Behavior Modification: A Nursing Approach for Young Children With Atopic Eczema
Pauline I. Buchanan
Managing atopic eczema represents one of the most challenging aspects of dermatology nursing, especially in children. A main contributing factor to the difficulty in management is the unrelenting pruritus experienced by sufferers. A practice model for behavior modification can be an effective nursing strategy in the management of pruritus and scratch associated with atopic eczema.
This educational activity is designed for nurses and other health professionals who care and educate patients regarding children with atopic eczema. A multiple choice examination follows this offering and is designed to test the reader’s achievement of the objectives listed below. After studying the information presented in this article, the reader will be able to:
1. Outline the medical interventions used in managing atopic eczema.
2. Identify the four key nursing principles that underpin a systematic approach to nursing care of a patient with atopic eczema.
3. Demonstrate a greater understanding of the cognitive-behavioral approaches used in managing atopic eczema.
4. Identify measurable subjective and objective criteria for evaluating nursing intervention.
Managing atopic eczema represents one of the most challenging aspects of dermatology nursing (Spowart, 1993). A main contributing factor to the difficulty in management is the unrelenting pruritus experienced by sufferers. The complexity of the disease, the chronic relapsing nature, and the fears surrounding topical therapies often results in less than optimum management regimens. Ineffective management regimens over long periods of time lead to feelings of frustration, disillusionment, and/or exhaustion for all concerned (Donald, 1995). The purpose of this article is to review of the topical management of atopic eczema with specific reference to the role of nursing. Management strategies discussed will include behavior modification as an additional dimension to care. A model for practice will be presented as a nursing strategy in managing pruritus and scratch associated with atopic eczema.
Medical Approaches to Topical Management
Atopic eczema is a very common condition affecting at least 3% of children, as well as a smaller proportion of adults (Hunter, Savin, & Dahl, 1989). Managing atopic eczema forms a significant part of the workload for nurses within dermatology and in general practice. Most cases are relatively mild but can be very distressing for patients and their parents.
Most mild to moderate cases are adequately managed within primary care with only the most severe and recalcitrant cases being referred to specialty units. The use of emollients and corticosteroids represent the mainstay of topical management for atopic eczema (David, 1995). Antibiotic therapies (topical and systemic) also have a place as research continues to demonstrate the link between staphylococcus aureus and acute exacerbations of eczema (Abeck & Mempel, 1998). Topical coal tar preparations are useful as they are soothing, anti-inflammatory, and anti-pruritic. Unfortunately, cosmetic acceptability and compliance are poor due to the smell, mess, staining, and color of preparations.
Emollient therapies are directed towards managing dry skin, which underlies an eczematous condition. The mode of action is directly on the skin and aims to reduce the pruritus, correct the disturbed barrier function, decrease the transepidermal water loss, and decrease the irritancy which is associated with dry skin. Emollients fundamentally moisturize the skin and ease the itch. They are prepared in various formulations, which include sprays, liquids, lotions, creams, pastes, ointments, and greases. Evidence-based medicine purports that the therapeutic use of these preparations depends on the severity of xerosis (the dryer the skin the greater the need for a grease-based product). However, dermatology is a medical science and an art, which demands the practice of applied common sense. Therefore the emollient of greatest therapeutic value is the one which the patient or caregiver will use regularly. Emollient therapies are the cornerstone to successful management of atopic eczema and are continued even in the absence of overt disease.
Topical corticosteroids are used as anti-inflammatory agents in managing atopic eczema. They suppress inflammation and are not curative in nature. Relapse and rebound of the skin disease may occur when treatment is discontinued. The potency of corticosteroids varies greatly from mild (hydrocortisone) to very potent (clobetasol propionate) and are presented in cream, lotion, grease, and mousse formulations. Clear and concise guidelines on applying steroids are offered due to the well-documented list of side effects which include Cushing’s syndrome, pituitary-adrenal axis suppression, thinning of the skin, striae atrophicae, and telangiectasia (British National Formulary, 1999). However, with no less than 98 different steroid products listed in the British National Formulary, the most appropriate drug is sometimes difficult to determine. This, together with fears and misconceptions about topical steroids often results in inappropriate topical therapies.
