Eczema Emollients

Eczema Emollients

Emollients are specialised medical moisturisers designed to manage eczema as well as other dry skin disorders. Compared to cosmetic moisturisers, they are perfume-free and do not contain anti-ageing ingredients. Having been used for more than 5,000 years, emollients remain a cornerstone of treatment for dry skin conditions. They are both safe and effective, offering relief by soothing, hydrating, and protecting the skin. A consistent skincare routine with emollients can significantly reduce the frequency of eczema flare-ups.

What Makes Emollients Effective?

Dry skin is a primary indicator of eczema, often caused by a genetically impaired skin barrier in individuals with atopic eczema. This weakened barrier makes the skin more susceptible to allergens, irritants, and bacteria.

Eczema also causes intense itching, leading to a distressing itch-scratch-damage cycle. Scratching not only worsens skin damage but also increases the risk of irritants and harmful microorganisms penetrating the skin.

Emollients work by soothing irritation and alleviating itchiness. They create an oily layer on the skin’s surface, which locks in moisture and helps restore the skin’s natural barrier. By strengthening this barrier, emollients minimise the entry of allergens, irritants, and bacteria, thus reducing the likelihood of eczema flare-ups and infections.

Leave-On Emollients

The NHS approves more than 120 emollient products (as listed in the ‘NHS Drug Tariff’). Nevertheless, healthcare providers can usually prescribe only a limited selection, depending on your location. These products can also be bought in pharmacies or stores, though some may require special orders.

Finding the appropriate emollient can be a challenge, as effectiveness and personal preference vary. You may require multiple types to meet your skin’s unique needs. Therefore, understanding the different formulations and how they work can help you choose the most suitable option for your skin and lifestyle.

Healthcare professionals often refer to emollients that provide prolonged hydration as “leave-on” emollients. These products form a protective layer over the skin to reduce water loss, a process known as an “occlusive” effect (a medicinal term that means to block or obstruct).

Many emollient creams, lotions, and gels offer a lighter occlusive effect, typically keeping the skin hydrated for 1 to 4 hours. On the other hand, ointments and sprays create a thicker layer and can provide moisture for up to 8 hours.

Some emollients contain additional ingredients like glycerine or urea with natural moisturising properties. They are called humectant emollients and can maintain hydration for 6-24 hours. Despite this, applying them two times per day is recommended for optimal results.

Formulations

Emollients come in various formulations, including lotions, sprays, creams, gels, and ointments. Each is directly applied to the skin and serves different purposes:

  • Lotions: These contain less fat and more water compared to creams. While they spread easily and feel cool, they are less effective for dry skin as they do not sufficiently repair the skin barrier. Lotions are thus ideal for hairy areas, weeping eczema, or when quick absorption is needed. However, they require preservatives, which can occasionally cause sensitivity.
  • Creams: With a balanced mix of water and fat, creams are light, non-greasy, and easy to apply on sore or weeping skin. They are often preferred for daytime use but need frequent application (after every 3 to 4 hours) to successfully correct the skin barrier. Humectant creams with ingredients like glycerine or urea are more hydrating and require application only twice daily.
  • Hydrating gels: These are light and non-greasy in spite of having a relatively higher oil content. They work by forming a three-dimensional molecular structure that traps moisture.
  • Sprays: Emollient sprays, made with ingredients like paraffin and coconut oil, are convenient for hard-to-reach areas. They form a protective layer and are easy to apply.
  • Ointments: Although rigid and greasy, ointments are highly effective at sealing in moisture and repairing the skin barrier. They are ideal for very dry or thickened skin and are often used before bedtime or under wet wraps. However, they should not be applied to weeping eczema. Ointments need fewer preservatives, making them suitable for those with sensitivities.

Additional Ingredients

Some emollients are enhanced with additional ingredients to provide specific benefits:

  • Antimicrobials: These antiseptic agents, found in some lotions, creams, and wash products, help eliminate bacteria. However, prolonged use may cause sensitivities in some individuals.
  • Humectants: Ingredients like glycerine, urea, and propylene glycol draw water into the outermost and second layer of the skin, keeping it hydrated longer than non-humectant emollients.
  • Anti-itch agents: Lauromacrogols, a type of local anesthetic, are included in certain creams to relieve itching.
  • Ceramides: Present in some lotions and creams, ceramides restore the balance of fats essential for maintaining the skin barrier.
  • Oatmeal: Included in some creams, lotions, and bath oils, oatmeal offers antioxidant properties to soothe and protect the skin.

Washing with Emollients (Baths and Showers)

Skin cleansing is a key aspect of managing eczema. A daily bath or shower using an emollient is required to get rid of skin debris and dirt that could lead to infections. Plain water alone can dry out the skin, but adding an emollient helps to cleanse, soothe itchiness, and repair the skin barrier by locking in moisture. Ensure the water is lukewarm since hot water can worsen eczema. If the water itches your skin, consider applying your leave-on emollient all over your body before getting in, and then gently rinse it off.

