Key learning points:
– Skin cleansing and washing is an essential component of complete emollient therapy
– Patients should be given a choice of emollient wash products that suit their skin
– Nurses are well placed to advise patients with common chronic dermatological conditions on skin care
Adults and children with common chronic dermatological conditions and symptoms of dry skin need to be aware of the principles of skin cleansing for dermatological conditions, to aid in skin barrier repair and help prevent acute flares. This article will focus on skin cleansing, with particular reference to washing for patients with common dermatological conditions, including eczema, psoriasis and ichthyosis. Nurses will encounter patients with these skin conditions frequently; and will be asked for advice on general skin care, including cleansing and washing.
Dry skin – a symptom of chronic dermatological conditions
Dry skin, is a major symptom of chronic skin conditions, including eczema, psoriasis and ichthyosis. Dry skin causes flaking, scaling, fissures and physical discomfort; shedding skin can also cause embarrassment and psychological distress. In dermatological conditions, dry skin is usually due to genetic factors, which alter the skin barrier and cause transepidermal water loss (TEWL) and a deficit in natural moisturising factors (NMFs). Dry skin often leads to itchy skin, which can become a vicious itch-scratch cycle.1 This is often described in eczema, but occurs in all dry and irritated skin. The physical symptoms of psoriasis include inflamed, thick, scaly, itchy plaques; constant skin flaking; cracked and painful skin fissures, which may bleed.2 Dry and scaly skin is pronounced in ichthyosis, but an itch is not a problem.3
In atopic eczema, the skin barrier is defective causing dry and eczematous skin, this is influenced by genetic changes in structural proteins, filaggrin and protease genes. These include decreased levels of natural moisturising factors (NMFs) in the skin which lead to a reduction in the water retaining capacity of the skin and breakdown of lipid lamellae from the corneocytes in the stratum cornum, which causes skin barrier breakdown and transepidermal water loss (TEWL). As the corneocytes lose their water retaining capacity, they shrink and open cracks, permitting the penetration of irritants and allergies. Cytokines are also released, which causes inflammation, leading to acute eczema flares.2 Ichthoysis is an autosominal dominant disease, with two filaggrin mutation (R501X and 2282de14), which result in absence of filaggrin in kerinocytes.3
Natural moisturing factors
Natural moisturising factors (NMFs), e.g urea, glycerine, lactate and animo acids are decreased in dry skin conditions and this reduces the amount of water held within the corneocytes in the stratum corneum.4 NMFs are humectants (meaning they draw water out of the atmosphere to our skin) having a huge impact on the biochemical and mechanical properties of our skin. Having an adequate NMF level in our skin can prevent or reduce skin tightness, cracking, scaling, and flaking. In atopic eczema, levels of NMFs are reduced by up to 80%; this is due to changes in filargrin, protease and protease inhibitors and genes that determine the structure of the stratum ciromuem.4 In psoriasis NMFs are reduced by 40% and in ichthyoses there is a virtual absence of NMFs.3
Why is skin cleansing so important?
Dry skin in dermatological conditions needs to be treated on a daily ongoing basis. In order to maintain skin health and prevent skin barrier breakdown, each individual should have an emollient regimen consisting of emollient wash products (including bath and shower products), and leave-on creams and ointments. The National Institute for Health and Care Excellence (NICE) recommend that for all children with atopic eczema and for all dry skin diseases the most important treatment is complete emollient therapy: "everything that goes on the skin should be emollient based and all soaps replaced with emollient wash products".5
In psoriasis, emollients help ease itching, reduce scaling, softens cracked areas and assist the penetration of other topical treatments.6 In addition, well moisturised skin will mean that the skin is more supple and protected against damage; diminishing the risk for skin cracks and fissures and the consequent Koebner phenomenon.7 Emollients are the main treatment for ichthyosis and regular complete emollient therapy is recomemned.3
Practical aspects of skin cleansing and washing
Cleansing and washing with emollients is essential for complete emollient therapy. In order to maintain skin health and prevent skin barrier breakdown, each individual should have emollient regimen. Daily washing and bathing is recommended and most leave-on emollients (with the exception of ointment containing 50% white soft paraffin) can also be used as soap substitute. Some people may require one emollient product (using as a wash/bath product and leave-on emollient), others may require several products. Informed patient choice is very important when helping patients select emollient wash products, as what suits one individual does not always suit another or fit in with their lifestyle.
The following practical points give nurses an overview for advising patient with chronic dermatological conditions on cleansing and washing:
Avoiding irritants – soaps and detergents
Soap is made of a combination of natural oils or fats with sodium hydroxide, sodium lauryl sulphate or other strong alkaline solutions. Soap and detergent washes are thought to be effective cleansers but this can be out-weighed by negative effects of soap on skin lipids (fats) and pH. All soap (with the exception of sensitive skin cleansing bars) is typically alkaline, and has been shown to increase the pH of skin. Therefore all soaps, cosmetic washes, shower gels and bubble baths should be avoided.
