Emollient Acceptability in Childhood Atopic Dermatitis: Not All Emollients are Equal

Recommendations on the Use of Moisturizing Products Prepared by Spanish Dermatologists Using the Delphi Method

BACKGROUND AND OBJECTIVE

Moisturizing products are widely used in conditions affecting skin hydration. However, the lack of scientific evidence leads to discrepancies and great variability in the recommendations used by different health professionals. The aim of this consensus document is to generate recommendations based on the evidence and experience of dermatologists to unify and facilitate the use of moisturizing products in the routine clinical practice.

MATERIALS AND METHODS

A 49-statement questionnaire on moisturizing products was prepared and, then, arranged in 5 blocks: 1) concept; 2) characteristics, 3) frequency and quantity, 4) product use and areas of application, and 5) special populations. Twenty-two expert dermatologists in the management of patients with eczema answered to the survey using a 2-round Delphi methodology (adding an item on the 2nd round).

RESULTS

Consensus was reached on 27 statements (54%), most (n=23) via agreement. The highest level of agreement was reached in the blocks on quantity, product use and areas of application (77.8%), followed by the blocks on characteristics (73%) and frequency (62.5%). Regarding the blocks on concept and special populations, the level of consensus on the items proposed was 37.5% and 10%, respectively. Consensus on the use of emollients for xeroderma (71%) was higher vs atopic dermatitis (64%) and inflamed skin (33.3%).

CONCLUSIONS

Consensus recommendations can help all prescribers and improve the available evidence regarding their use.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Pilot Studies on Two Complementary Bath Products for Atopic Dermatitis Children: Pine-Tar and Tea

Background: Few standardized bath product clinical trials were performed for atopic dermatitis patients. Pine-tar and green tea extracts are plant-derived products that have been described as having anti-allergic effects which may reduce AD disease severity. Methods: The efficacy of two complementary bath products was studied and compared. Efficacy and acceptability of the bath products were measured by patient general acceptability of treatment (GAT: very good, good, fair or poor), disease severity (SCORAD: SCoring Atopic Dermatitis), quality of life (CDLQI: Children Dermatology Life Quality Index), and pertinent clinical parameters were measured before and after four weeks of treatment. Sample size calculations for further clinical trials were performed. In one group, nine AD patients were subjected to bathing with a pine-tar bath oil for 10–15 min daily for four weeks. In another group, 20 AD subjects bathed with a teabag containing green tea extracts for four weeks. Results: Significant improvements in clinical- and patient-orientated parameters were found in the pine-tar bathing group, but not the tea-bag bathing group. Both groups reported very good/good GAT on the studied products. Teabag bathing was considered not efficacious for further clinical trials. Conclusions: The pilot studies provided preliminary data on the efficacy of pine tar bath oil. We do not document a significant efficacy for bathing with tea extracts. Bathing with pine-tar is potentially a complementary topical treatment with good patient acceptance and adherence, but further evidence-based research for its recommendations is needed.

Testing an Ectoin Containing Emollient for Atopic Dermatitis

AIM

To describe the methodology in studying patient's acceptability and efficacy of an ectoin containing emollient for atopic dermatitis (AD).

METHODS

We described the methodology that we used in studying emollients and moisturisers, and patient acceptability of a group of AD patients before and following usage of an ectoin-containing proprietary emollient. These data were also compared with other brand emollients that we previously reported, namely Restoradom®, Ezerra® and Ezerra plus®.

RESULTS

30 subjects (50% Male, Mean (SD) age: 9.8 (3.6) years with AD used the trial emollient W for four weeks. AD severity of subjects (by objective SCORAD) was moderate (n=22) and severe (n=8). Compliance was good and patients generally managed to use the moisturisers daily, with individual reports of a 'tingly' sensation by some subjects when applied to inflamed wounds. 63% reported "very good" or "good", whereas 37% reported "fair" or "poor" acceptability of the moisturisers. Following use of the trial emollient, area affected, disease intensity and severity significantly improved, as demonstrated in objective SCORAD (p=0.002). There were also significant improvements in POEM (p=0.035), and PADQLQ scores (p=0.017). For skin measurements, only transepidermal water loss had improved (p=0.035) after the treatment. There was no significant improvement of itch or sleep scores, skin hydration, pH, S. aureus colonization status, or need for use of topical medications. When compared with historical data of other emollients, the mean age of patients on emollient W was younger; efficacy and acceptability among these emollients were similar.

CONCLUSION

Methodology of emollient research is described. Doctors should provide evidencebased information about the efficacy of emollients. The ectoin-containing proprietary emollient improves disease and quality of life following its use in 4 weeks. Efficacy and acceptability are similar among 4 proprietary emollients.

Emollient treatment of atopic dermatitis: latest evidence and clinical considerations

Aim

To review current classes of emollients in the market, their clinical efficacy in atopic dermatitis (AD) and considerations for choice of an emollient.

Methods

PubMed Clinical Queries under Clinical Study Categories (with Category limited to Therapy and Scope limited to Narrow) and Systematic Reviews were used as the search engine. Keywords of ‘emollient or moisturizer’ and ‘atopic dermatitis’ were used.

Overview of findings

Using the keywords of ‘emollient’ and ‘atopic dermatitis’, there were 105 and 36 hits under Clinical Study Categories (with Category limited to Therapy and Scope limited to Narrow) and Systematic Reviews, respectively. Plant-derived products, animal products and special ingredients were discussed. Selected proprietary products were tabulated.

Conclusions

A number of proprietary emollients have undergone trials with clinical data available on PubMed-indexed journals. Most moisturizers showed some beneficial effects, but there was generally no evidence that one moisturizer is superior to another. Choosing an appropriate emollient for AD patients would improve acceptability and adherence for emollient treatment. Physician’s recommendation is the primary consideration for patients when selecting a moisturizer/emollient; therefore, doctors should provide evidence-based information about these emollients.