Internet-Delivered Cognitive Behavior Therapy for Atopic Dermatitis: A Randomized Clinical Trial

Abstract

Importance: Atopic dermatitis is a common and debilitating skin condition characterized by intense itching and chronic inflammation. Research on behavioral treatments with high accessibility is needed.

Objective: To investigate the efficacy of a highly scalable internet-delivered cognitive behavior therapy (CBT) for adults with atopic dermatitis.

Design, setting, and participants: This randomized clinical trial from a medical university in Stockholm, Sweden, included 102 adults with atopic dermatitis, recruited from across Sweden, who received 12 weeks of internet-delivered CBT (March 29, 2017, to February 16, 2018). The first participant provided screening data on November 27, 2016, and the last 1-year follow-up assessment was conducted on June 28, 2019.

Interventions: Participants were randomized in a 1:1 ratio to 12 weeks of therapist-guided internet-delivered CBT (n = 51) or a control condition (n = 51) that gave instructions about standard care.

Main outcomes and measures: The primary outcome was the between-group difference in mean reduction of atopic dermatitis symptoms as measured by the Patient-Oriented Eczema Measure and modeled intention to treat during the 12-week treatment period.

Results: A total of 102 participants (mean [SD] age, 37 [11] years; 83 [81%] female) were recruited and randomized. The primary analysis indicated that participants receiving internet-delivered CBT, relative to the controls, had a significantly larger mean weekly reduction in symptoms of atopic dermatitis as measured with the Patient-Oriented Eczema Measure (B = 0.32; 95% CI, 0.14-0.49; P < .001), with a moderate to large, controlled effect size after treatment (d = 0.75; 95% CI, 0.32-1.16). Secondary analyses indicated that internet-delivered CBT also produced significantly larger reductions in itch intensity, perceived stress, sleep problems, and depression. Gains were sustained at 12 months of follow-up. Treatment satisfaction was high, and therapists spent a mean (SD) of 39.7 (34.7) minutes per treated patient providing internet-delivered CBT.

Conclusions and relevance: Internet-delivered CBT appears to be efficacious for reducing symptoms of atopic dermatitis, despite requiring minimal therapist resources. Thus, internet-delivered CBT has the potential to increase access to effective adjunct behavioral treatment for patients with this common skin condition.

Trial registration: ClinicalTrials.gov Identifier: NCT03051958.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hedman-Lagerlöf reported receiving grants from Stockholm County Council (ALF Medicine) and Hudfonden during the conduct of the study and owning shares in DahliaQomit, which specializes in online services for symptom assessment outside the submitted work, and having a patent for a cognitive behavioral treatment manual for irritable bowel syndrome, with royalties paid from Pear Therapeutics. Ms Bergman reported receiving grants from Stockholm County Council (ALF Medicine) and Hudfonden during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.. Treatment Contents

AD indicates atopic dermatitis; CBT, cognitive behavior therapy; UV, ultraviolet. This Figure is reproduced with permission from Hedman-Lagerlöf et al.

Figure 2.. CONSORT Flowchart

AD indicates atopic dermatitis; CBT, cognitive behavior therapy; UV, ultraviolet.

Figure 3.. Model Estimated and Observed Symptom Course on the Patient-Oriented Eczema Measure (POEM)

Vertical bars represent 95% CIs. CBT indicates cognitive behavior therapy; 6MFU, 6-month follow-up; 1YFU, 1-year follow-up.