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This article presents an evidence-supported clinical pathway for dry skin prevention and treatment. The development of the pathway involved the following: a literature review was conducted and demonstrated that literature on dry skin is scarce. To compensate for the gap in the available literature, a modified Delphi method was used to collect information on prevention and treatment practice through a panel, which included 10 selected dermatologists who currently provide medical care for dermatology patients in Ontario. An advisor experienced in this therapeutic area guided the process, including a central meeting. Panel members completed a questionnaire regarding their individual practice in caring for these patients and responded to questions on assessment of dry skin etiology, frequency of skin care visits for consultation and follow-up, assessment, and referral to other specialties. The panel members reviewed a summary of all responses and reached a consensus. The result was presented as a clinical pathway. The panel concluded that our current awareness of dry skin and therefore prevention and effective treatment is limited; that identifying dry skin and its clinical issues requires tools such as clinical pathways, which may improve patient outcomes; and that additional research on dry skin etiology, prevention, and treatment is necessary.
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BASIC/CLINICAL SCIENCE
Pathway to Dry Skin Prevention and Treatment;
L. Guenther<, C.W. Lynde, Anneke Andriessen, B. Barankin, E. Goldstein, S.P. Skotnicki-Grant, S.N. Gupta, K. Lee
Choi, N. Rosen, L. Shapiro, and K. Sloan
Background: This article presents an evidence-supported clinical pathway for dry skin prevention and treatment.
Objective: The development of the pathway involved the following: a literature review was conducted and demonstrated that
literature on dry skin is scarce. To compensate for the gap in the available literature, a modified Delphi method was used to collect
information on prevention and treatment practice through a panel, which included 10 selected dermatologists who currently provide
medical care for dermatology patients in Ontario. An advisor experienced in this therapeutic area guided the process, including a
central meeting. Panel members completed a questionnaire regarding their individual practice in caring for these patients and
responded to questions on assessment of dry skin etiology, frequency of skin care visits for consultation and follow-up, assessment,
and referral to other specialties. The panel members reviewed a summary of all responses and reached a consensus. The result was
presented as a clinical pathway.
Conclusion: The panel concluded that our current awareness of dry skin and therefore prevention and effective treatment is
limited; that identifying dry skin and its clinical issues requires tools such as clinical pathways, which may improve patient outcomes;
and that additional research on dry skin etiology, prevention, and treatment is necessary.
Renseignements de base: Dans le pre´ sent document, nous de´ crivons un parcours clinique avec preuves a` l’appui pour pre´venir et
traiter la peau se` che.
Objectif: La mise au point du parcours a ne´ cessite´ les e´ tapes suivantes: une analyse documentaire a permis de conclure que la
litte´ rature sur la peau se` che e´ tait peu abondante. Pour combler cette lacune documentaire, nous avons utilise´ une me´ thode Delphi
modifie´ e en vue de recueillir l’information sur les me´ thodes de pre´ vention et de traitement par le truchement d’un groupe d’experts
compose´ de 10 dermatologues duˆ ment se´ lectionne´ s, lesquels prodiguent actuellement des soins me´ dicaux a` des patients atteints de
maladies de la peau en Ontario. Un conseiller jouissant d’une expe´ rience dans ce domaine the´ rapeutique, a guide´ le processus, y
compris lors d’une re´union centrale. Les membres du groupe ont rempli un questionnaire sur leurs me´ thodes personnelles de
prestation des soins a` ces patients et ont re´ pondu a` des questions sur l’e´ valuation de l’e´ tiologie de la peau se` che, la fre´ quence des
visites de soins de la peau quant aux consultations et suivi, a` l’e´ valuation, et a` l’aiguillage vers d’autres spe´cialite´ s. Les membres du
groupe ont passe´ en revue un sommaire de toutes les re´ ponses et en sont arrive´s a` un consensus. Le re´ sultat a e´te´ pre´ sente´ sous
forme de parcours clinique.
Conclusion: Les membres du groupe ont conclu que notre niveau de sensibilisation a` la peau se` che et donc a` sa pre´ vention et a`
son traitement efficace est limite´ ; que le diagnostic de la peau se` che et de ses enjeux cliniques ne´ cessite des outils comme les
parcours cliniques qui peuvent ame´ liorer les re´ sultats pour les patients; et que des recherches supple´ mentaires sur l’e´ tiologie de la
peau se` che, sa pre´ vention, et son traitement, sont ne´ cessaires.
SKIN IS PRONE TO INJURY owing to=both internal
and external insults, especially in the frail and elderly
population.
1,2
Epidermis that lacks moisture or sebum
presents as dry skin, which is often characterized by a
pattern of fine lines, scaling, and itching.
3–5
Dry skin is a
common condition that affects about 75% of those
64 years and older.
1–6
Evidence-based medicine or health care is patient care
based on evidence derived from the best available studies
and/or clinical practice. The approach is valuable for the
development of clinical guidelines such as clinical path-
ways. Literature on dry skin prevention and treatment is
scarce. To compensate for the gap in the available
literature, we synthesized the evidence base on dry skin
prevention and treatment with balanced expert opinion to
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From Andriessen Consultants.
Disclaimer: The content of this document is intended for general
information purposes and is not intended to be a substitute for medical or
legal advice. Do not rely on information in this article in place of medical
or legal advice.
>
Address reprint requests to:
DOI 10.2310/7750.2011.10104
#2011 Canadian Dermatology Association
===========================================================
Journal of Cutaneous Medicine and Surgery, Vol 15, No 0 (month), 2011: pp 000–000 1
develop recommendations for dry skin prevention and
treatment measures.
Role of the Panel
An expert panel was established to formulate an
evidence-supported clinical pathway for dry skin pre-
vention and treatment based on a consensus statement.
The panel consisted of 10 nationally recognized derma-
tologists who practice in Ontario in medical dermatol-
ogy, including an advisor with an international clinical
and scientific background in this field. The group
included Dr. L. Guenther (chairperson-dermatologist);
Dr.C.W.Lynde,Dr.B.Barankin,Dr.E.Goldstein,Dr.
S.P.Skotnicki-Grant,Dr.S.N.Gupta,Dr.K.LeeChoi,
Dr.N.Rosen,Dr.L.Shapiro,Dr.K.Sloan,andDr.A.
Andriessen (advisor).
?
The panel population is representative of the health
care providers likely to assess and treat patients with
severe dry skin. The care described by the panel may be
better than typical dry skin care because panel mem-
bers treat a high proportion of patients with severe dry
skin and are well trained in this area. However, select-
ing a panel composed of opinion leaders was deemed
appropriate to ensure that a high quality of care is
enabled.
Procedure
A systematic literature review was carried out (Table 1 and
Figure 1). The results showed that, in general, dry skin
often develops in the elderly and those who are exposed to
external factors, such as dry, cold, or low-humidity
climates, and those with specific diseases. The goal of
therapy may be to decrease the risk of development of dry
skin and to improve skin condition more quickly than can
be achieved in other circumstances.
After this review, a modified Delphi method was used
to collect further information on prevention and treatment
practice. Panel members completed a questionnaire
regarding their individual practice in caring for patients
with a tendency for dry skin and those with dry skin and
responded to questions on assessment of dry skin etiology,
frequency of skin care visits for consultation and follow-
up, assessment, and referral to other specialties.
The panel convened on August 21, 2009, in Toronto,
supported by an unrestricted educational grant (Stiefel
Canada Inc.) to define prevention and treatment measures.
