There is one experience that many North American children will share this winter. I’ll give you a hint. It’s red, itchy, and although it can occur any time of year, is most uncomfortable in cold, low humidity weather. No, I am not referring to a scratchy wool sweater exclaiming seasonal cheer. It’s eczema.
Eczema is the most common inflammatory skin disease of childhood, affecting up to 20% of kids every year (Bialy, Foisy, Smith, & Fernandes, 2011). Eczema is associated with IgE-mediated diseases. This means that kids who have asthma, food allergies, and allergic rhinitis will be most at risk. Although severity varies from child to child, the most common presentation of eczema is a dry, red, sore, intractably itchy rash on a localized patch of skin. Eczema often interferes with a child’s quality of life, impacting their self-esteem and ability to initiate and sustain relationships with others, highlighting the need for effective management and prevention strategies.
We know there are a number of treatments available for the management of eczema-related symptoms; however, not all of these treatments are effective for everyone. Given the prevalence and complexity of successfully managing eczema symptoms, preventative methods have been explored. There is little known about the efficacy of interventions targeting the prevention of eczema. The Cochrane overview summarized in this blog reviews the evidence for preventing eczema. The evidence comes from 39 randomized controlled trials involving over 11,000 participants.
Here is a summary of what the current evidence suggests:
Exclusive breastfeeding for a defined period of time: Exclusive breastfeeding for at least six months in place of introducing solids to a child’s diet at three to six months does not reduce the risk of developing eczema overall; however, it may be helpful for high risk infants (i.e., infants born into families who have eczema, asthma, or hay fever).
Hydrolyzed protein formulas for infants who are not exclusively breastfed: Short-term feeding in the first days of life with hydrolyzed formula does not reduce the risk of developing eczema.
Soy formulas for infants who are not exclusively breastfed: Feeding with soy formula instead of cow’s milk does not reduce the risk of developing eczema.
Maternal dietary antigen avoidance: Maternal dietary antigen avoidance is a type of diet restriction where a mother does not consume foods that cause the body to produce antibodies against it, like eggs or cow’s milk. Maternal dietary antigen avoidance versus a normal diet does not reduce the risk of the child developing eczema.
Omega-3 or -6 fatty acid supplementation: Supplementation does not reduce the risk of developing eczema.
Prebiotics: One small study (n= 150) suggests that addition of lactulose to the prebiotics polydextrose and galacto-oligosaccharide in the first four months may reduce the incidence of eczema during the first two years of life, especially among high risk infants (children with IgE mediated disease). However, it is not known whether all children will benefit.
Probiotics: Taking probiotics does not reduce the risk of developing eczema.
The authors of the overview conclude that there is no “clear evidence that any of the main interventions reviewed can reduce eczema incidence.” However, they also indicate that the currently available evidence “does not mean to say that some interventions do not work, as new larger, well-reported trials may indeed show a modest benefit in time…the current evidence is simply not strong enough to influence practice recommendations.”
Parents would be best advised to focus on management strategies for children that are already showing signs and symptoms of eczema.
What are the recommended treatments?
The Eczema Society of Canada recommends the following 3-step approach to treating eczema:
- Bathing and moisturizing to repair skin barrier
- Prescription treatments to reduce inflammation and bacteria
- Trigger avoidance to reduce flare ups
However, it is important to note that this approach may not be helpful for all types of eczema.
What treatments are lacking in evidence?
- Dietary supplements including: fish oil, zinc, selenium, vitamin D, vitamin E, pyridoxine (vitamin B6), sea buckthorn oil, hempseed oil, and sunflower oil. High doses of vitamin D can be dangerous, and supplements can be quite costly. Dietary supplements for established atopic eczema; Cochrane Summary
- Dietary exclusion including: egg and milk exclusion, few foods elimination diet, and an elemental diet. Although, an egg free diet may be beneficial for infants who have specific IgE to eggs. Dietary exclusions for established atopic eczema; Cochrane Summary
- Oral evening primrose oil and borage oil: do not appear to be more effective than placebo. Oral evening primrose oil and borage oil for eczema; Cochrane Summary
- Probiotics: do not appear to be more effective than placebo, and treatment carries a small risk of adverse events like infections and gut problems. Probiotics for treating eczema; Cochrane Summary
- Topical pimecrolimus: does not appear to be more effective than moderate or potent corticosteroids in treating eczema. Topical pimecrolimus for eczema; Cochrane Summary
Reviews included in overview:
Kramer MS, Kakuma R. Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating atopic disease in the child. Cochrane Database Syst Rev 2006; 1: CD000133.; Cochrane Summary