Emollients and Eczema Creams

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.

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.

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.)

What types of emollients are there?

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 is the best emollient to use 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. Your doctor, nurse or pharmacist can advise on the types and brands available and ones which may best suit you. For example:

• If you only have 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 you need to use a pot, use a clean spoon or spatula to get the contents out, rather than your fingers.

How do I use and apply emollients?

Creams, ointments and lotions

Whenever you use an emollient, apply it liberally to the affected area of skin. Emollients should be applied by smoothing them into the skin along the line of hair growth, rather than rubbing them in. You cannot overdose, as emollients do not contain active medicines which pass through the skin. If you wash, or have a bath or shower, apply an emollient to washed areas as soon as possible afterwards in addition to any other times that you use emollients. Also, apply after swimming.

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.

Bath additives and shower gels

Various emollient preparations come as bath additives and shower gels. These may be considered in people with extensive areas of dry skin. However, there is some debate as to how well these work, or even if they should be used. The amount of emollient deposited on the skin during bathing or showering is likely to be far lower than with directly applied emollient creams, ointments or lotions. So, one concern is that some people may under-treat their skin if they rely on bath or shower emollients only. Therefore, If you do use them you should use them in addition to, not instead of, creams, ointments or lotions that you rub directly on to the skin.

Note: bath additive emollients will coat the bath and make it greasy and slippery. It is best to use a mat and/or grab rails to reduce the risk of slipping. Warn anybody else who may use the bath that it will be very slippery.

How often should I apply emollients?

Apply as often as needed to keep the skin supple and moist. This varies from person to person and 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.

If you have eczema, you should keep on applying emollients every day, even when you 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.

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.

Are there any side-effects from emollients?

Skin sensitivity

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. This was once commonly used. However, it is now known that there is a high rate of reactions to this product. Therefore, it is now less commonly used.

If you suspect that you are sensitive to an emollient then see your doctor for advice. 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.

Some 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.
• A dry dressing may be helpful if your eczema is moderate or severe. This helps to keep the emollient from being rubbed off the skin and stops scratching. However, you should not use a dressing if infection is present.
• Paraffin-based emollients are flammable. Keep them away from lights and flames.

In summary

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

• When you have a bath or shower, consider adding a emollient oil to the bath water or as you shower. This can give your skin a general background oiling.
• Use a thick emollient ointment as a soap substitute for cleaning. You can also rub this into 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 your skin.
• Between baths or showers, use a cream, ointment or lotion as often as necessary.
• Use an emollient ointment at bedtime.