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Management of xerosis cutis with cream of
cashew shell oil: A case report
Jwala Jayaram, S. Swathy, M. S. Soumya, Shaithya Raj, Rabinarayan Tripathy

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Abstract:
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Xerosis cutis is one of the common clinical conditions in clinical practice. Reduced skin hydration
DOI: is the alarming characteristic of xerosis, that if ignored, can lead to insidious onset of cutaneous
10.4103/JACR.JACR_36_20 infections and chronic ulcers. Although various studies have been in vogue in this field, no standard
method of treatment has yet been formulated. An abundantly available drug, cashew shell oil, has
been used as a folklore practice in various parts of Kerala, for this condition. This case study is an
attempt to evaluate the efficacy of cashew shell oil in cream form in the management of xerosis
cutis of plantar surface. A 31‑year‑old female presented with the complaints of dry skin in the
plantar region of the right foot with deep cracks, fissures, and flakes in the skin for two years.
Diagnosis was done based on the clinical examination. Pre and post assessments were done based
on DermaLab Combo parameters, namely hydration, transepidermal water loss (TEWL), skin pH,
elasticity, temperature, skin color, videoscope, and Specified Symptom Sum Score system (scaling,
roughness, redness, crack or fissure). Cashew shell oil cream was applied for a period of 30 days.
Skin hydration levels improved and TEWL reduced after treatment. Skin pH, though raised during
the period of intervention, came to normalcy by the end of treatment. There was improvement in
skin viscoelasticity (VE), with reduced retraction time. The oil constituent being an antioxidant,
reduces lipid peroxidation and protects from cell membrane damage, thus maintaining skin barrier
function. Digital images evaluated using the DermaLab Combo parameters also depicted flaky dry
skin being replaced by normal Stratum Corneum (SC) cells, with increased skin hydration. Cashew
oil, though being a skin irritant, can be efficiently used in skin conditions, especially xerosis cutis,
when administered in appropriate dose and formulation.
KEYWORDS: Cashew shell oil, Padadari, skin hydration, transepidermal water loss, xerosis cutis

INTRODUCTION sudation should be done, followed by external

application of a medicine in the form of ointment

Department of Shalya
Tantra, Amrita School
V arious occupational screening examinations
have revealed that, approximately every third
individual between the age of 16 and 70 years is
with bee wax as base.[2,3]

Xerosis cutis or dryness of epidermal layers

of Ayurveda, Amrita affected by xerosis cutis. The prevalence increases of skin, attributed to the Stratum Corneum
Vishwa Vidyapeetham, (SC), is characterized by decreased quality
with increasing age. Older individuals have been
Amritapuri, Kollam,
Kerala, India shown to develop xerosis cutis in 99.1% of cases.[1] and quantity of hydrophilic substances
Xerosis cutis of feet is a condition very much and lipids.[4] With diminished hydration in
Address for correspondence: closer to Padadari mentioned under Kshudraroga cutaneous layers, the normal regulation
Dr. Rabinarayan Tripathy,
Department of Shalya Tantra,
by Acharya Sushruta. Here, Vata increased due of skin homeostasis is impaired.[5] Water
Amrita School of Ayurveda, to excessive walking produces cracks in the soles molecules lost from the SC, though normal
Amrita Vishwa Vidyap‑ of feet. In Padadari, venepuncture, unction, and in small amounts, can be hazardous when
eetham, Amritapuri, Kollam,
Kerala, India.
increased beyond a limit. This can result
E‑mail: drrabi73@gmail.com This is an open access journal, and articles are distributed under the terms in dysfunctional Natural Moisturizing
of the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0
License, which allows others to remix, tweak, and build upon the work
Submitted: 16-Jun-2020 How to cite this article: Jayaram J, Swathy S, Soumya MS,
non‑commercially, as long as appropriate credit is given and the new
Revised: 24-Aug-2020 Raj S, Tripathy R. Management of xerosis cutis with cream
creations are licensed under the identical terms.
of cashew shell oil: A case report. J Ayurveda Case Rep
Accepted: 28-Aug-2020
2020;3:75-80.
Published: 16-Oct-2020 For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

© 2020 Journal of Ayurveda Case Reports | Published by Wolters Kluwer - Medknow 75

