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Managing common dry skin conditions in primary care

Managing common dry skin conditions in primary care

 - Dry skin is a major symptom of most chronic inflammatory skin conditions
 - Daily complete emollient therapy is essential for managing dry skin
 - Patient choice is a very important factor when advising on emollient therapy
Dry skin is a major symptom for many chronic inflammatory skin conditions for all age groups. Dry, lipid deficient skin occurs over the age of 60 years as a result of ageing, which can lead to the development of eczematous skin conditions for the older person.1 Preventing dry skin is essential for maintaining healthy skin; two out of three skin conditions in older people could be prevented with adequate skin care. This article will give an overview of dry skin conditions and management with emollient therapy. 
Why does skin become dry?
Dry skin occurs as a result of the impairment of the hypolipid system (startum corneum) - a natural protective covering consisting of water, lipids and natural moisturising factors (NMFs). In normal skin, the healthy barrier is smooth, supple and resilient, preventing water loss from the body and the penetration of irritants and allergens.3 When skin is dry, particularly in eczematous skin conditions, there are several changes, which lead to skin barrier breakdown. Natural moisturising factors (NMFs) are acids, which inhibit protease activity thereby maintaining a low skin pH on the surface of the stratum cornuem.3 
NMFs are decreased in dry skin and this reduces the amount of water held within the corneocytes in the stratum corneum; in addition the lipid lamellae surrounding the corneocytes also breaks down. In atopic eczema, levels of NMFs are reduced by up to 80%; this is due to changes in filargrin, protease and protease inhibitors, genes that determine the structure of the stratum ciromuem.4 In order to visualise skin barrier breakdown, imagine a brick wall, with crumbly mortar and broken bricks, open to the elements and unable to remain waterproof.3 In psoriasis, dry skin includes scaling and flaking, due to cell proliferation in psoriatic plaques.5
Skin ageing causes skin changes which may be intrinsic or extrinsic (sun damage, smoking, genetics). Intrinsic skin changes include a reduction in epidermal cell replacement, which halves by the seventh decade, and collagen formation, resulting in wrinkles, thin and fragile skin which is susceptible to breakdown and ulceration. The epidermis becomes thinner with age, with cells less evenly aligned, and a reduction in NMFs, leading to water loss. These changes reduce the skin’s barrier function, resulting in water loss, causing dry, scaly and itchy skin and a reduction in defense against bacterial, fungal and chemical irritants.6
Dry skin management
The most important treatment for all dry skin diseases is complete emollient therapy. Everything that goes on the skin should be emollient-based, and all soaps replaced with emollient wash products. Complete emollient therapy should consist of:
 - Emollient creams and ointments.
 - Emollient wash products.
 - Emollient bath and shower products.3,7
There is a wide range of emollient formulations available, on prescription and over the counter. Emollient formulations include bath oils, emollient washes, lotions, creams, gels and ointments. The words emollient and moisturiser are used interchangeably; recent consensus states that in dermatological therapy, the word emollients should be used as an inclusive term.1 The term ‘leave-on’ emollient is useful to distinguish between emollients for washing and moisturising. The British National Formulary includes over 60 emollients, which are also listed in the Nurse Prescribers’ Formulary for Community Practitioners.8
Emollients are essential, ongoing treatments for dry skin. They may be used by themselves to relieve dry skin or alongside other therapeutic treatments. A daily emollient routine is essential for treating and reducing dry skin, as a symptom of skin disease. In atopic eczema, emollients have been shown to reduce the amount of high-potency topical steroids.9 For psoriasis, emollients are considered adjuvant therapy, to be used alongside other topical or systemic interventions.10
Emollients treat dry skin by providing a surface film of lipids, increasing water in the stratum corneum which restores barrier function and helps prevent the entry of environmental agents or triggers.7 Leave-on emollients work in two ways: an occlusive effect, with lipids trapping water within the stratum corneum and reduce epidermal water loss; or by occluding with a humectant effect, attracting and holding water in the stratum corneum by the action of NMFs (for example urea and glycerol) and physiological lipids (for example ceramide) which are added ingredients in the emollient.3
