Emollients are effective first-line treatment to decrease symptoms of eczema and reduce the need to use steroids in children (strength of recommendation [SOR]: A, consistent randomized, controlled trials [RCTs]). Tar preparations work, but compliance may be limited (SOR: B, single small RCT). Gamma-linoleic acid preparations, borage oil, and evening primrose oil show efficacy in small studies (SOR: B, small RCTs). MAS063DP cream (Atopiclair) is effective (SOR: B, single RCT)

Flake, Donna

Phifer, Jennifer B.

Yates, Jennifer E.

University of Missouri: MOspace

CLINICAL INQUIRIES Evidence Based Answers from the Family Physicians Inquiries Network280 VOL 58, NO 5 / MAY 2009  THE JOURNAL OF FAMILY PRACTICEFAST TRACK  Do nonmedicated topicals relieve childhood eczema?Emollients are effective ﬁ rst-line treatment to decrease symptoms of eczema and reduce the need to use steroids in children.Evidence-based answerYes. Emollients are effective fi rst-line treatment to decrease symptoms of eczema and reduce the need to use steroids in children (strength of recommendation [SOR]: A, consistent randomized, controlled trials [RCTs]).  Tar preparations work, but compliance may be limited (SOR: B, single small RCT). Gamma-linoleic acid preparations, borage oil, and evening primrose oil show effi cacy in small studies (SOR: B, small RCTs). MAS063DP cream (Atopiclair) is effective (SOR: B, single RCT).  Chamomile (SOR: B, inconsistent RCTs) and bathing in acidic hot spring water (SOR: C, case-control study) may be effective, but these treatments have not been adequately evaluated. Wet wrap dressings may be effective but increase the risk of skin infections (SOR: B, single RCT).  Hamamelis distillate creams (SOR: B, limited RCT) and massage with essential oils/aromatherapy are ineffective (SOR: C, case-control study). ❚ Evidence summaryEczema is a chronic, infl ammatory, prurit-ic skin disorder that affects infants, chil-dren, and adults. Therapeutic effi cacy is defi ned as symptom relief and decreased infl ammation. Topical corticosteroids and calcineurin inhibitors (such as tacrolimus and pimecrolimus) are the standard of care for prescription therapy in children, but their potentially harmful side effects argue for safer, nonmedicated treatments.Topical treatments that workEmollients have demonstrated effi cacy in several RCTs compared with placebo and corticosteroids alone. No 1 preparation has proved superior to another; all reduce steroid use and improve skin hydration.1-3  Tar. Only 1 study has evaluated the use of tar: a comparison of 30 patients (mean age 11.8 years) who were treated with tar on one side of the body and 1% hydrocortisone on the other. Both treat-ments produced comparable results and were well tolerated. But compliance can be a problem with tar products because they smell unpleasant and stain clothing.4 Gamma-linoleic acid. Small studies have evaluated the effi cacy of gamma-linoleic acid (GLA)—including borage oil (24% GLA) and evening primrose oil (7%-10% GLA). An RCT of 12 patients (ages 4-46 years, mean 18 years) that compared eve-ning primrose oil with placebo found that patients treated with primrose oil showed a subjective improvement in skin scaling, dryness, redness, and itching.5 A double-blind, placebo-controlled trial of 32 children that assessed the ef-fects of undershirts coated with borage oil compared with noncoated undershirts found statistically signifi cant improve-ments in both itching and erythema.6MAS063DP is a nonsteroidal, hydroli-Jennifer E. Yates, MD, and Jennifer B. Phifer, MDCoastal Area Health Education Center, Family Medicine Residency, Wilmington, NCDonna Flake, MSLS, MSASCoastal Area Health Education Center, Health Sciences Library, New Hanover Regional Medical Center, Wilmington, NCFAST TRACK VOL 58, NO 5 / MAY 2009 281www.jfponline.comTopical corticosteroids are the standard of care for Rx therapy in kids, but their potential side effects argue for safer, nonmedicated treatments.pidic cream containing glycyrrhetinic acid (GrA), vitis vinifera (grapevine extract), and telmestine. A recent multicenter RCT of 142 children compared MAS063DP to vehicle cream alone. The primary out-come was treatment success defi ned as an Investigator’s Global Assessment score of ≤1 (range 0-5), measured on day 22. Therapy was successful in 77% of the treatment group vs 0% of the vehicle-only group (number needed to treat=1).7 Hot