Application of Medical Moisture Retention Cream (ALHYDRAN®), A New Option in the Treatment of Venous Eczema

Abstract

Aim: Patients with venous eczema may suffer considerably from redness, crusts, pain, flaking and itching. In general, as treatment, compression therapy and indifferent ointments/crèmes are used, often together with topical steroids, though the latter may exhibit considerable side effects. This study aims to explore the effect of Medical Moisture Retention Cream (MMRC = ALHYDRAN®) on the symptoms and complaints of patients suffering a venous eczema, often next to an existing VLU. The working mechanism of MMRC involves a combination of the moisturizing effect of Aloe Vera gel and the moderate occlusion effect of added fatty acids.
Method: In an open case series, 18 patients attending an outpatient wound clinic with moderate venous eczema (maximum TIS score<3) participated. MMRC was applied twice a day and its use was clinically assessed for 4 consecutive weeks. Next to the registration of patient characteristics and capturing the clinical details of the skin lesions in weekly pictures, a VAS scale to assess the patients’ and caregivers’ experience with the treatment was used.
Results: During the application of MMRC, the signs and symptoms of a dry, itchy, scaly, crusty and erythematous skin, fainted in all patients. The skin condition of most participating patients improved and there was also a visibly better skin hydration status in all patients. Relevant aspects such as ‘night rest’, ‘mood’ and ‘social participation’ improved, except for 2 patients. The clinical skin condition of one of these deteriorated in a week, which was not related to the use of MMRC. No side effects to the use of MMRC were observed. The wound care experienced nurses assessed MMRC as effective and feasible.
Conclusion: This study shows that MMRC is effective, safe, and feasible in the treatment of venous eczema. Future Randomized Controlled Trials are necessary to compare the efficacy and feasibility of MMRC with the application of other hydrating creams/ointments and topical steroids.

Full text

Application of Medical Moisture Retention Cream (ALHYDRAN®), A New
Option in the Treatment of Venous Eczema
Rondas AALM1,2* and Schols JMGA1
1Maastricht University, Department of HSR - CAPHRI, Care and Public Health Research Institute, Maastricht, The Netherlands
2Kenniscentrum Wondbehandeling, De Zorggroep, Venray, The Netherlands
*Corresponding author: Rondas AALM, Maastricht University, Department of HSR - CAPHRI, Care and Public Health Research Institute, Maastricht, Kentstraat 20,
6137 JT Sittard, The Netherlands, Tel: +31478514044; E-mail: a.rondas@maastrichtuniversity.nl
Rec date: Jan 23, 2017; Acc date: Feb 07, 2017; Pub date: Feb 09, 2017
Copyright: © 2017 Rondas AALM, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Aim: Patients with venous eczema may suffer considerably from redness, crusts, pain, flaking and itching. In
general, as treatment, compression therapy and indifferent ointments/crèmes are used, often together with topical
steroids, though the latter may exhibit considerable side effects. This study aims to explore the effect of Medical
Moisture Retention Cream (MMRC = ALHYDRAN®) on the symptoms and complaints of patients suffering a venous
eczema, often next to an existing VLU. The working mechanism of MMRC involves a combination of the moisturizing
effect of Aloe Vera gel and the moderate occlusion effect of added fatty acids.
Method: In an open case series, 18 patients attending an outpatient wound clinic with moderate venous eczema
(maximum TIS score<3) participated. MMRC was applied twice a day and its use was clinically assessed for 4
consecutive weeks. Next to the registration of patient characteristics and capturing the clinical details of the skin
lesions in weekly pictures, a VAS scale to assess the patients’ and caregivers’ experience with the treatment was
used.
