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The use of emollients for treating atopic eczema

Sandra Lawton
MSc RGN OND
ENB 393 RN(Child)
Nurse Consultant Dermatology
Queen's Medical Centre
University Hospital Nottingham

Atopic eczema can be a highly distressing condition; it affects a large number of people and is especially prevalent in children. It can be triggered by factors including animal hair, foodstuffs, house dust mite, bacteria or exposure to irritants. One of the most prominent clinical features in atopic eczema is widespread regions of dry itchy skin (see Figure 1).

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Atopic skin displays an impaired barrier function, an increase in transepidermal water loss (TEWL) and diminished water-binding properties, making the skin more susceptible to irritation and damage from scratching.(1) This article will focus on how emollients can be used effectively in the management of atopic eczema.

Factors affecting skin barrier function
The skin forms a biological barrier to the external environment, by preventing the penetration of irritants and allergens. It also prevents water loss and maintains internal homeostasis. Although certain eczematous conditions, such as atopic eczema, have a genetic component, there has been an increase in the prevalence of eczematous conditions, which suggests environmental factors may also contribute to loss of barrier function and lead to an exacerbation of the existing disease.(2)
Washing with conventional soap products that contain surfactants has a drying effect on the skin, removes lipids and reduces the thickness of the epidermis (stratum corneum).(2,3) The surface of the stratum corneum is covered by a hydrolipid film consisting of lipids from sebaceous gland secretions (sebum), water (perspiration), proteins and salts from sweat glands, and provides a protective acid coating.(4)
Cleansing products are designed to remove dirt and sweat, but also remove sebum and oils from the skin resulting in immediate afterwash tightness (AWT), dryness, barrier damage, redness, irritation and itch,(5) and therefore, for most skin disorders, may exacerbate the problem.(6)
Further repeated contact with irritants, such as detergents, solvents, acids and alkalis, water and wet foods, causes loss of skin lipids and drying of the epidermis. This is also affected by low humidity, air conditioning and extremes of temperature, which all induce profound changes in the epidermal proliferation and function, resulting in further inflammation.(2)

Emollients
Emollients play an important part in the treatment of all dry, scaling skin conditions. They have multiple pharmacological effects on the skin, but the most important of these is the moisturisation of the stratum corneum, which results from the occlusive effect of the emollient.(7) Applying an emollient provides a surface film of lipids and restores some of the barrier function. This oily layer traps the water under the stratum corneum, reduces TEWL and makes the skin soft and supple.(8) Emollients alter the physical properties of the stratum corneum, which increases its extensibility, pliability and plasticity. This is especially important in eczema as the abnormal and inflamed epidermis is more brittle and results in painful fissuring.(7)
Other less easily explained pharmacological activities include an anti-inflammatory effect, antimitotic effect and antipruritic effect.(7) Used regularly, emollients may reduce flare-ups of eczema and also have a direct anti-inflammatory effect, and they may reduce the need to use topical corticosteroids, known as a "steroid-sparing effect".(9)
 
Emollient choice
There is a lack of good-quality clinical trial evidence on the use of emollients. It is important that patients choose the most appropriate one; the best emollient is always the one they will actually use.
Issues often raised by patients include: smell, texture and consistency, how easy it is to apply, does it make their skin too shiny, packaging (tubes and pumps are popular), can the medication be used as a soap substitute/moisturiser, does it make their clothes greasy, and does the emollient sting?(4) Ideally, samples of emollients should be made available through the pharmacy; this provides an opportunity for nurses to demonstrate their use and allows the patients to choose a product. This can also avoid several different products being prescribed simultaneously, reducing costs and wasted prescriptions.(10)

Types of emollients and emollient consistency
Emollients come in a variety of forms and vehicles, such as creams, lotions, ointments, sprays, soap substitutes, bath additives, shower products and moisturisers. It is important that nurses are aware of these in order to help patients make an informed choice.(4)
Preparations may be light in texture with high water content or have a higher "grease" content. Light preparations are absorbed quickly and do not leave the skin feeling greasy, but have a shorter period of effectiveness and so more frequent applications are needed. More greasy preparations are more effective for very dry, fissured skin as they have a lower quantity of water and the effect is longer lasting.(10) Generally the more oily the preparation the better the emollient effect; however, the consistency has to be acceptable for the patient.(8)

Other ingredients
Emollients have added ingredients to keep them chemically stable, such as preservatives, and some are specifically marketed for their antiseptic and antipruritic effects.

Suitable packaging
It is often useful to supply emollients in tubes or encourage the patients to decant the product to a smaller container. Smaller containers are easier to carry around and thus encourage regular use during the day for washing and moisturising.(8,10) Products should not be shared and must be individually prescribed. Pump dispensers are preferable to prevent contamination with skin scales and bacteria; decanting into smaller pots or containers also reduces the risk of infection.(11)

Adequate supplies
Successful treatment depends on providing suitable quantities of emollient as well as appropriate product selection.
Prescribing sufficient quantities of emollient reinforces the need for regular application,(8) and the recommendation is 250g per week for children and 500g per week for adults.(12)

The patient's lifestyle
Emollient routines need to be realistic and achievable for the patient. Seasonal factors may influence the choice of product used: for example, during very hot, humid weather a less greasy emollient may be preferred, but during the winter months, when the central heating is on and the weather is very harsh, a greasier product may be used.
Patients may also prefer a less greasy product for daytime and a greasier product for nighttime use.

