Childhood eczema

4-10%  of children with atopic eczema are referred to a dermatologist for further advice

Evidence at a glance on childhood eczema

The NIHR has invested significant research activity into identifying treatment options for childhood eczema that are helpful, and those that are probably ineffective. Whilst there is no cure, treatments aim to sooth sore skin, reduce itching, or prevent infection. The main types of treatment are moisturisers (emollients) and topical corticosteroids. These can be onerous to apply so parents and children are keen to search for other things that might work for eczema; NIHR research is helping.

The Cochrane Skin Group

The NIHR provides funding to the Cochrane Skin Group. This review group is based in Nottingham but consists of a network of individuals from across the world who review trials on skin conditions and summarises findings for healthcare professionals and service users. You can view their full range of systematic reviews, which include many reviews on childhood eczema.

What do the research findings tell us?

The NIHR has funded a variety of projects into skin conditions. Here are a few key findings on treatments for childhood eczema:

• During an eczema flare up, using a moisturiser alongside a topical active treatment had a better outcome that the active treatment alone. However, there are no particular moisturisers that are more beneficial than others for eczema. These were the results from a systematic review comparing over 70 trials of different types of moisturisers.
• Antibiotics to treat infections in mild to moderate eczema did not have any beneficial effect and researchers concluded that antibiotics should only be prescribed in cases of severely infected eczema. In this study oral and topical (applied to the skin) antibiotics were used to treat infections developed by children with eczema aged 3 months to 8 years (CREAM study).
• In a study of over 300 children aged 1-15 years, it was found there was no clear benefit of wearing silk clothing in terms of eczema severity (CLOTHES study). The children wore the silk clothing for 6 months and eczema symptoms were independently assessed by research nurses.
• Installing water softeners at home to soften hard water used for washing had no beneficial effect over and above treatment as usual on eczema severity in children aged 6-16 years (SWET study).
• Two Cochrane reviews found no evidence that dietary supplements reduced the severity of eczema symptoms. The supplements reviewed included: fish oil, zinc, selenium, vitamin D, vitamin E, vitamin B6, sea buckthorn oil, hempseed oil, sunflower oil, evening primrose oil and borage oil.

Although many of the projects above do not have positive findings, these ‘negative studies’ provide us with a better understanding of interventions that are not beneficial. Research can then focus on established interventions that do have beneficial effects, such as moisturisers, and the best way to use these in a treatment plan. Ongoing NIHR studies are highlighted in the “Going forward - Ongoing research” section.

I estimate that I refer less than five percent of children that I see with eczema to the dermatology team at the hospital in Nottingham. These are children with much more extensive or severe eczema or whose situation is complicated by other conditions. I may see them a few times before we conclude that they need the input of the dermatology doctors and nurses. If they are discharged from the hospital they will come back to my care but they will sometimes be offered an ‘open appointment’. This means they can go back to the hospital service for up to a year without needing to be referred again.

Dr Jane Coleman, non-specialist GP, Nottingham

We have to be honest with parents. Eczema can be managed but there isn’t a cure. We can’t know whether any given child will grow out of their eczema but we do know we’ve got to find the best treatment for them and ensure that the child and the parents are confident to use the treatments.

Dr Sarah El-Heis, Dermatology Clinical Research Fellow in an NHS Secondary Care Trust

The GREAT Database

A recent NIHR programme of research led to the development of the GREAT database (Global Resource of Eczema Trials), which brings together eczema studies from across the globe. Here you can freely and easily access results from hundreds of eczema studies. This database provides a comprehensive collection of different eczema treatments based on randomised controlled trials from 1967 and systematic reviews published after 2000. As of July 2017, this included over 800 randomised controlled trials and 115 systematic reviews.

Key Questions for Patients and Families

• Has your GP/practice nurse explained the most beneficial treatment options to you?
• Are there specialist services available in your GP surgery?
• Do you know the different types of moisturisers available?
• How severe is your/your child’s eczema?
• How do I support my child to manage their eczema symptoms?
• Do I/does my child need a referral to a dermatologist?

I probably see children with eczema in our practice every week. The practice team can manage most children’s eczema.  We work out – by trying treatments - what works best for the child and then we stick with that, encouraging the child and their family to manage the eczema, using the prescribed medication and recommended self-management techniques. We look at each child’s progress at a medication review each year, but of course parents will bring the child back in to see us if something changes in the meantime.

