Key learning points:
- Dry skin in children is very common
- Emollients are first-line therapy for all dry skin symptoms and chronic skin conditions
- Primary care nurses have a role in recognising dry skin symptoms
Dry skin in children is due to developmental, environmental and pathological reasons. It may be transient, but for many children with a chronic inflammatory skin condition it will be a daily occurrence. Primary care nurses can recognise dry skin and give parents and carers correct advice.
Identifying dry skin conditions
Skin develops from 20 weeks gestation and in the first year, as skin is still developing, there are distinct differences between infant and adult skin. The stratum cornuem is up to 30% thinner in infants and has a higher rate of trans-epidermal water loss (TEWL), which reduces barrier integrity, resulting in dry skin.1 Infant skin has a higher pH (6.34-7.5). Mild inflammation is normal in infants and seen in transient infant skin conditions, eg toxic erythema.2 Atopic eczema in infants is also very common – 60% of all children with atopic eczema develop it in the first six months of life.3
Skin barrier dysfunction is likely to be central to the evolution of allergic responses, including food allergy in atopic patients with relevant environmental exposure.4 In infants, eczema usually develops on the face, where it can be severe, often wet and weepy (sometimes infected); and generalised in patches on the body. Often the nappy area is spared.5
The following are the most common dry skin conditions found in children.
Seborrhoeic dermatitis
Seborrhoeic dermatitis causes flaking, scaling and inflammation without itch. In infants, it presents as ‘cradle cap’, but the nappy area and flexures can be affected. This is usually a developmental condition due to overactivity of the sebum glands between three to eight months, when it disappears.6 The distinction between atopic and seborrhoeic eczema is not clear, and a recent study found that a higher number of infants with seborrhoeic dermatitis developed atopic eczema within a short space of time.7
Atopic eczema is a complex interaction between the environment and genes, with skin barrier and local systemic immune deregulation.8 The cardinal symptom of eczema is itch exacerbated by dry skin, which results in an itch-scratch-damage cycle, leading to ‘eczema flares’ of inflammation, weeping and crusting, often complicated by bacterial infection.5 Allergens and environmental allergies are related to all atopic conditions. An overactive immune response to environmental factors contributes to eczema flares.5
Keratosis pilaris
Keratosis pilaris is an epidermal disorder of skin kerinisation affecting the follicles, causing dry rough skin and a ‘goose bump’ texture. It is very common, developing in childhood, generally on the extensor surfaces of the upper arms, and it can worsen around puberty.9
Ichthyosis
There are several types of the genetic condition ichthyosis, which causes extremely dry, scaly and fissured skin. It is a life-long condition caused by genetic mutations in the epidermis and the most common type is ichthyosis vulgaris. The severity and extent of ichthyosis varies widely from mild dryness to extensive areas of thickened skin and scaling over the body, arms, legs and face. Palms and soles may be particularly thickened and cracked, and the scalp may shed scales like heavy dandruff.10
Psoriasis
Psoriasis is less common in children than adults, but around one-third of people with psoriasis will start developing symptoms before the age of 15.11 Psoriasis is a group of chronic, inflammatory and proliferative conditions of the skin with systemic manifestations in many organ systems. The skin lesions are red, scaly, sharply demarcated plaques, particularly over extensor skin surfaces and the scalp. Guttate psoriasis is more common in children and young adults and presents as a shower of small dry lesions diffusely over the body, often precipitated by a streptococcus pharyngitis in 60% of cases.12
Irritant dermatitis
Irritant dermatitis and dry skin can occur in all children, due to over-washing with soap and cleansers. Over-washing causes the pH of the skin to change. Water alone has a neutral pH of 7 and soaps are alkalis pH 7-12, which damage the skin barrier function and leave irritating carbonate acids on skin. Sebum is removed, facilitating TEWL and making the skin more permeable to chemicals, leading to dermatitis. Over-washing alters normal microbiome and dry skin is more prone to skin infection, for example Staphylococcus aureus resulting in impetigo.13
The skin barrier is easily compromised by the winter climate due to environmental (central heating, lack of humidity) and climatic factors (freezing temperatures, wind chill) causing dry skin, known as ‘winter skin’.14 When skin is dry, the skin barrier becomes less effective as decreased levels of natural moisturising factors (NMFs) in the skin lead to a reduction in the water-retaining capacity of the skin, shrinking and opening cracks, allowing for the penetration of irritants and allergies.15 In the summer months, dry skin can also be caused post sunburn or by irritation from sweating and swimming.
