Pharmacists are often asked what emollients are best by their patients. But the answers are rarely simple, says Rod Tucker
Walk into any pharmacy and take a look at the skincare section, or even the dispensary shelves where topical therapies are kept, and you are met with a vast array of products.
It's perhaps not surprising that patients, when faced with so much choice are bewildered and ask ‘what's the best emollient for my eczema?’ My standard answer is always that it depends on which one you like. This response is invariably met with a confused look and so when elaborating, I explain that once they find a product that suits them, it will get used.
With many still looking bemused, I continue with an example. A greasy product would be less problematic if they had hand eczema and worked outdoors, but more troublesome if they had an office-based job and spent a good deal of time handling documents or working at a keyboard, because the product is soon transferred onto everything they touch.
After clarifying the cosmetic issues, another consideration is which, if any, of the components in an emollient are likely to provide the greatest benefit. Emollients can contain very few ingredients like Vaseline, which contains only petroleum jelly, whereas others include a cocktail of ingredients with purported benefits. For instance, one product containing colloidal oatmeal, claims to be ‘proven to restore the skin’s natural barrier’, while another explains how inclusion of urea and lactate is the ‘key to trapping moisture into the skin, which ensures long-lasting hydration’.
These are powerful and convincing messages that can create difficulties for both patients and healthcare professionals in deciding which product to choose.
The clinical reviews
With such alluring claims, where is the clinical evidence to support the use of a particular product or even ingredient and does it stand up under scrutiny?
Recently, two systematic reviews have attempted to address the clinical effectiveness of emollients in eczema. In the first, which identified 48 studies investigating the effects of emollients in patients with atopic eczema and associated dry skin conditions, e.g. irritant hand dermatitis and or ichthyosis, it was concluded that urea-containing emollients may be preferable as first-line treatments. The second, which was a Cochrane review, included 77 studies in over 6,500 patients and was more circumspect about recommending specific ingredients, concluding that no firm inferences could be made based on the available evidence.
So what should I choose?
Both reviews highlighted the lack of high quality evidence and comparative studies between emollients (or more importantly, specific components) in the management of eczema. The evidence does, in fact, suggest that emollients containing urea, glycerol and colloidal oatmeal are more effective than placebo comparators, but whether inclusion of one particular ingredient confers a degree of superiority over the others remains unclear.
Despite this, the evidence from both reviews provides support for current practices in dermatology, showing that:
- Emollients have a beneficial effect in those with atopic eczema and are better than not using an emollient, especially in reducing eczema associated itch though due to differences in study designs it was impossible to quantify this effect.
- Emollients improve skin barrier function though the extent to which this occurred varied substantially
- Use of emollients helps to reduce the rate of eczema flares
Any emollient will work if used correctly and health professionals should not worry too much about whether or not a product contains a particular ingredient. Far more important is that the patient finds an emollient that suits them because they will be more inclined to use it and therefore see the benefits.