|Year : 2017 | Volume
| Issue : 3 | Page : 179-181
Role of emollients
Sandipan Dhar1, Deepak Parikh2, Ramkumar Rammoorthy3, Sahana Srinivas4, Rashmi Sarkar5, Arun Inamadar6, Manish Shah7, Raghubir Banerjee8, Amrinder Jit Kanwar9, Vibhu Mendiratta10, Renu George11, Ram Gulati12
1 Department of Pediatric Dermatology, Institute of Child Health, Kolkata, West Bengal, India
2 Department of Pediatric Dermatology, Wadia Children Hospital, Mumbai, Maharashtra, India
3 Consultant Pediatric Dermatologist, Kanchi Kamakoti Childs Trust Hospital, Chennai, Tamil Nadu, India
4 Consultant Pediatric Dermatologist, Indira Gandhi Institute of Child Health, Bangalore, Karnataka, India
5 Department of DVL-1, CMC, Vellore, Tamil Nadu, India
6 Department of Dermatology, Sri B M Patil Medical College, BLDE University, Bijapur, Karnataka, India
7 Hon. Pediatric Dermatologist, Wadia Hospital for Children, Mumbai, Maharashtra, India
8 Professor of Dermatology, Vivekananda Institute of Medical Science, Kolkata, West Bengal, India
9 Department of Dermatology, Sharda Hospital, Greater Noida, Uttar Pradesh, India
10 Department of Dermatology, Lady Hardinge Medical College, Delhi, India
11 Department of Dermatology, MAMC and Associated LNGP Hospital, New Delhi, India
12 Consultant, Dermatologist, S D M Hospital, Jaipur, Rajasthan, India
|Date of Web Publication||7-Jun-2017|
Flat 9C, Palazzo, 35, Panditia Road, Kolkata - 700 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dhar S, Parikh D, Rammoorthy R, Srinivas S, Sarkar R, Inamadar A, Shah M, Banerjee R, Kanwar AJ, Mendiratta V, George R, Gulati R. Role of emollients. Indian J Paediatr Dermatol 2017;18:179-81
|How to cite this URL:|
Dhar S, Parikh D, Rammoorthy R, Srinivas S, Sarkar R, Inamadar A, Shah M, Banerjee R, Kanwar AJ, Mendiratta V, George R, Gulati R. Role of emollients. Indian J Paediatr Dermatol [serial online] 2017 [cited 2017 Sep 26];18:179-81. Available from: http://www.ijpd.in/text.asp?2017/18/3/179/207613
The pivotal role of AD management is the restoration of the deranged epidermal barrier function by adequate emollient therapy. The selection of emollients should be individualized depending on the degree of xerosis and possible history of contact allergy. Emollients now target the restoration of the skin barrier lipids in AD skin with generally a compromised barrier function.,
Emollients alone improve the hydration and should be applied within 5 min after the bath when the skin is still moist and applied all over the body. Some recommend the use before and after bath or swim preferably within a 3 min time frame. Emollient therapy also involves doing away with irritating cleansers and using emollient bath additives., This is mainly governed by the clinicians' assessment of the extent of dryness and the environmental conditions.,, The application of emollients should be more frequent during acute flares, depending on the xerosis and the climatic conditions. Use of adequate quantities 100–200 g/week in children and 200–300 g/week in adults provides good moisturization., There is a dearth of evidence on the efficacy of bath emollients and their effectiveness compared with the use of emollients directly on the skin surface.,
A wide variety of moisturizers have been found to repair a defective skin barrier and also reduce exposure to irritants demonstrating anti-inflammatory and antimicrobial properties which is of benefit in AD patients., The recommended practice is to cleanse with a nonirritating cleanser and use emollient all over and use medication over the active diseased areas. More frequent application of moisturizer is recommended during active disease flare-ups., Moisturizers will benefit and should be used regardless of the flare up status and can be combined with active therapy. Emollient as a co-therapy to topical corticosteroid (TCS) provide a steroid-sparing efficacy and thus reduces the incidence of flares.,
Moisturizers are available as creams, ointments, oils, gels, or lotions. Ointment or oily cream-type moisturizers are more used for AD patients although they are greasy in nature. Xerosis in winter time will need more lipid-based preparations. Vegetable oils in our set up like coconut oil, is a useful emollient. However, sunflower oil improves barrier function, but these vegetable oils may become rancid during summer months.
The use of colloidal oatmeal in the moisturizer is helpful in combating the xerosis in AD. Ointment or oily cream-type moisturizers are useful for AD patients. Use of a lotion or aqueous cream type moisturizers is useful at bedtime. In winter, higher lipid content emollients offer better skin care. The selection of emollients should be individualized depending on the degree of xerosis and the possible role of contact allergy'. Prescribing moisturizers should also be individualized depending on the choice of the patients, as adolescents tend to treated with creams only if they like it. Occlusive emollients can lead to folliculitis.
