Atopic Eczema or Atopic Dermatitis: a Chronic Relapsing Inflammatory Skin Condition - Essay Example

?Nursing Eczema is one of the most common childhood conditions (Lawson 2008) and the most prevalent inflammatory disease in the UK (Kerr 2007). The term “‘Eczema’ refers to the superficial inflammation of the skin and impaired function of the epidermal barrier” (Mandelin 2010, p. 8) characterized “by an itchy, erythematous, poorly demarcated skin eruption, which has a predilection for the skin creases” (Mandelin 2010, p. 10). It has affected about a staggering 15 - 20% of children and 2 - 3% of adults of the United Kingdom.        Atopic eczema (atopic dermatitis), which this paper deals with, is described by Brown & Reynolds (2006) as a chronic relapsing inflammatory skin condition associated with epidermal dysfunction. Atopic eczema mostly begins at the stages of infancy and childhood. Among the children affected, about 65% developed the symptoms of Atopic eczema within their first year of life and 85% were affected with it before they were 5 years old (Atopic Dermatitis, 2011). Though Atopic eczema is found to be severe in infants and children, about 60 - 70% of the affected children are naturally cured of Atopic eczema by their early teens. Those children who inherited this atopic condition may suffer from its symptoms at any time, even in their teens, if triggered by environmental factors. Moreover, the atopic eczema patients are at an increased risk for asthma and allergic rhinitis. (Mandelin 2010).        Nurses play a major role in the management of atopic eczema.  Since there is no cure for eczema, patients and their caregivers can become despondent over time (NICE 2007). However, if a good skin care routine can be maintained, the majority of eczema patients can cope with the condition without too much trouble (Ward 2008).  Educating the patient about eczema is essential but this must be accompanied by demonstrating how to apply treatments, listening to what patients and parents/ caregivers have to say and working together to devise a skin care routine that fits in with their lifestyle in a holistic manner (Ward 2008).  Therefore “both the theoretical and clinical experience of a nurse is vital to assist both family and child in the condition” (Anderson & Miller, 2006).       The primary aim in the treatment of atopic eczema is to heal the skin and to prevent the flare ups. For the treatment of the skin, the parents have to follow an assisted skin care routine, to prevent the worsening of the condition. However, the amount of help and guidance a parent will receive for the treatment of atopic eczema from their GP or nurse can often vary (Ward 2008).  It is, therefore, of great importance that children’s nurses are aware and up to date with evidence based practice (Lawston 2008).          Nurses, since frequently make informed care decisions based on evidence based practice and research (Thompson 2002), they can assist and guide the family of atopic eczema patients and plan and devise an appropriate treatment. Today, nurses are accountable for their own practice and are answerable for their own acts or omissions, regardless of any direct instructions received and are expected to take responsibility for delivering care supported by best practice, a sound evidence base and validated research (NMC 2004).        The changes evolved in the field of Nursing is evident from the new roles of Nurses, such as a nurse practitioner running nurse led dermatology clinics, clinical nurse specialist at the forefront of a medical practicing field, etc. In the modern health care industry, Nurses need to be up-to-date with evidence based practice and it is the responsibility of the nurse to maintain and implement research into practice (Polit & Beck, 2010). Newell & Burnard (2011) reiterated this stating that one’s practice should always be evidence based and as being a health care professional, it is one’s ethical responsibility.        This paper focuses on the research studies conducted to find out the efficiency of prevailing treatments for childhood eczema. Corticosteroid creams and ointments and immunosuppressive drugs are the chosen treatments for atopic eczema, which aids in preventing flare ups and in the healing of skin.        Research critique plays a vital role in this paper as it allows thorough systematic review of literature for relevance using a framework (Brotchie and Waters 2005). Polit & Beck (2010) states that critiquing a piece of work is the conclusion or judgment which summaries the merit or value and may indicate ways to improve the research study.  For research findings to be understood and implemented into practice nurses must learn to critique as their practice must be evidence based practice (Newell & Burnard (2006).  To be aware of research concepts, process and principles that are currently being done to assist a nurse’s knowledge, this paper will critically appraise two quantitative research studies relating to a topic in health and social care and examine the implications of these studies for practice.        As reiterated by Polit and Beck (2010), it is vital for the nurse to know the difference between quantitative and qualitative research methods before they can implement theory to practice. The quantitative research method, which favors towards positivist tradition, uses deductive reasoning to generate predictions that are tested in the real world (Polit & Beck, 2010).  It describes a relative topic by using a specific measurement and quantification approach involving an accurate and restricted design (Polit & Beck 2010).        