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Managing dry skin and eczema

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Atopic eczema is an itchy skin condition that often develops during the first few years of life
Atopic eczema is an itchy skin condition that often develops during the first few years of life

What can you recommend to patients to help them manage these common skin conditions?

In this pharmacy CPD module you will learn about:

  • How these skin conditions can be differentiated
  • What other conditions could be confused with dry skin or eczema
  • The range of treatments available and how to use them effectively
  • How the pharmacy team can promote emollient use

Download a printable PDF of this module – including the five-minute test – here.

Perrigo has paid for this piece and has been involved in its creation and editing

What is the function of the skin barrier?

Skin is the biggest organ in the body, measuring about 1.5-2m2 in adults and accounting for about 15% of total body weight.(2)

It has several important functions, including being our first defence against invading irritants, allergens and pathogens – even though it has three million micro-organisms per cm2 itself. In addition, it helps to ensure that water loss is minimised.

The skin contains two main layers: the epidermis (containing several outer layers of cells) and the dermis (an inner layer containing connective tissue, blood vessels, nerve endings and other components). In general, these layers act to protect the body and are self-maintaining. However, if they experience trauma it can result in invasion by micro-organisms, causing infection and the consequent inflammatory response, characterised by redness, pain and swelling.(2)

A weakened barrier function makes the skin less capable of retaining its water balance. This lowering of the water content leads to dry skin.

Dry skin is more prone to weakening and has increased vulnerability to damage. Therefore, it is important to ensure its integrity is maintained. In addition, repeated itching and scratching of the skin can also lead to skin damage, increasing the risk of infections, eczema and secondary inflammation.(3)

The skin protects the body from the damaging effects of ultraviolet (UV) rays by producing the pigment melanin. This pigment is produced by exposure to sunlight and absorbs UV light, protecting cellular DNA.(2)

The skin also helps with the body’s thermoregulation processes, by constricting blood vessels to conserve heat and causing shivering to generate heat through involuntary muscle action,(2) or by dilating blood vessels and sweating to cause heat loss.

Differentiating dry skin and eczema

Dry skin

Dry skin occurs when the normal levels of moisture required are not maintained. This may be due to a lack of natural body oils, which make up the lipid bilayer in the skin,(3) leading to water loss from the stratum corneum. This makes the skin more likely to crack.(4) This can be caused by sun damage, water or chemical exposure, or may be genetic.(5) In addition, the epidermis and the dermis become thinner and flatter as the skin ages. Therefore, elderly people are more prone to dry skin.(4)

dry skin dermalex

It is difficult to determine the level of dry skin in the general population, because it is often underreported(5) and patients may wait many years before asking a healthcare professional for advice or recommendations.(5) However, a study showed almost one-quarter of people have suffered from dry skin in the past 12 months,(16) while about 85% of elderly people have dry skin.(17)

Eczema

Eczema is the name for a group of skin conditions that cause inflammation in response to a trigger, which in turn causes itching and redness. Although there are several types of eczema, the most common types are atopic and contact.(6)

Atopic eczema is a very itchy skin condition that often develops during the first few years of life, but can also occur in adults. It affects one in five children(7) and up to one in 10 adults.(8) Eczema clears in 60-70% of children by their early teens.(11)

eczema dermalex

Most patients diagnosed with atopic eczema have a personal history of asthma and/or hay fever or an immediate family history of one or more of the following atopic conditions: atopic eczema, asthma or hay fever.(11)

The signs of atopic eczema include diffuse redness, excoriation, lichenification (skin thickening when chronic), cracking and scaling.(11) It can affect any part of the body, but the most common areas to be affected are the:

  • outside or flexure of the elbows and knees
  • neck
  • hands
  • cheeks
  • scalp.(12)

Atopic eczema is thought to be caused by a genetic link(10) that leads to defective skin barrier and skin breakdown.

This most common form of eczema occurs when the body’s immune system overreacts to triggers that would not normally cause any harm, leading to inflamed and itchy skin. Examples of triggers include:

  • irritants (such as soaps, fragrances and detergents)
  • environmental factors (such as cold and dry weather, dampness)
  • allergens (such as animal dander, house dust mite droppings and pollen)
  • hormonal changes (women may find their symptoms get worse in the days before their period or during pregnancy)
  • skin infections.(9,12)

Contact eczema, typically referred to as contact dermatitis, occurs when the skin responds to external allergens or irritants. It is either an immune inflammatory response (after exposure to an allergen) or a non-immune inflammatory response (after damage to the skin caused by an irritant).(11) Approximately 80% of cases are irritant contact dermatitis. Both conditions affect mainly adults; women are affected slightly more overall.(11)

It commonly affects the hands, because this is where irritants are most likely to make contact with the skin. Although anyone can suffer from contact eczema, it is much more common in certain work environments, such as cleaning, agriculture, hairdressing, food preparation and painting.(11)

In contact eczema, the reaction results in a red, itchy and inflamed rash that is usually confined to the area that made contact with the irritant or allergen. However, it can spread due to scratching and the body’s immune response. The response may include scaling of the skin, blister formation and weeping at the site.

