend the limitations of traditional dermatological treatment.¹¹ Disease severity, treatment options, and the associated challenges vary according to disease stage and individual differences. Based on the extent of skin lesions, itch severity, and impact on quality of life, AD is generally classified into mild, moderate, and severe categories. Treatment options follow a stepwise approach: basic therapy includes emollients/moisturizers, topical corticosteroids, or calcineurin inhibitors; for moderate-to-severe patients, systemic immunosuppressants, ultraviolet phototherapy, and more recently targeted biologics and JAK inhibitors are required.² Research indicates that although clinical treatment can provide short-term symptom relief, the recurrence rate exceeds 60%, suggesting that reliance solely on medical intervention is insufficient for long-term control. Long-term effective management and proper regular treatment can lead to complete remission or significant improvement of AD symptoms and prevent acute exacerbations.¹² The chronic, recurrent, and incurable nature of the disease determines that patients must become the primary agents of disease management. The characteristics of AD and its treatment challenges make patient self-management a key factor in disease control and quality of life improvement. Self-management, through active identification and avoidance of triggers, becomes crucial in breaking the vicious cycle of “itch—scratch—inflammation”. Multiple studies have shown that the self-management status of AD patients is suboptimal.^13–15 Therefore, AD patients need to enhance their awareness of long-term management, adhere to long-term treatment, medication use, and emollient application as prescribed, adopt reasonable lifestyle and self-management strategies, and maintain a positive mindset to promote recovery and prevent relapse.

Whether the symptoms of AD and the discomfort caused by its treatment can serve as the main driving factors affecting patients’ self-management behavior still requires further investigation. This review aims to systematically summarize the influencing factors of self-management behavior in AD patients, focusing on key variables such as “disease cognition and psychological factors” that drive self-management behavior, so as to provide theoretical support for constructing targeted health intervention strategies, optimizing patient education programs, and enhancing long-term treatment adherence and quality of life. It should be noted that this review does not cover comparisons of specific drug efficacy mechanisms in AD or genetic molecular-level explorations.

Methods

This study adopts a narrative review approach, describing the synthesis of knowledge, the systematic methods and processes employed, and providing a detailed account. It is particularly suitable for exploring self-management behaviors in patients with AD, a research topic of substantial scope and complexity. The reason for choosing a narrative literature review is its irreplaceable role in translating the latest scientific findings into practical clinical applications, enabling a systematic integration of existing knowledge in a given field.

Inclusion and Exclusion Criteria

Inclusion Criteria

1) studies focusing on factors influencing self-management behaviors of patients with AD or related intervention strategies; 2) study types including experimental, observational, or mixed-methods studies; 3) participants diagnosed with AD, both adults and children; 4) primary outcomes focusing on the level of self-management behavior and its improvement.

Exclusion Criteria

1) non-English or non-Chinese literature; 2) studies with incomplete data or where full text is not accessible; 3) literature with low methodological quality (eg, lacking explicit study design, very small sample sizes, or high risk of bias); 4) duplicate publications.

Search Strategy

Searches were performed in multiple databases to obtain a more comprehensive collection of literature. The following keywords were used: “atopic dermatitis”; “self-management behaviors”; “influencing factors”; “intervention strategies”. The databases searched included China National Knowledge Infrastructure(CNKI) and PubMed.

Taking PubMed as an example, we developed the following search strategy:

#1: “Atopic Dermatitis” [Title/Abstract] OR “Eczema” [Title/Abstract] OR “Dermatitis, Atopic” [Title/Abstract]

#2: “Self-Management” [Title/Abstract] OR “Self Care” [Title/Abstract] OR “Self-Efficacy” [Title/Abstract] OR “Patient Compliance” [Title/Abstract] OR “Adherence” [Title/Abstract] OR “Self-Management Behaviors” [Title/Abstract]

#3: “Influencing Factors” [Title/Abstract] OR “Determinants” [Title/Abstract] OR “Intervention” [Title/Abstract] OR “Intervention Strategies” [Title/Abstract]

#4:#1 AND#2 AND#3

Study Selection and Data Extraction

After removing duplicate records using EndNote software, two researchers independently screened the literature and extracted data in a double-blind manner. Any disagreements were resolved through discussion or by consulting a third co-author.

Results

Literature Search Results

After removing duplicates, the search yielded 345 potentially relevant studies to address the topic. Among these 345 articles, 268 were excluded after title and abstract screening, leaving 11 for full-text analysis (see Figure 2).