The most commonly expressed fear by parents relates to over absorption of the drug through the skin. Indeed, health professionals and pharmacists frequently reinforce this fear. The words or instruction “use sparingly” always appear on the pharmacist’s label. Much of the work undertaken by nurses within dermatology involves increasing awareness, education, and supporting parents in the application of the steroids (David, 1987). Therefore, considerable time may be spent re-educating parents, allaying fears, and demonstrating the appropriate use of topical steroids. Parents often fear overuse of these drugs when in reality the problem identified by nurses is underuse, which results in inadequate control of the disease.
Atopic eczema is part of the atopy syndrome and includes asthma, hay fever, and rhinitis. Investigation into the role of allergy in these conditions is focusing on environmental trigger factors and diet (Williams, 1995). There appears little doubt that allergy has important relevance in managing atopic eczema (Hanifin & Rajka, 1980; Rajka, 1989; Reitamo et al., 1986; Tan, Weald, Strickland, & Friedmann, 1996). Management strategies include allergen avoidance and dietary manipulation as an adjunct to orthodox medical intervention. Recent innovation and research in medical approaches are focusing on topical immunosuppressants such as tacrolimus and ascomycin (Van Leent et al., 1998).
Pruritus is clearly the most distressing symptom reported by patients with eczema. Unlike spontaneous itch, which most of us experience and quickly relieve by scratching, patients with eczema suffer deeply with itchy skin. This presents as a diffuse, intense itch, often described as deep within the skin and impossible to relieve. Medical interventions include the use of antihistamines, some of which have sedative properties and aid restful sleep. Menthol in topical emollients also provides limited symptomatic relief.
Nursing Approaches to Care
Nursing the patient with atopic eczema requires a patient-centered approach, a family-centered approach, and investment in time. Indeed, one may argue that the most valuable nursing contribution is the investment in time; that is, time for support, time for education, time for care, and time for reflection. It is advisable to use a systematic approach to care, which utilizes a thorough assessment, detailed planning, comprehensive implementation, and regular evaluation. A variety of nursing models help to facilitate this and are particularly useful in dermatology nursing (Ruane Morris, Thompson, & Lawton, 1995). Key nursing issues or problems require identification and clarification if care needs are to be met. This is often difficult when caring for young children, therefore a family-centered approach is fundamental. The most common identified nurse/patient problems are pruritus, breakdown in skin integrity; anxiety, and physical and social dysfunction. All nursing interventions are aimed at promoting healing, maintaining good skin integrity, understanding the nature of the disease, increasing knowledge, understanding management strategies, allaying anxiety and fears, promoting good social and physical functioning for all members of the family, and providing long-term support.
In addressing these issues nurses are required to implement nursing management strategies which incorporate the appropriate application of topical therapies, psychosocial support, and health education. Each and every case differs, as atopic disease and family dynamics are complex and influence management outcomes. A typical nursing intervention program incorporates an initial consultation with the patient and caregiver(s). This will include skin assessment and degree of itch, identifying primary nurse/patient problems, discussion of management strategy, demonstrating techniques, and time for discussion. Followup is vitally important to the success of management regimens. Each consultation visit requires two or perhaps three followup visits. This will ensure efficacy of management and ongoing support for parents. Regular re-assessment is recommended as it facilitates early intervention should complications arise. Re-assessment also helps convey to parents that management is not a cure, but aimed at suppressing the disease process. The practical aspects in managing atopic eczema involve enlisting the help of other health professionals. Nurses in dermatology specialist units are seen as resources and should take the initiative in supporting others in multidisciplinary team working. The investment in time for professional development will ultimately lead to quality assurance across all boundaries.
With this type of support and understanding, key nursing strategies such as occlusive bandaging (wet-wraps) will be appropriately used in management programs (Bridgeman, 1994). Primary care nurses should be aware of the evidence that supports the use of occlusive bandaging. They certainly should be aware of the evidence which contraindicates their use. They also require information regarding the provision of psychosocial support. Using such intensive (and somewhat alarming) bandaging techniques can be distressing to patients and parents. Occlusive bandaging is one nursing strategy used in managing atopic eczema. However, the efficacy of bandaging depends on the topical medication applied underneath. This represents another area of confusion for nurses as many techniques are reported in the literature and all demonstrate benefits and disadvantages.