Prescription Emollient Devices
These prescription emollient devices claim to be superior to restore skin barrier defects which include ratios of lipids mimicking that of physiological composition ceramides: cholesterol: Essential fatty acids in the ratios of 3:1:1 or 1:1:1., Modern emollients containing agonists of peroxisome proliferator-activated receptors (PPARs) are highly unsaturated fatty acids, certain flavonoids, which cause activation of specific nuclear receptors and thus increase the synthesis of endogenous lipids, improving the function of the epidermal barrier; they also have an anti-inflammatory effect similar to corticosteroids by inhibiting nuclear factor-kB. Some moisturizers containing substances with nonsteroidal anti-inflammatory effects like those containing N-palmitoylethanolamine and sunflower seed oil have recently been used and show significant reduction of pruritus, xerosis, and inflammation.,
Contact dermatitis or moisturizer allergy can result in burning sensation and better be avoided in inflamed skin. Hence, emollients with fragrance and preservatives may cause irritation and are not recommended. Skin irritation in young children <2 years of age is often seen and hence recommended to use emollients without protein allergens or peanut extracts which increase the risk of sensitization. Glycerol is better tolerated than urea, sodium chloride, or propylene glycol in children.,
Emollient Reinforcement of the Skin Barrier from Birth
This study reveals the first randomized controlled trial that daily full-body emollient therapy from birth can play a role in preventing AD. Correction of the subclinical skin barrier dysfunction and inflammation in predisposed infants before AD development is a key factor to control the disease onset. The skin hydration with reduction of permeability prevents the xerosis and cracking hence preventing penetration by allergens and irritants. This might explain the potential for skin barrier protection to reduce IgE sensitization. This view is further strengthened by human and mouse studies suggesting that the skin barrier might be a site for IgE sensitization. The order of application does not matter in the treatment of AD in children and parents can apply topical medications in whichever order they prefer that is emollient followed by TCS after 15 min or in the reverse order. It is still not very well established whether formulations with additives, such as ceramides, improve the skin barrier function better than simple petrolatum-based emollients.
- Emollients have a role in relieving the pruritus in AD patients (A, 1a)
- Emollients enhance the skin barrier function, reduce exposure to irritants, and have anti-inflammatory and antimicrobial effects (C, 4)
- Daily use of emollient therapy is recommended to enhance the integrity of the skin barrier (A, 1)
- Moisturizers after bathing within 3–5 min maintains the skin hydration (B 2)
- Moisturizer should be used at least twice to thrice in a day and even during acute flare-ups in quantity of 100–200 g per week in children (D, 5)
- Avoid use of use of bath emollient additives and nonsoap cleansers as emollients with fragrance and preservatives may cause irritation (C, 3)
- Moisturizer should be used during active disease flares in conjunction with topical anti-inflammatory agents, and also as maintenance therapy
- Daily use of moisturizer has steroid-sparing effects and reduces the incidence of acute flares and can be used as emollient followed by TCS after 15 min or in the reverse order (A, 1b)
- Conventional moisturizers contain occlusives, humectants, and emulsions selection of the vehicle like greasy emollients for dry skin and more creamy textures for red, inflamed eczema
- Active emollients consisting predominantly of ceramides restore skin barrier defects in ratios of lipids mimicking that of physiological composition ceramides: cholesterol: essential fatty acids in the ratios of 3:1:1
- Emollient reinforcement of the skin barrier from birth offers good results in AD prevention.
Financial Support and Sponsorship
This activity was sponsored by Curatio Health Care (I)Pvt. Ltd. from their unlimited Educational Grant.
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Ring J, Alomar A, Bieber T, Deleuran M, Fink-Wagner A, Gelmetti C, et al.
Guidelines for treatment of atopic eczema (atopic dermatitis) Part II. J Eur Acad Dermatol Venereol 2012;26:1176-93.
Osawa R, Akiyama M, Shimizu H. Filaggrin gene defects and the risk of developing allergic disorders. Allergol Int 2011;60:1-9.
Chen H, Common JE, Haines RL, Balakrishnan A, Brown SJ, Goh CS, et al.
Wide spectrum of filaggrin-null mutations in atopic dermatitis highlights differences between Singaporean Chinese and European populations. Br J Dermatol 2011;165:106-14.
Chiang C, Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol 2009;26:273-8.
Draelos ZD. An evaluation of prescription device moisturizers. J Cosmet Dermatol 2009;8:40-3.
Simpson E, Trookman NS, Rizer RL, Preston N, Colón LE, Johnson LA, et al.
Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: Results from an open-label study. Pediatr Dermatol 2012;29:590-7.
Nowicki R, Trzeciak M, Wilkowska A, Sokolowska-Wojdylo M, Lugowska-Umer H, Baranska-Rybak W, et al.