Results: During the application of MMRC, the signs and symptoms of a dry, itchy, scaly, crusty and erythematous
skin, fainted in all patients. The skin condition of most participating patients improved and there was also a visibly
better skin hydration status in all patients. Relevant aspects such as ‘night rest’, ‘mood’ and ‘social participation’
improved, except for 2 patients. The clinical skin condition of one of these deteriorated in a week, which was not
related to the use of MMRC. No side effects to the use of MMRC were observed. The wound care experienced
nurses assessed MMRC as effective and feasible.
Conclusion: This study shows that MMRC is effective, safe, and feasible in the treatment of venous eczema.
Future Randomized Controlled Trials are necessary to compare the efficacy and feasibility of MMRC with the
application of other hydrating creams/ointments and topical steroids.
Keywords: Venous eczema; Venous leg ulcer; Moisturizer
Introduction
A venous leg ulcer (VLU) is due to sustained venous hypertension,
which results from chronic venous insuciency (CVI) [1-3]. Venous
hypertension is usually caused by a combination of factors of which
venous disease, obesity, and immobility are the most important.
Venous eczema is an erythematous dermatitis and according to the
Clinical Etiologic Anatomic and Pathophysiologic (CEAP)
classication it is classied as C4a [4,5]. e prevalence of community
dwelling VLUs is between 0.18% and 1% [6,7]. Over the age of 65, the
prevalence increases to 4% [8]. Due to the aging population, within the
next forty years there is an expected grow of people suering from
immobility and obesity, and this may lead to an additional increase of
the incidence of venous hypertension and venous leg ulceration as well
[9].
Venous hypertension increases the size and permeability of the
dermal venules and arterioles leading to extravasation, or leakage of
uid and electrolytes, plasma protein and macromolecules, such as
brinogen, into the dermis [10]. is leakage initiates a cascade of
inammatory reactions, including leukocyte activation which
increases metabolic activity in the aected areas of skin [11,12]. Over
time, inammation causes varying degrees of injury to the vessels,
tissues and skin, and lengthens the healing process [13,14]. Varices,
corona ebectatica, edema, hyperpigmentation (brown discoloration),
hyperkeratosis, atrophy blanche, induration and lipodermatosclerosis
are physical signs of CVI. However, the most serious clinical
consequence, related to CVI, is a (venous) leg ulcer [1].
Venous eczema oen appears in addition to a VLU, and results in an
annoying erythematous, weeping, scaly, itchy and aching skin [9]. In
the urban area of 24 cities in Italy the prevalence of venous eczema was
3.4% [15].
Appropriate wound assessment helps in the treatment and
management of VLUs. Optimizing wound management focuses on
assessment and treatment beyond the wound edge, also including the
periwound skin. In developing a treatment plan, it is important to
ensure the correct diagnosis and to develop a treatment plan that takes
into consideration the holistic needs of the patient, as well as
addressing the wound and also periwound skin problems that may
impact healing [16,17].
Journal of Gerontology & Geriatric
Research
Rondas and Schols, J Gerontol Geriatr Res 2017,
6:1
DOI: 10.4172/2167-7182.1000395
Research Article OMICS International
J Gerontol Geriatr Res, an open access journal
ISSN: 2167-7182
Volume 6 • Issue 1 • 1000395

A healthy stratum corneum forms an eective permeability barrier
that restricts water loss from the body and blocks the penetration of
harmful irritants and allergens [18,19]. Both patients with dry skin
conditions and patients with a healthy skin commonly use
moisturisers. However, a lack of knowledge persists regarding the
eects of moisturisers on skin barrier function [18,20]. Studies
conducted on individuals with both healthy and diseased skin have
shown that some moisturisers tend to weaken the skin barrier
function, whereas others may strengthen it, and these discrepant
results might be caused by the varied compositions of moisturisers
[18,20].
