Professional Documents
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emollient therapy
A statement for healthcare professionals
Hair
Sweat pore
Epidermis
Sweat
gland
Sebaceous gland
(produces sebum that oils the skin)
Dermis
Hair
follicle
Blood vessels
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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.
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Glossary
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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
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Hair
Sweat pore
Epidermis
Sweat
gland
Sebaceous gland
(produces sebum that oils the skin)
Dermis
Hair
follicle
Blood vessels
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
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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)
Imidurea
Isopropyl palmitate
N-(3-Chloroallyl) hexaminium chloride
(quaternium 15)
Polysorbates
Propylene glycol
Sodium metabisulphite
Sorbic acid
Wool fat and related substances, including
Lanolin
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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
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Table 2
Changes in elderly skin
Changes in the skin
Consequence
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
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
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Antimicrobial products may lower the bacterial load on the skin and
therefore lessen the chance of an acute are up
NICE, 2001
Akdis et al, 2006
Marks, 2001
Hall, 2003
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?)
Marks, 1997
Held et al, 2001
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
Evidence
Statement
Statement 1
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S10
12
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
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
Statement 2
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Microbiological principle
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
Statement 3
DERMATOLOGICAL
DERMATOLOGICALNURSING
NURSINGBEST
SUPPLEMENT
PRACTICE
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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
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
Individuals with dry skin conditions should be able to discuss and be shown the
application of emollients by a healthcare professional
Nicol, 1987
Boguniewicz and Nicol, 2002
Microbiological principle
Physiological principle
Evidence
Rationale
Statement
Statement 4
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* 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
Statement 5
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Appendix 1
References according to evidence level
Systematic Review
Hoare et al (2000)
Research
Systematic review for treatments of atopic eczema
Review
Gradwell et al (2002)
Akdis et al (2006)
Grimalt et al (2007)
Hanin et al (1998)
Watsky et al (1992)
Britton (2003)
Quantities of emollients
Cork (1997)
Cork et al (2004)
Cetta et al (1991)
De Groot (2000)
Sensitising substances
Cork et al (2003)
De Korte et al (2005)
Structure of epidermis
Elias (1993)
Epidermal lipids
Ersser (2000)
Ersser et al (2005)
Fendler (2000)
Finlay (1997)
Emollients in psoriasis
Flyn et al (2001)
Hall (2003)
Harding et al (2000)
Holden et al (2002)
Loden M (2003a)
Loden M (2003)
Marks (1997)
Surveys
Betzuegge-Pffaf and Melze (2005)
McNally et al (1998)
Miyake et al (2004)
Experiments
Ghadially et al (1995)
Held et al (2001)
Emollient quantities
Marks (2001)
Review of emollients
Nicol (1987)
Nicol et al (1995)
Nicol (2005)
Peters (2001)
Rawlings et al (1994)
Rawlings et al (2004)
Smoker (2007)
Subramanyan (2004)
Stone (2000)
Trotter (2004)
Van Onselen (2001)
Voegeli (2007)
Williams et al (2003)
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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
quantities ofemollients
Hall (2003)
Referral guidelines
Review of cleansers
Technology Appraisal
Effects of lanolin
Care of the newborn skin
Psoriasis
Skin breakdown and its prevention
Atopic eczema
Government guidelines
Department of Health (2007)
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Appendix 2
Examples of emollients
Less greasy for dry skin
Bath additive
LOTIONS
OINTMENTS
E45 Lotion
Unguentum M
Doublebase
Emulsifying ointment
Aveeno
E45 Cream
Keri Lotion
Diprobase ointment
Vaseline Dermacare
Diprobase cream
Hydrous ointment
Epaderm
Cetraben emollient
Gammaderm
Hydromol ointment
Lipobase
Aquaphor
Oilatum
Dermalo
Ultrabase
Diprobath
Zerobase
Aveeno
Hydromol emollient
Decubal
Imuderm
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Appendix 3
Emollient measures (Britton, 2003) These quantities are appropriate for a single application for an adult
Body site
Amount of moisturiser
Amount of moisturiser
Amount of moisturiser
Arm
Chest
Abdomen
Upper back
Lower back
Thigh
Shin
Total
20 pumps/20g
50 pumps/50g
100 pumps/100g
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
Lotions
Face
1530 g
100ml
Both hands
2550 g
200ml
Scalp
50100 g
200ml
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
Emulsier
Epidermis
Excipient
Exfoliative
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
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