t5p11 emollient therapy bp

8/10/2019 T5p11 Emollient Therapy BP

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Best practice in

emollient therapyA statement for healthcare professionals

Horny (scaly) layer of epidermis Hair Sweat pore

Basal cell layer of epidermis(produces new skin cells)

Sweatgland

Epidermis

Dermis


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DERMATOLOGICALNURSINGBEST PRACTICE

2 Dermatological Nursing, 2007

The steering group consisted of the following experts:

Steven Ersser Professor of Nursing Development and Skin Care Research, University of Bournemouth

Susan Maguire British Dermatological Nursing Group Professional Officer

Noreen Nicol Chief Clinical Officer and Dermatology Nurse Specialist, National Jewish Medical and Research Centre, Colorado, USA

Rebecca Penzer Independent Nurse Consultant in Skin Health, Opal Skin Solutions, OxfordJill Peters Dermatology Nurse Practitioner, Suffolk PCT and Ipswich Hospital NHS Trust

This supplement was reviewed by the following experts:

Sara Burr Community Dermatology Nurse, Kings Lynn

Julie Carr Senior Childrens Dermatology Nurse Specialist, Sheffield Childrens Hospital

Coleen Gradwell Clinical Nurse Specialist, Dermatology, Queens Medical Centre, Nottingham

Diane Hamdy Dermatology Specialist Nurse, Surrey PCT East Locality

Karina Jackson Nurse Consultant Dermatology, St Johns Institute of Dermatology, London

Vineet Kaur Consultant Dermatologist, Varanasi, India

Pat Kelly Chief Professional Nurse and Lecturer, Division of Dermatology, University of Cape Town, South Africa

Stephen Kownacki General Practitioner Albany House Medical Centre, Wellingborough and Hospital Practitioner in Dermatology at Northampton

General Hospital

Sandra Lawton Nurse Consultant Dermatology, QMC, Nottingham

Barbara Page Dermatology Liaison Nurse, Fife, Scotland

Sheila Robertson Dermatology Liaison Nurse, Fife, Scotland

Terence Ryan Emeritus Professor of Dermatology, Green College, University of Oxford

Jean Robinson Clinical Nurse Specialist, Paediatric Dermatology, Barts and The London NHS Trust

Annabel Smoker Lecturer in Nursing, University of Southampton

Annette Steadman Community Nursing Sister, Profession Practice Teacher, Surrey PCT East Locality

Corinne Ward Tissue Viability Nurse Specialist, Malta and Gozo

This supplement is published by Dermatology UK Ltd, Aberdeen AB10 1BATel: 01224 637 371

All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any meanswithout the prior written permission of Dermatology UK. Opinions expressed in articles are those of the author s and donot necessarily reflect those of Dermatology UK.

This best practice statement has been sponsored by Hermal and has the support of theInternational Skin care Nursing Group and the British Dermatological Nursing Group.


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3Dermatological Nursing, 2007

BESTPRACTICESTATEMENT

CONTENTS

A best practice statement for emollient therapy 4

Steven Ersser, Susan Maguire, Noreen Nicol, Rebecca Penzer, Jill Peters

Best practice statement 1: choosing emollient products 11

Best practice statement 2: the types of emollients and quantities that

should be used 12

Best practice statement 3: the frequency and timing of emollient

application 13

Best practice statement 4: method of emollient application 14

Best practice statement 5: applying emollients in relation to other

therapeutic topical products 15

Appendix 1: References according to evidence level 16

Appendix 2: examples of emollients 17

Appendix 3: emollient measures 18

Glossary 19


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IntroductionThis document has been developed

to give guidance to practising nurses

and other healthcare workers on

the effective use of emollients. This

guide is the result of an international

collaborative effort to provide clear,

practical and, where possible, evidence-

based information about emollients

and their use. It has been written

with significant contributions from an

Expert Panel and then reviewed by a

wide range of healthcare professionals.

The first section provides background

information about emollients and how

they work. The second section consists

of five statements that give practical

guidance about emollients and how they

should be used.

Overview of skin functionThe skin is a complex multi-function

organ, which has a unique capacity to

renew itself (Figure 1). The key functions

of the skin are as follows.

Barrier function

The skin acts as a barrier to the

external environment and also as a

protector of the internal environment.

It has a very effective physical presence

and when intact prevents pathogens

and bacteria penetrating through theskin. It also prevents moisture from

escaping (except through sweat). The

skin also acts as a barrier through its

chemical make up. It has an acid mantle,

which means that pathogens struggle

to survive. However, there are bacteria

and fungi that live on the skin which

are not affected by the acid pH. These

are known as commensal bacteria

and under normal circumstances

do us no harm (indeed they help

to protect us from pathogens). The

skin also produces melanin, its own

protection from ultraviolet radiation.

Finally, the skin has an immunological

role in protecting the bodys internal

environment through the presence of

specialised dendritic cells known as

Langerhans cells. These cells special ise

in presenting antigens to T-cells, which

then destroy them.

Sensation

The skin is an organ of sensation

and it allows us to experience touch.

Extensive networks of nerves run

through the dermis allowing individuals

to feel pain, itch, heat, cold and pressure.

Biochemical reactions

Biochemical reactions in the skin include

the production of Vitamin D, essential

for the regulation of calcium absorption

from the gut and its mobilisation from

the bones.

ThermoregulationHeat is lost or conserved through the

skin via different thermoregulatory

systems. Superficial blood vessels

constrict to conserve heat when the

ambient temperature is cold and dilate to

release heat in hot climates. The eccrine

sweat glands also facilitate heat loss by

releasing sweat onto the skin surface.

Display

The skin is an organ of display and as

such its appearance can profoundlyimpact on the psychological well-being

of an individual. The way the skin looks

can provide signals about the cultural

background of an individual and allows

people to make judgements about that

person and their way of life.

EmollientsEmollients have been part of human life

for centuries. Records suggest that the

ancient Greeks used wool fat on their

skin as early as 700BC (Marks, 2001).

Emollients in the modern day are much

more user-friendly than raw wool fat.

While they are commonly used for

cosmetic purposes, they are also vital for

the treatment of dry skin conditions and

for the promotion of skin health.

What are emollients?

To many people, emollients and

moisturisers are synonymous. However,

technically emollients and moisturisers

can be described differently, an emollient

being something that smoothes and

softens the skin, usually via occlusion, and

a moisturiser being something that actively

adds moisture to the skin. The lack of

consistency on the use of these terms

throughout the literature can be confusing.

In this document the word emollient is

being used as an inclusive term to define

substances whose main action are to

occlude the skin surface and to encourage

build up of water within the stratum

corneum (Marks, 2001).

The word emollient is a Latin

derivation and implies a material that

softens and smooths the skin both

to the touch and to the eye (Loden,

2003a). Emollients should have the

effect of reducing the clinical signs of

dryness, such as roughness or scaling,

and improving sensations, such as

itching and tightness. They should also

be acceptable cosmetically, that is they

should be useable by the individual in a

way that fits in with their lifestyle at thesame time as promoting concordance

with treatment (Loden, 2003a).

