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Evaluation of an Optimal Method for Topical Application of Moisturizer
Abstract
The optimal method and dosage for topical application of moisturizers (Hirudoid®Soft and Hirudoid®Lotion) were investigated. To this end, we examined the Finger-tip unit(FTU), moisturizing effects for artificial dry skin at varying dosages, moisturizing effects at varying frequencies of application, and the relationship of moisturizing effects to the timing of topical application after bathing. The results suggest that FTU serves as a convenient and reliable indicator of the optimal dosage of moisturizers, and that higher moisturizing effects may be obtained if the moisturizers are applied at dosages slightly higher than the seemingly appropriate dosage, at frequencies higher than usual and soon after bathing.
... Concerning terfenadine (manufacturing was discontinued because of QT prolongation as a side effect), its lack of teratogenicity was confirmed, and also no differences were found in the incidence of congenital malformations or teratogenicity between its active metabolite, fexofenadine, and cetirizine. 453 However, in a case-control study by the National Birth Defects Prevention Study in the USA, 340 logistic analyses regarding congenital anomalies and antihistamines involving 44,029 study participants (32,200 patients and 11,829 controls) between 1997 and 2011 revealed 20 significant associations. These associations were not significant through strict statistical adjustment, but some significant associations remained on slightly loose adjustment; neural tube defect, left ventricular hypoplasia, and tetralogy of Fallot were associated with exposure to antihistamines in the first trimester. ...
... To determine the amount of agent to apply, a fingertip unit is helpful. The amount extruded from the tube(5 mm in diameter) from the length of the tip of the second finger to the first joint (approximately 0.5 g) (fingertip unit) is the adequate dose for two adult palmars in the UK, that is, approximately 2% of the adult body surface area.105,106,200 Generally, transepidermal water loss (TEWL) is often found in the skin of patients with AD, not only in the lesion, but also in normally appearing areas representative of the dry skin.201 ...
This is the English version of the Clinical Practice Guidelines for the Management of Atopic Dermatitis 2021. Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. In Japan, from the perspective of evidence‐based medicine, the current strategies for the treatment of AD consist of three primary measures: (i) use of topical corticosteroids, tacrolimus ointment, and delgocitinib ointment as the main treatment of the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. In the present revised guidelines, descriptions of three new drugs, namely, dupilumab, delgocitinib, and baricitinib, have been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity‐related patient outcomes with respect to several important points requiring decision‐making in clinical practice.
... This suggested that higher antipruritic effects might be obtained if MPS cream was applied more frequently. Some studies also supported that twice-daily application of hirudoid preparations was more effective than once-daily application (44,45). Therefore, MPS cream is recommended to be applied twice daily or more in clinical practice. ...
Background: Mucopolysaccharide polysulfate (MPS) cream as a moisturizer is widely applied to treat eczema, and a lot of clinical trials have demonstrated its efficacy and safety. However, there is no further research to collect and analyze these studies.
Objective: This meta-analysis aimed to assess the efficacy and safety of MPS cream as monotherapy or add-on therapy for non-exudative eczema.
Methods: Ten databases were searched to identify the eligible randomized controlled trials (RCTs) from their inception to July 31, 2021. Revman 5.3 software was used for the meta-analysis.
Results: A total of eligible 20 studies were included. Among the 20 studies, 2 studies compared MPS cream with other moisturizers, 14 compared MPS cream plus topical corticosteroids (TCS) with TCS alone, and 4 compared with MPS cream plus tacrolimus ointment with tacrolimus ointment alone. The pooled results demonstrated that MPS cream had a higher total efficacy rate [Risk ratio (RR) 1.21, 95% CI: 1.12 to 1.30, P < 0.00001], a lower recurrence rate (RR 0.44, 95% CI: 0.26 to 0.74, P = 0.002) and a lower pruritus score [mean difference (MD) −1.78, 95% CI: −2.16 to −1.40, P < 0.00001] than urea cream or vaseline ointment. Moreover, in comparison with TCS or tacrolimus ointment alone, the combination treatment performed better in terms of total efficacy rate, total symptom score, recurrence rate, and pruritus score. For safety, the skin adverse events were mild, and MPS cream as monotherapy or add-on therapy did not increase the risk of skin adverse events.
Conclusions: MPS cream as monotherapy or add-on therapy could provide a good effect for treating non-exudative eczema with mild and tolerable skin adverse events. However, due to the suboptimal quality of the included studies, high-quality and large-sample RCTs are needed in the future for update or validation.
