BEE Trial

Design and population. The Best Emollients for Eczema (BEE) trial (Ridd et al., Lancet Child Adolesc Health 2022) was a pragmatic, phase 4, superiority RCT in 77 English general practices. It randomised 550 children aged 6 months to 12 years with Atopic Dermatitis (POEM score >2) to one of four emollient types: lotion (137), cream (140), gel (135) or ointment (138). Median age was 4 years (IQR 2–8), so many participants were toddlers or preschoolers. Mean baseline POEM was 9.3, i.e. mostly mild-to-moderate eczema. It was funded by the NIHR, not by manufacturers, and was described by the lead GP as the first trial to compare emollient types directly. BEE Trial [part-of] Emollient Therapy BEE Trial [relates] Atopic Dermatitis

Intervention and primary outcome. Families were given 500 g or 500 mL of their allocated type, to apply twice daily and as needed, alongside usual treatment such as Topical Corticosteroids. Later prescriptions were up to the family. The primary outcome was parent-reported eczema severity on weekly POEM over 16 weeks, analysed as randomised. POEM [defines] BEE Trial

Result. There was no difference between the four types (global p = 0.77). All pairwise POEM differences were under half a point, for example ointment versus lotion −0.01 (95% CI −0.93 to 0.91), far below the 3-point minimal clinically important difference. Sensitivity and subgroup analyses gave the same answer. Adverse events were common and similar across groups (35–40%; p = 0.79), but stinging was less frequent with ointments (9%) than with lotions (20%), creams (17%) or gels (19%). Interviews showed that families’ preferences were driven by how products looked and felt: some liked lotions that soak in quickly, others the “barrier” of ointments. BEE Trial [relates] Urea Creams BEE Trial [supports] Cost of Eczema Care

Limitations. Clinicians and parents were not blinded, and the primary outcome was parent-reported. Only standard emollients of each type were used, so the trial says nothing about “active” additives such as Ceramides or urea. Most children had mild-to-moderate disease, and adherence after the first prescription was left to families. The authors said further work is needed for adolescents and adults. BEE Trial [relates] Ceramides

What it means for toddlers. There is no “best” moisturiser type for a 1–4-year-old. The right one is the one the child will tolerate and the parent will actually apply often, which supports trying different types and the NHS practice of prescribing the cheapest acceptable product. If a toddler cries or rubs at a cream, an ointment is less likely to sting. The finding challenges the common advice that ointments are needed for more severe eczema (see the conflict in Emollient Therapy). BEE Trial [supports] Soak and Seal BEE Trial [relates] Treatment Outcomes Comparison

Connections

• Emollient Therapy — no type superior, source: Lancet Child Adolesc Health 2022
• Urea Creams — did not test urea; supports choosing by tolerance/preference, source: Ridd 2022
• Ceramides — did not test ceramides; type made no difference, source: Ridd 2022
• POEM — primary outcome, weekly over 16 weeks, source: Ridd 2022
• Cost of Eczema Care — supports prescribing cheapest acceptable emollient, source: Bristol CAPC 2022
• Topical Corticosteroids — continued as usual care alongside emollients, source: Ridd 2022