On my blog I have written much about the benefits of emollients over the years. They are the mainstay of treatment in dermatology in maintaining skin integrity and health for a range of dermatoses. Regular application can increase the skins flexibility, suppleness and prevent complications such as drying and fissuring. Their benefits are exemplified in conditions such as atopic eczema where emollients can reduce inflammation [1], itching and erythema but are there any other benefits? Two recent papers have investigated tinea pedis and its recurrence, suggesting additional benefits of regular emollient use.
The Research
The first paper [2] highlights current issues around chronic dermatophytosis in India, which is a real health concern which covered in an earlier blog. Once chronic infection has been cleared, recurrence of infection is very common with tinea pedis with reinfection from shoes and socks. Consequently, the researchers wished to investigate if adjuvant use of an emollient had any additional benefit.
A randomised open label study of 80 adult patients diagnosed with chronic and recurrent tinea pedis. The patients were randomised into two groups with both groups receiving oral itraconazole for 6 weeks along with concurrent topical azole (luliconazole). Subsequently, group A received 6 weeks further topical luliconazole and group B six weeks of an emollient only. At 18 weeks both groups were assessed for recurrence.
The results showed at week 12, 100% of patients were in remission, however by week 16 recurrence had occurred 15% of Group A and 12.5% group B patients had reinfection, but this was not statistically significant.
In a second study undertaken in Gujarat [3], India evaluated the use of adjuvant emollient versus 1% topical luliconazole. A total of 135 patients were randomised into two cohorts. Cohort one (n=67) received six weeks of active treatment - oral itraconazole with a twice daily application of a bland emollient. Cohort 2 (n=67) received the same except the bland emollient was replaced with twice daily luliconazole topical cream. A final review took place at week 10, four weeks of no treatment. Dropout rates were identical in both groups. At the end of the active treatment phase of the study (Week 6) cure rates were slightly higher in the luliconazole group but this was not statistically significant (75% cohort 1, 82% cohort 2). Relapse rates at week 10 (four weeks on from the cessation of active treatment) were similar (cohort 1, 32% and cohort 2, 21%).
What does this mean - can emollients prevent athletes foot?
The studies here have been undertaken in response to widespread concern where there is a staggering rise in the number of cases of extensive tinea corporis, probably fuelled by the rise in terbinafine resistant dermatophytes along with over use of potent topical steroids [4]. Reducing cases and recurrence is paramount. In these two studies it was shown that an emollient is probably equally effective as a topical antifungal at preventing recurrence – although based on just these two studies a more robust trial would be warranted.
However, on face value, here maybe a benefit to their use. Emollients are cheap and freely available. The use of emollient as an additional measure was proposed [5] in guidelines in India where dermatophytosis has become endemic. Emollients are known to reduce trans epidermal water loss and promote restoration of the skin’s natural barrier.
Dermatophyte invasion has been studied and relies on adhesion of fungal elements onto the epidermal surface before establishing infection [6]. The mere act of emollient application, twice a day may be sufficient to remove/detach any fungal elements from establishing infection or prevent strong adhesion. Moreover, the physiological effects of emollients of reducing trans epidermal water loss and promoting a skin barrier, may disrupt invasion of dermatophytes, leading to fewer infections being established.
Summary
In summary, this work has demonstrated that emollients may have a role in preventing recurrence of tinea, by an unexplored mechanism. As ever, more research is required to substantiate this, but it is another potential benefit of emollient use emphasising why we should continue the message to our patients to regularly moisturise their skin.
References
1. van Zuuren, E.J., et al., Emollients and moisturisers for eczema. Cochrane Database of Systematic Reviews, 2017(2).
2. Pathania, Y.S., K. Cds, and A. Kumar, Comparing emollient use with topical luliconazole (azole) in the maintenance of remission of chronic and recurrent dermatophytosis. An open-label, randomized prospective active-controlled non-inferiority study. Mycoses, 2023. Early View.
3. Rana, D.K., et al., Evaluation of the benefit of the addition of 1% topical luliconazole versus topical bland emollient to the systemic itraconazole therapy for the management of disseminated dermatophytosis: A randomised control trial. Mycoses, 2024. 67(1): p. e13681.
4. Bristow, I.R. and L.T. Joshi, Dermatophyte resistance – on the rise. Journal of Foot and Ankle Research, 2023. 16(1): p. 69.
5. Rajagopalan, M., et al., Expert Consensus on The Management of Dermatophytosis in India (ECTODERM India). BMC Dermatology, 2018. 18(1): p. 6.
6. Watanabe, K., H. Taniguchi, and T. Katoh, Adhesion of dermatophytes to healthy feet and its simple treatment. Mycoses, 2000. 43: p. 45-50.