Dr Jane Coleman, non-specialist GP, Nottingham

How NIHR research fits with NICE guidelines for childhood eczema

Eczema is a complex inflammatory skin condition influenced by an interaction between genetic and environmental factors. Eczema can range from quite mild, with dry, flaky and itchy skin, to severe weeping and bleeding. Whilst there is no cure for eczema, there are a range of treatment options that aim to reduce inflammation as well as any infection. GPs, practice nurses and dermatologists work with patients and their families to identify the most beneficial approach.

NICE clinical guidelines for childhood eczema recommend a stepped approach where the treatment is tailored to the severity of the eczema:

• mild eczema: moisturisers (emollients) and mild topical corticosteroids
• moderate eczema: moisturisers, moderate topical corticosteroids, bandages
• severe eczema: moisturisers, stronger topical corticosteroids, topical tacrolimus ointment, bandages, phototherapy (UV light).

Not all children respond to the same treatments in the same way so we have to keep things under review. Our eczema specialist nurse works closely with the families on that. It’s important that as the children get older – into the teenage years – they take ownership of their condition and the treatment, to get the best outcomes. The specialist nurse plays a key part in helping that process, too.

Dr Sarah El-Heis, Dermatology Clinical Research Fellow in an NHS Secondary Care Trust

Self-care, such as reducing scratching and avoiding triggers like perfumed soap and heat, is always important. Moisturisers should be unperfumed and used liberally and regularly every day to prevent the skin from becoming dry. The NIHR review on moisturisers found that whilst no particular moisturiser was most effective, during a flare-up combining a moisturiser with a topical active treatment (a corticosteroid applied to the skin) had a better outcome than just using the active treatment alone. Moisturisers are an important part of the treatment plan and individuals with eczema may try different ones to find out which works best for them.

As eczema in an inflammatory condition, it is important to get eczema under control with topical active treatment. The strength of the topical corticosteroid ointment or cream depends on the severity of the eczema. Specialist dermatological advice is important when strong topical corticosteroids are required because these can have side-effects.

NICE recommend oral antibiotics to treat infections. The NIHR study found that antibiotics should only be prescribed with severely infected eczema as there is no benefit to using antibiotics for mild to moderate eczema. Antihistamines may be prescribed for severe itching, particularly at night.

The POEM (Patient Oriented Eczema Measure) is a tool recommended by NICE that has been developed to measure the severity of childhood eczema. The POEM can be completed by a healthcare professional or by a parent and their child and discussed with a clinician.  http://www.nottingham.ac.uk/research/groups/cebd/resources/poem.aspx

It is important to have regular reviews with a GP to ensure an optimal treatment path is being achieved.

The NICE Guidelines were checked for new evidence in 2016, and a further review is scheduled for 2019.

We also have to think beyond the clinic and the medication regime for the rest of the children’s lives. We talk a lot with parents about ways to manage the impact of eczema on their child’s life. This includes clothing options, ways to manage sleeplessness and the range of alternative therapies that parents might consider. We often write to schools to explain a child’s medication and support needs - this is such a big part of a child’s life, it’s important they are well supported there as well as at home.

Dr Sarah El-Heis, Dermatology Clinical Research Fellow in an NHS Secondary Care Trust

You can find the latest NICE guidelines on childhood eczema at: https://www.nice.org.uk/guidance/cg57

Where can I get advice and how can I get involved?

Centre for Evidence Based Dermatology, University of Nottingham

This centre conducts high quality, independent research into different skin conditions. As well as providing a collection of free resources, it encourages patients and families to get involved in the research through participating in studies or joining a Patient Panel.  The Centre also collaborates with patients and parents in producing the Nottingham Support Group for Carers of Children with Eczema, providing support and information for families touched by eczema, mainly through web-based media.

www.nottingham.ac.uk/dermatology

National Eczema Society

In addition to providing independent and practical advice, the National Eczema Society campaigns to raise awareness of living with eczema with healthcare professionals, schools and the government.  Amongst other activities, they run a free Helpline, develop free resources for the public and professionals, and provide information about Regional Support Groups.

http://www.eczema.org/

Eczema Outreach Scotland

Eczema Outreach provides 1:1 support to families and children living in Scotland. They run ‘Learn and Share’ events throughout the year to enable families to meet and share their experiences, as well as the ‘High 5 Club’ for children. They also have Outreach workers who run workshops at local schools to raise awareness about eczema.

http://eczemaoutreachscotland.org.uk/

Allergy UK

Allergy UK is a national charity providing support and advice on living with allergies. Their website includes a section dedicated to eczema with free factsheets to download, advice and case studies for patients and families and information and resources for professionals.

https://www.allergyuk.org/

British Association of Dermatologists

The BAD is a UK charity set up to research and provide advice on best practice in dermatology. They are always keen to hear from individuals who can share their stories to help raise the profile of living with a skin disorder.