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Jayaram, et al.: Management of xerosis cutis with cream of cashew shell oil
Factors (NMFs) in the SC, which will further evoke loss
of skin moisture. The NMF is responsible for preserving
hydrated structures in conditions of compromised
hydration.[6] The bi‑lipid layer matrix of SC encasing
layers of corneocytes, is periodically desquamated, thereby
maintaining the normal texture of skin.[7] This empowers
the skin barrier mechanism. It is due to the dysfunctional
skin barrier that the skin undergoes dryness way beyond
normal limits and is unable to prevent the excessive loss
of moisture from SC. The skin barrier mechanism is also
contributed by the acidic pH of skin, the sebum secretions,
and the elasticity of skin. In xerosis cutis, the level of skin
pH and elasticity varies. It has been found that, a normal
cutaneous acidic level between 4 and 6 pH enables the skin
to maintain normal lipid secretions.[6] Various intrinsic and
extrinsic factors are responsible for the development of
xerosis cutis. Use of soaps, exposure to cold, low humidity,
repeated bathing, etc., are a few of the common etiology
that enhances the loss of water from the SC.[7] The NMF
in the corneocytes are responsible for the regulation of
normal corneocyte desquamation. Xerosis cutis is a result
of dysfunction of the NMF due to impaired desquamation
of corneocytes, which is involved in reduced hydration of
skin. Studies show that lower limbs, especially foot, are
more affected than arms, trunk, and face.[4] Xerosis cutis
of the plantar region can result in flaking of the plantar
skin with heel cracks and fissures.
Although various studies have been undertaken for the
evaluation and management of this condition, a satisfactory
efficient remedy is not yet available. Cashew shell oil is an
inexpensive and abundantly available drug, which can be a
better choice than that of other classical formulations. With
this background, the efficacy of cashew shell oil in cream
form in the management of xerosis cutis is thought of.
Cashew shell oil has been used as a folklore medicine since
many years for plantar cracks and fissures due to xerosis
cutis of plantar skin.[8] In Ayurveda, cashew is referred
as a medicine for skin disorders, ulcers, and infectious
conditions.[9]
CASE REPORT
A 31‑year‑old, non-hypertensive, non-diabetic female
reported to the outpatient department in July 2019 with
complaints of dry skin in the plantar region of the right
foot with deep cracks, fissures, and flakes in the skin for two
years. There was slight redness in the affected area. Detailed
history and clinical examination revealed no significant family
history, medical history, or conditions involving systemic
diseases. On the basis of clinical history and examination,
the condition was diagnosed as xerosis cutis. Other
76 Journal of Ayurveda Case Reports - Volume 3, Issue 2, April-June 2020
dermatological diseases were ruled out based on clinical
observations. Plantar psoriasis which has similar symptoms
of dry scaly skin was ruled out as the cardinal features such
as erythematous sharply defined plaques and other features
such as Auspitz’s sign and candle grease sign characteristic of
psoriasis were absent.[10] “Itch that rashes” is the main clinical
feature of eczema. As such itching was absent in this case,
eczema was excluded out.[11] Vipadika is a condition similar
to Padadari. It is characterized by Pani‑pada Sphutana (~fissure
in the palm and soles) and Teevra vedana (~with severe pain).
The Doshas involved in Vipadika are Vata and Kapha dosha.[12]
Padadari is a Vata‑predominant condition unlike Vipadika.
Besides, severe pain is not a feature present in this case.
Therefore, Vipadika can also be ruled out from the diagnosis.
Hence, the present case was diagnosed as xerosis cutis based
on physical examination and DermaLab Combo assessment
including high‑resolution images and Specified Symptom
Sum Score (SRRC) system (scaling, roughness, redness,
crack, or fissure).
Clinical findings
Inspection of the plantar skin revealed a dry scaly skin, with
skin plaques, redness, cracks, and fissures, with palpation,
roughness of the dry skin, cracks, and fissures felt.
Therapeutic intervention
Preparation of cream
Cashew shell oil was extracted by roasting method. The oil
was converted into cream form with 50% concentration
of oil and cream base  (paraffin oil, paraffin wax,
triethanolamine, stearic acid, and water). Methyl paraben and
propyl paraben were added as preservatives. The aqueous
and oil mixtures were heated to 80°C simultaneously to
attain a homogeneous mixture of the contents. It was then
added slowly and triturated continuously and manually to
form emulsion with creamy consistency. The product was
allowed to cool, and then collected and preserved in an
air‑tight container.
Method of intervention
The patient was instructed to clean the affected area, make
it dry, and apply the cream twice a day for a period of four
weeks. The patient was advised to avoid the use of other
products or soaps during the study period.
Diagnostic assessments
The outcome measures were assessed with DermaLab
Combo. It is a multi‑parameter skin analysis system operated
by a wirelessly connected tablet PC. It can be freely configured
with the parameters including hydration, TEWL, skin pH,
elasticity, temperature, skin pigmentation, and videoscope
image by using specific probes. Subjective criteria for
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Jayaram, et al.: Management of xerosis cutis with cream of cashew shell oil

