Optimized User Experience, Efficiency, and Resource Use in Online Self-Management of Atopic Dermatitis

Abstract

This quality improvement study describes the revision of an internet-delivered, self-guided psychological treatment for atopic dermatitis.

Cognitive behavioral therapy (CBT) for atopic dermatitis (AD) has had mixed outcomes.¹ An online CBT protocol with exposure as its main component was developed by Hedman-Lagerlöf et al,² showing moderate to large benefits for eczema symptoms. Online CBT often uses written therapist guidance.³ However, to our knowledge, many clinical psychologists are not knowledgeable about AD, and psychologists are rare in dermatological care. Therefore, an intervention requiring no therapist support may be more accessible and easier to implement.⁴

Stringent clinical processes, clinical monitoring, high-quality material, and intuitive design have been suggested as prerequisites for self-management treatment to fill the many functions of a therapist.⁴ In this uncontrolled quality improvement study with a pretest-posttest design, we revised the original treatment² into a self-care intervention and performed an uncontrolled pre-post evaluation of its potential utility.

Methods

We developed this intervention with dermatologists, who deemed the exercises to be safe. The Swedish Ethical Review Authority approved the study, and informed consent was obtained digitally. We followed the SQUIRE reporting guideline.

Participants were recruited by advertisements, interviewed by telephone (all those interviewed were included), and started treatment afterward. Inclusion criteria were age 16 years or older and self-reported AD, and the exclusion criterion was disease or condition with priority before AD. The study was conducted from March 15 to August 20, 2021.

The self-care intervention was administered on a secure website. Participants read educational material and used the same CBT-based tools of mindfulness and exposure developed for the original intervention.³ The eMethods in the Supplement provides an extended description.

The primary outcome was the Patient Oriented Eczema Measure (POEM) score (range: 0-28, with the highest scores indicating very severe eczema). A POEM score change of 3.4 points is considered to be a clinically significant response.⁵ Response was operationalized as 4 points or higher on POEM.² A secondary outcome was the Client Satisfaction Questionnaire score (range: 8-32).⁶

Dependent samples t tests and within-group effect sizes (Cohen d) were performed. Data were analyzed per protocol, and other observations were analyzed descriptively. SPSS, version 27 (IBM Corp), was used for all statistical calculations, and 2-sided P = .05 indicated significance.

Results

Twenty female participants (mean [SD] age, 42.5 [16] years) were included. Table 1 compares the demographic and treatment characteristics associated with the original vs revised intervention. The revised intervention is much shorter than the original (16 726 vs 111 142 words) (Table 2).

Table 1. Differences Between the Original and Revised Interventions.

Variable	Online CBT (original)	Psychological self-care (revised)
Participant characteristics
All participants	51	21
Female sex, No. (%)	41 (80)	20 (96)
Male sex, No. (%)	10 (20)	1 (4)
Age, mean (SD), y	37.0 (11.0)	42.5 (16.0)
Eczema severity at start, No. (%)
Very severe	7 (14)	3 (14)
Severe	22 (43)	8 (38)
Moderate	21 (41)	8 (38)
Mild	1 (1)	2 (10)
Educational level, No. (%)
≥University	31 (65)	13 (61)
≤Secondary school	14 (28)	6 (28)
Othera	4 (8)	2 (11)
User interface b
Total No. of words	111 142	16 726
Duration of treatment, wk	12	8
Therapist time, mean (SD)	40.0 (37.2) min/participant	0 min by design
Means of support	Personalized therapist messages	Generalized automated messages
Unlocking new modules	Opened by therapist	Automated if/when: 1 wk had passed and participant interacted with all content
Within-group effect, Cohen d (95% CI)
Postintervention POEM score	0.93 (0.32-1.24)	0.61 (0.11-1.12)
Follow-up POEM score	0.89 (0.50-1.28)	0.84 (0.38-1.37)
Responders at follow-up, No. (%)c	33 (65)	11 (69)
Treatment satisfaction, mean (SD)	25.0 (4.4)	22.7 (4.2)

Abbreviations: CBT, cognitive behavioral therapy; POEM, Patient Oriented Eczema Measure.

