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‘The best emollient is one the patient uses’ – prescribing emollients in primary care



The current situation

In 2018, the NHS Clinical Commissioners, an independent collective voice of CCGs, published their recommendations for ‘conditions for which over the counter items should not routinely be prescribed in primary care’.1 This included advice that treatment should not normally be offered for the mild irritant dermatitis or mild dry skin.

Then, in June 2019, the NHS Clinical Commissioners published further guidance to CCGs.2 This included a short section on the use of bath additives and shower preparations for dry and pruritic conditions.

Around the country, many CCGs took these two directives as a green light to discourage the prescription of emollients generally and subsequently many patients with significant and serious skin conditions have complained that they are being denied effective treatment for their skin conditions. That surely was never the intention of this advice?

Choosing an emollient

In my experience, most eczema will not settle unless emollients are used in place of soaps and other harsh detergents, and leave-on emollients are used regularly. Poorly managed eczema is not only distressing and disabling, but also results in a greater use of topical steroids and greater use of antibiotics both topically and systemically. That can be improved by using quality emollients.3

There are several issues that should be considered when choosing an emollient. Cost is one of them but, unlike the advice I see from several CCGs around the country, should not be the overriding factor.

First and foremost is patient preference – there is no point recommending an emollient that won’t be used! Greasier emollients will have greater barrier protecting effects but are unacceptable for many people while they are up and about, however they are often tolerated as a leave-on at bedtime. Most ointments are markedly water-repellent, but Hydromol and Epaderm ointments are water-miscible and can be used as soap substitutes. Emollient creams can also be used as soap substitutes, however that would be extravagant with the more expensive, ‘sophisticated’ emollients.

Ingredients matter

The constituents of an emollient are clearly critical. Sodium lauryl sulfate (SLS) should never be put on the skin as it will aggravate eczema4,5 and damages normal skin.6 Emulsifying ointment contains 3% SLS so shouldn’t go anywhere near the skin and Aqueous cream (which is a dilution of emulsifying ointment in water) is also dangerous.

All emollients are combustible, but those containing paraffin are highly flammable.7 Those with high concentrations are especially dangerous and include all the ointments. It is essential that patients are warned about this risk. For example, even pyjamas, that have been washed after being worn by someone using a paraffin-based emollient, are highly combustible.8 The only emollient that I know of that doesn’t have any paraffin is Aproderm colloidal oat cream.

Some emollients prevent water loss from the skin for prolonged periods of time (this can be measured as trans-epidermal water loss, or TEWL). Emollients with a long TEWL protection are not only convenient, but also more cost-effective as they do not need to applied throughout the day. Balneum and CeraVe for example have a TEWL of 24hrs and emollients containing Povidone (such as Doublebase Dayleve or Oilatum) have a TEWL of at least 12 hours.

Most quality emollients contain humectants, which are hygroscopic molecules that hold water in the stratum corneum. They complement the body’s ‘natural moisturising factors’, enhancing hydration of dry skin conditions, supporting the skin barrier and extending the TEWL. Typical humectants include: urea, glycerol, lactic acid or even sodium pyrollidine carboxylate.

There are several emollients on the market now with colloidal oatmeal. This has been shown to have soothing, anti-inflammatory effects, which are particularly useful in inflammatory skin conditions such as atopic eczema.

Recommendations

Adex gel is a relatively new emollient. It is essentially Doublebase gel with the addition of nicotinamide and is indicated for dry or inflamed skin. Nicotinamide has direct anti-itch and anti-inflammatory properties and I have found it particularly useful in patients with active inflammatory skin diseases including eczema, psoriasis and even rosacea. Lipikar AP+ Baume contains niacinamide, also has a humectant (7% glycerine) and is licensed from birth. Uniquely, it contains the prebiotic aqua posae filiformis, which I really like as it supports the normal healthy microbiome.

CeraVe is a new emollient, extremely popular in the USA, and contains three essential ceramides – oily molecules that fill the intercellular space between epidermocytes, sealing the skin barrier. It also has two powerful humectants (7.5% glycerine and hyaluronic acid), so it is powerfully hydrating. It is an interesting emollient with a very long TEWL, complimented also by its unique Multivesicular Emulsion Technology, resulting in the slow release of its ingredients over 24 hours.

