Features

Eczema: soothing soreness

07 December 2018

Recent research has cast doubt over the use of additive bath oils to treat childhood eczema. Journalist John Windell asks what the best advice is to give parents now.

Eczema affects around one in five children in the UK (National Eczema Society (NES), 2018). Although a common condition, it is also highly personalised: the underlying causes and the triggers vary from case to case, as do the symptoms.

Some children experience eczema as a patch of mildly dry, red, itchy skin, often behind the knees or in the crook of the elbow. Others will have extensive areas of their bodies that are inflamed, cracked and crusty, even weeping and bleeding. At its most severe, eczema is uncomfortable, stressful and distressing for children and their families.

Children with acute eczema are often prescribed corticosteroids, but the usual treatment for the condition is simple emollients (moisturisers). Various lotions, creams and ointments are available, with two key roles. The first is to replace soap or soap-based washing products, which can harm the skin. The second is to form a protective barrier when they are applied directly to the skin and left on. Sometimes a third type of emollient is used – an oil added to bath water, intended to create another filmy, protective layer for the skin. These bath additives recently came under the scrutiny of the UK BATHE study, which looked at whether they offered any benefit beyond that of soap substitute and leave-on emollients (Santer et al, 2018).

Lead author of the study Miriam Santer, associate professor of primary care research at the Faculty of Medicine, University of Southampton, says: ‘Although there is strong evidence for the benefit of leave-on emollient and widespread consensus around the need for soap substitutes,’ she says, ‘the role of emollient bath additives was far less clear.’

Expert concern

‘Additive bath emollients didn’t seem to help – though neither did they make things worse’

Researchers divided 483 children with eczema into two randomised groups.

One group followed their usual treatment, while the other used bath additives as well. At the end of the trial, the researchers found that, while eczema symptoms had eased slightly for most of the children, there was no significant difference between the two groups. They concluded that additive bath emollients didn’t seem to help – though neither did they make things worse.

‘There was no difference between the groups in the number of problems experienced with bathing like stinging or redness following the bath,’ says Miriam. ‘So there was no suggestion that emollient bath additives are doing harm, although we do know from previous qualitative research that some parents see them as “easier” than leave-on emollients, in which case parents are substituting an effective treatment for an ineffective one.’

The NES welcomed the research, but was alarmed when it received reports that a number of GPs had responded to the results by telling parents that they would no longer provide bath emollients for their children on prescription. ‘It would have been more beneficial to compare the use of bath emollient alone with a leave-on emollient used as a soap substitute alone,’ wrote the NES in its members’ magazine. ‘If someone has applied a lot of emollient before getting into the bath, it’s not surprising that an extra barrier in the form of a bath emollient has little to no effect. In clinical practice, patients are usually recommended to use only one emollient wash product when bathing: either a leave-on emollient as a soap substitute or a bath emollient.’

Faulty barrier

Miriam Santer concedes that the research team was concerned that clearly communicating its results would be a challenge, given that many people are unclear about the different uses of emollients. She also says they liaised with the NES to coordinate their messages before the publication of the trial.

One thing they can agree on, though, is that the role of other emollients for childhood eczema is not in question.

‘All other treatment advice remains unchanged,’ says Santer. ‘Leave-on emollients – that is, moisturisers or topical creams and ointments – are particularly important to help lock moisture into the skin and lock out irritants. Used regularly, they can prevent eczema flare-ups.’

‘The most important part is that emollients are used for washing with and as leave-on,’ echoes Julie Van Onselen, dermatology nurse adviser to the NES.

It is also beyond dispute that more children than ever are being diagnosed with eczema. ‘The year-on-year prevalence is rising all the time,’ says Julie. While nobody knows for certain why it has become so much more common, a number of factors are thought to contribute. ‘It is a very complex condition,’ she says. ‘It is often genetically based. Then there is the issue of immunology, which is also complex, though we are learning more about this.’

Many people with eczema are deficient in a particular protein, which means the skin does not work in quite the way it should.