spring baths, chamomile may helpIn a case control study of 70 patients (ages 12-80 years, mean 23 years,) bathing in acidic hot spring water (42º C) helped con-trol edema, erythema, exudation, and ex-coriation in refractory cases of eczema.8Several adult and mixed adult-child studies have found mild effi cacy for chamomile extracts. One RCT demon-strated topical chamomile to be equiva-lent to 0.25% hydrocortisone cream for treating mild eczema.9Wet wraps may help, but may raise skin infection riskA critical review suggests that short-term use of wet wraps in combination with topical steroids and emollients is effective for severe eczema. However, a small RCT of 50 children found no additional benefi t over standard care and an increased risk of skin infection (95% CI, 5%-42%; P=.05) with a number needed to harm of 5.10,11Essential oils, hamamelis distillate don’t workIn 1 case control study, massage with es-sential oils didn’t improve eczema com-pared with massage without essential oils.12 Hamamelis (witch hazel) distillate cream was inferior to steroid creams.13RecommendationsThe American Academy of Dermatology guidelines state that emollients are the standard of care for childhood eczema and have a steroid-sparing effect (level of evidence [LOE]: A). Tar preparations have therapeutic benefi ts, but compliance is a major limitation (LOE: B). Not enough evidence exists to recommend acidic baths. The guidelines make no recommendations about other topical therapies.A task force to formulate practice pa-rameters has been created by the Ameri-can College of Allergy, Asthma, and Im-munology; the American Academy of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology. The task force’s latest rec-ommendations suggest that emollients, tar preparations, and wet dressings are benefi cial for treating eczema.2 ■References 1.  Grimalt R, Mengeaud V, Cambazard F; Study In-vestigators’ Group. The steroid-sparing effect of an emollient therapy in infants with atopic derma-titis: a randomized controlled study. Dermatology. 2007;214:61-67.  2.  Leung DY, Nicklas RA, Li JT, et al. Disease manage-ment of atopic dermatitis: an updated practice param-eter. Joint Task Force on Practice Parameters. Ann Al-lergy Asthma Immunol. 2004;93(3 suppl 2):S1-S21.  3.  Hanifi n JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis, developed in accor-dance with the American Academy of Dermatology (ADA)/American Academy of Dermatology Asso-ciation “Administrative Regulations for Evidence-Based Clinical Practice Guidelines.” J Am Acad Dermatol. 2004;50:391-404.  4.  Munkvad M. A comparative trial of Clinitar versus hydrocortisone cream in the treatment of atopic eczema. Br J Dermatol. 1989;121:763-766.  5.  Anstey A, Quigley M, Wilkinson JD. Topical evening primrose oil as treatment for atopic eczema. J Der-matol Treat.1990;1:199-201.  6.  Kanehara S, Ohtani T, Uede K, et al. Clinical effects of undershirts coated with borage oil on children with atopic dermatitis: a double-blind, placebo-controlled trial. J Dermatol. 2007;34:811-815. 7.  Boguniewicz M, Ziechner JA, Eichenfi eld LF, et al. MAS063DP is effective monotherapy for mild to moderate atopic dermatitis in infants and chil-dren: a multicenter, randomized, vehicle-controlled study. J Pediatr. 2008;152:854-859.  8.  Kubota K, Machida I, Tamura K, et al. Treatment of refractory cases of atopic dermatitis with acidic hot-spring bathing. Acta Derm Venereol. 1997;77:452-454. 9.  Ross SM. An integrative approach to eczema atop-ic dermatitis. Holist Nurs Pract. 2003;17:56-62. 10.  Devillers AC, Oranje AP. Effi cacy and safety of “wet-wrap” dressings as an intervention treatment in children with severe and/or refractory atopic der-matitis: a critical review of the literature. Br J Der-matol. 2006;154:579-585. 11.   Hindley D, Galloway G, Murray J, et al. A ran-domised study of “wet wraps” versus conven-tional treatment for atopic eczema. Arch Dis Child. 2006;91:164-168. 12.  Anderson C, Lis-Balchin M, Kirk-Smith M. Evalu-ation of massage with essential oils on childhood eczema. Phytother Res. 2000;14:452-456. 13.  Korting HC, Schäfer-Korting M, Klövekorn W, et al. Comparative effi cacy of hamamelis distillate and hydrocortisone cream in atopic eczema. Eur J Clin Pharmacol. 1995;48:461-465. Eczema on the leg ofa 9-year-old boy.

Do nonmedicated topicals relieve childhood eczema?

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