Figure 2.

The literature screening process.

Characteristics of Included Studies

After summarizing the 11 empirical studies that met the inclusion criteria, the existing evidence primarily points to four major categories of factors influencing self-management behaviors in patients with AD: sociodemographic factors, disease-related factors, psychological factors, and family and social support factors. Meanwhile, intervention strategies focus on systematic management programs. These 11 articles are all high-quality empirical studies published between 2023 and 2026 in the fields of nursing, dermatology, and public health. The studies strictly adhered to the guidelines for the diagnosis and treatment of AD. The core feature of these studies is the comprehensive use of cross-sectional surveys, randomized controlled trials, and longitudinal follow-up designs to systematically analyze the multidimensional factors affecting self-management behaviors and to evaluate the clinical effectiveness of structured interventions. The studies generally demonstrated the significant effects of interventions in improving patients’ lifestyle behaviors and reducing recurrence rates. Therefore, they provide a solid theoretical foundation and data support for developing precise, stratified clinical intervention strategies (see Table 1).

Table 1.

Characteristics of Included Studies

Studies	Influencing Factors/Intervention Strategy	Authors	Year	Country
[16,17]	Sociodemographic factors	Huiwen Zheng et al Danni Wang et al	2026 2025	China China
[18]	Disease-related factors	Xue Chen et al	2026	China
[19]	Psychological factors	Florence Mei Fung Wong et al	2026	China
[20,21]	Family social support factors	Sunyeob Choi et al Sheena Chatrath et al	2024 2024	Korea America
[22]	Health education	Mason McDowel et al	2026	England
[23,24]	Behavioral intervention	Sanae Kishimoto et al Dorian Kern et al	2023 2025	Japan Sweden
[25]	Digital technology intervention	Ali M Aleid et al	2025	Saudi Arabia
[26]	Lifestyle intervention	Michael R Perkin et al	2026	England

The Concept of Self-Management Behaviors

Self-management, a concept first proposed by American scholar Thomas Creer,²⁷ refers to an individual’s proactive management of their own behaviors and their engagement in effective disease management activities based on personal cognitive understanding. Specifically, it involves patients actively participating in treatment and consistently undertaking daily tasks to mitigate the disease’s impact on health, thereby achieving therapeutic goals through health-promoting behaviors.²⁸ In the context of AD, self-management behaviors entail patients addressing critical challenges in disease management—such as poor adherence, low follow-up rates, and noncompliance with prescribed treatments—by actively acquiring disease-related knowledge, mastering self-management techniques under guidance, and collaborating with healthcare providers to establish treatment goals.^29,30 Throughout this process, patients actively engage in implementing treatment plans, leveraging their problem-solving skills, self-efficacy, and self-regulatory capacity to foster positive changes in self-management behaviors, including improved adherence, follow-up compliance, and medication practices.^16,31

Discussion

Current Status of Self-Management Behaviors in AD Patients

AD requires prolonged treatment with significant individual variability and differing management approaches across disease stages, rendering long-term self-management particularly challenging. Current international research predominantly focuses on pediatric AD, with studies prioritizing treatment, pathogenesis, and online management models.^25,31,32 Children with AD also face significant challenges in self-management behaviors. Due to age limitations, their self-management is highly dependent on the cognition and executive ability of parents or caregivers.¹⁶ Studies have shown that.^33,34 However, evidence indicates that adult AD patients exhibit suboptimal self-management behaviors, characterized by widespread nonadherence to medical advice, insufficient disease knowledge, and poor treatment persistence. Among newly diagnosed patients, only 24.4% of tacrolimus ointment users were still persisting with treatment after 6 months (with a discontinuation rate of 75.6%), and the proportion persisting after one year further decreased to 22.5% (with a discontinuation rate of 77.5%).³⁵ Psychological burdens further exacerbate management difficulties, with approximately 43% of patients experiencing anxiety or depressive symptoms and 15% reporting suicidal ideation.^36,37

Pruritus, psychological factors, and disease severity critically impair quality of life. Studies utilizing the Dermatology Life Quality Index (DLQI) reveal that AD patients experience quality-of-life impairments comparable to those with psoriasis.³⁸ In clinical practice, addressing emotional well-being through neuropsychiatric interventions (eg, relaxation therapy) has been shown to improve psychological states, enhance self-efficacy, and promote active self-management, thereby alleviating AD symptoms.³⁹ Emerging evidence supports the efficacy of digital self-management programs. For example, Cherrez-Ojeda et al⁴⁰ demonstrated that online self-management interventions significantly improved patients’quality of life and disease severity, achieving outcomes comparable to in-person care while potentially reducing healthcare costs. Similarly, Andrade et al⁴¹ confirmed the effectiveness of web-based self-management education.