Systematic Review Registration: PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/ ), identifier: CRD42021265735.
... [15][16][17] Moisturizers are known to exert a more beneficial effect when applied twice daily rather than once daily. 18 guidelines for the management of atopic dermatitis 2018" in Japan state that moisturizers should be applied twice daily. 20 As for the volume of moisturizer to be applied, some reports recommended applying a 1 FTU equivalent dose, 7 but the recommended volume has not been supported by clinical studies. ...
Asteatosis is characterized by decreased stratum corneum water content, and the basic treatment is to keep the skin moisturized. Poor application of moisturizers by patients may reduce treatment efficiency, so it is important to continue application as instructed by dermatologists. Application instructions based on the finger‐tip unit are useful for patients, but there is no clear evidence of its efficacy. We investigated the effects of the volume of the moisturizer (Hirudoid® Cream 0.3%) administrated with 1/3 finger‐tip unit and 1 finger‐tip unit equivalent doses per target lower leg of patients with asteatosis (twice daily, 28 days) on the overall dry skin scores, itch numerical rating scale scores, and skin physiological parameters (stratum corneum water content, transepidermal water loss, and skin pH). Sixty patients were randomized with a 1:1 allocation ratio into two groups: the 1/3 finger‐tip unit and 1 finger‐tip unit equivalent dose groups. The results showed that 43.3% of the patients in the 1 finger‐tip unit equivalent dose group, compared with 13.3% in the 1/3 finger‐tip unit equivalent dose group, presented zero overall dry skin scores 1 week later. As the overall dry skin scores improved, the stratum corneum water content also increased. In patients with moderate itching, the itch numerical rating scale scores of the 1 finger‐tip unit equivalent dose group decreased significantly compared with those of the 1/3 finger‐tip unit equivalent dose group. The results suggested that the application of 1 finger‐tip unit equivalent dose of the moisturizer twice daily in clinical practice could induce remission more quickly. With the 1/3 finger‐tip unit equivalent dose, prolonged treatment may be necessary to achieve the desired effect; therefore, application adherence is strictly required. In conclusion, the application of a 1 finger‐tip unit equivalent dose would be quite reasonable in clinical practice.
... This was originally the standard amount of topical steroid application, and its applicability for moisturizers has been reported previously. 15 Video-assisted education was provided to all participants to demonstrate appropriate application methods. Any oral, injectable, or topical medication, including antipruritic medications, that was being used at the start of study treatment (week 0) and required continuation during the study period was continued with no change to the dosage regimen. ...
Xerosis and pruritus are common in patients undergoing dialysis. These symptoms are treated with moisturizers, but limited evidence supports the efficacy of such treatment. Our exploratory study suggested the effectiveness of a heparinoid-containing product for xerosis in dialysis patients. We conducted a multicenter, open-label, randomized, before-after, parallel-group comparative study to verify the exploratory study results (Clinical Trial Registry: UMIN000029360). Seventy-one Japanese patients undergoing dialysis with chronic kidney disease and xerosis were randomly assigned to receive a heparinoid-containing product for 2 weeks (group A [n = 36]) or 8 weeks (group B [n = 35]). Patients were instructed to apply the study product based on the fingertip unit method. The efficacy endpoints were the water content of the stratum corneum (WCSC), skin dryness score, pruritus visual analog scale score, and Dermatology Life Quality Index. Safety was assessed by monitoring adverse events. The mean WCSC (arbitrary units) was 26.0 ± 9.6 in group A and 25.2 ± 10.0 in group B at the start of treatment (week 0), significantly increased to 39.0±12.5 in group A and 38.5 ± 11.0 in group B (P < 0.0001 for both vs week 0) by week 2, and then decreased only in group A. Thus, the WCSC at week 4 (the primary endpoint) remained significantly higher in group B (36.4 ± 12.2 vs 28.8 ± 10.4; P = 0.0068). Other endpoints improved during treatment with the study product. One patient developed a rash and erythema as treatment-related adverse events. In conclusion, 8 weeks’ application of a heparinoid-containing product was effective for xerosis in patients undergoing dialysis.
