Main Issue March 2012

Don’t Neglect Skin Care For Any of Your Patients

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Patients intuitively recognize that ongoing proper skin care is essential to preserve cutaneous health, to support therapeutic interventions, or to prolong skin clearance. Yet many patients fail to adhere to a skin care regimen, and many more adopt regiments that use suboptimal products that provide little to no benefit and sometimes contribute to skin damage.

Past articles in this publication have addressed skin care within the context of discussion of certain diseases or therapeutics, however, dermatology clinicians require a comprehensive approach to skin care education and product recommendation for all patients in order to ensure that they adopt good habits. Following are some guidelines on skin care education and tips to encourage adherence.

Sunscreens

Although sunscreen is not the first skin care product a patient will apply each day, it may be the most important. In light of emerging data about patients’ UV protection habits, as well as upcoming sunscreen label revisions, education about sunscreen selection and use may be especially important.

A recent survey revealed that sunscreen use among American high school students has actually decreased.1 From 1999 to 2009, the percentage of white or Hispanic high school students who said they never or rarely applied sunscreen when spending more than an hour in the sun increased from 57.5 to 69.4 percent and 71.6 to 77.9 percent respectively. At the same time, surveys of parents of adolescents indicate low compliance with UV safety recommendations among these adults. Although sunscreen use was the most commonly reported UV protection strategy of parents, rates of sunscreen use were low, and many individuals were found to apply products improperly.2

Sunscreen recommendations and instructions must be clear and concise. Data confirm that perceived ambiguity about skin cancer prevention recommendation directly correlate with reduced adherence with those recommendations. 3 To that end, emphasize:

• Daily use of a broad-spectrum sunscreen SPF 30 or higher daily. • Repeat application of sunscreen to sun exposed skin per label recommendations.
• Application of sufficient sunscreen to provide protective effects.
• Use of other UV limiting strategies, including protective clothing, shade-seeking, and avoidance of natural or UV lamp-based tanning.

One major goal of the label revisions (see sidebar) was to help clarify the level and duration of protection that sunscreen formulations afford. FDA is limiting claims of product durability, and all labels will contain clear guidance on the amount and frequency of sunscreen application. Therefore, clinicians can feel comfortable advising patients to follow the manufacturer’s recommendation for re-application.

Technology incorporated into sunscreen formulations has advanced dramatically, leading to a wide array of products intended to meet patients’ needs and preferences. There are sprays, sticks, lotions, and gels. There are products formulated for application to wet skin and those intended to leave a dry skin feel. These multiple options increase the likelihood a patient will find a suitable product for use when spending time outdoors at the beach, participating in sports, hiking, etc. The reality remains, however, that most standard sunscreens have a distinctive fragrance and most patients do not use general purpose sunscreens for application to the face.

For daily application to the face, advise patients to identify a moisturizing sunscreen that they like. Drug store brand versions of popular cosmetic lines are now available at a very reasonable cost. Product lines designed for dermatology patients typically contain moisturizing sunscreens (such as CeraVe Moisturizing Lotion AM, SPF 30) and may be a good choice for many patients. These lines, available at drugstore nationally, are competitively priced and provide a range of basic skin care products for patients. Recommending one of these lines means the patient has to remember just one brand name for their purchases.

There is some dispute about the relative merits of physical versus chemical sunscreens. Some parties have expressed concerns that chemical sunscreen ingredients are absorbed by the body and cause all manner of maladies, including cancer,4 though there is no solid evidence of any of these assertions. There are also concerns that physical sunscreen nanoparticles can similarly enter the bloodstream.

Studies suggest that perhaps trace amounts of zinc are absorbed through intact human skin,5 although other reliable evidence suggests that neither zinc nor titanium dioxide are absorbed transdermally.6

Given their perceived safety and the fact that they are broad-spectrum screening agents, physical sunscreen ingredients may be preferred by some patients. However, the available data do not suggest that patients must avoid chemical sunscreens. Those who ask about sunscreen safety may be reminded that UVR is a known carcinogen, whereas chemical sunscreens have been the subject of unproven weak associations with possible health risks.

