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The Role of Moisturizers in Addressing Various Kinds of Dermatitis: A Review

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Moisturizer is a major component of basic daily skin care, particularly in presence of epidermal barrier alteration and reduced epidermal water content. It is an important part of a dermatologist's strategy to maintain skin health as well as treating various dermatoses which co-exist with skin dryness, linked to impaired skin barrier function such as in atopic disorder as well as other types of dermatitis. Mastering the knowledge regarding action mechanism, application, dosage, adverse effects as well as specific clinical usage of moisturizers is must for a dermatologist, in order to support the capability to recommend their use, particularly for therapeutic purposes, in accordance with evidence-based medicine. This review is aimed to discuss the use of moisturizer both as skin health maintenance as well as a definitive or adjuvant therapy, particularly for many kinds of dermatitis.
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Review
Copyright © 2017 Marshfield Clinic Health System
The Role of Moisturizers in Addressing Various
Kinds of Dermatitis: A Review
Schandra Purnamawati, MD; Budi Satria, MD; Niken Indrastuti, Dr;
Retno Danarti, Dr; and Tatan Saefudin, MD
Short running footer: The role of moisturizers in addressing various kinds of dermatitis
Source of support: None
Total number of tables presented in the manuscript: 5 tables
Word count of the text: 5486 words
Word count of the abstract: 146
Corresponding Author:
Schandra Purnamawati, MD Received: March 10, 2017
Universitas Gadjah Mada Revised: October 23, 2017
Dermatology and Venereology Accepted: November 13, 2017
Jl. Farmako Sekip Utara, Sinduadi, Mlati
Sleman, Jogjakarta 55281 doi:10.3121/cmr.2017.1363
Indonesia
Tel: +6281317701232
Email: schandra_widikusumo@yahoo.com
. Published online ahead of print December 11, 2017 as doi:10.3121/cmr.2017.1363Rapid ReleaseCM&R
Copyright 2017 by Marshfield Clinic.
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ABSTRACT
Moisturizer is a major component of basic daily skin care, particularly in presence of epidermal
barrier alteration and reduced epidermal water content. It is an important part of a dermatologist's
strategy to maintain skin health as well as treating various dermatoses which co-exist with skin
dryness, linked to impaired skin barrier function such as in atopic disorder as well as other types
of dermatitis. Mastering the knowledge regarding action mechanism, application, dosage,
adverse effects as well as specific clinical usage of moisturizers is must for a dermatologist, in
order to support the capability to recommend their use, particularly for therapeutic purposes, in
accordance with evidence-based medicine. This review is aimed to discuss the use of moisturizer
both as skin health maintenance as well as a definitive or adjuvant therapy, particularly for many
kinds of dermatitis.
Keywords: Moisturizers; Atopic dermatitis; Seborrheic dermatitis; Contact dermatitis;
Nummular dermatitis
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I. WHAT IS MOISTURIZER?
Interestingly, there is no consensus regarding the definition of moisturizer. This term was
developed by marketers, promoting its function to moisten the skin.1 Moisturizer and emollient
are often regarded as a synonym, even when occlusives and humectants are also part of it.
Emmolients are mostly made up of lipids and their components, which fill intercorneocytes
cluster gaps to enhance skin hydration, smoothness, softness, flexibility. Occlusives are other
type of moisturizer which is mostly oil based and serve the function of maintaining skin water
content by creating a hydrophobic barrier over the skin and blocking trans epidermal water loss.
The last type of moisturizer are humectants, consisted of hygroscopic substances which help the
stratum corneum to absorb water by attracting water from dermis and humid environment into
the epidermis. 2 Moisturizers efficacy depends largely on proper selection and compliance to
continuously use it.
II. WHY DO WE NEED MOISTURIZERS?
Skin appearance is essential as flawed presentation may results in reduced self-esteem.3
Moisturizers are commonly used to reduce fine lines, smoothen and hydrate skin. This may
improve patient’s social life, psychological satisfaction and quality of life. 4
Moreover, either normal skins or dermatoses with dry skin symptoms may both gain optimal
benefit from proper utilization of moisturizers. Impression of skin dryness consist of visible and
tactile changes of the skin as well as alteration in skin’s sensory components, which presents as
dry skin symptoms. These symptoms include dryness feeling and discomforts; consist of
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tightness, pain, itch, stinging, and tingling.5 Moisturizers work effectively to overcome dry skin
underlying dermatoses, interrupting dry skin cycle while maintaining skin smoothness.6
Moisturizers also have several benefits aside skin moistening. Some of the possible functions
provided by moisturizers are as follows:
1. Anti-inflammation: Some moisturizer components, such as glycyrrhetinic acid,
palmitoyl-ethanolamine, telmesteine, Vitis vinifera, ceramide-dominant barrier repair
lipids and filaggrin breakdown products have considerable anti inflammation properties
through various mechanism, such as blocking cyclooxygenase activity and down
regulating cytokines as well as proinflammatory prostanoids production, providing
soothing effect on inflamed skin, such as in dermatitis.1-2, 4-8 Further discussion on each
substances will be discussed later in this review.
2. Antipruritic: Water based moisturizers provides cooling effect from water evaporation on
the skin surface,and some moisturizers may contains menthol as additive, which provides
cooling sensation and therefore reducing itch symptoms.4-7
3. Antimitotic: Mineral oils possess low-grade epidermal antimitotic properties and bring
therapeutic benefit for dermatoses with increased epidermal mitotic activity such as
psoriasis.4-6
4. Wound healing: Hyaluronic acid had demonstrated to promote wound healing
acceleration.7,8
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III. HOW DO MOISTURIZERS WORK?
The skin functions as barrier, protecting underlying tissues from desiccation, infection,
mechanical stress and chemical irritation. Impaired function leads to increasing trans-epidermal
water loss (TEWL), associated with various kinds of dermatitis.9
Water from deeper epidermal layers moves upward to hydrate stratum corneum (SC) cells, which
is then lost to evaporation. Epidermal water content is essential to prevent skin dryness and
maintain plasticity.10 Stratum corneum is an active membrane, described as bricks and mortar
model, where loss of intercellular lipids, forming the bilayers (e.g: ceramides, cholesterol and
fatty acids) will result in water barrier formation damage, leading to dry skin.1
Stratum corneum structure is the pivotal factor in skin water flux, retention and overall
moisturizing level.10 There are four key processes in SC formation and functioning; corneocyte,
SC lipid, natural moisturizing factor (NMF), and desquamation.11 Corneocytes are SC’s physical
barrier, contributing to elasticity when hydrated. Stratum corneum’s lipid bilayers act as moisture
barrier and despite preventing many chemicals entry; they are also means of entry for most
topically applied substances. The NMF within corneocytes is a hygroscopic molecules mix,
which maintain and keep corneocyte’s hydration. Fifty percents of NMF are amino acids
originating from keratinocytes protein filaggrin, the remainings are salts, including lactates, urea,
and electrolytes. NMF production is directly related to external humidity. In desquamation,
corneodesmosomes are degraded by water-dependent hydrolytic agent, which work less
efficiently in low moisture SC. Dry skin signs appear when corneocytes accumulate on skin
surface (when SC has less than 10% water content) and lose its continuity.12
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Moisturizers improve skin barrier repair, maintain skin’s integrity and appearance by acting as
humectants, emollients, and occlusives, each with its own mechanism of actions.13 Moisturizers
improves skin hydration and increases SC water content by directly providing water to the skin
from their water phase and increasing occlusion to reduce TEWL, it also covers small skin
fissures, provide soothing protective film and protect skin from friction. Furthermore,
moisturizer application smoothes skin surface by filling spaces between partially desquamated
skin flakes and restores the ability of the intercellular lipid bilayers to absorb, retain and
redistribute water. Skin mechanics change thereafter as increased hydration facilitate degradation
of corneodesmosomes, preventing corneocytes accumulation, while promoting its continuity.14
Loden concludes that skin care products does not only stay inactively on skin surface, but also
penetrate to influence skin’s structure and function.5
IV. MOISTURIZERS CONSTITUTES AND MAIN TYPES
Moisturizer may be considered as cosmetics as well as therapeutic products when addressed to
overcome diseases associated with skin dryness.5 Moisturizers consist of actives and excipients
(emulsifiers, antioxidants, preservatives). Recent evidences shows that actives and excipients
induce prominent cutaneous effects. Some ingredients improve skin barrier function and clinical
outcomes, whereas others deteriorate skin condition. For example, emulsifiers may weaken skin
barrier while petrolatum provides an immediate barrier-repairing effect.2 Types of moisturizers
are listed in Table 1.