The key issue is clinical assessment (Buchanan, 1998; Dewitt, 1990), as the type, formulation, frequency of application, and duration of course is dependent on skin status. This applies to all emollients and corticosteroid topical preparations. The nursing assessment should be thorough with support and explanations offered as to why and how treatments are to be applied. This is time consuming but an essential component of the supportive-educative aspect of care.
Behavioral Approaches to Care
Throughout this medical and nursing review it is clear that atopic eczema can be difficult to manage and represents a challenge to all caregivers. Atopic eczema can be a disfiguring handicap because of the unrelenting itch and desire to scratch. Scratching damages the skin, disturbs sleep, disrupts relationships, triggers mood changes, and alters affect. It is the cause of significant emotional difficulties for many sufferers as well as other family members. The condition itself can be exacerbated by psychological factors (Gill et al., 1987). This has led to psychological interventions being incorporated into management strategies to reduce scratching behaviors that exacerbate the eczema.
Cognitive behavioral approaches focus on the ability and intention to change behavior to the benefit of the individual and others (Turk & Salovey, 1996). Westmacott and Cameron (1981) describe a functional behavioral change approach. This work, which was developed at Southampton University, identified the now well-documented “ABC” of behavior change. When attempting to change an undesirable behavior, careful analysis of the behavior is necessary. This demands identification of the Antecedents, the Behavior itself, and the Consequences of that behavior. After identifying the ABC of behavior change, one can introduce clear strategies on how to change behavior. For example, normal spontaneous itch is the antecedent, scratching is the behavior, and relief is the consequence. In atopic skin the antecedent is severe itch, the behavior is vigorous scratching, and the consequences are no relief, excoriation, and pain.
Work published in the United States identified “habit reversal” as a method of eliminating nervous habits and tics, whereby an alternative or competing behavior was adopted in place of the undesirable behavior (Azrin & Nunn, 1973). Swedish researchers combined the theories of habit reversal and the ABC behavior change and applied the new approach to managing atopic eczema (Noren & Melin, 1989; Noren, 1995). Further development of their work has resulted in renewed interest in a behavioral change approach to care. A wealth of literature has recently been published demonstrating the value of habit reversal in behavior modification programs (Allen, 1998; Biovin, 1998; Elliott et al., 1998; Freese, 1998; Miltenburger, Fuqua, & Woods, 1998; Rapp et al., 1998; Sloan & Mizes, 1999).
A combined approach, which incorporates habit reversal with conventional topical therapies, has been adapted and developed by researchers at the Chelsea and Westminster Hospital, London. This work offers a new dimension to managing atopic eczema for children and adults (Bridgett, Noren, & Staunton, 1996). The treatment program recognizes that, in the chronic form, many patients and caregivers have poor understanding of the principles of conventional topical treatment. To optimize conventional therapies an educational approach is adopted, with written material and repeated discussion to ensure understanding. This approach is very similar to the nursing approaches already discussed in this article. In addition, however, the Chelsea and Westminster program advocates the introduction of behavior modification (habit reversal) to reduce or eradicate the destructive scratching behavior associated with atopic eczema. An alternative behavior is taught to patients and caregivers such as pressing or patting the skin, squeezing balls, or clenching fists. The researchers suggest that after 4 to 6 weeks of using this combined approach the chronic syndrome of scratching can be eliminated. Followup is essential within the program as the patient is taught to deal with relapses, danger times, and triggers. Throughout the treatment program attention is focused on the patient’s attitude to his/her condition and its treatment. The success of this program has prompted training sessions for general practitioners, nurse practitioners, and nurse specialists in order to implement programs of care in the community and other secondary health care settings.
Implementing Programs of Care
The work described by Bridgett and colleagues (1996) focuses mainly on the use of behavior modification programs for adults and adolescents. This represents a small portion of patients as the natural course of atopic disease improves as the child reaches maturity. Few individuals are handicapped in adult life with the very chronic form of atopic eczema. However, in 90% of newly diagnosed cases the onset of disease occurs before the age of 2 years (Verbov, 1988). Young children represent the largest group of individuals with atopic eczema seen by dermatologists, general practitioners, primary care nurses, and nurse specialists. A behavior modification program for this group of patients may enhance nursing care and improve quality of life for patients.