Avoid regular wash products like soap, bubble baths, wipes, or other cosmetic gels or creams, as they often contain alkaline ingredients, detergents, and fragrances that can irritate and dry out the skin.

  • Soap substitutes

For showering, handwashing, and bathing, use soap substitutes instead of traditional soaps. During the COVID-19 pandemic, persons with eczema were instructed to thoroughly wash their hands with soap first to remove the virus and then apply an emollient. This is because emollients alone were not sufficient for this purpose.

You can use specially formulated emollient wash products or your regular leave-on emollient as a soap substitute. Apply it to your skin before or during your bath or shower, and rinse it afterwards. While soap substitutes do not foam like traditional products, they are effective at cleaning the skin. However, avoid using very greasy options like 50:50 Ointment for washing.

  • Bath and shower oils

You can put emollient bath and shower oils in bath water or apply them directly to the skin during a shower. These products help hydrate the skin by forming an oily layer that holds moisture. Some oils are enriched with antimicrobial or anti-itch properties. While these products are widely available for purchase, they are rarely prescribed by the NHS.

Healthcare professionals normally recommend using a leave-on emollient as a soap substitute instead. Bath oils can be particularly helpful for individuals with sensory sensitivities who may find the texture of leave-on emollients uncomfortable.

Choosing the Right Emollient

The appropriate emollient is the one that suits your skin and that you enjoy using, as this increases the likelihood of consistent application. Healthcare professionals may offer samples of different emollients for you to try. Before starting a new product, test it on a small region of unaffected skin for at least 48 hours to check for any adverse reactions.

Different areas of your body may require distinct emollient types to achieve optimal hydration and restore the skin’s barrier function. You might prefer lighter options like gels or creams during the day or in the warmer months of spring and summer. Richer, greasier emollients may work better at night or in the colder autumn and winter.

Additionally, remember to apply your leave-on emollient as a soap substitute for washing (with the exception of 50:50 Ointment).

When and How to Apply Emollients

Emollients help reduce itchiness and make one feel more comfortable. They keep the skin hydrated and flexible, preventing cracks. However, they are often underused because people may see them as just moisturisers and may not fully understand their importance in managing eczema. When appropriately applied as part of a daily routine, emollients act as efficient ‘active treatments.’ To get the most benefit from emollient therapy, it’s essential to understand not only the products but also how and when you should use them. Here are some helpful tips:

  • Frequency: Apply your chosen emollient at least twice a day. When eczema flares up, or the skin becomes very dry, use it more frequently, ideally every few hours. Adults should use around 500g weekly when eczema affects bigger areas of the body, and at least 250g for children.
  • Post-wash: After washing or bathing, gently pat your skin dry with a soft towel and reapply your leave-on emollient immediately (except if you’re using a topical steroid).
  • Application: Gently apply the emollient in the direction of hair growth. Avoid rubbing it up and down since this can trigger itching, obstruct hair follicles, and cause heat to build up in the skin. Start by dotting small amounts of emollient around the body (ask for help if you need assistance applying it to your back) to ensure every area of skin is covered.
  • Full coverage: Apply emollient to all areas of your skin, not only where eczema is present.
  • Ongoing use: Keep using emollients even after your eczema gets better to avoid flare-ups.
  • Hygiene: Always use a spoon to scoop emollient from tubs to prevent contamination. A metal dessert spoon works well and is easy to clean. For pump dispensers, you can pump the emollient directly onto your hands without touching the nozzle.
  • Storage: Store your emollient product at room temperature or in a warm airing cupboard. Avoid placing it on a hot radiator, which could promote bacterial growth. For extra comfort, you might refrigerate emollient cream since coolness can help soothe itchiness. However, don’t freeze it or refrigerate emollient ointments.
  • On the go: Carry with you a small bottle of emollient for use whenever needed throughout the day.
  • Protection: Before handling substances that could irritate your skin (sand, particular foods, paint, or clay), apply emollient and consider wearing gloves to protect your hands.
  • Other treatments: Continue using emollients along with other prescribed medicines.

Using emollients with steroid creams:

Recent studies show that using emollient products before a topical steroid may limit the amount of steroid getting to the skin. Therefore, applying the steroid first is recommended—this can be done after a bath or shower. Leave about 30 minutes between the steroid and the emollient application to prevent steroid dilution and spreading to parts that don’t require treatment.

Using emollients with topical calcineurin inhibitors:

For topical calcineurin inhibitors, like tacrolimus (Protopic), a 2-hour gap should be left between applying an emollient and the medication, as recommended by the manufacturer. However, no gap is required with pimecrolimus (Elidel).

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