Topical steroids are oen used to treat the existing periwound
eczema, even though there still is little evidence for their eect [21]. In
addition, they may exhibit systemic side eects e.g. on bone density,
glaucoma and growth as a result of local treatment. erefore one is
searching for less harmful creams of which Medical Moisture
Retention Cream (MMRC) is an example. MMRC is an oil in water
emulsion with freshly processed pure Aruba Aloe Vera gel, oils and
other fatty ingredients. e working mechanism of MMRC involves a
combination of the moisturizing eect of the Aloe Vera gel with a
moderate occlusion eect of the special fatty ingredients of the
hydrating cream [22]. e balanced degree of occlusion and hydration
bring the Trans Epidermal Water Loss back (TEWL) to values slightly
above the level of normal skin [22,23].
In this case series, Medical Moisture Retention Cream was explored
in patients having symptoms and complaints of an existing venous
eczema, oen next to an existing VLU.
Methods
Design
Descriptive study design, a case series.
Population
Patients were included when they attended an outpatient wound
clinic and suered from a moderate venous eczema according to their
ree Item Severity score (TIS), with the maximum TIS score<3 [21].
ey were at least 18 years of age and signed an informed consent.
ey were excluded when they were known to have an allergy to one of
the components of MMRC or when they already had used the cream in
the four weeks before their start in this study (Table 1).
Procedure
At the start of evaluation the duration of the skin problems as well
as their precise location (upper leg, knee, goiter, lower leg or ankle)
were registered using a prepared and Medically Ethically approved
evaluation template. Except for patients’ age and sex and duration of
their skin disorder, the local treatment before using MMRC and also
the relevant main underlying diagnosis and co-morbidities were
registered. Related symptoms of the skin problem, e.g. the experience
of a dry and/or itchy and/or aky skin, were noted. Additionally to the
clinical assessment, the Ankle Brachial Pressure Index (ABPI) or their
Toe Ankle Index (TAI) was measured. e ABPI or TAI indicates
whether the actual skin disorder has an underlying peripheral arterial
disease (ABPI <0.6; TAI <0.5). At the start of evaluation and thereaer
every week at the time of evaluation, a photograph of the aected skin
was taken. At each evaluation patients were asked to score three
questions regarding their well-being (night rest, mood, social
participation) in an analogue scale from 1-10 (1 = totally disagree; 10 =
totally agree). e rst question was whether their ‘night rest’ was
negatively aected by the venous eczema. Question two and three
asked if their ‘mood’ and/or ‘social participation’ were negatively
aected by their skin problem.
MMRC was applied at least twice a day up to a few centimetres
beyond the visually aected area and its use was clinically assessed for
the maximum of 4 consecutive weeks aer their inclusion visit.
At the end of the evaluation period, patients’ satisfaction with the
received MMRC treatment was noted as well as whether their initial
complaints had fainted. At the clinic, the nurses were asked if the
MMRC therapy had been eective and /or feasible and to score their
assessment on an analogue scale from 0 to the maximum of 10 (not
eective vs. eective and not feasible vs. feasible, respectively). e
nurses were also asked to give their professional clinical impression
whether the aected skin area of the patients showed to be 'improved',
'not changed', 'worsened' or 'healed'.
Ethical considerations
From all patients informed consent was obtained. Permission from
the medical ethics committee was received to undertake the case series,
using a prepared and Medically Ethically approved evaluation
template. Condentiality was maintained throughout the evaluation
period.
Results
Finally 18 patients with a venous eczema were included in this case
series. e male to female ratio was 12:6. e mean age was 69.8 years
(SD 13.6). All skin problems were situated at the patients’ lower legs
(Table 1).
Inclusion Criteria Exclusion criteria
Patient or legal guardian received
a comprehensive explanation of
the evaluation and provided
informed consent
Known allergy for one of the ingredients of
MMRC
Aged over 18 years Patient treated with MMRC within the
previous 4 weeks
Patient has:
(extreme) dry and itching skin
associated with venous eczema
or
dry and/or itchy and/or flaky skin
around venous or mixed leg
ulcers
No informed consent
Affected skin area treatment at least twice a day
The patient has signed an informed consent
Table 1: Patients with a chronic wound, suering from moderate
venous eczema: inclusion and exclusion criteria.