Common irritants include detergents, cosmetics, machine oils and plants. Common allergens include cosmetic ingredients, metals (such as nickel), rubber and textiles.

What else could be the cause of the skin condition?

You and your staff in the pharmacy may be presented with a patient complaining of dry skin or eczema. You should ensure that you rule out other conditions before making recommendations to the patient, including those listed below.

Psoriasis

psoriasis

A condition characterised by inflammation of the skin and the development of plaques.(12) The most common form is plaque psoriasis; its symptoms are red or pink plaques covered in silver-white scales with a well-defined border.

Fungal skin infection

fungal skin infection

This is common and generally mild. It is nicknamed ‘ringworm’ due to the typical presentation of round, red/pink scaly patches. The reddened areas can be inflamed, itchy and pustular, but the central area is often less red and scaly. These may present as separate or overlapping rings.

Urticaria

urticaria

Also known as hives, this is a raised, swollen, itchy rash. It can vary in size from a few millimetres to the size of an adult palm.(14,15) The reaction is due to a release of chemical mediators, eg histamine, from the body in response to an external factor, such as an allergy or insect sting.(15)

Treating dry skin and eczema

The pharmacy team need to know how to treat dry skin and eczema, because they are often the first port of call for patients. Dry skin is typically treated using emollients applied regularly, whereas the treatments available for eczema depend on severity.

National Institute for health and Care Excellence (Nice) definitions of eczema and the recommended treatment regime(19)

eczema severity

How to apply moisturisers

There is no one ‘right’ emollient; the type used depends on how dry the skin is and what is acceptable to the patient. However, those who apply moisturiser should wash their hands beforehand, because this helps remove any bacteria the patient may have picked up. If using a tub, place the cream on hands using a clean spatula or a spoon to help prevent contamination. Remind patients to apply the emollient downward in the direction of hair growth and to leave a thin layer to soak in – this can take 10 minutes.

using moisturiser

Patients should apply cream as directed on the product or prescription or when the skin feels dry. This is often between two and four times a day. If a topical steroid is required, emollients should be applied at least 30 minutes before or after the steroid.(21)

Emollients and the risk of fire

You should be aware that emollients pose a fire risk if they soak into clothes or bedding. Patients who use large quantities should be advised to keep away from naked flames, lit cigarettes and other potential causes of ignition. Clothes or bedding that have become impregnated with moisturisers or paraffin-based products should be regularly changed and washed at a high temperature.

When does eczema require referral?

Although dry skin and eczema can be treated with moisturisers and mild corticosteroids bought from the pharmacy, there are some circumstances in which you should refer a patient to their GP, such as:

  • the affected patient is under 10 and needs therapy with corticosteroids
  • there are lesions on the face that are unresponsive to emollients
  • over-the-counter treatment has been ineffective
  • widespread or severe eczema is present
  • infection is suspected(18)
  • the patient’s mental wellbeing is affected.

When does eczema require referral?

The emotional impact of eczema

Dry skin can be considered to be unsightly and may have severe consequences for a patient’s quality of life through itching, discomfort and embarrassment about their appearance.(5)

Helping patients to find the right words to explain their visible symptoms to others can sometimes help them feel less self-conscious in public settings and make them more comfortable.(1)

emotional impact of eczema

To assess the psychological impact of atopic eczema, ask about its effect on daily activities (school, work and social life), sleep and mood. The impact of eczema on quality of life and psychosocial wellbeing can be categorised as:

  • none – no impact on quality of life
  • mild – little impact on everyday activities, sleep and psychosocial wellbeing
  • moderate – moderate impact on everyday activities and psychosocial wellbeing, as well as frequently disturbed sleep
  • severe – severe limitation of everyday activities and psychosocial functioning, as well as loss of sleep every night.
Patient preference

It is important that patients using emollients and moisturisers accept the product that they use. This can be influenced by many factors, such as:

  • texture – some patients may prefer ointments, because they can tell the product is on their skin, while others may prefer lotions, because they typically absorb quickly, leave less residue and are considered less greasy
  • previous experience – a patient may prefer a particular brand or product because it is what they, or someone they know, used in the past
  • perceived effectiveness – product marketing can result in patients perceiving that one product has an increased effectiveness over another; endeavour to provide a product that will have the highest effectiveness for that patient.
Avoiding flare-ups of eczema

Patients may be able to determine the cause of their flare-up, or they may get help from a healthcare professional to identify it. Once they understand the cause, it is important that they avoid triggers for their eczema.

