Clinical dermatology • Review article CED

Clinical and Experimental Dermatology

CPD

Use of emollients in dry-skin conditions: consensus statement

G. Moncrieff,1 M. Cork,2,3,4 S. Lawton,5 S. Kokiet,6 C. Daly7 and C. Clark8
1
Health Centre, Bicester, Oxfordshire, UK; 2Academic Unit of Dermatology Research, Department of Infection and Immunity, Faculty of Medicine, Dentistry
and Health, University of Sheffield Medical School, Sheffield, UK; 3Dermatology Department, Royal Hallamshire Hospital, Sheffield Teaching Hospitals Trust,
Sheffield, UK; 4Paediatric Dermatology Clinic, Sheffield Children’s Hospital, Sheffield, UK; 5Dermatology Department, Queen’s Medical Centre, Nottingham
University Hospitals NHS Trust, Nottingham, UK; 6Bedford House Medical Centre, Ashton-under-Lyne, Greater Manchester, UK; 7Mid Norfolk Clinical
Commissioning Group, North Elmham, Norfolk, UK; and 8Christine Clark Ltd, Rossendale, Lancashire, UK

doi:10.1111/ced.12104

Summary Emollients can perform an important role in the treatment of a number of dermato-
logical conditions. Currently, the use of emollient therapy in the UK is supported only
by limited guidelines and a best-practice statement, although guidelines do exist for
specific conditions such as childhood eczema. To address this need, a group of clinical
professionals covering acute community-care settings and medicines management
met to review current data and practice. Their aim was to support other professionals
in their approach to the use of emollient therapies in dry-skin conditions.

Introduction by environmental factors such as frequent washing,

use of harsh detergents and exposure to low-humidity
As our understanding of the pathophysiology of dry-
(e.g. air-conditioned) environments. Dry skin can be
skin conditions grows, it is increasingly possible to
unsightly, and can have severe consequences on the
choose the most appropriate product for an individual
patient’s quality of life through itching, discomfort and
patient. This offers the potential both to improve out-
embarrassment about their appearance.2 Left
comes and to ensure that National Health Service
untreated, dry skin can lead to a flare of the under-
(NHS) resources are used effectively.
lying condition such as AE.
The objective of emollient therapy is to correct some
Dry skin is synonymous with a skin-barrier defect,
of the factors that contribute to dry skin, to restore
and is caused by loss of water from the stratum corne-
the skin barrier, and to reduce the likelihood of further
um (SC). The healthy SC forms an effective permeabil-
damage. It is important to recognize that emollients
ity barrier, referred to as the ‘skin barrier’, which
are not all the same, and that prescribing should be
restricts water loss from the body, and prevents the
guided by clinical need and informed patient choice.
penetration of harmful irritants and allergens. It com-
prises tightly packed, well-hydrated corneocytes that
Dry skin are enclosed within a matrix of intercellular lipids. The
corneocytes contain natural moisturizing factor (NMF),
Dry skin (xerosis) is a common symptom of a number
a collection of hygroscopic compounds, which attract
of skin conditions, including atopic dermatitis/eczema
and hold water in the cells. Together, these natural
(AD/AE), ichthyosis, irritant contact dermatitis, psoria-
humectants are required to maintain the skin’s plastic-
sis and asteatotic eczema.1 Dry skin can be aggravated
ity and development of dehydration of the corneocytes.
Such dehydration would lead to the development of
Correspondence: Dr George Moncrieff, Health Centre, Bicester, cracks between the corneocytes, resulting in inflamma-
Oxfordshire, OX26 6AT, UK
tion and pruritus. The lipids of the SC are made up of
E-mail: georgemoncrieff@nhs.net
ceramides, cholesterol and free fatty acids, and are col-
Conflict of interest: none declared lectively referred to as the lipid lamellae. Both the lipid-
Accepted for publication 24 December 2012 filled extracellular compartment and the humectant/

