The right moisturiser for children with eczema is the one that they like to use, study finds
Press release issued: 24 May 2022
The Best Emollients for Eczema trial has found that no one type of moisturiser is better than another. This study, the first in the world to directly compare different types of moisturisers, highlights the importance of patient education and choice when deciding which moisturisers to use for children with eczema. The results from the National Institute for Health and Care Research (NIHR) funded study are published in The Lancet Child & Adolescent Health and British Journal of General Practice today [24 May].
Moisturisers (also called emollients) are recommended for the one in five children who have eczema (also known as atopic eczema/dermatitis), which causes dry and itchy skin. Over 100 different moisturisers are prescribed in the NHS, costing over £100 million a year. Lack of research in this area means NHS guidelines vary widely in what is recommended, which leads to confusion and waste.
In the study, led by the universities of Bristol, Nottingham and Southampton, 550 children with eczema aged under 12 years were randomised to use one of four types of moisturiser (lotion, cream, gel or ointment) as their main moisturiser for 16 weeks. Parents completed diaries about their child's eczema for a year, and some were interviewed to gain an in-depth understanding of how they used the moisturisers and what they thought of them. All children also had an independent examination of their skin.
Used alongside other eczema treatments, there was no difference in effectiveness of the four types of moisturiser used in the study. Skin reactions such as itching or redness were common with all moisturiser types. Awareness of the different types of moisturiser was low, and users had different preferences based on how the moisturisers look and feel. For example, some people liked how lotions quickly soaked in whereas others preferred the “barrier” provided by ointments.
Professor Matthew Ridd, a GP and study lead from Centre for Academic Primary Care at the University of Bristol, said: “A study of this type has been long overdue. It has not been in the interest of the manufacturers to directly compare types of moisturiser in the way we have done in this trial. Our findings challenge conventions about how often moisturisers need to be applied, which types are less likely to cause problems and which patients should be recommended certain types. For example, ointments are often suggested for more severe eczema, yet they were found to be no better.”
Hayley, the mother of Abriarna who took part in the trial, said: “The trial helped us find an emollient we had never used before, which has helped keep Abriarna’s skin in good condition for the longest time. Her eczema often requires a different emollient for various purposes, for example, Abriarna has a regular day-to-day moisturiser, which we found through the trial. She then has an emollient for days when her eczema is agitated and then an emollient to wash in as well as to use after handwashing.”
Tiffany Barrett, pharmacist and co-researcher added: “NHS prescribing of moisturisers is determined by locally agreed formularies. These formularies are based on both cost and perceived effectiveness. What this study does is emphasise the importance of having the four main types of moisturisers available on formularies for children with eczema, so that the right product can be used at the right time.”
Professor Hywel Williams, consultant dermatologist and co-researcher at the University of Nottingham, explained: "Along with anti-inflammatory treatments such as topical corticosteroids, emollients are a really key part of treatment for childhood eczema, preventing flares and helping to soothe the skin and improving the quality of life for children and their carers.
"Our study shows that one size does not fit all, and points to the need for doctors to make parents aware of the different emollient types and to help them choose which one is mostly likely to work for them. At last we have evidence that supports the saying, ‘The best moisturisers are the ones the patient will use."
Professor Nick Levell, NIHR National Specialty Lead for Dermatology, said: "Around one in five children get eczema and the scratching and sleep loss affects school performance and exhausts children and their parents. This study confirms that parent and patient preference is very important in choosing a moisturiser to treat eczema. Some people prefer ointments, but others like gels, creams or lotions. No one option is best. As reactions to moisturisers are common, it is important that the NHS provides a wide choice to help parents find something that soothes and calms their child’s fiery skin."
Further work is needed to determine if these findings apply to adolescents and adults with eczema, and people with other dry skin conditions.
‘Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial’ by M Ridd et al in The Lancet Child & Adolescent Health [open access]
‘How parents and children evaluate emollients for childhood eczema: a qualitative study’ by Eileen Sutton, Alison RG Shaw, Matthew J Ridd, Miriam Santer, Amanda Roberts, Helen Baxter, Hywel C Williams and Jonathan Banks in British Journal of General Practice [online first]
Best Emollients for Eczema trial case study: Hayley and her daughter, Abriarna
Abriarna was diagnosed with eczema shortly after birth, after she was found to be dairy intolerant. Her eczema mainly affects certain areas of her body such as her feet, including the soles, the palms of her hands and her shoulders and back. She suffers with genetically dry skin, but her flare ups only affect her eczema areas.
