Update on emollients - PDF Free Download

Update on emollients Amal Mhanna, MD Pediatric Dermatologist Clemenceau Medical Center Disclosure: I was a member of an advisory board y for J&J and received honoraria.

Emollients and moisturizers are a cornerstone of Atopic Dermatitis therapy and should be always included in the management plans*. They are also needed in other skin disorders like psoriasis, xerosis, ichtyosis, etc. The use of emollients was found to decrease the duration and amount of topical steroids used on the skin of patients with eczema. * Guidelines of care for the management of atopic dermatitis, Journal of the American Academy of Dermatology, July 2014

Q&A The prolonged use of topical steroids may result in: a- thinning of the skin and appearance of stretch marks b- increased hair on the face c- all the above

Atopic dermatitis is a pruritic disease of unknown etiology that usually starts during infancy. The hallmarks of the disease are dryness and eczema. The eczematous changes are seen on the face and extremities usually and sometimes the whole body.

Q&A Atopic dermatitis is due to a- genetic factors b- environmental factors c- both a and b

The disease, due to a combination of genetic and environmental factors, is characterized by an abnormal barrier function at the level of epidermis (leading to increased transepidermal water loss and inflammation of the skin).

Atopic Dermatitis Mainstay of treatment include emollients (to reduce dryness and itching), topical steroid cream and topical calcineurin inhibittors (to reduce inflammation). Emollients alleviate dryness, decrease itching and may reduce high-potency topical corticosteroid use in children with moderate-to-severe to AD

The ideal emollient for a patient with eczema should be safe, effective, inexpensive, and free of additives, fragrances, perfumes, and other potentially ti sensitizing i agents. However..

2 key ingredients have proven their efficacy when incorporated in the new emollients: ceramides and oatmeal.

Outline: An overview of the structure and function of ceramides, the composition and function of colloidal oatmeal, and their role in the skin and clinical i l use in emollients.

Ceramides structure and function: The stratum corneum is made up of the keratinocytes t surrounded d by intercellular l lipids. Ceramides are the predominant lipids. Others include cholesterol l and free fatty acids. These lipids are essential for maintaining the skin barrier function and preventing TEWL.

Ceramides structure and function: The basic ceramide is composed of a sphingosine conjugated to a fatty acid via an amide bond.

Ceramides structure and function: There is over 340 ceramide species only in the forearm s.c. Ceramides differ in different areas and species depending on the size of the sphingoid base or the esterification of the fatty acid.

Ceramides structure and function: Ceramides are produced de novo in the skin beginning in the stratum basale and packaged into vesicles that move upward as the keratinocytes differentiate until they organize along with cholesterol and f.f.a into lamellar layers in the intercellular space of corneocytes in s.corneum.

Ceramides in skin diseases: Skin ceramides were markedly reduced in atopic dermatitis patients as compared to people without atopic dermatitis. Also there is a difference in composition of ceramides in lesional vs non-lesional skin (Larger ceramides were reduced whereas smaller ceramides were increased.)

Ceramides in skin diseases: In psoriasis, abnormal composition and not abnormal amount of ceramides was found (e.g long-chain Ceramides with ester-linked F.A were reduced) This also affects the proper skin barrier function and increase TEWL.

Clinical use of ceramides in emollients: Ceramides are now added to newer emollients to exogenously replenish the skin ceramides, with many clinical studies demonstrating the effectiveness in improving skin hydration and barrier function* * Wiren et al. Treatment with a barrier-strengthening moisturizing cream delays relapse of atopic dermatits: a prospective and randomized controlled clinical trial. J Eur Acad Dermatol Venereol 2009;23:1267-72

Colloidal oatmeal composition and function Oatmeal has been used for centuries in various inflammatory diseases and dry skin conditions, like contact and atopic dermatitis, as a skin barrier and protectant and to relieve itching and irritation (various forms).

Colloidal oatmeal composition and function Available formulations have demonstrated efficacy and safety but scientific studies have only recently started to reveal the mechanisms by which oatmeal acts on the skin, namely its anti-inflammatory, hydrating and anti-pruritic properties.

Colloidal oatmeal composition and function Colloidal Oatmeal is a natural product derived from oat grains that have been ground into a very fine powder. The composition of oatmeal is predominantly starch (65-85%), proteins (15-20%), lipids (3-11%) and about 5% each of fiber and beta glucans. The active phytochemical involved in skin diseases was recently identified to be Avenanthramide*. *Sur et al. Avenanthramides, polyphenols fro oats, exhibit anti-inflammtory and anti-itch activity. Arch Dermatol Res. 2008;300(10):569-74

Colloidal oatmeal composition and function Avenanthramides are low molecular weight phenolic compounds found at about 0.03% 03% in oats with potent antioxidative effects as well as anti-inflammatory inflammatory and anti-itching itching effects

Colloidal oatmeal composition and function Avenenathramides inhibit inflammation via inhibition of Nuclear Factor-kappa B activation, and reduced production of pro-inflammatory cytokines, namely IL-8 (usually secreted by keratinocytes in inflamed skin). Avenanthramides also significantly inhibit neurogenic inflammatory responses when topically applied, thus their anti-itch effect. (? antihistaminic effect).

Colloidal oatmeal composition and function Other effects of colloidal oatmeal include the formation of a protective moisturizing barrier over the skin by the proteins and polysaccharides, thus reducing TEWL.

Oatmeal clinical use in emollients Oatmeal has been added to emollients for many years: Emollients containing colloidal oatmeal alleviates dryness, decrease itching and may reduce high-potency topical corticosteroid use in children with moderate-to-severe AD as shown in a randomized-controlled study published in 2007*. *Grimalt et al. The steroid-sparing effect of an emollient therapy in infants with atopic dermatitis: a randomizedcontrolled study. Dermatology 2007;214:61-67

Future prospects In the future it may be possible to specifically formulate emollients or skin products with different ceramides for different diseases or conditions. Trials are underway to test if skin barrier protection via the use of emollients from birth may reduce the likelihood of developing eczema in genetically predisposed infants.

Conclusion Emollients are a cornerstone in the treatment and maintenance regimens of atopic dermatitis and other skin disorders Ceramides and oatmeal have proven their efficacy and safety when incorporated in the new emollients.

In Atopic dermatitis, the abnormal barrier function is at the level of: a- Epidermis b- Dermis This results in a- increased Transepidermal water loss b- decreased Transepidermal water loss

The basic ceramide is composed of a sphingosine conjugated to: a- a fatty acid via an amide bond. b- an amino acid via an amide bond c- a fatty acid via a hydroxyl bond d- an amino acid via a hydroxyl bond

The composition of oatmeal is predominantly a- Proteins b- Starch c- Lipidsid