ª The Author(s)
CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238 231
Use of emollients in dry-skin conditions ! G. Moncrieff et al.
water-filled intracellular compartment of the SC are
important for the barrier function and water-holding
properties of the skin.3,4
NMF and free fatty acids within the SC also help
maintain a low pH within the SC.5 This pH level is a
central regulator in maintaining the balance between
formation and degradation (desquamation) of the epi-
dermal barrier, which in the normal course of events is
continually renewed. Factors that perturb this system,
including both genetic skin-barrier defects and negative
environmental conditions, result in dry skin.3,4 For
instance, loss-of-function mutations in the FLG gene,
which encodes the epidermal barrier structural protein
filaggrin, are associated with persistent dry skin and
increased risk of developing AE.6–8 In the SC, filaggrin
is naturally broken down to yield some of the compo-
nents of NMF, therefore reduced levels of filaggrin
result in poor skin hydration and raised pH levels in
the SC.5,9 Washing the skin has similar effects on the
skin barrier; the use of soap and harsh detergents, such
as sodium lauryl sulfate (SLS), has been shown to
remove skin lipids, extract NMF and increase the sur-
face pH of the SC.10 At high pH levels, epidermal-
barrier homeostasis is perturbed, leading to increased
desquamation and reduced formation (decreased pro-
cessing of lipids), an effect that can last for over 48 h.
Infants and elderly people are more at risk, as their
skin is thinner and more vulnerable compared with
the skin of a young adult. Reduced levels of NMF and
alterations in the lipid composition of the SC, which
occur during the optimization of the skin barrier from
birth and as a result of intrinsic skin ageing, leave the
skin vulnerable to drying effects.9,11,12
Emollients
Simple emollients leave a fine occlusive layer of non-
physiological lipid or oil, such as petrolatum or mineral
oil, over the skin surface, thereby reducing water loss
from the SC. Emollient products can be formulated with
additional ingredients such as humectants, physiologi-
cak lipids and antipruritic agents.1 Humectants such as
urea and glycerol attract and hold water in the SC, and
therefore compensate for the reduced levels of NMF and
other natural humectants in diseased and older
skin.13,14 Physiological lipids such as ceramides, choles-
terol and free fatty acids, naturally found in the SC,
replenish and restore the intercellular lipid matrix.15,16
Not all emollients are the same, and as our under-
standing of the pathophysiology of dry-skin conditions
advances, more informed choices can be made to
match the emollients prescribed with the patient’s
232 CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238
needs.1,17,18 There is mounting evidence that aqueous
cream BP should be avoided, both as a leave-on emol-
lient and as a washing product. It contains approxi-
mately 1% SLS, an anionic surfactant known to be
profoundly irritant. Recent studies have shown that
the application of aqueous cream BP weakens the
epidermal barrier and actually increases transepidermal
water loss.19,20 Thus, rather than restoring the skin
barrier, it appears to cause more damage. SLS is used
as a skin irritant in patch testing, and is therefore an
ingredient that should never be included in an emolli-
ent formulation.21 However, in order to produce
oil-in-water cream formulations, emulsifiers are required.
Aqueous cream was first produced in 1958, and at that
time SLS was a standard emulsifier.22 Today, however,
there are emulsifiers that are much less damaging to
the skin, and these are now available in emollient
formulations.10 Consequently, no emollient product
containing SLS as a leave-on or washing product
should be used in any patient with dry skin.19,20
Patient management
Although emollients are widely prescribed in general
practice in the UK, they are often not prescribed in
sufficient quantity for optimal effect.23–25 In addition,
patients often experience dry-skin symptoms for many
years before seeking professional advice.
Around 24% of the population present to their gen-
eral practitionsers in the UK each year with a skin
problem.26 Quality standards require that all primary-
care commissioners ensure that appropriate provision
is made for assessment and management of all dermato-
logical conditions. In particular, Quality Standard 1
requires that all patients who manage their condition
themselves are supported with high-quality informa-
tion from trained nurses, patient support groups and
community pharmacists.27
Consensus themes
The starting point for discussion was a general agree-
ment that emollients should be the first-line therapy
for all dry-skin conditions,1 including eczema,24 astea-
totic eczema,28 and psoriasis29; that patients’ skin con-
ditions and emollient needs change during their lives;
and that these changes need to be considered when
choosing which emollient to use.18,30 Moreover, it was
noted that emollient preparations are not all the same.
Some emollient preparations, such as aqueous cream
containing SLS, have a deleterious effects on the skin,
whereas others comprise adjuvant ingredients with a
ª The Author(s)