Main diagnosis
12 patients clinically suered from a venous leg ulcer, 5 patients had
a post-traumatic leg ulcer and 1 patient had a pressure ulcer. All 18
patients clinically suered from chronic venous insuciency and had a
Citation: Rondas AALM, Schols JMGA (2017) Application of Medical Moisture Retention Cream (ALHYDRAN®), A New Option in the Treatment
of Venous Eczema. J Gerontol Geriatr Res 6: 395. doi:10.4172/2167-7182.1000395
Page 2 of 6
J Gerontol Geriatr Res, an open access journal
ISSN: 2167-7182
Volume 6 • Issue 1 • 1000395

venous eczema, whereas the existence of serious peripheral vascular
diseases was excluded. In all cases the conducted ABPI and TAI were
measured higher than 0.9 or 0.75, respectively.
Use of other creams or ointments before the start of the
MMRC application
One patient (patient number 7, Table 2) used uticasone 0.05%
cream, once a day, three weeks in advance of the MMRC. Another
patient used hydrocortisone 1%, once a day, for two weeks until the
start of MMRC (patient number 13, Table 2). Also indierent creams
such as milking grease (patient number 11, Table 2) and
cetomacrogolis cream (patient number 16 and 18, Table 2) were used
in advance.
Complaints related to the skin disorder
At the start of application of MMRC all 18 included patients had
some signs of a dry, itchy, scaly, sometimes crusty and erythematous
skin, which fainted during the consecutive 4 weeks of application of
MMRC (Table 2).
Photographs of the aected skin
Aer 4 consecutive weeks of application of MMRC, the patient’ s
skin disorder was visually assessed by the clinical nurses as ‘improved’
in 17 cases. One patient clinically showed a much more scaly skin only,
aer one week of application of MMRC. Local treatment with
triamcinolone acetonide 0.1% cream applied once a day, for two weeks
long, let her signs and symptoms completely disappear (Figure 1).
Wellbeing of the patients at start of application of MMRC (by
analogue scale 1-10)
With regard to their ‘night rest’, ‘social participation’ or ‘mood’, 11
patients had no complaints at the start of the MMRC application.
In particular, 3 patients complained about their ‘night rest’ (and
scored 2, 2 and 9 out of 10 on the analogue scale) and 3 patients
experienced that their mood was negatively aected (scores of 2, 2 and
3, respectively). Another 2 patients experienced that their social
participation was hampered because of the existing venous eczema
(scores of 8 and 2, on the analogue scale) (Table 2).
Wellbeing of the patient aer 4 weeks of application of
MMRC (by analogue scale 1-10)
Aer 4 consecutive weeks of application the ‘night rest’, ‘mood’ and
‘social participation’ of all patients improved, except for 2. Aer 4
weeks of application 1 patient complained of his negatively aected
mood and also experienced a hampered social participation (scores of
3 and 2, respectively). However, he had a better ‘night rest’ better than
before the start of application of MMRC (Table 2).
Just aer one week of application of MMRC the scores of a second
patient deteriorated considerably. Aer one week of application she
scored high numbers on ‘night rest’, ‘mood’, and ‘social participation’
(scores of 8, 8 and 5, respectively). e wound care experienced nurse
assessed that patient's clinical situation had worsened considerably one
week aer the start of the study (Table 2).
Professional assessment
Aer 4 weeks of follow up of patients the wound care experienced
nurses were asked to assess the ecacy and feasibility of the MMRC by
means of an analogue scale. e nurses scored a mean of 6.6 (out of 10)
on the ecacy of the MMRC, and a mean of 7.6 (out of 10) on its
feasibility (Table 2).
Figure 1: Examples of pictures taken from 7 patients their aected
skin at the start of the study and aer 4 weeks of consecutive
application of MMRC.