Nonetheless, inadequate patient understanding of long-term treatment necessity, medication safety, and therapeutic efficacy often undermines proactive self-management. Poor adherence to prescribed therapies, irregular medication use, and failure to address psychological stress frequently lead to disease exacerbation or recurrence.¹⁸

Factors Influencing Self-Management Behaviors in AD Patients

Sociodemographic Factors

Research shows that AD patients with different ages, genders, education levels, family histories, marital statuses, socioeconomic statuses, and places of residence exhibit certain differences in self-management behaviors, but the findings are inconsistent (See Table 2). Regarding age, studies have found a positive correlation between patient age and self-management ability, with older adult patients showing better treatment satisfaction.⁴² This may be because older patients have accumulated more disease management experience and have a deeper understanding of treatment plans. Better treatment adherence in older patients compared to younger ones may also be related to increased health awareness. In contrast, adolescent AD patients face unique challenges in self-management.¹⁶ These factors may affect the self-management ability and adherence of adolescent patients.⁴³ Findings on the relationship between gender and self-management in AD patients are contradictory. Studies show that⁴⁴ female AD patients report higher treatment satisfaction, which might be related to their more proactive involvement in managing the disease. Male AD patients may have more severe disease, require more extensive treatment, and experience a greater impact on their quality of life. This finding suggests that male patients may need more support and education to improve their self-management behaviors. However, a study by Carmanius et al Showed⁴⁵ a higher proportion of topical corticosteroid (TCS) use among males compared to females, which may reflect higher proactivity in certain self-management behaviors among males.

Table 2.

Factors Influencing Self-Management Behaviors of Patients with AD

Category	Specific Factor	Key Findings
Sociodemographic Factors	Age	Older adult patients demonstrate stronger self-management ability and higher treatment satisfaction.
	Gender	Inconsistent results: female patients report higher treatment satisfaction; male patients show a higher rate of topical corticosteroid use.
	Residence	Urban residence is associated with severe AD, potentially increasing the difficulty of self-management.
	Education Level	Patients with higher education levels are more inclined to use complementary and alternative medicine (CAM) and have better health literacy; parents’education level directly influences their management cognition and behavior for pediatric patients.
	Other sociodemographic factors	Differences exist in family history, marital status, socioeconomic status, etc, but findings are inconsistent.
Disease-Related Factors	Disease Severity	Severity is negatively correlated with self-management ability; higher severity increases psychological burden and reduces motivation.
	Disease Duration	Disease duration affects the patient’s initiative in self-management.
Psychological Factors	Psychological Stress	Most AD patients believe that psychological stress can worsen eczema and itching symptoms; chronic stress has a greater impact.
	Anxiety/Depression	AD patients have significantly higher rates of anxiety and depression than the general population; negative emotions reduce self-management motivation and ability, affecting treatment adherence and disease control.
Family and Social Support Factors	Family Support	Family functional resilience and coping ability have a direct impact on self-management.
	Healthcare Professional Support	Insufficient support: 41.9% of patients did not discuss mental health issues, 50.5% were never asked about them, and 64% did not receive mental health referrals.
	Peer Support	School-age patients face multiple conflicts at school; support groups can improve quality of life and reduce disease severity, with the best effects observed in age-specific groups.
	Digital/Technological Support	Online behavioral interventions and digital health education can significantly improve the self-management ability of patients and caregivers, and reduce short-term recurrence rates in moderate-to-severe pediatric patients.

Place of residence also influences self-management in AD patients. A study by Luo et al found⁴⁶ that urban residence was associated with severe AD, which may increase the difficulty of self-management. Regarding education level, one study focusing on adult AD patients found that higher education levels were associated with higher usage rates of complementary and alternative medicine (CAM).⁴⁷ This may indicate that patients with higher education levels are more inclined to actively seek diverse treatment methods, demonstrating stronger self-management awareness. Previous studies have shown that¹ while patients with higher education levels generally possess better health literacy, they are also more likely to develop topical corticosteroid phobia, which can serve as a significant barrier to, rather than a facilitator of, self-management.⁴⁸ For children with AD, the educational level of parents directly influences their management cognition and behaviors. Higher educational level is significantly positively correlated with better AD knowledge among caregivers;^16,17 families of children whose fathers have a master’s or doctoral degree are more likely to exhibit management characteristics with high coping ability.⁴⁹