Before the meeting took place, the document and
statements were initially reviewed by the panel members.
The advisor guided the meeting, where the panel members
reviewed a summary of all responses, reached a consensus
as to the meaning of each question, and then provided a
final response about their prevention and treatment of
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Table 1. Databases Included in the Search*
Database Details
Cochrane database Cochrane Dermatology
http://www.doctor411network.com/Alabama/Cochrane-dermatology.html
MEDSCAPE http://www.medscape.com/home
MEDLINE PubMed; http://www.pubmed.de/data/nlm.link.html
EMBASE Excerpta Medica DataBase; in DIMDI database
CINAHL Cumulative Index to Nursing and Allied Health Literature: http://www.cinahl.com/library/
journals.htm http://www.trcc.commnet.edu/library/guides/.../Cinahl_search_guide.htm
National Library of Medicine (dry skin) http://www.nlm.nih.gov/medlineplus/ency/article/003250.htm
AAD and supported by the AAD http://www.aad.org/public/publications/pamphlets/skin_dry.htm @
http://www.aad.org/public/publications/pamphlets/sun_mature.html
health.yahoo.com/skinconditions.../dry-skin.../healthwise--hw107895.html
http://www.cigna.com/healthinfo/hw107895.html
ETRS Wound Repair and Regeneration, publication of WHS, ETRS, JSWH, and AWMA
http://www.etrs.org/
Tissue Viablity Society Glanville Centre, Salisbury District Hospital, Salisbury, UK
http://www.tvs.org.uk
AAD 5American Academy of Dermatology; AWMA5; DIMDI 5; ETRS 5; JSWH 5; WHS 5.A
*A systematic literature review was carried out on dry skin and the treatment of dry skin using the following key words: dry skin, ichthyoses,xerosis,skin
integrity in elderly populations,guidelines on topical treatment of dry skin,emollients,moisturizers,hydration of dry skin, and humectants. We searched
published studies that met the following criteria: publications in English, German, French, or Dutch and studies performed on animal or human subjects as
well as laboratory studies and review articles.
2Guenther et al
patients with dry skin. A modified Delphi process was also
used to determine the final statements that were applied in
the proposed clinical pathway for dry skin prevention and
treatment. The final document and statements were edited
and reviewed by the panel after the meeting.
Outcome of Panel Discussions
The panel concluded that our current awareness of dry
skin and therefore prevention and effective treatment is
limited; that identifying dry skin and its clinical issues
requires tools such as clinical pathways, which may
improve patient outcomes; and that additional research is
necessary. Specific areas requiring research include (1) the
identification of critical etiologic and pathophysiologic
factors involved in dry skin development and the impact
on further damage (in chronic conditions such as chronic
venous hypertension), (2) clinical and diagnostic criteria
for describing dry skin conditions, and (3) clinical studies
evaluating patient outcomes when applying an evidence-
informed pathway of dry skin prevention and care. The
statements from this consensus document are presented
in a clinical pathway and was designed to facilitate
Bthe
implementation of knowledge-transfer-into-practice tech-
niques for quality patient outcomes. This implementation
process should include professional teams concerned with
the care of individuals at risk for dry skin or with dry
skin.
Application of the Pathway and Limitations
The pathway to dry skin prevention and treatment is
proposed as a platform for optimal skin care. This
approach includes therapeutic treatment concepts, does
not address specific conditions such as eczema and
psoriasis, and is limited to prevention and treatment of
dry skin only. Clinicians may consider treating all of the
visible manifestations of dry skin and define an individual
pathway for dry skin prevention and treatment. The
starting point is a clinical pathway that is supported by
peer consensus.
The use of the Delphi technique with health profes-
sionals actively involved with continuing medical educa-
tion and treatment in this area and representing the
discipline that provides such care is expected to represent
this care. CThe information contained herein does not
necessarily represent the opinions of all panel members or
the sponsor.
Consensus
Consensus was reached on the following: EX
Causes of Dry Skin
Healthy, young vital skin is usually able to maintain
sufficient moisture.
1–3
In dry skin, the barrier function
may be insufficient owing to a variety of reasons.
1–4,6
Although anyone can develop dry skin, the condition is
more prone in the 65-year and older age groups; in those
who live in dry, cold, or low-humidity climates; and in
those who bathe or shower very frequently. Although most
cases of dry skin are caused by environmental exposures,
certain diseases can also significantly alter the function and
appearance of the skin. Potential causes of dry skin include
the following:
&Weather. In general, skin is driest in winter, when
temperatures and humidity levels plummet. Winter
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Figure 1. Types of articles that were
identified in the literature review.
RCT 5randomized, controlled trial.
Pathway to Dry Skin Prevention and Treatment 3
conditions also tend to make many existing skin
conditions worse. But the reverse may be true for
desert regions, where temperatures can soar, but
humidity levels remain very low.
&Central heating and air conditioning, wood-burning
stoves, space heaters, and fireplaces. All of these reduce
humidity and dry the skin. Winter is a peak time for dry
skin owing to the low humidity in ambient air and
heating systems that force hot, dry air into the home or
workplace.
6
However, air conditioning also induces dry
skin because it removes much of the moisture from air.
Furthermore, artificial air treatment, frequently used in
airplanes, also exposes the skin to dry air, desiccating its
upper layers.
6
&Tight clothing or compression (eg, for venous insuffi-
ciency). Tight clothing or compression can increase the
risk of dry skin and worsen existing dry skin through
abrasive friction.
1
&Baths, showers, and swimming. Frequent showering or
bathing, especially with hot water, for long periods
breaks down the lipid barriers in the skin. Similar
changes occur with frequent swimming, particularly in
heavily chlorinated pools.
7
&Harsh soaps and detergents. Normal skin has a correct
balance of moisture and oils and is slightly acidic at a
pH of 4.5 to 5.75. When soaps are used, the pH of the
skin may change. Soaps are alkalis of pH 7 to 12, which
damage the skin barrier function. Many soaps and
detergents strip lipids and water from the skin.
7
Deodorant and antibacterial soaps are usually the most
damaging, as are many shampoos, which dry out the
scalp.
7
Synthetically produced detergents may be a
better option as their pH can be set to the normal skin
pH of 5.5.
7
&Sun exposure. Like all types of heat, the sun dries the
skin. Yet damage from ultraviolet radiation penetrates
far beyond the top layer of skin (epidermis). The most
significant damage occurs deep in the dermis, where
collagen and elastin fibers break down, leading to deep
wrinkles and loose, sagging skin (solar elastosis). Sun-
damaged skin may appear dry.
2
&Aging. The occurrence of dry skin is frequent in the
elderly.
3,4,6
As we age, the activity in the sebaceous and
sweat glands is reduced.
3–6
Generally, sebaceous activity
peaks at puberty, remaining high until the age of
menopause. There is a gender difference in sebaceous
activity with aging. Male sebaceous activity remains
robust until the eighth decade, whereas in women, it
starts to fall much sooner. Women in their sixties have
only 60% of the sebaceous activity that they had in
youth. The decline continues through much of the
seventh decade.
3,5
Dry skin is also more common in patients with zinc or
essential fatty acid deficiency, end-stage renal disease,
hypothyroidism, neurologic disorders that decrease sweat-
ing, human immunodeficiency virus (HIV), malignancies,
or obstructive biliary disease and in those who have had
radiation.
