The National Institute for Health and Care Excellence (NICE) wants to stop doctors prescribing bath emollients for children with eczema. NICE is consulting on proposals to change its guidelines for treating children with atopic eczema and the deadline for responses is Tuesday 4 April.
National Eczema Society believes children with atopic eczema and their families will be disadvantaged and suffer as a result of these proposals. We are asking NICE to reconsider and continue recommending bath emollients in clinical circumstances where it is appropriate to prescribe them. Bath emollients are used by many children and their parents as part of a skincare regimen to help manage eczema.
Emollients and soap substitutes are vital in helping manage the dry skin associated with eczema. National Eczema Society is concerned that only children whose families can afford to buy bath emollients will have access to these products under the new proposals. The poorest families will be hit hardest and it seems especially unjust as many are grappling with the cost of living crisis. We believe doctors should be able to continue prescribing bath emollients when it’s in the child’s best interests, to achieve the best eczema care. Hard-pressed parents can’t always find the time to use leave-on emollients with their children and they may rely on bath emollients to help manage their child’s eczema.
For some parents, using bath emollient is more practical and more effective than applying leave-on emollient to their children in the bath. Adding a capful of bath emollient to the bath while the water is running is quicker and easier than trying to emulsify a leave-on emollient to serve the function of a bath emollient. This can be important when busy parents have a number of children to care for and limited time. Caring for children with eczema can be exhausting and relentless for parents, as evidenced by the extensive literature on carer burden.
Bath emollients are formulated to disperse evenly and well in bath water. This is not the case for leave-on emollients. As anyone knows who has tried to disperse leave-on emollient in water, it usually ends up as blobs of emollient in the bath water, rather than a uniform film that covers the child’s skin more evenly and comfortably. This point is particularly relevant to children with sensory perception disorders, who can find it difficult to be touched or dislike the texture of leave-on emollients on their skin. Bath emollients can help restore the skin barrier without physical touch. The notion that using leave-on emollient as a soap substitute for washing children in the bath is equally or more effective than bath emollients for all children is not supported by the literature.
These NICE proposals are based largely on the results of the BATHE (Bath Additives in the Treatment of cHildhood Eczema) research study. National Eczema Society has expressed concerns about the design of this study and how much this reflects real-world use of emollients, soap substitutes and bath emollients.
The BATHE study did not address the questions that would have been most insightful, such as ‘what is the best soap substitute?’ and ‘are bath emollients more effective than leave-on emollients as soap substitutes?’ Rather, the BATHE study focused on a nuanced research question that looked at the efficacy of bath emollients in a very specific set of theoretical circumstances. It looked at outcomes when children used leave-on emollient during the day and leave-on emollient in the bath as a soap substitute, and bath emollient in the bath, compared to children who used only leave-on emollient and leave-on emollient in the bath as a soap substitute. Parents would typically use a bath emollient OR a leave-on emollient as a soap substitute when bathing their children, not both. National Eczema Society argues that the BATHE study design does not sufficiently reflect real world patient experience or prescribing practice.
The BATHE study addresses likely population level impacts only and was not adequately powered to identify subgroup differences. As such, the BATHE study does not take into account sufficiently the heterogeneous nature of atopic dermatitis. It is a complex immune mediated disease and affects children differently. Treatments and treatment approaches that work for one child may not be effective for another. In particular, different or more intense treatments are often appropriate for children with more severe eczema.
For these reasons and others, National Eczema Society is asking NICE to reconsider and continue recommending bath emollients in clinical circumstances where it is appropriate for healthcare professionals to prescribe them.