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Best practice in

emollient therapy
A statement for healthcare professionals

Horny (scaly) layer of epidermis

Hair

Sweat pore

Epidermis
Sweat
gland

Basal cell layer of epidermis


(produces new skin cells)

Sebaceous gland
(produces sebum that oils the skin)

EmmolientBest Practice Cover C.indd 3

Dermis

Hair
follicle

Blood vessels

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DERMATOLOGICAL NURSING BEST PRACTICE

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

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 Ofcer
Noreen Nicol Chief Clinical Ofcer and Dermatology Nurse Specialist, National Jewish Medical and Research Centre, Colorado, USA
Rebecca Penzer Independent Nurse Consultant in Skin Health, Opal Skin Solutions, Oxford
Jill 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, Shefeld 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 1BA


Tel: 01224 637 371
All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means
without the prior written permission of Dermatology UK. Opinions expressed in articles are those of the authors and do
not necessarily reect those of Dermatology UK.

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DERMATOLOGICAL NURSING BEST PRACTICE

BEST PRACTICE STATEMENT


CONTENTS
A best practice statement for emollient therapy
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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A best practice statement for


emollient therapy
Introduction
This 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, evidencebased information about emollients
and their use. It has been written
with signicant contributions from an
Expert Panel and then reviewed by a
wide range of healthcare professionals.
The rst section provides background
information about emollients and how
they work. The second section consists
of ve statements that give practical
guidance about emollients and how they
should be used.

Overview of skin function


The 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 the
skin. 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
4

environment through the presence of


specialised dendritic cells known as
Langerhans cells. These cells specialise
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.
Thermoregulation
Heat is lost or conserved through the
skin via different thermoregulatory
systems. Supercial 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 profoundly
impact 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.

Emollients
Emollients 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 dene
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 ts in with their lifestyle at the
same 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

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Horny (scaly) layer of epidermis

Hair

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 element
ensures that it is trapped there.

Sweat pore

Epidermis
Sweat
gland

Basal cell layer of epidermis


(produces new skin cells)

Sebaceous gland
(produces sebum that oils the skin)

Dermis

Hair
follicle

Blood vessels

Figure 1: The structure of the skin.


the vast array of emollients available.
These are discussed below.
The consistency of an emollient is
affected by:
8 Ambient temperature
8 The type of lipid within the
emollient, e.g. wax or oil
8 The proportion of lipid to water
within the product
8 Other additives.

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).

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).

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 the
role 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%.

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). Specically,
depending on the constituents of
the emollients, they work either by
occlusion, trapping moisture into the
skin (which slows the evaporation of

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

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 antiinammatory (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 eld 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 that
emollients 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 benecial
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
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DERMATOLOGICAL NURSING BEST PRACTICE


certain emollient formulations may
increase water loss through the skin
(Buraczewska et al, 2007).
Adverse effects
Emollients 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 inammatory
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 often
requires 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
identied, their presence in commercial
preparations can be difcult to ascertain.
Common culprits within topical
products are perfumes and preservatives
(de Groot, 2000). As ointments usually
do not contain preservatives they have
a lower irritant/sensitising potential than
creams or lotions. The British National
Formulary lists 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
6

Table 1
Common excipients found in topical products (British Medical Association and Royal
Pharmaceutical Society of Great Britain, 2007)
Beeswax
Benzyl alcohol
Butylated hydroxyanisole
Butylated hydroxytoluene
Cetostearyl alcohol (including cetyl and stearyl
alcohol)
Chlorocresol
Edetic acid (EDTA)
Ethylenediamine
Fragrances
Hydroxybenzoates (parabens)

Cork et al (2003) showed that aqueous


cream caused stinging and discomfort
in a signicantly 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 a
product 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 rened
(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 inammation. This can usually be
avoided 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 sufcient 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

Imidurea
Isopropyl palmitate
N-(3-Chloroallyl) hexaminium chloride
(quaternium 15)
Polysorbates
Propylene glycol
Sodium metabisulphite
Sorbic acid
Wool fat and related substances, including
Lanolin

are less important. In these situations,


and particularly when there is a high
bacterial load on the skin, the use of
occlusive emollients particularly, 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 is
particularly 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.
Parafn-based emollients such as
50/50 white soft parafn/liquid parafn,
do pose a re risk as they are easily
ignited by a naked ame when soaked
into dressings or clothing. The risk is
especially high if used in large quantities.
Those using parafn-based emollients
should be advised not to smoke or
come into contact with re while
using the preparations (British Medical
Association and Royal Pharmaceutical
Society of Great Britain, 2007).

