Eczema in children: uncertainties addressed

Since there is no cure for eczema, prevention would be especially beneficial. Eczema tends to run in families and a simple idea was to use emollients to improve the skin barrier from birth in high risk infants (family with eczema, asthma or hay fever). In a randomised controlled trial involving 1394 newborns, the Barrier Enhancement for Eczema Prevention (BEEP) study found no evidence that daily emollient application plus usual skin care advice during the first year of life prevented eczema at 2 years, when compared to usual skin care advice alone. There was some suggestion of an increased risk of skin infections. 

This was recently confirmed at 5 year follow-up. Daily emollient application did not prevent or delay eczema or reduce its severity. There was also no preventative effect on related conditions: food allergy, asthma or hay fever.

A 2022 Cochrane review of skin care interventions to prevent eczema was funded by the NIHR, and included the BEEP trial. It reaffirmed the findings among healthy infants during the first year of life. Compared to no skin care or usual skin care for babies, the review concluded that interventions such as emollients are probably not effective for preventing eczema by age one to three years (7 trials; 3075 babies), and probably increase risk of skin infection (6 trials; 2728 babies).

The findings relate to the use of emollients to prevent eczema. For the management of established eczema, emollients are an important part of eczema treatment.

Emollients are an important part of eczema treatment. They are recommended for all patients as a ‘leave-on’ treatment to add and help retain moisture in the skin. NICE guidance suggests that skin is moisturised each day, even in periods of remission. In 2019, in England and Wales, the NHS spent over £95 million on emollients. 

Many different emollients are available in the UK, on prescription and over the counter. This can be confusing for professionals and parents. The 2023 Best Emollient for Eczema (BEE) trial was set up to provide better information about emollients for patients and the NHS. It directly compared the effectiveness and acceptability of the four most commonly used leave-on types: lotion, cream, gel, ointment. 

From 78 GP practices, 550 children with eczema, aged between 6 months and 12 years, were randomised to one of the four types for 16 weeks. The trial found:

• all types of emollient were equally effective; no one type was better than another
• skin reactions, such as itching or redness, were common with all types 
• overall satisfaction was highest for lotions and gels.

Interviews with 44 parents and 25 children highlighted differing opinions about the same emollient types. For example, some favoured thinner emollients (lotions) and gels, which are absorbed into the skin more quickly. An 11-year old said, “being absorbed by the skin is quite helpful because when it’s … just sitting on top is not something very attractive to use.” Others saw this quality as negative, and felt the thinner consistency did not give lasting protection. An 8-year old said, “I’ll put some on, just a little bit, rub it in and almost make sure it’s soaked in and then I tend to put some more on whereas with the thicker one you could put one lot on, you could kind of see it all and know it was going to stay on.” 

All emollients were effective, so users need to be able to choose from a range of emollient types to find one that suits them. Doctors and pharmacists can ensure that families are aware of the different emollients available, help them select the type most likely to suit them, and provide clear information on how best to use them, the researchers say. 

Bath emollients (liquid emollients poured directly into the water) are available over the counter and, despite an NHS England recommendation (2018) not to prescribe them, prescribing has continued in primary care. In response, NICE recently (2023) updated its guidance to advise that bath emollients should not be offered to children with eczema. The evidence came from NIHR research: the 2018 Bath Additives for the Treatment of Eczema in Children (BATHE) trial. 

The BATHE randomised controlled trial compared bath emollients in addition to standard care (leave-on emollients and steroid creams) with standard care alone. It included 482 children aged 1 to 11 years from 96 GP practices. The study looked at eczema severity over a year, including the number of flare-ups, quality of life and adverse effects. 

The trial found that bath emollients provide no clinical benefit and are therefore not a useful additional treatment for children receiving standard eczema care. 

The new NICE recommendation should further reduce prescribing of bath emollients. This would save the NHS money. Families who stop buying bath emollients over the counter could also save money.

Another NIHR trial that saved the NHS money is the 2017 CLOTHing for the relief of Eczema Symptoms (CLOTHES) trial. This provided the evidence to stop routine prescriptions of specialist silk clothing for eczema; it was outlined in NHS England’s 2018 guidance for primary care.

The CLOTHES randomised controlled trial included 300 children aged 1 to 15 years with moderate to severe eczema. All received standard eczema care (emollients and steroid creams). In addition, half wore specialist silk clothing (long-sleeve tops and leggings) as often as possible day and night for 6 months. 

Wearing silk clothes had no effect on eczema severity assessed by nurses, infection rates, and medication use. Overall, quality of life did not significantly improve more in those wearing silk clothes. The researchers concluded that silk clothing does not provide useful extra benefits over standard care, and is not value for money for patients or for the NHS.

Much of central and southern England has hard water (> 200 mg/l calcium carbonate). Hard water may make eczema worse; increased use of soap and detergent in hard water areas can cause skin irritation, for instance. The 2011 Softened Water Eczema Trial (SWET) tested whether installing water softeners at home could reduce the severity of eczema in areas where the water is hard.

