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Do nonmedicated topicals relieve childhood eczema?
Yes. 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).
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 summary
Eczema is a chronic, inflammatory, pruritic skin disorder that affects infants, children, and adults. Therapeutic efficacy is defined as symptom relief and decreased inflammation. 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 work
Emollients have demonstrated efficacy 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 treatments 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 efficacy 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 evening primrose oil with placebo found that patients treated with primrose oil showed a subjective improvement in skin scaling, dryness, redness, and itching.5
Eczema on the leg of a 9-year-old boy.A double-blind, placebo-controlled trial of 32 children that assessed the effects of undershirts coated with borage oil compared with noncoated undershirts found statistically significant improvements in both itching and erythema.6
MAS063DP is a nonsteroidal, hydrolipidic 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 outcome was treatment success defined 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 help
In a case control study of 70 patients (ages 12-80 years, mean 23 years,) bathing in acidic hot spring water (42° C) helped control edema, erythema, exudation, and excoriation in refractory cases of eczema.8
Several adult and mixed adult-child studies have found mild efficacy for chamomile extracts. One RCT demonstrated topical chamomile to be equivalent to 0.25% hydrocortisone cream for treating mild eczema.9
Wet wraps may help, but may raise skin infection risk
A 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 benefit over standard care and an increased risk of skin infection (95% CI, 5%-42%; P=.05) with a number needed to harm of 5.10,11
Essential oils, hamamelis distillate don’t work
In 1 case control study, massage with essential oils didn’t improve eczema compared with massage without essential oils.12 Hamamelis (witch hazel) distillate cream was inferior to steroid creams.13
Recommendations
The 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 benefits, 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 parameters has been created by the American College of Allergy, Asthma, and Immunology; the American Academy of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology. The task force’s latest recommendations suggest that emollients, tar preparations, and wet dressings are beneficial for treating eczema.2
1. Grimalt R, Mengeaud V, Cambazard F. Study Investigators’ Group. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomized controlled study. Dermatology. 2007;214:61-67.
2. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol. 2004;93(3 suppl 2):S1-S21.
3. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (ADA)/American Academy of Dermatology Association “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 Dermatol 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, Eichenfield LF, et al. MAS063DP is effective monotherapy for mild to moderate atopic dermatitis in infants and children: 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 atopic dermatitis. Holist Nurs Pract. 2003;17:56-62.
10. Devillers AC, Oranje AP. Efficacy and safety of “wet-wrap” dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature. Br J Dermatol. 2006;154:579-585.
11. Hindley D, Galloway G, Murray J, et al. A randomised study of “wet wraps” versus conventional treatment for atopic eczema. Arch Dis Child. 2006;91:164-168.
12. Anderson C, Lis-Balchin M, Kirk-Smith M. Evaluation 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 efficacy of hamamelis distillate and hydrocortisone cream in atopic eczema. Eur J Clin Pharmacol. 1995;48:461-465.
Yes. 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).
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 summary
Eczema is a chronic, inflammatory, pruritic skin disorder that affects infants, children, and adults. Therapeutic efficacy is defined as symptom relief and decreased inflammation. 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 work
Emollients have demonstrated efficacy 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 treatments 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 efficacy 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 evening primrose oil with placebo found that patients treated with primrose oil showed a subjective improvement in skin scaling, dryness, redness, and itching.5
Eczema on the leg of a 9-year-old boy.A double-blind, placebo-controlled trial of 32 children that assessed the effects of undershirts coated with borage oil compared with noncoated undershirts found statistically significant improvements in both itching and erythema.6
MAS063DP is a nonsteroidal, hydrolipidic 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 outcome was treatment success defined 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 help
In a case control study of 70 patients (ages 12-80 years, mean 23 years,) bathing in acidic hot spring water (42° C) helped control edema, erythema, exudation, and excoriation in refractory cases of eczema.8
Several adult and mixed adult-child studies have found mild efficacy for chamomile extracts. One RCT demonstrated topical chamomile to be equivalent to 0.25% hydrocortisone cream for treating mild eczema.9
Wet wraps may help, but may raise skin infection risk
A 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 benefit over standard care and an increased risk of skin infection (95% CI, 5%-42%; P=.05) with a number needed to harm of 5.10,11
Essential oils, hamamelis distillate don’t work
In 1 case control study, massage with essential oils didn’t improve eczema compared with massage without essential oils.12 Hamamelis (witch hazel) distillate cream was inferior to steroid creams.13
Recommendations
The 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 benefits, 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 parameters has been created by the American College of Allergy, Asthma, and Immunology; the American Academy of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology. The task force’s latest recommendations suggest that emollients, tar preparations, and wet dressings are beneficial for treating eczema.2
Yes. 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).
