Adding online mindfulness and self-compassion training to usual care may improve quality of life (QOL) in adults with atopic dermatitis (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, and colleagues write in JAMA Dermatology. “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
AD, a chronic, relapsing, inflammatory, multifactorial skin disease involving intense itching, affects an estimated 15%–30% of children and 2% to 10% of adults, with the incidence increasing in industrialized countries, the authors state.
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 add.
“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 quality of life.”
A Program Focused on Wise, Kind Self Care
In the SMiLE study, 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 one year beginning in July 2019.
Participants averaged 36.3 years of age, 80% were women, and their mean AD duration was 26.6 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. Those in the training group received eight 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 one-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 notes.
At 13 weeks, after completing electronic assessments, patients in the training group showed greater improvement in the DLQI score than those on the waitlist (between-group difference estimate, -6.34; 95% CI, -8.27 to -4.41; P < .001). The standardized effect size (Cohen’s d) at 13 weeks was -1.06 (95% CI, -1.39 to -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 one patient, was judged to be unrelated to the intervention.
Online Format May Give More Patients Access to Treatment
Dr Peter Lio
“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. “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.
Lio explained that excluding participants on dupilumab (Dupixent) makes the results slightly less generalizable to patients with moderate to severe AD, who may have the most serious QOL challenges and who are often candidates for dupilumab.
“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.
Dr Susan Massick
Susan Massick, MD, clinical associate professor of dermatology at The Ohio State University Wexner Medical Center in Columbus, 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, the joint developers of dupilumab. M assick reports no relevant financial relationships.
JAMA Dermatol. Published online May 10, 2023. Abstract
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