5,6
There are also systemic and primary derma-
tologic diseases with dry skin and/or itchy skin as a sym-
ptom, such as psoriasis, dermatitis, and ichthyosis.
2–4,8
Individuals with diabetes often have autonomic neuro-
pathy, a condition that increases the risk of dry skin. Some
medications, such as diuretics and antiandrogens, predis-
pose a patient to dry skin.
Although dry skin is often experienced in the winter, in
certain individuals, it may be a lifelong concern.
4
The skin
is often driest on the arms, lower legs, and sides of the
abdomen; however, this pattern can vary considerably
from person to person.
Furthermore, signs and symptoms of dry skin depend
on age, health status, ambient humidity, and other
environmental factors.
5
A study found that dry, pruritic
skin was the most common dermatologic problem seen in
nursing homes.
3
There are numerous reasons for this
finding. In advanced age, the epithelial and fatty layers of
the tissue atrophy and become thinner. In dry and fragile
skin conditions, skin and blood vessels are easily damaged
and purpura may occur. Vascular response and tissue
repair are often delayed.
The skin is more easily torn in response to mechanical
trauma, especially shearing forces. It is drier, brittle, and
more prone to injury (Figure 2). The number of melanocytes
per unit of body surface area decreases, diminishing
protection against, for example, sun damage.
1,2,4
There is
reduced interlocking of the dermal and epidermal layers, and
decreased collagen synthesis may occur.
2,5,9
Dry skin is thinner: subcutaneous tissue, which is a
shock absorber and insulator, is decreased. The loss of
protective padding results in an increased risk for both
weight-bearing and pressure-prone surfaces to break
down.
5,10
In individuals with dry skin, there may be a
decreased sensitivity to pain, pressure, shear, and fric-
tion.
5,10
A slower or absent inflammatory response and
decreased blood flow result in less nutrients and oxygen to
the cells. There is a reduced ability to fight invading
pathogens and a decrease in the number of Langerhans
cells.
5,10
Thermoregulation of the skin decreases as a result
of changes in blood capillaries and eccrine sweat glands.
5,10
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4Guenther et al
Signs of inflammation, such as redness, heat, and swelling,
may be minimal or absent.
10
Dry skin with a compromised barrier may have a
decreased ability to absorb and clear substances, such as
medicated creams.
5
The risk of skin breakdown from
maceration, especially in skin folds, and chemical contact
dermatitis is increased.
5
Topical medication containing
alcohol can also dry the skin and should be avoided.
5,10
EO Presentation of Dry Skin
Manifestations of dry skin occur along a spectrum, often
becoming more severe as the condition persists. Dry skin
may have a reticulate, cracked, or crazy-paving appearance
(eczema craquele
´). It is more likely to appear on the trunk
and limbs. The skin feels rough and uneven, and if due to
loss of hydration
EP in the epidermis, dryness continues,
scaling may worsen, and cracks and fissures appear.
4,6
If
fissures are deep enough, there may be pain on weight
bearing, for example, on the heel. The edges or rim around
the heel or elbows will generally have a thicker area of skin
(callus). Some people tend to have naturally dry skin that
predisposes them to fissures. As fissures extend, they may
deepen and eventually reach the depth of dermal
capillaries, causing bleeding.
2,4
Pruritus may develop as a result of dry skin and may be
severe.
3,8,11
Scratching or rubbing to relieve it may result in
excoriation, and secondary infection may occur. Pruritus
owing to dry skin is to be differentiated from other pruritic
conditions, such as contact or atopic dermatitis. A fungal
infection may also cause itchy skin.
8
The experience with dry skin may vary according to the
body location. Individuals with dry skin may experience
one or more of the following:
&A feeling of skin tightness, especially after showering,
bathing, or swimming
&Skin that appears shrunken or dehydrated
&Skin that feels and looks rough rather than smooth
&Itching and pain that sometimes may be intense
&Slight to severe scaling or peeling
&Fine lines, cracks, and/or fissures
&Erythema, inflammation
&Deep fissures that may bleed in severe cases
Pathway to Dry Skin Treatment and Prevention
The proposed pathway has four different levels (Figure 3).
Level I looks at assessment of the individual that presents
with dry skin. Level II addresses the differential diagnosis
and gives definitions of the different presentations of dry
skin: tendency for dry skin, mildly dry skin, moderately
dry skin, and severely dry skin. Level III looks at the
treatment and prevention of dry skin in three different
body areas: the trunk, the face, and the hands/feet. Finally,
level IV addresses the follow-up.
Classification
The presentation of signs and symptoms is described as a
continuum (Table 2). Individuals may have a tendency for
dry skin, but at the time of presentation, the skin shows no
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Figure 2. Examples of signs that may
occur in dry skin.
Pathway to Dry Skin Prevention and Treatment 5
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Figure 3. Clinical pathway for dry skin prevention and treatment. EQ
6Guenther et al
signs and symptoms of dry skin. These individuals may
benefit from dry skin prevention.
Mildly dry skin is defined as skin that is rough and
shows mild scaling. Itching may be present, as well as mild
erythema, with no pain and no fissures.
Moderately dry skin is defined as the presence of
moderate scaling, mild or moderate itching, and pain.
There may be mild erythema, and fissures may be present.
The skin is defined as severely dry when there is severe
scaling, severe itching, severe pain, and at least mild
erythema. Fissures may be present and severe.
Prevention and Treatment of Dry Skin
For the specific approach given for the three defined areas,
see Figure 3, level III. The measures proposed below are
relevant for all categories of dry skin.
Cleansing
For individuals with dry skin, a brief shower or bath
(,10 minutes) is advised.
4
Use cold or lukewarm water;
the cooler water temperature dries the skin less than
sustained immersion in hot water. Avoid the use of shower
gels and washes and apply fragrance-free bath oils
cautiously.
4
Although some bath oils may leave a layer of
protective oil on the skin, research has shown that they
may also leave a residue of irritating chemicals, exacer-
bating the problem rather than alleviating it.
7
The
surfactants and soaps used in bathing decrease surface
skin oils and may adversely affect the skin’s proteins.
11
Avoid use of topical antimicrobial cleansers.
7
Fragrance-
free and botanical-free cleansers or cleansing bars may be
used. However, subjects with severely dry skin should
minimize the amount of soap or cleansers they use when
showering, for instance, only to the axillae and groin.
7,11
Proposed general measures for prevention and treat-
ment of dry skin are as follows:
&Use fragrance-free and botanical-free products.
&For washing clothes, the detergent is to be fragrance
free; use double rinses and a quarter cup of vinegar or
fabric balls instead. Do not use fabric softener or bleach.
&Wear loose cotton or linen clothing, allowing for sweat
wicking.
&Consider using vaporizers and cool-air humidifiers.
&General education on dry skin prevention ER
For prevention and treatment of dry skin, the following
also applies:
&Sweating can worsen dry skin.
&Patting the skin dry is better than rubbing or harsh
toweling.
&Apply moisturizers and or emollients while the skin is
still moist; apply liberally once a day at a minimum and
reapply when required.
&When emollients and moisturizers are insufficient, the
use of ceramides may be considered
&A barrier cream may be useful for hands and feet.
&When scaling is present, consider a keratolytic such as a
urea-based moisturizer, salicylic acid, lactic acid, or
glycolic acid for mildly, moderately, and severely dry
skin. Consider a higher concentration keratolytic
product on hands and feet.
&Avoid topical steroids and/or calcineurin inhibitors in
nonpruritic, noninflamed dry skin.
