Winter skincare - Module 0149
Winter can play havoc with the face and hands, so make sure you're prepared to offer specific advice to protect skin in the cold months ahead
• learn why cold weather affects the skin
• discover how different types of emollients work
• find out when to refer customers with skin conditions to the pharmacist.
Download a pdf version of this module here
Download the Test Your Knowledge questions here
As we wrap up against the harsh winter elements, everyone is likely to notice a difference to their skin at this time of year. The cold, wind and low humidity can worsen everything from dry skin to more severe skin conditions.
Eczema, which affects five million children and adults in the UK, can flare up in wintry weather and if sufferers have a cold. Cold, dry weather can also make life harder for psoriasis sufferers and the characteristic red scaly plaques can become more inflamed.
Psoriasis affects 2-3 per cent of people in the UK, and these customers also need to be especially cautious about contracting a streptococcal throat infection, which usually strikes in the winter months and can cause psoriasis to flare badly.
Cold and your skin
The skin is made up of three distinct layers:
Epidermis – the outer layer
Dermis – the second layer, containing blood vessels, nerve endings, hair roots and sweat glands
Subcutaneous fat – the third layer, containing larger blood vessels and nerves.
It is the top layer of the epidermis – the stratum corneum – that plays a key role in helping contain moisture within the skin. The surface cells of the stratum corneum are shed continuously and replaced with fresh new skin. The epidermis contains natural enzymes that are important for getting rid of old skin cells and these enzymes need moisture to work properly.
Normally, up to 15 per cent of the stratum corneum consists of water. When the moisture content of the stratum corneum falls below 10 per cent, the skin appears dry and flaky; further drying can result in reduced flexibility and cracking. In severe skin conditions, this can lead to infection and inflammation.
The spaces between the cells in the epidermis are packed with lipids (fats) and other components. Over-exposure to cold weather can cause a reduction of lipids, resulting in the skin's inability to retain water.
Cold weather can also strip away the skin's natural protective barrier, causing the top layer to dry and flake off and the blood vessels to constrict, making them less effective at delivering water to the surface of the skin. Harsh winds evaporate moisture and central heating significantly reduces air humidity, making dry skin even drier.
Treatment
For most people, regular use of a moisturiser should help protect the skin, but more severe conditions such as eczema and psoriasis need extra attention with an emollient.
Emollient is simply the medical word for moisturiser. However, emollients differ from cosmetic moisturisers in that they tend to be unperfumed and do not have anti-ageing ingredients.
Emollients are often perceived to be inactive moisturisers, but if used correctly as a daily skin regimen, emollients become effective ‘active treatments'.
In the majority of cases, using emollient therapy alone can successfully treat mild to moderate eczema. Unfortunately, people with eczema often underuse emollients, as they do not understand why they are so important. Eczema sufferers need to apply emollients liberally and frequently (at least three times a day) so that their skin is not allowed to dry out.
Choosing an emollient
When the skin is very dry, using a combination of emollients helps to give the best hydration and restore the skin's barrier function to normal. Different types of emollients are available.
Creams contain a mixture of fat and water and feel light and cool on the skin. They are easy to spread over sore skin and are not greasy.
Lotions contain more water and less fat than creams. They spread very easily and are cooling, but are not very effective at moisturising very dry skin. They are useful for hairy areas or for quick absorption if time is short.
Ointments do not usually contain water so they don't need a preservative, making them ideal for people who are allergic to these ingredients. Some people find them cosmetically unacceptable because they are often stiff and greasy. As they are very effective at holding water in the skin, ointments are useful for very dry and thickened skin, under wet wraps or if a heavier cream is required at night. The absence of preservatives in ointments makes them vulnerable to contamination by bacteria transferred from the skin so it's a good idea to decant the ointment required into a clean container before applying it to the skin.
Soap substitutes can be used in place of soap, which is alkaline and drying to the skin. Hands are particularly at risk, as they are washed more frequently. Soap substitutes can either be applied before bathing, showering or washing or a handful of cream can be scooped up and applied over the skin while in the water. Emollient soap substitutes do not foam and may take a while to get used to.
