Emollients (Part 1) - A quick guide to emollients

Hello and welcome to this Skin Deep podcast, where we'll be looking at skin-related issues and treatments in, what I hope is, an interesting and informative way. I'm Dr Roger Henderson, and I'm a GP with a long-standing interest in this area of health. And I'm Dr George Moncrieff. I was also a GP, though I retired from my practice a few years ago. I'm also the past chair of the Dermatology Council for England.

In this one, we'll be looking at the use of moisturisers in dry skin and giving practical advice as to how and when these should be used. Now, I'm going to start with a simple question here, George, um, although you might think it's not a simple question. What exactly is a skin moisturiser? Well, actually, as you say, it's not simple at all. We use the words "moisturiser" and "emollient" almost interchangeably. But, accurately, a moisturiser contains an occlusive agent.

Basically, something that repels water. So it stops water from leaving the skin. So it's what's called a "hydrophobic layer". And that's things like petrolatum or waxes or different sorts of fats. So it's a fatty material. And then it concludes the emollient. And the emollient is essentially an astringent. An example would be isopropyl myristate. If you look at the ingredients on a moisturiser, you'll see it often has isopropyl myristate, and this soothes and smooths.

It softens the skin and generally renders the product less tacky, less sticky, less greasy. Makes it more cosmetically acceptable. All moisturisers are buffered to maintain that mildly acidic acid mantle on the surface of the skin. So critical for our skin health. So, unlike detergents, which are alkaline, emollients and moisturisers are mildly acidic.

And then, finally, many of these products contain additional agents, which we could go through if you like, but often contain natural moisturising factors, like those small molecules I talked about last time that draw water into the skin. So they penetrate the skin cells, and then draw moisture to themselves. So things like urea and amino acids and glycerol are often used. Lactic acid sometimes. The list is quite large, though.

So I suppose, in a nutshell, the aim of moisturising emollients is to hydrate the skin cells. Keep those nice and plumped and hydrated, and prevent or reduce that hydration disappearing out of the skin. Otherwise, just try and keep it at the pH level that it should be, keep it as hydrated as it can be and to stop the skin drying as quickly as it other... as it otherwise might. I mean, it's a little bit simplistic, but it's pretty much my view. That's where we are. Would you agree? Absolutely.

In a nutshell, that's exactly what they're about. But they're also a very convenient vehicle for bringing other ingredients onto the skin. Helpful, useful ingredients, which we can talk about shortly. So, having said all that, Roger, what are your basic views on emollients in your practice? Well, unfortunately, I'm going back so many years now to when I was a medical student, and I suspect it's the same with you George. My sort of medical skin training was "If it's dry, wet it.

If it's wet, dry it." Fortunately, we've both moved on a bit from that. But the bottom line, I suppose, of what I've learned over all these years is that you can have the best emollients in the world, but it's only going to be effective if it's used appropriately. And I found that it's absolutely the case that patient preference is the key here in encouraging adherence.

There is no point in sort of trying to hit a patient over the head with a tub of emollient if they don't understand why you want them to use it. And in general, I've found that emollient creams are more cosmetically acceptable to people very often, and they penetrate the skin nice and easily. And although heavy emollient ointments also can work really well, a lot of people consider them too greasy for their everyday use.

Although many patients of mine, I suppose, are prepared to use them at bedtime. I also have found over the years that simple emollients should always be used as soap substitutes. Then the more sophisticated emollients - and I think we might touch on what that actually means - being the choice for leave-on treatments here. Yeah, I absolutely agree with you there. The soap substitutes are going down the drain.

So, really, what we want there is something that's going to regrease the skin rather than degrease it, and something that's going to maintain the surface pH. And so that can be a very, very cheap emollient. It doesn't matter which one you use. I would go for something as cheap and cheerful as you can get, but just using an emollient to wash with rather than soaps or detergents.

And on that point, it's really important to remind patients that it will render the shower tray or the bath dangerously slippery, so they may need to use a bath mat inside the bath or something inside the shower to stop them falling. The other thing, in fact, just to warn patients is that they will actually clog up the drains. So they may need to pour some boiling water down the drain every week, just to stop that grease from clogging things up. So just a simple, practical tip there.

Yeah, that's something people forget is the mini fatberg, uh, from [laughter] from using... It's interesting about the safety aspects, which you've got to think of. Not only just the slipping over, but from my point of view, I always have to try and remind myself about the use of the heavy, paraffin-based emollients.

Products such as white, soft paraffin; or white, soft paraffin and the 50% liquid paraffin or emulsifying ointments that have contact with dressings or clothing, [these can be considered] as potential fire risks. And there are some slightly chilling stats, I think, about this, if I remember rightly. Well, absolutely. Yep. All emollients are fatty based, and fat is flammable and, certainly, paraffin is flammable. Almost every single emollient contains paraffin.

In fact, the only one that doesn't is AproDerm® Colloidal Oat Cream. But paraffin is particularly flammable, but all emollients are flammable. And I believe the Medicines [and] Health[care Products] Regulatory Authority, (the MHRA) have over 50 cases of people who have died, because they've caught fire. They've put an emollient on, and they've gone near to a naked flame. So we have a medical legal responsibility as doctors to warn our patients about this.

Do not put an emollient on and then go close to a naked flame, a fire or whatever. Even smoking could cause things to catch fire. A frightening figure is that, even if you put an emollient on and then go to bed with your pyjamas [on], and you [then] wash those pyjamas, even after they've been washed and dried, they're still massively more flammable than pyjamas that have never been exposed to that emollient at all. So even washing pyjamas does not render them less flammable.

