E

White Soft Para�n BP

(100% para�n content)

Emulsifying Ointment BP

(70% para�n content)

No suitable alternative

Zerobase® cream

(21% para�n content)

No suitable alternative

(70% para�n content)

(12% para�n + 5% re�ned soya bean oil)

(28% para�n content)

(15% para�n + 15% isopropyl myristate)

(urea 10%) (urea 10%)E

Aqueous Cream BP

Diprobase® cream

Balneum creamBalneum® Plus cream,Calmurid® cream,Dermatonics Once Heel Balm®E45® Itch relief creamEucerin® Intensive cream,Flexitol® Heel Balm,Nutraplus® cream

N/A N/A N/A

Green StatusPreferred products

Greasy ointments

50:50 Liquid and White Soft Para�n Ointment NPF

Zeroderm® ointment

Rich cream

Creams

Gels

Zeroguent® cream

Aquamax® cream

Zerodouble® gel

Preparations containingurea

Aquadrate®cream

Not recommended

Pharmaceutical form of emollient

Very greasy Ointments

Emollients and Soap Substitutes for Dry Skin Conditions

Ointments

Creams and gels

Lotions

Incr

easi

ng p

ara�

n co

nten

t

Products not recommended for prescribing

(similar to preferred product)

E

E

E,S,B

E

E,S

(similar to Epaderm® and Hydromol® ointment)

(similar to Unguentum M®cream)

(suitable replacement for Aqueous cream)

(similar to Doublebase® gel & Dayleve)

Hydromol Intensive®

Cream

1st line choice

2nd line choice

(100% para�n content)

Epaderm® ointment

Hydromol® ointment

Thirty:30® ointment

Unguentum M® cream

The most important factor when selecting an emollient is to �nd one that the patient will use. The emollient of choice is the least expensive one that is e�ective, and which the patient �nds acceptable and is prepared to use on a regular basis.4

Which Emollient?There is considerable variation in patient response to a particular product, thus making it di�cult to compare emollients or to predict how much an individual will bene�t.1

The most important factor in selecting an emollient is to �nd one that the patient will use. The emollient of choice is the least expensive one that is e�ective, and which the patient �nds acceptable and is prepared to use on a regular basis.4

10 Factors to consider when selecting an emollient

Patient preference – acceptability and tolerability to patient, ease of application, product consistency.

Type of dry skin condition and past history.

Previous products used and their e�cacy and tolerability.

Severity of dry skin condition: greasy ointments achieve better occlusion than cream-based emollients.

Intended use of product - leave-on emollient, soap substitute or both; di�erent emollients for di�erent parts of the body (eg. greasier product for limbs, lighter product for face).

Emollient or lipid content (fats, waxes, oils). Excipients that may be potential sensitisers.5

Safety issues – �re hazard with para�n-based emollients; soap substitutes may make surfaces slippery.

Cost.

Container – product accessible to patient; can patient use a pump dispenser?

Evidence and Rationale for Use

There is a lack of good quality clinical trials concerning the use of emollients but long-term experience supports their e�cacy.2

The skin acts as a barrier to the external environment as well as providing protection for the internal environment.

Dryness and in�ammation of the skin can lead to loss of its barrier function thus making it more susceptible to allergens, irritants, pathogens, bacteria and further water loss.1

Emollients help restore the epidermal barrier by their occlusive e�ect thus reducing the likelihood of infection, irritation and in�ammation.

For emollients to be e�ective, patients should frequently apply appropriate amounts.

Emollients should form the basis of atopic eczema management and should always be used, even when the atopic eczema is clear.3

Complications of emollient use

• Some formulations contain potential skin sensitisers5 such as lanolin, preservatives, fragrances and sodium lauryl sulphate. • Ointments contain fewer potential irritants than creams and lotions.

• Risk of slippery skin and surfaces when using soap substitutes.

• Potential �re hazard with para�n- based emollients in contact with dressings or clothing as they may be easily ignited by a naked �ame.

• The use of ointments may exacerbate acne. The risk of folliculitis can be reduced if the patient applies the emollient in the direction of hair growth.

Bene�ts of emollient use

Improve the hydration, suppleness and appearance of dry skin.2,4 Restore skin barrier function thus reducing susceptibility to infection, irritants and allergens.4 Regular use of suitable quantities of emollients will help prevent �are ups of eczema.4 Appropriate use may reduce the need for topical corticosteroids in atopic eczema.3 Improved well-being of the patient. Severe dryness and in�ammation can be distressing for the patient and impact on their wellbeing and con�dence.

