Have we forgotten the importance of emollient therapy, the ‘unsung heroes’ of dermatological treatments?
– a Dermatology Nurse Consultant’s perspective
by Paula Oliver RGN BSc (Hons) MSc INP
Emollients have been part of human life for centuries; records suggest that the ancient Greeks used wool fat to moisturise their skin as early as 700BC1. However, today emollients are much more user-friendly and cosmetically acceptable to wear on the skin.
Whilst they do have cosmetic purposes, they act, first and foremost, as the mainstay of treatment for patients with dry skin conditions to aid maintenance of healthy skin barrier function.
The skin is a complex organ, acting as a barrier to the external environment and as a protector. It is our ‘cutaneous envelope’ and, when healthy and intact, it prevents penetration of pathogens and allergens, while also helping to ensure water is held in the skin.
More recently, filaggrins have been identified as critical proteins in the skin; they bind to keratin fibres in cells, giving skin the structure that is essential to maintaining a healthy barrier. Loss of filaggrin leads to increased skin permeability (due to the loss of barrier function), reduction in natural moisturising factors and increased pH of the skin, which leads to inflammation. Emollients are vital for minimising these effects2.
So, what are emollients?
The terms emollient and moisturiser are often used interchangeably in everyday practice. The word emollient is a Latin derivative and implies a product that softens and smoothes the skin. Emollients should reduce the clinical signs of dryness such as scaling and lichenified skin and reduce sensations such as tightness and itch.
It’s important and well documented that patients should find an emollient product that they find cosmetically acceptable enough to maintain their usual lifestyle. In dermatology, we know that if a patient doesn’t like the emollient product they have been prescribed, they simply won’t use it, which can lead to wastage at a time when optimisation of budgets is so important in the NHS.
The ingredients of emollients vary but most contain lipids (fats, waxes and oils), which influence how occlusive they are, with greasy (high lipid content) emollients on one end of a continuum and more water-based (low lipid content) emollients on the other. There are many different types and formulations so it’s important to consider what is best for each individual on a case by case basis.
Types of emollients available
Have a cooling effect and may be preferred to ointments or creams for application over a hairy area. Lotions in an alcoholic base can sting if used on broken skin.
Are emulsions of oil and water and are generally well absorbed into the skin. They tend to be more cosmetically acceptable than ointments because they are less greasy and easier to apply.
Consist of active ingredients in suitable hydrophilic or hydrophobic bases and generally have a high water content. Gels are particularly suitable for application to the face and scalp.
Are greasy preparations which are normally anhydrous, insoluble in water and are more occlusive than creams, making them particularly suitable for chronic, dry lesions. The most commonly used ointment bases consist of soft, liquid and hard paraffin.3
The current problem
Since 2018 many patients have contacted the National Eczema Society stating that there are emerging problems with obtaining their emollients on prescription via their General Practitioner (GP). According to the National Eczema society (NES), recent NHS guidance recommended GPs stop prescribing emollient for mild dry skin and mild irritant dermatitis. However, this guidance was misinterpreted by some commissioners, who believed emollient prescriptions should be stopped altogether.The NES recommend that an adult with widespread skin disease should use approximately 500g per week (250g for children) to manage their skin condition effectively. Despite this, prescribing of lower volumes is often considered a way to save costs and patients are often asked to reduce their usage and make their
emollient last longer.4
Emollients form part of all care plans for eczema patients and can be as, if not more, important in their treatment than medicated treatments such as topical steroids. We find that increased use of emollients results in better eczema control, leading to reduced flare ups, fewer hospital admissions and less need for topical steroids.
Despite their importance in optimising treatment outcomes, recent NHS UK guidance suggests patients buy emollients direct from pharmacy, reserving prescriptions and GP-involvement only for more severe cases of eczema, psoriasis and ichthyosis5. This encouragement for patients to self-fund their emollient therapy may further reduce the chance of adequate volumes being used and this, combined with the necessity to reduce prescribing costs, has the potential to undermine the importance of emollient therapy in the eyes of patients.
The BATHE study in 2018 found that pouring emollient additives into the bath does not add any clinical benefit over standard management. Standard management of childhood eczema includes soap avoidance, leave-on emollients and corticosteroid ointments6. NHS England now recommend that bath emollients should not be
prescribed for any new patient, and “deprescribing” should be encouraged for existing patients. However, some dermatology patients do like to immerse themselves in a warm bath with an added oil so an alternative to a bath oil is to dissolve an ointment-based emollient in hot water and then to vigorously incorporate it into the bath water to disperse the lipid.
CCG Formulary
Clinical Commission Group (CCG) formularies are important to consider and prescribing decisions made by practitioners should be rational, evidence-based and cost effective. In terms of emollient prescribing, the practitioner needs to consider the most appropriate emollient formulation(s) for the patient’s skin condition and, most importantly, involve the patient in the prescribing decision. It’s also key to follow guidance and, where possible, prescribe the emollient with the ‘lowest acquisition cost’ from the range of emollients on the formulary. If a patient’s emollient products are changed to a cheaper alternative, it’s also important to ensure that it is comparable with, or better than the original one.
Take home messages
- Emollients are used to help manage dry skin conditions such as eczema, psoriasis and ichthyosis and can help to reduce inflammation and flare ups of these common dermatological conditions.
- Patients with skin conditions should have access to prescribed emollient therapy to manage their diagnosed skin condition.
- Consider the appropriate emollient formulation for each individual and ensure sufficient quantities are prescribed.
- Consider prescribing low cost products that are comparable with, or better than, higher costed products.
References
- Marks R. 2001 Sophisticated emollients. Thieme Publishing Group, Stuggart
- British Dermatology Nursing Group. Best Practice in emollient Therapy December 2012
- British National Formulary 71 March- September 2016 British Medical Association – Royal Pharmaceutical Society
- National Eczema Society (NES) November 2012 [accessed online 27/05/19] www.eczema.org/emollients-on-prescription
- NHS England Emollients [accessed online 27.05/19] https://www.nhs.uk/conditions/Emollients/
- Emollient bath additives for the treatment of childhood eczema (BATHE): multicentre pragmatic parallel group randomised controlled trial of clinical and cost effectiveness by Miriam Santer, Matthew J Ridd, Nick A Francis, Beth Stuart, Kate Rumsby, Maria Chorozoglou, Taeko Becque, Amanda Roberts, Lyn Liddiard, Claire Nollett, Julie Hooper, Martina Prude, Wendy Wood, Kim S Thomas, Emma Thomas-Jones, Hywel C Williams, Paul Little. BMJ. May 2018