&For reduction of inflammation, a topical steroid or a
calcineurin inhibitor is advised, together with a
keratolytic, such as urea-based products.
Skin Care Products
Individuals with dry skin can choose from a host of
products and interventions. After cleansing their skin
and drying off with a soft towel, skin care products are
applied.
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Table 2. Classification of Dry Skin
Classification Signs and Symptoms
Tendency for dry skin Clear
Mildly dry skin Rough and/or scaling (+)
No or mild itching (2or +)
No pain (2)
No or minimal erythema (2or +)
No fissures (2)
Moderately dry skin Rough and moderate scaling (++)
Mild or moderate itching (+or ++)
Mild or moderate pain (+or ++)
Mild erythema (++)
May have fissures (2or +)
Severely dry skin Rough and severe scaling (+++)
Severe itching (+++)
Severe pain (+++)
At least mild erythema (++)
May have fissures (2or +to +++)
25not present; +5mild; ++ 5moderate; +++ 5severe.
Itching is defined as moderate if it is present up to 10% of the time and
interferes with the ability for daily living. It is defined as severe if it is
present most of the time and makes the individual wake up at night. If
fissures are present, the score is moderate or severe.
Pathway to Dry Skin Prevention and Treatment 7
Emollients Emollients close fissures by filling spaces
around desquamating and attached skin flakes, sealing
moisture into the skin through the production of an
occlusive barrier.
4,10–13
The net effect is softening of the
skin. Ingredients in emollients include mineral oils (eg,
liquid paraffin, petrolatum), waxes (eg, lanolin, beeswax,
carnauba), long-chain esters, fatty acids, and mono-, di-,
and triglycerides.
10–13
Moisturizers Although the term moisturizer is often used
interchangeably with emollient, moisturizers are products
that combine a humectant with an emollient.
11,14
Humectants hydrate the stratum corneum through a
hygroscopic effect, increasing its elasticity.
9,13,14
Humec-
tant agents include alpha-hydroxy acids, such as lactic acid
and glycolic acid, as well as urea, glycerine, propylene
glycol, ceramides, and hyaluronic acid.
11,13
With increased moisture, the skin barrier can be
restored.
9,13,15
For protection, mineral oil or silicone-
based products may be used. To rehydrate, glycerine,
panthenol, hyaluronic acid, propylene glycol, butylene
glycol, and urea-containing products are applied. To
restore the skin barrier, stearyl alcohol, cetyl alcohol,
tocopheryl acetate, and products containing prolipids can
be used. They are more effective than simple emolli-
ents.
6,9,11
Urea creams may contain different levels of urea
for keratolytic and antipruritic action, providing soothing
for dry or itchy skin.
6,13
Products containing salicylic acid
are not recommended for large areas of the body owing to
the risk of salicylism.
Most products marketed for dry skin employ a
combination of ingredients to enhance efficacy in
combating dry skin.
For dry skin with fissures, a higher-concentration urea
cream or a cream with salicylic acid or lactic acid can be
applied to the surrounding skin.
For mildly and moderately itchy skin, pramoxine-,
menthol-, or camphor-containing products may be used.
15
When inflammation is not controlled with these measures,
consider the use of topical steroids or calcineurin
inhibitors.
Consider an oral antihistamine for relief of itch. Avoid
topical antihistamines as they can be associated with
contact sensitization. Phototherapy may be considered for
renal or hepatic patients with itching.
A formulary is proposed together with the clinical
pathway for dry skin prevention and treatment that defines
products according to category, activity, and ingredients
(Table 3).
Conclusion
Dry skin is common, especially in the aging population.
Current awareness of dry skin and therefore prevention
and effective treatment is limited. Identifying dry skin and
its clinical issues requires may benefit from tools such as
clinical pathways. ES
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Table 3. Formulary for the Pathway of Dry Skin Prevention and Treatment
Category Activity Ingredients
Cleansing Removing environmental pollutants and bacteria
that cause unacceptable odors and skin infections
1–4
Synthetically produced detergent cleansers, oil
Emollients Close fissures by filling spaces around desquamating
and attached skin flakes, sealing moisture into the
skin through the production of an occlusive
barrier
1–6,8, 9,11
; softening of the skin
Mineral oils (eg, liquid paraffin, petrolatum), waxes
(eg, lanolin, beeswax, carnauba), long-chain esters,
fatty acids, and mono-, di-, and triglycerides
11
Moisturizers Protection and restoring; hydrate the stratum
corneum through a hygroscopic effect, increasing
its elasticity
1–6
Combine a humectant with an emollient, eg, alpha-
hydroxy acids, such as lactic acid, glycolic acid,
and tartaric acid, as well as urea, glycerine, and
propylene glycol
11
Keratolytic and antipruritic action, providing
soothing, nourishing relief for dry/itchy skin
3,8,11
Topical steroids and
moisturizers
Antiinflammatory and effects of the moisturizer
3,8,11
Combine a moisturizer, such as urea cream, with
topical steroids
Calcineurin inhibitors Antiinflammatory to be considered only for severe
cases; the complex of cyclosporine and cyclophilin
inhibits calcineurin
16
Cyclosporine
Antiitch Reduce itching Menthol, camphor, Benadryl, cold wrap
Closing of fissures Sealing of fissures Glue, flexible collodion
8Guenther et al
The proposed evidence-based clinical pathway to dry
skin prevention and treatment, which was developed by
means of a consensus meeting with dermatologists, may
support clinicians to motivate their patients to improve
their dry skin condition.
Acknowledgment
Financial disclosure of authors: This work was supported by
an unrestricted educational grant from Stiefel Canada Inc.
ET
Financial disclosure of reviewers: None reported.
References
1. Egawa M, Oguri M, Kuwahara T, Takahashi M. Effect of exposure
of human skin to a dry environment. Skin Res Technol 2002;8:
212–8, doi:10.1034/j.1600-0846.2002.00351.x.
2. Rawlings AV, Harding CR. Moisturization and skin barrier
function. Dermatol Ther 2004;17 Suppl 1:43–8, doi:10.1111/j.1396-
0296.2004.04S1005.x.
3. Norman RA. Xerosis and pruritus in the elderly: recognition and
management. Dermatol Ther 2003;16:254–9, doi:10.1046/j.1529-
8019.2003.01635.x.
4. Fleckman P. Management of the ichthyoses. Skin Ther Lett 2003;8
(6):3–7.
5. Kammerlander G, Andriessen A, Asmussen P, et al. Role of the wet
to dry phase of cleansing in preparing the chronic wound bed for
dressing application. J Wound Care 2005;14(8):1–5.
6. Zouboulis CC, Boschnakow A. Chronological ageing and photo-
ageing of the human sebaceous gland. Clin Exp Dermatol 2001;26:
600–7, doi:10.1046/j.1365-2230.2001.00894.x.
7. Kuehl BL, Fyfe KS, Shear NH. Cutaneous cleansers. Skin Ther Lett
2003;8(3):1–4.
8. Lode
´n M. Role of topical emollients and moisturizers in the
treatment of dry skin barrier disorders. Am J Clin Dermatol 2003;
4:771–88, doi:10.2165/00128071-200304110-00005.
9. National Library of Medicine. Dry skin. Available at: http://
www.nlm.nih.gov/medlineplus/ency/article/003250.htm (accessed
July 20, 2009).
10. Keller BP, Wille J, van Ramshorst B, van der Werken C. Pressure
ulcers in intensive care patients; a review of risks and prevention.
