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

Published on 27 June 2017

doi: 10.3310/signal-000431

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.

  •   Medicines, Skin conditions
Moisturisers improve eczema symptoms and lessen the need for corticosteroids

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 systematic review of 77 randomised controlled trials that looked at various moisturisers used alone or in combination. Moisturisers were compared to other treatments, 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 bias, and many of the trials were small, with 20 to 60 participants. Interventions varied between studies. The results therefore need to be treated cautiously.

What did it find?

  • Moisturiser use reduced eczema severity slightly compared to no moisturiser according to the SCORAD score, mean difference [MD] -2.42 (95% 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.

Expert commentary

Patients with eczema and their carers are always told to moisturise the skin regularly. This comprehensive review of randomised trials of moisturisers tells us that doing so correctly and regularly (at least daily) helps to reduce the symptoms of dry skin (including itch), and both improve the effectiveness of, and reduce the need for, topical corticosteroids. 

However, it also reminds us that we still don’t really know which is “best” (in terms of effectiveness, acceptability and adverse events) for different patients, body areas or times of the day or year.

Dr Matthew Ridd, Consultant Senior Lecturer in Primary Health Care, University of Bristol

Definitions

SCORAD (SCORing Atopic Dermatitis) is an assessment tool used by clinicians to evaluate the extent and severity of eczema. It was created and validated in 1990. The SCORAD consists of assessing disease severity across three criteria:

  1. Area: The sites affected by eczema are shaded on a drawing of a body. The affected area is calculated as a percentage of the whole body.
  2. Intensity: A representative area of eczema is selected. In this area, the intensity of each of the six signs is assessed as none, mild, moderate or severe.
  3. Subjective symptoms: Symptoms such as itch and sleeplessness are each scored by the patient or relative using a visual analogue scale where 0 is no itch (or no sleeplessness) and 10 is the worst imaginable itch (or sleeplessness).

It is scored between 0 (no symptoms) and 103 (worst symptoms). The minimal important difference for SCORAD is estimated to be 8.7, so anything below this is not considered “clinically relevant”.