4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline (see section 5).

4.1 Infant feeding

What is the optimal feeding regimen in the first year of life for children with established atopic eczema?

Why this is important

Dietary manipulation has the potential to decrease disease severity in children with proven food allergy. A study is needed to explore the potential benefits and harms of delaying the introduction of allergenic foods such as milk, egg and peanuts in infants with early signs of atopic eczema to assess the potential impact on atopic eczema severity and the subsequent development of food allergy, asthma and allergic rhinitis.

4.2 Prevention of flares

Which are the best, most cost-effective treatment strategies for managing and preventing flares in children with atopic eczema?

Why this is important

Atopic eczema is usually an episodic disease of exacerbation (flares) and remissions, except for severe cases where it may be continuous (2–6% of cases). Flares may occur as frequently as two or three times per month and have a very negative effect on quality of life. They are time consuming and expensive to treat.

There is limited evidence suggesting that strategies to prevent flares can reduce the number, frequency and severity of flares and the amount of treatment required. Identifying good strategies would improve patient care and quality of life, and free up NHS resources.

Strategies that could be considered in this research include continuous versus intermittent topical treatments or combinations of products such as topical corticosteroids and topical calcineurin inhibitors.

4.3 Early intervention

What effect does improving the control of atopic eczema in the first year of life have on the long-term control and severity of atopic eczema and the subsequent development and severity of food allergy, asthma and allergic rhinitis?

Why this is important

Uncontrolled atopic eczema in children may progress to chronic disease involving the production of auto-immune antibodies to the skin. Early intervention to restore the defective skin barrier might alter the course of atopic eczema by preventing allergen penetration. A systematic review is needed to evaluate the available evidence on these factors. The results should feed in to the design of a large randomised controlled trial investigating the long-term effect of controlling atopic eczema in the first year of life. Early effective treatment to control atopic eczema and the development of other atopic conditions would be extremely cost effective, have a major impact on service provision and improve the quality of life of children with atopic eczema and their parents and carers.

4.4 Adverse effects of topical corticosteroids

What are the long-term effects (when used for between 1 and 3 years) of typical use of topical corticosteroids in children with atopic eczema?

Why this is important

Around 70–80% of parents and carers of children with atopic eczema are concerned about the side effects of topical corticosteroids and this often prevents adherence to therapy (at least 25% of parents and carers report non-usage because of anxiety). Despite the fact that topical corticosteroids have been in clinical use since 1962, there are limited data on their long-term effects (greater than a few weeks) on skin thickness, hypothalamic–pituitary–adrenal (HPA) axis suppression and other side effects.

Clinical consensus suggests that long-term usage, within clinically recommended dosages, appears to be safe; research confirming this would greatly improve adherence to therapy and clinical outcomes, and reduce parental anxiety. The research could include comparisons between children who use topical corticosteroids for shorter and longer periods, and with those who use other topical preparations such as emollients and topical calcineurin inhibitors.

4.5 Education and adherence to therapy

How effective and cost effective are different models of educational programmes in the early management of atopic eczema in children, in terms of improving adherence to therapy and patient outcomes such as disease severity and quality of life?

Why this is important

Atopic eczema is a common childhood disease affecting one in five children in the UK. Effective therapy improves quality of life for children with atopic eczema and their parents and carers, and can be provided for over 80% of children with atopic eczema in a primary care setting. It is known that a lack of education about therapy leads to poor adherence, and consequently to treatment failure.

  • National Institute for Health and Care Excellence (NICE)