It was the nurses’ clinical impression that the aected skin of 17 out
of 18 patients had 'improved' (Table 2).
Citation: Rondas AALM, Schols JMGA (2017) Application of Medical Moisture Retention Cream (ALHYDRAN®), A New Option in the Treatment
of Venous Eczema. J Gerontol Geriatr Res 6: 395. doi:10.4172/2167-7182.1000395
Page 3 of 6
J Gerontol Geriatr Res, an open access journal
ISSN: 2167-7182
Volume 6 • Issue 1 • 1000395

Age
(yrs)
Sex
(M/F)
'Night rest'
at start
'Night rest’
after 4
weeks
'Mood'
at start
'Mood'
after 4
weeks
'Socially
hampered’
at start
‘Socially
hampered'
after 4
weeks
Effective Feasible Treatment effect
58 M 2 1 1 3 1 2 4 8 Improved
54 M 1 1 1 1 1 1 6 7 Improved
77 M 1 1 2 1 1 1 8 9 Improved
67 F 1 1 1 1 1 1 9 9 Improved
76 M 1 1 1 1 1 1 5 7 Improved
49 M 1 1 1 1 1 1 8 8 Improved
54 M 1 1 1 1 1 1 6 7 Improved
85 M 1 1 1 1 1 1 8 8 Improved
74 M 1 1 1 1 1 1 6 7 Improved
83 M 1 1 1 1 8 1 7 7 Improved
87 F 1 1 1 1 1 1 10 10 Improved
79 M 1 1 1 1 1 1 4 4 Improved
82 F 1 1 1 1 1 1 3 6 Improved
62 M 2 1 2 1 2 1 5 7 Improved
73 F 1 8 1 8 1 5 1 1 worsened-stop trial
after one week
83 F 1 1 1 1 1 1 8 8 Improved
71 M 1 1 1 1 1 1 7 8 Improved
42 F 9 1 3 1 1 1 8 9 Improved-follow up
of 21 days
Table 2: Patient and skin disorder related data: results of 4 consecutive weeks of application of MMRC and its eectiveness and feasibility assessed
by wound care experienced nurses.
Discussion
In general, the participating patients were satised using MMRC
twice a day, for the dry, itchy, scaly, sometimes crusty and
erythematous skin they experienced, in association with the venous
eczema they suered. Aer 4 consecutive weeks of application the skin
condition of most patients ameliorated and was visibly better hydrated
than before (Figure 1). e initial complaints of patients fainted and
the ‘night rest’, ‘mood’ and ‘social participation’ of most patients
improved, except for 2. Aer 4 consecutive weeks use of MMRC, the
wound care experienced nurses assessed the skin disorder of the
patients as ‘improved’ in 17 (out of 18) cases, and the use of the
MMRC eective (mean score of 6.6 out of 10) and feasible (mean score
of 7.6 out of 10) as well.
Optimal skin care includes an alleviation of complaints, the
prevention of relapses and the modication of the tactile and visual
characteristics of the surface of the skin [24,25]. Nowadays, reparation
of the skin barrier or prevention of barrier dysfunction is believed to
be the cornerstone in the therapeutic management of eczema. Since
the eects of moisturizers on skin barrier function have not yet been
well documented, selection of a suitable moisturizer for the treatment
of venous eczema is rather a matter of trial-and-error [26].
In other studies the measurement of the TEWL has been used to
demonstrate an immediate increase of water in the stratum corneum
and prove of the formation of water restricting fatty barrier layer of the
skin surface, increasing its hydration [27]. e specic composition of
the moisturizer has also been held responsible for the time period a
patient remains free of relapses [27,28].
Medical Moisture Retention Cream (MMRC) is an oil in water
emulsion with Aloe Vera gel as main ingredient. It contains both
freshly processed pure Aruba Aloe Vera gel, oils and fatty ingredients.
