Pruritus in pediatric patients with atopic dermatitis: a multidisciplinary approach - summary document from an Italian expert group

For all topical skin care, it should be highlighted that specifically formulated products should be used, which are free of preservatives and perfumes [25].

Despite the increasing prevalence of childhood AD, only a few studies have explored a specific educational approach in the last years. Recent national and international AD guidelines confirm that effective and standardized educational programs should be considered part of AD management and routine care. These treatment strategies are focused on patients and their families. Interventions must be delivered by a multidisciplinary team with an individual face-to-face or group education. The need for education and support will vary according to patient age, socio-cultural behavior, and severity of AD. The educational approach should be preferably focused on families of children below 6 years of age because of the significant and high impact on disease and allow good management following disease onset. It is clear that the motivation to treat is high if the parents receive more (and correct) knowledge about the disease. Parents who play a key role in their children’s treatment can considerably reduce the severity and impact of AD. This suggests that in addition to pharmacological treatment, providing educational support to parents is an important factor in achieving a positive long-term outcome. Less benefit for children more than 6 years with moderate or severe eczema has been reported because they become with time less motivated to treat themselves [59], and for this reason the educational program should start as soon as possible. The treatment of AD should ideally take into consideration both the patient’s physical and emotional aspects and the impact of the disease in personal and family contexts. Attention to the emotional area allows: (i) promotion of a psychological elaboration that integrates information and emotions, facilitating memorization and consolidation of new information; (ii) creation of a relational context in a dedicated area for listening to the patient and his/her parents (knowing what he/she knows, how the patient lives with the illness, how much it influences them and their family); (iii) supporting the resources and skills of the patient and parents. An early start of the training process is important, before any feelings of ineffectiveness and mistrust and/or relationship difficulties and conflicts are established. For management of AD and pruritus, we think that education should be based on an approach that addresses the needs of the child and parents at a level they can comprehend. Educators are dermatologists, pediatricians, nurses and psychologists. The educators’ role with the intervention group is to train, support, and motivate parents and children in self-management. One of the most important interventions in the management of AD is spending time listening to patients’ concerns, explaining its causes, and showing how to apply topical therapies on the basis of clinical features of the lesions and patient age. The application of topical therapies is an essential part of the successful management of pruritus and atopic eczema. Longer consultations and forming a good caregiver-patient relationship are the strongest predictors of adherence to skin-care treatment. Performing this role requires well-trained educators [60].

Treatment of children with AD and pruritus and adequate management of the daytime and nighttime problems due to itching have a strong impact on the entire family context, making it necessary to focus on emotional and relational aspects. In order to facilitate the management of pediatric patients during application of dressings and to provide tools to deal with frequent itching, the use of specific distraction techniques is crucial. These non-pharmacological procedures with a psychological approach have been described in the literature [61‐63], and are especially useful in pain management and during unpleasant procedures and or sensations. These are cognitive-behavioral techniques, aimed at shifting attention from pruritus and medication towards activities that intensely absorb the patient: the techniques imply active sensory perception, and not just a passive strategy, that can be entertaining the child. The techniques are based on two principles: (i) children have mental boundaries between fantasy and reality that are more fluid and permeable than in adults; (ii) and it is difficult, if not impossible, for a human to focus on more than one or two sensory stimuli at once. A detailed description of distraction techniques by age group along with specific examples is provided as Additional file 1.

The choice of distraction techniques (involvement, breathing, relaxation, hypnotic procedures such as visualization and desensitization) depends on several factors: age, personality, individual likes and dislikes, motivation, and emotions of reference figures. In addition, even the time of day is important since, for example, at night a massage would be favored over watching a cartoon. The application of these tools allows defusing the phenomenon of anticipatory anxiety and increased compliance to treatment. These techniques are useful not only for children, who are the main recipients, but also for parents and siblings. It is therefore important to educate the entire family on their use, and to adapt them in specific situations. Distraction techniques are also helpful to parents to feel more relaxed, they improve the interaction with their child, transmitting greater security and managing the disease with less anxiety. The utility of learning techniques has also been documented in the parents of very young children [59‐62].