So very worrying facts there. I think a lot of jaws will have hit the ground with that, because as we've said, you know, it is not generally recognised. It's particularly a risk, in fact, with the ointments. The ointments have a very high concentration of paraffin and a very low concentration of water. So the tubs of ointments are the ones that most worry me. The creams have a higher water content, and so, naturally, are going to be less flammable, but they are still flammable.

Well, I think this is a perfect time to take the opportunity to say a few words about our kind sponsor, AproDerm®, and their range of emollients and barrier creams. Now, as we know, everyone's skin is unique. In my many years as a GP, it's often been tricky to find an emollient that immediately suited one person and their one condition. And we know it's not as simple as one condition, one type of emollient.

It's often the case of patients trying an emollient, and then going back and forth with several prescriptions, several visits to the practice, which is far from ideal. But, fortunately, AproDerm® have developed a genius solution to simplify the whole process of selecting the right emollient for you. Their AproDerm® Emollient Starter Pack contains all four of their emollients in one pack, each having a unique consistency and level of hydration.

With just one prescription, you have the opportunity to try each one and find the one that works best for your skin. This allows you to choose the one or more that you prefer and that suits your lifestyle, whilst saving money, time, and more importantly, [making] fewer visits to the GP, pharmacist or nurse. Sounds like the perfect answer to me, as a GP. And if you can't make it to your healthcare professional, it's available to buy from your local pharmacy and Amazon.

I've been a big advocate of the AproDerm® range for a while now. It's such a great range of products. All are suitable from birth and free from common irritants and sensitisers. Yeah, and I have to say I love them even more now and, actually, use them myself.

So if you're affected by a dry skin condition and want to know which emollients will be the best for you, then do try the AproDerm® Emollient Starter Pack, which, incidentally, also comes with a handy self-care guide full of tips on helping you manage your condition, including useful advice on applying emollients, and potential triggers. It really is a game changer for the world of dermatology.

And, as George said earlier, it's available on prescription or to buy from your local pharmacy or Amazon. Now, I think I touched on simple and sophisticated emollients earlier on, George. So when we talk about "What is a simple emollient or a more sophisticated emollient?" - what are we actually meaning? Well, what I think of there is what those additional ingredients are that they've added to it to make it more sophisticated.

So sophisticated emollients usually contain high concentrations of what are called "humectants". These [are] small molecules that draw moisture to the cell, so they're mimicking natural moisturising factors. So things like urea, glycerol, lactic acids, and so on. Others contain ceramides. I mentioned in the first podcast these fatty materials that form a layer between these epidermocytes in that lipid lamellar bi-envelope.

That oily layer between the cells in the stratum corneum, the top layer of the epidermis. So ceramides are sometimes added, and our body naturally makes ceramides, but some emollients contain these and are trying to sort of support that oily layer. Some contain nicotinamide. Nicotinamide is vitamin B3, and, um, this is a very natural product. But we know it has fabulous anti-inflammatory properties, particularly in the skin. [It's] Antimitotic; i.e. stops cancer.

So we use it orally sometimes to help patients who are getting recurrent skin cancers. And it also supports and increases the natural production of the skin barrier, through promoting the production of these ceramides naturally in the skin. So nicotinamide is a particularly clever agent to add to an emollient to make it sophisticated. Some contain soothing agents that are anti-itch, almost anaesthetic, [coughs] things like lauromacrogols.

Some contain menthol, which is cooling, and that can also help to soothe [the] itch. Others contain antiseptics, so if someone's getting recurrent skin infections, they could use an emollient with an antiseptic to help to clear the abnormal bacteria. And others contain probiotics, which help to maintain and build up the normal, healthy microbiome on the skin. Then, finally, we've got some that include really sophisticated delivery mechanisms so that the emollient is released in a slow way.

So the emollient, you put it on once a day, and it lasts for 24 hours. So, for example, L'Oreal make one called CeraVe, which isn't available on NHS prescription, but it has a beautiful 24-hour effect because it's gradually releasing the emollient into the skin through this microvesicular technology. Generally, the sophisticated ones have a longer duration. So, you could actually... some of them you can put on just literally once a day, which is fabulously convenient.

If you've got somebody, for example, in a nursing home, they might be undressed once a day, they might have had... be washed once a day and have their clothes off once a day. Very easy to apply an emollient once a day.

If you've got somebody having to go into the home as a carer to look after somebody, if they only need an emollient, and it'll give [a] 24-hour emollient effect by putting it on once a day, it's worth using a sophisticated one that might be slightly more expensive, that achieves that. Whereas if you used a cheaper one that is more for [use as a] soap substitute, it would only give [an] emollient effect for a couple of hours and be nothing like as useful.

So, generally speaking, the sophisticated ones are more expensive, so I wouldn't want to use those as soap substitutes. But they're very much more convenient for patients as the leave-on and continue to moisturise the skin for... we can demonstrate that for at least 24 hours. But I think that might be an excellent area for us to talk about in a little bit more detail another time. It's a huge area. And interestingly, I was watching TV last night.

There was an advert for a moisturising cream or ointment, and heavily sort of mentioning ceramides and the vitamins and the long words. I'm not sure exactly how people are au fait with them, but it was a big selling point - the whole scientific, sophisticated moisturiser. Trying to sort of hook people and get them in. So it's obviously a growth area, um, in the world of creams and ointments.

In fact, one other ingredient I haven't mentioned - and perhaps one of the most important - is colloidal oat. Colloidal oat has been used now since biblical times on the skin and has wonderful soothing properties and anti-itch properties and anti-inflammatory properties. So there are a few emollients that contain colloidal oat, and that also extends its emollient effect quite significantly. So renders them very sophisticated, and that's one of the emollients I like the