Case scenario 1 A child with atopic eczema of moderate severity

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Figure 17.1 A child with flexural atopic eczema

QUESTIONS

What is the role of emollients? Efficacy

We found no systematic review for emollients in atopic eczema. Five randomised controlled trials (RCTs) are reported here.1-5 Other studies were excluded because we could not ascertain if they were properly randomised; they included conditions other than atopic eczema (for example Newbold6); or they presented only biometric data, the clinical relevance of which was difficult to ascertain (for example Pigatto et a/.7, Hagstromer et al8).

Kantor et al1 compared the use of an oil-in-water emollient (Moisturel) versus a water-in-oil emollient (Eucerin) using a left-right comparison design in 50 patients with symmetrical atopic eczema treated for 3 weeks. Test limbs affected by atopic eczema were treated once daily with the emollients and once daily with 2-5% hydrocortisone cream. Global severity showed a statistically significant reduction with both emollients compared with baseline.

The 1998 study by Hanifin et al3 compared the effects of adding an emollient called Cetaphil (manufactured by the study sponsor), applied three times daily, to twice-daily application of 0-05% desonide lotion (a topical steroid) versus twice-daily topical desonide alone. Eighty patients with atopic eczema were enrolled for a 3-week period. Outcomes were recorded by an investigator who was blinded to treatment allocation. At the end of 3 weeks the relative reduction in disease severity was 70% for desonide alone, compared with 80% for the desonide/emollient side (P<0-01).

The studies by Wilhelm et al4 and Andersson et al2 both evaluated the benefit of emollients containing urea preparations - a substance intended to improve the water-binding capacity of the outer layer of skin. In the study of Wilhelm et al,4 80 patients were randomised to apply a topical formulation containing 10% urea (manufactured by the study sponsors) versus the vehicle base as "placebo" for 4 weeks in a right-left forearm comparison. Skin redness was improved at 70% of the sites on which 10% urea was applied compared with 30% for the sites where the vehicle was applied.

The study by Andersson et al2 compared a "new" cream containing 5% urea as the active substance against an established licensed cream containing 4% urea and 4% sodium chloride. Forty-eight adults with atopic eczema were enrolled in a parallel-group double-blind study. Patients were asked to apply the creams at least once daily for 30 days. Clinical disease severity showed a significant benefit for both creams and there were no statistically significant differences between the preparations.

Larregue and colleagues5 compared 6% ammonium lactate (another substance designed to improve water-binding capacity of the skin) against its cream base in 46 children aged 6 months to 12 years with atopic dermatitis. The study was a within-person comparison of two symmetrical sites. Lichenification, hyperkeratosis and dryness were reduced in both groups but slightly more so in the ammonium lactate group. This was reported to be statistically significant at day 15 for lichenification and for erythema at day 30 (the final evaluation point of the study). Tolerability, as evaluated by the patients, was very similar in both groups.

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