IV(a). Emollients
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Long chain saturated fatty acids (stearic, linoleic, oleic, lauric acid and fatty alcohols) are
essential fatty acids examples of emmolients, found naturally in wool fat, palm oil, and coconut
oil, commonly used in cosmetic formulations or topical pharmaceuticals. Emollients influence
skin physiology and pathology by exerting many effects on skin barrier function, such as
eicosanoid production, membrane fluidity, and cell signaling, improving skin repair, and
permeability, playing important role for therapeutic benefits.15 Emollients classification is
showed in Table 2.
IV(b). Humectants
Many humectants also possess emollient properties. NMF, consist of low molecular weight
soluble hygroscopic substances mixture, plays major role for SC hydration (for example: lactic
acid, pyrolidone carboxylic acid, and amino acids).6
Humectants can also enhance TEWL by increasing water absorption from dermis into epidermis,
where it easily evaporates; therefore combination with occlusives is frequently required to help
enhancing epidermal barrier function and hydration.9 Honey, sorbitol, glycerin, panthenol, urea,
gelatin, hyaluronic acid, alpha hydroxy acids (glycolic acid, lactic acid, sodium pyrrolidine,
carboxylic acid), propylene glycol and butylene glycol are examples of humectants.
IV(c). Occlusives
Occlusives have the most significant effect when applied to dampened skin by creating
hydrophobic barrier over the skin; contributing to the inter-corneocytes matrix. Occlusives
diffuse into the intercellular lipid domains, contributing to their efficacy.9
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Petroleum is mineral oils source, consisting of complex hydrocarbons combination. The most
important materials are liquid paraffin and petrolatum. Petrolatum is the most effective classic
occlusive moisturizer, minimum concentration of 5%, can reduce TEWL by more than 98%,
with 170 times water vapor loss resistance than olive oil.16
Lanolin, mineral oil and silicones (e.g., dimethicone) can reduce TEWL by 20%-30%. Lanolin is
also effective and widely used. It is secreted by sheep sebaceous glands and has a complex
structure of esters, diesters, hydroxyesters of high molecular weight, lanolin alcohols, and lanolin
acids. Unlike human sebum, it has no triglycerides.1 Negative effects with occlusives is
unpleasant odor, potential allergenicity, and greasy consistency, making them less acceptable
cosmetically. A wide range of occlusives is as shown in Table 3.
V. MOISTURIZER FORMULATIONS
Most moisturizers combine emollients, occlusives, and humectants. Occlusives and humectants
combinations enhance skin’s water-holding capacity. Furthermore, addition of certain emollients
may improve esthetic quality and stability of moisturizer’s active ingredients.17 When glycerol
combined with occlusives, skin dryness will be synergistically alleviated.18 The predominant
formulation is cosmetic emulsions, most are lotions (oil-in-water emulsions) or creams (water-in-
oil emulsions). Complex emulsions (e.g., oil-in-water-in-oil, oleaginous mixtures, serums, gels,
sprays, and milks) are used to deliver and stabilize some active ingredients. Compliance is in
accordance with consumer preferences and desired results; hence, will likely be poor if the
patient is unsatisfied by the prescribed moisturizer.2
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Different skin types (oily, normal, or dry), application sites and existing dermatoses are the basis
for adjusting the formulas consisting oil-water ratio, occlusives, and emollients. Ideally,
dermatologists should recommend therapeutic moisturizers which is noncomedogenic, non
irritative, and compatible with current therapeutic regimens.21 Variety of moisturizer
formulations are listed in Table 4.
VI. MOISTURIZER APPLICATION METHODS
The right time and methods for moisturizers application hold the key to optimal benefits. Other
than humectants and hydrophilic matrices, absorbing water from atmosphere or underlying skin
layers, the more commonly used occlusive oils should be applied on moistened skin by prior
showering or sponge bath.1,6 After rubbing moisturizer in both palms, it should be lightly applied
along hair follicles direction. To prevent oil folliculitis from vigorous rubbing, application
methods should be carefully explained to the patient.
Moisturizer distribution depends on the vehicle. Thick ointments are more evenly distributed
compared to lower viscosity formulations and more volatile ingredients. Transfer of active
ingredients to surrounding surfaces is easier for creams and ointments than lotions and tinctures.
22 After application, ingredients may stay on the surface, absorbed into the skin, metabolized or
disappear from the body by evaporation, sloughing off or by contact with other materials. After 8
hours, only 50% moisturizer remained on the skin surface. Therefore, depending on dryness
severity, recommended application frequency varies between 1 and 3 times daily.
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VII. ADVERSE EFFECTS
Compared to other topical drugs prescription, moisturizers are rarely associated with health
hazards, even when used on large body surface areas over a long period of time. Various
discomforts associated with moisturizers are frequently encountered, as any substance may cause
skin reactions in sensitive areas of some individuals.
Skin irritation, which is sensory reactions or subjective sensations with/without signs and
symptoms of inflammation, is the most frequent adverse effect.6 Table 5 lists possible adverse
effects of moisturizers. By keeping them in mind, clinicians may select appropriate moisturizers
to prevent unnecessary discomforts.
IX. THERAPEUTIC USE OF MOISTURIZERS
Moisturizers have a wide array of benefits for many dry skin associated dermatoses. Skin
dryness is induced by complex interactions between environmental and individual factors.
Contributing factors includes low environmental temperature, low humidity, chemical exposures,
microorganisms, aging, psychological stress, atopic dermatitis, and eczemas.23-25
This review emphasizes therapeutic use of moisturizers in various dematitis, such as atopic,
seborrheic, contact, and nummular dermatitis.
IX(a). Moisturizer for atopic dermatitis:
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Atopic dermatitis (AD) is a chronic skin inflammation, characterized with pruritus and skin
barrier defect. Genetic mutations in AD lead to malfunctions leading to AD development and
severity. These mutations hamper filaggrin expression, the structural protein maintaining
epidermal barrier integrity as skin’s vital line of defense. Filaggrin deficiency leads to skin
barrier defects, allowing increased TEWL and facilitates exposures of environmental allergen
and infective organisms through the skin, leading to persistent skin inflammation.26
Due its chronic and relapsing nature, AD management involves treatment and prevention of
flares, requiring long term skin barrier restoration through effective patient counseling and
caregiver’s partnership. Moisturizers are the most important basic skin treatment for optimal AD
recovery regardless the severity.27,28 Moisturizers can penetrate and help reorganize skin layers
structure, therefore, it is recommended as key step for AD treatment , together with triggers
avoidance and therapeutic measures to control symptoms and inflammation. However, the choice
of moisturizer ingredients should be considered carefully as AD patients are more prone to
contact dermatitis when compared to normal population. 9,26,29
Natural oils are widely used as moisturizer ingredient to treat and prevent dermatoses, such as
AD. However, there are very limited data regarding their efficacy and safety profile. It has been
suggested that oleic acid ratio (OA) to linoleic acid (LA) in natural oils determines their
functions in skin hydrating and protecting effect on the skin. Positive effects are associated with
high LA and low OA ratios. High LA concentrations are believed to accelerate skin barrier repair
and development, improving skin hydration, and ameliorate AD severity, making them perfect
for steroid sparing.30-31 Safflower oil, sunflower seed oil, and sea buckthorn seed oil are natural
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oils with highest LA/OA ratios.30 A recent study involving Bangladesh preterm infants reveals
the excellent barrier repair and maintenance effects of sunflower seed oil, with 41 percent
decreased risk for developing nosocomial infections compared to controls. However, olive oil,
having relatively low LA/OA ratio, can significantly deteriorate skin barrier by disrupting SC
lipid structure and homeostasis.31 Further researches regarding natural oils safety and efficacy for
prevention and treatment of dermatoses are still required.
Humectants such as 10% urea has been shown to reduce TEWL in atopic patients.2 Urea also
reduce skin irritation from sodium lauryl sulfate exposure in both atopic and normal skin. In
mouse models of AD, application of glycerin-based moisturizer demonstrated a rapid hydration
effect compared to untreated skin.32 Alpha hydroxy acids are also effective treatment for dry
skin. While lactic acid, particularly the L-isomer of lactic acid stimulates ceramide synthesis,
resulting in a higher production of SC ceramide and promoting a superior skin lipid barrier and
dry skin resistance.9
Ceramides restore skin water permeability and barrier function. Recent studies suggested that
low skin ceramide levels is a major etiologic factor in skin diseases, such as in AD.33 Stratum
corneum consist of a significantly high ceramides composition (50 percent from total lipids).