Reducing the likelihood of sensitivity


A product can be considered an
irritant when the skin reacts adversely

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DERMATOLOGICAL NURSING BEST PRACTICE


to it in a non-immune mediated way.
This usually occurs within minutes or
hours, i.e. the skin produces an almost
immediate inammatory or cumulative
response (where the skin reacts after
a 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 rst 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 gure 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 fragrancefree 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 nding it difcult to nd
a product that suits them.

Emollient formulations
Emollients 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 generic
phrase used to describe:
8 Bath 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)
8 Soap 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 parafn, 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 is
difcult 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:
8 Soaps and bubble baths (these can
disrupt barrier function through
emulsification of lipids)
8 Excessively hot water (this will
increase water loss through the skin
by evaporation)
8 Vigorous rubbing with a towel after
the bath (this can disrupt barrier
function and lead to increased
irritation)
8 Staying 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 nding
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, although
gels and sprays are also widely available.
Ointments are the greasiest preparations
being made up of parafns, 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.
(See Appendix 2 for examples of
emollients from each category).
Emulsions, creams and lotions both
need stabilisers and emulsiers added
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DERMATOLOGICAL NURSING BEST PRACTICE


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 diseases


Emollients 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 sufcient 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 emollients
as 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
signicantly 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.
8

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 immunomodulator
tacrolimus 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 signicant improvement in chronic
inammatory 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 reect the importance
of emollient therapy for the treatment
of atopic eczema. Unlike many other
topical preparations, emollients have few
unpleasant side-effects, are usually quick
and easy to use and often signicantly
improve symptoms.

Emollient use to promote skin health


As 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 clinical
practice that they are also important for
promoting skin health and preventing
skin breakdown. This is especially so for
those who are particularly 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 rst 2-4 weeks
of life it is recommended that:
8 The skin is washed with plain water
8 The vernix should be left to absorb

naturally as it is an effective natural


emollient
8 Perfumed 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 adult
The 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 emollient
therapy is recommended along with
other preventive measures, such as
avoiding over-heating of the ambient
environment and maintaining effective
nutrition (Ersser, 2000). As dexterity
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 signicantly 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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DERMATOLOGICAL NURSING BEST PRACTICE


Berth-Jones J, Graham-Brown R (1992) How
useful are soap substitutes? J Dermatol Treat
3: 911

Table 2
Changes in elderly skin
Changes in the skin

Consequence

Epidermal turnover slows


Less effective barrier function
Less exible and softer collagen
Less evenly distributed melanin
Fewer sweat glands
Less sebum production

Thinner skin
More prone to infection/dryness
More prone to wrinkles and sheering
More prone to sun damage
Less effective temperature control
Increased skin dryness

uk.com/downloads/best_practice_
older_skincare.pdf

Summary
Emollients 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 and
rehydrate 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 re 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 little primary evidence
as to how emollients should be
effectively used. Common practice
has arisen and is reected 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:
8 How much should be used?
8 Which emollients should be used?
8 How frequently should they be
applied?
8 Where should they be applied?
8 When should they be applied?
8 How should they be applied in
relation to other therapeutic
products?
The following document includes
a 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. Allergy 61(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 DermatitisTechnical Report. Schaumburg , Illinois

Bettzuege-Pfaff B, Melze A (2005) Treating


dry skin and pruritus with a bath oil
containing soya oil and lauromacragols. Curr
Med Res Opin 21(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 and
their 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 Dermatol 156(3): 49298
Cetta F, Lambert G, Ross S (1991) Newborn
chemical exposure from over the counter
skin care products. Clin Paed 30(5): 28689
Cork M J (1997) The importance of skin
barrier function. J Dermatol Treat 8: 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 J 271: 74748
Cork MJ, Timmins J, Holden C et al (2004)
Getting results from emollient therapy on
atopic eczema. Derm Pract 12(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 management
programme. J Euro Acad Dermatol Venereol
19(1): 3541
DoH (2007) Birth to 5. DoH, London
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DERMATOLOGICAL NURSING BEST PRACTICE