Cost
The cost of emollients varies considerably; if all the points listed are considered then the emollient of choice should be the one that is effective and that the patient finds acceptable and is prepared to use on a regular basis.(8)

Practical use of emollients

Skin cleansing
Bathing and cleansing the skin using emollients is the mainstay of any dry skin care routine. Cleansing removes old treatments and scale, and hydrates the skin and prevents further drying.(13) Frequency will depend on individual choice and disease severity. Frequency of bathing/showering and the length of time in the water can make a difference to the dryness of the skin. Ideally a bath should be about 10 minutes long, and no longer than 20 minutes, otherwise the epidermis becomes waterlogged, the hydrolipid film is weakened, permeability increases and the skin becomes drier.(10)
If a bath oil is used it should be used carefully, observing the recommended dose, as irritant reactions can occur if an active agent, such as antiseptic, is present.(10) If a soap substitute is used it may be applied to the skin before washing, bathing or showering or used on a soft cloth.
Care must be taken, however, as these products will make the environment very slippery. Using a nonslip mat in the bath or shower and protecting the floor with a large towel or sheet will help prevent accidents.
After using emollients the bath or shower should be cleaned well with hot soapy water, then rinsed and dried to prevent slipping. This will also help to prevent a buildup of dead skin scales and old treatments, which increase the risk of infection and can potentially block drains, especially if very greasy products are used.(4) After cleansing, the skin needs to be carefully dried, preferably by patting - vigorous rubbing may damage the delicate or dry skin and aggravate itchy skin. It is important at this stage to apply an emollient to prevent further water loss; these should be applied gently to prevent further irritation and damage to the skin.(14)

Moisturising
Ideally emollients should be used at least twice daily, but this may increase depending on the severity of the skin condition, dryness and type of product used. The application should be light - a glisten on the skin, not a thick heavy application that damages clothing and furniture and often makes the patient too hot and itchy.(4) Emollients should be applied in smooth downward strokes, in the direction of hair growth, to reduce the risk of folliculitis (inflamed or infected follicles).(14) Usage will also need to be increased, especially on exposed areas such as the hands and face.(10)
Emollients should be applied to exposed areas of the skin before coming into contact with potential irritants, such as cold weather, swimming, wet or dusty activities, and certain foods and drinks. Applying a greasy emollient will protect the skin, which should be washed after exposure to the irritants and the emollient then reapplied.(13) This is especially important in babies and children with atopic eczema and adults whose occupations increase exposure to irritants.
 
Using other topical medications
Patients often become confused when using other treatments alongside an emollient. There is no scientific evidence to define the best order,(15) but best practice generally advises the use of emollients after bathing and allowing at least 30-60 minutes between topical medications, as this prevents dilution and the unknown effects on the stability and absorption of the medication.(16)
Emollients have so many beneficial actions, but they do have some adverse effects as well, the most frequent one being stinging and occasionally an allergic contact reaction to one of the constituents.(7) It is therefore essential to have a wide range of emollients available and the opportunity to change if stinging occurs.

Conclusion
The regular use of emollients for the management of atopic eczema can make a significant difference to the individual involved and the condition of their skin. Patients should always be involved in their skincare plan, which should be realistic and achievable for all those involved.

References

  1. Harding CR. Dermatol Ther 2004;17:6-15.
  2. Holden C, et al. J Dermatol Treat 2002;13:103-6.
  3. Cork MJ. J Dermatol Treat 1997;8(S1):7-13.
  4. Lawton S. Nurs Stand 2004;19(7):44-50.
  5. Anantha- padmanabhan KP, Moore DJ, Subramanyan K, Misra M, Meyer F. Dermatol Ther 2004;17:16-25.
  6. Subramanyan K. Dermatol Ther 2004;17:26-34.
  7. Mark R. J Dermatol Treat 1997;8(1):15-8.
  8. MeReC. The use of emollients in dry skin conditions. MeReC Bull 1998;9(12):45-8.
  9. Cork MJ. Complete emollient therapy. In: The National Association of Fundholding Practices Official Year Book. Dunstable: BPC Waterlow; 1998.
  10. Peters J. Br J Community Nurs 2001;6:645-51.
  11. Davis R. Treatment issues relating to dermatology. In: Hughes E, Van Onselen J, editors. Dermatology nursing: practical guide. London: Churchill Livingstone; 2001.
  12. Primary Care Dermatology Society. Guidelines for the management of atopic eczema. London: PCDS; 2000.
  13. Lawton S. Eczema. In:Hughes E, Van Onselen J, editors. Dermatology nursing: practical guide. London: Churchill Livingstone; 2001. p. 151-69.
  14. Pringle F, Penzer R. Normal skin: its function and care. In: Penzer R, editor. Nursing care of the skin. London: Butterworth-Heinemann; 2002. p. 20-45.
  15. Britton J. J Community Nurs 2003;17(9):22-5.
  16. Highet A. Dermatol Pract 2002;10(6):12-5.

Resource
National Eczema Society
W:www.eczema.org