Emollient Therapy

Emollients (moisturisers) are the foundation of treatment for Atopic Dermatitis in toddlers. They coat the skin with a film of oil or lipid (e.g. petrolatum, mineral oil) that reduces water loss from the stratum corneum, and some add humectants such as urea or glycerol that pull water into the skin (skin barrier). NICE states that emollients “should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear”, and asks clinicians to prescribe children 250–500 g a week from a choice of unperfumed products, with supplies available at nursery and pre-school. Under-prescribing and under-use are common and are linked to more flares (Nursing in Practice). Emollients are used as three things: leave-on moisturisers, Soap Substitutes, and Emollient Bath Additives.

Emollient Therapy [treats] Atopic Dermatitis Emollient Therapy [supports] skin barrier NICE [regulates] Emollient Therapy

Types and how to apply them. The NHS describes four main types: lotions (thin, spread easily, good for hairy or weeping areas, least moisturising), sprays (hard-to-touch or sore areas), creams (less greasy, good for daytime) and ointments (thick, greasy, most occlusive, good at night for very dry skin, usually preservative-free, but not for weeping eczema). Gels sit between creams and lotions. Apply generously and smooth, don’t rub, in the direction of hair growth to avoid blocking follicles; apply straight after bathing once skin is patted dry, and ideally 3–4 times a day (NHS). Protect a baby’s hands and cheeks with emollient before meals “to stop them getting sore from food and drink” (NHS). When also using Topical Corticosteroids, wait 20–30 minutes between the two so the steroid is not diluted or spread to unaffected skin. Scoop from tubs with a clean spoon, or use pumps/tubes, to avoid bacterial contamination; a new supply should be issued after a skin infection, because old tubs “can become contaminated and act as a source of infection” (NICE CG57 rec 1.5.1.37; Nursing in Practice).

Emollient Therapy [relates] Topical Corticosteroids Soap Substitutes [part-of] Emollient Therapy

Strength of evidence. The Cochrane review Emollients and moisturisers for eczema (van Zuuren et al., 2017; 77 RCTs, 6,603 participants) found that moisturisers lowered investigator-assessed eczema severity versus no moisturiser or vehicle (high-certainty), reduced flares (RR 0.33, moderate-certainty), lengthened time to flare (median 180 vs 30 days), and reduced the amount of Topical Corticosteroids needed. Moisturiser plus active treatment worked better than active treatment alone. The review found “no reliable evidence that one moisturiser is better than another”. Oat-based moisturisers (Colloidal Oatmeal) cut flares and steroid use in small studies but caused more adverse events. The BEE Trial (Best Emollients for Eczema; Ridd et al., Lancet Child Adolesc Health 2022) was the first head-to-head comparison. It randomised 550 children aged 6 months to 12 years (median age 4) to lotion, cream, gel or ointment and found no difference in parent-reported severity over 16 weeks (p = 0.77). Its message: “the best moisturisers are the ones the patient will use.”

Cochrane [supports] Emollient Therapy BEE Trial [supports] Emollient Therapy Emollient Therapy [relates] Colloidal Oatmeal

Conflict: [Nursing in Practice / NICE CKS, c. 2017] says ointments are “more effective than creams” for dry, non-inflamed skin. [BEE trial, Lancet Child Adolesc Health, 2022] found ointments no better than lotions, creams or gels for childhood eczema. Unresolved — add to open_questions.

Bath additives and prevention: two “no benefit” findings. The BATHE Trial (Santer et al., BMJ 2018) randomised 483 children aged 1–11 to emollient bath additives or none for 12 months, on top of standard leave-on emollients and soap substitutes. The difference in POEM score was 0.41 points, far below the 3-point minimal clinically important difference, and there was no gain in secondary or cost outcomes. Leave-on emollients and soap substitutes are what matter. Emollients also do not prevent eczema. In the BEEP Trial (Chalmers et al., Lancet 2020), 1,394 high-risk newborns given daily emollient for a year had about the same eczema rate at age 2 as controls (23% vs 25%; aRR 0.95). Skin infections were more frequent in the emollient group (IRR 1.55). The 2022 Cochrane review on infant skin care (Kelleher et al.; 33 RCTs, 25,827 infants) concluded that such interventions probably do not prevent eczema (RR 1.03, moderate certainty), probably increase skin infection (RR 1.33), and may increase Food Allergy (RR 2.53, low certainty). This applies to prevention in healthy babies, not to treating a toddler who already has eczema.