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 Stud 42(7): 82335
Fendler E (2000) Physico-chemical
considerations. 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 Treat 8: s2527
Flynn TC, Petros J, Clark RE, Viehman GE
(2001) Dry skin and moisturizers. Clin
Dermatol 19(4): 38792
Ghadially R, Brown B, Sequiera-Martin S,
Feingold K, Elias P (1995) The aged epidermal
permeability barrier: structural, functional and
lipid biochemical abnormalities in humans and
a senescent murine model. J Clin Invest 95(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
Dermatol 147(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
Hanin 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

10

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


different moisturisers on SLS-irritated human
skin. Cont Derm 44(4): 22934
Hoare C, Li Wan Po A, Williams H (2000)
Systematic review for treatments of atopic
eczema. Health Tech Assess 14(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 Treat 13(3): 10306
Loden M (2003) Role of topical emollients and
moisturizers in the treatment of dry skin barrier
disorders. Am J Clin Dermatol 4(11): 77188
Loden M (2003a) The skin barrier 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 Derma 11(3): 187
Lucky AW, Leach AD, Laskarzewski P, Wenck
H (1997) Use of an emollient as a steroidsparing agent in the treatment of mild to
moderate atopic dermatitis in children. Paed
Dermatol 14(4): 32124.
Marks R (1997) How to measure the effects
of emollients. J Dermatol Treat 8: 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
Res 94(1): 3337
National Institute for Health and Clinical
Excellence (2001) Referral Advice: A guide to
appropriate 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. Cutis 76(6S):
2631
Nicol N, Ruszkowski A, Moore J (1995)
Contact dermatitis and the role of patch

testing in its diagnosis and management.


Dermatol Nurs Supp Feb: 527
Peters J (2001) Caring for dry and damaged
skin in the community. Br J Comm Nurs 6(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 Therap 17(Suppl 1):
4956
Schlagel CA, Sanborn EC (1964) The weights
of topical preparations required for total and
partial body injunction. J Invest Dermatol 42:
25356
Smoker A (2007) Topical Steroid or
Emollient Which One do you Apply First?
An Investigation 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 Nurs 9(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 Dermatol 92: 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. Cutis 50: 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

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Antimicrobial products may lower the bacterial load on the skin and
therefore lessen the chance of an acute are up

If recurrent skin infections are an issue, using antimicrobial products may be


helpful

Hoare et al, 2000

NICE, 2001
Akdis et al, 2006
Marks, 2001
Hall, 2003

Dry skin conditions typically reect disruption to the normal functioning


of the skin barrier; emollients can contribute to the restoration of this
function through enhancing skin hydration
Due consideration must be given to the accessibility of these products
to ensure that they are available in adequate quantities via the most
appropriate mechanism, e.g. on prescription

Dry skin conditions require emollients as part of therapeutic treatment


regimes

If someone does not like the emollient that they have been recommended
they will not use it
Treatment adherence is dependent on the acceptability of medication used
(e.g. does it mark clothing?)

The above statement has to be modied, however, in order to take into


account the individuals preferences and lifestyle

All Party Parliamentary Group on Skin, 2006

Marks, 1997
Held et al, 2001

The greasier the product the more effective it is as an emollient. Lipid-rich


emollients restore the skin barrier most rapidly

A general rule is that the drier the skin, the greasier the emollient should
be, i.e. very dry skin is best treated with an ointment, moderately dry with a
cream or gel, and slightly dry with a lotion

An individual should be provided with a choice of products, preferably in


This allows for informed choice about what products suit for which
trial-size quantities, to allow them to make an informed decision about which
situations, e.g. a cream/gel moisturiser may be preferable for daytime use
they would like to use
with an ointment being suitable for use at night- time. The use of preferred
products enhances adherence

Evidence

Reasons underlying statements

Statement

Choosing emollient products

Statement 1

DERMATOLOGICAL NURSING BEST PRACTICE

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Bath additives leave a layer of oil over the skin after bathing and prevent
excessive moisture loss from the skin during washing
In order to be effective, the correct amount of product should be added
to wash water
Topical leave-on emollients are vital for rehydrating the skin, improving the Schlagel and Sanborn, 1964
symptoms of dryness such as itch, tightness and scaling and may enhance
BMA and Royal Pharmaceutical Society of Great Britain, 2007
the effectiveness of other products
Britton, 2003
The use of inadequate quantities of emollient does not provide an effective
occlusive barrier to water loss by evaporation