Many evidences showed that epidermal lipid barrier recapitulation with ceramides is effective as
adjunctive treatment for eczematous processes. According to Chamlin et al, topical mixtures of 3
key SC lipids consisting of ceramide, cholesterol, and free fatty acids in optimal proportions
(3:1:1 molar ratio) can accelerate barrier repair following various external, acute, or sustained
skin barrier disruption.33,34 Unlike non physiologic lipid mixtures such as petrolatum,
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physiologic lipids (ceramides, cholesterol, and free fatty acids) can traverse both intact and
disrupted SC.34 Therefore, natural or synthetic ceramides containing moisturizers are mostly
recommended for AD. Lipophilic compounds like cholesterol and ceramides had been used in
AD creams as they easily incorporate into liposomes, softening and smoothing skin texture.
Nanoencapsulated triceramides are also being used to improve skin hydration.35
Nowadays, anti-inflammatory agents are incorporated with emollients or humectants; providing
additional barrier repair and control dry skin. They are claimed as suitable for relieving mild-to-
moderate AD, may reduce or substitute topical corticosteroids (TCS) use, thus minimize side
effects.36,37 Some anti-inflammatory agents added in AD moisturizers are reviewed here. The use
of these agents are to be carefully considered and selected for each patient, as some of them may
be unsuitable for certain individuals who are allergic to these compounds.
Aloe vera has anti-inflammatory, anti-pruritic, analgesic and wound healing properties.38 It
contains substances such as salicylic acid, magnesium lactate and gel polysaccharides.39 Previous
study demonstrate that application of 0.1, 0.25 and 0.5% of aloe vera extract for two weeks
increase skin hydration, without any significant effect on TEWL.40
Bisabolol, extracted from chamomile (Matricaria recutita) plant, contains anti-inflammatory and
anti-spasmodic substances such as sesquiterpene alcohol, chamazulene and flavinoids. The anti-
inflammatory effect is attributed to cyclooxygenase and lipoxygenase inhibition. Bisabolol was
also thought to play role in promoting granulation tissues for wound healing acceleration. 41 A
randomized, double blind clinical trial among 278 AD patients demonstrated that heparin and
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levomenol (α-bisabolol) formulation, applied twice daily for eight week significantly improve
pruritus and disease symptoms. Bisabolol alone can ameliorate itching and inflammation,
however, combination of these two agents showed higher efficacy.42
Shea butter is a fat derivation of Butyrospermum parkii kernels, composed of five major fatty
acids, including palmitic, stearic, oleic, linoleic, and arachidic acids. Stearic and oleic acids
account for 85-90% of this fatty acids.43 It also contains triterpene acetate and cinnamate esters,
demonstrating anti-inflammatory and anti-tumor promoting effects. 44
Glycyrrhetinic acid, a triterpenoid compound extracted from licorice root, has anti-inflammatory,
antiviral and antitumor effects. Evidence demonstrated that glycyrrhetinic acid suppress surface
markers and inflammatory mediators expression of lipopolysaccharide-stimulated mature
dendritic cells, thereby reduce skin inflammation.45 Other extracted compound from licorice root
is glycyrrhiza inflata. Licochalcone A, its main component demonstrated inhibition of T cell
proliferation and inflammatory cytokines production.46 Other components of glycyrrhiza inflata
includes licochalcone B and D which demonstrated anti-inflammatory effects.47 Previous study
involving mild-moderate AD children revealed that licochalcone containing formula application
twice daily improve AD symptoms comparable to hydrocortisone lotion. Furthermore,
licochalcone application site showed less relapse compared to other site, though this difference
was insignificant.48 Interestingly, a randomized half-head study among scalp inflammation
patients revealed that a leave-on tonic containing urea, lactate, polidocanol, and licochalcone A
could ameliorate dryness, pruritus and inflammation.49
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Niacinamide improve skin barrier functions by increasing epidermal ceramides and other
intercellular lipids levels as well as promoting serine palmitoyltransferase upregulation.50
Furthermore, twice daily application of niacinamide formulation may reduce inflammation,
decrease TEWL and increase SC thickness.51 Niacinamide also decrease TEWL in atopic dry
skin significantly better, compared to white petrolatum.52 In randomized, controlled, comparative
studies on SC integrity, niacinamide containing moisturizers application resulted in more rapid
and sustained skin dryness and SC barrier improvement compared to conventional
moisturizers.53
Palmitoylethanolamide (PEA) is an endogenous lipid from fatty-acid N-acylethanolamine
family. It resembles stratum corneum components and functions as peroxisome proliferators-
activated receptor α agonist.54 Thereby, PEA possesses both anti-inflammatory and analgesic
properties.55 A large multinational, multicenter study involving 2,456 mild to moderate severity
AD patients demonstrated that PEA containing moisturizers could improve pruritus, dryness and
eczema lesion. Moreover, 56% of patients can discontinue TCS usage.56
Zinc gluconate, is an effective treatment for many skin inflammations. Recent evidences shows
that its anti-inflammatory effects may target at peroxisome proliferator-activated receptors-α
(PPARs-α), human β-defensin-2, and psoriasin.57,58
Several examples of nonsteroidal, noncalcineurin inhibitor agents are now available.59
MAS063DP was the first approved by the U.S. Food and Drug Administration to alleviate AD
and allergic contact dermatitis symptoms. It is a nonsteroidal barrier repair cream, integrating
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glycyrrhetinic acid, Vitis vinifera extract and telmesteine in combination with shea butter
(emollient) and hyaluronic acid (humectant). Some randomized, vehicle-controlled studies
supported that this an effective monotherapy for pediatric and adult cases of mild-to-moderate
AD.59,60
Selection of moisturizer composition for AD play crucial role for treatment outcome as it
determines whether it will strengthens or deteriorates skin barrier function. AD patients are
particularly vulnerable to adverse skin reactions due to impaired barrier function, with thinner
SC cell layers and larger follicular pores. In worst situation, wrong moisturizer application could
increase dermatitis and asthma risk.6 There is still lack of knowledge as to the necessary moisturizer
ingredients to overcome the specific epidermal defect.13 Therefore, moisturizers selection in clinical
practice is mainly influenced by safety, efficacy, absence of sensitizing agents and individual
preference.61
United Kingdom clinical experts developed a guidance regarding moisturizer selection for
specific dry skin types in AD patients. For mild-moderate AD, occlusive emollient creams were
recommended, while considering barrier thickness, lipid content variability, AD severity and
body site. For more severe AD, occlusive emollient ointment was recommended; with the
concern that this may reduce its acceptability. For very severe AD, occlusive ointment with zero
water content is considerable. Lastly, for pruritus, emollients with antipruritic substances were
recommended. 28
Recent Asian-Pacific region consensus guidelines recommend regular moisturizer application for
AD maintenance and adjunctive therapy. It emphasized considerations of environmental
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humidity, climate, skin type and degree of dryness for moisturizer selection. Furthermore, AD
duration, severity, patient age, treatment compliance, and financial resources should all also be
taken into account. Other considerations include adjuvant properties, cosmetic acceptability, and
product availability.29
IX(b). Moisturizers for seborrheic dermatitis
Seborrheic dermatitis (SD) is a chronic-recurrent skin inflammatory disorder, commonly affects
male adults. Onset may occur during puberty, due to cutaneous lipids abundance from increasing
androgen-driven sebaceous gland development and sebum secretion.62
Seborrheic dermatitis commonly affects scalp, face, and periauricular region. Central chest,
axillae and genital region are also involved in some cases. Pruritus is often present but not
always found. Lesions most often appears as ill-defined erythematous patches with pityriasiform
scaling, involving predilection sites.62,63 In some cases, a thicker, more confluent areas,
sometimes with oval, discoid plaques (medallion lesions) may appear.
The exact SD etiology remain unknown, several factors such as sebaceous activity, Malassezia
colonization and individual susceptibility appears to contribute to SD pathogenesis. Epidermal
barrier integrity; host immune response, neurogenic factors, emotional stress, and nutritional
factors are several factors influencing individual susceptibility.63
Recent evidences show strong correlation between epidermal barrier integrity and SD severity.
In SD there were alterations of corneodesmosomal hydrolysis and impaired lipid organization,
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disrupting desquamation process, leading to aberrant barrier function.64 Electron microscopy
findings detected epidermal barrier structural abnormalities in dandruff scalp, including
corneocyte shape and corneodesmosomes alterations, disrupted lipid lamellar structure and
intercellular Malassezia yeasts.64,65 Furthermore, dandruff patients are more reactive to scalp
applications of histamine or oleic acid, with higher itch perception or flaking.66 These indicate
that disrupted epidermal barrier function play a role in dandruff aggravation. Recent genetic
studies suggest that disrupted barrier function may even directly cause SD-like conditions.66-7
Biochemical analysis further showed that dandruff scalp demonstrate alteration of SC protein,
ceramides and free fatty acids profiles, in the absence of apparent inflammation.67 These
evidences emphasized the crucial role of barrier restoration and maintenance in the management
of SD.