Unlike qualitative research, which favors a naturalistic approach and therefore aims to gather an in-depth understanding of human behavior, the “why”  and “how” of decision making, quantitative researchers use mechanisms designed to control the research situations so that the biases are minimized and the precision and validity are maximized (Polit & Beck, 2010).  While qualitative research describes a relative topic by using an in-depth and holistic approach to gather relative material in a flexible research design (Polit & Beck, 2010), a quantitative study, like the critically appraised in this paper, can measure efficiency of an ointment in children with atopic eczema with considerable accuracy and precision, but the same cannot be said of the psychological phenomena, such as self-esteem (Polit & Beck 2010).        The research studies, which this paper will review, aim to investigate and compare the efficiency of chosen treatments for atopic eczema in children. One study refers to tacrolimus ointment known as calcineurin inhibitors vs. fluticasone ointment, referred to as topical corticosteroid, being the mainstay of treatment (Doss et al, 2009). The relevance of this subject to parents and caregivers of children with eczema is particularly important as there has always been reluctance among caregivers to use recommended treatments (Callen et al 2007).        A literature search was carried out via. CLINAL with the key words: eczema, childhood, topical, treatments, which generated 500 articles. However, many of them were literature reviews. Some were not available and the others were just abstracts. The number then was reduced to 50.       The first study this paper deals with is by Thomas et al, (2002) “Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema” (Dermatol 2001). The second study taken for this paper is the research done by Doss et al, (2009) “Efficacy of tacrolimus 0.03% ointment as second-line treatment for children with evidence from a randomized, double-blind non-inferiority trial vs. fluticasone 0.005% ointment” (Kamoun MR et al. 2010). Both the above studies received the ethic approval since they were formulated around the ethical principles such as beneficence, nonmaleficence, fidelity, justice, veracity and confidentiality.  With strict observance of these principles, the participants of both the researches were made aware that at any point, they could withdraw from the study and that they should maintain confidentiality, privacy and anonymity (Holloway & Wheeler, 2010).         The objective of the first study, done by Thomas et al (2002), was “to determine whether a three day burst of a potent corticosteroid is more effective than a mild preparation used for seven days in children with mild or moderate atopic eczema” (Thomas et al. 2001). i.e., 0.1% betamethasone valerate applied for three days followed by the base ointment for four days verses 1% hydrocortisone applied for seven days. For this study, a randomised, double blind, parallel group study for 18 weeks’ duration was carried out on 207 children with mild or moderate atopic eczema. Out of 207 children, 174 were recruited from 13 general practices and 33 from the outpatient clinic of a teaching hospital in the Nottingham area.        The participants were divided into two blind groups one of which used 1% beta-methasone valerate to be applied for three days followed by the base ointment for four days while the second group applied 1% hydrocortisone for a seven day period as a treatment for atopic eczema. By measuring the total number of scratch-free days and number of relapses as the primary outcomes and median duration of relapses, number of undisturbed nights, disease severity, scores on two quality of life measures and number of patients in whom treatment failed in each arm as secondary outcomes.  The quality of life was measured according to the scores achieved in the questionnaire regarding children's life quality index and dermatitis family impact.        The study did not show much differences, in result, between the two groups, for both Primary and Secondary outcomes. The median number of scratch-free days, a measure for Primary outcome, was 118.0 for the mild group and 117.5 for the potent group and the median number of relapses, the secondary outcome, for both groups was 1.0 (Thomas et al. 2001). Both groups also showed considerable clinical improvement in the measures of disease severity and quality of life. This study, thus, came to a conclusion that a short burst of a potent topical corticosteroid is just as effective as a prolonged use of milder prepared topical corticosteroids for controlling mild or moderate atopic eczema in children.        Newell and Burnard (2010) commented that a research paper needs to be descriptive but concise so that when keywords are typed into the search engine it will be a paper that will appear on the page. While the title of this article is long it contains important keywords which catch the searchers eye.  Newell & Burnard (2010) also states that a title should inform the reader what the content should contain.  Therefore the title of this study which contains phrases such as “short burst” and “potent steroids” adheres to this statement as it clearly states what is to be expected within the article.         In an attempt to critique the qualities of this study, the knowledge generated ethical soundness and rigorousness of how it was conducted had to be analyzed. The strengths of this study included its eighteen weeks’ duration and the use of patient specific outcomes alongside validated scales for severity and quality of life.        It is important to note that this was not the first study of its kind to be carried out.  A recent systematic review of treatments for atopic eczema identified 83 randomized controlled trials dealing primarily with topical corticosteroids (Mc Henry et al, 1995).  