The constituent products of

emollients vary hugely, however, all will

have some quantity of lipid in them.

Lipid is a broad term used to describe

fats, waxes and oils (Marks, 2001). Most

animal fats are now rarely used, the

exception being lanolin (sheep wool

fat). Waxes include bees wax. The

most common type of lipid used is oil,

examples of which include vegetable oil,

petrolatum and synthetic oils such as

polysiloxane. Lipids are combined with

a range of other substances to produce

A best practice statement for

emollient therapy


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the vast array of emollients available.

These are discussed below.

The consistency of an emollient is

affected by:

8Ambient temperature

8The type of lipid within the

emollient, e.g. wax or oil

8The proportion of lipid to water

within the product

8Other additives.

Emollients can be thought of on a

continuum, with greasy, waxy (high lipid)

content products being at one end,

and less greasy, high water (low lipid)

content products being at the other (see

Appendix 2).

Mode of action

Emollients work to moisturise the skin

by increasing the amount of water held

in the stratum corneum (Cork, 1997;

Marks, 1997; Loden, 2003). Specifically,

depending on the constituents of

the emollients, they work either by

occlusion, trapping moisture into the

skin (which slows the evaporation of

water), or in an active way by drawing

moisture into the stratum corneum from

the dermis (Fendler, 2000; Flynn et al,

2001; Rawlings et al, 2004).

Occlusion is most effectively achieved

if greasy (heavy sealing) substances, such

as petrolatum are used (Fendler, 2000;

Harding et al, 2000). The occlusive effect

traps water in the stratum corneum

(preventing transepidermal water loss

by evaporation) and thereby mimics therole of natural emollients such as sebum

and natural moisturising factor (NMF).

Indeed, Rawlings et al (2004) report that

petrolatum jelly moisturisers reduce water

loss by 98%, whereas other oils only

manage to reduce water loss by 2030%.

The second mode of action involves

the active movement of water from

the dermis to the epidermis. Emollients

that have this effect contain substances

known as humectants, e.g. urea and

glycerine. These have a low molecular

weight and water-attracting properties

(Loden, 2003) and as they penetrate

the epidermis they draw water in

from the dermis. Some cream and

lotion emollients contain a mixture of

occlusive and humectant substances

the humectant draws water into the

epidermis while the occlusive elementensures that it is trapped there.

As well as holding water in the

epidermis, emollients do have other

useful properties. They can be exfoliative

(especially when combined with products

such as salicylic acid), and may have anti-

inflammatory (Cork, 1997), anti-mitotic

(Tree and Marks, 1975) and antipruritic

effects especially when combined with

other excipients such as lauromacrogols

(Bettzuege-Pfaff and Melze, 2005).

Impact of emollients on barrier function

Research work carried out in the field of

eczema provides some useful evidence

for the impact of emollients on the

barrier function of the skin. Rawlings

et al (1994) and Cork (1997) liken

the stratum corneum to a brick wall

the corneocytes represent the bricks

and the intercellular lipids, the mortar

(Elias, 1993). These lipid bilayers are

composed of ceramides, cholesterol and

free fatty acids (Downing and Stewart,2000). As the skin loses moisture

and becomes dry, the corneocytes

shrink and gaps develop between the

cells, thus compromising the barrier

function of the skin. When applied to

the skin, the emollient will trap water,

thus rehydrating the corneocytes. As

the emollient penetrates the stratum

corneum it mimics the natural lipids so

vital to the barrier function.

Research evidence suggests thatemollients accelerate regeneration of skin

barrier function following disruption, with

the most lipid-rich emollients restoring

the skin barrier more rapidly (Held et

al, 2001). Rawlings et al (2004) provide

a useful review of the evidence of the

effects of emollients on barrier function.

While there is a clinical consensus

that emollients have a beneficial

impact on barrier function, it has to

be acknowledged that the relationship

between the skin and an emollient is

complex and the effects of emollients

may not always be predictable. For

example, research has shown that



Horny (scaly) layer of epidermis Hair Sweat pore

Basal cell layer of epidermis(produces new skin cells)

Sweatgland

Epidermis

Dermis

Figure 1: The structure of the skin.


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certain emollient formulations may

increase water loss through the skin

(Buraczewska et al, 2007).

Adverse effectsEmollients are generally thought to be

safe, with limited adverse effects. The most

commonly reported adverse reaction

is stinging or discomfort on application,

generally related to one or more of the

constituents of the emollient (Marks,

1997). This is usually transient and could

often be considered a normal response to

an application of emollient rather than an

adverse effect. Patients who have other

underlying skin conditions, such as atopic

dermatitis or rosacea, have a tendency to

experience irritant responses (Boguniewicz

and Nicol, 2002). However, discomfort on

application may represent a true irritancy

to the substance or, on very rare occasions,

an allergy.

Contact dermatitis is the medical

diagnosis given to adverse inflammatory

changes in the skin caused by contact

with a product. This can be irritant or

allergic in nature. Determining whether

this is an immune-mediated allergic

response or an irritant response oftenrequires assessment by a healthcare

professional who specialises in allergic

skin disease. Suspected allergic contact

dermatitis can be investigated by

patch testing, but even if allergens are

identified, their presence in commercial

preparations can be difficult to ascertain.

Common culprits within topical

products are perfumes and preservatives

(de Groot, 2000). As ointments usually

do not contain preservatives they havea lower irritant/sensitising potential than

creams or lotions. The British National

Formularylists common excipients found

in topical preparations that may be rarely

associated with sensitisation (Table 1).

Some common emollients, such as

aqueous cream have constituents (e.g.

phenoxyethanol), which can lead to

contact dermatitis (Lovell et al, 1984).

Aqueous cream, which is commonly

prescribed as a leave-on emollient, was

originally designed as a soap substitute.

Its high water content makes it a less

effective leave-on emollient for those

with dry skin. Furthermore, an audit by

Cork et al (2003) showed that aqueous

cream caused stinging and discomfort

in a significantly higher proportion

of children with atopic eczema, than

other emollient products when used

as a leave-on product. For a certain

proportion of children, although aqueous

cream caused discomfort when used

as a leave-on product, it was acceptable

when used as a soap substitute. This

emphasises the importance of using aproduct for the purpose for which it was

originally designed (Cork et al, 2003a).

Although lanolin has often been

reported in the literature as a potent

sensitiser, newer more highly refined

(hypo-allergenic) types of lanolin

are very rarely the cause of adverse

reactions (Stone, 2000). Overuse of

very greasy ointments can block the

hair follicles, which can lead to irritation

and inflammation. This can usually beavoided by stroking, rather than rubbing,

the emollient into the skin following the

directional lie of the hair and/or using a

lighter less occlusive product. Occasionally

blockage of the hair follicle may lead to

painful pustules and infection, causing

folliculitis. Topical antibiotics or, rarely, oral

antibiotics, may be needed. However,

stopping the product is often sufficient to

resolve the problem.

Climatic conditions will have an

impact on the way that emollients

interact with the skin. In hot humid

conditions, the level of moisture in the

atmosphere may mean that emollients

are less important. In these situations,

and particularly when there is a high

bacterial load on the skin, the use of

occlusive emollients par ticularly, can

increase the likelihood of folliculitis.