http://www.bad.org.uk/for-the-public

An in-depth look at the research

An NIHR-funded programme grant for applied research aimed to review all available evidence on skin conditions and identify gaps that could be addressed in future studies. This included looking at different treatment options. Key findings about eczema included:

• A comprehensive review on eczema prevention and treatment. Thirty-nine trials involving over 11,000 participants aged 0-18 years were included in this ‘review of reviews’. No clear benefits from any of the interventions were found.
• A pilot randomised controlled trial to see if it was feasible for parents to apply moisturisers on their baby every day from birth to six-months to prevent eczema. Clinical results from the 124 families who took part indicated that this treatment had a positive effect. The NIHR subsequently funded a larger definitive trial which is currently underway (BEEP trial). You can read more about this in the ‘Going Forward – Ongoing Research’ Section.
• Identification of four top priorities for both healthcare professionals and patients: 1) the best and safest way of using topical corticosteroids; 2) long-term safety of corticosteroids; 3) the role of allergy tests in eczema management; and 4) the most effective emollients.
• The proposal of a randomised controlled trial of silk therapeutic clothing for eczema management in children. The trial was later funded by the NIHR and results have recently been published as an NIHR Signal.

The following studies are a selection of recent NIHR projects focusing on possible treatments for childhood eczema.

Silk clothing (CLOTHES study)

This was the first large, independent trial to investigate the benefits of specialist silk clothing (long-sleeve tops and leggings) for the management of moderate and severe childhood eczema. Over 300 children aged 1-15 years took part, wearing therapeutic silk clothing for 6 months alongside their standard eczema care. Children were asked to wear the clothing as often as possible, day and night. Alongside data collection, parents and children were invited to discuss their experiences. The study found that there was no benefit of wearing silk clothing over and above routine care (moisturisers and topical corticosteroids) in terms of eczema severity as measured by nurses. Questionnaires completed by families indicated that eczema symptoms in the silk clothing group may have improved more than for those children receiving only standard treatment. However the differences between the two groups were small and mainly seen in the first few months of the study. The researchers therefore concluded that silk clothing does not provide useful extra benefits over standard care and are not value for money.

Use of antibiotics (CREAM study)

This study investigated the use of antibiotics in children with clinically infected eczema. Over 100 children aged 3 months to 8 years took part. To treat their potential infection they were given one of three treatments: oral antibiotic and topical placebo, topical antibiotic and oral placebo or an oral and topical placebo, all for 1 week. Placebos have no medical effect but look identical to the medication. The children also continued with their standard eczema treatment of steroid creams and moisturisers. Most children in the study had clinical indications of a skin infection, and primarily had mild to moderate eczema. After measuring severity of eczema symptoms at week 2, it was found that oral and topical antibiotics had no effect. The researchers concluded that antibiotics should only be prescribed to children with severely infected eczema. There are no beneficial effects of using antibiotics in mild eczema flare-ups, and steroid creams and moisturisers are sufficient when there are no signs of severe infection. This is particularly important given the emerging evidence that bacteria are becoming more resistant to antibiotics.

Types of moisturisers for eczema

This project rigorously reviewed 77 randomised controlled trials that investigated the use of different moisturisers to treat eczema. In the studies, moisturisers were compared to either a placebo, other treatments or no treatments. The age range of participants was between 4 months to 84 years (mean age 18.6 years) who had mild to moderate eczema. Of the 77 studies, 42 were based in Europe and 20 in North America. Forty-six of the studies were funded by pharmaceutical companies. Although the results were not clinically significant, using a moisturiser reduced eczema severity slightly and the time between flare ups was reduced. There was no evidence that one type of moisturiser was better than another. However, it was found that adding a moisturiser to a topical active treatment had a better outcome than using an active treatment alone during an eczema flare-up.

Alternative interventions for eczema

It can be hard for children and their families to adjust to a life with eczema. I have to be open and honest with them from the start so that they understand what eczema is how it tends to develop. Eczema can’t be cured but it can be treated with much success, provided that children and families work at managing the condition. I don’t underestimate the effort it takes to do this and I will always support families who want to explore alternative, non-traditional treatments – who wouldn’t look at other possibilities that might help their child feel more comfortable?