Intensive Care Med 2002;28:1379–88, doi:10.1007/s00134-002-
1487-z.
11. Moses S. Pruritus. Am Fam Physician 2003;68:1135–42.
12. Grove G, Zerweck C. An evaluation of the moisturizing and anti-
itch effects of a lactic acid and pramoxine hydrochloride cream.
Cutis 2004;73:135–9.
13. Lynde CW. Moisturizers: what they are and how they work. Skin
Ther Lett 2001;6(13):3–5.
14. Del Rosso JQ. Cosmeceutical moisturizers. In: Drealos ZD, editor.
Procedures in cosmetic dermatology series: cosmeceuticals, 1st ed.
Philadelphia: Elsevier; 2005. p. 97–102.
15. Rwalings AV, Canestari DA, Dobkowski B. Moisturizer technology
versus clinical performance. Dermatol Ther 2004;17 Suppl 1:49–56,
doi:10.1111/j.1396-0296.2004.04S1006.x.
16. Lichtiger S, Present DH, Kornbluth A, et al. Cyclosporine in severe
ulcerative colitis refractory to steroid therapy. N Engl J Med 1994;
330:1841–5, doi:10.1056/NEJM199406303302601.
Journal of Cutaneous Medicine and Surgery JMS_2011_10104.3d 17/9/11 15:51:53
The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003)
Pathway to Dry Skin Prevention and Treatment 9
Authors Queries
Journal: Journal of Cutaneous Medicine and Surgery
Paper: JMS_2011_10104
Title: Pathway to Dry Skin Prevention and Treatment
Dear Author
During the preparation of your manuscript for publication, the questions listed below have arisen. Please attend
to these matters and return this form with your proof. Many thanks for your assistance
Query
Reference
Query Remarks
1 AU: Is the title complete?
ScholarOne cover sheet had
"Development of."
2 AU: Please provide first names for
all authors.
3 AU: Only one affiliation was pro-
vided on the ScholarOne cover
sheet. Please complete the affils,
including locations.
4 AU: Please provide an address.
5 AU: Are all panel members to be
listed as authors? If so, then is it
necessary to repeat the names in
text?
6 AU: Why is the second website for
AAD in italics in Table 1? Also, is
the URL complete?
7 AU: Please complete the expan-
sions for Table 1.
8 AU: The statements or the clinical
pathway was designed to facilitate
the implementation of knowledge
transfer...? Please clarify.
9 AU: The use of the Delphi techni-
que is expected to represent this
care? As you meant?
Journal of Cutaneous Medicine and Surgery JMS_2011_10104.3d 17/9/11 15:51:53
The Charlesworth Group, Wakefield +44(0)1924 369598 - Rev 7.51n/W (Jan 20 2003)
10 Guenther et al
10 AU: You had "Consensus was
reached on the following" in bold-
face, suggesting that it was to
serve as a heading and a sentence
simultaneously. Are the changes
okay?
11 AU: I can’t tell which sections you
intended to have under
Consensus. If the subheadings
shown were not supposed to be
subheadings, please advise.
12 AU: If what is due to loss of
hydration in the epidermis?
Please clarify.
13 AU: Assumed that in Fig 3, by ung
you meant unguent.
14 AU: The last item in the lsit of
general measures for prevention of
dry skin does not have the same
construction as the others. Please
make consistent.
15 AU: The sentence beginning
"Identifying dry skin and its clinical
issues" doesn’t make sense.
Pelase advise.
16 AU: Is this disclosure complete and
correct?
Journal of Cutaneous Medicine and Surgery JMS_2011_10104.3d 17/9/11 15:51:53
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Pathway to Dry Skin Prevention and Treatment 11
... Aged and care-dependent patients are at high risk for developing pressure ulcers (PUs), skin tears (STs), intertrigo, and incontinence-associated dermatitis (IAD) [3,4]. These are distinct clinical diagnoses, and condition-specific clinical guidelines and best practice recommendations are available [5][6][7][8]. On the other hand, these adverse skin conditions show many similarities in terms of etiology (e.g., skin fragility, immobility, and care dependency), prevention, and treatment [9]. ...
... However, all of these distinct approaches have the same aim: to enhance and maintain skin integrity in aged and care-dependent people. Thus, proposed interventions have a lot in common: avoidance of skin-stressing insults (e.g., mechanical loading and safe handling) [7,8], provision of skin protection and care (e.g., using protecting skin care products) [5,7], moisturization of dry and cracked skin [6], and minimization of prolonged and repeated exposures to irritation (e.g., urine, stool, and surfactants from cleansing products) [5,6]. ...
... However, all of these distinct approaches have the same aim: to enhance and maintain skin integrity in aged and care-dependent people. Thus, proposed interventions have a lot in common: avoidance of skin-stressing insults (e.g., mechanical loading and safe handling) [7,8], provision of skin protection and care (e.g., using protecting skin care products) [5,7], moisturization of dry and cracked skin [6], and minimization of prolonged and repeated exposures to irritation (e.g., urine, stool, and surfactants from cleansing products) [5,6]. ...
Article
Full-text available
Background: Aged long-term care receivers are affected by various adverse skin conditions like pressure ulcers, incontinence-associated dermatitis, dryness, intertrigo, and many more. Prevention of these skin problems and the provision of general hygiene and skin care activities are key areas of nursing practice. Numerous condition-specific guidelines are available and are implemented separately. On the other hand, there is huge overlap in terms of etiology, pathogenesis, and prevention of the skin conditions mentioned above. This leads to fragmented practice neglecting shared etiologies and prevention and treatment principles. Methods: The overall aims of this trial are to test the feasibility and to estimate possible effects of the implementation of a comprehensive skin care and prevention strategy targeting main nursing-relevant skin problems at the same time. A two-arm cluster-randomized controlled trial will be performed in 20 nursing homes randomly selected from the population of nursing homes of the state of Berlin, comparing skin care according to the skin care and prevention strategy with standard skin care. Discussion: It is expected that the implementation of this evidence-based skin care and prevention strategy will reduce the incidence of pressure ulcers, incontinence dermatitis, and other skin problems frequently related to care dependency. This trial will benefit individual patients and aged nursing home residents in general given the high prevalence and incidence of the addressed skin conditions. Findings of this exploratory trial may lay the foundation for a change in the development and evaluation of clinical standards and practices in general as it moves the perspective from individual conditions to a more comprehensive view on overlapping or coexisting health problems, in this case common skin conditions, in old-age long-term care receivers. Trial registration: The study is registered at the German Clinical Trials Register https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015680 (Deutsches Register Klinischer Studien, or DRKS; registration number: DRKS00015680 , date of registration: January 29, 2019) and ClincialTrials.gov (registration number: NCT03824886 , date of registration: January 31, 2019).
... Dry skin (xerosis) occurs because of loss of water from the corneal layer (outer layer). As a result, the skin is more susceptible to cracking, which can lead to itching, bleeding and dermatitis [2]. Dry skin, which is often characterized by itchy and prone to dermatitis, scaling [3]. ...
... Standardized skin care prevent and manage skin dryness [10]. Fundamental of Standardized skin care, which includes skin cleansing, is recommended with a brief shower or bath (< 10 minutes) is advised and used cold or lukewarm water; the cooler water temperature dries the skin less than sustained immersion in hot water [2,5]. According to the evidence based practice found that severely dry skin due to the amount of soap or cleansers used when showering. ...