Examples may include: avoiding fabrics that irritate the skin, eg wool or synthetic clothing; ensuring rooms are kept cool if heat aggravates the condition; and using soap substitutes if soaps or detergents affect the skin.(22)

If diet triggers symptoms, patients should speak to their GP, because it may be appropriate to stop consuming certain foods. The GP may in turn refer the patient to a dietician to create diets for them.

Negatives of corticosteroid use

Although there is evidence to support the use of corticosteroids in treating flare-ups of eczema, there are negative consequences that may cause patients to stop using them. Topical steroids tend to cause local side effects with prolonged treatment; these depend on the potency of the corticosteroid used. Examples include:

  • alopecia
  • increased susceptibility to infection
  • crusted scabies
  • genital ulceration
  • hypertrichosis (excessive hair growth) that is prevalent on the face and ears
  • rosacea
  • fixed vasodilation
  • purpura
  • ulceration
  • easy bruising
  • scarring
  • prematurely aged skin appearance.(20)

If corticosteroids are used, side effects can be reduced by: stopping the offending corticosteroid once the flare-up has cleared; reducing the frequency of application; using weaker corticosteroids; and maintaining the integrity of the skin.

Study 1: Dermalex compared with no treatment

A study funded by Perrigo has demonstrated the beneficial long-term effects of Dermalex Repair and Restore on maintaining cleared eczema in patients with atopic eczema, compared with no treatment. Daily treatment of Dermalex Repair and Restore resulted in six times more eczema-free days versus no treatment.(23)

Study design

In this randomised control trial, Dermalex Repair and Restore was compared with no treatment. The study included 44 patients over 18 years old, who were diagnosed with atopic eczema and showed visible signs of the condition. All patients were treated at the beginning with corticosteroids to clear the eczema, then split into two groups randomly to receive the Dermalex Repair and Restore treatment or no treatment. Patients applied the cream twice daily until eczema relapsed or for six months. (Relapse is defined as an episode requiring additional medical treatment based on the patient’s judgement of a worsening skin condition).(23)

Results

The median time to relapse for patients treated with moisturiser was greater than 180 days (ie the duration of the study) compared with 30 days for the no-treatment group. Maintenance treatment with a barrier-improving urea moisturiser (Dermalex Repair and Restore) on previously eczematous skin resulted in six times as many eczema-free days versus no treatment.(23)

Study 2: Dermalex compared with reference cream

Dermalex Repair and Restore has also been studied to investigate its ability to reduce the risk of relapse in atopic eczema versus a reference cream without humectants (eg urea).(25)

Study design

This double-blind, randomised control trial, funded by Perrigo, included 172 patients aged over 18 years old, who were diagnosed with atopic eczema and showed visible signs of the condition (corresponding to a total area of at least the size of the palm of one hand).(25)

All patients were treated at the beginning with corticosteroids to clear the eczema, then split into two groups randomly to receive the Dermalex Repair and Restore treatment or the reference cream. These patients were then provided with cream to apply twice daily until the eczema relapsed or for six months.(25)

Results

The risk of relapse of atopic eczema was reduced (p=0.011) among patients who received the Dermalex Repair and Restore treatment compared with the reference cream, increasing the symptom-free period by almost 50% and resulting in more than twice as many eczema-free patients after six months.(25)

Dermalex Eczema

dermalex eczema

Dermalex Eczema treatment cream has been clinically proven to provide relief from eczema symptoms after three weeks of treatment and is proven to be as effective as a 1% hydrocortisone cream in the long term.(26)

Dermalex Eczema treatment cream treats mild to moderate atopic eczema symptoms, such as itching, redness and dryness. It moisturises the affected area, reduces further moisture loss and prevents allergens and irritants from entering the skin.(26)

It works in three ways:

  • By forming a semi-occlusive layer on the skin, to prevent water loss and protect from irritants and allergens(26)
  • By providing an environment that supports the skin’s own repair mechanism(27,28)
  • By replenishing the missing natural ceramide components and replenishing moisture levels.(26)
Dermalex repair and restore

dermalex R+r

  • Dermalex Repair and Restore is suitable for treatment of dry and very dry skin symptoms that are present between flare-ups of atopic eczema, contact eczema and psoriasis.
  • Dermalex Repair and Restore is specifically designed for the daily treatment of dry and very dry skin symptoms.
  • Apply the cream twice a day, ensuring the skin is clean first.
  • In order to prevent flare-ups, Dermalex Repair and Restore should be used on symptom-free days.
  • Always re-apply cream after showering or bathing.
  • It is suitable for daily long-term use.