However, the relationship between socioeconomic status and AD is controversial. A systematic review by Bajwa et al found⁵⁰ that 42% of studies reported AD was associated with higher socioeconomic status, 15% reported a negative association, and 43% showed no association or inconsistent results. There is a significant positive correlation between the self-management behaviors of patients with AD and their socioeconomic status.⁵¹ Higher education levels and higher income are generally associated with better disease knowledge, a more positive treatment attitude, and more standardized self-management; whereas low socioeconomic status, low health literacy, or lack of social support often lead to insufficient self-management ability, undertreatment, and poorer health outcomes.

Regarding financial circumstances, economic factors directly affect patients’ ability to access appropriate treatment. Research has found that the annual social cost of AD in European adults is estimated at 30 billion euros, including 10.1 billion euros in direct medical costs and 4.7 billion euros in out-of-pocket expenses for patients/families.⁵² This substantial economic burden may prevent some patients from affording necessary treatments, thereby affecting their self-management outcomes. A cross-sectional study has shown that a higher per capita monthly household income is significantly associated with more proactive prevention and management practices among caregivers.¹⁶ Another cross-sectional study using latent profile analysis also indicated that households of children with AD whose per capita monthly household income exceeds 20,000 yuan tend to be classified as having a “low intimacy, high coping” management profile, demonstrating stronger disease coping and management capabilities.⁴⁹ A study conducted in China showed that the average annual total cost per household due to AD was approximately 28,591.92 yuan, with 92.8% being direct costs. Outpatient or emergency costs were 90.7% out-of-pocket, and hospitalization costs were 43.4% out-of-pocket.⁵³ These high out-of-pocket expenses may lead some economically disadvantaged patients to delay seeking medical care or choose cheaper but potentially less effective treatments.

Disease-Related Factors

Disease severity is a crucial factor influencing self-management behaviors in AD patients. A cross-sectional study demonstrated a negative correlation between AD severity and self-management behaviors. A questionnaire survey of 164 children with AD and their parents found that the higher the severity of the disease, the poorer the family’s self-management ability..⁵⁴ This may be attributed to the fact that severe symptoms increase the psychological burden on patients, thereby reducing their motivation for self-management. Up to 87% of adolescent and young adult patients reported that the severity of AD directly affected their self-management ability.⁵⁵ Furthermore, disease duration serves as another significant influencing factor. Another study revealed negative correlations between disease duration and scores for anxiety and self-direction,⁵⁶ suggesting that long-term illness may lead to feelings of helplessness, consequently diminishing patients’ initiative in self-management. A 2021 cross-sectional study further confirmed the impact of disease duration on self-management behaviors. This research compared adherence to guideline-recommended preventive measures between two cohorts of German AD patients in 2010 (n=1678) and 2017–2019 (n=706). Analysis identified that longer disease duration was one of the predictors for patients’ adherence to obligatory preventive measures (eg, regular skin care, irritant avoidance, smoking cessation, relaxation techniques).⁵⁷ This implies that prolonged disease duration may enhance patients’ propensity to adopt and maintain evidence-based self-management behaviors through continuous learning and accumulated experience. Concerns about medication safety are a key bottleneck affecting adherence. Among adolescent and young adult patients, 45.5% experienced self-management barriers due to fear of side effects from AD treatment medications,⁵⁵ concerns about adverse reactions to systemic therapy are also an important cause of insufficient treatment adherence and management discontinuation among both patients and caregivers.⁵⁸

Psychological Factors

In recent years, the prevalence of AD has shown an increasing trend. AD not only affects patients’ physical health but also significantly impacts their psychological well-being. Self-management plays a crucial role in the long-term control of AD, but patients often face various psychological challenges when implementing self-management practices. Due to intense itching during acute flares and concerns about disease progression, AD patients frequently experience psychological conditions such as anxiety and depression. Psychological stress and negative emotions are key factors influencing self-management in AD patients.¹⁹ A focus group study found that all AD patients believed psychological stress could exacerbate eczema and itching symptoms.⁵⁹ Chronic stress is considered to have a greater impact on AD than acute stress. Furthermore, AD patients often experience emotional issues such as anxiety and depression, and these negative emotions may affect patients’ motivation and ability for self-management,^60,61 as patients adopt positive attitudes and actions when facing the disease with an optimistic mindset. Multiple studies have shown that the incidence of anxiety and depression in AD patients is significantly higher than in the general population. A systematic review and meta-analysis incorporating 39 studies, involving 234,306 AD patients and 10,935,459 control individuals, demonstrated a significantly increased risk of depression in AD patients, a risk present across child, adolescent, and adult populations.⁶² These findings suggest that anxiety and depression may influence disease control and prognosis in AD by affecting patients’ self-management abilities and treatment adherence.