However, most of these trials lasted less than 6 weeks, less than a third of the duration of the study in question, reinforcing its need to be carried out. Greenhalgh (2010) comments that there is negativity associated with systematic reviews, however systematic reviews have assisted in better practice to save lives.  The references for this systematic review were recent and applicable to the study.        The size of the population in this study had strengths and weaknesses. Sample size is extremely important to any study as the study needs to be big enough to make a statistical difference (Crookes & Davies, 2006). Greenhalgh (2010) states that if there is no sample size calculation the intervention has no effect and the authors have found it more difficult to recruit to the study. Calculations determined that this study required one hundred participants in each group to be able to detect a difference of at least 15% in the mean number of scratch-free days between the two groups.  However, the total number of participants was far below this criterion. The remaining number was computer generated, which raises the question, whether the results should be applied to the wider population, as they are not true to life the ratio of error in such a small group of real participants would be much higher (Polit & Beck 2010).  However, this population reflects a wider group of patients with eczema than in previous hospital based studies, generating a wider knowledge for use in general practice.        The weighing of the population in this study also suggests a weakness in the statistical method of the study. 33 out of the 207 participants were recruited from a hospital which is a controlled environment. This under- weighted group being treated in such an environment would have an effect on the results of those participants from general practices.  As the study wanted to see the results within the community, this group would unbalance the results.        One of the side effects of the treatments researched in this study is the thinning of the skin. Therefore, for comparative analysis, one of the methods to measure the efficiency of these treatments was measuring the thickness of the skin over the 18 week period. However, this area of the study was rather weak as eczematous skin tends to be lichenified (abnormally thick).  Therefore, data collected which showed a reduction in the skin’s thickness may have been due to the skin returning to normal thickness, rather than the thinning side effect of the treatment.        Further, this study pointed out that a number of children did not complete the treatment and therefore, as 100% participants were needed in each study, one cannot generalize the findings to the wider population.  However, this weakness in results, in turn, raises and reiterates the issue that the clinical nurse specialists in dermatology often come across: non-compliance to topical treatment.        Parents and caregivers commonly eliminating the use of treatment often due to lack of information, put their children’s skin at risk (Cork & Dandy, 2009). Therefore this article encourages specialist nurses and ward nurses to be informed with evidence based research to reiterate the positive use of corticosteroids appropriately (Crookes and Davis 2006).        The final discussion in this study highlighted its strengths and weakness. This is an opportunity for the researcher to clarify the results in nonprofessional terms as identified by Polit & Beck (2010).        The second study carried out by Doss et al (2009), “Efficacy of tacrolimus 0.03% ointment as second-line treatment for children with evidence from a randomized, double-blind non-inferiority trial vs. fluticasone 0.005% ointment” (Doss et al. 2009) looked at the efficacy and safety of tacrolimus 0.03% and fluticasone 0.005% ointments in children with moderate-to-severe Atopic Eczema. These children, belonging to the age bar of 2 – 15 years, were the second-line patients of Atopic Eczema who had not responded sufficiently to mild- to-moderate potent ointments.        The aim of this study is to investigate the effects of topical 0.03% Tacrolimus ointment, which, when applied to the skin, is absorbed by the skin cells to inhibit cytokines produced by the T-Cells, leading to inflammation (NICE, 2007), versus 0.005% fluticasone pivalate ointment, a potent steroid, which has anti-inflammatory and immune suppressive effects. The latter is absorbed by the skin, however, only working with the immune receptors (NICE, 2007).         The study, which was very clear and concise, took place in 80 centers in Belgium, Finland, France, Morocco and Tunisia, over a 6 week period. This double blind, non-inferiority study was carried out on 479 children, who were between 2 - 15 years. The children, randomly put in to two groups, were made to apply either Tacrolimus ointment or fluticasone ointment twice daily until clearance or, in case of persistent lesions, up to 3 weeks and once daily for up to 3 weeks further.         The 6 week duration of study had Primary and Secondary end-points, each extending to a 3 week time. The rate of percentage of modified Eczema Area and Severity Index assessed the Primary end-point whereas pruritus and sleep quality, global assessment of clinical response, incidence of new flares and safety assessed the Secondary end-point.        At Primary end-point, there was more than 60% improvement in modified Eczema Area and Severity Index in children. None of the parents withdrew children from the treatment on the grounds of lack of efficacy.  