... The amount extruded from the tube (5 mm in a diameter) from the length of the tip of the second finger to the first joint (approximately 0.5 g) (fingertip unit) is the adequate dose for two adult palmars in the United Kingdom, that is, about 2% of adult body surface area. 91,92,148 Generally, transepidermal water loss (TEWL) is often found in the skin of patients with AD and not only in the lesion, but also in normal appearing areas representative of the dry skin. 149 Therefore, topical moisturizers should be applied all over the body including sites that appear to be normal. ...
Atopic dermatitis (AD) is a disease characterized by relapsing eczema with pruritus as a primary lesion. The current strategies to treat AD in Japan from the perspective of evidence‐based medicine consist of three primary measures: (i) the use of topical corticosteroids and tacrolimus ointment as the main treatment for the inflammation; (ii) topical application of emollients to treat the cutaneous barrier dysfunction; and (iii) avoidance of apparent exacerbating factors, psychological counseling and advice about daily life. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity‐related patient outcomes with respect to several important points requiring decision‐making in clinical practice.
... Regular use of moisturizer constitutes the core of the management of AD. A moisturizer repairs the skin barrier, maintains skin integrity and appearance, reduces transepidermal water loss, and restores the lipid barrier's ability to attract, hold, and redistribute water [28] [ Table 5]. Data from RCTs show that moisturizers have a long-and short-term steroid-sparing effect in mild to moderate AD and in preventing AD flares. ...
Background: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin
condition that affects all age groups. There was a dearth of consensus document on AD for
Indian practitioners. This article aims to provide an evidence‑based consensus statement for
the management of AD with a special reference to the Indian context. This guideline includes
updated definition, etiological factors, classification, and management of atopic dermatitis.
Methodology: The preparation of guidelines was done in multiple phases. Indian Dermatology
Expert Board Members (DEBM), recommended by the Skin Allergy Society of India, prepared 26
evidence‑based recommendations for AD. An extensive literature search was done in MEDLINE,
Google scholar, Cochrane, and other resources. Articles published in the past 10 years were
reviewed and recommendations were graded based on the quality of evidence as per GRADE.
After forming the initial structure, DEBM met in Mumbai and gave their decisions on an agree
and disagree scale with an Indian perspective. Finally, their suggestions were compiled for
preparing the article. After DEBM finalized the draft, a treatment algorithm was formulated
for the management of AD. Results: DEBM suggested a working definition for AD. The panel
agreed that moisturizers should be used as mainstay of therapy and should be continued in
all lines of therapy and in maintenance phase. Topical corticosteroids and topical calcineurin
inhibitors should be considered as the first line of treatment. Among systemic therapies,
cyclosporin should be considered first line, followed by azathioprine, methotrexate, and
mycophenolate mofetil. Phototherapy can be an effecive alternative. Empirical food restriction
was recommended against. Conclusion: These guidelines should form a reference for the
management of patients with AD in an evidence‑based manner.
... Lubrication of the skin by moisturizer depends on the number of times the moisturizer is used. [32][33][34] Therefore, we proposed to ...
The combination of skin external preparation and transdermal patch is influenced by drug absorption through the skin. We investigated the effect of heparinoid cream on the transdermal absorption of oxybutynin hydrochloride using an oxybutynin transdermal patch and determined the combined effect of these medications. Normal skin and dry dorsal skin in hairless mice were treated with heparinoid cream, followed by the application of the oxybutynin transdermal patch. A blood sample was collected from the mouse tail vein and the blood concentration of oxybutynin hydrochloride was analyzed by LC-MS/MS. Transepidermal water loss, the hydration level of the stratum corneum, and the stratum corneum thickness in the dorsal skin were measured. The blood concentration and area under the curve (AUC)0→24 of oxybutynin hydrochloride increased when the 4.0-cm² oxybutynin transdermal patch was applied 1 h after the application of the moisturizer, compared to the values without moisturizer. Normal skin and dry skin did not affect this result. As the hydration level of the stratum corneum and stratum corneum thickness increased before patch application by pre-treatment with moisturizer, it was suggested that transdermal absorption of oxybutynin hydrochloride was increased by skin hydration. The increased blood concentration of oxybutynin hydrochloride was regulated by changing the effective area of the patch and applying additional moisturizer at intervals. The pharmacokinetics of oxybutynin hydrochloride under the regulation of combination treatment was similar to that of treatment without moisturizer. These findings indicate that the application conditions of the oxybutynin transdermal patch and heparinoid cream influence the proper use of the patch.
