Adverse Effects of Moisturizers Should Be Considered in Eczema Studies—Reply

We thank Nedorost and Scheman for their interest in the CASCADE trial1 and are pleased to address their concerns. We appreciate the authors’ attention to the potential for allergic contact dermatitis in our trial; however, we respectfully differ in our interpretation of certain points regarding the etiology of atopic dermatitis (AD) and the role of emollients in its management. The authors posit that both AD and allergic contact dermatitis (ACD) result from irritation of the skin from rapid water evaporation, leading to the development of type II inflammation. While water exposure can harm the skin barrier, prevailing scientific evidence suggests the cause of AD, in contrast to ACD, involves complex interactions between genetic susceptibility (85% concordance in twin studies) and environmental exposures involving both the skin barrier and exaggerated immune responses.