Emollient application from birth to prevent eczema in high-risk children: the BEEP RCT
Authors: Bradshaw Lucy E , Wyatt Laura A , Brown Sara J , Haines Rachel H , Montgomery Alan A , Perkin Michael R , Sach Tracey H , Lawton Sandra , Flohr Carsten , Ridd Matthew J , Chalmers Joanne R , Brooks Joanne , Swinden Richard , Mitchell Eleanor J , Tarr Stella , Jay Nicola , Thomas Kim S , Allen Hilary , Cork Michael J , Kelleher Maeve M , Simpson Eric L , Lartey Stella T , Davies-Jones Susan , Boyle Robert J , Williams Hywel C 
Published: May 2024

Background
Atopic eczema is a common childhood skin problem linked with asthma, food allergy and allergic rhinitis that impairs quality of life.

Objectives
To determine whether advising parents to apply daily emollients in the first year can prevent eczema and/or other atopic diseases in high-risk children.

Design
A United Kingdom, multicentre, pragmatic, two-arm, parallel-group randomised controlled prevention trial with follow-up to 5 years.

Setting
Twelve secondary and four primary care centres.

Participants
Healthy infants (at least 37 weeks’ gestation) at high risk of developing eczema, screened and consented during the third trimester or post delivery.

Interventions
Infants were randomised (1 : 1) within 21 days of birth to apply emollient (Doublebase Gel®; Dermal Laboratories Ltd, Hitchin, UK or Diprobase Cream®) daily to the whole body (excluding scalp) for the first year, plus standard skin-care advice (emollient group) or standard skin-care advice only (control group). Families were not blinded to allocation.

Main outcome measures
Primary outcome was eczema diagnosis in the last year at age 2 years, as defined by the UK Working Party refinement of the Hanifin and Rajka diagnostic criteria, assessed by research nurses blinded to allocation. Secondary outcomes up to age 2 years included other eczema definitions, time to onset and severity of eczema, allergic rhinitis, wheezing, allergic sensitisation, food allergy, safety (skin infections and slippages) and cost-effectiveness.

Results
One thousand three hundred and ninety-four newborns were randomised between November 2014 and November 2016; 693 emollient and 701 control. Adherence in the emollient group was 88% (466/532), 82% (427/519) and 74% (375/506) at 3, 6 and 12 months. At 2 years, eczema was present in 139/598 (23%) in the emollient group and 150/612 (25%) in controls (adjusted relative risk 0.95, 95% confidence interval 0.78 to 1.16; p = 0.61 and adjusted risk difference −1.2%, 95% confidence interval −5.9% to 3.6%). Other eczema definitions supported the primary analysis. Food allergy (milk, egg, peanut) was present in 41/547 (7.5%) in the emollient group versus 29/568 (5.1%) in controls (adjusted relative risk 1.47, 95% confidence interval 0.93 to 2.33). Mean number of skin infections per child in the first year was 0.23 (standard deviation 0.68) in the emollient group versus 0.15 (standard deviation 0.46) in controls; adjusted incidence rate ratio 1.55, 95% confidence interval 1.15 to 2.09. The adjusted incremental cost per percentage decrease in risk of eczema at 2 years was £5337 (£7281 unadjusted).
No difference between the groups in eczema or other atopic diseases was observed during follow-up to age 5 years via parental questionnaires.

Limitations
Two emollient types were used which could have had different effects. The median time for starting emollients was 11 days after birth. Some contamination occurred in the control group (< 20%). Participating families were unblinded and reported on some outcomes.

Conclusions
We found no evidence that daily emollient during the first year of life prevents eczema in high-risk children. Emollient use was associated with a higher risk of skin infections and a possible increase in food allergy. Emollient use is unlikely to be considered cost-effective in this context.

Future research
To pool similar studies in an individual patient data meta-analysis.

Trial registration
This trial is registered as ISRCTN21528841.

Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/67/12) and is published in full in Health Technology Assessment; Vol. 28, No. 29. See the NIHR Funding and Awards website for further award information.