Systematic review of treatments for atopic eczema.

Background Atopic eczema is the commonest inflammatory skin disease of childhood, affecting 15–20% of children in the UK at any one time. Adults make up about one-third of all community cases. Moderate-to-severe atopic eczema can have a profound effect on the quality of life for both sufferers and their families. In addition to the effects of intractable itching, skin damage, soreness, sleep loss and the social stigma of a visible skin disease, other factors such as frequent visits to doctors, special clothing and the need to constantly apply messy topical applications all add to the burden of disease. The cause of atopic eczema is unknown, though a genetic predisposition and a combination of allergic and non-allergic factors appear to be important in determining disease expression. Treatment of atopic eczema in the UK is characterised by a profusion of treatments aimed at disease control. The evidential basis of these treatments is often unclear. Most people with atopic eczema are managed in primary care where the least research has been done. Objectives The objectives of this scoping review are two-fold. Methods Results A total of 1165 possible RCTs were retrieved in hard copy form for further scrutiny. Of these, 893 were excluded from further analysis because of lack of appropriate data. The 272 remaining RCTs of atopic eczema covered at least 47 different interventions, which could be broadly categorised into ten main groups. Quality of reporting was generally poor, and limited statistical pooling was possible only for oral cyclosporin, and only then after considerable data transformation. There was reasonable RCT evidence to support the use of oral cyclosporin, topical corticosteroids, psychological approaches and ultraviolet light therapy. Conclusions Recommendations for research Urgent primary research priorities include RCTs of wet-wrap treatments, the clinical benefit of allergy testing, the use of water softeners, the role of specialist nurses, comparisons of tacrolimus and ascomycin against topical corticosteroids, studies of disease prevention, and the use of emollients in preventing disease relapse. Such RCTs should ideally be pragmatic and simple in design, with a few outcome measures that doctors and patients find easy to understand. They should ideally be of 4 months' or more duration in order to capture the chronicity of disease as well as shortterm effects. If such trials are intended to inform primary care, where patients may have milder disease, then they should be conducted in a primary care setting.