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Self-Care: Those people with dry skin without a diagnosed dermatological condition requesting a general dry skin moisturiser should purchase these over the counter.
NHS England (NHSE) has published new prescribing guidance for various common conditions for which over-the-counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include mild irritant dermatitis and mild dry skin.
Many of these products are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.
Emollients are essential in the management of diagnosed dermatological conditions, such as eczema or psoriasis, and their regular use can alleviate symptoms and reduce flare ups; prescribing of emollients should be reserved for these patients.
Emollients should be used as a soap substitute, as normal soap tends to dry the skin. It is important to use a product which suits the patient and is effective for them. Evidence from randomised controlled trials to support the use of one emollient over another is lacking, therefore selection is based on the known physiological properties of emollients, patient acceptability, dryness of the skin, area of skin involved and lowest acquisition cost.
Careful explanation of how to use emollients, as well as how much to use, may encourage compliance. Emollients should be smoothed on in the direction of hair growth. They should not be rubbed in. They should be continued to be used even after the skin condition has cleared, if the clinical condition justifies continued use.
Sufficient quantities should be prescribed to allow liberal application as frequently as required, once patient preference is established:
MHRA Drug Safety Update (April 2016): Fire risk with paraffin-based skin emollients on dressings or clothing:
MHRA Drug Safety Update (December 2018): Emollients: new information about risk of severe and fatal burns with paraffin-containing and paraffin-free emollients:
Pot Hygiene: Where possible, prescribe an emollient with a pump dispenser to minimize the risk of bacterial contamination. When supplying patients with pots of emollient, it is important to educate them about the hygiene required. Patients should be advised to decant from the pot onto plate/bowl using a spoon. Hands should not be put into the pot as this will lead to the introduction of foreign particles.
All primary and secondary care prescribers should where possible select the emollient with the lowest acquisition cost from the range available in the agreed preferred product list.
For most types of emollient, several products have been included to allow for patients to try a number of options, before clinicians consider non-formulary options.
Ointments are good for very dry, thickened skin and night-time use as they are greasy, thick and very moisturising; however, they are not always acceptable to patients due to their greasiness. They should be applied every 6–8 hours.
Gels are relatively light and non-greasy, despite having reasonably high oil content. They should be applied every 3–4 hours.
Creams are not greasy and are quite easy to spread over sore and weeping skin; so many patients prefer them to ointments for daytime use. They should be applied every 3–4 hours.
Some patients may to prefer an emollient cream containing colloidal oatmeal.
Urea, which acts as a humectant, draws water into the skin. These products are not indicated for routine use as they are more expensive but may be useful for very dry conditions such as ichthyoses and for keratosis pilaris (used sparingly). 5% and 10% urea-containing creams should be applied every 6-8 hours.
Patients can be advised that smaller volumes of urea-based emollients can be purchased OTC, please see guidance above.
Skin and footcare specialists recommend high percentage urea (25%) as the initial starting treatment for callused, anhidrotic, fissured, and hard foot skin.
Patients should decrease to the low percentage urea (10%) for maintenance treatment when there has been improvement in the skin condition; then further stepping down to standard emollient preparations when hydration has returned.
If there is no improvement in skin condition after 6 weeks continual use of urea preparations, please seek further advice from skin and footcare specialists.
Local specialists have indicated that 25% urea preparations are considered suitable options for patients with diabetes who suffer from neuropathy where the skin is very dry with callus; in these patients continuous use would be recommended.
For all patients with hydrated heels with little or no drying skin with no callus, a standard emollient should be used.
Indications and dose
Indications and dose
Lotions are quick to apply but take a little longer to dry. Useful for hair-bearing areas prone to folliculitis. They should be applied every 6-8 hours.
Sprays are an option for some patients where the emollient can be applied without touching the skin; this may be an advantage where the patient cannot reach the affected area or where touching the skin may be detrimental.
Following national guidance from NHS England, bath and shower preparations for dry and pruritic skin conditions are not recommended for use due to a lack of robust evidence of clinical effectiveness. Click here for more information. Prescribers should not initiate bath and shower preparations for dry and pruritic skin conditions for any new patient.
A multicentre pragmatic parallel group RCT looking at emollient bath additives for the treatment of childhood eczema (BATHE, 2018) showed that there was no evidence of clinical benefit for including emollient bath additives in the standard management of childhood eczema. NHS England has stated that in the absence of other good quality evidence "it is acceptable to extrapolate this to apply to adults until good quality evidence emerges".
Emollients can still be used for treating eczema and these emollients can still be used as soap substitutes. Any emollient listed in the formulary (except White Soft Paraffin 100%, and Liquid Paraffin 50% & White Soft Paraffin 50%) can be applied before bathing, showering or washing, or while in the water.
Patients should be aware of the potential dangers of slipping when using emollients in a bath or shower, or on a tiled floor. Parents may also wish to be cautious when removing children from the bath.
Use only when skin is infected or if infection is a frequent complication; i.e. folliculitis or secondary infection of eczema. Antimicrobial emollients are not for prolonged use (Maximum of one month's use).
Creams are not greasy and are quite easy to spread over sore and weeping skin.
Lotions are quick to apply but take a little longer to dry. They may be useful for hair-bearing areas.