Emollients (Moisturisers) for Eczema

What are emollients?

Emollients are often called moisturisers. They 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 emollient 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 lipid (oil) 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?

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, then a lotion or cream may be best.
• If you have moderate to severe dryness then a thicker cream or an ointment is usually best. Creams are usually 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.

How do I use and apply emollients?

Creams, ointments and lotions

Whenever you use a 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' drugs which pass through the skin. If you wash, or have a bath or shower, apply an emollient to the 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 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. If you do use them they should be used in addition to, not instead of, creams ointments or lotions that you rub onto 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, but 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 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 corticosteroid. 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 possible 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 sensitised ('allergic') to an ingredient. This can make the skin inflammation worse rather than better. A particularly notable preparation is aqueous cream. This was 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 this uncommon problem. Note: ointments tend to cause less 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

• A common mistake is to use too little emollient. It is common for an adult with eczema to use at least a 500 gram tub of emollient per week, and a child to use a 500 gram tub every two weeks.
• 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.
• Paraffin based emollients are flammable. Keep them away from naked lights and flames.

In summary

A typical routine for an 'average' person with eczema might be:

• When you have a bath or shower, consider adding an emollient oil to the bathwater or as you shower. This will 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 or ointment to any remaining dry areas of skin.
• Between baths or showers, use an emollient cream, ointment or lotion as often as necessary.
• Use an emollient ointment at bedtime.

Further help and information

National Eczema Society

Hill House, Highgate Hill, London, N19 5NA
Tel (Helpline): 0800 089 1122 Web: www.eczema.org