Pathway to Dry Skin Prevention and Treatment

Abstract

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.

Full text

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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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.
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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