Comment

The first two studies were of very short duration, and the quality of reporting was generally poor, with little description of randomisation method, limited blinding and no intention-to-treat (ITT) analysis. The Kantor et al. study1 failed to show any benefit of one emollient preparation over another (in the presence of a moderate-potency topical steroid), and the Hanifin et al. study3 suggested that regular use of an emollient with a topical steroid may result in a small increase in treatment response compared with a topical steroid alone. Neither study showed a steroid-sparing effect for emollients.

The first of the two studies on urea preparations4 showed a possible benefit of a urea-containing preparation compared with vehicle. Comparison of two preparations containing urea in different concentrations failed to show any additional benefit of higher concentrations of urea. Quality of reporting on randomisation, blinding and ITT analysis was poor in both studies. Similar findings were found in the Larregue et al. study.5

It is extremely disappointing to see a virtual absence of clinically useful RCT data on the use of emollients in atopic eczema. In addition to measuring efficacy of emollients in treating mild atopic eczema, it is important that future RCTs of emollients measure long-term tolerability, patient preferences and cosmetic acceptability since these are probably key determinants for successful long-term use. There is an urgent need to answer several basic questions, preferably through industry-independent randomised controlled trials. Possible questions that require an answer are as follows.

1. Do emollients have a useful therapeutic effect (with or without wet wraps) for treating minor flares of atopic eczema compared with mild topical steroids?

2. Do emollients have a topical-steroid-sparing effect without loss of efficacy in the long-term management of atopic eczema?

3. Does the regular use of emollients between eczema flares treated by topical steroids help to reduce relapse rates?

4. For children with atopic eczema, do expensive bath emollients provide any additional benefit over application of a cheap emollient directly to the skin after a bath?

5. Does the regular use of emollients reduce the incidence and severity of secondary infection in atopic eczema?

6. Do educational interventions designed to teach the appropriate use of emollients improve the symptoms of atopic eczema?

7. How common is clinically relevant contact sensitisation to emollient constituents such as lanolin?

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