assessment were based on the SRRC system by scoring the The relationship between xerosis cutis and the values of
values for scaling, redness, roughness, cracks, and fissures, hydration, TEWL, skin pH, elasticity, temperature has
developed by the European group on efficacy measurement been established in various studies. The cutaneous barrier
of cosmetics and other topical products.[13] Weekly assessment function is maintained by its water content. Furthermore,
with DermaLab Combo and SRRC scoring system was done studies show that dermatological dysfunction results due
based on the above‑mentioned parameters to estimate the to curtailed hydration levels of skin.[15] TEWL, a criterion
pre‑ and post‑levels of skin dryness. which can be used to characterize barrier function of skin,
is the amount of water molecules escaped from within the
TIMELINE skin to the external environment.[16] As the skin dryness
decreases, there is improvement in hydration levels of
A timeline of the events during the treatment period is skin and reduction in TEWL.[16,17] This indicates that
shown in Figure 1. the skin physiology has improved and its moisture levels
FOLLOW UP AND OUTCOME
are maintained after the trial period. By disseminating
the plugged‑up corneocytes, which are responsible for the
The pre and post values [Table 1] showed increased skin loss of normal regulation of TEWL and hydration, the
hydration and decreased TEWL levels after the treatment skin attains better moisturizing levels after the application
duration of four weeks. The skin pH levels initially were of cashew shell oil cream. In addition, the cream, with both
normal and increased during the treatment period and again the drug and the cream bases being oil, can act as a barrier
declined to normal pH of the skin by the end of four weeks. to reduce the TEWL. The skin being more lipophilic
The viscoelasticity (VE) increased after treatment, but the than hydrophilic,[18] can easily absorb the oil content in
elasticity values were rather not much affected. The melanin the drug and thus maintains its hydration. Cashew shell
and erythema values increased during cream application and oil is a mixture of cardanol, cardol, and anacardic acid. It
had returned to normal with the completion of treatment. is found to accelerate wound healing.[19] The antibacterial
Temperature variation before and after treatment, was and wound‑healing activities of cashew nut shell liquid
negligible. The videoscope images [Figures 2‑6] showed have been analyzed systematically. It has been found to
gradual diminution of cracks and flakes to normal skin, accelerate wound closure in L929 cells.[8] Cardanol being an
even though the image clearly specified the pigmentation antioxidant reduces lipid peroxidation and protects from
of the skin during the trial period. The scoring system cell membrane damage, thus maintaining the skin barrier
based on scaling, redness, roughness, cracks, and fissures function and balancing TEWL and hydration.[5]
also showed periodic reduction of scores by the end of Table 1: DermaLab Combo assessment values
treatment [Table 2]. No adverse effects were found during Parameters BT AT1 AT2 AT3 AT4
the treatment period and follow‑up. Hydration (µS) 21 10.3 10 17.8 25
TEWL (g/m2/h) 19 18.3 22.5 10.6 9.3
DISCUSSION Skin pH 5.8 5.5 5.8 5.7 5.1
VE (MPa) 42.2 44 25.8 29.4 48.9
Xerosis cutis causes plugging up of corneocytes on SC, Elasticity (MPa) 27.3 23 17.3 25.9 21.3
leading to flakiness, callosity, cracking, fissuring, scales, Retraction time (ms) 140 134 859 144 81
tenderness, and pain. Xerosis cutis of feet is a condition Temperature (°C) 33.5 34.5 31.8 32 33.4
very much closer to Padadari. In Padadari, venepuncture, Melanin (pigmentation index) 56.6 47.8 68.7 41.8 56.9
Erythema (redness index) 15.4 16.1 18.7 16.2 15.2
unction, and sudation should be done, followed by external
BT: Before treatment, AT1: After treatment of 1 week, AT2: After
application of a medicine in the form of ointment with treatment of 2 weeks, AT3: After treatment of 3 weeks, AT4: After
bee wax as base to maintain moisture and prevent further treatment of 4 weeks; TEWL: Transepidermal water loss; VE:
Viscoelasticity
crack formation.[14]
Table 2: Assessment based on the Specified Symptom Sum
Score system
Parameters BT AT1 AT2 AT3 AT4
Scaling 2 1 0 0 0
Roughness 3 2 1 1 0
Redness 2 1 0 0 0
Cracks and fissures 4 4 3 2 1
BT: Before treatment, AT1: After treatment of 1 week, AT2: After
treatment of 2 weeks, AT3: After treatment of 3 weeks, AT4: After
Figure 1: Timeline of events during the treatment period treatment of 4 weeks; TEWL: Transepidermal water loss

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Jayaram, et al.: Management of xerosis cutis with cream of cashew shell oil

Figure 2: First assessment – Before treatment Figure 3: Second assessment – After one week of treatment