Bath and shower oils can be added to warm (not hot) water to clean and hydrate dry skin, coating it with a film or oil to trap water in the skin. They can be added to the bath water or directly to the skin in the shower. Some bath oils are fully-dispersing while others are semi-dispersing, leaving more or less oil on the skin. People with dry skin should not use bubble baths as they are extremely drying and can potentially irritate conditions such as eczema.
If you are unsure how an emollient should be used, ask your pharmacist.
It is important to use emollient products for the purpose for which they were designed. For example, aqueous cream was designed as an emollient soap substitute, and if it is used as a leave-on emollient cream it can irritate the skin. Dr Michael Cork, head of academic dermatology at the University of Sheffield, comments: "Aqueous cream should never be used as a leave-on emollient as it is likely to exacerbate, rather than improve, the eczema."
Creams, ointments and bath additives containing coal tar are suitable for treating mild to moderate psoriasis. Coal tar relieves itching and is mildly antiseptic but it is generally used for psoriasis because it reduces thickening and scaling. Coal tar
can stain clothes and bedding and has a strong smell.
Emollients can be used in combination with other prescribed treatments, such as topical steroids and topical calcineurin inhibitors. Although there are no standard rules regarding whether to apply a steroid preparation after or before using an emollient, it's important to leave as long a period as practical (at least 15 minutes) between the two treatments. This will avoid diluting the strength of the prescribed treatment and prevent it from being spread to areas not affected by eczema.
When to refer
Assessing the severity of skin conditions is important. Customers need to be referred to the pharmacist if:
• there are signs of infection (yellow or oozing with pus) or the skin is broken severe dry skin is cracking, swollen, red or bleeding
• a skin condition has worsened after using an OTC product
• a skin condition does not improve after a week of steroid treatment
• customers (often elderly) present with erythema ab igne – toasted skin syndrome. This is characterised by skin discolouration and mottling, and can occur if people sit too close to open fires or electric heaters or repeatedly use hot water bottles.
Top tips for skin protection
• Cover up against the cold and wind in winter and wear a cotton layer against your skin – wearing wool or heavy synthetic fabrics directly on the skin can cause irritation from too much friction.
• The best time to apply a moisturiser is after a bath or shower while the skin is still moist.
• Have warm rather than hot showers or baths, as water that is too hot makes skin feel more dry and itchy.
• If water stings your skin, apply a soap substitute or emollient all over before bathing.
• Pat the skin dry after a bath or shower – don't rub as this will remove the skin cells and oils you have just applied.
Cold sores
With the onset of winter, chances are that someone will come into your pharmacy with a cold sore on their lip, which they wrongly believe is related to the cold weather. This is a myth; cold sores are usually caused by the herpes simplex virus type 1 (HSV-1).
Once someone has been exposed to this highly contagious virus, it remains dormant most of the time. However, certain triggers such as emotional upset, fatigue or illnesses like colds can activate the virus.
An outbreak of cold sores usually starts with a tingling, itching or burning sensation around the mouth. Small fluid-filled sores then appear, most commonly on the edges of the lower lip. These lesions grow in size and cause irritation and pain. They may weep and eventually grow a crust or scab within 48 hours of the initial tingling sensation.
OTC cold sore creams, which contain antiviral agents aciclovir or penciclovir, can speed up the healing time of the infection. They should be applied from the early tingling stage to help prevent the progress of the cold sore (some preparations are also used once blisters have formed – check the packaging).
A light therapy device is also available. This uses light at a frequency of 1072nm, which is invisible, to stimulate the body's immune response. It is safe, and can be used at the tingle stage and when a blister has formed to shorten the duration and severity of an outbreak, and help prevent the cold sore coming back. The light therapy device should be used three times a day for two days, and wiped clean after each use to prevent reinfection with the cold sore virus. It can also be used for several years, so could be a long-term investment for people who regularly experience cold sore outbreaks.
Key points
• Wintry weather can strip away the skin's natural protective barrier, causing the top layer to dry and flake off.
• It is important to use emollient products for the purpose for which they were designed.
• It is a myth that cold sores are related to cold weather – they are frequently a sign that someone is run down or under stress.nvestment for people who regularly experience cold sore outbreaks.
Evaluation
• Think how you might help customers choose between different emollients.
• What advice can you give customers to help them protect their skin in winter?
• Do you know when to refer skin problems to the pharmacist?
