Skin Salve share study by National Institute for Health research on eczema and moisturisers

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NIHR Signal Moisturisers improve eczema symptoms and lessen the need for corticosteroids

Published on 27 June 2017

Moisturisers help reduce eczema symptoms compared to no treatment, but to a minor extent. They do lengthen the time between each flare, and reduce the number of flares. Importantly they reduce the amount of corticosteroid creams required. Moisturisers seem well tolerated, though there is little data on patient satisfaction.

This Cochrane review of 77 trials does not provide information on which moisturiser might be preferred for different parts of the body or different disease severity. Nevertheless, since moisturisers reduce flares and form part of combined treatment with other active treatments, it makes sense to encourage their continued use.

Given the lack of a one size fits all approach, people should have the opportunity to choose between different moisturisers and use the ones that suit them best. Some may prefer using less oily creams during the day and thicker ointments at night.

 

    Why was this study needed?

    Eczema is a chronic skin disorder characterised by itchy dry skin. Scratching and cracking lead to further damage with redness, crusts, and oozing, and the itching can result in sleep deprivation and have a considerable impact on quality of life. Eczema often develops during the first year of life, although it may first appear in adults. People with eczema usually have periods when symptoms are less noticeable, as well as periods when symptoms become more severe (flares).

    Eczema is a common condition. In the UK, 15 to 20% of school-aged children and 2 to 10% of adults will be affected by the condition at some stage. Moisturisers are a cornerstone of treatment, but there is uncertainty about how helpful they are and whether one moisturiser is preferable to another. The aim of this Cochrane review was to assess the effectiveness of moisturisers for eczema.

    What did this study do?

    This was a placebo or no treatment. Participants had mild to moderate eczema and were aged from between four months to 84 years (mean age was 18.6 years).

    Most studies lasted between two to six weeks, with a few lasting six months. Forty-two studies were conducted in Europe, 20 in the USA or Canada, and the rest in Asia or Africa. Forty-six were funded by pharmaceutical companies.

    Most studies were assessed as being at high or unclear risk of confidence interval [CI] -4.55 to -0.28; three studies, 276 participants). However, the change was not considered clinically significant.

    Fewer people using moisturisers had flares, 27% compared to 67% not using moisturisers over six month follow up (risk ratio [RR] 0.40, 95% CI 0.23 to 0.70; two studies, 87 participants). Time between flares was prolonged with moisturisers (median of 180 versus 30 days)

    Less topical corticosteroids were needed for people using moisturisers – about a third of a standard tube less over six to eight weeks (MD -9.30grams, 95% CI -15.3 to -3.27; two studies, 222 participants).There were few comparative studies and little difference between moisturisers in terms of effectiveness and adverse events. Moisturisers were generally well tolerated. Adverse effects for the most part consisted of smarting, stinging, itching, redness, rash, and rarely folliculitis – an infection in the hair follicles.

      There was little information on participant satisfaction with treatment.

    What does current guidance say on this issue?

    The NICE Guidance from 2007 on eczema in under-twelve’s recommends a stepped approach for managing the condition. Moisturisers should form the basis of management and should always be used. Management can be stepped up or down, according to the severity of symptoms.

    SIGN guidance from 2012 on the management of eczema in primary care also recommends that people with eczema should have on-going treatment with moisturisers. They should also be advised to continue with moisturisers during any treatment with corticosteroids.

    What are the implications?

    Moisturisers continue to be an integral part of eczema care, but there is not much information to help choose between them. People with eczema should therefore have the opportunity to choose between different moisturisers to identify those that are most suitable for their own skin.

    The review does not report on the need for education in how to apply moisturisers, in particular how often they need to be applied and how much to use. The lack of research on patient satisfaction is disappointing as it could help adherence. This is especially important as moisturiser therapy is time consuming and often required throughout life.

    Citation and Funding

    van Zuuren EJ, Fedorowicz Z, Christensen R,et al. Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;2:CD012119.

    Cochrane UK and the Cochrane Skin Group are supported by NIHR infrastructure funding.

    Bibliography

    Consensus Report of the European Task Force on Atopic Dermatitis. Severity Scoring of Atopic Dermatitis: The SCORAD Index. Dermatology. 1993;186:23-31.

    NICE. Atopic eczema in under 12s: diagnosis and management. CG57. London: National Institute for Health and Clinical Excellence; 2007.

    SIGN. Management of atopic eczema in primary care. A national clinical guideline. Edinburgh: Scottish intercollegiate guidelines network; 2011.

    Why was this study needed?

    Eczema is a chronic skin disorder characterised by itchy dry skin. Scratching and cracking lead to further damage with redness, crusts, and oozing, and the itching can result in sleep deprivation and have a considerable impact on quality of life. Eczema often develops during the first year of life, although it may first appear in adults. People with eczema usually have periods when symptoms are less noticeable, as well as periods when symptoms become more severe (flares).

    Eczema is a common condition. In the UK, 15 to 20% of school-aged children and 2 to 10% of adults will be affected by the condition at some stage. Moisturisers are a cornerstone of treatment, but there is uncertainty about how helpful they are and whether one moisturiser is preferable to another. The aim of this Cochrane review was to assess the effectiveness of moisturisers for eczema.

