What is best for my dry skin?

A common question from patients. Dry skin (xerosis) is a frequent dermatological problem that increases in prevalence with age, see my earlier blog on this topic. How often as podiatrists do we observe dry feet and scaly legs in our older patients particularly? Too often, probably. What ensues in the consultation is a discussion about their shower habits and emollient use to prevent the skin from drying out.

Chronic xerosis can lead to asteototic eczema (winter itch) and its complications (figure 2), a topic covered previously in my blog. Research suggests that half of over 65s have dry skin [1] rising to 90% in the over 80’s [2, 3]. Emollients are the first line in treating the problem, but which ones are best? This blog explores some recent research – suggesting that not all emollients are the same.

Which cream might be best for older patients?

Emollient Guidelines

Emollient guidance has been published previously [4, 5] and the main message is that “the best emollient is the one that patient uses”. Basically, saying any emollient is a good emollient but is that necessarily the case? A recent paper in the British Journal of Dermatology challenged this belief suggesting that not all emollients are the same [6]. Dermatology researcher, Simon Danby highlighted how studies are uncovering some of the negative effects of emollients.

Most of us recall the news of irritation of the skin caused by the original aqueous cream due to its Sodium Lauryl Sulphate (SLS) content [7, 8]. Moreover, Dr Danby goes onto report how research has shown particular products when applied can improve drug delivery through the skin, for example, topical steroid drug delivery is enhanced when used in conjunction with an emollient [9].

The downside of an improved absorption rate is that unwanted elements can also take advantage of this enhanced route into the skin such as irritants, allergens and infection. This point is exemplified when studies examining whether the skin barrier in infants can be improved with a regular application of various emollients have had very mixed results [10]. Consequently, there is a call for further work to be conducted to find out what factors affect penetration such as formulation, ingredients, age of the patient, timings of applications etc.,

So where does that leave healthcare professionals in terms of giving the most relevant, up-to-date advice? When published evidence is not clear or doesn’t provide all the answers, using evidence-based principles, expert opinion can often help inform practice when there is doubt or uncertainty.

Figure 2: Winter Itch - Mild eczema on the top of the foot demonstrating drying of the epidermis

Consensus : When Evidence on Emollients is lacking

A recent consensus paper has been published in the International Journal of Dermatology which addresses a number of questions regarding dry skin in older patients [11]. The part of particular interest was the expert recommendation in terms of which emollients might work best. In order to understand this, it is important to consider the factors why the skin becomes drier as we age.

Challenges to older skin

Our skin for most of our life is well equipped to maintain itself and perform its role as a barrier – limiting loss of water and preventing ingress of microbes, allergens and UV. Water loss is limited by a range of processes – natural moisturising factors [NMF] (including amino-acids, lactic acid and urea) within the keratinocytes maintain their integrity whilst inter-cellular lipid layers of ceramides, cholesterol, and free fatty acids provide a hydrophobic barrier to water.

The main challenges to our skin physiology come from the environment and how we live. For example, our skin care habits:

·       Frequent / prolonged hot showers

·       Use of soaps, shower gels and skin care products containing  SLS content

·       Friction from harsh towelling

·       Central heating / air conditioning

·       Excessive sun exposure

In addition, older skin faces the effects of ageing. This includes:

·       Reduction in natural skin lipid production (ceramides) and increased skin recovery times

·       Side effects of drugs (like statins) and polypharmacy

·       Co-existing diseases (eczema, psoriasis etc.,)

·       Hormonal changes after menopause

All these factors can deplete the natural waterproofing from skin leading to xerosis. For example it has been shown even after short periods of water immersion, NMF levels are dramatically depleted for several hours after showering and bathing [12].

Recommendations

The main message in this consensus is around modifying, where possible, the factors listed above. In addition, they review more recent evidence about the benefits of ceramide containing skin care products citing a collection of papers, demonstrating their value in older patient’s skin care, improving skin barrier function.

Ceramides make up about 45-50% of the intracellular lipid content by weight. There are at least eight major free ceramides identified in the skin. Each ceramide type has unique properties that contribute to SC organization and cohesion and thereby provide the SC with its barrier function [13, 14]. Moreover, they promote barrier repair.  Research has established that ceramide production and content decreases with age [15].

The use of soaps and shower gels is detrimental to the skin because of its degreasing properties of its SLS content removing these lipid-based agents. Consequently, as suggested in emollient guidelines, SLS is best avoided and substituted with cleansers / emollient wash products. Other additives are also suggested - urea is a useful, natural ingredient due to its skin restoring properties. In addition, Hyaluronic acid, naturally occurring in the dermis and epidermis, plays a part in barrier function and is a welcome inclusion in skin care preparations for the older patient.

Which Emollients might be best?

The consensus suggests that ceramide-based products are advantageous for older, dry skin due to their properties. NMF’s, as discussed, naturally produced and are integral to normal skin function and so it makes sense include as many as possible in skin care products to mimic the skins natural chemistry.

