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The choice, application and review of topical treatments for skin conditions.

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VOL: 101, ISSUE: 04, PAGE NO: 55

Gail Dunning, BA, RN, RM, is clinical nurse specialist and project lead in dermatology, York Hospitals NHS Trust

Dry skin

Dry skin
In normal circumstances the skin is soft and supple due to its water and lipid content. However, when there is an imbalance due to an abnormality or decrease in skin surface lipids (fats) and increased transepidermal water loss, the water content of the horny layer (stratum corneum) of the skin is reduced (Highet, 2002). The skin loses its elasticity and becomes dry, brittle and scaly, which may result in painful cracks (fissures).

This dryness causes the skin to become irritable and sore. Patients frequently complain of an intense itch and an urge to scratch. As a consequence, an itch-scratch cycle develops that is hard to break. This can lead to thickening and inflammation of the skin with a form of eczema called lichenification (Highet, 2002).

Also, because the skin has lost its barrier function, there is an increased risk of infection with harmful micro-organisms. Staphylococcus aureus is the most common form, as it is carried on moist areas of the skin and in the nose.

Causes of dry skin
The four most common are:

- An inherent tendency to dry skin. The most common form is associated with atopic eczema (due to decreased amounts of lipids), but there are also some rare conditions with severe dryness such as ichthyosis (a skin disorder that causes the formation of dry skin);

- Repeated contact with irritants (causing a loss of skin lipids and drying of the epidermis);

- Inflammatory conditions affecting the epidermis such as eczema and psoriasis;

- The ageing process (Highet, 2002).

The use of emollients
Emollients (moisturisers) are the first-line treatment for dry skin and come in the form of ointments, creams, soap substitutes, and bath oils. Each preparation has particular advantages and disadvantages (Box 1). They have few side-effects and some emollients also have antibacterial and antipruritic properties.

Generally emollients soothe, soften and lubricate the skin, which in turn makes it supple, elastic and more comfortable for the patient.

The application of a layer of grease or oil on the skin surface has an immediate softening effect and reduces transepidermal water loss, so increasing hydration of the epidermis. Some substances used in topical treatment, for example, urea and glycerol, help to bind water in the skin, increasing its water-holding capacity and resulting in a moisturising effect.

Also, the evaporation of water from a cream has a cooling effect that may give some transient relief from irritation (Highet, 2002).

Factors affecting choice of emollient
Before choosing an emollient, it is important to consider the actions of each preparation and relate these to the needs of the individual patient. This must be based on the needs of the patient's skin and personal preferences.

The more choice and consultation the patient and carers have, the more likely they are to use their emollients appropriately (Chambers, 2002).

For example, it is important to fit a skin-care regime into the normal demands of family life, school, work and social activities. Consideration also needs to be given to the physical abilities of individuals to apply their emollients. It is essential to consult with the school or workplace on how best to achieve the most effective treatment plan.

In some instances a range of emollient preparations will be available from which patients can choose the one that is most appropriate at a particular time, dependent on their lifestyles.

For example, patients and carers should be made aware that clothes may be stained by emollients, particularly greasy ointments.

For this reason they may be more suited to application at night or when patients can wear old clothes. As a result, some patients decide that ointments are too greasy for daytime use and use a cream during the day and an ointment at night.

For patients with severely dry skin, intensive emollient use including several total-body applications may be required each day. Some patients, especially children, may benefit from the application of 'wet wraps'. These use a damp layer of pre-cut lengths of tubular bandage (or a ready-made garment) and a dry layer. This helps to keep the generously applied emollient in place and also helps to increase hydration.

This method can also be adapted to dry wrapping, that is, the use of pre-cut lengths of cotton tubular bandaging or ready-made garments over emollients without the wet layer. For patients with a moderately dry skin, a daily bath with emollient may be adequate.

But patients should be made aware that the moisturising effect of bath emollients can be negated or reduced by the presence of other materials, for example soap or shampoo, in the water.

It is important not to overburden anyone with an unnecessarily time-consuming regimen, so careful consideration should be given to its effect on patients and their families.

Packaging and quantity of emollients - Packaging of emollients needs to be considered, especially if the emollient is not for single-patient use. The nurse must ensure that infection-control measures are taken. For example, the risk of cross-contamination of tubs of cream can be avoided by using spatulas to decant the emollient.

It may be better to consider the use of tubes rather than tubs, especially when infection is suspected. Some emollients come in pump dispensers, which also reduce the risk of cross-contamination, although they are expensive.

Practical demonstration of how and when to apply emollients is essential. Following this, it is important to observe the patients or carers applying their treatments to check their understanding and compliance (Boxes 2-3). Unless this is done, patients commonly do not either use the right amount of emollient or apply it at the prescribed frequency.

Timing of treatments - The effectiveness of other topical treatments, namely steroids and antimicrobials, can be reduced if applied too soon after an emollient. It is suggested there should be a 30-minute interval between the application of two different preparations (Highet, 2002).

Topical treatments are a form of drug therapy and nurses must take care when prescribing and applying emollients, and reviewing their actions. Patients must be involved in any management decisions and their preferences and circumstances must be considered when developing clinical practice protocols for the management of dry skin.

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