Hello and welcome to this Skin Deep podcast, where we'll be looking at all things skin-related in an interesting and informed way. I'm Dr Roger Henderson; I'm a GP with a long-standing interest in this particular area of health. And I'm Dr George Moncrieff. I was also a GP, though I've now retired from my practice, and I was the past chair of the Dermatology Council for England. Today, Roger and I will be talking about emollients and why choosing the right one for your skin is so important.
Now this is the third of three Skin Deep podcasts about emollients. In previous ones you may have listened to, we've talked about the basic structure of our skin, why we need to keep our skin moisturised, and how to do this correctly and easily. So starting off this podcast, George, many people believe that a skin moisturiser is a moisturiser is a moisturiser, but we both know that's very far from the truth.
So if we can, I'd like to tease apart, here, the different types of emollients available to us and look at when each one might be the most appropriate for each of our listeners. So I suppose I'm thinking of creams, ointments, bath oils, lotions and gels as the main groups. So let's start perhaps with the most commonly used type in my
old-fashioned creams. Uhm. Creams, they're a sort of... well, they're a mixture of water and oil, aren't they? They're all a mixture of water and oil in different proportions, essentially. So an ointment has very little water in it and a very high grease content. Whereas a cream has significantly more moisture or water in it, which makes it easier to spread and more comfortable to put on, and it soaks in more quickly and easily.
Lotions have even more water in them, and then you can get on to gels as well. But the creams have a nice balance of water and grease, which means that they soak into the skin, typically within a few minutes, and they don't leave the skin feeling too tacky or greasy. So they're easier to spread, particularly to put onto wet, moist areas. So if you've got eczema in the flexures, for example, trying to put an ointment in that area can be very tricky. They just slip off.
Whereas the cream will move much more easily onto the skin and spread on much more comfortably. The problem with the higher water content is that bacteria like to live in watery environments. So ointments barely need any preservatives at all, whereas creams, having a higher water content, often need preservatives. And those preservatives can be stingy, but they can also cause reactions. Patients can actually become allergic to the preservatives.
Yes, I've seen that happen a number of times, which is unfortunate. But it's something we should be reminding our patients about. So we can sometimes confuse ointments and creams. So we've said that creams [are] quite easy to spread. From my point of view, [they're] quite useful to have in your bag, for example, if you just want to quickly put something on in the daytime from a practical and cosmetic point of view. It stops your hands getting too greasy if you put them on.
But ointments, they're perhaps more effective at what we call "occluding" the skin (putting a barrier over the skin) than creams, aren't they? Yes, but they're much less cosmetically acceptable. So unless you've got… Yeah. …dramatically dry skin or a really difficult problem, many patients won't want to use an ointment during the day. Trying to hold a steering wheel or operate the phone or shake hands with somebody becomes a pretty difficult experience if you've got ointment in the way.
So I generally try to think of ointments as being a bedtime treatment. And as you say, yep, they stay in place where you put them much more easily. They do make the skin feel quite tacky and sticky, but they have a much better hydrating effect. They prevent water escaping from the skin much more effectively. So as an emollient, they're more effective on the whole. And a lot of creams are trying to get around that by making them as good as an ointment, without being sticky and tacky.
An example of that would be Doublebase™ Once, which is a sort of creamy-type ointment, which is actually twice as hydrating as some ointments. But they stay in place nicely, but aren't so cosmetically acceptable. So if someone listening was thinking, "Well, an ointment at night that can sort of work all through the night and stay on when I'm asleep, and it doesn't interfere with my daily activities. Then, some top-up creams in the day if needed,
nice and quick acting." that's not a bad regime to be thinking of, is it? No, not really. Particularly if it's hand eczema or somewhere where you can get access to quite easily, which is where the rash was or the problem is. But if you have an emollient that has [a] 24-hour effect, then you'll probably find that you only need to use that once a day.
And then if you complemented that by putting an ointment on at bedtime as well, then you really are giving your skin a really good hydration boost by doing both of those. Yeah. Now patients sometimes think about creams and ointments as being the main type of emollients. But we mustn't forget about bath and shower preparations because we both know just how much both soaps and even simply bathing in hot water without using soap can dry the skin out.
So bath oils and shower oils and shower preparations should always be part of someone's armoury if they've got dry skin, shouldn't they? Well, the studies don't support that as much as I would expect them to have done. And as a result, doctors have been given fairly strict instructions that they're not to prescribe bath oils, and I think that's a very unfortunate and retrograde step. Because it's a very effective way of hydrating the skin. There are two sorts of bath oils.
There's those that form a film on the surface of the water. And you can see that it's almost like [an] oil slick on the surface of the water, which when you come out of the water, will connect itself to your skin. And then those that actually mix into the water as an emulsion and are softening the skin whilst you're actually in the water as well. The evidence that they help is lacking.
But if you are in a bath and you're washing with an emollient soap substitute, then that will effectively fill the water and act as a bath oil in that way. So that's doing a lot of good. If you're using a soap substitute emollient in the shower or whatever, then you're getting all the benefit you need. So bath oils being prescribed has sort of slipped out of practice recently. The only exception that I would have to that would be using Balneum® Plus Bath Oil. That contains lauromacrogols.