In hot, dry weather, highly occlusive

emollients can reduce heat loss with

lipids acting as insulators, decreasing

evaporation from the skin and thus

affecting thermoregulation; this isparticularly important in children.

An individual may feel very hot and

uncomfortable with the use of such

emollients and in this scenario a cream

or gel emollient is preferable. The

majority of bath oils and emollients can

make objects very slippery, therefore

caution must be taken when getting in

and out of the bath, especially when

caring for vulnerable groups such as

older people or when handling babies.

Paraffin-based emollients such as

50/50 white soft paraffin/liquid paraffin,

do pose a fire risk as they are easily

ignited by a naked flame when soaked

into dressings or clothing. The risk is

especially high if used in large quantities.

Those using paraffin-based emollients

should be advised not to smoke or

come into contact with fire while

using the preparations (British Medical

Association and Royal Pharmaceutical

Society of Great Britain, 2007).

Reducing the likelihood of sensitivityA product can be considered an

irritant when the skin reacts adversely

Table 1

Common excipients found in topical products (British Medical Association and Royal

Pharmaceutical Society of Great Britain, 2007)

BeeswaxBenzyl alcoholButylated hydroxyanisoleButylated hydroxytolueneCetostearyl alcohol (including cetyl and stearylalcohol)Chlorocresol

Edetic acid (EDTA)EthylenediamineFragrancesHydroxybenzoates (parabens)

ImidureaIsopropyl palmitateN-(3-Chloroallyl) hexaminium chloride(quaternium 15)PolysorbatesPropylene glycolSodium metabisulphite

Sorbic acidWool fat and related substances, includingLanolin


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to it in a non-immune mediated way.

This usually occurs within minutes or

hours, i.e. the skin produces an almost

immediate inflammatory or cumulative

response (where the skin reacts aftera number of exposures to a product).

An allergic reaction is an immune

mediated response where the individual

was previously exposed to the allergen

and has been sensitised to a substance.

The individual will always react to it no

matter how small the contact, however,

the reaction can be greater with greater

exposure. Thus, the reaction will not

occur on the first exposure, but on

subsequent exposures the allergic

response may occur immediately or be

delayed for about 4896 hours after

exposure (Nicol et al, 1995).

The least potentially sensitising

products are those that contain the

least number of ingredients. Ointments,

therefore, are likely to produce fewer

adverse reactions than creams and lotions.

Fragrances are known sensitisers with an

estimated 1% of the general population

being allergic to them. This figure may be

as high as 14% when considering people

with eczema (de Groot, 2000). Thus,products without perfume are preferable

for those who have sensitive skin.

Individuals need to look for true fragrance-

free products as many contain masking

fragrances. It is also wise to recommend

that individuals apply a small amount of

any product that is new to them to a

test area before applying it all over. This

should then be left for 48 hours in order

to observe for any reaction. This course

of action is particularly recommended if

someone reports finding it difficult to finda product that suits them.

Emollient formulationsEmollients can be applied to the skin in

a number of ways, i.e. they come in a

number of formulations. These include

wash products such as bath additives,

soap substitutes and skin cleansers, or

topical preparations such as creams,

ointments and lotions. A large variety

of brands are available on the market

suggesting that there is no correct

product for all individuals. People

with dry skin conditions are usually

recommended to make use of wash

products as well as topically applied

preparations (Cork, 1997; Boguniewicz

and Nicol, 2002; Holden et al, 2002).

Emollient wash products

Emollient wash products is a genericphrase used to describe:

8Bath additives that are added to

water in either the bath or a bowl

and are not rinsed off the skin

(unless they are used in the shower)

8Soap substitutes that are used

instead of soap and have cleansing

properties, are non-drying and are

rinsed off the skin.

Bath additives (also known as bath

oils) are usually branded products. They

are added to water in the quantities

indicated by the manufacturer. The

main ingredients of bath additives are

oil-based, usually liquid paraffin, although

some products are based on soya oil.

They are all non-foaming and many of

them are fragrance free. They help to

ameliorate some of the drying effects of

water by leaving a layer of oil over the

skin after bathing. Some bath oils have

anti-pruritic properties (these contain

lauromacrogols) or antiseptic properties

(which contain benzalkonium chloride,chlorhexidine hydrochloride or triclosan).

Anti-microbial products should not be

used as a routine product for normal skin

as their particular function is for skin that

is infected or prone to regular infective

episodes (e.g. atopic eczema) (Primary

Care Dermatology Society and British

Association of Dermatologists, 2006).

Some bath additives can be used in the

shower. In this instance the product should

be applied to wet skin and rinsed off. It isdifficult to measure the quantity used while

showering, however, if an antimicrobial

product is being use, care must be

taken not to exceed the manufacturers

instructions as irritation may result.

Soap substitutes (i.e. soap-free

cleansing products) may be branded,

but many of the topical emollients can

also be used as a soap substitute. Soap

substitutes are used like soap, being

applied over the body (using hands or a

wash cloth) and then rinsed off to aid the

removal of organic matter and enhance

the lipid coating on the skin. They have

the advantage of being non-drying. When

bathing, it is recommended that people

with dry skin should avoid the following:

8Soaps and bubble baths (these can

disrupt barrier function through

emulsification of lipids)8Excessively hot water (this will

increase water loss through the skin

by evaporation)

8Vigorous rubbing with a towel after

the bath (this can disrupt barrier

function and lead to increased

irritation)

8Staying in a bath longer than 15

minutes (water-logging of the skin

can disrupt barrier function).

Within three minutes of leaving the

bath or shower the individual should

apply emollient to trap moisture into

the skin. While cleansing the skin once

a day is generally considered optimal,

consideration should be given to the

build up of organic debris on the skin,

including dead skin cells and exudate.

If these are excessive, more frequent

bathing may be advisable. There is

evidence to show that water hardness

(i.e. the level of calcium and magnesium

in the water) has an impact on eczema.

A study by (McNally et al, 1998)showed that exposure to hard water

may increase the risk of eczema in UK

primary school age children. This finding

was replicated by a research team for

Japanese children (Miyake et al, 2004).

Leave-on topical emollients

Topical emollients are not a

homogeneous group of substances

and there are a number of different

formulations. The most common are

ointments, creams and lotions, althoughgels and sprays are also widely available.

Ointments are the greasiest preparations

being made up of paraffins, vegetable

oils, animal fats or synthetic oils (Loden,

2003). Creams are described as

emulsions of oil and water and their

less greasy consistency often makes

them more cosmetically acceptable.

Lotions have a higher water content

than creams, which makes them easier

to spread but less effective as emollients.

(SeeAppendix 2for examples of

emollients from each category).

Emulsions, creams and lotions both

need stabilisers and emulsifiers added




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to them to retain their properties (i.e.

to keep the oil and water constituents

mixed together). They are also prone

to bacterial contamination and thus

have preservatives added to them.Ointments generally do not have these

additional constituents.

Emollient use in dry skin diseasesEmollients may be used by themselves

without other therapeutic products.