Family Social Support Factors

Social support refers to the mental and material assistance provided to individuals by various aspects of society, including family, relatives, friends, and social organizations (See Figure 3).

Figure 3.

Factors influencing self-management behaviors in AD.

Family support is a crucial foundation for self-management in patients with AD, especially pediatric patients. A cross-sectional study constructed a family management structure model for children with AD, and the results showed that family functional resilience and family coping ability have a direct impact on self-management, explaining 78.9% of the model.²⁰ This indicates that family support plays a central role in self-management for patients with AD. Support from healthcare professionals is essential for self-management in patients with AD; studies found that 41.9% of AD patients had not discussed mental health issues with their dermatitis providers, 50.5% had not been asked about relevant issues, and 64% had not received a mental health referral.²¹ This suggests that there is still a shortfall in providing comprehensive support by healthcare professionals, particularly in mental health support. Peer support in self-management for patients with AD is receiving increasing attention. School-aged patients face multiple management conflicts at school. A qualitative study showed that adolescent patients experience conflicts between skin moisturization and the school’s time and space, between flare-ups and physical activity, and between follow-up visits and classes, and they commonly face a lack of school social support, including inadequate professional guidance, insufficient disease knowledge among teachers, and a lack of long-term treatment supervision.³²

A systematic review found that support groups can improve the quality of life of patients with AD and reduce disease severity, with the best effects observed in groups targeting specific age groups.⁶³ This suggests that peer support may help patients with AD manage the disease more effectively by providing emotional support and sharing experiences. Accessible medical technology support can significantly empower patients. Multiple randomized controlled trials have shown that introducing online behavioral intervention programs (such as Eczema Care Online) or smartphone-based digital health education can substantially enhance self-management abilities for patients and caregivers, raise patients’ empowerment levels, and effectively reduce short-term relapse rates in children with moderate to severe disease.⁶⁴

Interventions for Self-Management Behaviors in Patients with AD

Health Education

There is evidence that patient education is the foundation for improving self-management behaviors in patients with AD. Comprehensive patient education not only helps patients better understand the disease but also significantly improves treatment adherence, alleviates disease symptoms, and enhances patients’ quality of life.^22,65

Emphasis in Guideline Consensus

Multiple guidelines have emphasized the importance of patient education. The “Consensus on Comprehensive Management of Atopic Dermatitis” published by the Immunology Group of the Chinese Society of Dermatology emphasizes that patient education should run through the entire management process. Physicians should inform patients about the chronic and recurrent nature of the disease and explain the treatment goals, standardized treatment methods, and details of medication use at each stage.⁶⁶ The “Chinese Expert Consensus on Drug Treatment and Pharmaceutical Care of Atopic Dermatitis” published by the Hospital Pharmacy Professional Committee of the Chinese Pharmaceutical Association also suggests explaining the nature of the disease to patients, dispelling misconceptions, and providing detailed education on avoiding aggravating factors (such as non-specific irritants, contact allergens, environmental and food allergens, etc).⁶⁷ South Korea’s guidelines also suggest conducting training through structured and interdisciplinary collaboration.⁶⁸

Diversification of Educational Content and Formats

Research indicates, effective patient education content should be comprehensive and individualized, covering general knowledge about the disease, skin care (such as proper bathing and the use of emollients), avoidance of triggers, standardized medication use, and psychological adjustment.^66,67 The forms of education are becoming increasingly diverse. In addition to traditional doctor consultations and booklets, group education programs, “eczema schools”, nurse led clinics, and online resources (such as videos, articles, and electronic health portals)^66,68,69 have shown preliminary evidence that these methods are effective. Studies have shown that patient education programs can significantly reduce the severity of AD, and the impact of programs targeting adult populations can be comparable to those for children.⁷⁰

Application of Educational Tools

To enhance educational effectiveness, various tools have been developed and applied. Written Eczema Action Plans (EAPs) have been proven to improve treatment adherence and patient understanding.^68,71 A study published in 2024 developed “conversation cards” as agenda-setting tools to help patients collaboratively build a shared agenda with physicians during consultations that focuses on their needs, receiving positive evaluations from both patients and healthcare professionals.⁷² However, not all educational tools have shown expected results. A randomized controlled trial (n=175) published in 2021 evaluated an educational booklet designed for caregivers of children with AD. The results showed that while the booklet improved management confidence in families of new patients (P=0.012), there was no statistically significant difference in improving AD symptoms (as measured by the POEM score) compared to standard management.⁷³ However, it should be noted that there are significant differences in intervention content between different studies, and the consistency of the effects still needs to be confirmed by more large sample, multi center studies.