positive effect on the skin barrier.15,20,31–34 Although
there is a good theoretical rationale for the inclusion
of adjuvant ingredients, including ceramides, fatty
acids, urea and glycerol, there is a pressing need for
robust evidence to show that the addition of these
ingredients enhances efficacy.15,31,33
There is some evidence that emollient preparations
containing urea enhance efficacy, are steroid-sparing
and delay the relapse of AE, compared with no treat-
ment.13,14 As the skin ages, the levels of NMF fall, and
so the skin’s ability to retain water decreases, providing
a rationale for the use of emollients containing NMF
ingredients, such as urea, to help replace this defi-
ciency. Clinical studies are needed to compare the clini-
cal efficacy of emollient preparations containing urea
against their emollient base and against alternative
emollient preparations without adjuvant ingredients,
using different patient groups, including the older age
group, in which NMF deficiency has been noted.
Discussion of the issues surrounding emollient use in
the UK identified seven key topics that underpin the
application of appropriate standards of care in the use of
emollients, regardless of care setting. Each topic is listed
below, along with the key points identified by this group.
What is atopic eczema?
• AE is the first event in the ‘atopic march’, which
can lead on to food allergy, asthma and allergic
rhinitis.35,36
• The primary event in the development of AE is a
breakdown in the skin barrier, arising out of gene–
environment interactions.4,8
• AE is an intensely itchy, dry-skin condition, which
causes sleep disturbances, and has a major effect on
both the patient and family members.24
• AE is predominantly a condition of childhood, but it
can persist into adult life.36
• AE can be a severe, life-changing condition, with
significant effects on patient’s quality of life and
employment choices.2
• Staphylococcal colonization of the skin has a criti-
cal role in aggravating the inflammatory process.37
Prescribing emollients
• Patients should be given the opportunity to
consider a variety of emollients from the whole
spectrum of products available, and to identify the
most suitable products for their skin.18,24
ª The Author(s)
CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238
Use of emollients in dry-skin conditions ! G. Moncrieff et al.
• The choice of emollient may be driven by cosmetic
acceptability, cream or ointment formulation, oil
content, and adjuvant properties such as humec-
tant and/or anti-itching properties.1,18
• Aqueous cream BP should never be used, either as
a leave-on or washing product, because of the SLS
component.19,20
• An adequate quantity of emollient should be pre-
scribed for optimal effect (250–500 g/week).23,25
• Patients should be offered smaller-quantity packs
for use at work or school, in addition to their main
prescription.18
• Patients may require more than one emollient prod-
uct, depending on lifestyle, time of day, seasonal
factors or disease severity.18
• Patients prescribed a leave-on emollient should also
be prescribed an emollient washing product.38
• Emollients have a steroid-sparing effect, and should
be supplied in a 10 : 1 ratio of emollient to steroid
in order to to achieve the full benefit.23,39,40
• Emollients should be prescribed according to clinical
best practice, not false economy.19
Additional education regarding dry-skin conditions and
the use of emollients
• The first step in the management of AE should be
the avoidance of irritants (including detergents).24
• Avoidance of detergent use (soaps, shampoos, shower
gels, bubble bath and hand washes), including
so-called ‘soap-free’ products, should go hand in hand
with the provision of emollient therapy.38
• Emollient therapy should be introduced at an early
stage.24,41
• All healthcare practitioners advising patients about
skin disease should understand the ‘spectrum’ of
emollient options (Table 1).
• Correct application of emollient should always be
demonstrated to the patient.25
• There should be a time interval of at least 30 min
(1 h for tacrolimus) between the application of topi-
cal flare treatments (topical corticosteroids, topical
immunomodulators) and emollient.24
• Patients offered emollient therapy should be advised
about safety issues such as cross-infection, risk of
slipping and flammability, where appropriate.30,42
• Patients should be made aware of the NHS pre-
payment option, where appropriate.
• Using sufficient quantities of emollients may reduce
the frequency of flares. This would be likely to lead
to a reduced number of referrals, although no for-
mal study has been conducted14
233
Use of emollients in dry-skin conditions ! G. Moncrieff et al.

Table 1 Emollient products.

