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12th January 2023
Early prophylactic emollient use (EU) among high-risk infants, prevents the development of atopic eczema (AE) and emollient emulsions are likely to be the most effective, according to the findings of a network meta-analysis by Chinese researchers.
Atopic eczema is a chronic, inflammatory disorder of the skin and which affects between 0.9% and 22.5% of children aged 6 to 7. It is characterised by a persistent skin dryness, erythema and pruritus, leading to an impaired in quality of life. While the precise cause remains to be determined, a feature of the disease is a defective epidermal barrier that enables greater water loss through the skin leading to dryness.
However, this can be remedied to a large extent through EU, which alleviates the clinical symptoms and reduces the need for anti-inflammatory agents such as topical corticosteroids. In recent years, it has been suggested that early emollient use to high-risk infants, i.e., those with a family history of the disease or other atopic conditions such as asthma or hay fever, might prevent the subsequent development of AE.
The evidence to support this is equivocal, with one meta-analysis finding that use of emollients made no difference, whereas another concluded that prophylactic emollient use, initiated in early infancy may prevent AE, especially in high-risk populations and when used continuously. A further consideration and which might account for the observed discrepancies in the meta-analyses, is the type of emollient used. In fact, there is some data to show that different emollient creams have different effects on the skin and only certain types have the ability to improve the skin’s barrier and protect against irritants that trigger eczema.
With some uncertainty over whether early EU could prevent the development of AE, in the present study, the Chinese researchers undertook a network meta-analysis to address both whether the early application of emollients in infancy could prevent the later development of AE and which types of emollients were most effective. They used the surface under the cumulative ranking area curve (SUCRA) which to rank the different types of emollients, which could be either emulsions, creams or mixed formulations (e.g., creams, gels) and where a higher SUCRA value indicated a greater preventive efficacy.
Early emollient use and the development of atopic eczema
A total of 11 trials with 3,483 subjects were included in the network meta-analysis. Overall, the results showed that the development of AE was significantly lower after early emollient application (Risk Ratio, RR = 0.75, 95% CI 0.57 – 0.99, p = 0.001). In addition, this risk was also significantly lower, when the analysis was restricted to high-risk infants (RR = 0.64, 95% CI 0.47 – 0.88).
When examining the different types of emollients, the SUCRA values were highest for emollient emulsions, with values of 82.6% for all populations and 78.0% for high-risk populations.
The authors concluded that the early application of emollients is an effective strategy for preventing AE development in high-risk infants and that an emollient emulsion may be the optimal type of formulation.
Liang J et al. Systematic review and network meta-analysis of different types of emollient for the prevention of atopic dermatitis in infants. J Eur Acad Dermatol Venereol 2022
5th March 2020
Atopic eczema is characterised by a defective skin barrier and often precedes the development of food allergies and other atopic diseases. Could regular emollient use from birth actually prevent the development of the condition? Rod Tucker finds out.
Atopic eczema is a highly pruritic, inflammatory skin condition which affects 20% of children.1 The condition develops during infancy and classically leads to food allergies, asthma and allergic rhinitis in what has been termed the ‘atopic march’.2 A family history of atopic disease is an important risk factor for the development of atopic eczema. In addition, the presence of atopic eczema increases the risk of IgE-mediated food allergies and for example, infants with the condition are six times more likely to develop egg allergies.3
While the precise cause of eczema remains uncertain, the condition is characterised by a defective skin barrier and there is evidence that genetically determined loss-of-function mutations in the gene that codes for filaggrin, a protein that has an important role in skin barrier function, may contribute to eczema development during infancy.4 The presence of defective skin barrier serves as a possible entry route for allergens and this has been proposed as a possible route to sensitisation and the subsequent development of a peanut allergy.5
Emollients are the cornerstone of eczema management and are recommended for all patients with the condition.6 An emollient provides a water impermeable barrier over the surface of the skin which serves to both prevent water loss and ingression of potential allergens and irritants.
Given this dual role, is it possible that treatment with emollients soon after birth could actually prevent the development of atopic eczema and the ensuing atopic march? This was the question posed in the barrier enhancement for eczema prevention (BEEP) study published in the Lancet.7
The study was based on the observations of a pilot study undertaken by the same group which found that the incidence of atopic eczema was lower (22% vs 43%) in 124 infants treated with the daily application of an emollient from birth.8 But this was not simply blue sky thinking: several lines of evidence had pointed to a role for emollients in preventing inflammation as well as work which illustrated how the barrier dysfunction in atopic eczema appeared to be a secondary phenomena to subclinical inflammation present in dry atopic skin.9
The BEEP study recruited 1,394 high-risk (that is, where at least one first-degree relative had either eczema, allergic rhinitis or asthma) babies who were randomised to either once daily application of an emollient (Diprobase or Doublebase gel) to the whole body excluding the scalp or best practice skincare advice (the control group). This latter group received advice to use mild cleansers and shampoos specifically formulated for infants but also to avoid soaps, bubble bath and baby wipes.
The primary outcome measure was a diagnosis of eczema at two years of age. The results showed no difference: eczema was present at two years of age in 23% of infants assigned to daily emollient use and 25% in the control group. There were also no significant differences in the incidence of food allergies or other allergic diseases and the authors were at a loss to explain their findings.
An alternative strategy to reducing food allergies is through early exposure to potentially allergenic foods in order to allow the development of tolerance and this was the subject of the preventing atopic dermatitis and allergies (PreventADALL) study which was also published in the same issue of The Lancet.
In PreventADALL, Norwegian researchers explored the dual approach of daily emollient use and early introduction of potential allergic foodstuffs such as peanut butter, wheat porridge and eggs10 and the incidence of eczema was recorded after 12 months.
The study had four arms: control (no advice); skin emollients; early feeding and finally combined emollient and early feeding. The incidence of eczema at 12 months was 8% (control group), 11% (emollient group), 9% (food group) and 5% (combined group) and these differences were not significant. In other words, neither a combination of daily emollient use and early introduction of potential allergenic foods reduced the development of atopic eczema at 12 months.
The results of both studies, although disappointing, recognise the limited value of these primary prevention strategies. However, these results do not undermine the importance of regular emollient use in the management of established atopic eczema.
Whether changing the composition of an emollient makes any difference remains to be seen and is the subject of the ongoing PEBBLES study.11