So if somebody's got a really itchy skin problem, soaking in a tepid to warm bath with some Balneum® Plus can be very soothing. And doing that last thing at night, for example, can help them to get off to sleep and have a good night's rest. That's about the only thing where I will go out of my way to say, "Look, I really do want to prescribe this." There's another one called Oilatum® Plus, which is an antiseptic bath oil. I have mixed feelings about antisepsis.
Yes, if someone's having problems with severe and recurrent skin infections or flares, then eradicating the bacteria on their skin might be a wise thing to do. But these antiseptics are very broad. Oilatum® Plus contains benzalkonium and triclosan. And the triclosan in particular, 2% triclosan, is very damaging to fish life and ecology. So I'm not terribly keen to have that pushed down the drains.
And the benzalkonium is at 6%, and a lot of people tell me that they find that quite stingy at that concentration. So I tended to sort of move a bit away from using Oilatum® Plus Bath Oil. So, no, bath oils have rather slipped out of my practice in recent years. Yeah, yeah; mine too. If we think about lotions, we talked about 24-hour skin cover that sometimes people need to top up in the day.
I do sometimes recommend lotions to people who need to moisturise their skin in the middle of a busy day, but we do have to be a little careful with these don't we? Yes, lotions have a very high water content so they are very easy to spread, but they're much less effective at helping very dry skin conditions. They're significantly less occlusive than creams and ointments.
But yeah, as you say, for mild eczema as a nice, convenient emollient to put on that will rapidly soak in and doesn't leave the hands feeling sticky and tacky. If you want speed of absorption, that's really effective. But they often contain preservatives, not all of them, and that can, of course, cause skin reactions in some patients. Yeah. Yeah. And gels. I sometimes feel sorry for gels. [Laughing] They can be forgotten about. But they can be really effective, in my view.
But for some reason, they seem to sort of get a bit of a poor press and [are] always at the bottom of everybody's list. Yes. When you say the word "gel", I think of some sort of, clear… Yes. …products that you can sort of see through and is quite sticky and tacky. But that's not the case, and a lot of gels have higher emolliency than a cream and without the greasiness of an ointment.
And they form this lovely protective barrier to help retain moisture and rehydrate the skin, often containing humectants. And one of my favourites is actually the AproDerm® Gel. It's a very, very nice white, cream-like gel. It's one of the cheapest in their range and it's superb as a leave-on, and it's very easy to spread. Lovely, comfortable thing. I have used it myself. I really, really like it.
I think, I suppose, one of the take-home points that anyone listening to this podcast is it's obvious from what George and I are saying there's this enormous range now of emollients that are available to anyone who needs them. And it really is horses for courses and a one size does not fit all. So if you are using a particular cream or ointment or gel and you're thinking, "Well, it's okay-ish, but it could be better," don't feel you've got to put up with that.
You know, a very simple, easy change to your skin ointment or cream regime can make a massive difference. So if you are finding that you're getting flares or your dry skin isn't quite as good as you'd want it to be, please don't hesitate to get in touch with your doctor or your healthcare professional who's dealing with your skin. Just saying, "Is there an alternative option here? It's just not quite doing
the job that I think that it should be doing." No one's going to sort of have any concerns about you saying that, and you may find the one that suits you perfectly. Then, if you do find the perfect one for you, you know you're set for a very, very long time. Yeah, I think it's so important that patients are involved in making the choice of which emollient they like, which one they're going to use. And we've been really pushing that message now to the profession for a long time.
So the doctor is quite likely going to be restricted to a formulary that's been imposed on them, and they've been told that these are the emollients that you're allowed to prescribe. And the one that you like may not be on that formulary. But they're not an expensive part of the NHS. In fact, they're probably one of the cheapest things in the NHS, and using an emollient well and effectively can make an enormous difference.
So I really would urge you to go back in that situation and have a sensible discussion with your doctor about what you're using and how you can get hold of it. I do think emollients should be prescribed, I really do, for people with dry skin conditions, and that is very much the view of the NHS. So do insist on having the emollient that you like, the one that you will use, and that's effective, and that can transform your dry skin problem.
I would urge you also to keep an open mind, that maybe the doctor is recommending one because there's good evidence as to why it is a good emollient; at least try it. But if you want to look at a range of emollients, AproDerm® are the first company to have put their emollients into small tubes, which can now be prescribed as an AproDerm® Emollient Starter Pack.
It has the four [emollients] (emollient cream, the colloidal oat cream, the gel and the ointment) in little tubes, which you can take away. And then you can try those out and say, "Yep, this is the one I like." Looking around the country, I'm increasingly seeing that the AproDerm® range is being incorporated into formularies because it's an excellent range. It's cost-effective; the way that they're packaged, the pumps and things are really at the top of the range.
So it really is a sensible option to look at those carefully. Completely agree, and it's really nice to be given an option of trying sort of three, four different ones to find the one that's right for you, and that's a lovely point to end this particular podcast on.
George and I do hope that you've found this series of podcasts on emollients interesting, and you've now got much more confidence to use skin moisturisers correctly and regularly if you need to, as well as being able to ask the question if you feel that it's not quite doing the job that you'd want it to do. So Roger and I hope you'll join us for our next podcast, when we'll be discussing more skin-related issues.
And we'd very much like to thank our sponsor, AproDerm®, for all their help in putting these Skin Deep podcasts together. We couldn't have done it without them. So as always, until the next time, it's goodbye from George. Goodbye. And it's goodbye from me. Goodbye.