In these instances they will relieve

symptoms, improve the way the

skin looks and make it feel more

comfortable. If the only problem with

the skin is that it is dry, the use of

emollients is likely to be sufficient to

alleviate this problem (Nicol, 2005).

If, however, there is a chronic skin

condition present, e.g. psoriasis or

eczema, emollients may be considered

as an adjuvant therapy, that is therapy

that is best used alongside other topical

or systemic interventions regardless of

what those treatments are (Finlay, 1997;

Van Onselen, 2001; Boguniewicz and

Nicol, 2002). Evidence-based guidelines,

drawing on a systematic review,

advocate the prescription of emollientsas well as topical steroids for eczema

management (Hoare et al, 2000). A

study of 173 infants under the age of

12 months, showed that emollients

significantly reduced the amount of

high-potency topical steroids needed

to control atopic dermatitis (Grimalt et

al, 2007). However, there is uncertainty

regarding the exact effect of emollients

on the penetration of other topical

therapies, in particular topical steroids.

Evidence collected by Smoker (2007)

supports the need to investigate the

complex interplay between emollients

and topical steroids in order to provide

clear guidance on the optimum order

of application and the time intervals

between these two types of treatment.

There is debate, for example, about when

an emollient is applied prior to a topical

steroid and whether this in some way

blocks the effective absorption of steroid.

This may depend on the type of emollient,

for example, its level of occlusiveness,

or it may be affected by the amount of

time that elapses between applying the

emollient and the topical steroid.

Manufacturers do not generally offer

guidance on what stage an emollient

should be applied in relation to other

therapeutic topical products. One

exception is the immunomodulatortacrolimus the usage instructions

clearly state that an emollient should not

be used two hours before its application

(National Institute for Health and Clinical

Excellence, 2004).

Labelling emollients as adjuvant

therapy should not underplay their

importance as effective treatments for

the skin. They are not optional extras. In

the view of the Expert Panel involved in

compiling this best practice statement,

using emollients effectively can make

a significant improvement in chronic

inflammatory skin conditions such as

eczema as well as impacting positively

on quality of life. However, in a summary

of the evidence, Williams et al (2003)

highlight a virtual absence of clinically

useful randomised controlled trial data on

the use of emollients in atopic eczema,

but add that this paucity of quality

evidence does not reflect the importance

of emollient therapy for the treatment

of atopic eczema. Unlike many othertopical preparations, emollients have few

unpleasant side-effects, are usually quick

and easy to use and often significantly

improve symptoms.

Emollient use to promote skin healthAs has been highlighted above,

emollients should be considered a key

therapeutic agent in the management

of dry skin diseases such as eczema and

psoriasis. In addition, despite the lack of

evidence, it would seem from clinicalpractice that they are also important for

promoting skin health and preventing

skin breakdown. This is especially so for

those who are particular ly prone to dry

skin and breakdown of the skin barrier

due to common problems such as

incontinence (Ersser et al, 2005).

Skin care for babies

The very young, i.e. those under six

months, have vulnerable skin with an

immature skin barrier that should be

treated with care. In the first 2-4 weeks

of life it is recommended that:

8The skin is washed with plain water

8The vernix should be left to absorb

naturally as it is an effective natural

emollient

8Perfumed products should be

avoided.

After this time, tiny amounts of a

neutral pH baby bath product, containing

minimal dyes and perfumes, can be

introduced 23 times a week (Cetta et

al, 1991; Trotter, 2004). A Department

of Health advice booklet (Department

of Health, 2007), recommends bathing

babies 23 times per week, however, the

babys hands, face, neck and bottom should

washed every day with plain water.

Pre-term babies will be at even greater

risk of skin dryness and sensitisation and

the above precautions should be followed

for up to eight weeks (Trotter, 2004). They

are also of particular importance if there

is a family history of atopy. Children under

two years of age have a thinner stratum

corneum and the hydrolipid layer is less

well developed (Peters, 2001). This means

they may be prone to dryness and be

particularly sensitive to products such as

baby oils and bubble bath.

Skin care for the older adultThe skin of the older adult tends to be

drier through increased permeability of the

skin (Ghadially et al, 1995). It is also more

sensitive as the ageing process diminishes

the effectiveness of the hydrolipid layer

and less sebum is produced. Table 2

outlines the changes that occur in ageing

skin and the consequences of these

physiological changes.

In order to prevent poor skin

health, a regime of routine emollienttherapy is recommended along with

other preventive measures, such as

avoiding over-heating of the ambient

environment and maintaining effective

nutrition (Ersser, 2000). As dexter ity

may be an issue for some elderly

people, assistance may be needed to

help apply emollients on hard-to-reach

areas. A critical review of evidence

on nursing intervention for skin

vulnerability and urinary incontinence,

which significantly affects older people,

is provided by Ersser et al (2005).

A best practice document relating

to caring for the older persons skin

can be found at: http://www.wounds-


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uk.com/downloads/best_practice_

older_skincare.pdf

SummaryEmollients are important for promoting

skin health (especially in vulnerable

groups such as the very young and very

old) and for treating dry skin diseases

such as eczema and psoriasis.

The skin is an organ that can

heal itself and its key functions are

barrier, sensation, biochemical activity,

temperature regulation and display

(linked to psychosocial well-being).

Emollients soften, smooth andrehydrate the skin, helping to decrease

the unpleasant sensations associated

with dry skin. They usually contain lipids

and work through occlusion, trapping

natural moisture in the skin, or through

a humectant effect, which draws water

from the dermis into the epidermis.

Emollients help to restore barrier

function and have few side-effects,

however, those that do exist include

contact dermatitis, folliculitis, overheating(by occlusion), slipperiness in the bath

and possible fire risk when ointments

are used extensively. Emollients come

in different formulations including

wash products (skin cleansers and

bath additives) and leave-on products

(lotions, creams, gels and ointments).

A survey of the literature indicates

that there is l ittle pr imar y evidence

as to how emollients should be

effectively used. Common practice

has arisen and is reflected in the

clinical literature. One of the main

issues is that the use of emollients

is dependent on individual need, for

example, how dry the skin is and the

size of the person. Practitioners are

left with key questions that remain

largely unanswered by the literature.

These are:

8How much should be used?

8Which emollients should be used?

8How frequently should they be

applied?

8Where should they be applied?

8When should they be applied?

8How should they be applied in

relation to other therapeutic

products?

The following document includesa series of best practice statements

that attempt to answer the above

questions using the best evidence

available. Where direct evidence was

not available, reference has been made

to physiological or microbiological

principles. These have been formulated

by the Expert Panel and commented

on by a wide range of reviewers (see

beginning of document).

References

Akdis C , Akdis M, Bieber T, et al (2006)

Diagnosis and treatment of atopic dermatitis

in children and adults: European Academy

of Allergy and Clinical Immunology/

American Academy of Allergy, Asthma

and Immunology/ PRACTALL Consensus

Report.Allergy61(8):96987

All Party Parliamentary Group on Skin (2006)

Report on the Enquiry into the Adequacy and

Equity of Dermatology Services in the United

Kingdom. APPGS, London

American Academy of Dermatology (2003).

