Lotion demotion: smearing emollients on babies doesn’t prevent eczema
EBM Focus - Volume 15, Issue 8
Eczema affects one in five children, with rates 2-3 times higher in those with a family history. The disease is associated with impaired quality of life for affected kids and their parents (Lancet 2016). Several preventative measures have been reported to reduce the risk of developing eczema, including breastfeeding, probiotic therapy, animal exposure, and regular emollient use (J Allergy Clinical Immunology 2014).
The Barrier Enhancement for Eczema Prevention (BEEP) trial was a randomized multicenter study in the United Kingdom comparing emollient use or usual skin care for the prevention of eczema in infants. A total of 1,394 term infants (born at ≥ 37 weeks gestation) with one first-degree relative with an atopic condition (eczema, atopic dermatitis, or asthma) were randomized within 21 days of birth to either daily emollient use plus best-practice skin care or best-practice skin care until age one year. Best practice skin care included avoiding soaps, bubble baths, and baby wipes and using mild cleansers and wet cloths to clean the diaper area. Unblinded parents chose from two emollients after initial sampling at home; both were petroleum-based products available over-the-counter in the UK. Families were followed via questionnaire at 2 weeks and 3, 6, 12, and 18 months. Evaluation by a nurse blinded to the intervention was conducted at age 2 years. The children also had skin prick testing for peanut, egg, and dairy allergies. Parent-reported compliance at 12 months was 75% in each group, and 87% of participants completed follow-up at 2 years. In the control group, 15% of parents crossed over to emollient use for non-study reasons. In a modified intention to treat analysis at two years, there was no difference in the rate of the diagnosis of eczema (23% in emollient group versus 25% in usual care group, adjusted relative risk [RR] 0.95, 95% CI 0.78-1.16). The rates of moderate or severe eczema at 1 and 2 years and parent-reported clinical diagnosis of eczema at 2 years were similar. Rates of common food allergies (diagnosed with either a positive challenge or skin prick test) were also similar in both groups (7% vs. 5%, adjusted RR 1.47, 95% CI 0.93-2.33). Parent-reported physician diagnosis of skin infections, including impetigo, were higher with emollient use compared to usual care (15% vs. 11%, NNH = 25 at 1 year).
In addition to breastfeeding and general skin care advice such as less frequent bathing and avoiding irritating soaps, previous smaller studies have demonstrated that emollients may reduce the risk of eczema. In contrast, this larger study found no significant effect of emollients on the risk of developing eczema. Although a defective skin barrier has been implicated in the development of eczema, supplementing an infant’s natural barrier with an emollient does not appear to confer benefit and may increase the risk of skin infections. Parents rejoice: the slippery and time-consuming intervention of emollient application might slide out of the bedtime routine.
For more information, see the topic Atopic Dermatitis in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Carina Brown, MD, Assistant Professor at Cone Health Family Medicine Residency. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School, Dan Randall, MD, Deputy Editor for Internal Medicine at DynaMed, and Katharine DeGeorge, MD, MS, Associate Professor of Family Medicine at the University of Virginia and Clinical Editor at DynaMed.