... There are contributory factors for skin dryness prevention and maintain skin integrity among elderly people, which include intake diets which contain vitamin A, B12, and fibers, drinking enough fluids, and increase physical activity and exercise [4,6]. This situation is extremely difficult because professional nurses and caregivers, particularly those in long-term institutional care, have a major responsibility in product selection, skin care, care education, reception and their relatives [2,7]. ...
Article
Full-text available
Background: Aged Nursing home residents suffer from a wide range of skin problems. Skin dryness is the most prevalent skin problems in this group. Aim of the study: The present study aimed to evaluate the effect standardized skin care guidelines on dry skin among elderly people at Ismailia City. Design: A quasi-experimental design was utilized to conduct this study. Setting: The study was conducted in all nursing homes for elderly at Ismailia city. Sample: A purposive sample of 105 Nursing home elderly residents who fulfilled the study inclusion criteria. Tools: Two tools were used in the present study; the first tool was a structured interview questionnaire consisted of three parts; the second tool was the clinical scoring systems of EEMCO guidance. Results: The results revealed statistically significant improvements in total scores of dry skin knowledge and skin care practices. There were statistically significant improvements of overall dry skin score (ODS) and in all dry skin specified symptoms (scaling, roughness, redness, and cracks fissures (SRRC)) at post skin care guidelines. Conclusion: Standardized skin care guidelines are effective in reducing skin dryness in aged nursing home residents. Recommendations: Standardized skin care guidelines should be implemented in the study settings on a long term basis to test its sustainability, and in similar settings to confirm its effectiveness and for further improvements.
... Subjective symptoms, such as pruritus, or the affected body surface area are not included in these scores. Based on expert consensus, Günther et al. (2012) classified xerosis cutis and its symptoms into four grades of severity (0-3) [28]. Visible signs still included roughness/scaling, erythema and fissures. ...
Article
Full-text available
Background and rationale: Xerosis cutis (also referred to as xeroderma, dry skin, asteatosis) affects more than 10 million individuals in Germany. It is among the most common dermatological diagnoses and a cardinal symptom of many dermatological, internal and neurological diseases. Even though it has been established that basic skin care plays a significant role in the management of patients with xerosis cutis, there are as yet no evidence-based algorithms for diagnosis and treatment. Objective: The present position paper provides physicians across all specialties with a practical, symptom-based approach to the prevention, diagnosis and treatment of xerosis cutis. Methods: Within a structured decision-making process, a panel of experienced dermatologists first defined questions relevant to everyday clinical practice, which were then addressed by a systematic review of the literature. Based on the evidence available as well as expert consensus, diagnostic and treatment algorithms were subsequently developed and agreed upon. Results: Xerosis cutis is generally diagnosed on clinical grounds. Possible trigger factors must be avoided, and comorbidities should be adequately and specifically treated. Suitable skin care products should be chosen with a view to improving skin hydration and restoring its barrier function. They should therefore contain both rehydrating and lipid-replenishing components. The "drier" the skin appears, the greater the lipid content should be (preferably using water-in-oil formulations). The choice of ingredients is based on a patient's individual symptoms, such as scaling (e.g., urea), fissures/rhagades (e.g., urea or dexpanthenol), erythema (e.g., licochalcone A) and pruritus (e.g., polidocanol). Other factors to be considered include the site affected and patient age. Ingredients or rather combinations thereof for which there is good clinical evidence should be preferentially used. The best evidence by far is available for urea, whose efficacy in the treatment of xerosis is further enhanced by combining it with other natural moisturizing components and ceramides. The "xerosimeter" is a tool developed in an effort to facilitate patient management and for training purposes. It not only includes practical tools for diagnosis and follow-up but also a classification of ingredients and a structured treatment algorithm. Conclusion: The structured symptom- and evidence-based approach proposed herein contains a road map for diagnosis and treatment of xerosis cutis. It aims to raise awareness in terms of prevention and early treatment of this condition and may thus improve quality of life and prevent potential sequelae.
... It is recommended to use lipophilic leave-on products containing humectants such as urea, dexpanthenol or glycerine. The application should be performed at least twice daily or more often, depending on the severity of skin dryness (Guenther et al., 2012;Lichterfeld et al., 2015). Nurses play a key role in the quality of skincare (Kottner & Surber, 2016). ...
Article
Full-text available
Aims To describe the prevalence of dry skin in nursing homes and hospitals and to describe relationships between topical skincare interventions and dry skin. Design Two multicentre descriptive cross‐sectional prevalence studies. Methods The studies were performed in German nursing homes and hospitals in 2015 and 2016. Data were collected by trained nurses based on a standardized data collection form. The severity of dry skin was measured using the Overall Dry Skin Score. Results In total, 1,662 nursing home residents and 1,486 hospital patients participated. The prevalence of dry skin was 41.2% in nursing homes and 55.2% in hospitals. In case of skincare dependency, the proportions of participants with dry skin were higher, particularly in hospitals (70.2%). In both institutions, the application of leave‐on products increased when dry skin was present but remained lower in hospitals. Considering the high amount of skin dryness in skincare‐dependent participants, interventions seem not to be successful. Results indicate a need for skincare improvement in future.
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Abstract Introduction Facial moisturizers are commonly used by healthy women and increasingly men of all age groups. This study aimed to investigate the effects of moisturizer discontinuation and the subsequent evolution of symptoms. Methods Two prospective observational split-face comparison pilot studies were performed in Switzerland and enrolled (I) 20 healthy women aged 17–25 years in winter and (II) 36 female subjects 15–20 and 40–55 years of age in summer. Moisturizers were stopped on the investigational half of the face. On the control side, the usual skin care regimen was continued. Daily subjective (I/II) and objective (I) skin assessments for the occurrence of typical symptoms of dry skin (dryness, itching, scales, redness, wrinkles) were collected. Results In the winter study (cohort I) in both the subjective and objective assessment, all skin changes increased significantly within 1 day after discontinuation. On day 7, dryness (p
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Purpose of review: Although genetic factors clearly play a role in the development of atopic dermatitis (AD), the recent dramatic increase in the prevalence of AD in low- and middle-income countries is not consistent with only a role of genetic factors. These findings strongly suggest that environmental factors may play an important role in the pathogenesis of AD. Recent findings: We reviewed the role of gene-environment studies; in utero exposures including tobacco smoke, alcohol, maternal stress, various digestive supplements, and gestational diabetes; early-life exposures including diet, gut microbiota, antibiotics, and breastfeeding; climate including temperature, ultraviolet radiation exposure, and air pollution; and household products, indoor allergens, water hardness, pH, and skin microbiota and their effects on AD. Environmental factors definitely play a role in the pathogenesis of AD. However, identifying definitive factors continues to be difficult in the setting of conflicting evidence and the complex interactions between genotypes and the environment resulting in a multitude of AD phenotypes. All of the different environmental interactions discussed highlight the importance of intervening on multiple levels in a patient's environment to improve or even prevent AD symptoms. Further, the importance of modifying environmental factors early on in a person's life is demonstrated. When possible, all of these environmental factors should be considered in treating a patient with AD and the appropriate modifications should be made at population and individual levels.