Non-SPF Moisturizers

After sunscreens, moisturizers may be the most important skin care products dermatology clinicians can recommend. Whether we realize it or not, most skin care recommendations involve moisturizers. As has been noted by Zoe Draelos, MD, “Whether the product is a facial foundation, an antiaging night cream, a sunscreen, a topical antioxidant, or a skin-lightening serum, the formulation is basically a moisturizer.”7 Moisturizers, including facial moisturizers, are appropriate for the vast majority of patients, including those with “oily skin,” and can be beneficial for both healthy and diseased skin. Properly used moisturizers improve skin hydration by reducing transepidermal water loss (TEWL) and can contribute to enhanced barrier function.8 Given that many inflammatory dermatoses, including rosacea, atopic dermatitis, psoriasis, and acne, are associated with impaired barrier function, use of moisturizers may be considered supportive in the management of these conditions.

Use of moisturizers may optimize topical therapeutic approaches in many dermatoses. For example, in a four-week pilot study that compared skin hydration in 36 healthy adult women randomized to treatment with one of four topical acne therapies (two different clindamycin 1%/benzoyl peroxide 5% gels, sodium sulfacetamide 10% lotion, or over-the-counter moisturizing cream), subjects treated with OTC moisturizer or sodium sulfacetamide exhibited decreased water loss, increased water retention, similar or improved levels of skin hydration, and decreased desorption rates. Patients using moisturizer demonstrated slight decrease in skin dryness. However, subjects treated with clindamycin/benzoyl peroxide had increased water loss, decreased water retention, decreased hydration, and increased desorption rates.9

The potential irritation caused by topical therapies requires that prescribers offer soothing adjuvant moisturizers. Consider results of a recent patient survey that revealed that patients using clindamycin 5%/BPO combination formulations reported dry (55 percent), flaky/peeling (45 percent), irritated skin (44 percent), or itchy skin (39 percent) and redness (37 percent). Experience of side effects led patients to use products as a spot treatment (33 percent) or only when acne flared (28 percent) or to decrease frequency of medication application (32 percent), institute drug holidays (32 percent), switch to a different prescription medication and/or an over-the-counter acne product (28 percent), or discontinue therapy altogether (10 percent). Interestingly, fewer than half of subjects (41 percent) said they used moisturizers to counteract dryness and redness.10 The contribution of ingredients that may offset potentially drying or irritating therapeutic agents has led to the development of novel topical acne formulations that incorporate soluble collagen and glycerin.11

Given the dry, xerotic and sometime pruritic nature of atopic skin, the need for moisturizing among these patients is obvious. While use of moisturizers was once thought to provide only symptomatic relief, it is now recognized that certain moisturizers can actually help improve barrier function and therefore support skin healing. The class of prescription barrier repair devices has been shown to support barrier repair and support resolution of atopic dermatitis. Importantly, data show that less expensive OTC formulations can be as or more effective than prescription barrier repair devices in promoting optimal barrier function.12

Facial Cleansing

Issues around cleansing tend to focus on the face. To prevent dry, tight, or irritated skin, all patients and especially those with active dermatoses, should avoid the use of synthetic detergent bars or harsh detergents on the face. Instead, moisturizing or emollient cleansers should be used. A popular option for facial cleansing has been a non-foaming cleansing lotion (Cetaphil Gentle Skin Cleanser), but for patients who prefer a cleanser that foams, appropriate foaming options have emerged (such as CeraVe Hydrating Cleanser). Mesh sponges, abrasive scrubs, and woven face cloths typically are not appropriate for cleansing by patients with barrier damage.7

Hand Cleansing

Hand cleansing may be a commonly overlooked issue in the dermatology clinic. Certainly patients with hand eczema or irritant or allergic hand dermatitis should receive education on proper hand cleansing and skin care, but dry, cracked, tight, peeling, and/or itchy skin of the hands occurs with great frequency, especially in colder months or among patients who are frequent handwashers. Hand concerns are usually a secondary cause for presenting to the clinic, and sometimes patients fail to ask about their hands at all.