An issue that requires further discussion relates to the management of pruritus (itch) which is the most distressing symptom felt by patients with atopic eczema. Practitioners must be clear about the difference between scratch and itch. This is fundamental in planning nursing interventions. Using the ABC theory previously discussed, itch is identified as the Antecedent to the Behavior of scratching. The Consequence of scratching is normally relief and pleasure. However, in atopic eczema the itch may be so severe and unrelenting the consequence of scratching is pain, excoriations, emotional relief or dismay, regret, and guilt. Scratching is a reflex action that is controlled at the spinal cord level although modified at higher levels (Greaves, 1992); thus, scratching is difficult to prevent in the presence of itch.
Sometimes, albeit infrequently, learned behavior and cognitive influences can result in scratch becoming an inappropriate behavior. Parents report self-injurious behavior by children with atopic eczema, such as biting and scratching. Case histories also report incidences and situations whereby scratch is used as a weapon to manipulate parents. It is proposed that this group of children (and parents) would benefit most from behavior modification. Early nursing intervention using behavior modification is seen as a primary preventive strategy in health promotion; that is, preventing ill health before any overt signs of disease are apparent (Meredith-Davies, 1983).
In short, the management of itch uses biological approaches to health care, whereas the management of scratch also demands applied psychology. By introducing an alternative behavior to scratching, the anticipated consequence is skin healing or preservation of skin integrity. Work undertaken in Holland promotes this psychodermatologic approach to managing scratching in eczema (Van der Schaar & Lamberts, 1997). The use of a soft scratch pad was demonstrated by a Dutch group at the 8th International Conference in Dermatology and Psychiatry in Paris in June 1999 as an alternative behavior to scratching skin. The Chelsea and Westminster group does not adopt this specific strategy as they argue the scratching or rubbing of the pad reinforces the undesirable behavior of scratching skin. It may also be argued that the complete avoidance of scratching behavior (which is a reflex action) is impossible to achieve and will deny the patient the satisfaction and pleasure of therapeutic scratch. When working with very young children it may be impossible to avoid scratching behavior altogether; therefore, scratching without trauma is the goal.
Incorporating Behavior Modification into Practice
The following model for nursing practice is based on the published research reviewed in this article. It is proposed that behavior modification programs may be feasible if incorporated into clinical practice routinely. Nursing interventions demand an eclectic approach to care, using biological, medical, nursing, psychological, and sociological theories. This model for practice is offered as one approach to care which applies the sciences of medicine, nursing, and psychology into care. Key stages are identified and recognized as prerequisites as progression is made.
Combined Behavioral Model for Care
Stage 1: Plan a systematic approach to care.
1. Identify the problem of scratch: excessive scratching and/or scratch used in absence of itch.
2. Plan interventions using family-centered approach: (a) clarify ability and understanding of child and parent(s); (b) identify family medical/social history; (c) discuss use of emollients and topical steroids; (d) discuss use of topical antibiotics; and (e) discuss habit reversal technique.
3. Implement actions: (a) awareness program, (b) introduce competing response, and (c) psycho-social support and followup.
4. Evaluate care and intervention using objective and subjective criteria.
Stage 2: Initiate an awareness training program for child and parent(s). Identify specific strategies for parent(s) to raise awareness of child’s scratching. This may involve keeping a diary for a 7-day period. Similarly a chart may be used to record all scratching sessions. A hand-held clicker is useful for the mothers of very young children.
Inform parent(s) about applying emollients and topical corticosteroids. Demonstrate application of creams, ointments, and bandaging as required. Reinforce the importance of medical management and nursing care. Explain the scratchitch cycle to parents. Ask parents to identify danger times and specific triggers (heat, mood, and fatigue may influence degree of scratching). Teach parents about avoidable triggers (wool, stress, allergens) and unavoidable triggers (atopy, season, illness). Be aware of social influences and factors such as number of siblings, marital status, socio-economic status, and age of parents. Plan support to suit family and child needs.
Discuss treatment plans for acute flare-ups and maintenance programs. Discuss the healing process to parents, including obvious and hidden healing. Ensure understanding in not discontinuing treatment too soon. Reinforce spoken word with written instructions, time plans, and treatment plans. Allow time for questions. Book appointments with no interruptions (approximately 1 hour per session). Encourage parent(s) to avoid saying “Stop Scratching!” Ask parents never to leave the child alone in the first few days of the program.