Type of product Class Definition Usage Priority patient groups*

Leave-on Occlusive Oil-in-water emulsion intended Moderately dry skin conditions. First-line emollient therapy for
products emollient to prevent water evaporation Patient choice should be mild/moderate-severity
cream from the skin by providing considered regarding the thickness dry-skin conditions.
a film of lipid of barrier, variable lipid content, e.g. AE in children
severity of condition, body site
Occlusive Water-in-oil emulsions intended Drier skin conditions requiring First-line emollient therapy for
emollient to provide a thicker film of lipid a thicker lipid film. May be limited more severe dry-skin
ointment on the skin. 100% lipid in use because of patient conditions. e.g. severe AE
ointments are also included. acceptability
Occlusive Examples include white soft Very dry skin Very severe dry-skin conditions.
ointment, paraffin (WSP), liquid paraffin e.g. very severe AE
no water (LP), or a 50:50 ratio of
the WSP/LP
Humectant- Emollient product containing Dry skin in cases where other First-line use in cases where
containing humectants such as urea and products are not acceptable or simple emollients are not
emollients glycerin. Humectants attract effective effective or greasier products
and hold water in the stratum are unacceptable. e.g. for
corneum older people and for patients
with psoriasis
Antipruritic Emollient products containing Pruritus First-line therapy for pruritus.
emollient antipruritic agents Adjuvant to other emollient
products in cases where itch
is not controlled, and in all
dry-skin conditions and other
pruritic dermatoses e.g. uraemic
pruritus
Washing Emollient Emollient products containing All patients for washing. Some Should be used in conjunction
products washing emulsifiers, designed for washing simple emollients may also be with leave-on emollients
products usage. Do not contain harsh used for washing
detergents such as SLS†
Antiseptic Emollient washing products Useful in managing or preventing Recurrent infections in AE
washing containing flares of eczema. Should be used
products topically active antibacterial according to instructions
agents
Bath Bath oil Deposits a layer of oil on the Protection of the skin barrier Should be used in conjunction
emollients surface of bathwater, during bathing with leave-on emollients
which coats the patient on exit
Antiseptic Bath oil containing topical Prevention of infection AE with frequent infective
bath oil antiseptic agent exacerbations
Antipruritic Bath oil containing antipruritic Protection of the skin barrier during Should be used in conjunction
bath oil agent bathing when pruritus is a problem with antipruritic emollient
cream when pruritus is not
controlled

AE, atopic eczema; SLS, sodium lauryl sulfate. *Patient priority groups are examples of diseases and are not exhaustive. †Aqueous
cream BP is not recommended in any form because of the SLS component; this includes the combination with menthol.

The role of the multidisciplinary team

• All healthcare professionals should be consistent in
their communication to patients regarding emolli-
ent therapy.27
• Supporting information (e.g. about emollient
choice) should be appended to referral letters and
shared with the patient.
Health economics of emollient use
• Use of emollients can help control dry-skin condi-
tions and prevent flares of AE.
• This could lead to a reduction in referrals and
improving quality of life.13–15,43,44
• Emollient products must remain on prescription.

ª The Author(s)
234 CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238
 Use of emollients in dry-skin conditions ! G. Moncrieff et al.

the appropriate therapeutic approach for each class of

• Prescribers should be aware of the costs and proper-
ties of the various emollients.
• Using sufficient quantities of emollients reduces
flares.14,25,43
Healthcare priorities
• Education of children and families with AE is a
cost-effective intervention.25,45
• Appropriate use of emollients will reduce
flares14,43,46 and the need for other treatments,39
and may delay progression of the ‘atopic march’.35
emollient for treatment where dry skin is a feature.
The choice of emollient should be shared with the
patient to ensure adherence, taking into account the
emollient consistency, cosmetic acceptability, packag-
ing, lifestyle needs and mode of application.18 Ideally,
all products used on the skin should be emollient-
based, and emollient washing products should be
prescribed as soap substitutes.38 Consequently, patients
will often need a prescription for more than one prod-
uct. Conventional soaps and detergents (including
shower gels and bubble bath) should be avoided.24

Evidence for emollient efficacy
• Volunteer studies have shown that aqueous cream
BP is damaging to both the normal and atopic skin
barrier.19,20
• Clinical trials have shown that adjuvant emollient
therapy prevents flares of AE14,44 and psoriasis.43,46
• Emollients have anti-inflammatory proper-
ties.13,15,16,39,47
Conclusions and recommendations
Appropriate use of emollient, prescribed at the right
time and in sufficient quantity, has the potential to
improve patients’ quality of life and reduce prescribing
costs.17,18,25 We feel it is important to spend time edu-
cating patients about their condition and helping them
to make an informed choice of emollient, which
ensures effective adherence to treatment and can
make a large difference to their quality of life.25,45
To aid the selection process, we have produced a
guide to the different types of emollient products avail-
able, categorized by their adjuvant properties (Table 1).
The table is intended to provide a clear indication of
Summary
The following points summarize the key conclusions
and recommendations (Table 2).
• Emollient efficacy is dependent on usage and
patient adherence, and therefore informed patient
choice from the spectrum of emollients available is
pivotal in optimizing emollient therapy.
• When considering choice of emollient, the emollient
class, additional agents, price and application
frequency should be considered.
• Emollients should be applied correctly and generously;
sufficient quantities must therefore be prescribed.
• Ideally, emollients should be applied several times a
day to keep the skin hydrated. Humectant-containing
products can produce greater barrier repair per
gram than an emollient without humectants. This
has implications for cosmetic acceptability, patient
adherence and overall treatment costs.
• There is no place for the use of aqueous cream
products, even as washing agents.
• The correct use of emollients, by reducing the
number of flares, reduces the need to treat flares and
the need for general practitioner (GP) and secondary-
care consultations.