Abriarna is mixed race - her father and mother have sensitive skin but no diagnosis of eczema. Following further investigations, it was found Abriarna was lactose intolerant, so her parents adjusted her diet accordingly. Abriarna also has a peanut allergy, but this is not thought to be related to her eczema.
Hayley, Abriarna’s mother, said: "Abriarna has learnt to manage her own skin routine since she was a young child. The Best Emollients for Eczema trial has really helped Abriarna to gain confidence but also to understand it’s okay to have eczema and that she is not alone in her battle with the condition.
"The trial helped us find an emollient we had never used before, which has helped keep Abriarna’s skin in good condition for the longest time. Her eczema often requires a different emollient for various purposes, for example, Abriarna has a regular day-to-day moisturiser, which we found through the Best Emollients for Eczema trial. She then has an emollient for days when her eczema is agitated and then an emollient to wash in as well as to use after handwashing."
Abriarna is now eight years old and can speak about how eczema affects her and what foods help her skin condition like red flesh foods - Abriarna found this out by herself. Abriarna is self-aware of her eczema and is excellent at managing her skin care regime.
We were often told she will grow out of eczema, but it hasn't happened yet. Weather, heat, emotions and food can all affect her eczema. The greatest thing Abriarna has learnt from the BEE trial is how to live and manage her eczema.
Unfortunately since the end of the Best Emollients for Eczema trial, Abriarna has been referred for specialist support of her eczema as she is now suffering with continual follicles believed to be caused by her condition.
We are very grateful for the Best Emollients for Eczema trial as it has opened a new world of learning knowledge and also skin products that have helped get Abriarna’s skin to a good condition.
Medicine Management/Formulary Teams should include at least two emollients of each type of lotion, cream, gel and ointment on prescribing formularies.
Prescribers and pharmacists should:
- Ensure that parents and older children are aware of the different emollient types and their different characteristics.
- Identify users’ priorities and preferences, and use this to help them decide which emollient to try first.
- Give advice (verbal, written and/or online videos) on their purpose and how to use them alongside other treatments.
- Emollients treat the dry skin but any underlying inflammation needs anti-inflammatory preparations such as topical corticosteroids. Some side effects may reflect under-treatment of the inflammation in the skin rather than a problem with the emollient itself.
- Encourage parents and children to give a new emollient a sufficient “trial period” of at least two weeks, unless any major problems with localised skin reactions.
They might also:
- Suggest parent complete weekly patient-reported outcome measures such as the Patient Orientated Eczema Measure, as this may support emollient use.
- Offer early (4 week) and thereafter regular (6-12 monthly) review of prescribed emollient(s). This may support initial and on-going use, by identifying problems with new emollients or changes in needs as the child grows or their situation changes (e.g. starting school or seasonal effects).
About the Best Emollients for Eczema trial
Best Emollients for Eczema was a research study designed to improve the treatment of childhood eczema by finding out which emollients (moisturisers) are most acceptable and effective.
Follow us on Twitter: @bee_study
About the National Institute for Health and Care Research (NIHR)
The mission of the National Institute for Health and Care Research (NIHR) is to improve the health and wealth of the nation through research. We do this by:
- Funding high quality, timely research that benefits the NHS, public health and social care;
- Investing in world-class expertise, facilities and a skilled delivery workforce to translate discoveries into improved treatments and services;
- Partnering with patients, service users, carers and communities, improving the relevance, quality and impact of our research;
- Attracting, training and supporting the best researchers to tackle complex health and social care challenges;
- Collaborating with other public funders, charities and industry to help shape a cohesive and globally competitive research system;
- Funding applied global health research and training to meet the needs of the poorest people in low and middle income countries.
NIHR is funded by the Department of Health and Social Care. Its work in low and middle income countries is principally funded through UK Aid from the UK government.
About the Centre for Academic Primary Care, University of Bristol
The Centre for Academic Primary Care (CAPC) at the University of Bristol is a leading centre for primary care research in the UK, one of nine forming the NIHR School for Primary Care Research. It sits within Bristol Medical School, an internationally recognised centre of excellence for population health research and teaching.
Follow us on Twitter: @capcbristol