The randomised controlled trial included 336 children, aged 6 months to 16 years, with moderate to severe eczema. All received standard eczema care (emollients and steroid creams). In addition, half had a water softener installed in the family home to soften hard water used for bathing and washing clothes. Mains drinking water was not affected.

After 12 weeks, eczema severity improved for both groups. There was no additional benefit of water softening on the children’s eczema symptoms. The researchers concluded that water softeners provided no additional benefit to standard care in treating childhood eczema.

During flare-ups, in addition to emollients, treatment with steroid creams (topical corticosteroids applied to the skin) can help reduce swelling, redness, dryness and itching. They are recommended by NICE and commonly prescribed in primary care. But people may feel confused about which steroid cream to use, how often and how best to use it. Current NICE guidance on steroid use is from 2007 or earlier. 

Two recent systematic reviews from a large NIHR project provided up-to-date evidence to support their best use. The first, a 2022 Cochrane review, examined the effectiveness of different ways of using steroid creams.

Nearly half of the trials in the review (43 out of 104) included children only, others included adults only or did not specify. The findings apply to children and adults.

The review concluded that:

• once a day application of strong steroid cream is as good as twice a day
• using steroid cream for two days in a row every week prevents eczema flare-ups in people with regular flares
• stronger steroid creams are more effective than weaker ones.

People may be concerned about potential unwanted effects of steroid creams, such as skin thinning. These concerns can result in under-treatment of eczema. The second NIHR review (2023), looked at the longer-term safety of steroid creams when used for 12 months or more. Such information could help informed decision making.

Seven studies, including 2 randomised controlled trials in children only, were included. The review found no clear evidence of major safety issues with steroid creams used over longer periods. For example, only one episode of skin thinning was reported among 1213 children who used steroid creams for up to 5 years to treat flare-ups. Steroid creams were not associated with growth abnormalities in children. 

Overall, the evidence provides reassurance about the safety of steroid creams used intermittently to manage eczema for up to 5 years. More research is needed, but the review could inform balanced discussions between people with eczema (especially those who are nervous of using steroids) and healthcare professionals, the researchers say.

If topical anti-inflammatories (steroid creams and topical calcineurin inhibitors) fail to control eczema flare-ups, systemic treatments (medicines taken by mouth or injection) that suppress the immune system can be used. They are only recommended for children with severe eczema. 

Different types of systemic treatment include older, conventional medications that have a broad immunosuppressive effect, and newer, biological treatments that more directly target an immune response. Conventional treatments are usually tried first. A 2020 Cochrane review found limited and inconclusive evidence on systemic treatments for eczema in children, and called for more research. An NIHR trial has provided much-needed evidence.

The 2023 TREatment of severe Atopic eczema in children Taskforce (TREAT) randomised controlled trial compared the two main conventional medications: methotrexate and ciclosporin. It included 103 children with severe eczema, aged 2 to 16 years, at 13 centres. They were given oral methotrexate or ciclosporin for 9 months and then followed up for a further 6 months. The study found that: 

• both ciclosporin and methotrexate are effective, well-tolerated treatments for children with severe eczema
• ciclosporin worked faster at the start of treatment, whereas methotrexate provided more lasting relief, even after treatment had ended
• side effects were similar for both treatments.

Methotrexate is cheaper and may be more cost-effective. A separate study is looking at which treatment represents the best value for money for the NHS.

Skin infections are a common complication of eczema flare-ups. Signs include fluid oozing from the skin, a yellow crust, worsening eczema and fever. GPs may prescribe oral or topical antibiotics as treatment but guidance has recently changed. Based on an NIHR trial and subsequent Cochrane review, NICE guidance (2021) now states that antibiotics should not routinely be offered for bacterial infection of eczema to people who are not systemically unwell (those without a fever, for instance).

The 2016 Children with Eczema, Antibiotic Management (CREAM) randomised controlled trial included 113 children with mild to moderate eczema and a suspected infection (not a severe infection). The children were aged 3 months to 8 years, from 32 GP practices and one dermatology clinic. They were treated for 1 week with either: placebo (both oral and topical); oral antibiotic plus topical placebo; topical antibiotic plus oral placebo. The children continued with their standard eczema treatment of emollients and steroid creams.

Children’s eczema improved by 2 weeks in all 3 groups; antibiotics provided no extra benefit, whether oral or topical. The researchers concluded that children with suspected infected eczema who do not have signs of severe infection do not benefit from either oral or topical antibiotics. They recommend that treatment with emollients and steroid creams continues, with appropriate safety-netting (follow-up plans) in place.

Views and experiences of people with eczema can shed light on the impact of the condition and how to offer support. These were explored in a 2020 systematic review, part of a large NIHR project. The review was based on data from 32 studies, including 1007 people (405 parents of children with eczema). Four themes emerged.