Identify specific strategies for the child (dependent on age and ability). Hand-held clickers or counters are useful for the older child. Parental help is required for younger children. Enlist the help of the child through imagination, diversion, and play. Create games when applying creams and bandages. Reward desirable behavior. Ignore undesirable behaviors. Keep the child active.
Stage 3: Introduce competing response training (habit reversal). Demonstrate other behaviors that the child may adopt in place of scratching. These may include pressing the skin, fist clenching, patting the skin, or using a soft scratch pad. Choose one or a combination of these behaviors and teach the child and parent to practice them repeatedly. Reinforce the theme of “practice makes perfect.” Reinforce the value of applying creams and ointments to inflamed skin. Explain the importance of occlusive bandaging in protecting the skin from trauma. Ensure parent(s) recognize the early warning signs of an acute flare and infection. Practice the behaviors during danger times. Ask parent(s) to document any change in skin condition, itch, sleep pattern, mood, and behaviors. Reinforce and reward desirable behaviors.
Stage 4: Provide ongoing support.
1. Always arrange weekly consultations. These may be at home, at the practitioner’s office, or at the hospital.
2. Provide contact numbers for parent(s). Be available to speak to them when they telephone.
3. Enlist the help of the dermatologist, general practitioner, school teacher, school nurse, social worker, and clinical psychologist if necessary.
4. Enlist the help of other members of the family, for example, grandparents.
5. Review and evaluate progress weekly. Reinforce desirable behaviors.
6. Review application of topical therapies weekly.
7. Evaluate and document progress in nursing notes.
8. Provide open/flexible appointment schedule for parent(s) and child in long-term management.
Stage 5: Review evaluation strategies. Outcome measures can be objective or subjective. Evaluation may be weekly initially for the first 4 weeks then monthly as required. Objective outcome measures are numerous. These include frequency of scratching, degree of excoriation, degree of self-injurious behavior, number of hours of undisturbed sleep, morbidity rate, length of remission, severity of acute flares, frequency of acute flares, amount of corticosteroid used, frequency of corticosteroid application, amount of emollient used, frequency of emollient use, frequency of occlusive bandaging, and frequency of hospital admission/attendance.
Subjective outcome measures include degree of pruritus, satisfaction survey, and quality of life index. Together these outcome measures will determine the success of a behavioral intervention program. The list appears quite comprehensive but most will formulate a valuable evaluation and audit of nursing intervention. Followup appointments and evaluation should span over several months and years.
Nursing care of a child with atopic eczema requires skill, understanding, and time. A holistic family-centered approach is essential if traditional medical and nursing strategies are to be successful. A psychological approach (behavior modification) may provide a third dimension to care which further reduces morbidity and enhances quality of life for the patient and the family. A behavioral model for care using the habit reversal technique can be developed and implemented into existing nursing care plans. Ongoing assessment and evaluation are necessary if quality assurance and high standards of care are to be maintained.
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Abeck, D., & Mempel, M. (1998). Cutaneous staphylococcus aureus colonisation of eczema: Mechanisms, pathophysiological importance and therapeutic consequences. Der Hautarzt, 49(12), 902.
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Bridgeman, A. (1994). Management of atopic eczema in the community. Health Visitor, 67(7), 226-227.
Bridgett, C., Noren, P., & Staunton, R. (1996). Atopic skin disease: A manual for practitioners. Petersfield, England: Wrightson Biomedical.
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Buchanan, P. (1998). Dermatology: RCN continuing education series. Nursing Standard, 12(40), 48-55.
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David, T.J. (1987). Steroid scare. Archives of Diseases in Children, 62, 876-878.
Dewitt, S. (1990). Nursing assessment of the skin and dermatological lesions. Nursing Clinics of North America, 25(1), 235-245.
Donald, S. (1995). Atopic childhood eczema. Nursing Standard, 10(9), 33-37.
Elliott, A.J., Miltenburger, R.G., Rapp, J. et al. (1998). Brief application of simplified habit reversal to treat stuttering in children. Journal of Behavior Therapy and Experimental Psychiatry, 29(4), 289-302.