Dr Jane Coleman, non-specialist GP, Nottingham

Families are keen to find non-pharmacological and/or complementary treatments for their child’s eczema. The NIHR has funded a number of studies looking at a range of possible options. Here are a few completed projects:

Water Softeners (SWET study)

In a study involving over 300 children aged 6-16 years, researchers investigated whether installing ion-exchange water softeners could improve moderate to severe eczema symptoms. Water softener devices were installed in the family home to soften hard water used for bathing and washing clothes, but mains drinking water was not affected. Children also continued with their normal treatment. After 12 weeks, there was no additional benefit of water softening on the children’s eczema symptoms, which was objectively measured by research nurses. The researchers concluded that water softeners provided no additional benefit to usual care in treating childhood eczema.

Dietary Supplements

A Cochrane review looked at the use of dietary supplements for atopic eczema. Eleven studies were identified, involving almost 600 individuals (including children and adults). A range of supplements were assessed, including fish oil, zinc, selenium, vitamin D, vitamin E, vitamin B6, sea buckthorn oil, hempseed oil, and sunflower oil. The review found there was no evidence of any beneficial effect on eczema symptoms by taking these supplements.

Another review examined 27 studies that used evening primrose oil and borage oil to treat eczema. The studies included in this review involved over 1500 adults and children from 12 different countries. The researchers concluded there was no evidence to indicate that either supplement had any beneficial effect on eczema.

Psychological and Educational Interventions

This Cochrane review looked at studies which focused on educational and/or psychological interventions for managing childhood eczema alongside usual pharmacological treatments. Educational and psychological interventions may be delivered in the community or hospital setting. Such interventions typically aim to provide useful information and strategies for dealing with eczema for the whole family. The review identified ten studies. Unfortunately, the researchers could not draw definite conclusions due variations between the studies. However, they did suggest that educational interventions and certain techniques such as relaxation methods could be beneficial in reducing eczema severity and improving quality of life, but more high-quality research is needed.

About the evidence on childhood eczema

This Highlight is based on the following 8 NIHR studies:

• Setting priorities and reducing uncertainties in the prevention and treatment of people with skin diseases

Thomas KS, Batchelor JM, Bath-Hextall F, Chalmers JR, Clarke T, Crowe S, et al. A programme of research to set priorities and reduce uncertainties for the prevention and treatment of skin disease. Programme Grants Appl Res 2016;4(18). https://dx.doi.org/10.3310/pgfar04180

• Randomised controlled trial of silk therapeutic clothing for the long-term management of eczema in children (CLOTHES Trial: CLOTHing for the relief of Eczema Symptoms)

Thomas KS, Bradshaw LE, Sach TH, Cowdell F, Batchelor JM, Lawton S, et al.Randomised controlled trial of silk therapeutic garments for the management of atopic eczema in children: the CLOTHES trial. Health Technol Assess 2017;21(16). https://dx.doi.org/10.3310/hta21160

• The CREAM Study - Children With Eczema, Antibiotic Management study

Francis NA, Ridd MJ, Thomas-Jones E, Shepherd V, Butler CC, Hood K, et al. A randomised placebo-controlled trial of oral and topical antibiotics for children with clinically infected eczema in the community: the ChildRen with Eczema, Antibiotic Management (CREAM) study. Health Technol Assess 2016;20(19). https://dx.doi.org/10.3310/hta20190

• Emollients and moisturisers for eczema

van Zuuren EJ, Fedorowicz Z, Christensen R, Lavrijsen APM, Arents BWM. Emollients and moisturisers for eczema. Cochrane Database of Systematic Reviews 2017, Issue 2. Art. No.: CD012119. DOI: 10.1002/14651858.CD012119.pub2.

• Randomised controlled trial of ion-exchange water softeners for the treatment of atopic eczema in children (SWET)

Thomas K, Koller K, Dean T, O'Leary C, Sach T. A multicentre randomised controlled trial and economic evaluation of ion-exchange water softeners for the treatment of eczema in children: the Softened Water Eczema Trial (SWET). Health Technol Assess 2011;15(8). https://dx.doi.org/10.3310/hta15080

• Dietary supplements for established atopic eczema

Bath-Hextall FJ, Jenkinson C, Humphreys R, Williams HC. Dietary supplements for established atopic eczema. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD005205. DOI: 10.1002/14651858.CD005205.pub3.

• Oral evening primrose oil and borage oil for eczema

Bamford JTM, Ray S, Musekiwa A, van Gool C, Humphreys R, Ernst E. Oral evening primrose oil and borage oil for eczema. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004416. DOI: 10.1002/14651858.CD004416.pub2.

• Psychological and educational interventions for atopic eczema in children

Ersser SJ, Cowdell F, Latter S, Gardiner E, Flohr C, Thompson AR, Jackson K, Farasat H, Ware F, Drury A. Psychological and educational interventions for atopic eczema in children. Cochrane Database of Systematic Reviews 2014, Issue 1. Art. No.: CD004054. DOI: 10.1002/14651858.CD004054.pub3.

