Parental Response to Written Eczema Action Plans in Children with Eczema

INTRODUCTION

The treatment of eczema in the pediatric population can be a complex and dynamic process. A typical care plan may include over-the-counter and prescription topical agents, oral medications, as well as bathing and dietary recommendations. Inevitable disease fluctuations demand treatment modification and thus parental and patient confusion can easily occur. Unsurprisingly, adherence in eczema management is poor and has been reported to be as low as 32% with simple regimens.¹

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

METHODS

During clinic appointments at our tertiary allergy program, children with eczema treatment regimens requiring multiple topical and/or oral medications were approached by their provider to participate in the study and were given an individualized EAP (Figure 1) similar to a previously published eczema action plan.⁵ Parents completed a baseline survey addressing parents’ perceived severity of their child’s eczema, treatment comfort level, and whether or not they had previously received a written eczema care plan. Parents were contacted via telephone between 3–12 months later to complete a follow-up survey regarding the severity of their child’s eczema and the utility of the EAP, specifically if it clarified which medications to use during an eczema flare. This study was approved by the Children’s Hospital, Boston Investigational Review Board (Committee on Clinical Investigation). Descriptive statistics were used to explore the characteristics of the study population and statistical significance was determined by McNemars test for paired data.

Figure 1.

Children’s Hospital Boston Eczema Action Plan. All children received a personalized eczema action plan at the time of their baseline visit.

RESULTS

Thirty five children with a diagnosis of eczema were included in the study with 100% completion of baseline and follow-up surveys. The subjects’ ages ranged from 4 months to 17 years with 63% (22/35) male (Table 1).

Table 1.

Demographics of Study Population

Total N = 35 subjects
Age	% (n)
< 1 year      1 – 4 years      5 – 9 years      > 9 years	34% 40% 12% 14%	(12) (14) (4) (5)
Sex
Male      Female	63% 37%	(22) (13)
Race*
White      Black      Hispanic      Asian      Other      No response	49% 17% 9% 9% 9% 9%	(17) (6) (3) (3) (3) (3)

^*Race was self-reported

At baseline, 80% (28/35) reported having never received a written, individualized eczema care plan. Of the thirty-five subjects, 51% (18/35) of parents self-rated their child’s skin as severe and 46% (16/35) as moderate. All subjects completed a follow-up survey via telephone between 3–12 months after the clinic encounter, with a median time of 3.9 months. At the time of follow-up, 80% (28/35) of the parents rated their child’s eczema on a lower severity scale with 57% (20/35) mild, 40% (14/35) moderate, and 3% (1/35) severe. Parental comfort level of skin care improved from a baseline 57% (20/35) to 86% (30/35) after receiving the EAP (p = 0.016).

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

DISCUSSION

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

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

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