“Doctor, I’ve tried everything for my child’s eczema. Aveeno, E45, Nivea… None of it works. What can I do?”
With so much research published each year, inevitably lots will go under the radar. The challenge is finding the information which can help us in our day to day clinical work. Eczema is one of those common clinical challenges which doesn’t get a lot of attention in the major medical journals, but all primary care clinicians need a good strategy on how to manage it.
Eczema is a chronic inflammatory condition characterised by itchy, dry skin with patches of erythema. My patient is struggling to control her child’s eczema because we have yet to manage the inflammatory aspect of the condition – realistically she will need topical steroids. It is tempting to think that this alone will be sufficient but let’s not underestimate the importance of simple emollients.
A Cochrane review of emollients in 2020 found that they reduce the amount of topical steroids required and reduce the number of flares of eczema. As we say on our upcoming Hot Topics Dermatology for Primary Care course – “prescribe lots of emollients!”
But with more than 60 options available on the NHS, how should we choose between them? Which one is the best?
A BMJ Uncertainties paper in 2019 explains there are four broad categories of emollients which can be considered: lotions, creams, gels and ointments – the higher the ratio of water to oil the lighter it is. Thicker emollients tend to have a longer action, cause less irritation, and have traditionally been considered a more effective option for eczema but they are greasier and less cosmetically acceptable.
Should thicker emollients be our default choice anyway?
The BEE – Best Emollients for Eczema - study recently published in the Lancet Child and Adolescent Health journal. This was a pragmatic randomized trial conducted in UK general practices with 550 children participating. Researchers compared the four categories of emollients and found no difference in effectiveness for treating eczema. However, this quantitative data hides an important truth revealed in a linked qualitative analysis published in the BJGP: no one emollient will suit all children, and the right moisturiser is the one they like to use.
It may be that one emollient stings, may not feel nice or frequently stains clothing and furniture. These may be an important barrier to regular use for our patient. Different people will have different concerns. But if one doesn’t suit, try an alternative. Our options will be guided by our local formularies, but if we consider those emollients in these four groups we can easily recommend alternatives and find what is the most acceptable, or “best”, emollient for our patient.
Of course, there are lots of other issues to consider: Are there triggers? What is the best way to apply emollients? Do we need to counsel about fire risks? Which steroid is most appropriate? Can we prescribe topical calcineurin inhibitors? Should we worry about cardiovascular risk?
For these questions join us on Saturday 10th September for our new Hot Topics Dermatology in Primary Care live webinar. We will discuss eczema in detail, plus diagnosis and management of a range of common skin conditions including psoriasis, urticaria, benign and malignant skin lesions and common skin infections.