Emollients and skin care in atopic dermatitis

Management of dry skin is critical to help maintain barrier function. The effective use of bathing and emollients are frequently recommended as an essential component of atopic dermatitis therapy (Wollenberg et al., 2018).

Cleansing and bathing

Cleansing the skin is essential to carefully remove dead skin and eliminate bacterial contaminants. However, it must be performed gently, and quickly to avoid irritation and epidermal dehydration. The use of bath oils, non-soap-based and acidic-cleansers as well as the addition of antiseptics have all been suggested to help manage atopic dermatitis (Mollanazar et al., 2016; Wollenberg et al., 2018).

Emollients

Emollients represent the mainstay of atopic dermatitis management and typically contain a humectant to promote stratum corneum hydration, and an occludent to reduce evaporation. It has been demonstrated that long-term emollient therapy improves xerosis associated with atopic dermatitis and the daily use of emollients from birth may significantly reduce the incidence of atopic dermatitis in a high-risk population. However, long-term follow-up data is required to confirm this (Wollenberg et al., 2018). Importantly, the use of emollients has been shown to be steroid sparing, reducing the side effect risks commonly associated with their prolonged use. A short-term steroid sparing effect has been observed in children and adults with mild-to-moderate atopic dermatitis following emollient use (Grimalt et al., 2007; Eberlein et al., 2008; Szczepanowska et al., 2008), while long-term maintenance of stable disease has been achievable through regular use of emollients following induction of remission with TCS (Mengeaud et al., 2015; Åkerström et al., 2015).

Some caution should be exercised over the use of certain emollients in young children as some ingredients may cause irritation or under-desirable side effects. Urea can be used as a humectant but has been shown to cause irritation and kidney dysfunction in infants and should be avoided, while in toddlers, a lower concentration should be used than in adults. Meanwhile propylene glycol can irritate the skin of children aged below 2 years and so should not be used (Wollenberg et al., 2018). Concerns have also been raised about emollients containing intact proteins. While the use of colloidal oat meal has been shown to improve clinical outcomes in atopic dermatitis (Fowler et al., 2012), there are fears that it may increase the risk of skin sensitisation and allergy in at risk patients and so should be avoided in children below two years of age (Wollenberg et al., 2018).

Finally, it is worth considering that the sole use of emollients without sufficient topical anti-inflammatory therapy increases the risk of disseminated bacterial and viral infection – a risk that is already elevated in those with atopic dermatitis (Wollenberg et al., 2003).