Aqueous cream is often advised or prescribed as an alternative to soap. A consensus statement in 2013 stated that Aqueous cream BP should not be prescribed or even used as a soap substitute. Dermatologists have been aware of the irritant effects of sodium lauryl sulphate (SLS); clinical studies have confirmed that Aqueous cream weakens the skin barrier and increases TEWL, as SLS is a harsh surfactant.8 The medicines and healthcare products regulatory agency (MHRA) have a drug safety update for aqueous ceam, with a warning on potential local skin irritation and advise that patients with eczema should be warned of the risk during consultation.9
Bath or shower
Daily baths or showers remove dirt and skin debris, which could cause infection. Emollient bath and shower oils and warm water, should be used as they will clean and hydrate the skin, coating it with a film of oil to trap moisture. Bath oils or emollients washes can be added to the bath water or directly to the skin in the shower. Some bath oils contain lauromacrogols, which is an anti-itch ingredient that may provide some added comfort and relief for very itchy skin conditions.
Sometimes when skin is very dry, water may sting, so advise leave-on emollient to be applied all over before getting into the bath or shower and then gently wash it off in the water or under the shower. It is important to be aware of safety aspects and tell patients that bath oils can make surfaces extremely slippery, so always use a bath/shower mat. A bath or shower is a personal choice, and depends on facilities in the home. If emollients are used showers can be a good way to moisturise skin; however soaking in an emollient bath can also be very soothing.
There is a lack of clinical evidence demonstrating that bath/shower products are either effective or more effective than simply using a soap substitute within the bath or shower. It is believed that using a bath/shower product ensures that the emollient is applied to a larger area of skin. However, bath/shower products have a much lower contact time with the skin than a leave-on emollient and it is therefore difficult to establish their effectiveness.10
Children with dry skin can sometimes find it upsetting not to be able to have bubble baths. Try and make bath times fun, depending on the child’s age, perhaps suggest parents buy some special new bath time toys or bath crayons to draw pictures on the bath.
These are used instead of soap bars or liquid soap to cleanse the skin. Emollient soap substitutes do not foam, so they may take a little while to get used to. However, it is not essential to have bubbles to clean the skin and emollient washing creams are very effective cleansers.
The definition of a soap-free product is one that is made without the combination of fats and alkaline. In soap-free products, emulsifying agents break up fats to cleanse the skin. Therefore a regular leave-on emollient can be used as a soap substitute or a product designed specifically for washing can be used.
The hands are particularly at risk, as they are washed more frequently and each wash degreases the skin. Detergent-based liquid soaps/cleansers and perfumed products should also be avoided as they tend to irritate dry skin, so advise patients to use emollient or soap free hand washes; or simply carry round a small pot for their leave-on emollient to use for washing their hands, during daily activities.
Hard /soft water and water softeners
Hard water has an alkaline pH and it has been shown that rinsing with even slightly alkaline tap water can raise skin pH for several hours, and causes irritancy and dry skin.11 Patients may ask if installing a water softener may be helpful for dry skin.
The current evidence base for water softeners is based around the softened water eczema trial (SWET) study. This study which was carried out on eczema patients hoped to show that water softeners would be effective and help dry skin in eczema. However, the trial showed no objective difference in outcomes between the people whose homes were fitted with a water softener and those without.
Hard water can be an irritant for people, due to water pH and its impact on the skin barrier. This is because hard water is slightly alkaline; and a pH above neutral can affect the skin barrier and lead to skin barrier breakdown. If you add in soap and bubble baths, the pH levels of the skin rise further and cause more skin barrier breakdown and irritation. One reason why the SWET trial had an unexpected outcome (no evidence of benefit) is thought to be because the type of water softener used – ion exchange does not address water pH.
Due to the impaired skin barrier all dry skin conditions can be susceptible to infection. Infection is a complicating factor for eczema, due to a higher level of staphylocoocus aureus on the skin of people with atopic eczema.
NICE recommends that antiseptics (bath oils and emollient washes) are a helpful adjunct for decreasing bacterial load in cases of recurrent infected eczema, however, long-term continual use should be avoided.5 NICE recommends that eczema infected with staphylocoocus aureus should be treated with a one to two week course of systemic antibiotics. Localised areas of bacterial infection can be treated with topical antibiotics including those combined with topical steroids for a maximum of 14 days.5
Washing and cleansing in dermatological conditions is a very important aspect of general skin care. Using emollient with products or leave-on emollients as soap substitutes, as part of complete emollient therapy is very beneficial in helping to address dry skin symptoms and help with the constant repair of the skin barrier. Patients with dermatological conditions will benefit from nurses providing advice and practical tips on washing and cleansing.
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9. MRHA (2013) Drug safety warning: Aqueous cream may cause skin irritation. MRHA. www.gov.uk/drug-safety-update/aqueous-cream-may-cause-skin-irritation (accessed 24 June 2015)
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12. Thomas K, Koller K, Dean T et al A multicentre randomised controlled trial and economic evaluation of ion-exchange water softeners for the treatment of eczema in children: the softened water eczema trial (SWET). Health Technology Assessment 2011. Vol 15(9): 1-156.
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