The main goals of SD therapy are to alleviate visible signs and associated symptoms of SD,
particularly pruritus. Available treatment options include TCS, topical antifungal agents, topical
calcineurin inhibitors, and most recently, a nonsteroidal “device” cream.68, 69
Nonsteroidal topical device (NSTD) cream is a water-based, fragrance-free cream, approved by
US FDA as medical device to manage and relieve SD symptoms, such as itching, erythema,
scaling, and pain. NTSD cream is suggested to be applied on affected areas 2 to 3 times daily.
The formulation won’t be able to claim any individual active ingredient(s). However, ingredients
which may contribute to symptoms improvement include the biocide piroctone olamine, multiple
antioxidants (e.g., telmesteine, tocopheryl acetate, ascorbyl tetraiso-palmitate), multiple skin
conditioning agents (e.g., ethylhexyl palmitate, bisabolol, shea butter, Vitis vinifera), and
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alglycera, composed of allantoin and glycyrrhetinic acid, the latter demonstrated anti-
inflammatory quality. 69
Two studies had evaluated NSTD cream antifungal activity. In guinea pig model, three days,
once-daily topical application of both NSTD cream and ciclopirox cream decreased M furfur
counts below quantification limit. In humans, tape stripping evaluation of Malassezia spp
colony-forming units (CFUs) following twice-daily NSTD cream application for seven days to
one side of the chest was compared to untreated side in healthy volunteers (N=10). At the end of
the study, percentage reduction in Malassezia spp CFUs was 94 percent on the treated side
versus 49 percent on the untreated side (P=0.03). These studies suggest that NSTD cream may
be effective for SD, at least partially due to reduction in Malassezia spp, with the antifungal
effect likely related to the presence of piroctone olamine.70,71
A randomized, investigator-blinded, parallel-group, multicenter, pilot study comparing safety
and efficacy of NSTD cream (n=38) versus desonide cream 0.05% (n=39) twice daily for mild-
moderate facial SD in adults demonstrated significant signs and symptoms improvement
following 14 and 28 days of treatment. Subjects percentage achieving “clear” or “almost clear”
according to Investigator Global Asessment was 92 percent in the desonide group and 85 percent
in the NSTD cream group. Even when number of patients rated as “clear” at day 14 was greater
in desonide (39%) than NSTD cream group (20%), in NSTD cream arm 71.4 percent of subjects
who were clear at day 14 remained clear at Day 28 as compared to 14.3 percent in the desonide
arm (P=0.0173).72 Despite the limited sample, this study demonstrated that response onset may
be faster with TCS in the first two weeks, but with prolonged application, both therapies have
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comparable efficacy. Furthermore, following lesion clearing, relapses were sooner and more
frequently occur with the TCS treatment. Larger studies with longer follow up duration are
required to further explore timing and SD relapse rate with different therapeutic agents.
For treating mild-moderate SD, a variety of nonsteroidal treatment options, including
ketoconazole 2%, ciclopirox 1%, pimecrolimus 1%, or NSTD cream are practically applied
twice-daily. Many patients favorably respond to such application. For mild symptoms, many
patients achieve SD relief within 1 to 4 weeks. Except pimecrolimus 1% cream, these agents
may be long term continued to prevent relapse without concerning any adverse effects. All four
of these agents can be used intermittently to control milder flares with favorable speed. However,
in more prominent cases with moderate-to-severe involvement, and/or symptoms, a short course
of TCS, once or twice daily for 1 to 2 weeks (depending on potency), in combination with a
nonsteroidal agent, is a rational therapeutic choice.
Once the symptoms are controlled to a milder state or lesion clearance, usually within the first
few to several days, TCS can be ceased at once or tapered off over 1 to 2 weeks. Nonsteroidal
agent should be continued for at least a few more weeks to prevent relapse. There is no certain
way to approach SD. Clinicians should individually modulate approaches to manage SD cases
based on disease severity, response to treatment, and tendency for relapse.69
IX(c). Moisturizers for contact dermatitis
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Contact dermatitis (CD) is a common skin inflammation characterized by pruritic and
erythematous skin lesions, induced by contact with foreign substances. It is divided into two
major groups: irritant (ICD) and allergic (ACD).73
Clinical manifestation of CD varies according to the causative allergen or irritant and the skin’s
affected area. Contact dermatitis usually appears as erythema and scaling with relatively well-
demarcated, visible borders. The hands, face, and neck are usually involved, although it may
occur in any area. Some CD manifestations can be both allergic and irritant. Patient may
complains itching and discomfort, but some seek medical care due to the rash appearance. Acute
cases may involve a dramatic flare with erythema, vesicles, and bullae; chronic cases may
involve lichen with cracks and fissures. Patient history is crucial for diagnosis, and causative
substance must be identified and avoided to resolve CD and prevent further aggravation. 73 ,74
Localized acute ACD lesions are successfully treated with mid- or high-potency TCS. On thinner
skin areas, lower-potency TCS is helpful to minimize the side effects. 74 There are insufficient
data to support the use of TCS for ICD. However, because it is difficult to clinically distinguish
between ACD and ICD, these agents are often used successfully for ICD.
Primary prevention of ICD and ACD involves avoidance of irritants and allergens exposure. It may be
accomplished by several means including substance elimination, substitution, training, and job task
rotation. The use of personal protective equipment such as gloves, goggles face shields, and/or other skin
protective equipment is important. 74 Cotton liners under gloves can be used to enhance comfort and
sweat absorption. Skin should be kept clean, dry, and as well moisturized as possible.
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Patients with CD should wash their skin using lukewarm water with mild soap and dry it gently.
Soap should be removed carefully from finger web spaces as it is a surface-active agent,
providing alkaline environment which is not gentle for the skin. Jewelry, including rings, could
trapped allergens and retained local moisture.74,75
Emollients are a good secondary prevention measures to avoid continuous exposure.74 After-
work creams should be procured in workplaces and workers should be instructed to use them
regularly. Barrier creams are often recommended to prevent occupational contact dermatitis, this
may also involve the use of specialized creams such as barrier creams containing quaternium-18
bentonite (organoclay) to prevent rhus dermatitis or creams containing chelators such as penta
acetic acid to prevent nickel, chrome, or copper dermatitis.76 However, Cochrane systematically
reviewed that barrier creams may not have a long-term protective effect. Another reason why it
shouldn’t be promoted is that it may prevent workers for using more effective preventative
measures.74
Frequent moisturizer application provides protection and strengthens skin barrier function. Lipid-
rich moisturizers, is particularly recommended to be routinely used in all CD patients. When
frequent moisturizer application is impractical to do, a proper emollient application overnight may
be recommended.76
Ointments are preferred over creams, as creams may have sensitizing preservatives and mildly
irritating emulsifiers.77 Simple petroleum based emollients are nearly as effective as emollients
containing skin-related lipids, although several studies suggest that topical mixtures of key SC
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lipids, including ceramides, may accelerate barrier repair.34,78 Regardless of CD type, restoration
of damaged epidermal barrier and adequate skin hydration is extremely important for prevention
of chronic CD, even when all symptoms has resolved. Gutman et al advocate the ‘‘soak and
smear’’ approach with mid- to high-potency TCS ointments or emmolients application, over a
dampened skin following thorough skin hydration to “lock in” moisture.79
Keratolytic agents such as salicylic acid or urea are helpful in hyperkeratotic dermatitis. In
double-blind studies moisturizers with urea have demonstrate TEWL reduction in atopic and
ichthyotic patients. Urea also makes normal and atopic skin less susceptible against irritation to
sodium lauryl sulphate (SLS).2 Treatments improving skin barrier function may decrease the
possibility of further aggravation of CD.
A sterol-enriched fraction from canola oil has demonstrated to ameliorate clinical signs of SLS
induced irritation, while other lipids (such as, fish oil, petrolatum, shea butter, and sunflower
seed oil) had no effect on the degree of irritation.9 Loden and Andersson suggested that canola
oil facilitate the skin by supplying the damaged barrier with adequate lipids. Essential fatty acids
(i.e., linoleic and alpha-linoleic acids) influence skin physiology and pathology via their effects
on skin barrier functions, eicosanoid production, membrane fluidity, and cell signaling.80
Squalene is the most commonly produced sebum component. It is a singlet oxygen quencher,
protecting skin from lipid peroxidation due to ultraviolet and other ionizing radiation exposure.
