Different emollient formulations appear to be equally effective for the management of eczema symptoms in children according to a recent RCT
Differences in emollient formulations do not make an appreciable impact on patient-related outcomes in children with atopic eczema. This was the key finding of a pragmatic, randomised trial by UK researchers led a team from the Population Health Sciences, University of Bristol, UK.
In the UK, it is estimated that 11-20% of children and 5-10% of adults are affected by the inflammatory skin condition, atopic eczema. Emollients are the mainstay of treatment for all patients with atopic eczema (or simply eczema) and according to guidance from NICE should form the basis of management and always be used, even when the skin is clear. There are a wide range of emollients and emollient formulations available but little evidence to direct the choice of treatment although physicians play a pivotal role in assisting patients to select an emollient that they will accept and use consistently. There is a general perception that the greasier an emollient the more effective it is, as it is able to trap more moisture in the skin although greasier emollients can be less acceptable or tolerable.
Nevertheless, despite the perception that greasier emollient formulations are more effective, there is little, if any, evidence to support this claim. For the present study, the UK team set out to compare the effectiveness of four different emollient formulations; lotions, creams, gels and ointment for children with eczema. The Best Emollient for Eczema trial was a pragmatic, multi-centre, individually randomised, parallel group superiority trial of the four types of emollient. It enrolled children aged 6 months to less than 12 years of age with a healthcare professional diagnosis of eczema of mild or higher severity, as determined using the Patient Orientated Eczema Measure (POEM). This 7-item questionnaire of eczema symptoms (e.g. itching, redness, skin dryness etc) ranges from 0 to 28, with higher scores indicative of more severe disease. Eligible children were required to have score of > 2 and randomised 1:1:1:1 to receive lotions, creams, gel or ointment with an initial prescription for 500g or 500ml and which was to be applied twice daily and as needed. The primary outcome measure was the parent-reported POEM score and which was measured weekly over 16 weeks, with the minimum clinically important difference in POEM scores set at 3.
Emollient formulations and POEM scores
A total of 550 children with a median age of 4 years (46% female) were randomised to one of the four different emollients and the overall mean baseline POEM score was 9.3.
At week 16 there was no statistically significant difference (p = 0.77) between the different treatments based on the final POEM scores which were lotion (6.8), cream (7.6), gel (7.5) and ointment (7.0).
The authors concluded that their data suggest that there are no important differences between emollients, despite the widely held view that a more greasy formulation, which by trapping moisture, would be the most effective. They suggested that patients should be allowed to choose from a range of emollient formulations.
Ridd M et al. Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial Lancet Child Adolesc. Health 2022