Cochrane for Clinicians
Putting Evidence into Practice
Effectiveness of Moisturizers in the Treatment of Patients with Eczema
Am Fam Physician. 2018 Jan 1;97(1):18-19.
Author disclosure: No relevant financial affiliations.
Are moisturizers an effective treatment for eczema?
Moisturizers decrease the rate of eczema flare-ups by 3.7 times vs. no treatment (number needed to treat [NNT] = 4), as well as the amount of topical corticosteroids used per eczema flare-up (9.3 g less). Adverse effects are minimal.1 (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Over the past three decades, the prevalence of eczema has tripled in industrialized countries, with a prevalence of 15% to 30% in children and 2% to 10% in adults.2 Severe eczema is associated with a higher frequency of health care system use, numerous chronic comorbid conditions, and a decrease in overall quality of health.3 This Cochrane review addressed whether moisturizers are an effective treatment for eczema.1
The authors examined 77 randomized controlled trials involving 6,603 participants four months to 84 years of age (mean age = 18.6 years) who had mild to moderate eczema. Outcomes were not separated by age. Patients with contact dermatitis, nummular eczema, and dyshidrotic eczema were excluded. Various validated scoring systems were used to characterize eczema severity, including the Eczema Area and Severity Index (EASI), the objective SCORing Atopic Dermatitis (SCORAD) scale, and the Patient Oriented Eczema Measure (POEM). The authors included comparisons between different emollients and placebo for a variety of outcomes.
Compared with patients using placebo, vehicle, or no treatment, participants found that moisturizers more effectively treated eczema (NNT = 2; 95% confidence interval [CI], 2 to 3) based on a validated Likert scale survey. Moisturizers decreased the overall rate of flare-ups over six weeks to six months compared with control (NNT = 4; 95% CI, 3 to 5). Moisturizer use decreased topical corticosteroid use (9.3 g less; P = .003) over two months.
According to patient assessment on a validated Likert scale, a steroid- and paraben-free emollient barrier cream effectively treated eczema compared with placebo, vehicle, or no treatment (NNT = 2; 95% CI, 1 to 2). Patients also experienced fewer flare-ups (NNT = 3; 95% CI, 3 to 5) over a 50-day period. Urea-containing creams improved disease severity over four weeks (NNT = 5; 95% CI, 3 to 18), as well as the number of flare-ups over six months (NNT = 3; 95% CI, 2 to 11). With glycerol-containing moisturizers, patients noted disease improvement over four weeks as measured on a validated Likert scale (NNT = 6; 95% CI, 3 to 60). Oat-containing moisturizers were found to decrease flare-ups over six months (NNT = 2; 95% CI, 1 to 5). Adding a moisturizer to any active treatment reduced the number of flare-ups compared with active treatment alone over the course of three weeks of treatment (NNT = 6; 95% CI, 3 to 57).
Adverse effects of moisturizers were reported in 41 of the 77 studies. Patients using urea-containing creams experienced more adverse effects over one month compared with placebo (number needed to treat to harm = 4; 95% CI, 2 to 11). Adverse effects included odor, messiness, stinging or burning sensation, or skin irritation. In some cases, these led to the development of contact dermatitis.
Moisturizers applied soon after bathing reduce disease severity as well as the need for further pharmacologic intervention.4,5 According to the National Institute for Health and Clinical Excellence guidelines, moisturizers are the foundation of treatment and should be applied to a patient's entire body even when the patient has no visible eczema.6 The findings in this review support these guidelines.
The practice recommendations in this activity are available at http://www.cochrane.org/CD012119.
Referencesshow all references
1. van Zuuren EJ, Fedorowicz Z, Christensen R, Lavrijsen A, Arents BW. Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;(2):CD012119....
2. Bieber T. Atopic dermatitis. N Engl J Med. 2008;358(14):1483–1494.
3. Silverberg JI, Simpson EL. Association between severe eczema in children and multiple comorbid conditions and increased healthcare utilization. Pediatr Allergy Immunol. 2013;24(5):476–486.
4. Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis. Section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71(1):116–132.
5. Chiang C, Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol. 2009;26(3):273–278.
6. National Institute for Health and Clinical Excellence (NICE). Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. London, United Kingdom: NICE; 2007.
These are summaries of reviews from the Cochrane Library.
This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.
A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.
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