Occlusive leave-on emollients may be lotions, creams or ointments. Lotions have a short emollient effect for dry skin, so would need to be applied every couple of hours. Creams contain more oil than lotions but still need to be applied every four hours. Lotions and creams are more cosmetically acceptable but with a shorter emollient effect than greasy ointments. Ointments trap more water into the stratum corneum and have a longer-lasting effect than creams. Humectant emollients are creams containing NMFs and can produce similar longer occlusive effects and rehydration as grease-based emollients.3
The wide choice of emollient products means that patients should be able to find and choose the emollients that suit their skin and that they themselves like. Some people may find individual product preservatives irritant, so several different emollients may need to be tried. Leave-on emollients should be applied after washing, prior to bedtime and at regular intervals to keep skin well hydrated. They should be smoothed into skin, not rubbed in, using a downward, gentle stroking motion following the direction of hair growth. Adults require at least 500g/per week and children at least 250g per week of ‘leave-on’ emollient to be prescribed and applied. Topical treatment should be applied to well moisturised skin (leaving a gap between applications).1
For washing, emollients should always be used and soaps and detergents avoided. Emollients can be used as soap substitutes to cleanse the skin, reducing staphylococcus aureus; further moisturising effects may be achieved by adding a bath additive to washing water.1 Some people may manage with one product for washing and moisturising, while others may require a selection of products, for example a bath oil or wash product, a cream emollient for the day and a greasy emollient for the night.
Aqueous cream should be avoided for all dry skin conditions, both as a leave-on and washing emollient. Aqueous cream contains 1% sodium lauryl sulphate (SLS), an anionic surfactant known to be very irritant. Aqueous cream has no therapeutic emollient qualities as it weakens the epidermal barrier and increases trans-epidermal water loss.11
Patient support and practical advice
Nurses need to advise patients on practical issues associated with using emollient therapy. A summary of points to include when educating patient about complete emollient therapy is included in Box 1. There are some safety issues to consider when advising patients on emollient use. Emollients used for washing may cause the bath or shower to become slippery, so a bath mat should always be used. There is a potential fire hazard with liquid paraffin-based emollients (emulsifying ointment or 50% white soft paraffin in 50% liquid paraffin); when in contact with a naked flame it could easily ignite clothing. The risk is greater when liquid paraffin is applied to large areas and patients should be told not to smoke and keep away from open fires.8
Emollients should be stored in cool environments away from heat sources. Formulations are not affected by cooling, which may make the emollient more soothing for very itchy or inflamed skin. Pump dispensers are less vulnerable to contamination.1 It is a good idea to decant cream and ointment from tubs into a small bowl and advise against putting fingers directly into a tub. Once opened, guidance suggests that cream in tubs may last three months and ointments may last for six months. As pump dispensers are closed units, it is assumed that pump dispensers are treated as tubs.1
This article has provided an overview on managing dry skin conditions with complete emollient therapy. Patient choice is a very important factor in dry skin management. However, healthcare professionals need to help patients make an informed choice based on the science of dry skin and different emollient formulations. 
1. Penzer R. Best practice in emollient therapy – a statement for health care professionals. Dermatological Nursing 2012;11(4):S4-S19.
3. Cork MJ, Danby S. Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing 2009;18(14):872-7.
4. Cork MJ, Robinson DA, Vasilopoulos Y. Epidermal barrier dysfunction in atopic dermatitis. In Rawlings AV, Leyden JJ (eds) Skin Moisturization (2nd Edition). New York: Informa Healthcare USA; 2009.
5. Fluhr J, Cavallotti C, Berardesca E. Emollients, moisturizers and keratoytic agents in psoriais. Clinical Dermatology 2008;19(4):387-92.
6. Millington GW, Graham-Brown RA. In Burns T, Breathnach S, Cox N, Griffiths C (eds). Rook’s Textbook of Dermatology (8th Edition). Vol 1, Chapter 8. Oxford: Wiley-Blackwell; 2010. 
7. Cork MJ. The importance of skin barrier function. Journal of Dermatology Treatment 1997;8:S7-13.
8. Joint Formulary Committee. Skin. British National Formulary. 2012;64:13.2. London: BMA and RPS Publishing; 2012.
9. Grimalt R, Mengeaud U, Cambazard F. The steroid sparing effect of emollient therapy in infants with atopic dermatitis: a randomised controlled study. Dermatology 2007;14(1):61-7.
10. Finaly AY. Emollients as an adjuvant therapy for psoriasis. Journal of Dermatology Treatment 1997;8:S25-27.
11. Cork MJ, Danby S. Aqueous cream damages the skin barrier. British Journal of Dermatology 2011;164(6):1179-80.

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