Atopic eczema in under 12s: diagnosis and management—summary of updated NICE guidance

Posted: 14th August 2023

What you need to know

  • Do not offer emollient bath additives to children under 12 years old with atopic eczema

  • Offer personalised advice to all so that children and carers are educated on how to wash with emollients

Atopic eczema is a common condition in children under 12 years old that can negatively affect quality of life for children and their carers. Emollients form the basis of eczema management and are available as either leave-on preparations (which include lotions, sprays, creams, and ointments), emollient soap substitutes, or emollient bath additives. Management of eczema with emollients includes regularly applying leave-on emollients and washing with leave-on emollients or emollient soap substitutes (box 1).

Box 1

Tips on emollient safety

  • Emollients can transfer from skin to clothes, bedding, and bandages, which can then become flammable. Regularly washing clothes and bedding at the highest temperature allowed for the fabric can reduce build-up of emollient, but it does not completely remove it and carers should try to keep children away from fire, flames, and cigarettes1

  • Patients and carers should try to prevent contamination of emollients by either using a pump dispenser or by scooping emollients out of pots using a clean spoon or spatula rather than their hands23

  • Emollients can make the bath or shower slippery. Patients and carers should always use a non-slip bathmat, clean the bath or shower after washing, and dry the bath or shower with paper towels or tissue2

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Emollient bath additives are also available; these are emollient products that are formulated to be added to bath water. In 2018, the BATHE trial found that emollient bath additives are not effective or cost effective when used in addition to standard care.4 Prescriptions for emollient bath additives remain limited in some areas of England,5 which has given rise to geographical variation in prescribing.

This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) guideline for the diagnosis and management of atopic eczema in children under 12 years old.6 Recommendations and full details of evidence are available via the NICE website. This guideline is a short update and replaces recommendations on emollient bath additives in the 2007 NICE guideline on atopic eczema in under 12s.

Recommendations

NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Emollient bath additives

When updating the guidelines, a systematic literature review was conducted to evaluate the effect of eczema care with emollient bath additives compared with eczema care without emollient bath additives. The recommendations were mainly informed by the BATHE randomised controlled trial which recruited 483 children aged 1-11 years with atopic dermatitis from 96 general practices in Wales and England.4 The trial found that emollient bath additives did not significantly improve eczema severity, as determined by the patient oriented eczema measure (POEM) score, when used in addition to standard care (leave-on emollients, standardised written advice on how to wash, and topical corticosteroids when required), with a mean difference at 16 and 52 weeks of −0.9 (95% CI −2 to 0.2) and −1.1 (−2.27 to 0.07) respectively.4 The BATHE trial also found no significant difference in quality of life between the intervention and comparator arms.7

Based on this evidence, the guideline committee concluded that use of emollient bath additives in addition to standard care is unlikely to be cost effective, as it is more expensive than standard care alone and does not demonstrate clinical effectiveness or generate quality of life gains. The BATHE trial found that there was no increase in incidence of adverse events, such as slipping in the bath or stinging and redness, with emollient bath additive use, suggesting that they are safe.4 The guideline committee also reviewed evidence from a single non-randomised within-patient comparison study8; however, this study had only nine participants and was assessed to be of very low quality according to GRADE. Therefore, these results were not considered during decision making.

Emollient bath additives are available over the counter, and the guideline committee considered that they may not be affordable for families on low incomes. However, the guideline committee agreed that lack of access to emollient bath additives is unlikely to negatively impact children from lower socioeconomic groups because they do not improve eczema severity when used in addition to standard care.

  • Do not offer emollient bath additives to children with atopic eczema. [Based on moderate quality evidence from one randomised controlled trial and one non-randomised within-patient comparison study]

Personalising washing advice to the patient and their carers

Educating and tailoring emollient washing advice to the needs of patients and their families is an integral component of managing eczema successfully.

The guideline committee discussed that personalised bathing advice may be particularly important for certain groups of children—for example, those with social and behavioural communication difficulties and sensory processing disorders who are unable to tolerate leave-on emollients that are applied directly to their skin and rely solely on bathing with emollients. For these children, it may be beneficial to wash with emollients in the bath or dilute suitable leave-on emollients in hot water and add them to the bath water. This advice may also be relevant for children who have been offered emollient bath additives previously and thought they were beneficial, as well as those who experience stinging of eczematous skin in the bath. Therefore, the guideline committee amended two recommendations from 2007 based on their experience.

  • If their current emollient causes irritation or is not acceptable, offer a different way to apply it or offer an alternative emollient.

  • Offer personalised advice on washing with emollients or emollient soap substitutes, and explain to children with atopic eczema and their parents or carers that:

    • They should use leave-on emollients or emollient soap substitutes instead of soaps and detergent-based wash products

    • Leave-on emollients can be added to bath water

    • Children aged under 12 months should use leave-on emollients or emollient soap substitutes instead of shampoos

    • Older children using shampoo should use a brand that is unperfumed and ideally is labelled as suitable for eczema and they should avoid washing their hair in bath water.

      [Based on the experience and opinion of the Guideline Committee (GC) 2007 recommendations considered by the GC within the context of the current update]

Implementation

Despite advice from NHS England that emollient bath additives should not be prescribed in primary care routinely,9 prescribing of emollient bath additives has continued. In October 2022 spending on bath additives ranged from £727 to £26 725 between integrated care boards.5 Although the guideline committee believed that a substantial proportion of this spend was due to repeat prescriptions for patients already using emollient bath additives, there are regional variations in prescribing practices for emollient bath additives. The guideline committee believed that a NICE recommendation not to offer emollient bath additives to children aged under 12 years with atopic eczema would further reduce prescribing and geographical variations that are present currently. The guideline committee also believed that personalised washing advice will aid implementation, because it will allow clinicians to provide patients and carers with alternative ways to wash with emollients. This may be particularly relevant for some patients who have previously been offered emollient bath additives and are disappointed that they are no longer available.

Source: Atopic eczema in under 12s: diagnosis and management—summary of updated NICE guidance | The BMJ

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