At Secondary end-point, there was 86.3% improvement with tacrolimus group and 91.5% improvement with fluticasone group. A score of 93.6% and 92.4% was observed on the physician’s global assessment and 84.0% and 91.5% improvement in pruritus, across Tacrolimus and Fluticasone groups respectively. Both groups reported 92% improvement in sleep quality. Both Tacrolimus and Fluticasone groups reported similar side-effects. A 5.5% of the tacrolimus group and 11.3% of the fluticasone group, experienced new flare-ups after 21 days. The tacrolimus group also experienced skin burning sensation on the application site.        This study, therefore, concluded that 0.03% Tacrolimus ointment is similar in its efficacy to 0.005% fluticasone pivalate ointment and that it can be used in the second-line treatment of moderate to severe atopic eczema in children. (Mandelin 2010, p. 31). Like the previous study this also was a double blinded randomised control study but this was the first of its kind.  A double blinded randomised control study means that the tacrolimus ointment and fluticasone ointment came in unmarked packaging, so that the participants were not aware of the medication they were using. According to Parahoo (2006) the random allocation is a way to ensure that the researcher and the participant are not aware of the allocation. This study was a quantitative design where the researchers where using structured observation. By getting the research question and design correct, one can ensure that the research gathered will be of good quality (Crookes & Davies 2004).  Parahoo (2006) commented that the design needs to be planned in such a way that the research can be implemented into practice in a simple way.        There were 479 patients, between the ages of 2 and 15, in the study. Children any younger could not be studied as tacrolimus is only licensed for use in children over 2 years of age (NICE, 2007).  The study ran from February 2004 with the last patient completing the study in July 2005.  The group to test for tacrolimus consisted of 240 participants. Among them, one was excluded and received no medication, thereby reducing this number to 239.  In the end, however, only 219 completed the study.  The group size of 239 was large enough for the sample to make a significant difference when the findings were analyzed (Crookes & Davies, 2006).  Within quantitative research, the sample size is important.  This was a large sample size in comparison to the previous study, which reduced errors in results (Polit & Beck 2010).        Both treatments, topical tacrolimus vs. fluticasone, were applied twice daily until the skin was clear or for the maximum of 21 days.  The skin was measured by a tool called the Eczema Area Severity index, (EASI) which was validated in 2001 as a reliable tool to use to measure atopic eczema skin (Hanifin et al. 2001). The patients’ skin was measured by the EASI tool on day 1, 7, and 21, within one of the 80 centers running the study.         Both treatments resulted in a significant difference in the condition of children.  Both the ESAI score and quality of sleep had improved in both groups. The only safety issue that arose from both treatment groups was the burning sensation commented earlier, which is a known side-effect of tacrolimus. Therefore, the study shows that tacrolimus is safe alternative to topical corticosteroids (Doss et al. 2004). Also any previous studies done on fluticasone ointment had the same result, therefore, eliminating bias.  The graphs in the study were clear and concise and this study had only one limitation commented on by the author, which is the shorter duration of the study, of 6 weeks.  However, any topical corticosteroids of strong potency should not be used continuously to contain eczema as the side effects are too great (NICE 2007).        By criticizing these two papers, it is evident that topical corticosteroid or calcineurin inhibitors are the only means to control red inflames (flare ups) in atopic eczema, whether it be a short burst of potent topical corticosteroids vs. weaker steroid for a longer period of time or potent topical corticosteroid vs. calcineurin inhibitors.  Whatever you choose as a parent to manage your child’s eczema, all medications has side effects and that is what stops parents using the medication.  However, the quality of life for both the family and the child outweigh the side effects, as a life with eczema can be extremely difficult (NICE 2004). NICE (2007) states that the amount of thinning of the skin that happens to the skin, whilst using steroid, is not significant and it does not outweighs the benefit of quality in life, which are sleep and healthy skin of the child with atopic eczema.           It can be concluded from the studies conducted by Thomas et al (2002) and Doss et al (2009) that both the treatments chosen for atopic eczema are efficient, as the results are the same, provided, the topical corticosteroid or topical calcineurin inhibitor are used and monitored correctly in order to reduce risk. NICE (2004) comments that management of atopic eczema involves good skin care regime which has been highlighted in the introduction of this assignment.  Both of these papers identifies that topical corticosteroids should be used as first line treatments to manage the symptom of flare ups, however, with moderate to severe atopic eczema, a potent topical corticosteroid or 0.03% Tacrolimus ointment is required as a second line treatment to manage the eczema.  Reference List Anderson, C. & Miller, O P. 1990. 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The value of research in clinical decision making. Nursing Times 98 (42) pp 30. Ward, S. 2008. Eczema: From Birth to Old Age. Dermatolgoy Nursing. 7 (2) pp 54 -57. Print.                    Read More