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IntroductionPatients with androgenetic alopecia treated with alcohol-based minoxidil topical solutions often report local irritation, dryness, and redness of the scalp. We evaluate the in-use tolerance of 5% minoxidil novel formulation topical solution—test product (TP)—compared with 5% minoxidil alcohol-based topical solutions—reference product 1 (RP1) and reference product 2 (RP2)—in Indian men with androgenetic alopecia.Methods In this randomized double-blind study, patients aged ≥ 18 years with androgenetic alopecia were randomized 1:1:1 to apply TP, RP1, and RP2 twice daily for 30 days. The safety endpoints included mean hydration, mean redness, and mean scaling on scalp.ResultsAll screened patients (N = 100) were enrolled and randomized to TP (n = 33), RP1 (n = 33), or RP2 (n = 34). At day 30, the mean (SD) hydration was significantly increased in patients treated with TP [9.74 (4.98)] but significantly reduced in patients treated with RP1 [3.28 (2.67)] or RP2 [3.03 (1.57)] (p-value 0.001). The mean (SD) score for redness was significantly decreased in the TP group [0.01 (0.04)], (p-value, 0.009) at day 30 compared with baseline, while no change was observed in the RP1 [0.08 (0.13)] or RP2 [0.11 (0.17)] group. After 30 days of treatment, no significant difference was observed in the mean score of scaling in any of the three groups.Conclusions Twice daily application of 5% minoxidil novel formulation for 30 days significantly improved hydration and reduced redness of the scalp. Hence, 5% minoxidil novel formulation could be a safer alternative in treating men with androgenetic alopecia who are sensitive to alcoholic formulations.Trial RegistrationClinical Trial Registry of India; CTRI/2018/11/016431.
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Zusammenfassung 1 Hintergrund und Rationale Die Xerosis cutis (Synonym: Xerodermie, trockene Haut, hydrolipidarme Haut) ist mit > 10 Millionen Betroffenen nicht nur eine der häufigsten dermatologischen Diagnosen in Deutschland, sondern auch Leitsymptom vieler dermatologischer, internistischer und neurologischer Erkrankungen. Trotz der medizinischen Relevanz der topischen Basistherapie für die Xerosis cutis gibt es in Deutschland für ihr Management bisher keinen wissenschaftlich belegten Diagnostik‐ und Therapiealgorithmus. 2 Ziel Dieses Positionspapier vermittelt Ärzten fachübergreifend einen an individuellen Symptomen orientierten, praxisnahen Leitfaden für die Prävention, Diagnostik und Therapie der Xerosis cutis. 3 Methodik Im Rahmen eines strukturierten Entscheidungsprozesses wurden von erfahrenen dermatologischen Experten zunächst praxisrelevante Fragestellungen definiert und systematisch aufgearbeitet. Auf der Basis von Evidenz und Expertenkonsens wurden daraus diagnostische und therapeutische Algorithmen mit Empfehlungen für die Praxis entwickelt und konsentiert. 4 Ergebnis Die Xerosis cutis kann grundsätzlich klinisch diagnostiziert werden. Auslöser und/oder Grunderkrankungen müssen abgeklärt und vermieden bzw. spezifisch behandelt werden. Bei der Wahl der geeigneten Basistherapie ist es wichtig, dass nicht nur die Hauthydratation verbessert, sondern auch die Barrierefunktion der Haut wiederhergestellt wird. Sie sollte daher aus einer Kombination von rückfeuchtenden und rückfettenden Inhaltsstoffen bestehen. Je trockener die Haut, desto lipidhaltiger sollte die Hautpflege sein (bevorzugt Wasser‐in‐Öl‐Formulierungen). Die individuelle Auswahl der Inhaltsstoffe orientiert sich nach kausaler Prüfung an den Symptomen Schuppung (v.a. Urea), Fissuren/Rhagaden (v.a. Urea oder Dexpanthenol), Rötung (v.a. Licochalcone A) und Pruritus (v.a. Polidocanol), sowie an der Lokalisation und dem Alter der Patienten. Inhaltsstoffe bzw. Inhaltsstoffkombinationen mit guter Studienevidenz sind zu bevorzugen. Die mit Abstand beste Evidenz bei der Xerosis cutis weist Urea auf, dessen Wirksamkeit in Kombination mit anderen natürlichen Feuchthalte‐Komponenten und Ceramiden noch gesteigert werden kann. Zur Arbeitserleichterung am Patienten und zum besseren Erlernen wurde das Xerosimeter entwickelt, das die praktische Umsetzung der Diagnostik und Verlaufskontrolle, eine Klassifikation der Inhaltsstoffe und einen strukturierten Therapiealgorithmus enthält. 5 Schlussfolgerung Das hier vorgeschlagene strukturierte symptom‐ und evidenzorientierte Vorgehen mit Diagnostik‐ und Behandlungspfad soll für die Prävention und frühzeitige Behandlung der Xerosis cutis sensibilisieren. Damit können die Lebensqualität verbessert und Folgeerkrankungen verhindert werden.
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Emollients and moisturizing creams are used to break the dry skin cycle and to maintain the smoothness of the skin. The term ‘moisturizer’ is often used synonymously with emollient, but moisturizers often contain humectants in order to hydrate the stratum corneum. Dryness is frequently linked to an impaired barrier function observed, for example, in atopic skin, psoriasis, ichthyosis, and contact dermatitis. Dryness and skin barrier disorders are not a single entity, but are characterized by differences in chemistry and morphology in the epidermis. Large differences also exist between moisturizing creams. Moisturizers have multiple functions apart from moistening the skin. Similar to other actives, the efficacy is likely to depend on the dosage, where compliance is a great challenge faced in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance. Once applied to the skin, the ingredients can stay on the surface, be absorbed into the skin, be metabolized, or disappear from the surface by evaporation, sloughing off, or by contact with other materials. In addition to substances considered as actives, e.g. fats and humectants, moisturizers contain substances conventionally considered as excipients (e.g. emulsifiers, antioxidants, preservatives). Recent findings indicate that actives and excipients may have more pronounced effects in the skin than previously considered. Some formulations may deteriorate the skin condition, whereas others improve the clinical appearance and skin barrier function. For example, emulsifiers may weaken the barrier. On the other hand, petrolatum has an immediate barrier-repairing effect in delipidized stratum corneum. Moreover, one ceramide-dominant lipid mixture improved atopic dermatitis and decreased transepidermal water loss (TEWL) in an open-label study in children. In double-blind studies moisturizers with urea have been shown to reduce TEWL in atopic and ichthyotic patients. Urea also makes normal and atopic skin less susceptible against irritation to sodium laurilsulfate. Treatments improving the barrier function may reduce the likelihood of further aggravation of the disease. In order to have optimum effect it is conceivable that moisturizers should be tailored with respect to the epidermal abnormality. New biochemical approaches and non-invasive instruments will increase our understanding of skin barrier disorders and facilitate optimum treatments. The chemistry and function of dry skin and moisturizers is a challenging subject for the practicing dermatologist, as well as for the chemist developing these agents in the pharmaceutical/cosmetic industry.