The skin is a barrier that protects us from all sorts of infections and irritations, consisting of different layers of cells, water, fats and oils. The fats and oils help us to retain water, but if we don’t produce enough of them, we are less able to hold on to water. At this point, the barrier begins to malfunction. As the level of moisture falls, the skin loses some of its structure and gaps begin to appear, making it easier for bacteria and other irritants to penetrate the barrier. The strong detergents in soap, washing-up liquid and bubble bath will remove even more oil and moisture.

When the skin is dried out and damaged in this way, it becomes cracked and inflamed – and is then prone to even more irritation if it comes into contact with substances that can trigger allergic reactions.

‘These triggers and irritants can be very individual,’ says Julie. ‘We also know there are a lot more environmental irritants and that allergies are on the increase in general. Another factor for children is that their immune systems are immature.’

Some children will find their eczema eases or disappears altogether as they get older, but for some it will be a lifelong condition. ‘Half of people with eczema have the defect with the skin barrier,’ says Julie, ‘so in effect they will always have it. Even though it can get better, there is always a danger it will recur, particularly when people get older.’


Emollients: how they work

Emollients create an oily layer that retains moisture below it. This helps to restore the skin’s natural barrier, so easing itchiness and irritation, and helping to prevent infections and flare-ups. But to work at their best, emollients need to be used properly:

  • Use them frequently – at least twice a day. It is recommended at least 250g a week is used on a child, 500g for an adult.
  • After washing or bathing, pat the skin dry and immediately apply a leave-on emollient.
  • Apply emollient gently, in the direction of hair growth. Never rub up and down vigorously as this could trigger itching.
  • Continue to use emollients alongside other treatments prescribed by a GP.
  • Most topical steroids can be applied before or after an emollient, but leave at least 20 to 30 minutes between the two treatments.
  • Apply a thicker-than-usual layer of emollient before swimming.
  • Use a spoon or spatula, not fingers, to remove emollient from a tub and replace the lid after use. Or use a pump dispenser.
  • Carry a small container of emollient when out and about.
  • Using emollient even after the eczema has improved will help prevent flare-ups.
  • Apply the emollient to all of the skin, not just the affected area.
  • Store emollients at room temperature or in the airing cupboard. Creams can be kept in the fridge, ointments cannot.

NES, 2018b


Sound advice

Where does this leave community practitioners? Miriam believes that because health visitors are often the first health professionals that parents turn to, they have a vital role in supporting parents of children with eczema: ‘Advise parents to keep using leave-on emollients (moisturisers) and to avoid soap, using emollient as a soap substitute. Some people might find an emollient bath additive is useful as a soap substitute and there is nothing wrong with this, but we now know that simply pouring it into the bath isn’t effective. If emollients aren’t working, then health visitors could help in directing parents to consult with their GPs, as a topical corticosteroid may be necessary to get control of the eczema. Getting it under control early may mean that children have fewer problems with allergies later on.’

Julie agrees that health visitors are an important source of advice for parents: ‘The key message is that for children with eczema an emollient bath is therapeutic. Always use an emollient to wash with, as that cleanses the skin, and it’s really important to control the levels of staphylococcus aureus on the skin of babies and children with eczema. We also recommend every day for an emollient bath. It’s a bit of a myth that you should restrict bathing. Just don’t add soap and bubble baths as they will damage the skin.’


Resources

  • The National Eczema Society offers lots of information and resources at eczema.org. Its helpline is 0800 089 1122
  • Allergy UK has a large section on eczema at allergyuk.org
  • NHS Choices covers eczema at bit.ly/NHS_atopic_eczema
  • Details of the BATHE study, including a useful infographic and summary video, can be found at

References

  • National Eczema Society. (2018a) What is eczema? See: eczema.org/what-is-eczema (accessed 16 November 2018).
  • National Eczema Society. (2018b) Emollients. See: eczema.org/documents/459 (accessed 16 November 2018).
  • Santer M, Ridd MJ, Francis NA, Stuart B, Rumsby K, Chorozoglou M, Becque T, Roberts A, Liddiard L, Nollett C, Hooper J, Prude M, Wood W, Thomas KS, Thomas-Jones E, Williams HC, Little P. (2018) Emollient bath additives for the treatment of childhood eczema (BATHE): multi-centre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness. BMJ 361:k1332
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