Lip-lick chelitis is a sucking irritant dermatitis, caused by dry skin on the lips and around the mouth. Lip-licking quickly becomes habit forming and can result in secondary infection. It can also be caused by dribbling, thumb sucking or as a direct result of chapping, especially in the winter.5
Risk factors and impact
All children will experience dry skin. Primary care nurses need to be vigilant in the early recognition of dry skin, and consider whether it is a transient symptom or the first sign of a chronic skin condition. The risk factors for children developing a chronic skin condition are high; 20% of children in the UK have atopic eczema,3 ichthyosis vulgaris can affect one in 250 children10 and the prevalence of psoriasis in children is 3–4%.12
The impact of dry skin symptoms and conditions on the child and family should not be underestimated. For example, in atopic eczema, quality of life can be affected. Sleep deprivation leads to tiredness, mood changes and impaired psychosocial functioning of the child and family, particularly at school and work. Embarrassment, comments, teasing and bullying frequently cause social isolation and may lead to depression or school avoidance. The child’s lifestyle is often limited, particularly in respect to clothing, holidays, staying with friends, owning pets, swimming or the ability to play or do sports.16
Latest treatment for dry skin conditions
- Oils in infant skin care
Olive oil is often a traditional choice in assisting baby massage (and for treating cradle cap), but there is evidence that high concentrations of oleic acid found in olive oil significantly damage the skin barrier and have the potential to both exacerbate existing problems and promote the development of atopic eczema.17 Using olive or sunflower oil on newborn babies’ skin damages the barrier that prevents water loss and blocks allergens and infections,18 but paraffin-based mineral oils have been found to be acceptable and not damaging to the skin barrier. Therefore, it would be prudent to avoid oils and use paraffin oil or emollients for managing cradle cap in infants with atopic eczema or a family history of atopy.
- Complete emollient therapy
Emollient therapy is an evolving area in terms of the increased understanding of the normal and abnormal skin barrier causing dry skin symptoms and new products representing more choice for patients. Dry skin symptoms in children should be treated first line with complete emollient therapy – the most important treatment for all dry skin diseases.19 Everything that goes on the skin should be emollient based and all soaps, detergents and skin products should be replaced with emollient wash, bath and shower products.19 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.19 Emollients soften the skin and reduce itch; used regularly to maintain skin hydration, they can reduce the frequency of flare-ups. Leave-on emollients may be lotions, creams, ointments or gels; they have either occlusive or additional humectant action. Emollients with occlusive effects trap water within the stratum corneum and reduce epidermal water loss. This effect may last for a few hours with emollient creams or longer with grease-based emollients.19
- Bathing and washing
Daily baths are recommended for children with atopic eczema, as dry skin requires hydration. Daily baths should be followed by moisturiser, along with gentle drying by patting, and the immediate application of a moisturiser to ‘seal’ in moisture. This process is known as ‘soak and smear’.20 Leave-on emollients can be used for washing (as soap substitutes) and applied after washing.
- Humectant emollients
Humectant-containing emollients are the latest range of leave-on emollient products. Humectant emollients have been shown to prevent TEWL for considerably longer than simple emollients. Some emollients also contain povidone, which leaves a microscopic membrane on the surface of the skin and extends the TEWL effect to at least 12 hours.21
- Ceramides
Newer emollients may contain ceramides, which are fats found naturally in the cell membrane of most living tissue and serve as part of the ‘glue’ that holds surface skin cells together. The skin’s ceramide levels naturally deplete with time, and with environmental exposures this may result in the skin becoming weakened and more sensitive to irritants such as detergents and environmental factors. People who have eczema or dry, irritated and sensitive skin have significantly fewer ceramides in their stratum corneum. Ceramides have been shown to be effective in reducing disease duration, symptoms and time to clearance.22
Conclusion
Dry skin is an uncomfortable and often distressing symptom with a variety of causes. It may be transient, but for many infants and children, a chronic inflammatory skin condition with dry skin symptoms will need to be managed on a daily basis. Primary care nurses can support their patients by recognising dry skin in infants and children, giving parents and carers correct advice, directing them to reputable information sources and ensuring their advice is evidence based and up to date.
