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Moisturizers as Non-Pharmacologic Therapy for Eczema

A persistent feature of eczema is itchy dry skin that is caused by a dysfunctional skin barrier, which makes the skin hypersensitive to certain environmental triggers and initiates inflammatory responses by the body. Some medications that are used to treat eczema can further worsen the dryness, itching, and irritation.

Potential triggers, such as irritants, aeroallergens, climate and foods) on an already impaired skin barrier drive the dry skin cycle and leave skin vulnerable to microbial infections. For these reasons, maintaining adequate hydration and restoring epidermal barrier defenses provide the rationale for moisturization therapy. The daily use of moisturizers (as much as 3-4 times each day) is essential for successfully managing eczema, both during and in-between flare-ups.

What are moisturizers?

Moisturizers are composed of a combination of key ingredients that are categorized as emollients, humectants, and occlusives, which work together to enhance hydration and improve the skin barrier function. Not all moisturizers are equally effective and special care must be taken when selecting an appropriate formulation. Many brands contain potentially sensitizing ingredients, such as preservatives, fragrances and botanicals. Bland, perfume-free varieties are generally safer alternatives for eczematous skin.

  • Emollients are lipids and oils that hydrate and improve the appearance of the skin by contributing to softness, smoothness, and improved flexibility (Table 1).
  • Humectants attract and retain hydration in the skin by enhancing water absorption from the dermis into the epidermis, or by absorbing water from the external environment (Table 2). The most effective humectant is glycerine (also referred to as glycerol). Glycerin is the most widely used humectant. Although effective, avoid the use of urea-containing moisturizers in young children due to potential irritation.
  • Occlusives reduce water loss through the skin (transepidermal water loss) by creating a barrier over the skin (Table 3). Petroleum jelly (petrolatum) is the most effective occlusive, followed by lanolin, mineral oil, and silicones. Their main limitations include a "greasy" feel and potential irritation, however, silicone-based derivatives, such as dimethicone, are oil-free alternatives that are noncomedogenic, nonirritating, nonsensitizing, and more cosmetically acceptable.
Types of Emollients Examples

Astringent emollients

Cyclomethicone, dimethicone, isopropyl myristate, octyl octanoate

Dry emollients

Decyl oleate, isopropyl palmitate, isostearyl alcohol

Fatting emollients

Diisopropyl dilinoleate, isopropyl isostearate

Protein rejuvenators

Collagen, elastin, keratin

Table 1. Common substances with emollient properties



  • Gelatin
  • Glycerin
  • Honey
  • Hyaluronic acid
  • Panthenol
  • Propylene glycol
  • Sodium lactate
  • Ammonium lactate
  • Sodium pyrrolidone carboxylic acid (sodium PCA)
  • Sorbital
  • Urea

Table 2. Common substances with emollient properties



Types of Occlusives Examples

Fatty acids

Lanolin acid, stearic acid

Fatty alcohols

Cetyl alcohol, lanolin alcohol, stearyl alcohol

Hydrocarbon oils/ waxes

Caprylic/capric triglyderide, mineral oil, paraffin, petrolatum, silicone-derivatives (cyclomethicone, dimethicone), squalene

Phospholipids

Lecithin

Polyhydric alcohols

Propylene glycol

Sterols

Cholesterol

Vegetable waxes

Candelilla, carnauba

Wax esters

Beeswax, lanolin, stearyl stearate

Table 3. Common substances with occlusive properties



How do moisturizers work?

Emollients-based moisturizers work by reinforcing the skin barrier with lipid ingredients. Essentially, these key constituents in moisturizing formulas take on the functions of naturally occurring lipids, which are either absent or impaired in eczematous skin. Treatment of the skin with moisturizers can repair the skin barrier, increase water content, reduce transepidermal water loss (TEWL), and restore the lipid barriers' ability to attract, retain, and redistribute water.

  • The maximum benefits of moisturizers are derived from regular and frequent use.
  • By slowing TEWL and maintaining hydration levels, moisturizers help dry and/or aging skin to improve its structural integrity, appearance, and feel.
  • By covering tiny fissures and providing an occlusive protective film over the skin, moisturizers restore the epidermal barrier and reduce the ability of allergens and irritants to penetrate the skin.

Additional Benefits of Moisturizers

The regular use of suitable moisturizers has become essential standard therapy for eczema by serving as a foundation to support medical treatment.

The regimented use of moisturizers can reduce the need for topical medicines, such as corticosteroids and calcineurin inhibitors. Because adequate hydration can restore the skin barrier, the side-effects produced by some medications can be reduced. During flares, over-the-counter preparations combining a moisturizer with a topical corticosteroid, such as clobetasone and hydrocortisone, are helpful to control inflammation and improve the skin's barrier function.

Adapted from: Kraft JN, Lynde CB, Lynde CW. Skin Therapy Lett FP 5(2):5-7.

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