Eczema Patients Do Well With Self-Guided Cognitive Behavioral Therapy

Self-guided cognitive behavioral therapy (CBT) proved noninferior to clinician-guided CBT for reducing symptom severity in adults with eczema, a randomized trial from Sweden found.

At 12 weeks of follow-up, similar improvements on the Patient-Oriented Eczema Measure (POEM) were reported whether CBT was self- or clinician-guided (4.60 vs 4.20 points, respectively), with a mean difference in change that met criteria for noninferiority (0.36 points, 1-sided 97.5% CI -∞ to 1.75), according to researchers led by Dorian Kern, PhD, of the Karolinska Institutet in Stockholm.

In an intent-to-treat analysis, 60% of the self-guided group and 49% of the clinician-guided group were considered responders, a POEM improvement of at least 4 points.

“Overall, the findings support a self-guided intervention as a noninferior and cost-effective alternative to a previously evaluated clinician-guided treatment,” the authors concluded in JAMA Dermatology. “Because psychological interventions are rare in dermatological care, this study is an important step toward implementation of CBT for people with AD [atopic dermatitis].”

Face-to-face and online delivery of clinician– and self-guided CBT interventions — which focus on mindfulness training and exposure and response prevention — have been found similarly safe and feasible, the researchers explained. Self-guided CBT has the advantage of not requiring clinician involvement of course, which may allow for increased access, even in remote areas.

Psychological tools like CBT are “invaluable” for helping atopic dermatitis patients break the itch-scratch cycle, noted Danilo C. Del Campo, MD, of the Chicago Skin Clinic, who was not involved in the research.

“The study highlights how self-guided CBT could serve as an effective and scalable intervention for addressing the psychological and behavioral aspects of AD, which are often underappreciated and under-addressed in dermatology,” he told MedPage Today. “For patients who are motivated and have mild-to-moderate atopic dermatitis, a self-guided approach could offer a convenient and effective option — another tool in the toolbox for those who can potentially benefit.”

But he noted that clinician-guided CBT still has its place, especially for patients with severe disease or those requiring additional support.

“This study highlights the importance of having multiple tools available, as they allow us to tailor care to the unique needs of each patient. For physicians, having more evidence-based options like this is always a welcome advancement,” Del Campo said.

The single-blind study from Kern and colleagues was conducted at the Karolinska Institutet from November 2022 to April 2023. The authors used social media to enroll 168 adult participants with self-reported atopic dermatitis (84.5% women; mean age 39) to receive a 12-week CBT intervention that included mindfulness training and exposure and response prevention. POEM scores for atopic dermatitis symptom severity and frequency were measured at pre-assessment, 8 weeks, postintervention, and 6-month follow-up.

Most patients had moderate (29%) or severe (48%) eczema, with comorbid allergies in 15% of the self-guided CBT group and 29% of the clinician-guided group and asthma in 8% and 15%, respectively.

“According to the protocol, mindfulness increases awareness of emotional and behavioral reaction patterns, aiming to increase tolerance of aversive inner experiences, particularly itching,” the study authors noted.

The self-guided CBT protocol was optimized for brevity and usability without clinician guidance, and had significantly less text than the clinician-guided intervention, at approximately 17,000 and 111,000 words, respectively. The clinician-guided intervention required an average of 50 minutes of clinician time overall — 36 minutes on treatment guidance and 14 minutes on assessments — versus a total of 15.8 minutes for assessments in the self-guided group.

Overall, 90% of participants completed the postintervention assessment. Improvements on POEM after per-protocol sensitivity analysis limited to completers-only were 5.88 points for the self-guided CBT group and 6.44 points for the clinician-guided CBT group, an estimated mean difference of 0.49 points (1-sided 97.5% CI -∞ to 2.87).

“Secondary outcomes were similar between groups with moderate within-group effect sizes at postintervention,” Kern and co-authors noted. “Both groups showed significant improvements in QOL [quality of life], sleep, depressive mood, pruritus, and stress.”

No serious adverse events (AEs) were reported, although there were a few cases of minor AEs, such as stress and temporarily increased pruritus.

Study limitations included the fact that high data loss in many of the secondary measurements (about 30%) limited interpretation of those results, and that the vast majority of participants were female.