A Community-based Assessment of Skin Care, Allergies, and Eczema

AD affects over 9 million children in the U.S. and ranks first among all skin conditions in global disability burden. AD often heralds the development of several comorbidities including asthma, food allergy, skin infections and neurodevelopmental disorders. Because of the significant socioeconomic impact of atopic dermatitis and its effect on the quality of life of children and families, there have been decades of research focused on prevention with limited success. Recent advances in cutaneous biology identify epidermal defects and skin barrier dysfunction to be the key initiators of atopic dermatitis and possibly allergic sensitization. Our central hypothesis is that emollient therapy from birth can prevent the development of AD. The findings of this trial will support the development of evidence-based skin care clinical guidelines for infants that currently do not exist. Recently, our international multi-centered clinical trial found enhancing early skin barrier function with daily emollient use from birth significantly reduces the risk of AD development in high-risk populations by 50%. With CASCADE, we extend this work into the community setting and into newborns unselected for risk, so results will be immediately applicable to the population at large and will establish a new standard of care for all newborns.

The specific aims are as follows:

1. Perform a community-based pragmatic randomized controlled trial investigating whether daily full-body emollient application starting in the first 2 months of life prevents atopic dermatitis in a real-world setting. The population for this trial consists of newborns between 0-2monthsof age, not selected for risk. Recruitment of families will occur during the course of routine care within primary care offices that are members of practice-based research networks(PBRNs).The intervention includes general skin care recommendations plus full-body daily lipid-rich emollient use. The control population will receive general skin care advice only and refrain from daily emollient use. The primary outcome will be the cumulative incidence of atopic dermatitis at age 24 months as determined by blinded clinicians trained in the diagnosis of AD. Key secondary clinical outcomes include time to disease onset and incidence of self-reported food allergy and wheeze using parental questionnaires.
2. As an exploratory aim, determine whether a family history of allergic disease and key early life exposures such as pet ownership modify the preventive effect of emollient therapy on atopic dermatitis. While the primary objective of this clinical trial is to determine the effectiveness of an emollient intervention in a real-world setting, data will be gathered on allergy history in the family and pet ownership-variables that may modify the effect of emollient therapy. Future implementation studies may target subpopulations found most likely to benefit from emollient intervention.

Twenty-five primary care clinics that participate in PBRNs from Oregon, Colorado, Wisconsin and North Carolina are the setting for the study protocol. The expected results from this project would represent a major public health breakthrough with the potential for reducing the atopic disease burden on a global scale.

• Participant choice of over-the-counter emollients: Vaseline, Vanicream, CeraVe Healing Ointment, CeraVe cream, Cetaphil cream (Other): Lipid-rich emollient serving as skin barrier

Primary outcomes

• Provider-diagnosed Atopic Dermatitis [up to 24 months]: The cumulative incidence of AD as recorded in health records. Trained clinicians will assess for AD at each clinic visit and record in the health record.

