Emollients and eczema creams

What are emollients?

Emollients are lotions, creams, ointments and bath/shower additives which oil the skin to keep it supple and moist. Regular use of emollients is the most important part of the day-to-day treatment for people with eczema.

What is eczema?

The terms eczema and dermatitis mean much the same. That is, an inflammation of the skin. It causes red, itchy skin which may also blister. There are two main types of dermatitis/eczema:

• Atopic eczema. This is caused by a problem from within the body. If you have atopic eczema you are born with a tendency for your skin to become inflamed. Various parts of the skin tend to flare up with inflammation from time to time.

• Contact dermatitis. This is caused by a substance from outside the body. This typically causes patches of inflammation on areas of skin which have come into contact with the substance. If you avoid the offending substance, the skin inflammation should go away.

See the separate leaflets called Atopic Eczema and Contact Dermatitis which provide a general overview of the conditions.

How do emollients work?

People with eczema have a tendency for their skin to become dry. Dry skin tends to flare up and become inflamed into patches of eczema. Emollients prevent the skin from becoming dry and help to protect the skin from irritants. This helps to prevent itch and reduces the frequency of eczema flare-ups. So, the main role of emollients is to prevent eczema from flaring up. (This is different to steroid creams and ointments which reduce inflammation and clear flare-ups of eczema.)

Types of emollients

Emollients are available as:

• Lotions.

• Sprays.

• Creams.

• Ointments.

There are many types and brands of emollients, ranging from runny lotions to thick ointments. The difference between lotions, creams and ointments is the proportion of oil (lipid) to water. The lipid content is lowest in lotions, intermediate in creams and highest in ointments.

The higher the lipid content, the greasier and stickier it feels and the shinier it looks on the skin. As a general rule, the higher the lipid content (the more greasy and thick the emollient), the better and longer it works but the messier it is to use.

Which emollient is the best for eczema?

There is no "best buy". The type (or types) to use depend on the dryness of your skin, the area of skin involved and your preference. A doctor, nurse or pharmacist can advise on the types and brands available and ones which may best suit an individual. For example:

• If there is only mild skin dryness and flare-ups of eczema do not happen often, a lotion or cream may be best.

• With moderate-to-severe dryness then a thicker cream or an ointment is usually best. Creams are less messy but need to be put on more often than ointments.

• A lotion is often best for areas of hairy skin.

• For areas of weeping eczema, a cream or lotion is usually best, as ointments will tend to be very messy.

• Pump dispensers are better than pots because they are less likely to harbour germs. If a pot is needed, a clean spoon or spatula should be used to get the contents out, rather than fingers.

• Whichever emollient an individual finds easiest to use is often the best for them as they are more likely to use it regularly - regular use is more important than which brand.

How to get emollients

Emollients are both available over the counter and on prescription. They should be bought when they are being used for dry skin but can be prescribed for diagnosed skin conditions such as eczema or psoriasis. In some areas, the brands of emollient available on prescription are restricted due to cost. In these cases a similar alternative can be prescribed.

How to use emollients

Creams, ointments and lotions

An emollient should be applied liberally to the skin. Emollients should be applied by smoothing them into the skin along the line of hair growth (ie usually down the body) rather than rubbing them in. It is impossible to overdose or use too much as emollients do not contain active medicines which pass through the skin. After bathing, showering or swimming, an emollient should be applied to the washed areas as soon as possible afterwards in addition to the other times emollients have been applied.

Many people mix and match different emollients to suit their needs and daily routine. For example:

• Many people use a thick ointment as a soap substitute, as normal soap tends to dry the skin.

• Some people use an ointment at bedtime for the night but prefer a less messy cream during the day.

• Some people use an ointment on some areas of the body which are particularly dry and use a cream on the rest of the body.

• Some people use an ointment when their skin is particularly dry but switch to a cream when their skin is not too bad.

It is important to recognise that emollients are flammable and therefore there is a risk of them igniting and causing severe burns to the skin. It is important not to smoke or go near naked flames after applying an emollient. Bedclothes, clothing, bandages and any other fabrics with dried emollients on can also ignite easily.

Bath additives and shower gels

Various emollient preparations come as bath additives and shower gels. These are now not considered useful for most people as they is no evidence that they are beneficial. Since 2018, when a study showed no benefits from bath/shower emollients, these are no longer commonly available on prescription in the UK.

If these are bought over the counter, it is important to recognise that they can make the bath or shower cubicle greasy and slippery. Grab rails and mats may be needed to reduce the risk of slipping and it is important to warn others who might be using the same bath or shower.

When to apply emollients

These should be applied as often as needed to keep the skin supple and moist. This varies from person to person (and can vary from time to time in the same person, depending on how bad the skin dryness has become). A good starting point is to apply 2-3 times a day. However, some people need to increase this to up to every hour if the skin is very dry. As a rule, ointments need to be applied less often than creams or lotions for the same effect.

People with eczema should keep on applying emollients every day, even when they do not have any areas of inflamed skin. The emollients prevent the skin from drying and can help to prevent eczema from flaring up. Where appropriate, to help some people to apply emollients frequently, it may be best to keep separate packs of emollients at work or school.

As an example, a routine for a typical person with moderately severe eczema might be:

• Use a thick emollient ointment as a soap substitute for cleaning. This can also be applied to particularly dry areas of skin.

• After a bath or shower it is best to dry by patting with a towel rather than by rubbing. Then apply an emollient cream, ointment or lotion to the skin.

• Between baths or showers, use a cream, ointment or lotion as often as necessary.

• Use an emollient ointment at bedtime.

Using emollients and topical steroids together

Most people with eczema will also be prescribed a topical steroid (steroid creams and ointments) to use when eczema flares up. Topical steroids are very different to emollients and should be used and applied in a different way. See the separate leaflet called Topical Steroids for Eczema for more details.

When using the two treatments, apply the emollient first. Wait 10-15 minutes after applying an emollient before applying a topical steroid. That is, the emollient should be allowed to absorb before a topical steroid is applied. The skin should be moist or slightly tacky but not slippery, when applying the steroid.

Side-effects from emollients

Sensitive skin

Emollients used for eczema tend to be bland and non-perfumed. However, some creams contain preservatives, fragrances and other additives. Occasionally, some people become allergic (sensitised) to an ingredient. This can make the skin inflammation worse rather than better. A particularly notable preparation is aqueous cream which was once commonly used. However, it is now known that there is a high rate of reactions to this product and therefore it is now less commonly used.

If there is a suspicion of a sensitivity to an emollient then advice should be sought from a doctor or pharmacist. There are many different types of emollients with various ingredients. A switch to a different type will usually sort out this uncommon problem. Note: ointments tend to cause fewer problems with skin sensitivity as, unlike creams, ointments usually do not contain preservatives.

Folliculitis

Thick emollient ointments sometimes block the hair follicles in the skin. This may cause a mild inflammation or infection of the affected hair follicles, which is called folliculitis.

Other points about using emollients

• Another common mistake is to stop using emollients when the skin appears good. Patches of eczema, which may have been prevented, may then quickly flare up.

• All emollients are flammable. Keep them away from lights and flames.