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Can a Focus on Self Care Improve Quality of Life for People With Atopic Dermatitis?

  • Authors: News Author: Lorraine L. Janeczko, MPH; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 6/23/2023
  • Valid for credit through: 6/23/2024, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, dermatologists, nurses, physician assistants, nurse practitioners, pharmacists, and other clinicians who care for patients with atopic dermatitis (AD).

The goal of this activity is for members of the healthcare team to be better able to analyze how an Internet-based mindfulness-based stress reduction (MBSR)/mindful self-compassion (MSC) intervention might affect patients with AD.

Upon completion of this activity, participants will:

  • Evaluate how AD can affect psychosocial outcomes
  • Analyze how an Internet-based MBSR/MSC intervention might affect patients with AD
  • Outline implications for the healthcare team


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News Author

  • Lorraine L. Janeczko, MPH

    Freelance writer, Medscape


    Lorraine L. Janeczko, MPH, has no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine


    Charles P. Vega, MD, has the following relevant financial relationships:
    Consultant or advisor for: Boehringer Ingelheim Pharmaceuticals, Inc.; GlaxoSmithKline; Johnson & Johnson Pharmaceutical Research & Development, L.L.C.

Editor/Compliance Reviewer

  • Yaisanet Oyola, MD

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

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This activity has been peer reviewed and the reviewer has no relevant financial relationships.

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Can a Focus on Self Care Improve Quality of Life for People With Atopic Dermatitis?

Authors: News Author: Lorraine L. Janeczko, MPH; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/23/2023

Valid for credit through: 6/23/2024, 11:59 PM EST


Clinical Context

Atopic dermatitis (AD) affects between 15% and 30% of children and 2% to 10% of adults. The authors of the current study describe how, thanks to its high prevalence data, AD is associated with the highest overall population disease burden of all skin diseases, and this burden goes well beyond the skin. A previous cross-sectional study, which was published in the February 2021 issue of Dermatology and Therapy,[1] explored the psychosocial burden of AD.

A total of 1014 patients with AD from Europe completed surveys regarding mental and overall health. The prevalence of sleep, anxiety, and depressive disorders were 61.6%, 52.7%, and 75.8%, respectively. Negative outcomes for these health elements were associated with worse physical and mental function, as well as work impairment and an overall higher number of physician visits; however, they did not significantly affect the rate of hospitalizations in the study cohort.

Mindfulness-based stress reduction (MBSR) and mindful self-compassion (MSC) have employed with success for other chronic disease states, but the evidence for these interventions in AD is lacking. The current randomized trial by Kishimoto and colleagues addresses this issue.

Study Synopsis and Perspective

Adding online mindfulness and self-compassion training to usual care may improve quality of life (QOL) in adults with AD, according to results of a small randomized controlled trial in Japan.

"We found that skin disease-specific QOL improved over time with a large effect size," lead study author Sanae Kishimoto, MHS, MPH, of the School of Public Health, Graduate School of Medicine of Kyoto University, Kyoto, Japan, and colleagues wrote in JAMA Dermatology.[2] "These findings suggest that mindfulness and self-compassion training is an effective treatment option for adults with AD."

A Bothersome Disease That Worsens Quality of Life

Atopic dermatitis, a chronic, relapsing, inflammatory, multifactorial skin disease involving intense itching, affects an estimated 15% to 30% of children and 2% to 10% of adults, with the incidence increasing in industrialized countries, the authors stated. 

Measured by disability-adjusted life years, AD has the highest disease burden among skin diseases, and people with AD commonly have anxiety, depression, and sleep problems. Treatments include medications, other skin care, and lifestyle changes. New biologics appear to be effective but are expensive and need to be studied for their long-term safety, the authors added.

"Stress can make the skin worse, but at the same time the skin disease and symptoms cause stress," Peter A. Lio, MD, who was not involved in the study, told Medscape Medical News by email. "This vicious cycle contributes greatly to impairing [QOL]."

A Program Focused on Wise, Kind Self Care

In the SMiLE study,[2] the authors recruited adults with moderate to severe AD and Dermatology Life Quality Index (DLQI) score above 6 from dermatology clinics and through online announcements over 1 year, beginning in July 2019.

The mean age of participants was 36.3 ± 10.5 years of age, approximately 80% were women, and their mean AD duration was 26.6 ± 11.7 years. Everyone was allowed to receive usual care during the study, except for dupilumab (a newly marketed drug when the study started), psychotherapy, or other mindfulness training.

The researchers randomly assigned 56 adults to receive mindfulness training in addition to their usual care and 51 to the waitlist plus usual care. Persons in the training group received 8 weekly 90-minute online mindfulness and self-compassion sessions. Each group-based session was conducted at the same time and day of the week and included meditation, informal psychoeducation, inquiry, and a short lecture, along with an optional 1-day silent meditation retreat at week 7 and an optional 2-hour videoconferencing booster session at week 13.

The intervention encouraged a nonjudgmental relationship with stress using mindfulness-based stress reduction (MBSR) and emphasized a compassionate relationship with oneself during suffering using mindful self-compassion (MSC). The program was developed and taught by lead author Kishimoto, an experienced Japanese licensed clinical psychologist who has a history of AD, the paper noted.

At 13 weeks, after completing electronic assessments, patients in the training group showed greater improvement in the DLQI score than patients on the waitlist (between-group difference estimate, −6.34 [95% CI: −8.27, −4.41); P < .001. The standardized effect size (Cohen's d) at 13 weeks was −1.06 (95% CI: −1.39, −0.74).

