Barbara Page Dermatology Liaison Nurse Specialist NHS Fife Skin Integrity – the basics of skin care Emollients and use of Topical Steroids Barbara Page Dermatology Liaison Nurse Specialist NHS Fife

Functions of the Skin Barrier Temperature control Sensory Vitamin D synthesis Communication & display

Promoting Healthy Skin……. The Basics of Skin Care Emollients…… Emollients…...

Healthy Skin Allergens Water Water Water Water Water Water Water Water Normal healthy skin Looking at the top layer of skin which is known as the epidermis or the “cell factory” of the skin where cells develop through a number of stages until they form the stratum corneum From base to surface this takes around 28 days……..much slower as the skin ages. The skin cells produce natural lipids which hold the skin cells together. If we can relate this simply to a brick wall ……… bricks are the cells ……..mortar, the natural lipids ……… surface is intact, like a smooth coping stone on top of the wall ……… what happens when the surface layer (stratum corneum/coping stone) is not intact ……… there is a loss of barrier function Water Water Water Water © 2001 Elliott/Cork/Cork 4

Loss of Skin Barrier Loss of water Loss of water Loss of water Loss of fat Loss of fat Loss of skin barrier………. entry point for : Allergens Irritants Infection allergens/irritants/infection into skin - skin reacts © 2001 Elliott/Cork/Cork 5

Internal and External Factors Affecting Skin Cold Trauma Nutrition Fluid intake Sun Central Heating Infestation Heredity Factors Skin General Health Pollution Infection Stress Hormone Change Drugs Chemicals/ Allergens/ Irritants Ageing Lifestyle

Emollients play a vital role in the management of skin disease Definition and function Classification When to apply How to apply Which emollient

Emollients providing partial occlusion that hydrates and “ Emollients are oils that spread easily on the skin, providing partial occlusion that hydrates and improves the Stratum Corneum” Rawlings A.V. et al., Dermatologic Therapy, Vol. 17, 2004, 49-56

Emollient……Definition and Function Medical term for moisturiser Safe Simple Effective Steroid sparing Intrinsic anti-inflammatory action

Emollients also help to………… Replace water lost from the skin Lubricate the skin Reduce scaling Seal the Stratum Corneum

Classification of Emollients…. Lotions / Gels Contain more water and less fat than cream Creams Contain a mixture of water and fat Ointments Do not contain water Lotions and gels are very light and more suitable to apply to hairy areas eg scalp or chest of a male Creams contain preservatives which contain potential sensitisers – refer to your emollient chart to identify if a problem occurs with emollient therapy Ointments do not contain any preservatives – preferred treatment for very dry skin A cream could be applied day time and a greasier ointment at night to give optimum therapy 11

Classification cont……………… Bath oils Clean and hydrate - trap water in skin Soap substitutes Not astringent - not alkaline - do not dry out the skin

Emollients…..when to apply As frequently and liberally as possible At least 3 times per day After bathing when the skin is still moist

Emollients….how to apply effectively Bathing Generously but gently Do not rub vigorously - may cause itching or irritation Smooth emollient along arms, legs and body following the natural hair growth

Emollient………the choice Paramount importance Cosmetic acceptability essential Compromise between efficiency and cosmetic acceptability

Which Emollient ? The very best emollient for any individual is……………. the one they prefer

Emollient Base……... Important point to remember……… Use a cream base for moist/wet skin Use an ointment base for dry/cracked skin

Quantities of Emollient For an adult with dry or compromised skin Bath additives 300mls per month Creams or ointments 2000gr per month

Emollient Chart

Emollient Chart

Topical Steroids Used in the treatment of inflammatory skin conditions other than those due to an infection Act as an immuno-suppressant Reduce inflammation Help to alleviate itch Should not be used in ulcerated skin May worsen secondarily infected lesions

Topical Steroids Lotion Gel Cream Ointment Impregnated tape

Which Steroid ? Always use the least potent strength necessary to gain maximum effectiveness

Mild Topical Steroids Use for mild inflammatory skin conditions May be used on the face

Moderate Topical Steroid More suited to prolonged use of topical steroid for inflammatory skin condition

Potent Topical Steroids Acute inflammatory skin condition When titrating from very potent steroid

Very Potent Topical Steroids Severe inflammatory skin conditions Not responding to less potent steroids Short term use – usually under specialist supervision Titrate after 7 days – less potent steroid

Points of Note Steroids may be combined with other agents Antibiotics Antifungal agents Both of the above

Points of note Mild /moderate steroids rarely cause side effects Prolonged use of potent steroids can cause side effects eg. thinning, striae, atrophy, telangiectasia, perioral dermatitis, depigmentation Caution when applying under occlusion as potency is increased Caution when applying to specific sites Always prescribe enough topical treatment for correct application

Use the “fingertip unit” (FTU) How much to apply ? Use the “fingertip unit” (FTU) 1 FTU is distance from tip of an adult index finger to the first crease 1 FTU is approx. 500mgm 1 FTU sufficient to cover an area twice that of the flat adult hand 3-4 FTUs to cover lower leg 7 FTUs to cover whole leg

Useful Web Sites www.dermnetnz.com www.nhsfife.scot.nhs.uk/skinintegrity www.nhsfife.scot.nhs.uk/skincare www.bad.org.uk www.bdng.org www.sdns.co.uk www.eczema.org www.pathways.scot.nhs.uk/dermatology