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You are a paediatric SHO, on a night shift. You are called to the ward to see a 6 year old girl, who cannot get to sleep because her eczema is too itchy. The nurses want you to prescribe an antihistamine, but you doubt the efficacy of this treatment. As it is a surprisingly quiet shift, you go off to do a literature search.
Structured clinical question
In children with atopic eczema [patient], does the use of oral antihistamines [intervention] reduce the incidence of itching [outcome]?
CLINICAL BOTTOM LINE
Oral antihistamines have not been shown to decrease symptoms of itch in children with atopic eczema.
We should endeavour to optimise conventional treatment with liberal use of emollients and appropriate strength of topical steroids, which is efficacious in reducing symptoms.
Search strategy and outcome
PubMed: search words—“atopic dermatitis” AND “chlorpheniramine” OR “antihistamines”.
Limits—English, human, child <18 years.
Searched without limit to child—unreasonable number of hits, all adult related.
Search outcome—14 papers, of which two were relevant.
SUMSearch—one paper, already retrieved by Pubmed.
See table 1.
Current teaching in the treatment of atopic dermatitis incorporates the use of oral antihistamines to eliminate itch. These are thought to work on the H1 receptor to decrease histamine release and therefore eliminate itch. In addition the older antihistamines have a sedative effect, encouraging a complete night’s sleep.
The study by La Rosa et al was a small study, with only 12 patients per group. It is therefore difficult to establish the statistical significance of their results. The authors did not provide the raw data, instead referring to isolated percentage changes which were difficult to interpret.
The Munday et al study was a more comprehensive study, with larger numbers. However, some of the patients were recruited from Poland and they had not received optimal eczema therapy prior to the onset of the trial. These patients then received steroid and emollient creams, so their improvement might have been a result of the improved eczema management, rather then the antihistamines. Despite this, there was still no difference between the two groups.
There are no good quality studies investigating the efficacy of oral antihistamines. Neither of the two studies reviewed showed any significant reduction in symptoms, nor did they show a statistical difference. We feel that the case was not proven either way for the use of antihistamines, but due to the flaws pointed out above, further trials are needed in children.