Early Emollient Use Reduces Dermatitis in At-Risk Infants

Brandon May

September 26, 2022

Recent study findings published in Allergy suggest that twice-daily application of emollients within the first 8 weeks of life significantly reduces the cumulative incidence of atopic dermatitis (AD) among infants at high risk for the condition, at least within the first year of life.

The single-center STOP-AD clinical trial recruited term infants within 4 days of birth who were at high risk for AD, as determined on the basis of a parent-reported history of the disease or asthma or allergic rhinitis. Infants were randomly assigned to undergo either a standard skin care routine (control group; n = 160) or twice-daily emollient application for the first 8 weeks of life (intervention group; n = 161).

In the intervention group, infants received an emollient that was specifically formulated for AD-prone skin. The control group received standard skin care advice, which did not include specific advice on bathing frequency or regular emollient use.

The mean age of the infants at randomization was 1.9 days. A total of 41 infants in the intervention group and 20 infants in the control group were withdrawn from the study. Most withdrawals (80%) occurred prior to the 2-week visit.

At 12 months, the cumulative incidence of AD was 32.8% in the interviention group and 46.4% in the control group (P = .036). The investigators note that daily emollient use was associated with a 29% lower risk of cumulative AD at 1 year in comparison with the control intervention.

No significant difference was observed between the groups regarding the incidence of parent-reported skin infections during the treatment period (5.0% vs 5.7%; P > .05).

Study investigator Jonathan O'Brien Hourihane, MBBS, of the Royal College of Surgeons in Ireland, told Medscape Medical News by email that previously published findings from the BASELINE study supported the rationale for the early use of emollients in infancy to prevent AD.

The investigators of the BASELINE study found that skin barrier function, as measured by transepidermal water loss, increased from birth to 8 weeks but then became stable at 6 months. These observations suggest that the period during early infancy "could be a critical window in which to protect the skin barrier" of infants at risk for AD, Hourihane added.

Hourihane, who serves as the head of Department of Pediatrics at the Royal College of Surgeons in Ireland, explained that the long-term clinical burden of AD is often more significant if the condition begins earlier in life, underscoring the importance of early prevention and control.

"The casual role [of AD] in other allergic conditions remains suspected but not proven, but its association is clear," he said. He noted that infants with eczema "also have poorer sleep, and the condition causes increased family disruption," highlighting the far-reaching burden of AD.

Commenting on the study, Adelaide Hebert, MD, a professor of pediatric dermatology with McGovern Medical School at UTHealth Houston, told Medscape by email that the barrier defect observed in AD is one of the prime areas to address as a means of controlling the chronic, relapsing disorder. She noted that the use of emollients can repair this defective barrier.

"Early initiation of emollients has the potential to reduce dryness, itching, transgression of allergens, and infectious agents," explained Hebert, who wasn't involved in the study. "Emollient application also allows the parent to inspect the skin surface and address any challenges in a timely manner."

In the STOP-AD trial, Hourihane and colleagues also found that among patients with loss-of-function (LoF) mutations in the filaggrin gene (FLG), the prevalence of AD at 6 and 12 months seemed to be a higher than among patients with the wild-type gene, but the difference did not reach statistical significance.

Commenting on this finding, Hebert noted that LoF FLG mutation carriers may benefit especially from emollient use, given that LoF mutations in FLG is associated with reduced production of natural moisturizing factors in the skin.

Regarding future research directions, Hourihane stated that there is a need for replication and validation of the findings in studies that include infants from different ethnic backgrounds as well as those from various social settings. These studies should also include variable treatment windows to determine both short- and longer-term effects of emollient use in this population, Hourihane explained.

Hourihane added that he and the investigators do not yet understand which aspect of the study's program was key for reducing the incidence of AD in the first year of life. "The timing of emollient initiation, the duration of treatment, the products, or maybe just a combination of these" could be possible explanations, Hourihane suggested.

The study was independently supported. Hourihand reports receiving grant funding from Aimmune Therapeutics and DBV Technologies. Hebert reports no relevant financial relationships.

Allergy. Published online August 23, 2022. Full text

Brandon May is a freelance medical journalist who has written more than 900 articles for medical publications in the United States and the United Kingdom. He resides in downtown Brooklyn, New York City. Twitter: @brandonmilesmay.

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