Further moisturising effects may be achieved by adding a bath additive to


wash water as per the manufacturers instructions. Some can be used as a
wash product in the shower

A leave-on topical emollient should be applied to the skin regularly in order


to keep it well-hydrated. Quantities will vary but between 250600g per
week is recommended, depending on the level of skin dryness, the extent of
the dryness and the size of the individual. For a child, 250g is usual and for
an adult, 500600g. See Appendix 3 for a detailed chart on delivering the
correct quantity of emollient

BMA and Royal Pharmaceutical Society of Great Britain, 2007

Berth-Jones and Graham-Brown, 1992


Subramanyan, 2004

The surfactant effect of soap removes natural skin lipids sebum. Soap
substitutes cleanse the skin without drying it and may improve skin
hydration

During skin cleansing, care should be taken to minimise the potential drying
effects from washing. Soap substitutes otherwise known as skin cleansers or
synthetic detergents syndets should be used to wash the skin. They should
be applied to the skin using hands or a wash cloth, and then rinsed off

Emollients for scalps need to be easy to apply despite the presence of hair.
Topical leave-on emollients are vital for rehydrating the skin, improving the
Oils are effective, particularly coconut oil, which is solid at room temperature
symptoms of dryness such as itch, tightness and scaling.They can also soften
but melts on contact with skin
scale, helping to remove it

Evidence

Rationale

Statement

The types of emollients and quantities that should be used

Statement 2

DERMATOLOGICAL NURSING BEST


SUPPLEMENT
PRACTICE

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Cork 1997; Hall 2003; Cork et al, 2004


Holden et al, 2002

Dry skin is characterised by a loss of moisture. This can be ameliorated or


reversed through the use of emollients
Applying a topical emollient after washing helps to trap moisture into the
skin, maximising its hydrating effect
The skin will dry out over night due to insensible loss and by perspiration;
this is likely to be aggravated by heat

Emollients are used to treat dry skin

Emollients should be used during washing and as a topical leave-on product


applied after washing. The skin should be gently dried, leaving it slightly moist
before applying the leave-on emollient product

Leave-on topical emollients should be applied before going to bed. It may


be more acceptable to use a greasy emollient, for example, an ointment at
this time

Microbiological principle

It is easier to carry small amounts of emollient around. This will help to


promote treatment adherence
Using clean cylindrical containers will reduce the potential for cross
contamination
Applying topical medications (such as topical steroids) to
well-moisturised skin increases the efcacy of said product (see Statement
5 for more detail)

It is useful for individuals to have smaller quantities of emollient decanted


into clean cylindrical containers (which should be washed and dried
regularly), that can be carried around and used as necessary

Emollients should be applied to the skin and allowed to absorb before


applying other topical products, for example, topical steroids *

Hoare et al, 2000

Physiological principle

Emollients should be applied at other points in the day that suit the
Individuals with dry skin conditions will nd that their skin becomes dry
individual. These will vary from person to person, however for someone with
quickly due to disruption of the barrier function and water loss
a very dry skin condition (e.g. atopic eczema), it is not unusual to need to
Emollients are easily rubbed off the skin by clothing
apply emollient every 23 hours, particularly to exposed areas
To maximise their efcacy, emollients should be applied regularly

Physiological principle

Evidence

Rationale

Statement

Frequency and timing of emollient application

Statement 3

DERMATOLOGICAL
DERMATOLOGICALNURSING
NURSINGBEST
SUPPLEMENT
PRACTICE

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14

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Physiological principle

The act of rubbing the skin will stimulate the circulation, generate heat and
make the skin feel itchier
Rubbing against the lie of the hair can aggravate the hair follicle causing
folliculitis, particularly when greasy ointments are used
For some conditions, the emollient may not only be being used as a
therapeutic product in its own right, but as part of a massage regimen. In
these instances, the importance of stimulating, for example, lymphatic or
venous return outweigh the possibilities of folliculitis
By dipping an ungloved hand into a pot of emollient it is possible to cause
microbial contamination of the product
This is particularly relevant in creams that have a water content. This can
be minimised by removing the quantity required with a spoon or spatula
Pump dispensers are less prone to contamination and also deliver a set
amount, although these will not work for ointments
Each pot of emollient should only be used by one person
Emollients can be applied to non-affected areas of the skin without any
undue effects
Occluding the skin using any of these devices enhances the penetration
and therefore efcacy of the emollient