Guidelines of Care for Atopic Dermatitis-

Technical Report. Schaumburg , Illinois

Berth-Jones J, Graham-Brown R (1992) How

useful are soap substitutes?J Dermatol Treat

3: 911

Bettzuege-Pfaff B, Melze A (2005) Treating

dry skin and pruritus with a bath oilcontaining soya oil and lauromacragols. Curr

Med Res Opin21(11):1735090

Boguniewicz M, Nicol N (2002) Conventional

Therapy for Atopic Dermatitis. Immunology

and Allergy Clinics of North America, Atopic

Dermatitis. WB Saunders, Philadelphia

BMA and Royal Pharmaceutical Society

of Great Britain (2007) British National

Formulary. BMA and Royal Pharmaceutical

Society of Great Britain, London

Britton J (2003) The use of emollients andtheir correct application.J Comm Nurs 17(9):

2225

Buraczewska I, Berne B, Lindberg M, Torma

H, Loden M (2007) Changes in skin barrier

function following long-term treatment with

moisturizers, a randomised controlled trial. Br

J Dermatol156(3):49298

Cetta F, Lambert G, Ross S (1991) Newborn

chemical exposure from over the counter

skin care products. Clin Paed30(5):28689

Cork M J (1997) The importance of skinbarrier function.J Dermatol Treat8:s713

Cork MJ, Britton J, Butler L, Young S, Murphy

R, Keohane SG (2003) Comparison of parent

knowledge, therapy utilization and severity of

atopic eczema before and after explanation

and demonstration of topical therapies by a

specialist dermatology nurse. Br J Dermatol

149(3):58289

Cork MJ, Timmins J, Holden, C et al (2003a)

An audit of adverse drug reactions to

aqueous cream in children with atopic

eczema. Pharma J271: 74748

Cork MJ, Timmins J, Holden C et al (2004)

Getting results from emollient therapy on

atopic eczema. Derm Pract12(3): 16-20

de Groot A (2000) Sensitizing substances. In:

Lodn M and Maibach HI (Eds). Dry Skin and

Moisturizers Chemistry and Function. CRC

Press, Boca Raton

de Korte J, Van Onselen J, Kownacki S,

Sprangers M, Bos J (2005) Quality of care in

patients with psoriasis: an initial clinical study

of an international disease managementprogramme.J Euro Acad Dermatol Venereol

19(1): 3541

DoH (2007) Birth to 5. DoH, London



Table 2

Changes in elderly skin

Changes in the skin Consequence

Epidermal turnover slows

Less effective barrier functionLess flexible and softer collagenLess evenly distributed melaninFewer sweat glandsLess sebum production

Thinner skin

More prone to infection/drynessMore prone to wrinkles and sheeringMore prone to sun damageLess effective temperature controlIncreased skin dryness


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Downing D, Stewart M (2000) Epidermal

composition. In: Lodn M and Maibach HI

(Eds). Dry Skin and Moisturizers Chemistry

and Function. CRC Press, Boca Raton

Elias P (1993) Epidermal lipids, barrier

function and desquamation.J Invest Dermatol

80(6):4449

Ersser S (2000) Pruritus (Itching). Encyclopedia

of Care of the Elderly. New York, Springer

Publishing Co

Ersser S, Getliffe K, Voegeli D, Regan S (2005)

A critical review of the inter-relationship

between skin vulnerability and urinary

incontinence and related nursing intervention.

Int J Nurs Stud42(7): 82335

Fendler E (2000) Physico-chemicalconsiderations. In: Lodn M and Maibach HI

(Eds). Dry Skin and Moisturizers Chemistry

and Function. CRC Press, Boca Raton

Finlay A Y (1997) Emollients as adjuvant

therapy for psoriasis.J Dermatol Treat8: s2527

Flynn TC, Petros J, Clark RE, Viehman GE

(2001) Dry skin and moisturizers. Clin

Dermatol19(4):38792

Ghadially R, Brown B, Sequiera-Martin S,

Feingold K, Elias P (1995) The aged epidermal

permeability barrier: structural, functional andlipid biochemical abnormalities in humans and

a senescent murine model.J Clin Invest95(5):

228190

Gradwell C, Thomas KS, English JS, Williams

HC (2002) A randomized controlled trial of

nurse follow-up clinics: do they help patients

and do they free up consultants time? Br J

Dermatol147(3):513-7.

Grimalt R, Mengeaud U, Cambazard F (2007)

The steroid sparing effect of emollient

therapy in infants with atopic dermatitis:

A randomised controlled study. Dermatol

214(1): 617

Hall M (2003) Target Skin. The Association of

the British Pharmaceutical Industry, London

Hanifin J, Herbert A, Mays S (1998) Effects

of a low potency corticosteroid lotion plus

a moisturizing regimen in the treatment of

atopic dermatitis. Curr Therap Res Clinical Exp

59(4): 22733

Harding CR, Bartolone J, Rawlings AV

(2000) Effects of natural moisturizing factor

and lactic acid isomers on skin function. In:

Lodn M and Maibach HI (Eds). Dry Skin and

Moisturizers Chemistry and Function. CRC

Press, Boca Raton

Held E, Lund H, Agner T (2001) Effects of

different moisturisers on SLS-irritated human

skin. Cont Derm44(4): 22934

Hoare C, Li Wan Po A, Williams H (2000)

Systematic review for treatments of atopiceczema. Health Tech Assess14(37)

Holden C, English J, Hoare C et al(2002)

Advised best practice for the use of emollients

in eczema and other dry skin conditions.J

Dermatol Treat13(3): 10306

Loden M (2003) Role of topical emollients and

moisturizers in the treatment of dry skin barrier

disorders.Am J Clin Dermatol4(11): 77188

Loden M (2003a) The skin barr ier and use of

moisturizers in atopic dermatitis. Clin Dermatol

21: 145157

Lovell C, White I, Boyle J (1984) Contact

dermatitis from phenoxyethanol in aqueous

cream BP. Con Derma11(3): 187

Lucky AW, Leach AD, Laskarzewski P, Wenck

H (1997) Use of an emollient as a steroid-

sparing agent in the treatment of mild to

moderate atopic dermatitis in children. Paed

Dermatol14(4): 32124.

Marks R (1997) How to measure the effects

of emollients.J Dermatol Treat8:s1518

Marks R (2001) Sophisticated Emollients.

Thieme, Stuttgart

McNally N, Williams H, Phillips D et al (1998)

Atopic eczema and water hardness. Lancet

352(9127): 52731

Miyake Y, Yokoyama T, Yura A, Iki A, Shimizu

T (2004) Ecological association of water

hardness with prevalence of childhood atopic

dermatitis in a Japanese urban area. Environ

Res94(1): 3337

National Institute for Health and Clinical

Excellence (2001) Referral Advice: A guide toappropriate referral from general to specialist

services.NICE, London

National Institute for Health and Clinical

Excellence (2004) Technology Appraisal 82

Tacrolimus and Pimecrolimus for Atopic Eczema.