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Review of the literature concerning pressure ulcers in the intensive care setting. DATA SOURCE AND STUDY SELECTIONS: Computerized databases (Medline from 1980 until 1999 and CINAHL from 1982 until 1999). The indexing terms for article retrieval were: "pressure ulcers", "pressure sores", "decubitus", and "intensive care". Nineteen articles met the selection criteria, and seven more were found from the references of these articles. One thesis was also analyzed. Data on prevention, incidence, and costs of pressure ulcers in ICU patients are scarce. Overall there are no conclusive studies on the identification of pressure ulcer risk factors. None of the existing risk-assessment scales was developed especially for use in ICU patients. It is highly questionable to what extent these scales can be used in this setting as they are not even reliable in "standard care". The following risk factors might play a role in pressure ulcer development: duration of surgery and number of operations, fecal incontinence and/or diarrhea, low preoperative protein and albumin concentrations, disturbed sensory perception, moisture of the skin, impaired circulation, use of inotropic drugs, diabetes mellitus, too unstable to turn, decreased mobility, and high APACHE II score. The number of patients per study ranged from 5 from 638. The definition of "pressure ulcer" varied widely between authors or was not mentioned. Meaningful comparison cannot be made between the various studies because of the use of different grading systems for pressure ulcers, different methods of data collection, different (or lack of) population characteristics, unreported preventive measures, and the use of different inclusion and exclusion criteria. There is a need for well-conducted studies covering all these aspects.
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Skin cleansers may be an important adjunct to the regimen of those who use cosmetics, have sensitive or compromised skin, or utilize topical therapies. Cleansers emulsify dirt, oil and microorganisms on the skin surface so that they can be easily removed. During cleansing, there is a complex interaction between the cleanser, the moisture skin barrier, and skin pH. Cleansing, with water soap or a liquid cleanser, will affect the moisture skin barrier. Soap will bring about the greatest changes to the barrier and increase skin pH. Liquid facial cleansers are gentler, effecting less disruption of the barrier, with minimal change to skin pH, and can provide people with a cleanser that is a combination of surfactant classes, moisturizers and acidic pH in order to minimize disruption to the skin barrier.
Article
There has been no new effective drug therapy for patients with severe ulcerative colitis since corticosteroids were introduced almost 40 years ago. In an uncontrolled study, 80 percent of 32 patients with active ulcerative colitis refractory to corticosteroid therapy had a response to cyclosporine therapy. We conducted a randomized, double-blind, controlled trial in which cyclosporine (4 mg per kilogram of body weight per day) or placebo was administered by continuous intravenous infusion to 20 patients with severe ulcerative colitis whose condition had not improved after at least 7 days of intravenous corticosteroid therapy. A response to therapy was defined as an improvement in a numerical symptom score (0 indicated no symptoms, and 21 severe symptoms) leading to discharge from the hospital and treatment with oral medications. Failure to respond to therapy resulted in colectomy, but some patients in the placebo group who had no response and no urgent need for surgery were subsequently treated with cyclosporine. Nine of 11 patients (82 percent) treated with cyclosporine had a response within a mean of seven days, as compared with 0 of 9 patients who received placebo (P < 0.001). The mean clinical-activity score fell from 13 to 6 in the cyclosporine group, as compared with a decrease from 14 to 13 in the placebo group. All five patients in the placebo group who later received cyclosporine therapy had a response. Intravenous cyclosporine therapy is rapidly effective for patients with severe corticosteroid-resistant ulcerative colitis.
Article
The human sebaceous gland undergoes both extrinsic and intrinsic ageing. The latter is associated with morphological changes and alteration in the sebaceous gland activity. The high androgen-dependent sebum secretion in neonates falls during childhood, starts to rise again during puberty and reaches its maximum in young adults. While the number of sebaceous glands remains the same during life, sebum levels tend to decrease after menopause in females, whereas no major changes appear until the eighth decade of life in men. Reduced androgen levels in aged individuals lead to a slow cellular turnover in the sebaceous glands resulting in hyperplasia of the facial sebaceous glands in advanced age. Ultraviolet radiation and immune suppression (cyclosporin A with corticosteroids) represent cofactors for the development of sebaceous gland hyperplasia. Current molecular findings indicate that overexpression of the ageing-associated gene Smad7 and parathormone-related protein correlate with sebaceous gland hyperplasia, whereas c-myc overexpression is associated with enhanced sebum production. On the other hand, down-regulation of the mismatch repair genes hMLH-1 and hMSH-2 may promote the development of sebaceous gland carcinoma. In addition to spontaneous single tumours, sebaceous gland carcinomas have been reported in immune-suppressed transplant recipients (azathiorpine, cisplatin, cyclosporin A) and in association with the Muir-Torre syndrome. Microsatellite instability with a loss of the mismatch repair gene hMSH-2 has been detected in immune suppressed patients and under photo-induced DNA damage. Topical and systemic oestrogens offer treatment options for skin xerosis in menopausal females. A combination of isotretinoin and interferon-alpha may prevent tumour development in patients with Muir-Torre syndrome.
Article
Moisturizers are widely used in various dermatologic and cosmetic skin therapies. Different classes of moisturizers are based on their mechanism of action, including occlusives, humectants, emollients and protein rejuvenators. Commercially available moisturizers often utilize components of each of these classes to provide their beneficial effect. Dry skin (xerosis) is the major indication of use. Others include atopic dermatitis, irritant contact dermatitis, ichthyosis, and dermatoheliosis. Although generally efficacious, moisturizers can cause a number of unwanted side-effects, including occlusive folliculitis, irritation, allergic contact dermatitis and contact urticaria.
Article
Changes in the skin conditions after exposure to low humidity have been generally experienced in everyday life, but there have been few reports to approach it-especially in healthy skin. We have examined the effect of low humidity on healthy human skin by using noninvasive measurement devices. Skin conditions on the ventral forearm and the cheek before and after 3 or 6 h exposure to low humidity were evaluated by measuring skin surface conductance, skin surface capacitance and transepidermal water loss. Skin surface replicas were also taken before and after exposure and analysed for roughness parameters--Ra (arithmetic mean roughness value), Rz (10-point height), Sm (mean value of the profile element) and VC1 (anisotropy of skin furrows). There was a significant decrease of water content of stratum corneum at both test sites from the time points 0 h to 3 h and 6 h (P < 0.01) and transepidermal water loss from the time point 0 h to 6 h (P < 0.05). Regarding the roughness parameters, a significant increase of Rz in the directions of 45 degrees/225 degrees and 90 degrees/270 degrees to the body axis and Sm in the directions of 0 degrees/180 degrees (P < 0.05) on the forearm and VC1 (P < 0.05) on the cheek. The parameter Rz also showed a tendency to increase in the directions of 45 degrees/225 degrees (P = 0.06) on the cheek. A specific pattern of the changes to be related to the Langer's lines in the surface morphology was observed. The changes of skin surface pattern in our experiment lead us to consider that exposure to low humidity even in such a short period would be related to inducing aggravation of skin texture and the formation of fine wrinkles. A short exposure of skin to a low-humidity environment induced changes in the moisture contents in the stratum corneum and skin surface pattern, which lead us to assume that a dry environment in our daily life would make fine wrinkles related to lack of water in the stratum corneum.
Article
The pathophysiology of xerosis is related to abnormal keratin production; elderly have decreased skin fatty acids that result in decreased skin barrier and hydration. The perceived itch of pruritus induces scratching and subsequently immunologically mediated inflammation. The condition is often associated with several underlying dermatological and systemic diseases. However, pruritus can be psychogenic in origin. Xerosis is the most common underlying dermatological condition. Several infectious, metabolic, hepatic, hematological and other systemic conditions are associated with pruritus. Immediate relief of pruritus is the initial treatment goal. After initial pruritic relief, a thorough history, physical examination and laboratory testing work-up is necessary to find the underlying treatable cause including genetic predisposition. Once the underlying etiology is uncovered, an effective pruritic treatment strategy is tailored to etiology.