Emollients do not tend to have side-effects and will not cause skin damage, Microbiological principle
unless an individual is sensitive to one or more of the ingredients
Most skin diseases are not contagious, however, where infection is
established (e.g. a bacterial infection or viral infection), the wearing of
gloves will help reduce cross-infection
Clean hands will help to reduce the likelihood of cross-infection
Shorter, smooth nails help to reduce the likelihood of trauma to the skin
Knowledge of, and concordance with, treatment is much more effective
if an individual has been shown how to do this properly through planned
education

Topical emollients should be smoothed gently into the skin following the
lie of the hair. It is not desirable to rub continuously until all the product is
absorbed

The only exception to the above is if an emollient is being used as part of


therapeutic massage when application is dictated by the specic massage
technique, e.g. lymphatic drainage

When large quantities of cream, gel or lotion are required, these should be
dispensed from a pump dispenser. If a pot of emollient is used, the required
amount per application should be scooped out with a clean spoon and then
applied to the skin

Although topical moisturisers can be applied just to the affected areas, it is


often helpful for the product to be applied all over

Emollients may be applied under occlusion such as dressings, paste bandages


and wet-wraps

In general, it is not necessary to wear gloves when applying emollient to


someone else. The decision to wear gloves should be taken on an individual
basis, taking into consideration universal precautions, local policies and the
environment

Hands should be washed before applying an emollient.


Fingers nails should be kept short and smooth

Individuals with dry skin conditions should be able to discuss and be shown the
application of emollients by a healthcare professional

Gradwell et al, 2002


Cork et al, 2003
de Korte et al, 2005

Nicol, 1987
Boguniewicz and Nicol, 2002

Microbiological principle

Physiological principle

Evidence

Rationale

Statement

Method of emollient application

Statement 4

DERMATOLOGICAL NURSING BEST PRACTICE

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Watsky et al, 1992


Lucky et al, 1997
Hanin et al, 1998
Finlay, 1997

There is some evidence to show that well-moisturised skin requires a


reduced amount of steroid
There is some evidence to show that dithranol treatment is more effective
following the use of emollients
Applying an emollient on top of a steroid means that the steroid may be
diluted and spread to areas of the body where it is not needed

Therapeutic topical products should be applied to


well-moisturised skin*

* These statements remain controversial and the practitioner needs to take into account the skin disease which is present and what topical agent is being used. In two extensive reviews of the evidence for the treatment of atopic eczema
(Hoare et al, 2000; American Academy of Dermatology, 2003), emollients were recognised as important, but no evidence-based guidance was provided to help the practitioner in the practical task of applying therapeutic topical agents. The
evidence that does exist suggests that topical emollients can be steroid sparing, and in general the experience of the Expert Panel is that topical steroids, in particular should be applied to well-moisturised skin. A review by Smoker (2007),
highlighted numerous concerns, including the possible occlusive effect of emollients preventing penetration of steroids (if occlusive emollients are applied rst) and the diluting/smearing effect of applying an emollient after a steroid. Smoker
was unable to nd any conclusive evidence to support either stance. It is therefore difcult to take a denitive stance as further evidence is required.

Moisturisers should be allowed to absorb into the skin before the application If the emollient has not been absorbed into the skin it may dilute the effect Physiological principle
of a therapeutic product. The skin should feel slightly tacky but not slippery* of the therapeutic topical preparation as it is applied to the skin. The length
of time that it takes for the emollient to absorb will depend on variables
such as how dry the skin is and how greasy the topical emollient is

Evidence

Rationale

Statement

Applying emollients in relation to other therapeutic topical products

Statement 5

DERMATOLOGICAL NURSING BEST PRACTICE

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DERMATOLOGICAL NURSING BEST PRACTICE

Appendix 1
References according to evidence level
Systematic Review
Hoare et al (2000)

Research
Systematic review for treatments of atopic eczema

Randomised controlled trial


Buraczewska et al (2007)

Review

Impact of emollients on transepidermal water loss

Gradwell et al (2002)