Hoeksema et al. performed an
in vitro
study to investigate the
occlusive and hydrating properties of MMRC. eir scar-like model
introduced in healthy volunteers was ideally suited to mimic the two
main properties of abnormal scarring i.e. an increased TEWL and a
decreased hydration state of the stratum corneum. Hoeksema et al.
concluded that MMRC
in vitro
is able to repair the skin barrier and to
create a balanced degree of occlusion and hydration, bringing back the
TEWL to values slightly above the level of normal skin [22].
Citation: Rondas AALM, Schols JMGA (2017) Application of Medical Moisture Retention Cream (ALHYDRAN®), A New Option in the Treatment
of Venous Eczema. J Gerontol Geriatr Res 6: 395. doi:10.4172/2167-7182.1000395
Page 4 of 6
J Gerontol Geriatr Res, an open access journal
ISSN: 2167-7182
Volume 6 • Issue 1 • 1000395

Vuylsteke revealed that the higher the average C-class (C3-C6),
according to the CEAP) classication, the more symptoms patients
show [29,30]. Although sleep disturbance (80%), pain (74%), and
lower limb swelling (67%) have been frequently expressed in the
presence of a venous eczema [31], in this case studies 16 patients (out
of 18) did not express pain, and experienced no ‘night rest’ problems,
‘mood’ disturbances or any hampering of their ‘social participation’.
e absence of these signs and symptoms in these case studies may be
the result of the inclusion criteria, including patients who had a
maximum TIS score of 3.
In the management of venous eczema, topical steroids are normally
used to decrease the intensity of skin eects and also to reduce the
number of exacerbations [21]. is has also been supported by 1
patient in this case series. Indeed, the local treatment with
triamcinolone acetonide 0.1% cream applied once a day, for two weeks
long, did disappear the signs and symptoms of the patient who showed
a much more scaly skin just aer one week of application of MMRC.
But basically, the use of topical steroids should be avoided because
of the possibility of sensitizing the skin (32) and the possibility of
causing systemic side eects e.g. on bone density, glaucoma and
growth [33,34]. e most eective therapy for venous eczema has not
been clearly dened yet. e possibility of introducing side eects as
result of the application of topical steroids has led to a request for
reasonable and safer alternatives, to treat patients eectively and safely
as well. e application of MMRC ts in this philosophy.
Case series focus on the clinical course of events in terms of patient’s
response to therapy, represent real-life care and provide a rationale for
future high-quality well designed, large scale randomized, and
placebo-controlled trials to document therapeutic eects on disease
severity, biophysical parameters, quality of life, and patient
acceptability. Case series are non-comparative because they lack a
control arm. erefore, treatment outcomes in the selected cases series
cannot be compared with those that did not receive treatment.
Randomized Controlled Trials are necessary not only to compare the
ecacy and feasibility of MMRC with other kind of moisturizers, but
also to examine whether MMRC is able to delay the time to relapse.
Conclusion
In a case series of 18 patients suering from a moderate venous
eczema, the use of MMRC appeared to be eective and feasible.
Complaints of a dry, itchy, scaly, sometimes crusty and erythematous
skin fainted aer a few weeks of use, twice a day. Except for 2 patients,
the ‘night rest’, ‘mood’ and ‘social participation’ of the other 16 patients
improved in 4 weeks’ time. Because of this positive result, it can be
advised that it is relevant to conduct future Randomized Controlled
Trials to compare the ecacy and feasibility of MMRC with the
application of other hydrating creams/ointments and to examine
whether relapses of eczema and also the prescription of steroids can be
delayed.
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Citation: Rondas AALM, Schols JMGA (2017) Application of Medical Moisture Retention Cream (ALHYDRAN®), A New Option in the Treatment
of Venous Eczema. J Gerontol Geriatr Res 6: 395. doi:10.4172/2167-7182.1000395
Page 6 of 6
J Gerontol Geriatr Res, an open access journal
ISSN: 2167-7182
Volume 6 • Issue 1 • 1000395