BATHE Trial [contradicts] Emollient Bath Additives BEEP Trial [contradicts] Emollient Therapy Emollient Therapy [relates] Food Allergy

Toddler safety. Adverse effects are usually mild: stinging, burning, itch and redness (Cochrane 2017), folliculitis and acne-like rashes (NHS). In the BEE trial, adverse events were similar across types (35–40%), but stinging was less common with ointments (9%) than with lotions (20%), creams (17%) or gels (19%). Aqueous Cream is no longer recommended as a leave-on emollient because its Sodium Lauryl Sulfate content irritates the skin. In one audit it caused immediate reactions in 56% of child exposures. Parents should use non-slip mats in the bath, and must keep children and fabrics away from flames (Emollient Fire Risk). NICE also notes that Olive Oil, used as a home skin remedy in some cultures, is likely to harm a child’s skin. Evidence: anecdotal. A parent in the BEE trial said the trial helped her find a moisturiser her daughter had never used before, which kept her skin in good condition “for the longest time”. She now keeps separate emollients for everyday use, flare days and washing.

Aqueous Cream [worsens] Atopic Dermatitis Sodium Lauryl Sulfate [part-of] Aqueous Cream Emollient Therapy [relates] Emollient Fire Risk NICE [opposes] Olive Oil

Fire risk from emollient residue on fabric

The MHRA (2018) warns that clothing, bedding and dressings with dried emollient residue ignite quickly and burn fiercely. This applies to all paraffin-containing emollients, whatever the paraffin percentage, and the risk cannot be ruled out for paraffin-free ones. Washing at high temperatures reduces the residue but does not remove it. Keep children and their clothing and bedding away from open flames, heaters and cigarettes.

Fragrance and stinging on broken skin

Use unperfumed emollients only (NICE QS44). If a product stings or burns and the feeling does not settle, stop using it and try a different type. Stinging is common with every type.

What parents report (evidence: anecdotal). Parents most often describe the turning point as using far more emollient than before. “When you think you’ve overdone it, apply more” (an allergist’s advice relayed on r/beyondthebump). Parents layer it as cream then petrolatum, and some say cheap store-brand cream works as well as premium brands (r/Parenting). Product preference varies a lot, and some UK parents find paraffin-based prescription emollients irritating (Mumsnet). See Parent Experiences.

Emollient Therapy [relates] Parent Experiences

Connections

• Atopic Dermatitis — treats (first-line, always used), source: NICE QS44
• Topical Corticosteroids — used together; emollients reduce steroid need; leave 20–30 min between them, source: Cochrane 2017; NHS
• Soap Substitutes — part of emollient regimen, source: NHS; BATHE
• Emollient Bath Additives — no added benefit, source: BATHE (BMJ 2018)
• BEE Trial — no emollient type superior, source: Lancet Child Adolesc Health 2022
• BEEP Trial — no prevention benefit; more infections, source: Lancet 2020
• Cochrane — 2017 review supports treatment; 2022 review no prevention benefit, source: CD012119; CD013534
• Food Allergy — infant skin-care may increase risk (low certainty), source: Cochrane 2022
• skin barrier — emollients reduce water loss, source: Nursing in Practice
• Aqueous Cream — not recommended as leave-on, source: MHRA 2013
• Sodium Lauryl Sulfate — irritant in aqueous cream, source: MHRA 2013
• Emollient Fire Risk — residue on fabric accelerates fire, source: MHRA 2018
• MHRA — safety regulator issuing warnings, source: MHRA DSU
• NICE — sets 250–500 g/week standard, source: NICE QS44
• Colloidal Oatmeal — oat moisturisers: fewer flares, more adverse events, source: Cochrane 2017
• Olive Oil — NICE says likely harmful to child skin, source: NICE QS44
• Herbal and Home Remedies for Eczema — Track A home-remedy comparator, source: Vaughn 2018; AAP
• Soak and Seal — apply emollient within ~3 min of bathing to damp skin, source: AAD; Medscape
• Urea Creams — urea emollients sting more than ceramide creams in children, source: Ho et al. 2020
• Ceramides — ceramide-based creams least irritating on excoriated skin, source: Ho et al. 2020
• No Moisture Therapy — online TSW regimen that stops emollients; untested, source: Zhu Cureus 2025
• Allergic Contact Dermatitis — emollient ingredients (lanolin, CAPB, propylene glycol) are common paediatric contact allergens, source: Tam & Yu 2022
• Cost of Eczema Care — cheapest acceptable emollient; main US out-of-pocket item, source: PrescQIPP B76; Chovatiya 2023
• Parent Experiences — parent reports (anecdotal), source: round-10 forum threads
• AAD Pediatric Guideline 2026 — strong rec (moderate certainty); no specific product preferred; avoid plant-based additives, source: JAAD 2026