Behavioral Intervention

Based on existing evidence, behavioral interventions have a moderate improvement effect on certain symptoms of AD, but the quality of the evidence varies depending on the research design. Regarding scratching behavior, a 2024 meta-analysis including 6 randomized controlled trials (RCTs) with a total of 246 patients demonstrated that behavioral interventions significantly reduced eczema severity (r=−0.39, p<0.001) and scratching severity (r=−0.19, p=0.017), but had no significant effect on itch intensity.⁷⁴ The results of this study are from a randomized controlled trial. Due to the small sample size of the included RCTs, the effect size may not be stable enough and further research is needed. According to the latest global guidelines and consensus on pediatric AD,^75–77 behavioral interventions for affected children include trimming nails short, wearing cotton gloves, and recognizing pre-scratching cues. Multiple studies targeting pediatric patients have also confirmed^78,79 that behavioral interventions can significantly reduce eczema severity and scratching severity.

These findings suggest that the improvement in scratching behavior through behavioral interventions may be mediated by non-itch-related pathways. At the psychological level, Psychological and behavioral interventions, such as cognitive-behavioral therapy (CBT), mindfulness training, and relaxation techniques, are gradually accumulating evidence for improving the psychological state and quality of life of AD patients, with some studies providing evidence for the efficacy of CBT.⁸⁰ The Chinese Expert Consensus on Pharmacotherapy and Pharmaceutical Care for Atopic Dermatitis has listed autogenic training, stress reduction and relaxation techniques, CBT, and habit reversal therapy as adjunctive treatment options.⁵ A 2023 randomized clinical trial involving 107 adults confirmed that an 8-week online mindfulness and self-compassion training significantly improved the Dermatology Life Quality Index (DLQI) (between-group difference estimate:-6.34, p<0.001) and concurrently improved all secondary outcomes, including itching, scratching, self-compassion, and psychological symptoms.²³ For children with AD, studies have shown that implementing behavioral interventions combined with psychological care can help alleviate the degree of itching, shorten the time for skin lesion resolution, improve sleep quality, and significantly ameliorate adverse psychological states such as anxiety and depression in pediatric patients.⁸¹ A systematic review indicated that, among pediatric AD patients, education on mindfulness and relaxation techniques demonstrated the strongest evidence for improving AD severity and quality of life,⁸² there is strong evidence to suggest that mindfulness and relaxation techniques education can improve AD severity scores and quality of life.

Furthermore, the efficacy of CBT has been widely validated: a 2023 feasibility study of an 8-week digital CBT intervention in 21 adult AD patients showed moderate to large improvements at the 3-month follow-up in skin-related quality of life (Cohen’s d=0.89), itching (Cohen’s d=0.85), and depressive symptoms (Cohen’s d=0.78).⁸³ In order to improve the accessibility of CBT, a randomized non inferiority trial in 2025 compared self-directed CBT and clinical guided CBT in 168 adult patients. The results showed that the self guided group improved POEM scores no less than the clinical guidance group (average difference: 0.36 points, below the predetermined non inferiority threshold of 3 points), suggesting that self guided CBT may be a feasible promotion method. However, it should be noted that this study is only single center, with a broad non inferiority threshold and moderate evidence strength, and still needs to be validated in different populations.²⁴ In summary, the evidence suggests that behavioral interventions may improve AD scratching behavior and may also enhance the overall quality of life of patients through psychological regulation pathways. However, the speculation that behavioral intervention improves itch behavior through psychological regulation pathways still lacks direct experimental data support. This conclusion is based on indirect evidence and needs further verification. In addition, the self-directed model is expected to overcome the accessibility barriers of traditional treatments and provide more practical strategies for the comprehensive management of AD.