NICE, London

Nicol N (1987) The (wet) wrap-up.Am J Nurs

87(12): 156063

Nicol N (2005) Use of moisturizers in

dermatologic disease:the role of health care

providers in optimizing outcomes. Cutis76(6S):2631

Nicol N, Ruszkowski A, Moore J (1995)

Contact dermatitis and the role of patch

testing in its diagnosis and management.

Dermatol Nurs SuppFeb: 527

Peters J (2001) Caring for dry and damaged

skin in the community. Br J Comm Nurs6(12):

64551

Primary Care Dermatology Society and

British Association of Dermatologists (2006)

Guidelines for the Management of Atopic

Eczema. Primary Care Dermatology Society

and British Association of Dermatologists,

London

Rawlings A, Scott I, Harding C, Bowser P

(1994) Stratum corneum moisturization at

the molecular level.J Invest Dermatol 103(5):

73140

Rawlings AV, Canestrari DA, Dobkowski B(2004) Moisturizer technology versus clinical

performance. Dermatol Therap17(Suppl 1):

4956

Schlagel CA, Sanborn EC (1964) The weights

of topical preparations required for total and

partial body injunction.J Invest Dermatol42:

25356

Smoker A (2007) Topical Steroid or

Emollient Which One do you Apply First?

An Investigat ion into the Sequencing of

Topical Steroid and Emollient Application

and the Most Clinically Effective Method of

Application. University of Southampton,

Southampton

Stone L (2000) Medilan: a hypo-allergenic

lanolin for emollient therapy. Br J Nurs9(1):

547

Subramanyan K (2004) Role of mild cleansing

in the management of patient skin. Dermatol

Therap 17(Suppl 1):2634

Tree S, Marks R (1975) An explanation for

the placebo effect of bland ointment bases.

Br J Dermatol92: 19598

Trotter S (2004) Care of the newborn:

proposed new guidelines. Br J Midwifery

12(3): 15257

Van Onselen J (2001) Psoriasis. Dermatology

Nursing- A practical guide. Churchill

Livingstone, Edinburgh

Watsky KL, Freije L, Leneveu MC, Wenck

H, Leffel DJ (1992) Water-in-oil emollients

as steroid-sparing adjunctive therapy in the

treatment of psoriasis. Cutis50:38386

Williams H, Thomas K, Smethurst D et al

(2003) Atopic eczema. In: Williams, HMB,

Diepgen T et al (Eds). Evidence-based

Dermatology. London, Blackwells, BMJ Books


11/19



Statement1

Choosinge

mollientproducts

Statement

Reasonsunderlyingstatements

Evidence

Ageneralruleisthatthedriertheskin,t

hegreasiertheemollien

tshould

be,i.e.verydryskinisbesttreatedwithanointment,moderately

drywitha

creamorge

l,andslightlydrywithalotion

Thegreasiertheproductthemore

effectiveitisasanemollient.L

ipid-r

ich

emollientsrestoretheskinbarriermostrapidly

Marks,19

97

Heldetal,2001

Theabovestatementhastobemodified,h

owever,inordertota

keinto

accountthe

individualspreferencesandlifestyle

Ifsomeonedoesnotliketheemollientthattheyhavebeenrecommended

theywilln

otuseit

Treatmentadherenceisdependent

ontheacceptabilityofmedicationused

(e.g.doesitmarkclothing?)

Anindividuals

houldbeprovidedwithachoiceofproducts,preferablyin

trial-sizequantities,toallowthemtomakeaninformeddecision

aboutwhich

theywouldliketouse

Thisallowsforinformedchoiceabo

utwhatproductssuitforwhich

situations,e.g.acream/gelm

oisturis

ermaybepreferablefordaytimeuse

withanointmentbeingsuitablefor

useatnight-time.T

heuseofpreferred

productsenhancesadherence

AllPartyParliamentaryGrouponSkin,2

006

Dryskinconditionsrequireemollientsaspartoftherapeutictreatment

regimes

Dryskinconditionstypicallyreflect

disruptiontothenormalfu

nctioning

oftheskinbarrier;emollientscancontributetotherestorationofthis

functionthroughenhancingskinhydration

Dueconsiderationmustbegiventotheaccessibilityoftheseproducts

toensurethattheyareavailableinadequatequantitiesviathemost

appropriatemechanism,e.g.onprescription

NICE,200

1

Akdiseta

l,2006

Marks,20

01

Hall,2003

Ifrecurrentskininfectionsareanissue,u

singantimicrobialp

roductsmaybe

helpful

Antimicrobialp

roductsmaylowerthebacterialloadontheskinand

thereforelessenthechanceofana

cuteflareup

Hoareetal,2

000


12/19

DERMATOLOGICALNURSINGSUPPLEMENT

S10 Dermatological Nursing, 2007


12

Statement2

Thetypes

ofemollientsandquantitiesthatshouldbeused

Statement

Rationale

Evidence

Duringskin

cleansing,careshouldbetakentominimisethepotentialdrying

effectsfrom

washing.Soapsubstitutesotherwiseknownasskinc

leansersor

syntheticde

tergentssyndetsshouldbeusedtowashtheskin.Theyshould

beappliedtotheskinusinghandsorawashcloth,andthenrinsedoff

Thesurfactanteffectofsoapremov

esnaturalskinlipidssebum.Soap

substitutescleansetheskinwithoutdryingitandmayimproveskin

hydration

Berth-JonesandGraham-Brown,1

992

Subraman

yan,2

004

Furthermoisturisingeffectsmaybeachievedbyaddingabathad

ditiveto

washwater

asperthemanufacturersinstructions.

Somecanbe

usedasa

washproductintheshower

Bathadditivesleavealayerofoilov

ertheskinafterbathingandprevent

excessivemoisturelossfromthesk

induringwashing

Inordertobeeffective,t

hecorrectamountofproductshouldbeadded

towashwater

Aleave-ontopicalemollientshouldbeappliedtotheskinregularlyinorder

tokeepitw

ell-hydrated.Q

uantitieswillv

arybutbetween2506

00gper

weekisreco

mmended,d

ependingonthelevelofskindryness,theextentof

thedryness

andthesizeoftheindividual.Forachild,2

50gisusuala

ndfor

anadult,500600g.SeeAppendix3foradetailedchartondeliveringthe

correctquantityofemollient

Topicalleave-onemollientsarevitalforrehydratingtheskin,improvingthe

symptomsofdrynesssuchasitch,t

ightnessandscalingandmayenhance

theeffectivenessofotherproducts

Theuseofinadequatequantitiesof

emollientdoesnotprovideaneffective

occlusivebarriertowaterlossbyevaporation

SchlagelandSanborn,1

964

BMAand

RoyalP

harmaceuticalS

ocietyofGreatBritain,2

007

Britton,20

03

Emollientsforscalpsneedtobeeasytoapplydespitethepresen

ceofhair.