You may also want to visit the Journals Library to discover further projects on skin conditions:

https://www.journalslibrary.nihr.ac.uk/#/

Going forward - Ongoing research

The NIHR has a portfolio of ongoing studies around eczema research, with several focusing on severe childhood eczema.

A brief summary is provided for each study, but for more information you can follow the link to the project page.

• BATHE (Bath Emollients for Treatment of cHildhood Eczema). Chief investigator: Dr Miriam Santer.

https://www.journalslibrary.nihr.ac.uk/programmes/hta/1115301/#/

The BATHE study is comparing the use of regular bath emollients alongside usual care, with usual care alone. Children aged between 1 – 11 years are taking part in this 16 week trial.  Results are expected in 2018.

• A randomised placebo-controlled study examining the role of anti-IgE in severe recalcitrant paediatric atopic eczema (ADAPT trial). Chief Investigaor: Dr Susan Chan.

https://www.journalslibrary.nihr.ac.uk/programmes/eme/111424/#/

The ADAPT trial is finding out whether anti-IgE (omalizumab) injections is a beneficial treatment for severe eczema that has failed to respond to other treatments. Young people aged between 6-19 years will receive either anti-IgE injections or a placebo injection. Researchers will assess the severity of eczema after 16 weeks. Results are expected in 2018.

• Assessing the efficacy and safety of methotrexate vs ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema in children Taskforce (TREAT) randomised controlled trial. Chief investigator: Dr Carsten Flohr.

https://www.journalslibrary.nihr.ac.uk/programmes/eme/135012/#/

The TREAT trial is evaluating the use of oral methotrexate (MTX) compared to ciclosporin (CyA) in the treatment of severe atopic eczema in children aged 2-16 years. Both drugs will be given for nine months. Severity of eczema symptoms will be measured after 12 weeks of treatment and 6 months after treatment has ended. Results are expected in late 2019/early 2020.

• A randomised controlled trial to determine whether skin barrier enhancement with emollients can prevent eczema in high risk children. (BEEP trial). Chief investigator: Professor Hywel Williams.

https://www.journalslibrary.nihr.ac.uk/programmes/hta/126712/#/

This study is recruiting parents whose children are at high risk of developing eczema. Half the parents receive a skin care advice package which includes a daily moisturiser to use on their baby every day from birth until 12 months. The other group of parents receive the skin care advice package without the moisturiser.  As of August 2017, almost 1400 families have been recruited. The children will be assessed at the age of 2 years for eczema symptoms and followed up until the age of 5 so researchers can assess for signs of asthma, hay fever and food allergies. Results are expected in 2022.

• Best Emollient for Eczema (BEE): Pragmatic, primary care, multi-centre, individually randomised superiority trial of four emollients in children with eczema, with internal pilot and nested qualitative study. Chief investigator: Dr Matthew Ridd.

https://www.journalslibrary.nihr.ac.uk/programmes/hta/1513007/#/

This new study is comparing four different emollients (a lotion, cream, gel and ointment) to treat mild, moderate or severe eczema. The researchers aim to recruit 520 children (130 per group) aged 6 months to 12 years who will use one of four emollients for 16 weeks. They will receive either Aveeno® lotion, Diprobase® cream, Doublebase® gel, or Epaderm® ointment. Eczema severity will be measured every week during the course of treatment and at a 12 month review. Interviews will also be conducted with participants to discuss their use of the moisturisers. Results are expected in 2020.

• The TEST (Trial of Eczema allergy Screening Tests) Study: feasibility randomised controlled trial with economic scoping and nested qualitative study. Chief investigator: Dr Matthew Ridd.

https://www.spcr.nihr.ac.uk/projects/the-test-trial-of-eczema-allergy-screening-tests-study-feasibility-randomised-controlled-trial-with-economic-scoping-and-nested-qualitative-study

This small study, carried out by the NIHR School for Primary Care Research, will be looking at whether it is useful to conduct routine allergy tests for children with eczema. The researchers aim to recruit 80 children. Half of the children will receive usual care from their GP. The other half will be asked extra questions about food intake and offered skin prick allergy tests consisting of six common allergy-causing foods (cow’s milk, peanut, hen’s egg, codfish, wheat and cashew). Parents will be advised on any allergies and what food to avoid if necessary. All children will be followed up for 6 months. Results are expected in 2019 and funding for a larger trial may be pursued if appropriate.