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Dermatitis - contact - Management
Which emollient should I prescribe?
- The choice of emollient should be determined by:
- The dryness of the skin.
- The type of skin to which the emollient is to be applied.
- The individual's preference, determined by the product's tolerability and convenience of use.
- Dryness of skin:
- Less to moderately dry skin is most acceptably treated with a cream.
- Moderately dry to very dry skin requires a higher intensity of treatment with an ointment to restore the skin to normal.
- Weeping dermatitis is best treated with a water-soluble cream, as ointments will tend to slide off, becoming unacceptably messy.
- The tolerability and convenience of a product can only be determined by a trial of treatment:
- Creams are generally better tolerated but will need to be applied more frequently and generously to have the same effect as a single application of ointment.
- The individual will need to balance the tolerability of a product against the convenience of its use and its effectiveness.
- More than one type of product may be required. Different products may be preferred at different times, depending on the intensity of treatment required and the area of skin to be treated (e.g. a cream may be preferable for application to the hands).
- Emollient soap substitutes are useful to avoid the drying effects of soaps and should be considered for all people with dermatitis. They are particularly useful for people who must wash or wet their hands frequently. The use of emollients as soap substitutes has been shown to reduce the incidence and prevalence of contact dermatitis [Lauharanta et al, 1991].
- Emollients containing active ingredients are not generally recommended, but may be useful in some people (although they increase the risk of skin reactions). Products containing:
- Lauromacrogols are reputed to relieve itch.
- Urea may improve skin hydration and have a limited role in the treatment of skin with heavy scaling.
- Antiseptics (e.g. benzalkonium chloride) have a limited role in protecting skin which is prone to infection.
- For a list of the emollient products available in the UK, see Table 1.
Table 1. Emollient products available in the UK.
Product type | Product names | Products with urea | Products with antiseptic |
|---|
Non-proprietary products | Aqueous cream, BP Emulsifying oinment, BP Hydrous ointment, BP* Liquid and White Soft Paraffin Ointment, NPF Paraffin, White Soft, BP Paraffin, Yellow Soft, BP | n/a | n/a |
Proprietary creams | Aveeno®§ Cetraben® Decubal® Clinic Diprobase® E45®* Hewletts® Hydromol Cream® Linola® Gamma‡ Lipobase® Neutrogena® Oilatum® QV® Ultrabase® Unguentum M® Vaseline Dermacare®§ Zerobase® | Aquadrate® Balneum® Plus† Calmurid® E45® Itch Relief Cream† Eucerin® Intensive Nutraplus® | Dermol® |
Proprietary ointments | Epaderm® Hydromol Ointment® Kamillosan® | n/a | n/a |
Proprietary gels, lotions, and sprays | Aveeno® lotion§ Dermamist® spray application Doublebase® gel E45® lotion*§ Keri® lotion* QV® lotion Vaseline Dermacare® lotion§ | Eucerin® Intensive lotion | Dermol® 500 lotion |
Proprietary washes and bath and shower additives | Alpha Keri Bath® bath oil* Aveeno® bath oil§ Aveeno Colloidal® bath additive§ Balneum® bath oil Balneum Plus® bath oil Cetraben® emollient bath additive Dermalo® bath emollient Doublebase® emollient shower gel Diprobath® bath additive E45® emollient bath oil§ E45® emollient wash cream§ Hydromol Emollient® bath additive Imuderm® bath oil Oilatum® emollient bath additive* Oilatum® Junior emollient bath additive Oilatum® shower emollient QV® bath oil QV® wash | n/a | Dermol® 200 shower emollient Dermol® 600 bath emollient Emulsiderm® liquid emulsion Oilatum Plus bath addtive® |
n/a = not available. * Contains lanolin or lanolin derivatives. † Contains lauromacrogols. ‡ Contains evening primrose oil. § The Advisory Committee on Borderline Substances states this on FP10 form. |
|
Basis for recommendation
- No evidence from controlled trials supports the use of one emollient over another; therefore, recommendations are based on the known physiological properties of emollients and pragmatic considerations:
- Emollients with high lipid contents are thought to restore the skin barrier more effectively, and more rapidly, than those with lower lipid contents [Dermatology UK, 2007].
- The person's preference is essential when selecting an emollient. The National Institute for Health and Clinical Excellence points out that, in atopic eczema, proprietary products are generally preferred (at least by children) to non-proprietary products, and therefore non-proprietary products are not suitable as first-line treatment. They also state that as proprietary products tend to be similar in cost, the person should be prescribed the emollient of their choice [National Collaborating Centre for Women's and Children's Health, 2007].
- In general, the evidence to support the use of active ingredients in emollients is limited. Therefore, if used, these products should be trialled on an individual basis:
- One randomized controlled trial (RCT, n = 80) was identified by a systematic review [Hoare et al, 2000] that found an emollient containing urea was more effective than the vehicle alone in the treatment of atopic eczema.
- Evidence from several small RCTs using emollients combined with an antiseptic were of poor quality and subject to bias.
- CKS did not identify any trials that used emollients containing lauromacrogols as an intervention.
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