Oilsareeffe

ctive,p

articularlycoconutoil,whichissolidatroomtemperature

butmeltsoncontactwithskin

Topicalleave-onemollientsarevitalfo

rrehydratingtheskin,improvingthe

symptomsofdrynesssuchasitch,tightnessandscaling.Theycanalsosoften

scale,h

elpingtoremoveit

BMAand

RoyalP

harmaceuticalS

ocietyofGreatBritain,2

007


13/19

DERMATOLOGICALNURSINGSUPPLEMENT

S11



Statement3

Frequency

andtimingofemollientapplication

Statement

Rationale

Evidence

Emollientsareusedtotreatdryskin

Dryskinischaracterisedbyalosso

fmoisture.T

hiscanbeamelioratedor

reversedthroughtheuseofemollients

Cork1997;H

all2003;C

orketal,2

004

Emollientsshouldbeusedduringwashingandasatopicalleave-onproduct

appliedafterwashing.T

heskinshouldbegentlydried,le

avingitslightlymoist

beforeapplyingtheleave-onemollientproduct

Applyingatopicalemollientafterw

ashinghelpstotrapmoistureintothe

skin,maximisingitshydratingeffect

Holdenetal,2

002

Leave-onto

picalemollientsshouldbeappliedbeforegoingtobed.I

tmay

bemoreacceptabletouseagreasyemollient,forexample,a

nointmentat

thistime

Theskinwilld

ryoutovernightdue

toinsensiblelossandbyperspiration;

thisislikelytobeaggravatedbyheat

Physiologicalp

rinciple

Emollientsshouldbeappliedatotherpointsinthedaythatsuitthe

individual.Th

esewillv

aryfrompersontoperson,h

oweverforso

meonewith

averydryskincondition(e.g.a

topiceczema),i

tisnotunusualto

needto

applyemollientevery23hours,particularlytoexposedareas

Individualswithdryskinconditions

willfi

ndthattheirskinbecomesdry

quicklyduetodisruptionofthebarrierfunctionandwaterloss

Emollientsareeasilyrubbedoffthe

skinbyclothing

Tomaximisetheirefficacy,emollientsshouldbeappliedregularly

Physiologicalp

rinciple

Itisusefulfo

rindividualstohavesmallerquantitiesofemollientd

ecanted

intocleancylindricalc

ontainers(whichshouldbewashedanddr

ied

regularly),th

atcanbecarriedaroundandusedasnecessary

Itiseasiertocarrysmallamountso

femollientaround.T

hiswillh

elpto

promotetreatmentadherence

Usingcleancylindricalc

ontainersw

illr

educethepotentialforcross

contamination

Microbiologicalp

rinciple

Emollientsshouldbeappliedtotheskinandallowedtoabsorbb

efore

applyingoth

ertopicalproducts,forexample,t

opicals

teroids*

Applyingtopicalmedications(suchastopicalsteroids)to

well-moisturisedskinincreasestheefficacyofsaidproduct(seeStatement

5formoredetail)

Hoareetal,2

000


14/19


15/19



Statement5

Applyinge

mollientsinrelationtoothertherapeu

tictopicalproducts

Statement

Rationale

Evidence

Therapeutic

topicalproductsshouldbeappliedto

well-moisturisedskin*

Thereissomeevidencetoshowth

atwell-moisturisedskinrequiresa

reducedamountofsteroid

Thereissomeevidencetoshowth

atdithranoltreatmentismoreeffective

followingtheuseofemollients

Applyinganemollientontopofas

teroidmeansthatthesteroidmaybe

dilutedandspreadtoareasofthebodywhereitisnotneeded

Watskyetal,1

992

Luckyetal,1

997

Hanifinetal,1

998

Finlay,199

7

Moisturisersshouldbeallowedtoabsorbintotheskinbeforeth

eapplication

ofatherapeuticproduct.T

heskinshouldfeels

lightlytackybutnotslippery*

Iftheemollienthasnotbeenabsor

bedintotheskinitmaydilutetheeffect

ofthetherapeutictopicalpreparationasitisappliedtotheskin.T

helength

oftimethatittakesfortheemollient

toabsorbwilld

ependonvariables

suchashowdrytheskinisandhow

greasythetopicalemollientis

Physiologicalp

rinciple

*Thesestatem

entsremaincontroversialandthepractitionerneed

stotakeintoaccounttheskindiseasewhichisprese

ntandwhattopicalagentisbeingused.Intwoextensivereviewsoftheevidenceforthetreatmentofatopiceczema

(Hoareetal,2

000;A

mericanAcademyofDermatology,2

003),emollientswererecognisedasimportant,butnoevidence-basedguidancewasprovidedtohelpthepractitio

nerinthepracticalt

askofapplyingtherapeutictopic

ala

gents.The

evidencethat

doesexistsuggeststhattopicalemollientscanbeste

roidsparing,andingeneraltheexperienceoftheEx

pertPanelisthattopicalsteroids,inparticularshould

beappliedtowell-moisturisedskin.AreviewbySm

oker(2007),

highlightednumerousconcerns,includingthepossibleocclusiveeffectofemollientspreventingpenetrationofsteroids(

ifocclusiveemollientsareappliedfirst)andthediluting/smearingeffectofapplyinganemollientafterasteroid.

Smoker

wasunableto

findanyconclusiveevidencetosupporteitherstanc

e.It

isthereforedifficulttotakeadefinitivestanceasfurtherevidenceisrequired.