Although it is naturally produced by human body, production drastically slows after age thirty;
causing skin dryness.81 Squalane is a saturated form of squalene, where hydrogenation have
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eliminated the double bonds, making it oxidation resistant and good as moisturizers. An added
quality of squalane is that even though it is technically oil, it is less greasy; odorless, non
comedogenic, antibacterial, and safe for sensitive skin. Moreover, it is also effective for treating
skin disorders such as CD, SD, or AD.82
IX(d). Moisturizers for nummular dermatitis
Nummular eczema (ND) is an eczematous disorder with pruritic coin-shaped patches on the skin,
often mistaken for ringworm or psoriasis. Men usually get ND later in their life while women get
it sooner. The etiology is unknown, but most patients have very dry skin, which allow epidermal
breach and permeation of allergens.83, 84 Local trauma, such as arthropod bites, chemicals
contact, or abrasions, may precede an outbreak.
Contact dermatitis due to to nickel, cobalt, or chromates may play a role in some ND cases.
Venous insufficiency, stasis dermatitis, and edema may be related to involvement of lower
extremities. 85, 86 Autoeczematization may account for the presence of multiple plaques. Severe,
generalized nummular eczema has been associated with interferon and ribavirin therapy for
hepatitis C and tumor necrosis factor inhibitors.87, 88
Patients may complain of pruritic, burning or stinging eruption that usually starts on the legs
within days to months. Symptoms waxes and wanes with winter; cold or dry climates, be
exacerbated by temperature swings and may improve with sunlight, humidity exposure or
moisturizer use. Lesion recurrence in old lesion locations is frequent. Patient may reveal past
history of eczema, AD, or dry and sensitive skin.85
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Diagnosis is made by observing the characteristic round-to-oval erythematous plaques,
particularly on the legs; however, they may occur anywhere on the trunk, hands, or feet. Lesions
may start as erythematous-to-violaceous papules or vesicles, coalescing to form confluent
plaques. Lesions often distributed symmetrically and size several centimeters. It may have
overlying erosions from excoriation. Aggressively scratched old lesions may develop lichen
simplex chronicus, often on lower legs, neck, scalp, or scrotum. Nummular dermatitis never
affects the face and scalp. 85
Treatments aimed at skin rehydration, epidermal lipid barrier repair, and inflammation/infection
control. Cleansing habits modification should be advised where soap is applied only to the axilla
and groin. Soapless, lukewarm or cool showers, followed by moisturizers or medicated topical
preparations application on damp skin may alleviate itching and rehydrate skin. Medicine
application to dampened skin results in more effective penetration and faster healing. The "soak-
and-smear" therapeutic regimen consists of 20-minute plain water soak followed by TCS
ointment or petrolatum application on wet skin. One study showed over 90% response in 27 of
28 patients with refractory chronic pruritic eruptions when the regimen was properly followed.79
Wet wrap treatments are often effective, involving skin dampening with lukewarm water for 10
minutes followed by petrolatum or TCS ointment application and 1 hour occlusion. Plastic wrap
can be used for small areas occlusion. Petrolatum application can be repeated 5-6 times a day
while TCS use should be carefully monitored to avoid adverse effect upon over usage.
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When eruption has resolved, ongoing aggressive hydration may decrease the flares frequency,
especially in dry environments. Ointments are more effective than creams due to more occlusive
form of skin barrier to the environment and more effective skin water retention. Heavy
moisturizers or petrolatum applied to dampened skin are often effective. Emollients consist of
bath oils, soap substitutes and moisturizing creams should be applied as often as required to
alleviate itching, scaling and dryness. Emollients should also be applied on unaffected skin to
overcome dryness. It may be necessary to try several different products to find suitable one.
Many people find one or more of these emollients to be effective: sorbolene, glycerine and
cetomacrogol cream, white soft paraffin/liquid paraffin mix, fatty cream, as well as wool fat
lotions. As nummular dermatitis often starts from minor skin injuries, skin should be carefully
protected. If the hands are affected, use gloves and protective tools to ensure the skin is avoided
from friction, detergents, solvents, other chemicals or excessive water exposure.
X. CONCLUSION
This paper emphasized specific clinical considerations of moisturizers to support health worker’s
capability to recommend and promote appropriate moisturizer application, particularly for
therapeutic purpose to alleviate symptoms from various kinds of dermatitis, in accordance with
evidence-based medicine.
XI. REFERENCES
1. Loden M. The clinical benefit of moisturizers. J Eur Acad Dermatol
Venereol. 2005;19(6):672-88.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 27
Copyright © 2017 Marshfield Clinic Health System
2. Loden M. Role of topical emollients and moisturizers in the treatment of dry skin barrier
disorders. Am J Clin Dermatol. 2003;4(11):771-88.
3. Ginsburg IH. The psychosocial impact of skin disease: An overview. Dermatol Clin.
1996;14:473-84.
4. Baumann L. Moisturizing Agents. In: Baumann L, editor. Cosmetic Dermatology- Principles
and Practices. 1st ed. New York: Tata McGraw Hill. 2002;93-99.
5. Draelos ZD. Therapeutic Moisturizers. Dermatol Clin 2000;18(4):597-607
6. Loden M. Effects of moisturizers on epidermal barrier function. Clin
Dermatol. 2012;30(3):286-96.
7. Marks R. Emollients. London: Martin Dunitz Ltd. 2002.
8. Nolan K, Marmur E. Moisturizers: reality and the skin benefits. Dermatol Ther. 2012;
25(3):229-33.
9. Kraft JN, Lynde CW. Moisturizers: what they are and a practical approach to product
selection. Skin Therapy Lett. 2005;10(5):1-8.
10. Rawlings AV, Canestrari DA, Dobkowski B. Moisturizer technology versus clinical
performance. Dermatol Ther. 2004; 17 Suppl 1:49-56 .
11. Johnson AW. Cosmeceuticals: Function and the skin barrier. In: Draelos ZD, editor.
Procedures in cosmetic dermatology series: cosmeceuticals. 1st ed. Philadelphia: Elsevier.
2005; 97-102.
12. Lynde CW. Moisturizers: what they are and how they work. Skin Therapy Lett. 2001;
6(13):3-5.
13. Madison KC. Barrier function of the skin: "la raison d'etre" of the epidermis. J Invest
Dermatol.2003;121(2):231-41.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 28
Copyright © 2017 Marshfield Clinic Health System
14. Jemec GB, Na R. Hydration and plasticity following long-term use of a moisturizer: a single-
blind study. Acta Derm Venereol.2002;l 82(5):322-4.
15. Mao-Qiang M, Brown BE, Wu-Pong S, Feinglod KR, Elias PM. Exogenous non-physiologic
vs physiologic lipids. Divergent mechanisms for correction of permeability barrier
dysfunction. Arch Dermatol.1995;131(7):809-16.
16. Ghadially R, Halkier SL, Elias PM. Effects of petrolatum on stratum corneum structure and
function. J Amer Acad Dermatol. 1992;26:387-96.
17. Draelos ZD. Therapeutic moisturizers. Dermatol Clin. 2000;18(4):597-607.
18. Summers RS, Summers B, Chandar P, Feinberg C, Gurskey R, Rawlings AV. The effect of
lipids with and without humectant on skin xerosis. J Soc Cosmet Chemists.1996;47:39.
19. Rawlings AV, Davies A, Carlomusto M. Effect of lactic acid isomers on keratinocyte
ceramide synthesis, stratum corneum lipid levels and stratum corneum barrier function. Arch
Dermatol Res.1996;288(7):383-90.
20. Marks R. Xerosis. In: Lebwohl MG, Heymann WR, Berth-Jones J, Coulson I, editors.
Treatment of skin disease: comprehensive therapeutic strategies. 1st ed. New York:
Mosby.2002;665-667.
21. Bikowski J. The use of therapeutic moisturizers in various dermatologic disorders.
Cutis.2001; 68(5 Suppl):3-11.
22. Ivens UI, Steinkjer B, Serup J. Ointment is evenly spread on a skin in contrast to creams and
solutions. Br J Dermatol.2001;145:264-7.
23. Ashida Y, Ogo M, Denda M. Epidermal interleukin-1 alpha generation is amplified at low
humidity: Implications for the pathogenesis of inflammatory dermatoses. Br J Dermatol.