It is important to rule out irritant or allergic contact dermatitis and treat appropriately. For “non-specific” hand dermatitis, treatment consists of two main strategies: prevention and treatment. Although the dermatitis is not strictly speaking a direct result of any exposure, frequent hand washing and exposure to detergents or other chemicals may contribute to the dermatitis. Patients should be advised to wear vinyl gloves during any wet work and whenever exposing the hands to chemicals.

Alcohol-based hand sanitizers may be a suitable option for these patients. There is good evidence to support the efficacy of alcohol-based hand sanitizers to kill bacteria and viruses on the hand. In fact, use of alcohol-based hand gels has been shown to reduce transmission of GI infections within families with children in daycare13 and to reduce absenteeism in elementary schools.14 It is also shown that these products can be better tolerated and less irritant than soap and water.15,16 Although several publications emphasize that alcohol-based hand sanitizers are intended as an alternative to hand-washing with detergent, it is noted that use of an alcohol-based hand rub may decrease skin irritation after a hand wash via mechanical partial removal of the detergent.

One publication notes the following mistakes associated with the use of alcohol-based hand sanitizers:

• Application to pre-irritated skin
• Washing hands before hand disinfection
• Washing hands after hand disinfection.17

Stinging or burning associated with the use of alcohol-based cleansers is thought to be a sign of existing skin barrier defect—usually visible cuts and scrapes—and alcohol is not shown to induce barrier dysfunction. It should be noted that while much of the research suggests that alcohol-based hand sanitizers are not a source of allergic contact dermatitis, the potential for sensitization has been raised. In a series of 1,450 patients patch tested with isopropyl alcohol during the period 1992-2011, 44 showed an allergic response to isopropyl alcohol. Eighty-four percent of the patients showed sensitization to three or more allergens.18 Of note to dermatology clinicians, alcohol-based gels have even been used as dermoscopy fluid.19

Patients who prefer to wash their hands with soap and water should select a gentle, emollient cleanser. Any hand cleansing should be followed by application of an appropriate moisturizer, including ceramide-rich barrier repairing formulations, as appropriate.

Hair and Body Cleansing

There is some dispute about the role of dyes, fragrances, and detergents in the development of allergic reactions to personal care products. Many cases may represent irritant reactions, which are nonetheless bothersome to patients. In an epidemiologic survey from the UK, 23 percent of women and 13.8 percent of men said they experienced some sort of adverse reaction to a personal care product over the course of a year.20 The authors of that study indicate that 10 percent of dermatologic patients who are patch tested are allergic to cosmetic products or their constituent ingredients. Patients with any dermatitis and those who report “Sensitive skin” may be advised to avoid synthetic detergent bar soaps and/or heavily perfumed body washes and shampoos. Those who are particularly sensitive may consider products with no fragrances added. However, such products can be hard to find. Usually but not always, “fragrance free” indicates that a product does not contain chemical fragrances. In contrast, “unscented” products can contain masking fragrances that neutralize their odor. Emollient-based washes are likely to provide most benefit.

Results of a recent study of children with AD suggest that patients should apply emollient moisturizers immediately after bathing. In the study, patients who bathed without applying moisturizer had 90-minute mean hydration levels at 91.4 percent of baseline. Those who bathed and immediately applied moisturizer and those who bathed and delayed moisturizer application by 30 minutes achieved equivalent 90-minute mean hydration levels (about 141 percent of baseline). Interestingly, those who applied emollient without bathing achieved 90-minute hydration levels of 206.2 percent of baseline! Mean hydration values at 90 minutes were greater for normal skin controls in all arms; trends mimicked those for AD patients.21

Back to Basic Skin Care

Experience and evidence show that anything a patient applies to the skin can influence their cutaneous health positively or negatively. The importance of supportive skin care is increasingly important, as the market for these products has grown exponentially and many products are truly beneficial. To ensure that patients select and use proper skin care products and avoid detrimental ones, clinicians must be prepared to make meaningful product recommendations. Give clear guidance on proper selection and use of sunscreens and facial sunscreens, advice on selection and application of hand and body moisturizers, instructions for the use of supportive skin care as adjuvant to topical therapies, tips for recognizing appropriate body cleansers, and strategies to preserve and protect the hands.