Table 2 Key points.

Condition Key points

Atopic eczema Application of emollients and steroids should be separated by 30 min (order of application does not matter)
Application of tacrolimus ointment should be separated from emollient application by 1 h
Emollient and steroid should be applied in a 10 : 1 ratio
Patients should not insert hands or fingers into emollient pots, in order to avoid microbial contamination of the contents.
They should instead decant the cream into a clean container with a clean spoon
Intermittent use of antiseptic bath oils can reduce flares
Plaque psoriasis Emollients can be effective in removing scaling before active treatments are used
Emollients have anti-inflammatory and anti-keratotic properties
Emollients should not be used in advance of phototherapy. Guidance should be given by specialists, as some emollients
can interfere with the effectiveness of phototherapy; refer to local guidelines
Flexural psoriasis Less greasy products may be more acceptable to patients

ª The Author(s)
CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238 235
Use of emollients in dry-skin conditions ! G. Moncrieff et al.
• It is therefore essential that emollients remain avail-
able on NHS prescription.
• Our suggestions reflect patient experience and
current knowledge about the underlying conditions.
As cost-saving measures begin to bite across the
NHS, one area for particular focus is the referral of
patients into secondary care. Dermatology is under
particular focus as GPs try to reduce the costs of hos-
pital referral.48 One solution to this challenge may be
to ensure that the use of emollients to manage dry-
skin conditions in the community setting is optimized,
thereby saving healthcare resources.
Acknowledgements
The Emollient Consensus Group meeting was set up for
the group to meet and discuss the contents of this article.
This meeting was organized and sponsored by Almirall
Ltd, and the production of this article has been funded by
Almirall Ltd. Almirall Ltd has had the opportunity to
review this article and has no editorial control. The final
editorial control resides with the author/contributors and
Wiley-Blackwell. The views and opinions of the author/
contributors are not necessarily those of Almirall Ltd.
Learning points
• Emollients are the first-line therapy for AE, irri-
tant contact dermatitis, asteatotic eczema, psoria-
sis and other dry-skin conditions.
• The patient’s age, individual needs, skin condi-
tion and preferences need to be taken into
account when selecting an emollient.
• Aqueous cream BP should not be prescribed or
used at all for people with dry skin, even as a
soap substitute.
• Humectant ingredients such as urea can
enhance the moisture-retaining ability of emol-
lients and thereby their efficacy.
• Emollients and steroids should be prescribed in a
10 : 1 ratio, to maximize the steroid-sparing effect.
• Informed patient choice and patient education
is crucial for maximum effect of emollients.
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CPD questions Question 4

Aqueous cream is not recommended for dry-skin con-

Learning objective
ditions. Which of its components has been shown to
To demonstrate up-to-date knowledge on the use of be an irritant?
emollients for dry-skin conditions. a) Cetostearyl alcohol.
b) Chlorocresol.
c) Liquid paraffin.
Question 1
d) Sodium lauryl sulfate.
What percentage of the UK population presents to e) White soft paraffin.
their general practitioner each year with a skin prob-
lem?
a) 5%. Question 5
b) 8%.
What factors are important when considering which
c) 12%.
emollient is appropriate for a patient?
d) 18%.
a) The type of dry-skin condition.
e) 24%.
b) Age of the patient.
c) Lifestyle.
d) Patient acceptability.
Question 2 e) All of the above.
What quantity of emollient should be prescribed for
optimal effect on dry skin?
Instructions for answering questions
a) 50–100 g/week. This learning activity is freely available online at
b) 100–150 g/week. http://www.wileyhealthlearning.com/ced.
c) 150–250 g/week.
Users are encouraged to
d) 250–500 g/week.
e) 500–1000 g/week. • Read the article in print or online, paying particular
attention to the learning points and any author
conflict of interest disclosures
Question 3 • Reflect on the article
• Register or login online at http://www.wileyhealth
What is the recommended ratio of emollient to steroid learning.com/ced and answer the CPD questions
for patients with atopic eczema? • Complete the required evaluation component of the
a) 5 : 1. activity
b) 8 : 3.
c) 10 : 1. Once the test is passed, you will receive a certificate
d) 12 : 1. and the learning activity can be added to your RCP
e) 2 : 3. CPD diary as a self-certified entry.

ª The Author(s)
238 CED ª 2013 British Association of Dermatologists ! Clinical and Experimental Dermatology, 38, 231–238