2001;144:23843.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 29
Copyright © 2017 Marshfield Clinic Health System
24. Morris-Jones R, Robertson SJ, Ross JS. Dermatitis caused by physical irritants. Br J
Dermatol. 2002;147:270-75.
25. Garg A, Chren MM, Sands LP. Psychological stress perturbs epidermal permeability barrier
homeostasis: Implications for the pathogenesis of stress-associated skin disorders. Arch
Dermatol. 2001;137:53-9.
26. Kabashima K. New concept of the pathogenesis of atopic dermatitis: interplay among the
barrier, allergy, and pruritus as a trinity. J Dermatol Sci. 2013;70:3-11.
27. Simpson E, Dutronc Y. A new body moisturizer increases skin hydration and improves
atopic dermatitis symptoms among children and adults. J Drugs Dermatol. 2011;10:744-9.
28. Moncrieff G, Cork M, Lawton S, Kokiet S, Daly C, Clark C. Use of emollients in dry-skin
conditions: consensus statement. Clin Exp Dermatol. 2013;38:231-8.
29. Rubel D, Thirumoorthy T, Soebaryo RW, Weng SC, Gabriel TM, Villafuerte LL, Chu CY,
Dhar S, Parikh D, Wong LC, Lo KK; Asia-Pacific Consensus Group for Atopic Dermatitis.
Consensus guidelines for the management of atopic dermatitis: an Asia-Pacific perspective. J
Dermatol. 2013;40:160-71.
30. Danby SG, Al Enezi T, Sultan A. Effect of olive and sunflower seed oil on the adult skin
barrier: implications for neonatal skin care. Pediatr Dermatol. 2013;30(1):42-50.
31. Darmstadt GL, Saha SK, Ahmed AS, Chowdhury MA, Law PA, Ahmed S, Alam MA, Black
RE, Santosham M. Effect of topical treatment with skin barrier-enhancing emollients on
nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial.
Lancet. 2005;365(9464):1039-45.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 30
Copyright © 2017 Marshfield Clinic Health System
32. Matsumoto K, Mizukoshi K, Oyobikawa M, Ohshima H, Sakai Y, Tagami H. Objective
evaluation of the efficacy of daily topical applications of cosmetics bases using the hairless
mouse model of atopic dermatitis. Skin Res Technol. 2005;11(3):209-17.
33. Choi MJ, Mainach HI. Role of ceramides in barrier function of healthy and diseased skin.
Am J Clin Dermatol. 2005;6(4):215-23.
34. Chamlin SL, Kao J, Frieden IJ, Sheu MY, Fowler AJ, Fluhr JW. Ceramide-dominant barrier
repair lipids alleviate childhood atopic dermatitis: changes in barrier function provide a
sensitive indicator of disease activity. J Am Acad Dermatol. 2002;47:198-208.
35. Lohani A, Verma A, Joshi H, Yadav N, Karki N. Nanotechnology-Based Cosmeceuticals.
ISRN Dermatology; 2014: Article ID 843687.
36. Varothai S, Nitayavardhana S, Kulthanan K. Moisturizers for patients with atopic dermatitis.
Asian Pac J Allergy Immunol. 2013;31:91-8.
37. Paediatric Dermatology Subspecialty Core Group of the Philippine Dermatological Society.
A guide to understanding moisturizers in atopic dermatitis. Quezon (PH): Philippine
Dermatological Society. 2014.
38. Feily A, Namazi MR. Aloe vera in dermatology: a brief review. G Ital Dermatol Venereol.
2009; 144: 85-91.
39. Bedi MK, Shenefelt PD. Herbal therapy in dermatology. Arch Dermatol. 2002; 138: 232-
242.
40. Dal’Belo SE, Gaspar LR, Maia Campos PM. Moisturizing effect of cosmetic formulations
containing Aloe vera extract in different concentrations assessed by skin bioengineering
techniques. Skin Res Technol. 2006;12: 241-246.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 31
Copyright © 2017 Marshfield Clinic Health System
41. Shenefelt PD. Herbal Treatment for Dermatologic Disorders. In: Benzie IFF, Wachtel-Galor
S, editors. Herbal Medicine: Biomolecular and Clinical Aspects. 2nd ed. Florida: Boca Raton.
2011.
42. Arenberger P, Arenbergerová M, Drozenová H, Hladíková M, Holcová S. Effect of topical
heparin and levomenol on atopic dermatitis: a randomized four-arm, placebo-controlled,
double-blind clinical study. J Eur Acad Dermatol Venereol.2011; 25: 688-694
43. Goreja WG. Shea Butter: The Nourishing Properties of Africa’s Best-Kept Natural Beauty
Secret. New York: Amazing Herb Press. 2004.
44. Akihisa T, Kojima N, Kikuchi T, Yasukawa K, Tokuda H. Anti-inflammatory and
chemopreventive effects of triterpene cinnamates and acetates from shea fat. J Oleo Sci.2010;
59: 273-280.
45. Kim ME, Kim HK, Kim DH, Yoon JH, Lee JS. 18β-Glycyrrhetinic acid from licorice root
impairs dendritic cells maturation and Th1 immune responses. Immunopharmacol
Immunotoxicol. 2013; 35: 329-335.
46. Kolbe L, Immeyer J, Batzer J, Wensorra U, tom Dieck K. Anti-inflammatory efficacy of
Licochalcone A: correlation of clinical potency and in vitro effects. Arch Dermatol Res.
2006; 298: 23-30.
47. Furusawa J, Funakoshi Tago M, Mashino T, Tago K, Inoue H. Glycyrrhiza inflata-derived
chalcones, Licochalcone A, Licochalcone B and Licochalcone D, inhibit phosphorylation of
NF-kappaB p65 in LPS signaling pathway. Int Immunopharmacol. 2009; 9: 499-507.
48. Udompataikul M, Srisatwaja W. Comparative trial of moisturizer containing licochalcone A
vs. hydrocortisone lotion in the treatment of childhood atopic dermatitis: a pilot study. J Eur
Acad Dermatol Venereol. 2011; 25: 660-665.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 32
Copyright © 2017 Marshfield Clinic Health System
49. Schweiger D, Baufeld C, Drescher P, Oltrogge B, Höpfner S. Efficacy of a new tonic
containing urea, lactate, polidocanol, and glycyrrhiza inflata root extract in the treatment of a
dry, itchy, and subclinically inflamed scalp. Skin Pharmacol Physiol. 2013; 26: 108-118.
50. Tanno O, Ota Y, Kitamura N, Katsube T, Inoue S. Nicotinamide increases biosynthesis of
ceramides as well as other stratum corneum lipids to improve the epidermal permeability
barrier. Br J Dermatol. 2000;143: 524-531.
51. Mohammed D, Crowther JM, Matts PJ, Hadgraft J, Lane ME. Influence of niacinamide
containing formulations on the molecular and biophysical properties of the stratum corneum.
Int J Pharm. 2013; 441: 192-201.
52. Soma Y, Kashima M, Imaizumi A, Takahama H, Kawakami T. Moisturizing effects of
topical nicotinamide on atopic dry skin. Int J Dermatol. 2005; 44: 197-202.
53. Christman JC, Fix DK, Lucus SC, Watson D, Desmier E. Two randomized, controlled,
comparative studies of the stratum corneum integrity benefits of two cosmetic
niacinamide/glycerin body moisturizers vs. conventional body moisturizers. J Drugs
Dermatol. 2012; 11: 22-29.
54. Kircik L. A nonsteroidal lamellar matrix cream containing palmitoylethanolamide for the
treatment of atopic dermatitis. J Drugs Dermatol. 2010; 9: 334-338.
55. D’Agostino G, La Rana G, Russo R, Sasso O, Iacono A. Central administration of
palmitoylethanolamide reduces hyperalgesia in mice via inhibition of NF-kappaB nuclear
signalling in dorsal root ganglia. Eur J Pharmacol. 2009; 613: 54-59.
56. Eberlein B, Eicke C, Reinhardt HW, Ring J. Adjuvant treatment of atopic eczema:
assessment of an emollient containing N-palmitoylethanolamine (ATOPA study). J Eur Acad
Dermatol Venereol. 2008; 22: 73-82.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 33
Copyright © 2017 Marshfield Clinic Health System
57. Poiraud C, Quereux G, Knol AC, Zuliani T, Allix R. Human β- defensin-2 and psoriasin, two
new innate immunity targets of zinc gluconate. Eur J Dermatol.2012; 22: 634-639.
58. Poiraud C, Quereux G, Knol AC, Allix R, Khammari A. Zinc gluconate is an agonist of
peroxisome proliferator-activated receptor-α in the epidermis. Exp Dermatol. 2012; 21: 347-
351.