Digital Intervention

With the development of mobile health technologies, digital interventions (such as mobile apps and remote monitoring) have become effective tools to support self-management in patients with AD, offering advantages in convenience, accessibility, and personalization.

Improve clinical outcomes and quality of life: Multiple studies have demonstrated the clinical effectiveness of digital interventions. In 2022, a prospective study of 21 adult AD patients who received a 6-week digital intervention showed a 44% improvement in SCORAD, a 46% improvement in POEM, a 41% improvement in DLQI after intervention (all indicators were p<0.001), and a significant 83% improvement in treatment compliance.⁸⁴ Due to the lack of a control group mentioned above, these improvements may be partially attributed to natural course or placebo effects, and cannot be fully attributed directly to the intervention. Another large randomized controlled trial published in 2022, including 340 children and their parents and 337 youths, showed that online behavioral intervention significantly improved eczema severity at 24 weeks compared with usual care (mean differences in POEM scores of-1.5 and-1.9, P≤0.002), with effects persisting to 52 weeks.⁶⁴ The research design is rigorous and the conclusions are relatively reliable.

Differential effects on various outcome measures: A 2024 systematic review and meta-analysis of 12 clinical trials involving 2424 participants found that mobile health apps and remote monitoring significantly improved patient-reported quality of life (DLQI mean difference-0.59) and self-management (POEM mean difference-1.57) (P≤0.001), but did not have a significant impact on objective disease severity (SCORAD P=0.91).²⁵ This suggests that digital interventions may exert more influence on patients’ subjective experiences and behavioral aspects. However, due to the high heterogeneity among included studies, the effect size is small, and the clinical significance is limited.

High engagement and acceptability: Patients show high engagement and satisfaction with digital health programs. A prospective intervention study in 2023 (n=21) found that 95% of participants completed the 6-week digital health program, with an average of 6.5 active days per week, completion rates for medication reminders and educational tasks staying above 90%, and an overall user satisfaction score of 6.2/7.⁸⁵

Lifestyle Interventions

Lifestyle adjustments, such as exercise, diet, and relaxation techniques, are spontaneously adopted by patients and perceived as beneficial for management.²⁶ But currently, the evidence base mainly comes from cross-sectional studies, and more high-quality intervention studies are needed to support it.

Patients’ practices and perceptions: A cross-sectional study published in 2022 involving 115 patients with AD found that 93.1% engaged in exercise, 41.4% used relaxation techniques, and 75.9% adjusted their diet. Most patients believed these interventions were helpful, especially relaxation techniques (87.0% found them helpful) and dietary adjustments (95.1% found them helpful).⁸⁶ However, cross-sectional study designs cannot prove causal relationships and there is recall bias, resulting in conclusions that only have descriptive value.

Guidelines recommendations: The China Experts Consensus on Pharmacological Therapy and Pharmacist Monitoring for Atopic Dermatitis states that moderate-intensity aerobic exercise can alleviate dermatitis symptoms and may serve as an alternative therapy for some patients, but care should be taken to rinse off sweat promptly after exercise.⁶⁷ Regarding diet, this consensus notes that, unless a specific food is confirmed to contribute to AD progression, an elimination diet for allergens is not recommended to avoid nutritional deficiencies.

Strengthen Doctor-Patient Communication

Establishing a good doctor-patient relationship and implementing a joint decision-making mechanism to improve doctor-patient communication and shared decision-making (SDM) may help increase the willingness and effectiveness of self-management in AD patients, with current evidence mainly coming from observational studies.

Patients’ expectations of SDM: A 2022 survey of 1313 patients and caregivers found that the majority of respondents wished to play an important role in care decisions, with nearly half (49.6%) indicating that they “want to make the final decision after carefully considering the doctor’s opinion”.⁷ The study also found that patients who were “very knowledgeable” about disease causes had 3.4 times the confidence in participating in future SDM compared with those who were “not well informed” (P<0.001), again underscoring the importance of patient education in empowering participation in decision-making.⁸⁷ This study revealed the significant impact of patients’ education level on their willingness to participate in decision-making through survey data, but did not delve into the specific definition of “full understanding” and the behavioral transformation in actual decision-making. The conclusion has reference value.