  1. Jones SE, Saraiya M, Miyamoto J, Berkowitz Z. Trends in sunscreen use among US High school students: 1999-2009. J Adolesc Health. 2012 Mar;50(3):304-7.
  2. Bandi P, Cokkinides VE, Weinstock MA, Ward E. Sunburns, sun protection and indoor tanning behaviors, and attitudes regarding sun protection benefits and tan appeal among parents of U.S. adolescents-1998 compared to 2004. Pediatr Dermatol. 2010 Jan-Feb;27(1):9-18.
  3. Han PK, Moser RP, Klein WM. Perceived ambiguity about cancer prevention recommendations: associations with cancer-related perceptions and behaviours in a US population survey. Health Expect. 2007 Dec;10(4):321-36.
  4. http://www.ewg.org/news/scrutinizing-safety-cosmetics-ingredients
  5. Gulson B, McCall M, et al. Small amounts of zinc from zinc oxide particles in sunscreens applied outdoors are absorbed through human skin. Toxicol Sci. 2010 Nov;118(1):140-9.
  6. Monteiro-Riviere NA, Wiench K, et al. Safety evaluation of sunscreen formulations containing titanium dioxide and zinc oxide nanoparticles in UVB sunburned skin: an in vitro and in vivo study. Toxicol Sci. 2011 Sep;123(1):264-80.
  7. Draelos ZD. Active agents in common skin care products. Plast Reconstr Surg. 2010 Feb;125(2):719-24.
  8. Draelos ZD. Concepts in skin care maintenance. Cutis. 2005 Dec;76(6 Suppl):19-25.
  9. Zhen Y, Stoudemayer M, Vamvakias G, Kligman AM. Pilot investigation of the hydrating effects of topical acne medications. J Drugs Dermatol. 2007 Aug;6(8):810-6.
  10. Feldman SR, Chen DM. How patients experience and manage dryness and irritation from acne treatment. J Drugs Dermatol. 2011 Jun;10(6):605-8.
  11. Ceilley RI. Advances in topical delivery systems in acne: new solutions to address concentration dependent irritation and dryness. Skinmed. 2011 Jan-Feb;9(1):15-21.
  12. Miller DW, Koch SB, Yentzer BA, et al. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. J Drugs Dermatol. 2011 May;10(5):531-7.
  13. Sandora TJ, Taveras EM, et al. A randomized, controlled trial of a multifaceted intervention including alcohol-based hand sanitizer and hand-hygiene education to reduce illness transmission in the home. Pediatrics. 2005 Sep;116(3):587-94.
  14. Dyer DL, Shinder A, Shinder F. Alcohol-free instant hand sanitizer reduces elementary school illness absenteeism. Fam Med. 2000 Oct;32(9):633-8.
  15. Batalla A, García-Doval I, de la Torre C. Products for Hand Hygiene and Antisepsis: Use by Health Professionals and Relationship With Hand Eczema. Actas Dermosifiliogr. 2011 Sep 6. Epub
  16. Löffler H, Kampf G, Schmermund D, Maibach HI. How irritant is alcohol? Br J Dermatol. 2007 Jul;157(1):74-81.
  17. Kampf G, Löffler H. Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. J Hosp Infect. 2003 Sep;55(1):1-7.
  18. García-Gavín J, Lissens R, Timmermans A, Goossens A. Allergic contact dermatitis caused by isopropyl alcohol: a missed allergen? Contact Dermatitis. 2011 Aug;65(2):101-6.
  19. Bellew SG, Weiss MA, Weiss RA. Medical pearl: rinse-free instant hand sanitizer for use as dermoscopy fluid. J Am Acad Dermatol. 2005 May;52(5):893-4.
  20. Orton DI, Wilkinson JD. Cosmetic allergy: incidence, diagnosis, and management. Am J Clin Dermatol. 2004;5(5):327-37.
  21. Chiang C, Eichenfield LF. Quantitative assessment of combination bathing and moisturizing regimens on skin hydration in atopic dermatitis. Pediatr Dermatol. 2009 May-Jun;26(3):273-8.

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