Patients in the training group also improved more in all secondary outcomes: severity, itch- and scratch-related visual analog scales, self-compassion, mindfulness, psychological symptoms, and adherence to dermatologist-advised treatments.

They were also more likely to follow their dermatologist's medical treatment plans, including moisturizer and topical steroid use.

One serious adverse event, endometrial cancer in 1 patient, was judged to be unrelated to the intervention.

Online Format May Give More Patients Access to Treatment

"With relatively limited data in the literature, this particularly well-done, important study is likely to positively shape thinking around this topic," said Lio, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois. "This study nicely demonstrates that an online approach can be effective.

"In theory, these methods or techniques could democratize treatments like this, and open them up to many more patients," he added.

He would like to see partially or entirely automated apps (free of cost), similar to meditation "apps," to treat patients more cost-effectively.

"However, given that we almost never have all the known variables for a study, we are generally comfortable extrapolating that the intervention would likely be helpful for patients taking dupilumab as well, despite it not being specifically evaluated in that group," he said.

Susan Massick, MD, clinical associate professor of dermatology at The Ohio State University Wexner Medical Center in Columbus, Ohio, advises clinicians to take a multipronged approach to treating the physical and behavioral components of AD and to embrace therapies beyond prescription medications.

"Self-compassion training is another tool in our toolbox toward finding the right fix for our patients," Massick said by email. She was not involved with this research.

"I applaud the focus of this study on behavioral health training as a means toward wellness and improved mindfulness," she added. "I was impressed by the extent to which these simple measures helped improve the quality of life for patients who used the training."

US Patients Can Benefit From These Findings

"My sense is that AD patients the world over have many similar characteristics and concerns, so I would anticipate that the results would be comparable in a US population," Lio said. "Other studies performed in the US also support this line of thinking."

Although the study involved highly motivated patients in Japan, the suffering that patients with AD experience is universal regardless of race or ethnicity, Massick said. "Americans may be even more willing to embrace mindfulness and self-compassion training as a path toward better health and wellness."

The study was funded the Japan Agency for Medical Research and Development and The Mental Health Okamoto Memorial Foundation, the KDDI Foundation, the Pfizer Health Research Foundation, and the Japan Society for the Promotion of Science.

Kishimoto and several co-authors report relevant financial relationships with pharmaceutical companies. Lio reports financial relationships with Sanofi and Regeneron Pharmaceuticals, Inc. Massick reports no relevant financial relationships.

Study Highlights

  • The trial was conducted between March 2019 and October 2022. Researchers recruited patients from dermatologic practices in Japan and through social media.
  • Study participants were between the ages of 18 and 64 years and reported a history of dermatologist-diagnosed AD with continuing symptoms for > 6 months. All participants had moderate to severe negative impacts on their QOL due to AD, and they had access to the Internet.
  • The study excluded patients who received a therapeutic agent or other psycho- or mindfulness-based therapy, as well as patients with personality disorders, posttraumatic stress disorder, or psychosis.
  • Investigators randomly assigned participants to an MBSR/MSC intervention or a waiting-group control intervention. MBSR/MSC involved weekly 90-minute live sessions for 8 weeks along with an optional 5.5-hour meditation retreat and optional 120-minute videoconferencing booster session.
  • The first 3 sessions were dedicated to MBSR, and the remaining 5 sessions to MSC. The program was designed to promote whole-person wellness, and participants completed homework assignments in between their weekly sessions.
  • The main study outcome was the DLQI, a measurement of QOL for persons experiencing skin diseases. Secondary outcomes included AD symptoms and measures of mental health. Researchers measured outcomes at weeks 4, 9, and 13 of the study.
  • They adjusted results to account for age, sex, and baseline DLQI score.
  • 107 participants underwent randomization. The mean age of participants was 36.3 ± 10.5 years, and 79.4% were female. 58.9% were college graduates. The mean duration of AD was 26.6 ± 11.7 years, and 74.8% of participants were attending outpatient dermatology clinics.
  • Only 1.9% of participants dropped out by week 13. The mean durations of home practice in the intervention group per day were 43.5 ± 17.1 minutes at week 4, 41.7 ±minutes at week 9, and 32.9 minutes at week 13.
  • The mean DLQI score at 13 weeks was −6.34 lower in the intervention vs control groups (P < .001), indicating a substantial improvement in disease-related QOL. There was an increasing separation between the intervention and control groups from weeks 4 to 13.
  • The percentages of participants experiencing a clinically meaningful improvement in DLQI were 81.5% and 33.3% in the intervention and control groups, respectively.
  • Atopic dermatitis symptoms as well as measurements of anxiety, depression, mindfulness, and self-compassion were all superior at week 13 in the intervention vs control groups, with large effect sizes for the last 2 outcomes.

Implications for the Healthcare Team

  • A previous study by Girolomoni and colleagues of adults with AD found that the prevalence rates of sleep, anxiety, and depressive disorders were 61.6%, 52.7%, and 75.8%, respectively. Negative outcomes for these health elements were associated with worse physical and mental function, as well as work impairment and an overall higher number of physician visits; however, they did not significantly affect the rate of hospitalizations in the study cohort.
  • In the current study by Kishimoto and colleagues, an Internet-based MBSR/MSC intervention improved disease-related QOL, AD symptoms, and mental health measures among adults with AD.
  • The healthcare team should consider a holistic approach when treating patients with AD and consider MBSR/MSC interventions as a component of a treatment plan for adults with moderate to severe AD.

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