Impact of SDM on outcomes: A survey across eight countries involving 3171 patients and caregivers found that although the reporting rates for self-management training and SDM are relatively low, they are significantly associated with better symptom control and higher satisfaction with treatment.⁸⁸

Role of professionals: Dermatology nurse specialists play a central role in building doctor–patient trust, providing emotional support, delivering systematic education, and enhancing patients’ self-management abilities.⁸⁹ At the same time, healthcare professionals should provide supportive and respectful assistance and possess deep AD knowledge, guiding consultations through agenda setting to meet patients’ specific needs.⁹⁰

Limitations

Evidence of Intervention Effectiveness is Not Strong

Although various interventions show potential, the quality of evidence from existing studies is generally not high. A 2021 systematic review noted few studies addressing interventions to improve primary care providers’ management of AD, with insufficient evidence supporting their effectiveness, and the studies carried moderate-to-high risk of bias and substantial design heterogeneity.⁹¹

Limitations of Behavioral Intervention Studies

A meta-analysis on behavioral interventions indicated that conclusions were constrained by a small number of randomized controlled trials, limited sample sizes, and short follow-up periods.⁷³

Availability Issues of Digital Interventions

Although digital interventions perform well in improving clinical outcomes, some studies revealed usability problems. A CBT-based digital intervention study found that systematic usability scores fell below predefined acceptable standards, indicating a need for improvements to enhance user experience.²⁴

Lack of Head-to-Head Comparisons Across Different Intervention Modalities

Most current research compares a single intervention with usual care, with few direct comparisons between different educational or intervention approaches. This makes it difficult to provide optimal intervention recommendations for patient groups with different characteristics.⁹²

Lack of Standardized Knowledge Assessment Tools

A 2025 scoping review found that knowledge assessment tools used to evaluate education effects in AD patients are diverse and lack validated, high-quality, standardized instruments, which may affect accurate assessment of educational interventions’ true effects.⁹³

Insufficient Self-Management Support for Specific Populations (eg, Young People)

Qualitative studies reveal that young adult patients face unique challenges in transitioning to self-management, feel uncertain about how to treat and manage AD, and receive limited self-management support from healthcare institutions.^94,95

Conclusion

Despite significant progress in research on self-management behaviors among patients with chronic diseases such as diabetes and asthma, studies focusing on self-management behaviors in patients with AD remain poorly documented in the existing literature. Moreover, the relevant research is often limited to small samples or descriptive designs, resulting in limited evidence strength. Due to factors such as recurrent episodes of the condition, uncontrollable itching, and social stigma, patients with AD may face numerous challenges during long-term self-management. Therefore, it is necessary to systematically analyze various influencing factors based on large-sample, rigorously designed studies, and to develop self-management behavior assessment tools tailored to the characteristics of AD, thereby providing more reliable evidence to support interventions.

Based on available specific studies, future interventions should be tailored according to different age groups and other relevant factors. For children and adolescents, preliminary evidence supports the inclusion of cognitive behavioral therapy in intervention programs to break the “itch-scratch” cycle and alleviate anxiety. However, existing studies generally have small sample sizes, and the heterogeneity of intervention effects across studies is substantial; their effectiveness still requires further validation through larger-scale, standardized randomized controlled trials. At the same time, a few studies suggest the use of mobile health platforms and wearable devices to provide personalized disease education and medication reminders. Additionally, some observational studies indicate that online and offline peer support networks should be established to enhance psychological support and self-efficacy. For adult patients, research suggests that a collaborative model involving physicians, nurses, and patients can help develop scientific skin care plans, thereby improving treatment outcomes and symptom control. Meanwhile, the use of social media tools to monitor potential environmental triggers of symptoms can be explored. For elderly patients, existing guidelines and retrospective studies emphasize the importance of focusing on comorbidity management and drug interactions. Furthermore, some feasibility studies recommend simplifying operational procedures and strengthening supervision. Family support and community interventions are also mentioned as potentially important factors in multiple descriptive studies.

In addition, due to the small sample sizes, high population heterogeneity, and lack of stratified analysis in existing studies, it is currently not possible to determine how future research should conduct subgroup analyses based on factors such as gender, disease stage, disease severity, and patients’ self-efficacy in order to develop more personalized intervention plans. Multilevel, personalized comprehensive self-management for AD may improve long-term prognosis and quality of life for patients. However, further validation through more rigorously designed, adequately powered randomized controlled trials with clear intervention components is needed to clarify the true effects of each intervention component across different populations.

Funding Statement

The authors received no specific funding for this work.

Data Sharing Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Ethics Approval and Informed Consent

Our study did not require an ethical board approval and informed consent because it did not contain human or animal trials.

Author Contributions

Zhirun Wang and Xue Chen share first authorship. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, literature search and screening, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors report no conflicts of interest in this work.