DEAR EDITOR, It is hypothesized that the impaired skin barrier in atopic dermatitis (AD) allows the immune system to be exposed to environmental allergens, resulting in sensitization and allergic disease. 1 Two small trials recently found that routine use of emollients reduced the incidence of AD during the active treatment period by approximately half. 2, 3 It remains unknown whether prophylactic use of emollients can prevent the development of AD beyond the treatment period (as opposed simply to delaying its onset) or whether this reduction in AD leads to a reduced risk of allergic sensitization. The previous trials in this area have used standard emollients. 2, 3 In this trial, we chose a ceramide-dominant emollient (EpiCeramTM; PuraCap Pharmaceutical LLC, South Plainfield, NJ, USA), as it may provide greater preventive effects. 4 Skin affected by AD is deficient in ceramides. 5

EpiCeram has been formulated to contain physiological ratios of ceramides, cholesterol and free fatty acids, and has a slightly acidic pH (540), which aids the production and secretion of ceramides by the skin. 6 Acidic emollients have been shown to help prevent AD and airway inflammation in a murine model. 7 We have previously demonstrated parent compliance, and initial evidence of safety, for use of EpiCeram for AD prevention in neonates. 8