Resources for patients
bad.org.uk/for-the-public British Association of Dermatology
britishskinfoundation.org.uk/Skinformation.aspx British Skin Foundation
ichthyosis.org.uk Ichthoysis patient support group
eczema.org National Eczema Society (NES) patient support group
psoriasis-association.org.uk The Psoriasis Association (PA) patient support group
References
1. Telofski S, Morello AP, MackCorrea MC et al. The infant skin barrier: can we preserve, protect, and enhance the barrier? Dermatology Research and Practice 2012; Article ID 198789.
2. Dyer J. New born skin. Seminars in Perinatology 2013;37:3-7.
3. Schofield J, Grindlay D, Williams H. Skin Conditions in the UK: a Health Care Needs Assessment. Centre of Evidence-Based Dermatology, University of Nottingham 2009;6:85-8.
4. Shaker M. New insights into the allergic march. Current Opinions in Paediatrics 2014;26:516-20.
5. Holden Arden-Jones MR, Flohr C, Reynolds NJ et al. Atopic Eczema. In Griffiths C, Barker J, Blekier T et al (Eds) Rook’s Textbook of Dermatology (Edition 9). 2016; 41:27.
6. Wakelin S. Seborrhoeic Dermatitis. In Griffiths C, Barker J, Blekier T, Chalmers R, Creamer D (Eds) Rook’s Textbook of Dermatology (Edition 9). 2016.
7. Alexopoulos A, Kakourou T, Orfanou I et al. Retrospective analysis of the relationship between infantile seborrhoeic dermatitis and atopic dermatitis. Paediatric Dermatology 2014;31:125-30.
8. Irvine AD, McLean WH, Leung DY. Filaggrin mutations associated with skin and allergic diseases. New England Journal of Medicine 2011;365:1315–27.
9. Poskitt L, Wilkinson JD. Natural history of keratosis pilaris. British Journal of Dermatology 1994;130:711-13.
10. Ichthyosis Support Group. Ichthyosis Overview. 2016. Available at ichthyosis.org.uk/category/types-of-ichthyosis/ (accessed 1 December 2016).
11. Tollefson MM, Crowson CS, McEvoy MT et al. Incidence of psoriasis in children: a population-based study. Journal of the American Academy of Dermatology 2010;62:979-87.
12. Burden D, Kirby B. Psoriasis and related disorders. In Griffiths C, Barker J, Blekier T et al (Eds) Rook’s Textbook of Dermatology (Edition 9). 2016.
13. Oakley A. Soaps and Cleansers. Derm Net NZ 2016. Available at dermnetnz.org/topics/soaps-and-cleansers/ (accessed 1 December 2016).
14. Oakley A. Dry Skin. Derm Net NZ 2015. Available at dermnetnz.org/topics/dry-skin/ (accessed 1 December 2016).
15. Cork MJ. The importance of skin barrier function. Journal of Dermatological Treatment 1997;8:suplt 4-7.
16. Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. International Journal of Clinical Practice 2006;60:984-92.
17. Danby SG, Al Enezi T, Sultan A et al. Effect of olive and sunflower oil on the adult skin barrier: implications for neonatal skin. Paediatric Dermatology 2013;30:42-50.
18. Olive Oil, Sunflower Oil or no Oil for Baby Dry Skin or Massage: A Pilot Assessor-blinded, Randomized Controlled Trial (the Oil in Baby SkincaRE [ObSeRvE] Study)’. Acta Dermato-Venereologica 2016;96: 323-30.
19. Cork MJ, Danby S. Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing 2009;18:872-7.
20. Assarian Z, O’Brien TJ, Nixon R. Soak and smear: an effective treatment for eczematous dermatoses. Australasia Journal of Dermatology 2015;56:215.
21. Moncrieff G, Van Onselen J, Young T. The role of managing emollients in skin integrity. Wounds UK 2015;11:72-6.
22. Draelos ZD. The effect of ceramide-containing skin care products on eczema resolution duration. Cutis 2008;81:87-91.