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Gill, K.M., Keefe, F.J., Sampson, H.A. et al. (1987). The relationship of stress and family environment to atopic dermatitis symptoms in children. Journal of Psychosomatic Research, 31(6), 673-684.
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RELATED ARTICLE: POSTTEST QUESTIONS
Choose one correct answer for each question.
1. The mainstay medical topical management for atopic eczema is:
a. Dithranol and ultraviolet light.
b. Emollients and corticosteroids.
c. Vitamin D derivatives.
d. Crude coal tar products.
2. Emollients are used in the management of atopic eczema to:
a. Encourage epithelialization.
b. Reduce the barrier function of the skin.
c. Increase the transepidermal water loss.
d. Moisturize the skin and ease pruritus.
3. Topical corticosteroids are classified as:
a. Anti-inflammatory agents.
4. Atopy is a syndrome that includes which of the following group of conditions:
a. Eczema, hay fever, rhinitis, and asthma.
b. Eczema, urticaria, and alopecia.
c. Eczema, psoriasis, and hay fever.
d. Eczema, acne, and psoriasis.
5. The most common organism responsible for infection in atopic eczema is:
b. Psuedomonas aeruginosa.
c. Staphylococcus aureus.
d. Tinea pedis.
6. The most distressing symptom reported by patients with atopic eczema is:
7. When caring for a young child with atopic eczema the nursing approach should be:
c. Family centered.
d. Group directed.
8. Identify one nurse/patient problem not associated with atopic eczema.
a. Physical and social dysfunction
c. Breakdown in skin integrity
9. The key issue in successful systematic nursing approach is:
a. Assessment and reassessment.
b. Daily followup visits.
c. Use of potent steroids.
d. Documentation of nursing interventions.
10. In order to change behavior it is necessary to first identify:
a. Where and when the behavior occurs.
b. The antecedents and consequences.
c. How the behavior disrupts family life.
d. A negative reinforcement.
11. The antecedent of a particular behavior is recognized as the:
a. Opposite reaction.
c. Patient’s attitude.
d. The resultant behavior.
12. For a patient with severe atopic eczema, itch is the antecedent and scratching is the behavior. What is the consequence?
a. Relief and satisfaction
b. Cessation of itch
c. Unrelenting itch, excoriation, and pain
d. Increased protection from infection
13. Ninety percent of newly diagnosed cases of atopic eczema occur in which age group?
a. 2 years and under
b. 3-4 years
c. 5-6 years
d. Over 6 years
14. Scratching behavior is difficult to prevent in young children because it is a:
a. Conditioned response
b. Reflex action
c. Learned behavior
d. Only carried out during sleep
15. A behavioral strategy that adopts an alternative or competing behavior in place of an undesirable behavior is known as:
a. Aversion therapy.
d. Habit reversal technique.
16. Habit reversal may be useful in the management of atopic eczema when assessment identifies the problems of:
a. Excessive scaling and lichenification.
b. Insomnia and hyperactivity.
c. Excessive scratching (with or without itch).
d. Excessive use of potent steroids.
Behavior Modification: A Nursing Approach for Young Children With Atopic Eczema
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Evaluation agree disagree
1. The offering met
the stated objectives.
a. Outline the medical 5 4 3 2 1
interventions used in
managing atopic eczema.
b. Identify the four key 5 4 3 2 1
nursing principles that
underpin a systematic
approach to nursing care
of a patient with atopic
c. Demonstrate a greater 5 4 3 2 1
understanding of the
approaches used in
managing atopic eczema.
d. Identify measurable 5 4 3 2 1
subjective and objective
criteria for evaluating
2. The content was 5 4 3 2 1
current and relevant.
3. The content was 5 4 3 2 1
4. The content was 5 4 3 2 1
5. I am more confident 5 4 3 2 1
of my abilities since
completing this material.
6. The material was
(check one)  new,
 review for me
7. Time required to
Less than 1 hour  1-2 hours  2-3 hours  More than 3 hours 
Pauline I. Buchanan, PhD/M.Phil, BSC, CNNA, is a Dermatology Nurse Consultant and Honorary Senior Lecturer, Bournemouth University, Department of Dermatology, Salisbury District Hospital, Salisbury, United Kingdom.
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