Area a�ected

Creams and ointments

Face Both Hands Scalp Both arms or legs Trunk Groin & genitalia

15-30g 25-50g 50-100g 100-200g 400g 15-25g

The table above suggests suitable quantities to be prescribed for an adult for a minimum of twice daily application for one week7

Suitable quantities of dermatological preparations to be prescribed for speci�c areas of the body

Doublebase® gel,

Doublebase® Dayleve gel,

isopropyl myristate 15%/liquid para�n 15% gel

*E=emollient, S= Soap substitute, B=Bath additive

East Surrey CCGGuildford & Waverley CCG

North West Surrey CCG Surrey Downs CCGSurrey Heath CCG

Aqueous Cream BP

The use of Aqueous Cream BP as a leave-on emollient or soap substitute is not supported due to its poor emollient properties and tendency to cause irritant reactions.6 It was originally formulated as a soap substitute and not as a leave–on emollient.1 It has a high water content (69%) thus making it a less e�ective emollient for those with dry skin.1 Its use as a leave-on emollient may increase the risk of skin reactions, particularly in eczema.7 NICE does not recommend the use of Aqueous Cream BP as a leave-on emollient for children with eczema.3

Whilst its formulation is not directly comparable to Aqueous Cream BP, Aquamax® cream o�ers the following advantages over Aqueous Cream BP:

It contains 33% more emollient than Aqueous Cream BP. It does not contain the detergent, sodium lauryl sulphate, a potential skin irritant.

References

1. Dermatology UK. Best practice in emollient therapy: a statement for healthcare professionals. 2007.2. Clark C. How to choose a suitable emollient. Pharmaceutical Journal 2004;273:351-33. National Institute of Health and Clinical Excellence. NICE Clinical Guideline CG57: Atopic eczema in children. 20074. National Prescribing Centre. The use of emollients in dry skin conditions. MeReC Bulletin 1998;9:125. Monthly Index of Medical Specialities, August 20126. Surrey Prescribing Advisory Database. http://pad.res360.net/7. British Medical Association, Royal Pharmaceutical Society. British National Formulary No 68. March 20158. International Journal of Toxicology, 27(Suppl. 4):1-82, 2008, American College of Toxicology: Final Amended Report on the Safety Assessment of Methylparaben, Ethylparaben, Propylparaben, lsopropylparaben, Butylparaben, lsobutylparaben,and Benzylparaben as used in Cosmetic Product9. Scienti�c Committee on Consumer Safety SCCS, Clari�cation on Opinion SCCS/1348/10 in the light of the Danish clause of safeguard banning the use of parabens in cosmetic products intended for children under three years of age http://ec.europa. eu/health/scienti�c_committees/consumer_safety/docs/sccs_ o_069.pdf

Parabens (p-hydroxybenzoic acid esters)

Parabens are employed in many cosmetic and skincare preparations and act as preservatives. They exhibit protection against a broad range of microorganisms.8 In 2011 the Danish government banned the use of 4 out 6 the parabens used in products and restricted the use in the remaining 2 – methyl and ethyl paraben.9

In light of this and an absence of de�nitive human risk analysis, it was decided to consider �rst, those preparations that were free of these additives.

Safety considerations

Products that are non-preferred and not encouraged to be prescribed

Epaderm® ointment Hydromol® ointment Thirty:30® ointmentUnguentum M® creamAqueous Cream BP

Diprobase® creamDoublebase® gelDoublebase® Dayleve gelIsopropyl myristate 15%/liquid para�n 15% gelBalneum® cream

Balneum® Plus creamCalmurid® creamDermatonics Once Heel Balm®E45® Itch relief creamEucerin® Intensive cream

Flexitol® Heel BalmNutraplus® cream

Patient advice

Finding the right emollient - Patient response to emollients varies. The initial supply of emollient should be a small pack for the patient to try. If this suits them, a larger quantity can then be prescribed. If unsuitable, they should be encouraged to try another product.

Apply liberally and frequently

Gently smooth the emollient onto the skin in the direction of hair growth. Do not rub in.

The frequency of application may vary depending on the condition of the skin. For very dry skin, application every 2 -3 hours would be considered normal.

Washing

Avoid using soaps, detergents and bubble bath. Use a soap substitute instead.

Gently dry the skin after washing and apply a leave-on emollient while the skin is moist. Take care if using emollients when bathing or showering as they may make the skin and surfaces slippery.

Fire hazard with para�n-based emollients

Emollient ointments in contact with dressings or clothing may be easily ignited by a naked �ame, particularly when applied to large areas. Keep away from �re or �ames and do not smoke when using these preparations.

Hygiene

Don’t share your emollient products or towels with others as those with broken skin are more prone to pick up skin infections. Emollients in tubs should be removed with a clean spoon or spatula to reduce potential bacterial contamination.

Topical corticosteroids and emollients

If using both, ensure the patient knows which is which. Corticosteroids should be applied sparingly often for limited periods; emollients should be applied frequently and liberally.

Emollients and Soap Substitutes

A leave-on emollient is a substance whose main action is to occlude the skin surface and to encourage the build up of water in the stratum corneum.1 Leave-on emollients soothe, soften and hydrate the skin and are suitable for patients of any age with a dry skin condition such as:2

• Dry and scaling skin disorders such as eczema, contact dermatitis, psoriasis, ichthyosis.

• Dry skin conditions caused by exposure to drying products or extreme environmental conditions. Dry or itchy skin associated with ageing.

• A soap substitute is used instead of ordinary soap products and is non-irritant and non-drying to the skin.

Emollients and Soap Substitutes for Dry Skin Conditions

Guideline developed by Sanjeev Sudera (NWS CCG) and Clare Curran (G&W CCG)

To be reviewed April 2017

East Surrey CCGGuildford & Waverley CCG

North West Surrey CCG Surrey Downs CCGSurrey Heath CCG