Atopic dermatitis: Current treatment guidelines. Statement of the experts of the Dermatological Section, Polish Society of Allergology, and the Allergology Section, Polish Society of Dermatology. Postepy Dermatol Alergol 2015;32:239-49.
Rubel D, Thirumoorthy T, Soebaryo RW, Weng SC, Gabriel TM, Villafuerte LL, et al.
Consensus guidelines for the management of atopic dermatitis: An Asia-Pacific perspective. J Dermatol 2013;40:160-71.
Kim SY, Jee SM, Lee SJ, Lee YJ, Park JE, Nam MH, et al
. Guidance for Development of Clinical Practice Guidelines. 1st
ed. Seoul: National Evidence-Based Healthcare Collaborating Agency; 2011. p. 607-8.
Shams K, Grindlay DJ, Williams HC. What's new in atopic eczema? An analysis of systematic reviews published in 2009-2010. Clin Exp Dermatol 2011;36:573-7.
Sher LG, Chang J, Patel IB, Balkrishnan R, Fleischer AB Jr. Relieving the pruritus of atopic dermatitis: A meta-analysis. Acta Derm Venereol 2012;92:455-61.
Peltonen JM, Pylkkänen L, Jansén CT, Volanen I, Lehtinen T, Laihia JK, et al.
Three randomised phase I/IIa trials of 5% cis-urocanic acid emulsion cream in healthy adult subjects and in patients with atopic dermatitis. Acta Derm Venereol 2014;94:415-20.
Tan WP, Suresh S, Tey HL, Chiam LY, Goon AT. A randomized double-blind controlled trial to compare a triclosan-containing emollient with vehicle for the treatment of atopic dermatitis. Clin Exp Dermatol 2010;35:e109-12.
Breternitz M, Kowatzki D, Langenauer M, Elsner P, Fluhr JW. Placebo-controlled, double-blind, randomized, prospective study of a glycerol-based emollient on eczematous skin in atopic dermatitis: Biophysical and clinical evaluation. Skin Pharmacol Physiol 2008;21:39-45.
Eberlein B, Eicke C, Reinhardt HW, Ring J. Adjuvant treatment of atopic eczema: assessment of an emollient containing N-palmitoylethanolamine (ATOPA study). J Eur Acad Dermatol Venereol 2008;22:73-82.
Diana R, Thiru T, Retno WS, Steven CKW, Teresita MG, Lillian LV. Consensus guidelines for the management of atopic dermatitis: An Asia-Pacific perspective. J Dermatol 2013;40:1-12.
Grimalt R, Mengeaud V, Cambazard F; Study Investigators' Group. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: A randomized controlled study. Dermatology 2007;214:61-7.
Sankaranarayanan K, Mondkar JA, Chauhan MM, Mascarenhas BM, Mainkar AR, Salvi RY. Oil massage in neonates: An open randomized controlled study of coconut versus mineral oil. Indian Pediatr 2005;42:877-84.
Fowler JF Jr. Colloidal oatmeal formulations and the treatment of atopic dermatitis. J Drugs Dermatol 2014;13:1180-3.
Miller DW, Koch SB, Yentzer BA, Clark AR, O'Neill JR, Fountain J, et al.
An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: A randomized, controlled trial. J Drugs Dermatol 2011;10:531-7.
Boralevi F, Saint Aroman M, Delarue A, Raudsepp H, Kaszuba A, Bylaite M, et al.
Long-term emollient therapy improves xerosis in children with atopic dermatitis. J Eur Acad Dermatol Venereol 2014;28:1456-62.
Schmuth M, Jiang YJ, Dubrac S, Elias PM, Feingold KR. Thematic review series: Skin lipids. Peroxisome proliferator-activated receptors and liver X receptors in epidermal biology. J Lipid Res 2008;49:499-509.
De Belilovsky C, Roo-Rodriguez E, Baudouin C, Menu F, Chadoutaud B, Msika P. Natural peroxisome proliferator-activated receptor-alpha agonist cream demonstrates similar therapeutic response to topical steroids in atopic dermatitis. J Dermatolog Treat 2011;22:359-65.
Lack G, Fox D, Northstone K, Golding J; Avon Longitudinal Study of Parents and Children Study Team. Factors associated with the development of peanut allergy in childhood. N Engl J Med 2003;348:977-85.
Åkerström U, Reitamo S, Langeland T, Berg M, Rustad L, Korhonen L, et al.
Comparison of moisturizing creams for the prevention of atopic dermatitis relapse: A randomized double-blind controlled multicentre clinical trial. Acta Derm Venereol 2015;95:587-92.
Simpson EL, Chalmers JR, Hanifin JM, Thomas KS, Cork MJ, McLean WH, et al.
Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol 2014;134:818-23.
Ng SY, Begum S, Chong SY. Does order of application of emollient and topical corticosteroids make a difference in the severity of atopic eczema in children? Pediatr Dermatol 2016;33:160-4.