59. Simpson EL. Atopic dermatitis: a review of topical treatment options. Curr Med Res Opin.
2010;26:633-40.
60. Boguniewicz M, Zeichner JA, Eichenfield LF, Hebert AA, Jarratt M, Lucky AW, Paller AS.
MAS063DP is effective monotherapy for mild to moderate atopic dermatitis in infants and
children: a multicenter, randomized, vehicle-controlled study. J Pediatr. 2008;152:854-9.
61. Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, Bergman JN,
Chamlin SL, Cohen DE, Cooper KD, Cordoro KM, Davis DM, Feldman SR, Hanifin JM,
Margolis DJ, Silverman RA, Simpson EL, Williams HC, Elmets CA, Block J, Harrod CG,
Smith Begolka W, Sidbury R. Guidelines of care for the management of atopic dermatitis:
section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad
Dermatol. 2014;71:116-32.
62. Gupta AK, Bluhm R, Cooper EA. Seborrheic dermatitis. Dermatol Clin. 2003;21:401412.
63. Borda LJ, Wikramanayake TC. Seborrheic Dermatitis and Dandruff: A Comprehensive
Review. J Clin Investigat Dermatol. 2015;3(2): 10.
64. Turner GA, Hoptroff M, Harding CR. Stratum corneum dysfunction in dandruff. Int J
Cosmet Sci. 2012; 34: 298-306.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 34
Copyright © 2017 Marshfield Clinic Health System
65. Schwartz JR, Cardin CW, Dawson TL. Seborrheic dermatitis and dandruff. In: Baran R,
Maibach HI, editor. Textbook of Cosmetic dermatology. London: Martin Dunitz, Ltd. 2010:
230-241.
66. Harding CR, Moore AE, Rogers JS, Meldrum H, Scott AE. Dandruff: a condition
characterized by decreased levels of intercellular lipids in scalp stratum corneum and
impaired barrier function. Arch Dermatol Res. 2002; 294: 221-230.
67. Kerr K, Darcy T, Henry J, Mizoguchi H, Schwartz JR. Epidermal changes associated with
symptomatic resolution of dandruff: biomarkers of scalp health. Int J Dermatol. 2011; 50:
102-113
68. Naldi L, Rebora A. Clinical practice. Seborrheic dermatitis. N Engl J Med. 2009; 360: 387-
396
69. Del Rosso JQ. Adult seborrheic dermatitis. J Clin Aesthet Dermatol. 2011;4(5):3238
70. Nalamothu V, O’Leary AL, Kandavilli S. Evaluation of a nonsteroidal topical cream in a
guinea pig model of Malassezia furfur infection. Clinics Dermatol. 2009;27:S3S5.
71. Kircik L. An open-label, single-center pilot study to determine the antifungal activity of a
new nonsteroidal cream (Promiseb Topical Cream) after 7 days of use in healthy volunteers.
Clinics Dermatol. 2009;27:S6S9.
72. Elewski B. An investigator-blinded, randomized, 4-week, parallel-group, multicenter pilot
study to compare the safety and efficacy of a nonsteroidal cream (Promiseb Topical Cream)
and desonide cream 0.05% in the twice-daily treatment of mild to moderate seborrheic
dermatitis of the face. Clinics Dermatol. 2009;27:S10S15.
73. Usatine RP. Contact dermatitis. In: Usatine RP, Smith M, Mayeaux EJ Jr, editor. Color Atlas
of Family Medicine. New York: McGraw-Hill; 2009.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 35
Copyright © 2017 Marshfield Clinic Health System
74. American Academy of Allergy, Asthma and Immunology; American College of Allergy,
Asthma and Immunology. Contact dermatitis: a practice parameter. Ann Allergy Asthma
Immunol. 2006;97(6):819.
75. Lynde C, Guenther L, Diepgen T. Canadian hand dermatitis management guidelines. J Cutan
Med Surg. 2010;14:267-84.
76. Nicholson PJ. Evidence-based guidelines: occupational contact dermatitis and
urticaria.Occupational Medicine. 2010;60:502506.
77. Coenraads PJ. Hand eczema. N Engl J Med. 2012;367:1829-37.
78. Kucherekova M, Van De Kerkhof PC, Van Der Valk PG. A randomized comparison of an
emollient containingskin-related lipids with a petrolatum-based emollient as adjunct in the
treatment of chronic hand dermatitis. Contact Dermatitis.2003;48:2939.
79. Gutman AB, Kligman AM, Sciacca J, James WD. Soak and smear: a standard technique
revisited. Arch Dermatol.2005;141:1556-9.
80. Loden M, Andersson AC. Effect of topically applied lipids on surfactant-irritated skin. Br J
Dermatol.1996;134(2):215-20.
81. Kelly GS. Squalene and its potential clinical uses Altern Med Rev.1999;4(1):29-36.
82. Wołosik K, Knaś M, Zalewska A, Niczyporuk M, Przystupa AW. The importance and
perspective of plant-based squalene in cosmetology. J Cosmet Sci.2013;64:59-66
83. Aoyama H, Tanaka M, Hara M, Tabata N, Tagami H. Nummular eczema: An addition of
senile xerosis and unique cutaneous reactivities to environmental aeroallergens.
Dermatology. 1999; 199: 135_9.
84. Ozkaya E. Adult-onset atopic dermatitis. J Am Acad Dermatol. 2005; 52: 579_82.
Purnamawati, et al. doi:10.3121/cmr.2017.1363
The role of moisturizers in addressing various kinds of dermatitis Page 36
Copyright © 2017 Marshfield Clinic Health System
85. Jiamton S, Tangjaturonrusamee C, Kulthanan K. Clinical features and aggravating factors in
nummular eczema in Thais. Asian Pac J Allergy Immunol. 2013;31(1):36-42.
86. Bendl BJ. Nummular eczema of statis origin. The backbone of a morphologic pattern of
diverse etiology. Int J Dermatol..1979;18(2):129-35
87. Shen Y, Pielop J, Hsu S. Generalized nummular eczema secondary to peginterferon Alfa-2b
and ribavirin combination therapy for hepatitis C infection. Arch Dermatol.2005; 141: 102_3.
88. Flendrie M, Vissers WH, Creemers MC, de Jong EM, van de Kerkhof PC, van Riel PL.
Dermatological conditions during TNF-alpha-blocking therapy in patients with rheumatoid
arthritis.Arthritis Res Ther.2005;7:666-76.
AUTHOR AFFILIATIONS
Schandra Purnamawati, MD*,; Budi Satria, MD*; Niken Indrastuti, Dr*; Retno Danarti, Dr*;
Tatan Saefudin, MD
*Department of Dermatology and Venereology, Faculty of Medicine, Universitas Gadjah
Mada/ Dr. Sardjito Hospital, Yogyakarta, Indonesia
Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia
Politeknik Kesehatan Jakarta, Indonesia
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TABLES
Table 1. Moisturizers mechanism of action1,6,9,12
Type
Emollients
Humectants
Occlusives
Mechanism of
action
Saturated & unsaturated
hydrocarbons with
variable length which
improves skin barrier
function, membrane
fluidity and cell signaling,
resulting in overall
improvement of skin
texture and appearance.