Increasingly we are seeing products in the market which mimic skin and contain a range of these including amino acids, urea, lactic acid, ceramides and hyaluronic acid. From the emerging research such products appear to have significant benefits, but ongoing research will hopefully to continue to discover more of their positive benefits in treating and preventing xerosis, a very common problem in the older patient.

Which Products are easily available to patients with ceramide?

Well, here’s the bad news. Unfortunately, ceramide containing creams are not widely available on prescription in the UK. The good news is that they are available to purchase over the counter. I have listed a few products below (please note, this is not an exhaustive list and other are available):

CeraVe® range includes:

·       CeraVe Hydrating Cleanser moisturising lotion and cleanser. A soap substitute containing 3 ceramides and hyaluronic acid.

·       CeraVe Intensive Moisturising Lotion. Made for very dry skin it contains 3 ceramides, hyaluronic acid and urea (5%).

·       CeraVe Daily Moisturizing Lotion. As above but without the urea content.

Eucerin® range includes:

·       Eucerin® Advanced Repair Body lotion. Contains urea and ceramide.

·       Eucerin® Advanced Repair Body cream. Contains urea and ceramide.

·       Eucerin® Urea Repair PLUS ( with 10% urea). Contains ceramide, urea and lactic acid.

·       Eucerin® Urea Repair Plus Foot Cream: a foot care product which contains both urea and ceramide.

Implications for Practice

The recommendations made in this paper make sense - if something is missing from the skin then replace it. If its a close to natural skin lipid then theoretically its likely to be compatible with fewer issues of compatibility, irritancy and allergy.

The recommendations are for dry skin, generally. For the plantar surface and all its unique properties the effects are not so well known or studied so its difficult to apply this specifically to that area. However, as most of our older patients will have generalised dry skin, its good to give this advice.

Author Note: The author has received no financial incentives in compiling this blog.

References

1.           Paul, C., et al., Prevalence and Risk Factors for Xerosis in the Elderly: A Cross-Sectional Epidemiological Study in Primary Care. Dermatology, 2011. 223(3): p. 260-265.

2.           Augustin, M., et al., Prevalence, predictors and comorbidity of dry skin in the general population. Journal of the European Academy of Dermatology and Venereology, 2019. 33(1): p. 147-150.

3.           Lichterfeld, A., et al., Dry skin in nursing care receivers: A multi-centre cross-sectional prevalence study in hospitals and nursing homes. Int J Nurs Stud, 2016. 56: p. 37-44.

4.           Moncrieff, G., et al., Use of emollients in dry-skin conditions: consensus statement. Clin Exp Dermatol, 2013. 38(3): p. 231-8.

5.           British Dermatological Nursing Group. Best practice in emollient therapy a statement for healthcare professionals (December 2012). 2012; Available from: https://bdng.org.uk/emollient/.

6.           Danby, S.G., Debunking the myth that all emollients are equal opens the door for future atopic dermatitis prevention studies. British Journal of Dermatology, 2024. 191(1): p. 6-7.

7.           Danby, S.G., et al., The effect of aqueous cream BP on the skin barrier in volunteers with a previous history of atopic dermatitis. British Journal of Dermatology, 2011. 165(2): p. 329-34.

8.           Cork, M.J. and S. Danby, Aqueous cream damages the skin barrier. British Journal of Dermatology, 2011. 164(6): p. 1179-80.

9.           Grimalt, R., V. Mengeaud, and F. Cambazard, The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomized controlled study. Dermatology, 2007. 214(1): p. 61-7.

10.        Katibi, O.S., et al., Moisturizer therapy in prevention of atopic dermatitis and food allergy: To use or disuse? Ann Allergy Asthma Immunol, 2022. 128(5): p. 512-525.

11.        Fluhr, J.W., et al., A global perspective on the treatment and maintenance of mature skin using gentle cleansers and moisturizers. International Journal of Dermatology, 2024. n/a(n/a).

12.        Robinson, M., et al., Natural moisturizing factors (NMF) in the stratum corneum (SC). II. Regeneration of NMF over time after soaking. J Cosmet Sci, 2010. 61(1): p. 23-9.

13.        Schachner, L., et al., Supplement Individual Article: The Importance of a Healthy Skin Barrier From the Cradle to the Grave Using Ceramide-Containing Cleansers and Moisturizers: A Review and Consensus. J Drugs Dermatol, 2023. 22(2): p. SF344607s3-SF344607s14.

14.        Schachner, L.A., et al., A Consensus About the Importance of Ceramide Containing Skincare for Normal and Sensitive Skin Conditions in Neonates and Infants. J Drugs Dermatol, 2020. 19(8): p. 769-776.

15.        Verdier-Sévrain, S. and F. Bonté, Skin hydration: a review on its molecular mechanisms. Journal of Cosmetic Dermatology, 2007. 6(2): p. 75-82.