16/19

Systematic Review

Hoare et al (2000) Systematic review for treatments of atopic eczema

Review

Akdis et al (2006) Guidelines for atopic dermatitis

American Academy of Dermatology (2003) Guidelines for atopic dermatitis

Boguniewicz and Nicol (2002) Guidelines for atopic dermatitis

Britton (2003) Quantities of emollients

Cork (1997) Skin barrier function

Cork et al (2004) Emollient use in atopic dermatitis

De Groot (2000) Sensitising substances

Downing and Stewart (2000) Structure of epidermis

Elias (1993) Epidermal lipids

Ersser (2000) Pruritus in the elderly

Ersser et al (2005) Skin vulnerability and incontinence

Fendler (2000) Emollients and interactions with the skin

Finlay (1997) Emollients in psoriasis

Flyn et al (2001) Dry skin and emollients

Hall (2003) Managing skin conditions

Harding et al (2000) Effects of emollients on skin function

Holden et al (2002) Emollient use in atopic dermatitis

Loden M (2003a) Emollients, atopic dermatitis and skin barrier function

Loden M (2003) Emollients, dry skin and barrier function

Marks (1997) Methods for measuring effects of emollients

Marks (2001) Review of emollients

Nicol (1987) Review of wet wrapping

Nicol et al (1995) Contact dermatitis patch testing

Nicol (2005) Treatment outcomes with emollients

Peters (2001) Caring for dry/damaged skin

Rawlings et al (1994) Moisturisation at the molecular level

Rawlings et al (2004) How emollients work

Smoker (2007) Order of treatment application

Subramanyan (2004) Review of cleansers

Stone (2000) Effects of lanolin

Trotter (2004) Care of the newborn skin

Van Onselen (2001) Psoriasis

Voegeli (2007) Skin breakdown and its prevention

Williams et al (2003) Atopic eczema

Research

Randomised controlled trial

Buraczewska et al (2007) Impact of emollients on transepidermal water loss

Gradwell et al (2002) Impact of nurse consultation

Grimalt et al (2007) Steroid-sparing effect of emollients

Hanifin et al (1998) Steroid-sparing effect of emollients

Watsky et al (1992) Steroid-sparing effect of emollients

Prospective clinical studies

Berth-Jones and Graham-Brown (1992) Effects of soap substitutes

Cetta et al (1991) Skin care products on newborns

Cork et al (2003) Impact of nurse consultation

De Korte et al (2005) Impact of nurse consultation

Lucky et al (1997) Steroid-sparing effect of emollients

Surveys

Betzuegge-Pffaf and Melze (2005) Use of anti-pruritic bath oil

McNally et al (1998) Impact of hard water on atopic dermatitis

Miyake et al (2004) Impact of hard water on atopic dermatitis

Experiments

Ghadially et al (1995) Function of older skin

Held et al (2001) Emollient effect on irritated skin

Schlagel & Sanborn (1964) Emollient quantities

Tree & Marks (1975) Effect of bland ointment emollients

Audit

Cork et al (2003) Adverse effects of aqueous cream in children with atopic eczema

Expert groups

All Party Parliamentary Group on Skin (2006) Dermatology services in UK

British Medical Association and the Royal Excipients in emollients and

Pharmaceutical Society of Great Britain (2007) quantities ofemollients

Hall (2003) ABPI guidance on skin

National Institute for Health and Clinical Excellence (2001) Referral guidelines

National Institute for Health and Clinical Excellence (2001) Technology Appraisal

Primary Care Dermatology Society and Guidelines for the management

British Association of Dermatologists (2006) of atopic eczema

Government guidelines

Department of Health (2007) Caring for children from 0-5 (guidance for parents)

Appendix 1

References according to evidence level




17/19



Appendix 2

Examples of emollients

Less greasy for dry skin Most greasy for very dry skin Bath additive

LOTIONS CREAMS AND GELS OINTMENTS

Eucer in lotion (10% urea) Balneum Plus (contains urea and anti-pruritic lauromacragols)

50% white soft paraffin 50% liquidparaffin

Balneum Bath Oil (soya oil)

E45 Lotion Unguentum M White soft paraffin Balneum Plus Bath Oil (soya oil withanti-pruritic lauromacragols)

Dermol 500 lotion (contains antiseptic) Doublebase Emulsifying ointment Oilatum Junior (fragrance free bathadditive)

Aveeno E45 Cream Yellow soft paraffin Oilatum Shower Formula Gel

Keri Lotion Eucerin cream (10% urea) Diprobase ointment Oilatum Bath Formula

Vaseline Dermacare Diprobase cream Hydrous ointment Oilatum Plus (with benzalkoniumchloride and triclosan)

Dermol cream (contains antiseptic) Epaderm Cetraben emollient

Gammaderm Hydromol ointment E45 Bath Additive

Lipobase Aquaphor Alpha Keri bath

Oilatum Dermalo

Ultrabase Diprobath

Zerobase Aveeno

Aquadrate (contains urea) Hydromol emollient

Decubal Imuderm

Calmurid (contains urea)

Nutraplus (contains urea)

Cetraben

Hydromol cream

Sensicare emollient

Aqueous cream (soap substitute)


18/19



Emollient quantities according to the British National Formulary(British Medical Association and Royal Pharmaceutical Society ofGreat Britain, 2007) These quantities represent sufficient amounts for a twice-daily application for a period of a week for an adult

Creams and Ointments Lotions

Face 1530 g 100ml

Both hands 2550 g 200ml

Scalp 50100 g 200ml

Both arms or both legs 100200 g 200ml

Trunk 400 g 500ml

Groins and genitalia 1525 g 100ml

Appendix 3

Emollient measures (Britton, 2003) These quantities are appropriate for a single application for an adult

Light dose regime Medium dose regime High dose regime

Body site Amount of moisturiser Amount of moisturiser Amount of moisturiser

Arm Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Chest Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Abdomen Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Upper back Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Lower back Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Thigh Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Shin Two pumps, one teaspoon Five pumps, one dessert spoon 10 pumps, one tablespoon

Total 20 pumps/20g 50 pumps/50g 100 pumps/100g

One pump is equivalent to 1g.


19/19


Glossary

To observe or following instructions closely

A reaction to a substance that started by the immune system

A substance or product that reduces inflammation

A substance or product that kills micro-organisms or suppresses their multiplication or growth

A substance or product that stops cells division

A substance or product that stops or reduces the sensation of itching

A substance or product which inhibits the growth of bacteria

A trade name given to a specific product, which is only made by a specific company

The basic unit of the sphingolipids

An agreement between individuals about a course of action (in this context agreeing to use a par ticular treatment)

Cells found in the stratum corneum, they have no nucleus and are full of the protein keratin

An oil in water mixture, usually with other substances such as preservatives and emulsifier s added

A mixture of two substances that are generally immiscible so shaking must occur to mix the two substances or an

emulsifier must be added

A substance which causes two immiscible substances to remain together in mixture

Top layer of the skin consists mainly of keratinocytes that mature to become corneocytes

Any more-or-less inert substance added to a drug

A substance or product that helps removal of the top layers of the epidermis (particularly helpful where there is

overgrowth of the epidermis in scaley conditions such as psoriasis)

Infection of the hair follicle which can present as small asymptomatic pustules, but can become large and painful

Organic compounds of carbon, hydrogen and oxygen that combine with glycerol to form fatsThe tube from which hairs grow, formed by ;an invagination of the epidermis

A substance or product that is water loving and draws water towards it

A term coined initially by the cosmetic industry to refer to a product that is less likely to cause and allergic reaction. No

official standard has been developed.

A reaction that is caused by a response from the immune system

Between cells

The infolding of a structure so that an external surface becomes and internal surface

A substance or a product that causes the skin to react in an unpleasant manner

A macrogol that has anti-pruritic propertiesWater in oil mixture

A naturally occurring humectants which help to keep water in the upper layers of the epidermis

A product that does not produce bubbles

The use of a bandage, dressing or topical application to reduce the loss of water from the skin

An oil based topical product

A mixture of hydrocarbons made from distillate of wood, coal or most usually petroleum

The top layer of the epidermis consisting of corneocytes that shed constantly

Oily substance that is secreted from the sebaceous glands into the hair follicle.

A product or substance to be applied externally to the skin

Across the epidermis

Used in topical products as a humectant

Adherence

Allergy

Anti-inflammatory

Anti-microbial

Anti-mitotic

Anti-pruritic

Antiseptic

Branded

Ceramides

Concordance

Corneocyte

CreamEmulsion

Emulsifier

Epidermis

Excipient

Exfoliative

Folliculitis

Fatty acidsHair follicle

Humectant

Hypo-allergenic

Immune-mediated

Intercellular

Invagination

Irritant

LauromacrogolsLotion

Natural moisturising factor

Non-foaming

Occlusion

Ointment

Paraffin

Stratum corneum

Sebum

Topical

Transepidermal

Urea

t5p11 emollient therapy bp

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