• Young people and parents of children with eczema often view eczema as a short-term condition. They may not see the need for long-term treatment, and often seek a cause or cure for the condition: “I wanted to know why she was getting it, was it diet orientated…?”
• People feel their condition is dismissed or underestimated by others as trivial or easy to treat: “[Health professionals say] ‘No, no it’s just dry skin’, ‘oh, it’s just eczema’. I don’t think they realise how much children can suffer from it.”
• People are cautious about treatment creams for eczema, especially those containing corticosteroids: “It makes your skin wither. Will they tell you later on that you shouldn’t use?” 
• Insufficient or inconsistent information and advice from health professionals contributes to concerns about treatment: “Could anyone please give me a clear answer about when I should use an emollient, or a mild steroid, or a stronger steroid?”

The review suggests that healthcare professionals could do more to address common misconceptions about eczema. Patients may need help to understand that the condition cannot be cured but it can be controlled with careful treatment. Professionals need to acknowledge the physical and emotional impact of living with eczema, and provide clear, consistent written advice and information.

Since the review, two 2021 NIHR studies gathered the views of children and young people on living with eczema. Similar findings emerged. Eczema needs to be taken seriously and its emotional impact appreciated. Young people would like a choice of treatments and consistent, practical advice. Eczema can be difficult to manage at school, children need support to manage their triggers, access their treatments and apply these with support and privacy.

“Before we had [the website] we weren’t as consistent with the maintenance of his skin […] since we’ve been using the website we’ve moisturised every single day, twice a day, without fail […] so the flare-ups have become less and less.”
Parent of a 2-year-old son, moderate eczema

Children with eczema and their parents need support to develop their knowledge, skills and confidence. A new website, created and tested as part of an NIHR study, can help. 

Building on the findings of the review above, the same researchers worked with clinicians (GPs, specialist nurses and dermatologists) and people with eczema to create and test the Eczema Care Online website. It aims to help people self-manage their condition; interactive elements include a quiz, videos, stories and advice from others with eczema. 

The website has two versions, one for parents of children with eczema, and another for young people and adults. The two versions were tested in two randomised controlled trials.  

98 GP practices in England took part in the trials. One included 340 parents and carers of children (0 – 12 years) with eczema; the other, 337 young people (13 – 25 years) with eczema. All participants received usual eczema treatments (emollients and steroid creams). In both trials, half were also given access to EczemaCareOnline. The other half had access to information on a standard website about eczema management.

In both trials, eczema symptoms improved more in the groups with access to the new website. Benefits were small but significant, and persisted for 1 year. People with access to the website had better understanding and were more able to manage their eczema. The researchers say the websites increased the confidence of parents and young people in managing their condition.

Eczema Care Online is free to use without registration. It is low cost to run, and is cost-effective. The researchers hope professionals will encourage parents and young people to use it.

“They love it [Dragon in my Skin book], the children feel they have more control and it has made them feel special ………… this for me has been one of the best tools”
Dermatology nurse

Books, animations and activities at school could also address misconceptions about eczema, and empower children to self-manage their care. Working with healthcare professionals, children and their parents, another NIHR project came up with 5 simple, consistent, evidence-based messages, which are: 

• eczema is more than just dry skin
• eczema does not just go away
• moisturisers are for every day
• steroid creams are okay when you need them
• you know your child’s eczema best.

Easy-to-understand, attractive and accessible resources were co-designed to explain these messages. The resources are intended to meet the needs of different audiences and include an animation, a book, and a teacher resource pack. They are all based on a story, ‘The Dragon in my Skin’, that follows four children and their matching dragons, through the ups and downs of life with eczema. 

The researchers shared the resources widely, providing them freely online, and sending hard copies to 792 primary schools. They also carried out in-person and online sessions of story reading and activities. Measuring the impact of these resources is difficult, but the researchers’ assessment suggested they contributed to improvements in self-management behaviours, and more understanding from teachers, children and their peers.

“So often it’s seen as ‘just eczema’… it’s nice to have something that shows how hard it is.”
Parent of child with eczema

Examples from NIHR Funding & Awards

• RAPID and Efficient Eczema Trials (RAPID programme). In collaboration with members of the public, RAPID is currently looking at how often to have a bath or shower when you have eczema, but hopes to answer many more patient-led questions over the lifetime of the 5-year project.
• Trial of IGe tests for Eczema Relief (TIGER): randomised controlled trial of test-guided dietary advice for children with eczema, with internal pilot and nested economic and process evaluations 
• Best systemic treatments for adults with atopic eczema over the long term (BEACON): A randomised, assessor-blind trial comparing ciclosporin, methotrexate and dupilumab
• Artificial Intelligence (AI) tool for measuring eczema severity in diverse skin tones 
• Validating a novel smartwatch to assess eczema severity and predict flare-ups 
• Eczema aNd Dermatitis Implementing The Combined ApproacH (END-ITCH)
• Development and feasibility testing of an intervention to prevent potentially harmful skincare practices during infancy
• Topical anti-inflammatory treatments for eczema: a network meta-analysis  (now published)