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. Today, we're going to look at some emollient essentials, including how to apply them.
But to start, George, obviously there are certain big no-nos as well. We've talked about all the, plusses and the pros about using emollients and ointments, but one of the ones that is still out there and are heavily used – and I think it's perhaps the mission of both of us to try and get out of people's thinking – is aqueous cream. Why, really, should we be kicking aqueous cream, not only into the long grass but into a different field. Oh, aqueous cream is awful.
It was designed in the early '50s as a soap substitute. The real problem with aqueous cream is it contains sodium lauryl sulfate [SLS], which renders the fat in it water-miscible. It means you can mix it with water, so you can wash with it. But we know that sodium lauryl sulfate [SLS] at the concentration in aqueous cream, which is 1%, is damaging to normal skin. Over half of children who have eczema [and] who use it find it stings and actually makes their eczema worse.
And who would want to put a cream on the skin that damages normal skin and makes eczema worse? If I see a tub of aqueous cream, you know what I do? I put some heavy-duty garden gloves on and I get a pair of tongs or something, which means I can pick it up from a distance. I carefully pick it up and deposit it in the dustbin as carefully as I can. I do not want it to get on my skin, and furthermore, it's cream in a tub. That's unforgivable.
So people are putting their fingers into it and are contaminating it. Did you know that, actually, aqueous cream can be made from emulsifying ointment? If you mix one part emulsifying ointment to two parts of water, you make aqueous cream. So emulsifying ointment has 3% sodium lauryl sulfate. So if I see emulsifying ointment, I don't just put my heavy-duty garden gloves on; I also put a rubber apron on and a mask. [Laughing] I'm very careful with that stuff.
It mustn't go near your body, let alone your skin. [Laughing] So, no, emulsifying ointment and aqueous cream, I think, should not be anywhere near the human body. Right, I think our Speakers' Corner message we're shouting today, that's probably top of both our lists, that one. So if anyone's taking away something from this podcast, it would... ... don't put it anywhere near your skin. Even as a soap substitute, no. Absolutely.
Now, as doctors, we often use emollients, um, obviously, on our patients every day, but also we often have to put on other topical treatments. I mean, for example, corticosteroids would be a good example of this as well as other preparations. What are the sort of general guidelines that you say to your patients about how to apply an emollient in conjunction with other topical treatments? Can it be sort of a bit hit-and-miss or do what you like.
Or is there sort of a format you should probably be thinking about using? I think it's really very simple actually. They just shouldn't both go on at the same time. You need an interval – and an interval [of] a minimum of half an hour – in between. It doesn't really matter which one goes on first and which one goes on second, to be honest. But if I do prescribe a steroid, for example, I virtually always prescribe it only as an ointment.
Ointments have a very low water content, and so therefore don't need preservatives. Ointments tend to stay in place, and I want the steroid to be where I want the steroid to work. Ointments also are better at hydrating the skin and preventing water escaping. But also, steroid ointments only ever need to be applied once a day. Simple as that. So you get very little additional advantage by using a steroid ointment more than once a day, and you get increased problems or side effects.
So I only ever prescribe steroids as ointments and once a day – virtually only ever, but it's not completely true. So that can go on at bedtime, last thing at night. And if you're washing in the morning, you can wash with a soap substitute, come out of the shower, dab your skin dry, and then immediately apply a sophisticated 24-hour emollient to go on your body then, all over. Do you have to leave a gap, um, between putting your emollient on and something like a topical steroid?
Or can you put them on one after the other? Yes. Absolutely. So, if you need to do [the] two close together, then I think all I say is have half an hour between. Personally, I think put the emollient on first, so you're covering everywhere, and then half an hour later, you put the steroid on where you want it. The disadvantage of doing it the other way around is you might be spreading some residual ointment onto skin that didn't need treating, when you start putting the emollient on.
So I generally say if you do need to put two things on together, have half an hour in between. Put the emollient cream on first, covering everywhere, give it half an hour and then put the steroid on where you want it, and then head off to bed. That's grand. And touching on that then – and that we have sort of mentioned this earlier the application of emollients, it's not just a case of sort of slip, slap, slopping it on, is it?
You know, there is way we should be putting emollients and moisturisers onto the skin. Yes, absolutely. So if it's from a pump dispenser, you just put little blobs along a limb, um, all along the limb. If it's from a tub of ointment, you use a spoon or whatever to take it out and put it into your hand. Then you got to mix it into your hand to create a sort of a bit of a smudge of it. And then you just stroke it down the limbs in the direction of the hairs.
You don't want to rub it in, because that'll just cause a folliculitis. And you don't want to warm the skin up; that'll make the skin more itchy. And you need to put enough on to leave a film of emollient on the skin after you've finished. So I say to patients, "If you've done enough, you should be able to just write your name in the emollient," or, "Write a little smiley face," for a little child. So they can see that that's the quantity they should be using.
And you should aim to be getting through, in a child, probably half a tub – 250 grams a week. And an adult, you could double that. That's the sort of quantities we need to be prescribing and patients need to be using. And then, of course, take care to avoid getting close to naked flames. Of course.
And I suppose one of the things that we haven't sort of mentioned – which is one of the driving factors about, um, putting emollients on on a regular basis – is not only is that going to improve, you know, your quality of life, your skin is going to get better. Not only are you going to be psychologically better because of it but you're going to be going to the doctor less, you're going to be having less flares – fewer flares – of your skin condition.
So it's a bit of a win-win situation all around. The pay off is way down the line and not just for that day. Absolutely. I couldn't agree with you more. I've seen patients who've got pretty severe eczema or psoriasis, for example, who are contemplating starting really powerful drugs by mouth or even perhaps going on to biologicals. And I've sat down and talked to them and discovered that they're washing with detergents. They're washing their hair with shampoos; it's rinsing over their skin.
They're barely using their emollients, and they're barely using any other treatments adequately. And just going through those basics with them, correcting all that – stopping the detergents, using a soap substitute, using a quality leave-on emollient, and then using the treatments they've been prescribed appropriately and properly. I've had patients who come back a few weeks later saying, "I don't even want
to think about any further treatments." And their condition sometimes, as you say, melts away, and you've set them up for a lifetime of now managing their skin without doctors. It's wonderful. It's the best thing we can do. Absolutely. A lifetime without doctors is to be recommended. I hope everyone listening has found this little chat interesting. And also, more importantly, you've got more confidence to use skin moisturisers correctly and regularly if, in fact, you need to.
So until next time, it's goodbye from me. And it's goodbye from me. Goodbye.