Secondary outcomes

• Parent Report of Atopic Dermatitis [up to 24 months]: Parent or guardian reports that a clinician has diagnosed their child with atopic dermatitis (eczema) at any quarterly contact up to 24 months of age.
• Atopic Dermatitis by UK Working Party Criteria [up to 24 months]: Parental report of AD using UK Working Party criteria. Parent responds "yes" to all parts of a modified version of the UK Working Party criteria at 12 and/or 24 month. Criteria include an itchy rash in flexural areas, generally dry skin, and asthma or hay fever in a first-degree relative.
• Atopic Dermatitis by Children's Eczema Questionnaire [up to 24 months]: AD as diagnosed by the Children's Eczema Questionnaire (CEQ). Parent response to 3 CEQ questions is consistent with AD at 12 and/or 24 months of age.
• Atopic Dermatitis With Prescription or Over-the-counter Therapies in Chart [up to 24 months]: Cumulative incidence of provider-diagnosed AD requiring prescription or over-the-counter therapies from chart review. Health records at primary care practice includes both a diagnosis of AD and prescription and/or over-the-counter (OTC) therapies. Prescription therapies could be steroids, calcineurin inhibitors, crisaborole, or antibacterials. OTC therapies could be steroids or antihistamines.
• Atopic Dermatitis With or Without Prescription or Over-the-counter Therapies in Chart (Ordinal) [Up to 24 months]: Ordinal coding of diagnosis of atopic dermatitis (eczema) in primary care health records, coded as none, eczema without prescription or over-the-counter (OTC) topical therapies, eczema with OTC only, or eczema with prescription therapies. Prescription therapies could be steroids, calcineurin inhibitors, crisaborole, or antibacterials. OTC therapies could be steroids or antihistamines.
• Prescribed or Over-the-counter Topical Skin Medication by Parent Report [up to 24 months]: Ordinal formulation of parent report: no AD, AD not treated with steroidal or non-steroidal cream or ointment ("therapy"), AD treated with over-the-counter (OTC) therapy, AD treated with prescription therapy. AD could be reported on annual questionnaires or quarterly contacts. Therapies reported on annual questionnaires.
• Skin Infections Diagnosed and Recorded in Chart Review [up to 24 months]: Chart outcome for provider diagnosis or medications associated with skin infections, including topical antibiotics. Skin infection diagnoses include impetigo, candida, wart/verruca, molluscum, or herpes simplex.
• Provider-diagnosed Asthma [up to 24 months]: Health records at primary care practice include at least one diagnosis of asthma.
• Severity of AD Symptoms Using POEM [12 months of age]: Patient-Oriented Eczema Measure (POEM) score, elicited from families of infants who reported AD diagnosis at this or any previous contact or whose CEQ response indicated AD. The POEM has seven items and ranges from 0 to 28, with higher scores reflecting more severe symptoms of AD.
• Severity of AD Symptoms Using POEM [24 months of age]: Patient-Oriented Eczema Measure (POEM) score, elicited from families of infants who reported AD diagnosis at this or any previous contact or whose CEQ response indicated AD. The POEM has seven items and ranges from 0 to 28, with higher scores reflecting more severe symptoms of AD.
• Severity of AD Symptoms Using IDQoL [12 months]: Symptom severity as reflected by the Infant Dermatology Quality of Life Instrument (IDQoL) elicited from families of infants who reported AD diagnosis at this or any previous contact or whose CEQ response indicated AD. The IDQoL has 12 items and ranges from 0-37 with higher scores reflecting greater adverse effect of AD on quality of life
• Severity of AD Symptoms Using IDQoL [24 months]: Symptom severity as reflected by the Infant Dermatology Quality of Life Instrument (IDQoL) elicited from families of infants who reported AD diagnosis at this or any previous contact or whose CEQ response indicated AD. The IDQoL has 12 items and ranges from 0-37 with higher scores reflecting greater adverse effect of AD on quality of life
• Food Allergy Symptoms [12 months, 24 months or both]: Parent reports immediate food allergy reaction in child at 12- or 24-month questionnaire, or both.
• Food Allergy Diagnosis With Positive Test [up to 24 months]: Parent reports a provider diagnosis of and a positive test for food allergy at 12- or 24-month questionnaire, or both.
• Primary Outcome of Provider-diagnosed Atopic Dermatitis [up to 12 months]: Diagnosis of atopic dermatitis (eczema) recorded by primary care providers in health records up to 12 months of age (rather than 24 months).
• Provider-diagnosed Atopic Dermatitis at 18 Months [up to 18 months]: Diagnosis of atopic dermatitis (eczema) recorded by primary care providers in health records up to 18 months of age.

Other outcomes

• Provider-diagnosed Atopic Dermatitis - Low-risk Population [up to 24 months]: Subgroup population: In the subgroup of participants who did not report atopic dermatitis in a first-degree relative, diagnosis of atopic dermatitis (eczema) recorded by primary care providers in health records
• Provider-diagnosed Atopic Dermatitis - High-risk Population [up to 24 months]: Subgroup population: In the subgroup of participants who reported atopic dermatitis in a first-degree relative, diagnosis of atopic dermatitis (eczema) recorded by primary care providers in health records

Sex: All, ages: 1 Day to 63 Days, accepts healthy volunteers

Inclusion Criteria:

* Parent can provide electronic signed and dated informed consent form.
* Parent is willing and able to comply with all study procedures for the duration of the study.
* Parent is a primary caretaker of an infant 0 to 2 months of age.
* Parent is 18 years of age or older at time of consent.
* Parent can speak, read, and write in English or Spanish.
* Parent has a valid e-mail address or phone that can receive text messages
* Parent has reliable access to the internet.
* Infant is a patient of a participating Meta-LARC clinic site at the time of consent.

Exclusion Criteria:

* Infant was born at less than 25 weeks gestational age.
* Infant has established eczema as diagnosed by the primary healthcare provider at clinic site of enrollment per parent report.
* Infant has known adverse reaction to petrolatum-based emollients.
* Infant has an immunodeficiency genetic syndrome such as Wiskott-Aldrich Syndrome or Severe Combined Immunodeficiency Syndrome.
* Infant has extremely low birth weight (less than 1000g or 2.2 lbs at birth).
* Infant has a sibling enrolled in the study.
* Parent is unwilling or unable to comply with study procedures.