Impact of nurse consultation

Akdis et al (2006)

Guidelines for atopic dermatitis

Grimalt et al (2007)

Steroid-sparing effect of emollients

American Academy of Dermatology (2003)

Guidelines for atopic dermatitis

Hanin et al (1998)

Steroid-sparing effect of emollients

Boguniewicz and Nicol (2002)

Guidelines for atopic dermatitis

Watsky et al (1992)

Steroid-sparing effect of emollients

Britton (2003)

Quantities of emollients

Cork (1997)

Skin barrier function

Prospective clinical studies


Berth-Jones and Graham-Brown (1992)

Effects of soap substitutes

Cork et al (2004)

Emollient use in atopic dermatitis

Cetta et al (1991)

Skin care products on newborns

De Groot (2000)

Sensitising substances

Cork et al (2003)

Impact of nurse consultation

De Korte et al (2005)

Impact of nurse consultation

Downing and Stewart (2000)

Structure of epidermis

Elias (1993)

Epidermal lipids

Ersser (2000)

Pruritus in the elderly

Ersser et al (2005)
Fendler (2000)

Skin vulnerability and incontinence


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)
Loden M (2003)
Marks (1997)

Emollients, atopic dermatitis and skin barrier function

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

Emollients, dry skin and barrier function


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)
Subramanyan (2004)
Stone (2000)
Trotter (2004)
Van Onselen (2001)
Voegeli (2007)
Williams et al (2003)

16

Lucky et al (1997)

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

Order of treatment application

National Institute for Health and Clinical Excellence (2001)

Referral guidelines

Review of cleansers

National Institute for Health and Clinical Excellence (2001)

Technology Appraisal

Effects of lanolin
Care of the newborn skin

Primary Care Dermatology Society and


British Association of Dermatologists (2006)

Guidelines for the management


of atopic eczema

Psoriasis
Skin breakdown and its prevention
Atopic eczema

Government guidelines
Department of Health (2007)

Caring for children from 0-5 (guidance for parents)

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Appendix 2
Examples of emollients
Less greasy for dry skin

Most greasy for very dry skin

Bath additive

LOTIONS

CREAMS AND GELS

OINTMENTS

Eucerin lotion (10% urea)

Balneum Plus (contains urea and antipruritic lauromacragols)

50% white soft parafn 50% liquid


parafn

Balneum Bath Oil (soya oil)

E45 Lotion

Unguentum M

White soft parafn

Balneum Plus Bath Oil (soya oil with


anti-pruritic lauromacragols)

Dermol 500 lotion (contains antiseptic)

Doublebase

Emulsifying ointment

Oilatum Junior (fragrance free bath


additive)

Aveeno

E45 Cream

Yellow soft parafn

Oilatum Shower Formula Gel

Keri Lotion

Eucerin cream (10% urea)

Diprobase ointment

Oilatum Bath Formula

Vaseline Dermacare

Diprobase cream

Hydrous ointment

Oilatum Plus (with benzalkonium


chloride 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)

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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.

Emollient quantities according to the British National Formulary (British Medical Association and Royal Pharmaceutical Society of
Great 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

400 g

500ml

1525 g

100ml

Trunk
Groins and genitalia

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Glossary
Adherence
Allergy
Anti-inammatory
Anti-microbial
Anti-mitotic
Anti-pruritic
Antiseptic
Branded
Ceramides
Concordance
Corneocyte
Cream
Emulsion

To observe or following instructions closely


A reaction to a substance that started by the immune system
A substance or product that reduces inammation
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 specic product, which is only made by a specic company
The basic unit of the sphingolipids
An agreement between individuals about a course of action (in this context agreeing to use a particular 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 emulsiers added
A mixture of two substances that are generally immiscible so shaking must occur to mix the two substances or an
emulsier must be added

Emulsier
Epidermis
Excipient
Exfoliative

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)

Folliculitis
Fatty acids
Hair follicle
Humectant
Hypo-allergenic

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 fats
The 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
ofcial standard has been developed.

Immune-mediated
Intercellular
Invagination
Irritant
Lauromacrogols
Lotion
Natural moisturising factor
Non-foaming
Occlusion
Ointment
Parafn
Stratum corneum
Sebum
Topical
Transepidermal
Urea

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 properties
Water 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

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