OTCs Today
Mary Warner
Approximately 16.5 million adults in the United States live with atopic dermatitis (a form of eczema), while dry skin (xerosis) affects approximately 20% of the population at any given time. Fifty percent of patients are diagnosed within the first year of life, and as many as 85% develop symptoms before the age of 5 years.
Atopic dermatitis causes dry, itchy, and inflamed skin and tends to be a chronic condition, necessitating long-term treatment, while dry skin tends to increase with age. Both conditions compromise skin integrity and can usually be treated by focusing on maintaining skin hydration through emollients or topical corticosteroids.
Multiple triggers can contribute to atopic dermatitis flares, including stress; household products such as detergents, soap, or perfume; weather (e.g., extreme heat or cold, dryness or humidity, the change in seasons, or altitude); environmental allergens such as cigarette smoke, pollen, or pet dander; clothing made from nonorganic materials such as polyester; and certain metals (e.g., nickel, gold, and copper). Food allergies can also trigger flare-ups, particularly in children after eating peanuts, milk, eggs, wheat, or soy. Different patients can have widely varying triggers, so it’s important to identify triggers so they can be avoided.
Dry skin, although usually not as chronic as atopic dermatitis, can be problematic, especially among older patients. To help reduce dry skin caused by bathing, patients should use warm, not hot, water, limit showers and baths to 10 minutes, wash with a non-soap cleanser, and pat skin dry rather than rubbing.
Moisturizers
When triggers cannot be avoided, initial treatment involves moisturizing to lock in water and create a barrier against skin irritants. Ointments, lotions, and creams are available to treat dry skin and atopic dermatitis.
Ointments are typically water-in-oil emulsions containing petrolatum, such as petroleum jelly. While ointments are recommended due to their high lipid content and ability to retain moisture, most patients avoid them because of the greasy feel. In addition, they’re not appropriate for oozing atopic dermatitis lesions because they don’t allow the lesions to dry and heal.
Lotions and creams are also oil-in-water emulsions but are less greasy than ointments. They can alleviate dry skin by virtue of their cooling effect as water evaporates from the skin surface. Moisturizers should be applied liberally and frequently, usually at least 3 times per day. Patients with dry hands should apply a moisturizer after each time they wash their hands.
Topical corticosteroids
When topical therapy with moisturizers doesn’t relieve symptoms, use of a topical corticosteroid may be needed. Hydrocortisone (0.5% or 1%) is the only FDA-approved nonprescription corticosteroid available for the topical treatment of dermatitis in the United States. Although its exact mechanism is unknown, it has been suggested that hydrocortisone suppresses cytokines involved in the development of inflammation and dry skin. Topical corticosteroids should not be used for treatment of children under the age of 2 years.
Topical steroids can be applied at any time of day but are ideally used after a bath or shower, as they seem to work better when the skin is slightly moist. They should be applied with clean hands in a thin layer so that the skin glistens, being careful not to apply more than the amount of cream that covers the first joint of an adult finger from the tip to the crease of the first joint. Moisturizer should be applied 30 minutes after the topical steroid to avoid diluting the steroid with the moisturizer.
What to tell your patients
Advise patients that they may need to try different moisturizers before they find one that works well for them. Also advise patients to contact their physician if symptoms limit daily activities, they experience ongoing flare-ups or worsening symptoms, or they have an unbearable itch and rash throughout the day as systemic therapy may be needed. Finally, ensure patients understand the importance of stopping the itch–scratch cycle by applying anti-itch moisturizers.
For further information, see the section on “Atopic Dermatitis and Dry Skin” in APhA’s Handbook of Nonprescription Drugs, available online in the bookstore at www.pharmacist.com or in APhA OTC on PharmacyLibrary (www.pharmacylibrary.com). ■