    What did this study do?

    This was a placebo or no treatment. Participants had mild to moderate eczema and were aged from between four months to 84 years (mean age was 18.6 years).

    Most studies lasted between two to six weeks, with a few lasting six months. Forty-two studies were conducted in Europe, 20 in the USA or Canada, and the rest in Asia or Africa. Forty-six were funded by pharmaceutical companies.

    Most studies were assessed as being at high or unclear risk of confidence interval [CI] -4.55 to -0.28; three studies, 276 participants). However, the change was not considered clinically significant.

    Fewer people using moisturisers had flares, 27% compared to 67% not using moisturisers over six month follow up (risk ratio [RR] 0.40, 95% CI 0.23 to 0.70; two studies, 87 participants). Time between flares was prolonged with moisturisers (median of 180 versus 30 days).

    Less topical corticosteroids were needed for people using moisturisers – about a third of a standard tube less over six to eight weeks (MD -9.30grams, 95% CI -15.3 to -3.27; two studies, 222 participants).

    There were few comparative studies and little difference between moisturisers in terms of effectiveness and adverse events. Moisturisers were generally well tolerated. Adverse effects for the most part consisted of smarting, stinging, itching, redness, rash, and rarely folliculitis – an infection in the hair follicles.

    There was little information on participant satisfaction with treatment.

    What does current guidance say on this issue?

    The NICE Guidance from 2007 on eczema in under-twelve’s recommends a stepped approach for managing the condition. Moisturisers should form the basis of management and should always be used. Management can be stepped up or down, according to the severity of symptoms.

    SIGN guidance from 2012 on the management of eczema in primary care also recommends that people with eczema should have on-going treatment with moisturisers. They should also be advised to continue with moisturisers during any treatment with corticosteroids.

    What are the implications?

    Moisturisers continue to be an integral part of eczema care, but there is not much information to help choose between them. People with eczema should therefore have the opportunity to choose between different moisturisers to identify those that are most suitable for their own skin.

    The review does not report on the need for education in how to apply moisturisers, in particular how often they need to be applied and how much to use. The lack of research on patient satisfaction is disappointing as it could help adherence. This is especially important as moisturiser therapy is time consuming and often required throughout life.

    Citation and Funding

    van Zuuren EJ, Fedorowicz Z, Christensen R,et al. Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;2:CD012119.

    Cochrane UK and the Cochrane Skin Group are supported by NIHR infrastructure funding.

    Bibliography

    Consensus Report of the European Task Force on Atopic Dermatitis. Severity Scoring of Atopic Dermatitis: The SCORAD Index. Dermatology. 1993;186:23-31.

    NICE. Atopic eczema in under 12s: diagnosis and management. CG57. London: National Institute for Health and Clinical Excellence; 2007.

    SIGN. Management of atopic eczema in primary care. A national clinical guideline. Edinburgh: Scottish intercollegiate guidelines network; 2011.

    Emollients and moisturisers for eczema

    Published on 7 February 2017

    van Zuuren, E. J.,Fedorowicz, Z.,Christensen, R.,Lavrijsen, A.,Arents, B. W. M.

    Cochrane Database Syst Rev Volume 2 , 2017

    BACKGROUND: Eczema is a chronic skin disease characterised by dry skin, intense itching, inflammatory skin lesions, and a considerable impact on quality of life.

    Moisturisation is an integral part of treatment, but it is unclear if moisturisers are effective.

    OBJECTIVES: To assess the effects of moisturisers for eczema. SEARCH METHODS: We searched the following databases to December 2015: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, the GREAT database.

    We searched five trials registers and checked references of included and excluded studies for further relevant trials.

    SELECTION CRITERIA: Randomised controlled trials in people with eczema. DATA

    COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures.

    MAIN RESULTS: We included 77 studies (6603 participants, mean age: 18.6 years, mean duration: 6.7 weeks). We assessed 36 studies as at a high risk of bias, 34 at unclear risk, and seven at low risk.

    Twenty-four studies assessed our primary outcome 'participant-assessed disease severity', 13 assessed 'satisfaction', and 41 assessed 'adverse events'.

    Secondary outcomes included investigator-assessed disease severity (addressed in 65 studies), skin barrier function (29), flare prevention (16), quality of life (10), and corticosteroid use (eight).

    Adverse events reporting was limited (smarting, stinging, pruritus, erythema, folliculitis).Six studies evaluated moisturiser versus no moisturiser.

    'Participant-assessed disease severity' and 'satisfaction' were not assessed. Moisturiser use yielded lower SCORAD than no moisturiser (three studies, 276 participants, mean difference (MD) -2.42, 95% confidence interval (CI) -4.55 to -0.28), but the minimal important difference (MID) (8.7) was unmet.

    There were fewer flares with moisturisers (two studies, 87 participants, RR 0.40, 95% CI 0.23 to 0.70), time to flare was prolonged (median: 180 versus 30 days), and less topical corticosteroids were needed (two studies, 222 participants, MD -9.30 g, 95% CI -15.3 to -3.27).