Graphical Abstract Fullsize Image
This is the English version of the 2024 clinical practice guidelines for the management of atopic dermatitis (AD). AD is a disease characterized by relapsing eczema with pruritus as a primary lesion. A crucial aspect of AD treatment is the prompt induction of remission via the suppression of existing skin inflammation and pruritus. To achieve this, topical anti-inflammatory drugs, such as topical corticosteroids, tacrolimus ointment, delgocitinib ointment, and difamilast ointment, have been used. However, the following treatments should be considered in addition to topical therapy for patients with refractory moderate-to-severe AD: oral cyclosporine, subcutaneous injections of biologics (dupilumab, nemolizumab, tralokinumab), oral Janus kinase inhibitors (baricitinib, upadacitinib, abrocitinib), and phototherapy. In these revised guidelines, descriptions of five new drugs, namely, difamilast, nemolizumab, tralokinumab, upadacitinib, and abrocitinib, have been added. The guidelines present recommendations to review clinical research articles, evaluate the balance between the advantages and disadvantages of medical activities, and optimize medical activity-related patient outcomes with respect to several important points requiring decision-making in clinical practice.
This is the English version of guidelines for the management of asteatosis 2021 in Japan. Asteatosis is a synonym of xerosis found in a wide range of diseases that induce dry skin through impaired functions of either water retention of the stratum corneum or skin covering with acid mantle. Patients with asteatosis may be accompanied by pruritus. Moisturizers are the first-line treatment for asteatosis and their adequate use must be recommended. The main purpose of the present guidelines is to define skin symptoms requiring treatment with moisturizers for medical use in patients with asteatosis. If the deterioration of marked scaling or scratch marks is predicted, therapeutic intervention with moisturizers for medical use should be considered even in the absence of pruritus. Regarding six important points requiring decision-making in clinical practice (clinical questions), we evaluated the balance between the benefits and harm of medical interventions in reference to previous reports of clinical research, and presented the recommendation grades and evidence levels to optimize the patient outcome by medical interventions.
Objective: Finger-tip unit (FTU) has been used in Western countries to apply a specific amount of steroid ointment available in tube form. Although prescription ointments for treating skin disorders are available in Japan, there are no indications for patients regarding the amount to be used. Therefore, we investigated the factual assessment of patient compliance instructions on using the ointments given by pharmacists and conducted a comparative test on the amount of ointment in 1 FTU using commercially available ointment tube products.
Methods: We conducted a questionnaire survey for 21 hospital pharmacists on patient compliance instructions for ointments. Using six types of ointments, we measured the aperture area of ointment tube, weight of 1 FTU and squeezing number of tube.
Results: Fewer than 50% of pharmacists explained the application methods and amounts for one-time use when they provided patient compliance instructions. There were many patients who used an ointment inadequately. The most were problems about the quantity of application. Wide variations were found among the amount of ointment in 1 FTU weight and number of available uses.
Conclusion: The survey results demonstrated that the methods used to apply the ointments are items that must also be emphasized by pharmacists when providing patients compliance instructions. Furthermore, the patient compliance instructions should include the amount of ointment in 1 FTU and number of available uses within pharmaceutical products.
Hand-foot skin reaction (HFSR) is one of the major adverse effects of sorafenib necessitating discontinuation of the drug, however, no standard interventions for HFSR have been established yet. At our hospital, we are using a urea-containing cream prophylactically for HFSR associated with sorafenib. We carried out this study in 74 hepatocellular carcinoma patients receiving treatment with sorafenib at our hospital between June 2009 and January 2011 to assess the benefit of prophylactic use of urea-containing cream against sorafenib-induced HFSR. Patients with a history of previous use of tyrosine kinase inhibitors or insufficient data in respect of the dose of urea-containing cream were excluded. The patients were divided into a high-dose group (38 patients) and a low-dose group (36 patients) according to the median dose (2.9 g per day) of urea-containing cream used within the first 2 weeks after the start of sorafenib treatment. The frequency of grade 2 or 3 HFSR was 42.1% in the high-dose group and 61.1% in the low-dose group(P = 0.105). The relative dose intensity of sorafenib was 71.1% in the high-dose group and 59.6% in the low-dose group (P = 0.043). No significant difference was observed in the response rate or time to progression between the two groups. In conclusion, prophylactic use of a urea-containing cream might enhance the relative dose intensity of sorafenib, but further prospective studies are warranted to elucidate its usefulness.
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