Participant flow

Outcome results

• Provider-diagnosed Atopic Dermatitis (Primary), Number, Participants with imputed values: Daily Emollient 217.7; Natural Skin 268.5 (p 0.019)
• Parent Report of Atopic Dermatitis (Secondary), Number, Participants with imputed values: Daily Emollient 161.1; Natural Skin 219.1 (p 0.002)
• Atopic Dermatitis by UK Working Party Criteria (Secondary), Number, Participants with imputed values: Daily Emollient 72.3; Natural Skin 83.1 (p 0.323)
• Atopic Dermatitis by Children's Eczema Questionnaire (Secondary), Number, Participants with imputed values: Daily Emollient 156.9; Natural Skin 195.3 (p 0.044)
• Atopic Dermatitis With Prescription or Over-the-counter Therapies in Chart (Secondary), Number, Participants with imputed values: Daily Emollient 116.5; Natural Skin 179.8 (p 0.0004)
• Atopic Dermatitis With or Without Prescription or Over-the-counter Therapies in Chart (Ordinal) (Secondary), Number, Participants with imputed values: Daily Emollient 385.3; Natural Skin 356.5 (p 0.004)
• Prescribed or Over-the-counter Topical Skin Medication by Parent Report (Secondary), Number, participants: Daily Emollient 410; Natural Skin 364 (p 0.013)
• Skin Infections Diagnosed and Recorded in Chart Review (Secondary), Count of participants, Participants: Daily Emollient 101; Natural Skin 107 (p 0.509)
• Provider-diagnosed Asthma (Secondary), Number, participants: Daily Emollient 14; Natural Skin 13 (p 0.900)
• Severity of AD Symptoms Using POEM (Secondary), Median, score on a scale: Daily Emollient 3 (1 to 7); Natural Skin 2 (0 to 5) (p 0.064)
• Severity of AD Symptoms Using POEM (Secondary), Median, score on a scale: Daily Emollient 2 (0 to 5); Natural Skin 1 (0 to 4) (p 0.007)
• Severity of AD Symptoms Using IDQoL (Secondary), Median, score on a scale: Daily Emollient 4 (2 to 7); Natural Skin 4 (1 to 6) (p 0.070)
• Severity of AD Symptoms Using IDQoL (Secondary), Median, score on a scale: Daily Emollient 3 (1.5 to 6); Natural Skin 3 (1 to 5) (p 0.085)
• Food Allergy Symptoms (Secondary), Number, participants: Daily Emollient 59; Natural Skin 77 (p 0.079)
• Food Allergy Diagnosis With Positive Test (Secondary), Number, participants: Daily Emollient 16; Natural Skin 18 (p 0.669)
• Primary Outcome of Provider-diagnosed Atopic Dermatitis (Secondary), Count of participants, Participants: Daily Emollient 115; Natural Skin 151 (p 0.013)
• Provider-diagnosed Atopic Dermatitis at 18 Months (Secondary), Count of participants, Participants: Daily Emollient 154; Natural Skin 196 (p 0.009)
• Provider-diagnosed Atopic Dermatitis - Low-risk Population (Other pre specified), Number, Participants with imputed values: Daily Emollient 102.1; Natural Skin 139.7 (p 0.012)
• Provider-diagnosed Atopic Dermatitis - High-risk Population (Other pre specified), Number, Participants with imputed values: Daily Emollient 115.7; Natural Skin 128.7 (p 0.303)

Adverse events

Time frame: 2 years (enrollment through 24 months +/- 3 months)

Serious adverse events by term

Other adverse events by term

• Results publication: Simpson EL, Michaels LC, Ramsey K, Fagnan LJ, Nease DE, Henningfield M, Dolor RJ, Lapidus J, Martinez-Ziegenfuss X, Vu A, Ferrara L, Zuckerman KE, Morris CD, Williams HC; CASCADE Consortium. Emollients to Prevent Pediatric Eczema: A Randomized Clinical Trial. JAMA Dermatol. 2025 Jul 23;161(9):957-65. doi: 10.1001/jamadermatol.2025.2357. Online ahead of print. PMID 40699587
• Results publication: Eichner B, Michaels LAC, Branca K, Ramsey K, Mitchell J, Morris CD, Fagnan LJ, Dolor RJ, Elder N, Hahn DL, Nease DE, Lapidus J, Cibotti R, Block J, Simpson EL. A Community-based Assessment of Skin Care, Allergies, and Eczema (CASCADE): an atopic dermatitis primary prevention study using emollients-protocol for a randomized controlled trial. Trials. 2020 Mar 4;21(1):243. doi: 10.1186/s13063-020-4150-5. PMID 32131885

• Study Protocol (PDF, 2021-06-04)
• Statistical Analysis Plan (PDF, 2023-04-18)

• Eric Simpson, MD, Principal investigator, Oregon Health and Science University

NIH grants: R01AR071057