Emollients and Moisturizers for Eczema

Abridged Cochrane Systematic Review Including Grade Assessments

E.J. van Zuuren; Z. Fedorowicz; B.W.M. Arents

Disclosures

The British Journal of Dermatology. 2017;177(5):1256-1271. 

In This Article

Abstract and Introduction

Abstract

Eczema is a chronic inflammatory skin disorder with considerable impact on quality of life. Emollients or moisturizers are widely recommended, but are these effective and safe? We searched for randomized controlled trials (RCTs) in the Cochrane Skin Group Specialised Skin Register, CENTRAL in The Cochrane Library, MEDLINE, Embase, LILACS, the GREAT database and five trial registers to December 2015. We included 77 RCTs with 6603 participants. Seven studies (9%) were at low risk of bias, 34 (44%) had unclear risk and 36 (47%) were at high risk. The quality of the evidence was mainly low or moderate for the prespecified outcomes. The most important comparison, 'moisturizer vs. no moisturizer', showed improved Scoring Atopic Dermatitis values in the moisturizer group compared with no moisturizer [mean difference −2·42, 95% confidence interval (CI) −4·55 to −0·28], but did not meet the minimal important difference of 8·7. Fewer flares were seen (risk ratio 0·40, 95% CI 0·23–0·70) and the rate of flares was reduced (hazard ratio 3·74, 95% CI 1·86–7·50). The groups applying moisturizer used less topical corticosteroids over 6–8 weeks (mean difference −9·30 g, 95% CI 15·3 to −3·27). Glycyrrhetinic acid-, urea- and glycerol-containing creams worked better than their controls (vehicle, placebo or no moisturizer) according to both participants and physicians. More flares were reported with moisturizer alone than when combined with twice-weekly fluticasone propionate (risk ratio 2·17, 95% CI 1·55–3·11). Adding moisturizers to topical anti-inflammatory treatment was more effective than anti-inflammatory treatment alone and resulted in fewer flares.

Introduction

Eczema, also referred to as atopic dermatitis or atopic eczema, is a common chronic itchy skin disease characterized by recurrent inflammatory flare-ups and subsequent remissions.[1,2] We have used the term 'eczema' according to the 'Revised nomenclature for allergy for global use'.[2] Eczema affects up to 20–30% of children and up to 10% of adults,[3,4] with a profound impact on their quality of life.[5] The diagnosis is made clinically, often with the criteria of Hanifin and Rajka[6] or the U.K. Working Party's diagnostic criteria for atopic dermatitis.[7] Management strategies for eczema include the avoidance of triggers, topical treatment with anti-inflammatory medication, use of systemic immunomodulators and phototherapy.[8]

Dry skin, which is a hallmark of eczema, is caused by a dysfunctional epidermal barrier and therefore moisturizing the skin is a cornerstone in eczema management.[8,9] Moisturizing is considered the first step in the treatment regimen because it makes the skin supple and softer by hydration and restores epidermal barrier function.[5,8] Furthermore, moisturizers may reduce itch, decrease the need for corticosteroids and prevent flares. Although the use of moisturizers is recommended in all clinical guidelines and they are widely prescribed by physicians, the current evidence for their effectiveness and safety is limited.[8,10–13] This article is a summary of the Cochrane review evaluating emollients and moisturizers for eczema.[1]

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