Figure 4: Third assessment – After two weeks of treatment Figure 5: Fourth assessment – After three weeks of treatment

treatment reflects a chronic state of SC instability, which

Figure 6: Fifth assessment – After four weeks of treatment
The normal skin pH is between 4 and 6. The acidity of
skin is compromised in xerosis cutis.[4] In addition, studies
reveal that an alkaline skin is specifically susceptible
to cutaneous infections.[20] Increased skin pH during
could be predisposing individuals to recurrences.[20] As the
xerosis is relieved, the skin pH returns to normal levels.
Normal skin is slightly acidic in nature as the acid mantle
layer plays a significant role in maintaining the skin barrier
function. pH has a role in lipid synthesis, differentiation,
and desquamation of epidermal layers. The skin pH
also regulates enzymes of ceramide metabolism such as
β-glucocerebrosidase and acid sphingomyelinase enzymes.
These ceramides are an important component of the
lipid bi‑layer matrix where corneocytes are embedded.
Proteases such as chymotryptic enzyme and cathepsin
D linked to epidermal differentiation and desquamation
are under the control of pH.[7] Cashew shell oil being an
acidic compound due to the presence of anacardic acid,[21]
has a role here to reduce the alkalinity of the skin, thereby
maintaining a normal skin barrier function. During the
treatment period, it can be seen that the pH levels are
raising and even fluctuating to alkaline pH. This is due to
the fact that the accumulated layers of corneocytes are

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Jayaram, et al.: Management of xerosis cutis with cream of cashew shell oil
getting desquamated by the intervention, and this results
in raised pH levels. It has been found that disruption of
the physical barrier results in raised pH levels.[20] After the
treatment, the skin pH levels attain normal acidity as the
acid mantle layer functionality is maintained, thus regaining
the skin barrier function.
Skin elasticity and VE though are closely related terms, the
hydrated skin shows better variations in skin VE rather
than skin elasticity. Elasticity is the immediate response
of the skin contributed by thin elastin fibers. During
the treatment, the clogged‑up layers of corneocytes
get desquamated and as a result the dry skin layer peels
off. Thus, it reduces the elasticity values. VE refers to
the bouncing property of the skin due to the quality of
viscosity of close bound molecules. VE is provided by
the fluids in the cutaneous layers and the  thick fibers
of cross-linking collagen  and elastin proteins. It is the
mechanism which protects the skin from minor wear and
tear.[22] With the application of cashew shell oil cream,
the water‑binding property of SC increases, thereby
raising the VE levels. In the present study, from the pre
and post values, it is clear that the VE had increased
after treatment and elasticity had slightly reduced after
treatment. However, the reduced retraction time indicates
the restoration of healthy skin layers [Table 1].
Previous studies on thermoregulation property of skin
and its relationship with skin dryness reveal that xerosis
is less likely to develop in higher temperatures. The
cold stress test and the recovery time from cold stress
show an indirect relation with the xerosis pathology.
Skin carries out thermoregulation with the aid of
sympathetic responses, providing timely vasodilation and
vasoconstriction with higher and lower temperatures,
respectively. Therefore, temperature has effect on skin
physiology. In addition to this, cold‑induced vasodilation,
which occurs as a protective mechanism against ischemic
damage, is found to be reduced with increasing age.[23] In
the present study, there is no remarkable variation in the
skin temperature during the trial period. However, the
hot potency of the drug as described in Ayurveda can be
incorporated here to hypothetically lay down a link with
reversing skin dryness.
The scaling, roughness, redness, crack, and fissure values
have reduced in this condition with the intervention. This
is due to the improved desquamation of the SC layers
which have been clogged up in piles due to xerosis cutis.
With withering off of old corneocytes, the NMFs of SC
become functional and regain their ability to regulate skin
moisturization and thus improve the skin barrier function.
Journal of Ayurveda Case Reports - Volume 3, Issue 2, April-June 2020 79
This can lead to a well‑balanced level of TEWL and skin
hydration.
CONCLUSION
Cashew oil, though being a skin irritant, can be efficiently
used in skin conditions, especially xerosis cutis, when
administered in appropriate dose and formulation.
However, trials conducted on a larger population are
required to assess the wide applicability of the drug in
xerosis cutis. The pigmentation of the skin with the
application of cashew shell oil cream, though temporary,
needs to be furnished with better formulations which can
mask the pigmenting effect of the drug. More studies on
the action potential of the drug would enable addressing
more dermal pathologies efficiently.
Declaration of patient consent
Authors certify that they have obtained patient consent
form, where the patient/caregiver has given his/her
consent for reporting the case along with the images and
other clinical information in the journal. The patient/
caregiver understands that his/her name and initials will
not be published and due efforts will be made to conceal
his/her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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