Which Moisturizer Makes a Difference in Childhood Eczema?

Clinical Context

Eczema affects approximately 20% of children, many of whom have risk factors for eczema, such as a family history of atopic disease or family history of eczema. Could a simple intervention such as the routine application of emollients during infancy prevent incident eczema? Chalmers and colleagues answered this research question; the results of their study were published in the February 19, 2020, issue of the Lancet.^[1]

A total of 1394 newborns with a family history of asthma were randomly assigned to receive skin care advice plus daily emollients or skin care advice only. The main study outcome was incident eczema at age 2 years, as assessed by study nurses blinded to the randomized treatment group. 

Adherence to emollients was good: 74% of children continued daily emollients through 12 months of age. Rates of incident eczema at age 2 years were 23% and 25% in the emollient and control groups, respectively, which was a nonsignificant difference. The mean number of skin infections per child in year 1 were 0.23 in the emollient group and 0.15 in the control group (incident rate ratio, 1.55; 95% confidence interval, 1.15-2.09).

In general, many clinicians recommend heavier emollients such as ointment for eczema, but there is little evidence as to which emollient is superior in clinical trials. The current study addresses this issue.

Study Synopsis and Perspective

Four common emollients (lotions, creams, gels, and ointments) are equally effective in treating childhood eczema, a randomized trial in the United Kingdom found.

"Our findings challenge the previous consensus that ointments are more effective, require less frequent application, and have fewer adverse effects than other emollient types, especially for more severe eczema," the researchers reported in the Lancet Child & Adolescent Health.

Overall satisfaction and intention to continue treatment was highest for families who used lotions and gels, according to the researchers, and "users need to be able to choose from a range of emollient types to suit their needs and preferences."

Daily use of emollients along with topical anti-inflammatory agents such as corticosteroids is widely recommended for eczema, which affects about 13% of children in the United States.^[3]

Previous research showed that emollients can reduce flare-ups of eczema but did not establish that 1 product works better than another, according to a Cochrane review published in 2017.^[4]

For the new study, researchers at the University of Bristol, England, and colleagues randomly assigned 550 children aged 6 months to 12 years with mild or worse eczema to use 1 of 4 types of emollients for 16 weeks. Each child's general practitioner selected a specific medication from local formularies.

The median age of the children in the study was 4 years, 255 (46%) were girls, and 473 (86%) were White. The mean Patient-Orientated Eczema Measure (POEM) score was 9.3, which indicates moderate disease.

Changes in disease severity reported by parents were similar among the treatment groups, according to the researchers. Over the course of 16 weeks, mean POEM scores improved by 1.9 for those using lotion, 1.7 for cream, 2.2 for gel, and 2.5 for ointment. Also, scores on the Eczema Area Severity Index collected by blinded evaluators at 16 weeks did not vary among the groups.

Nor were there differences in adverse events, which were reported in 205 participants (37%). Worsening of eczema, redness, and itching or inflammation were most common. Stinging was half as common in ointment users as other groups, the researchers reported.

With more than 100 emollients on the market in the United Kingdom, the researchers said that comparing these products by type rather than performing head-to-head comparisons rendered the findings more generalizable.

"A trial and error approach to prescribing is common, which can lead to underuse, waste, and frustration for families," they wrote.

Heidi Kong, MD, a senior investigator and chief of the Cutaneous Microbiome and Inflammation Section at the National Institute of Arthritis and Musculoskeletal and Skin Diseases, said that the findings may be relevant in the United States, where similar emollients are available.

However, the study's racial homogeneity could limit its applicability to the United States, said Dr Kong and Robert Sidbury, MD, MPH, a professor of pediatrics at the University of Washington, Seattle, and chief of dermatology at Seattle Children's Hospital. Neither Dr Kong nor Dr Sidbury was involved in the new study.

Another limitation is that fewer study participants had severe disease, which can make a patient more susceptible to stinging or other discomfort, Dr Kong told Medscape Medical News.

Still, Dr Kong said that the findings shift the focus to "the very important concept of considering individual patient and parent preferences on emollient type when making recommendations. If a type of emollient is preferable to a patient, they are more likely to use it."

Although ointments can be messy, uncomfortable, and promote inflamed hair follicles, clinicians and parents have promoted them "because common sense suggests they work better" because of being thicker and longer lasting, Dr Sidbury told Medscape Medical News. "This study suggests common sense may not be so sensible in this case," he added.

The study was funded by the National Institute for Health and Care Research, a United Kingdom government agency. One researcher in the Best Emollients for Eczema study is a consultant on an educational grant funded by Pfizer that is unrelated to the trial. Twenty other researchers involved with the study declared no competing interests. Dr Sidbury is a speaker for Beiersdorf, which makes emollients. Dr Kong reported no relevant financial relationships.

Lancet Child & Adolescent Health. Published August 1, 2022.

Study Highlights

• Study patients were between the ages of 6 months and 12 years and were attending primary care practices in England. All participants had a previous diagnosis of eczema and a Parent Orientated Eczema Measure (POEM) score of at least 2. POEM is a 7-item measure of eczema severity, with scores from 0 (no symptoms/signs) to 28 (severe eczema).
• Participants were randomly assigned to 1 of the 4 major types of emollients: cream, gel, ointment, or lotion. The study assessor was blinded to the randomization.
• Parents were instructed to apply the emollient twice daily and as needed. Children were allowed to continue other eczema treatments as previously prescribed.
• The main study outcome was the POEM score at 16 weeks. Parents completed these scores weekly for 16 weeks and then every 4 weeks through 52 weeks. Researchers also completed a physical exam for signs of eczema at 16 weeks.
• Researchers also followed rates of adverse events and parent preference for their randomized treatment.
• 550 children underwent randomization. The median age of children was 4 years, and 17% were younger than 2 years; 86% of the cohort was White and 82% met criteria for mild to moderate eczema.
• Most participants had previously used a cream, ointment, or lotion, but only 25% had tried a gel.
• There was no difference in the main study outcome of POEM score at 16 weeks when comparing the 4 different emollients. The mean POEM score declined about 2 points from a baseline to just more than 9 points in all groups. 
• Moreover, POEM scores continued to be similar at 52 weeks in the 4 groups.
• Likewise, there was no difference in the objective assessment scores for eczema at 16 weeks in comparing groups. An analysis revealed that blinding of the study assessor was excellent.
• 67% of parents in the lotion group reported being mostly or very satisfied with treatment, as were 64% of parents in the gel group. Conversely, 34% and 40% of parents were dissatisfied or very dissatisfied with creams and lotions, respectively.
• There were no serious adverse events reported, but 37% of cases experienced mild adverse events. There was no difference between emollients in the rates of adverse events.

Clinical Implications

• A previous clinical trial demonstrated that the routine application of emollients daily during infancy did not reduce the risk for incident eczema, and emollients were associated with a higher risk for skin infection vs usual care.
• The current study does not support the efficacy of 1 form of emollient over another in childhood eczema based on either parent survey or clinician examination. Lotions and gels were preferred by parents over ointments and creams.
• Implications for the healthcare team: The healthcare team can use family preferences to determine the preferred emollient for eczema during childhood.

Sent from my iPhone

Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

Please excuse the shortness of this message, as it has been sent from
a mobile device.