^a Others included the Swedish equivalent of middle school or junior high school (ends at year 9) and secondary school <3 years.

^b The user interface for the original online CBT was optimized for desktop computers, and the interface for the revised self-care treatment was optimized for mobile devices.

^c The data included those who filled out the follow-up questionnaires.

Table 2. Overview of the Themes of the Interventions.

Week	Online CBT (original)		Psychological self-care (revised)
	Content	No. of words	Content	No. of words
1	AD and CBT: introduction; AD from a CBT perspective; itch/scratch diary	13 692	Introduction: AD and CBT; how to navigate the intervention and mindfulness: psychoeducation about mindfulness and instruction about exercises	4605
2	Itch and psychological processes: education; itch/scratch diary; control strategies diary; mindfulness	12 878	Exposure: psychoeducation about exposure and instruction about exercises	4033
3	Primary and secondary suffering: education; diaries; mindfulness; thoughts; introducing exposure	19 648	Itch: psychoeducation about itchiness and the behavior of scratching. Participants continue to practice mindfulness and exposure	1112
4	Conditioned symptoms; exposure: education; diaries; mindfulness; thoughts; radical self-acceptance; exposure	14 178	Thoughts: psychoeducation about influence of thoughts on AD. Participants continue to practice	1119
5	Function of behaviors: education; mindfulness; diaries; exposure	11 032	Social stigma: psychoeducation about stigma around AD and what to do. Participants continue to practice	972
6	Eczema and social stigma: education; “scratch-free day”; functional behavioral analysis; self-compassion; mindfulness	8954	Sleep: psychoeducation about sleep problems. Participants continue to practice mindfulness and exposure	1729
7	Life values: education; exposure; mindfulness; “scratch-free day”; life compass	9580	Bad days: how to act when symptoms are considerable. Participants continue to practice	2105
8	Coping with sleeping problems: education; mindfulness; exposure; “scratch-free day”; plan for better sleep	6859	Relapse prevention: construction of a relapse plan and plan for future goals	1051
9	Treatment summary; bad days: education; mindfulness; exposure; treatment summary; exposure summary; “scratch-free week”	7734	NA	NA
10	Maintaining experiences: maintenance plan; continue to practice	5775	NA	NA
11	Continue to practice	282	NA	NA
12	Continue to practice	529	NA	NA
	Total word length	111 142	Total word length	16 726

Abbreviations: AD, atopic dermatitis; CBT, cognitive behavioral therapy; NA, not applicable.

Compared with baseline, postintervention data had a moderate effect size (t = 2.5162, df = 17; P = .04) and a moderate to large effect size (t = 3.9306, df = 15; P = .005) at the 3-month follow-up. No participant reported a clinically significant increase in symptoms, and no adverse events were reported. Eighty-five percent of participants (n = 17) registered at least 1 exposure exercise, and 65% (n = 13) returned at least 5 of 8 homework assignments. Treatment satisfaction was acceptable.

Discussion

We aimed to evaluate the potential utility of this online self-management psychological intervention for AD. We also compared it to the original, comprehensive, therapist-guided version.² Significant improvements in self-rated AD symptoms (POEM scores), with large effect sizes, were reported at the 3-month follow-up. These results are similar to those reported for the original treatment. Findings suggest that a self-care intervention is feasible and potentially comparable to a comprehensive, therapist-guided version,² provided that the intervention is well designed and includes clinical interviews and on-demand technical support.⁴

A study limitation is the lack of comparison to a control group; therefore, the findings are preliminary. A randomized comparison of the interventions is needed. If this self-care treatment is shown to be noninferior and resource effective, it may be a highly useful option for patients with AD.

Supplement.

eMethods