Tips for your planned learning 

What are you planning to learn?

I want to learn more about dry skin and eczema, including how they can be differentiated, other conditions with which they can be confused, the range of treatments available and how to effectively use them. I also want to improve my knowledge of how my pharmacy team can promote emollient use.

This learning will help me to improve my knowledge of dry skin and eczema and their treatment with emollients and to be able to confidently provide advice to patients and carers, to spot at-risk patients and to know when to refer.

How are you planning to learn it?

Give an example of how this learning has benefited the people using your services

I have learned about dry skin and eczema, including how they can be differentiated, other conditions with which they can be confused, the range of treatments available and how to effectively use them.

I have also improved my knowledge of how my pharmacy team can promote emollient use.

I was asked for advice recently by a girl with an itchy red rash on her hands. She had started a hairdressing course and wondered if the cause was linked to some of the products she had been using. Further questioning revealed that she thought she had suffered from eczema as a young child.

I was able to inform her that this might make her more susceptible to contact dermatitis. I discussed using a mild steroid cream and an emollient, making sure she was clear on how to apply them, and advised her to see her GP if there was no improvement.

 

References
  1. Tuckman, A, The potential psychological impact of skin conditions, Dermatol Ther (Heidelb) (2017) 7(Suppl 1): 53. (accessed 22/01/2019)
  2. Richardson, M, Understanding the structure and function of the skin, vol: 99, issue: 31, page no: 46  (accessed 22/01/2019)
  3. Lodén, M, Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders, Am J Clin Dermatol 2003; 4:771-788 American Journal of Clinical Dermatology (accessed 22/01/2019)
  4. Best Practice Journal, “Seventh age itch”: Preventing and managing dry skin in older people
  5. Moncrieff, G, et al, 2012, Use of emollients in dry-skin conditions: consensus statement. (accessed 22/01/2019)
  6. National Eczema Society, An overview of the different types of eczema. (accessed 22/01/2019)
  7. National Eczema Society, What is eczema? (accessed 22/01/2019)
  8. Patient.info, Atopic dermatitis and eczema.
  9. National Eczema Society, Atopic. (accessed 22/01/2019)
  10. Sandilands, A, et al, 2009, Filaggrin in the frontline: role in skin barrier function and disease, J Cell Sci, 2009 May 1; 122(9): 1285–1294. (accessed 22/01/2019)
  11. BMJ, Eczema: a guide to management. (accessed 22/01/2019)
  12. NHS Inform, Atopic eczema. (accessed 22/01/2019)
  13. Payne, J, 2018, Patient.info, Psoriasis. (accessed 22/01/2019)
  14. NHS Inform, Urticaria (hives). (accessed 22/01/2019)
  15. Dermnetnz.com, Urticaria – an overview. (accessed 22/01/2019)
  16. Opinium Research Study, April 2018, n=2006
  17. Beauregard, S, Gilchrist, B, et al, Arch Dermatol 1987;123:1638-43.
  18. Rutter, P, Community pharmacy, symptoms, diagnosis and treatment. Eczema and dermatitis. Fourth edition
  19. Nice, CKS, Eczema – atopic. (accessed 22/01/2019)
  20. Coondoo, A, et al, 2014, Side effects of topical steroids: A long overdue revisit. Indian Dermatol Online J, 2014 Oct-Dec; 5(4). (accessed 22/01/2019)
  21. Guy’s and St Thomas’ NHS Foundation Trust, John’s Institute of Dermatology, Emollients and how to use them. (accessed 22/01/2019)
  22. NHS, Atopic eczema, treatment. (accessed 22/01/2019)
  23. Wirén, K, et al, J Eur Acad Dermatol Venereol, 2009; 23: 1267-72 2009, 44 participants
  24. Lodén, M, et al, Acta Derm Venereol, 2010; 90: 602-606, 53 participants
  25. Åkerström, U, et al, Acta Derm Venereol, 2015; 95: 587-592 2015, 172 participants.
  26. Koppes, SA, et al, Acta Derm Venereol, 2016, 100 patients
  27. Proksch, E, et al, Int J Dermatol, 2005; 44: 151-157
  28. Denda M and Kumazawa N, J Invest Dermatol, 2002; 118: 65-72 )

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