    There was no statistically significant difference in adverse events (one study, 173 participants, risk ratio (RR) 15.34, 95% CI 0.90 to 261.64).

    Evidence for these outcomes was low quality.

    With Atopiclair (three studies), 174/232 participants experienced improvement in participant-assessed disease severity versus 27/158 allocated to vehicle (RR 4.51, 95% CI 2.19 to 9.29).

    Atopiclair decreased itching (four studies, 396 participants, MD -2.65, 95% CI -4.21 to -1.09) and achieved more frequent satisfaction (two studies, 248 participants, RR 2.14, 95% CI 1.58 to 2.89), fewer flares (three studies, 397 participants, RR 0.18, 95% CI 0.11 to 0.31), and lower EASI (four studies, 426 participants, MD -4.0, 95% CI -5.42 to -2.57), but MID (6.6) was unmet.

    The number of participants reporting adverse events was not statistically different (four studies, 430 participants, RR 1.03, 95% CI 0.79 to 1.33). Evidence for these outcomes was moderate quality.

    Participants reported skin improvement more frequently with urea-containing cream than placebo (one study, 129 participants, RR 1.28, 95% CI 1.06 to 1.53; low-quality evidence), with equal satisfaction between the two groups (one study, 38 participants, low-quality evidence).

    Urea-containing cream improved dryness (investigator-assessed) more frequently (one study, 128 participants, RR 1.40, 95% CI 1.14 to 1.71; moderate-quality evidence) with fewer flares (one study, 44 participants, RR 0.47, 95% CI 0.24 to 0.92; low-quality evidence), but more participants in this group reported adverse events (one study, 129 participants, RR 1.65, 95% CI 1.16 to 2.34; moderate-quality evidence).

    Three studies assessed glycerol-containing moisturiser versus vehicle or placebo. More participants in the glycerol group noticed skin improvement (one study, 134 participants, RR 1.22, 95% CI 1.01 to 1.48; moderate-quality evidence), and this group saw improved investigator-assessed SCORAD (one study, 249 participants, MD -2.20, 95% CI -3.44 to -0.96; high-quality evidence), but MID was unmet.

    Participant satisfaction was not addressed. The number of participants reporting adverse events was not statistically significant (two studies, 385 participants, RR 0.90, 95% CI 0.68 to 1.19; moderate-quality evidence).

    Four studies investigated oat-containing moisturisers versus no treatment or vehicle. No significant differences between groups were reported for participant-assessed disease severity (one study, 50 participants, RR 1.11, 95% CI 0.84 to 1.46; low-quality evidence), satisfaction (one study, 50 participants, RR 1.06, 95% CI 0.74 to 1.52; very low-quality evidence), and investigator-assessed disease severity (three studies, 272 participants, standardised mean difference (SMD) -0.23, 95% CI -0.66 to 0.21; low-quality evidence). In the oat group, there were fewer flares (one study, 43 participants, RR 0.31, 95% CI 0.12 to 0.7; low-quality evidence) and less topical corticosteroids needed (two studies, 222 participants, MD -9.30g, 95% CI 15.3 to -3.27; low-quality evidence), but more adverse events were reported (one study, 173 participants; Peto odds ratio (OR) 7.26, 95% CI 1.76 to 29.92; low-quality evidence).

    All moisturisers above were compared to placebo, vehicle, or no moisturiser. Participants considered moisturisers more effective in reducing eczema (five studies, 572 participants, RR 2.46, 95% CI 1.16 to 5.23; low-quality evidence) and itch (seven studies, 749 participants, SMD -1.10, 95% CI -1.83 to -0.38) than control.

    Participants in both treatment arms reported comparable satisfaction (three studies, 296 participants, RR 1.35, 95% CI 0.77 to 2.26; low-quality evidence). Moisturisers led to lower investigator-assessed disease severity (12 studies, 1281 participants, SMD -1.04, 95% CI -1.57 to -0.51; high-quality evidence) and fewer flares (six studies, 607 participants, RR 0.33, 95% CI 0.17 to 0.62; moderate-quality evidence), but there was no difference in adverse events (10 studies, 1275 participants, RR 1.03, 95% CI 0.82 to 1.30; moderate-quality evidence).

    Topical active treatment combined with moisturiser was more effective than active treatment alone in reducing investigator-assessed disease severity (three studies, 192 participants, SMD -0.87, 95% CI -1.17 to -0.57; moderate-quality evidence) and flares (one study, 105 participants, RR 0.43, 95% CI 0.20 to 0.93), and was preferred by participants (both low-quality evidence).

    There was no statistically significant difference in number of adverse events (one study, 125 participants, RR 0.39, 95% CI 0.13 to 1.19; very low-quality evidence). Participant-assessed disease severity was not addressed. AUTHORS' CONCLUSIONS:

    Most moisturisers showed some beneficial effects, producing better results when used with active treatment, prolonging time to flare, and reducing the number of flares and amount of topical corticosteroids needed to achieve similar reductions in eczema severity.

    We did not find reliable evidence that one moisturiser is better than another.

     


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