As well as being an excellent humectant, 5% urea has mild anti-pruritic effects. At higher concentrations, urea can help thin the skin. Most high urea emollients are very expensive, but I think Flexitol is a reasonably priced and a useful option for hyperkeratotic skin conditions. CeraVe SA Soothing Cream is a new emollient that contains 10% urea, as well as a ‘gentle’ concentration of salicylic acid (0.5%). This combination makes it an ideal choice for dry scaly conditions such as keratosis pilaris. The CeraVe range don’t have an NHS tariff yet but they are superb emollients for patients who are prepared to buy a quality emollient themselves.

Some pump dispensers are wasteful (for example Aveeno). Others are weak and the delay in refilling can be frustrating (for example Imuderm, but also all the ‘Exma’ range). Most pump dispensers cost around £2.50, which is a huge element of the total cost of a 500gm bottle of emollient! However, a quality pump dispenser, such as the Rieke pump used in the Aproderm range, allows 98% efficiency with minimal wastage, as well as delivering a consistent 4g per actuation. It also does not allow air back into the pump. which means fewer preservatives are necessary. Similarly the Doublebase and Adex pumps and bottle design are lovely, with 98% efficiency.

There is no excuse for dispensing a cream in a tub and so I cannot endorse those (e.g. Aquamax).

Epimax comes in a mayonnaise style tube, which makes it cheap and ideal as a soap substitute. However, it does draw air back into the tube risking contamination. Because of this, Epimax colloidal needs a strong preservative and some patients complain this stings their inflamed skin. Furthermore, some patients tell me they have problems squeezing the tube, which can also become slippery.

Ointments are so thick that they are always dispensed in a pot. However, patients must be instructed to take some out with a spatula or spoon, as otherwise the ointment could become contaminated within a week.9

Educating the patient

Once a patient has confirmed they like an emollient, it should be prescribed in adequate quantities. NICE recommended 250gm/week for children with atopic eczema10 and I would suggest adults need double that – 2kg a month!

Patients should be instructed on how to apply their emollient, dabbing it onto the skin and stroking it down the body and limbs in the same direction as the hairs. The whole skin in eczema is abnormal and so the whole body needs to treated with a leave-on emollient. The best time to apply an emollient is straight after washing, when the skin is fully accessible and moist. That way, the emollient will help to trap some moisture in the skin. It is important for patients to understand that dry skin conditions, such as eczema and psoriasis, need long-term treatment and that emollients should not be stopped once a flare has settled.

Finally, don’t forget to warn your patients not only about the risk of flammability, but also that the shower tray or bath could be rendered dangerously slippery and the drains may clog up unless they are regularly cleared.

References

  1. Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs. NHS Clinical Commissioners; 2018. Available from: https://www.england.nhs.uk/wp-content/uploads/2018/03/otc-guidance-for-ccgs.pdf 
  2. NHS England. Items which should not be routinely prescribed in primary care, 2019. Available from: https://www.england.nhs.uk/medicines/items-which-should-not-be-routinely-prescribed/
  3. Moncrieff G et al. Cost and effectiveness of prescribing emollient therapy for atopic eczema in UK primary care in children and adults: a large retrospective analysis of the Clinical Practice Research Datalink. BMC Dermatology. https://doi.org/10.1186/s12895-018-0076-y
  4. Cork M, Danby S. Aqueous cream damages the skin barrier. British Journal of Dermatology. 2011;164(6):1179-1180.
  5. Danby S et al. The effect of aqueous cream BP on the skin barrier in volunteers with a previous history of atopic dermatitis. Brit J Dermatol 165(2): 3290334
  6. Tang M, Guy RH. Effect of Aqueous Cream BP on human stratum corneum in vivo. Brit J Dermatol 163(5):954-958
  7. Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients, 2018. MHRA. Available from: https://www.gov.uk/drug-safety-update/emollients-new-information-about-risk-of-severe-and-fatal-burns-with-paraffin-containing-and-paraffin-free-emollients
  8. Paraffin-based skin emollients on dressings or clothing: fire risk, 2016. MHRA. Available from: https://www.gov.uk/drug-safety-update/paraffin-based-skin-emollients-on-dressings-or-clothing-fire-risk
  9. Carr J, Cork MJ et al. Contamination of Emollient Creams and Ointments with Staphylococcus aureus in Children with Atopic Dermatitis. Dermatitis: Sept-Oct 2008. Vol 19(5): 282 (Abstract from Kyoto Symposium)
  10. NICE. CG57 Atopic eczema in under 12s: diagnosis and management, London, NICE, 2007