Statement 5
When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids may mitigate AD occurrence and severity in predisposed infants.
A growing body of evidence supports skin care starting early in life, recognizing the benefits of ongoing daily use of non-alkaline cleansers and moisturizers to promote a healthy skin barrier (Table 4). When applied from birth onwards, gentle cleansers and moisturizers containing barrier lipids, like ceramides, help maintain the protective skin barrier and improve xerosis, possibly reducing the severity, delaying the occurrence, or preventing AD development in predisposed infants.11-13,39,40
Horimukai et al conducted a randomized, prospective, controlled trial to investigate whether applying a moisturizer during the neonatal period prevents the development of AD.12 Neonates (n=118) at high risk for AD based on family history were enrolled in this study. During the first 32 weeks of life, an emulsion-type moisturizer (2e) was applied daily to the treatment group (n=59). Study results indicated that 32% fewer neonates receiving the emulsion-type moisturizer had developed AD at week 32 compared to the participants receiving the petroleum jelly control (n=59; P=.012, log-rank test). The investigators concluded that daily applying an emollient-type moisturizer decreases the risk of AD in infants during the first 32 weeks of life.
Simpson et al performed a randomized controlled trial in the US and the United Kingdom in neonates (N=124) determined to be at high risk for AD.13 Starting within 3 weeks of birth, parents in the intervention arm applied full-body emollient therapy (in the UK, sunflower seed oil, Doublebase Gel, or liquid paraffin 50%; in the US, sunflower seed oil, Cetaphil Cream or Aquaphor Healing Ointment) to the neonates (n=64) at least once daily, whereas parents of the neonates in the control arm (n=60) did not apply emollients. This study identified a statistically significant protective effect in the neonates who received daily full-body emollient. In addition, a relative risk reduction of 50% (RR 0.50, 95% CI, 0.28-0.9; P=.017) on the cumulative incidence of AD was observed in this group. The investigators concluded that emollient therapy from birth is an effective approach for preventing AD; however, they suggested that this effect needs to be confirmed in larger trials.
Chaoimh et al conducted a randomized controlled clinical trial that investigated the incidence of AD at 12 months in high-risk infants in which emollient was applied daily from birth to 2 months.39 Infants were identified as high risk for AD based on parental history of AD, asthma, or allergic rhinitis. The newborns were enrolled in the study within 4 days of birth and were randomly assigned to receive either an emollient (containing oat ingredients, ceramides, and fatty acids) specifically formulated for very dry, AD-prone skin twice daily for the first 8 weeks of life (intervention group, n=161), or to standard routine skin care (control group, n=160). In the intervention group, the cumulative incidence of AD at 12 months was 32.8% vs 46.4% in the control group (RR 0.707, 95% CI, 0.516, 0.965; P=.036). The investigators concluded that the early application of an emollient specifically formulated for very dry, AD-prone skin until 2 months of age reduces the incidence of AD in high-risk infants at 1 year of age.
McClanahan et al conducted a randomized controlled trial enrolling neonates (n=100) at high risk for AD development based on family history.11 The intervention group received a once-daily full-body application of a ceramide and FLG-associated amino acid-containing emollient. The control arm used a full-body application of an emollient of their choice for dry skin but was requested not to apply it regularly. In the intervention and the control groups, AD was diagnosed in 13.2% vs 25.0% of the participants at 12 months (P=0.204) and 19.4% vs 31.0% at 2 years (P=0.296), respectively. Although a favorable trend was observed in the intervention group, it was not statistically significant, possibly because of a lack of power due to under-enrollment. The investigators concluded that the trends observed in this study suggest a protective effect of daily full-body therapy with the study emollient compared to the control.
The results of these studies on the prophylactic application of moisturizers for the prevention of AD in infants demonstrate positive trends, but conclusive evidence is lacking.12,13,40 A large-scale, randomized controlled study by Chalmers et al in neonates (N=1394) at high risk of developing AD (based on having at least 1 first-degree relative diagnosed with AD, asthma, or allergic rhinitis) failed to confirm these results.41 Newborns assigned to the intervention group (n=693) received emollient (Doublebase Gel or Diprobase Cream) applied at least once daily, and the control group (n=701) was treated with just mild cleansers or shampoos. The results of this study indicated that at age 2 years, AD was present in 23% of infants with evaluable data in the emollient group (n=598) and 25% of such infants in the control group (n=612; adjusted RR 0.95, 95% CI, 0.78 to 1.16; P=0.61; adjusted risk difference -1.2%, -5.9 to 3.6). The authors concluded that the study results provided "no evidence that daily emollient during the first year of life prevents eczema in high-risk children." However, it should be noted that study results were partly based on parent- and patient-reported secondary outcome measures rather than objective ascertainment. These included the parental report of clinical diagnosis/time to onset of AD, parent completion of UK Working Party criteria, and patient-reported severity of eczema.
Skjerven et al conducted a randomized controlled trial that included newborns (N=2397) who were not selected according to atopy.42 The newborns were randomized at birth into 4 groups: skin intervention (bath with added oil and face cream applied from age 2 weeks), food intervention (eggs, wheat, cow's milk, and peanut butter introduced between age 12-16 weeks), skin + food intervention, or no intervention (control group). By age 12 months,