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 summary
Eczema is a chronic, inflammatory, pruritic skin disorder that affects infants, children, and adults. Therapeutic efficacy is defined as symptom relief and decreased inflammation. 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 work
Emollients have demonstrated efficacy 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 treatments 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 efficacy 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 evening primrose oil with placebo found that patients treated with primrose oil showed a subjective improvement in skin scaling, dryness, redness, and itching.5
Eczema on the leg of a 9-year-old boy.A double-blind, placebo-controlled trial of 32 children that assessed the effects of undershirts coated with borage oil compared with noncoated undershirts found statistically significant improvements in both itching and erythema.6
MAS063DP is a nonsteroidal, hydrolipidic 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 outcome was treatment success defined 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 help
In a case control study of 70 patients (ages 12-80 years, mean 23 years,) bathing in acidic hot spring water (42° C) helped control edema, erythema, exudation, and excoriation in refractory cases of eczema.8
Several adult and mixed adult-child studies have found mild efficacy for chamomile extracts. One RCT demonstrated topical chamomile to be equivalent to 0.25% hydrocortisone cream for treating mild eczema.9
Wet wraps may help, but may raise skin infection risk
A 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 benefit over standard care and an increased risk of skin infection (95% CI, 5%-42%; P=.05) with a number needed to harm of 5.10,11
Essential oils, hamamelis distillate don’t work
In 1 case control study, massage with essential oils didn’t improve eczema compared with massage without essential oils.12 Hamamelis (witch hazel) distillate cream was inferior to steroid creams.13
Recommendations
The 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 benefits, 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 parameters has been created by the American College of Allergy, Asthma, and Immunology; the American Academy of Allergy, Asthma, and Immunology; and the Joint Council of Allergy, Asthma, and Immunology. The task force’s latest recommendations suggest that emollients, tar preparations, and wet dressings are beneficial for treating eczema.2
1. Grimalt R, Mengeaud V, Cambazard F. Study Investigators’ Group. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomized controlled study. Dermatology. 2007;214:61-67.
2. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol. 2004;93(3 suppl 2):S1-S21.
3. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (ADA)/American Academy of Dermatology Association “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 Dermatol 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, Eichenfield LF, et al. MAS063DP is effective monotherapy for mild to moderate atopic dermatitis in infants and children: 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 atopic dermatitis. Holist Nurs Pract. 2003;17:56-62.
10. Devillers AC, Oranje AP. Efficacy and safety of “wet-wrap” dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature. Br J Dermatol. 2006;154:579-585.
11. Hindley D, Galloway G, Murray J, et al. A randomised study of “wet wraps” versus conventional treatment for atopic eczema. Arch Dis Child. 2006;91:164-168.
12. Anderson C, Lis-Balchin M, Kirk-Smith M. Evaluation 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 efficacy of hamamelis distillate and hydrocortisone cream in atopic eczema. Eur J Clin Pharmacol. 1995;48:461-465.
1. Grimalt R, Mengeaud V, Cambazard F. Study Investigators’ Group. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomized controlled study. Dermatology. 2007;214:61-67.
2. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol. 2004;93(3 suppl 2):S1-S21.
3. Hanifin JM, Cooper KD, Ho VC, et al. Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (ADA)/American Academy of Dermatology Association “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 Dermatol 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, Eichenfield LF, et al. MAS063DP is effective monotherapy for mild to moderate atopic dermatitis in infants and children: 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 atopic dermatitis. Holist Nurs Pract. 2003;17:56-62.
10. Devillers AC, Oranje AP. Efficacy and safety of “wet-wrap” dressings as an intervention treatment in children with severe and/or refractory atopic dermatitis: a critical review of the literature. Br J Dermatol. 2006;154:579-585.
11. Hindley D, Galloway G, Murray J, et al. A randomised study of “wet wraps” versus conventional treatment for atopic eczema. Arch Dis Child. 2006;91:164-168.
12. Anderson C, Lis-Balchin M, Kirk-Smith M. Evaluation 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 efficacy of hamamelis distillate and hydrocortisone cream in atopic eczema. Eur J Clin Pharmacol. 1995;48:461-465.
Evidence-based answers from the Family Physicians Inquiries Network