Often combined with
emulsifier
Low molecular
substances in majority,
with capability to attract
water into stratum
corneum. Frequently
used with other
compounds which may
retain the water content
Consist of oils and
waxes, forming an
inactive layer on the
skin surface to
physically block water
evaporation from the
skin (TEWL)
Indication
Routine skin care, dry
and rough skin,
papulosquamous skin
disease
Xerosis, ichthyosis
Prevention of contact
dermatitis, xerosis,
atopic dermatitis
Adverse
effect
Contact irritation
(seldom)
Irritation (lactic acid,
urea)
Oily application,
cosmetically
disagreeable, folliculitis
(mineral oil), contact
dermatitis (lanolin),
acneiform eruption
Substance
Fatty acids, fatty
alcohols, cholesterol,
squalene,
pseudoceramides
urea, sorbitol, panthenol,
glycerol, propylene
glycol, hyaluronic acid,
alpha hydroxy acids
Mineral oil, petroleum
jelly, beeswax,
silicones, zinc oxide
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Table 2. Emollients classification1,6,9,12
Dry emollients
Fatty emollients
Astringent emollients
Protective emollients
Isopropyl palmitate,
isostearyl alcohol, decyl
oleate
Propylene glycol, octyl
stearate, glyceryl stearate,
jojoba oil, castor oil
Dimethicone,
cyclomethicone, octyl
octanoate, isopropyl
myristate
Isopropyl isostearate,
diisopropyl dilinoleate
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Table 3. Various types of occlusives 1,6,9,12
Class
Examples
Hydrocarbons
Petroleum jelly, paraffin, mineral oil, squalene, caprylic/ capric triglyceride
Fatty acids
Stearic acid, lanolin acid
Fatty alcohols
Lanolin, cetyl alcohol, stearyl alcohol
Phospholipids
Lecithin
Polyhydric alcohols
Propylene glycol
Sterols
Cholesterol
Vegetable waxes
Candelilla, carnauba
Wax esters
Beeswax, lanolin, stearyl stearate
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Table 4. Various kinds of moisturizer formulations10,19, 20
Classification
Lotions
Creams
Ointments
Gel
Phase
Oil in water (O/W)
Water in oil (W/O)
(hydrophobic) or oil in
water (hydrophilic)
Water in oil (W/O)
(hydrophobic)/ or oil
in water (hydrophilic)
Hydrophobic or
hydrophilic
Preparation
O/W prepared with
emulsifiers to
enhance spread
ability
O/W creams are
prepared at elevated
temperature, followed
by reduction to room
temperature for
internal phase to
solidify oil and water
(50% each)
Does not contain
enough water to
separate into second
phase at room
temperature. Most
contain 80% oil and
20% water
Has liquid phase in a
three dimensional
polymeric matrix with
physical or sometimes
chemical cross linkage
with appropriate gelling
agent
Composition
Oil, Water,
Propylene glycol
W/O: emulsifier such
as monoglycerides,
sorbitan esters and
wool fat
O/W: emulsifying
agents such as sodium
or triethanolamine
soaps, sulfated fatty
alcohols and
polysorbates. When
necessary may be
combined with W/O
emulsifying agents
W/O: water insoluble
hydrocarbons such as
paraffin, vegetable oil,
animal fats, waxes,
synthetic glycerides
and polyalkysiloxanes
O/W: mixtures of
liquid and solid
polyethylene glycols
(macrogols)
Hydrophobic gel
(oleogel): Liquid paraffin
with polyethylene or fatty
oils gelled with colloidal
silica, alumunium, or zinc
soaps
Hydrophilic gel
(hydrogel): water,
glycerol or propylene
glycol gelled with suitable
agents such as
tragacanth, starch,
derivatives of cellulose,
carboxy vinyl polymers
and magnesium/
alumunium silicates
Properties
Non greasy, thinner,
easily spreads to
cover large areas
Esthetic. Made of
heavier lipids
Greasy, glossy look
following application
Forming skin’s
protective layer,
particularly useful in
low humidity (< 60%)
environment
Smooth finishing, non
oily, non comedogenic,
absorbs easily
Usage
Daytime moisturizer
for face and body.
After shave lotions,
for application on
hairy areas
Night time moisturizers
for face hand, and non
hairy body parts
To use when no
occlusive effect is
required
Particularly beneficial
when high degree of
occlusive is required
Contraindicated for
intertriginous and
moisture bearing
areas
To be used in
intertriginous areas,
easily absorbed, high
acceptability for face, non
comedogenic
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Table 5. Possible adverse effects encountered with moisturizers1,7,16
Adverse effect
Possible causes
Subjective irritation
Humectants: Lactic acid, urea, preservatives such as
benzoic or sorbic acid
Irritant reactions
Proteins in vegetable oils, urea, hydroxyl acids,
propylene glycols, solvents
Allergic contact dermatitis
Lanolin, propylene glycols, vitamin E, Kathon CG,
preservatives, fragrances, sunscreens, herbal ingredients
(such as tea tree oil, olive oil, chamomile oil, aloe
Occlusive folliculitis
Petrolatum, mineral oils
Photosensitivity eruptions and photomelanosis
Fragrances, hydroxyl acids, preservatives, sunscreens
Cosmetic acne
Occlusive oils used in water in oil preparations
Contact urticaria
Preservatives such as sorbic acid, fragrances, balsam of
Peru
Poisoning in burn patients
Propylene glycol
Intoxication
Salicylic acid
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... Vegetable oils have been used widely as emollients in skincare or pharmaceutical products as consumers are more concerned about using natural and organic ingredients (Łopaciuk & Łoboda, 2013). Purnamawati et al. (2017) have reported that vegetable oil may enhance skin hydration levels which may lead to a moisturizing effect. The oil which acts as an emollient will form an occlusive layer on the skin while preventing the water loss kinetics of the skin. ...
... Natural oils with long-chain fatty acids such as coconut oil, palm oil, olive oil, and sunflower seed oil are commonly used as emollient and moisturizer ingredients in cosmetic formulations or topical pharmaceuticals to treat and prevent skin diseases such as atopic dermatitis (Purnamawati et al., 2017;Simon, et al., 2018;Danby et al., 2020). According to Danby et al. 2020, the oleic acid to the linoleic acid ratio in olive oil and sunflower seed oil oils improved skin hydration by accelerating skin barrier repair and development. ...
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... 33 Moisturizer is used to treat various dermatomes which co-exist with skin dryness such as in atopic disorders. 34 Moisturizers are often used in the prevention and treatment of irritant contact dermatitis. The moisturizer was applied shortly before SLS provocation, which cause rashes and redness, sensitive skin are more prone to redness and rashes. ...
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... okolja. S tem povečajo vsebnost vode v zgornjih plasteh kože (18). Njihov učinek je najboljši, če jih kombiniramo z emolienti. ...
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Atopic dermatitis (AD) is a disease that affects millions of patients worldwide and is characterized by debilitating itch. The pathophysiology of pruritus in AD consists of multiple players, including pruritogens, unique receptors, and ion channels found on unmyelinated C-nerve fibers. The sensation of the itch is also perpetuated by the disrupted epidermal skin barrier characterizing this disease, as well as sensitization phenomena in both the peripheral and central nervous systems. Thankfully, treatment options for atopic itch are abundant. These range from topical therapies, to systemic immunomodulators, to systemic therapies, which attenuate itch transmission in the nervous system. Topical treatment of itch includes a variety of medications including corticosteroids, calcineurin antagonists, and phosphodiesterase-4 inhibitors. Systemic treatment includes oral prednisone, methotrexate, cyclosporine, azathioprine, and mycophenolate mofetil. Moisturizing topical treatments remain one of the mainstays of treatment. Emerging therapies, such as novel monoclonal antibodies that are directed against itch mediators, such as interleukin-31, as well as drugs targeting the Janus kinase-STAT system, are promising treatments that will hopefully improve the lives of many patients.
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Background: Toxic epidermal necrolysis (TEN) is a rare systemic allergic drug eruption with high patient mortality. Currently, no established treatments have been shown to be effective for TEN beyond supportive care. Prior studies of systemic corticosteroids have yielded conflicting data, with some showing a possible benefit and others reporting in increased mortality. However, topical steroids have shown promise for treatment of ocular sequelae of TEN, such as scarring and vision loss. We have designed a randomized controlled trial to evaluate topical clobetasol for treatment of the epidermal manifestations of TEN. In addition, we propose genetic studies to characterize the TEN transcriptome and alterations in cutaneous gene expression that might occur following topical steroid treatment. Methods/design: This split-body randomized, double-blind, placebo-controlled Phase IIa proof-of-concept trial will evaluate the safety and efficacy of once-daily topical clobetasol applied to the skin of patients with TEN. This multicenter trial will recruit a total of 15 patients between the ages of 12 and 85 from the University of California Davis Medical Center and Shriners Hospital for Children inpatient burn units. Designated treatment areas on opposite sides of the body will be treated with blinded clobetasol 0.05 % ointment or control petrolatum ointment daily for 14 days. On day 3 of therapy, a biopsy will be taken from the treated area for genetic studies. The primary study aims will be to establish the safety of topical clobetasol treatment and determine the time to cessation of skin detachment for the control and clobetasol-treated areas. Secondary endpoints will evaluate efficacy using parameters such as time to 90 % re-epithelialization and percentage of affected skin at 0, 3, 6, 9, 12 and 15 days. Genomic DNA and RNA will be obtained from biopsy samples, to characterize the TEN transcriptome and identify changes in gene expression after topical steroid treatment. Discussion: Topical steroids have shown promise for treating ocular complications of TEN, but to date have not been evaluated for cutaneous manifestations of the disease. This trial will investigate clinical and molecular outcomes of topical clobetasol application and hopefully provide insight into the disease pathophysiology. Trial registration: ClinicalTrials.gov NCT02319616. https://clinicaltrials.gov/ct2/show/NCT02351037.
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