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IJPD SYMPOSIUM
Year : 2017  |  Volume : 18  |  Issue : 3  |  Page : 179-181

Role of emollients


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 Publication7-Jun-2017

Correspondence Address:
Sandipan Dhar
Flat 9C, Palazzo, 35, Panditia Road, Kolkata - 700 029
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Source of Support: None, Conflict of Interest: None


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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 Nov 23];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.[1],[2]

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.[3],[4] This is mainly governed by the clinicians' assessment of the extent of dryness and the environmental conditions.[5],[6],[7] 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.[8],[9] 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.[10],[11]

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.[12],[13] 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.[14],[15] 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.[16],[17]

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.[18]

The use of colloidal oatmeal in the moisturizer is helpful in combating the xerosis in AD.[19] 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.[20]

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.[20],[21] 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.[22],[23]

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.[24],[25]

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.[26] 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.[26] 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.[27] 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.

Recommendations

  • 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.

 
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