Clinical Focus: pediatrics
Moisturizers for Skin
Diseases: New Insights
By Lidia Schettle, PA-C and Peter A. Lio, MD
O
ne of the most critical functions of the skin is
to provide a barrier from the outside world: to
keep water in and keep allergens, irritants, and Moisturizers continue to be an
infectious agents out. When the skin barrier is important adjunct therapy for a
not performing optimally—due to a genetic disease, the
presence of inflammation, or physical disruptors such as
variety of dermatologic conditions.
scratching—the vicious cycle of eczema may ensue. When As we learn more about skin barrier
this occurs, moisturizers can act in a number of ways to function and mechanisms leading to
stand in for the normal skin barrier function, ideally while
also helping to restore the skin to its natural state.
barrier dysfunction, new technolo-
Moisturizers are thus used in the treatment of numerous gies lead the way in our search for
skin conditions, such as eczema, psoriasis, and irritant der- the perfect moisturizer.
matitis, protecting and rehydrating the skin where needed.
Commercially available preparations cover the range of
excipients: from water-dominant lotions to greasy oint- lead to inflammatory reactions.3 However, even in patients
ments, and many intermediate preparations. Consumers with normal filaggrin genes, the presence of inflammation
spend billions of dollars each year1 on these products in the skin (specifically IL-4 and IL-13) causes significantly
in hopes of a simple solution for dry and irritated skin. reduced filaggrin gene expression, resulting in functional
Despite all the popularity and a dizzying array of options, filaggrin deficiency.4 In other words, irritated skin from
no accepted treatment guidelines exist for the use of mois- many causes can make for an impaired skin barrier, making
turizers in dermatology, forcing consumers and clinicians moisturizers just as important in restoring epidermal bar-
to rely on advertising, a patchwork of research, and per- rier function in these patients.
sonal experience to make sense of all the formulations. Psoriasis, though thought to consist of a predominantly
Th1-type of inflammatory response (versus the Th2-
Moisturizers and type seen in atopic dermatitis5), has long been known to
dermatologic conditions respond favorably to moisturizer use.6 The role of moistur-
Eczema (atopic dermatitis) is perhaps the “poster child” izers in psoriasis treatment seems to be to help normalize
for moisturizers and there is reasonably good evidence skin growth and differentiation as well as elicit anti-inflam-
that using moisturizers more frequently directly relates to matory effects, which may be similar to those in eczema.7
improvement in eczema severity.2 The structural protein
filaggrin helps maintain the integrity of the epidermal bar- Moisturizer classification
rier, an important line of defense. Loss of function muta- Moisturizers can be subdivided into several components
tions that prevent expression of filaggrin play an impor- based on their ingredients and mechanisms of action. The
tant role in the development of both atopic disease and main functions of moisturizers are reducing transepidermal
ichthyosis vulgaris.3 Indeed, filaggrin deficiency leads to a water loss (TEWL), attracting water to the stratum corneum,
defective skin barrier that allows increased water loss and and repairing the overall barrier function. Some of the
increased allergen exposure through the skin, which may important components include:
may 2013 PRACTICAL DERMATOLOGY 45
Clinical Focus: pediatrics
Occlusives, which physically block TEWL in the stratum tive acid mantle of the skin. They may also prevent and treat
corneum and enhance the penetration of ingredients. Most skin conditions that disrupt the skin barrier and its antimi-
effective occlusives are (in order of effectiveness): petrola- crobial functions.13 Ideally, those moisturizers with a pH near
tum, lanolin, mineral oil, and silicones.8 They are generally the ideal range (or perhaps even a bit more acidic) would
very greasy, which can lead to poor adherence in some be selected. However, there is more research to be done on
patients. When overused, they may cause folliculitis.8 this topic, as it is likely more complex than the measured pH
Emollients are oil-in-water or water-in-oil prepara- alone.
tions and include fatty acids, cholesterol, and ceramides.
Emollients play a role in the water retention capability of the Novel moisturizer technologies
stratum corneum and function to make the skin smooth Some of the newest formulations contain ceramides or waxy
and supple.9 lipid molecules composed of sphingosine and fatty acids.
Humectants are hygroscopic (water-attracting) substanc- Ceramides restore skin water permeability barrier function, and
es that actively pull water and hydrate the stratum corne- there are recent studies to suggest that decreased ceramide
um. Examples of humectants include glycerin, alpha hydroxy levels are a major etiologic factor in skin disease.14 The stratum
acids, and other sugars. Their function is to restore the skin’s corneum contains an exceptionally high concentration of
ability to attract, hold, and redistribute water.10 ceramides (as much as 50 percent of total lipids) with nearly
Moisturizers are made in a variety of formulations, which equimolar ratios of cholesterol and essential/nonessential fatty
continue to become more complex with new technologi- acids. This ratio is believed to be responsible for the normal
cal advancements. Popular water-based products include functioning of the epidermal barrier. Furthermore, changing
gels, lotions, suspensions, and aqueous creams. Water-based the ratio to 3:1:1:1 with cholesterol being the dominant mol-
preparations are generally more cosmetically elegant and ecule has shown to accelerate epidermal barrier recovery.15
preferred by consumers, as they do not leave a sticky resi- Prescription barrier creams are commonly formulated with
due. However, they may lack some occlusive properties as ceramides coupled with cutting-edge delivery technologies to
compared to the ointment-based vehicles, and can actually provide a controlled release of ingredients over time. Some of
end up adding very little water to the skin in some cases.11 these delivery mechanisms utilize biologically inert microscopic
Certain water-based formulations (particularly lotions and polymer particles (microspheres) that absorb, trap, or bind to
gels) can cause stinging and burning sensations, especially specific ingredients. Some prescription barrier creams have been
when applied to cracked or fissured skin.10 shown in some cases to be nearly as effective as topical cortico-
Ointment-based preparations are predominantly greases steroids in the prevention and treatment of atopic dermatitis.16
or oils, with little or no water. These tend to have excellent However, over-the-counter moisturizers, including some simple
occlusive properties and generally do not sting or burn. petroleum-based products, appear to have similar efficacy pro-
However, they may not be able to add hygroscopic mol- files at much lower cost.17
ecules to the skin or barrier components and may be per-
ceived as unpleasantly greasy.9 Natural Oils
Emulsions span a wide range of formulations, from water- Natural oils are used extensively throughout the world as
based lotions and gels to greasy ointments. These can be moisturizers and to treat and prevent dermatologic condi-
predominantly oil-based with some water (water-in-oil) or a tions, such as atopic dermatitis, acne, and rosacea. In spite of
predominant water base with some oil (oil-in-water). Many of their growing popularity, there is surprisingly limited data on
the most commonly recommended products fall into this cat- their efficacy and safety profile. It has recently been suggested
egory, and there is potential to have all of the important com- that the skin hydrating and protecting properties of natural
ponents of moisturization represented in a good emulsion. oils are largely dependent upon a particular phytochemical
There have been several attempts to better quantify the composition of the compound. More specifically, it seems
consistency or “feel” of moisturizers, with a recent study that the ratio of oleic acid (OA) to linoleic acid (LA) in natural
describing a measurement called the “hydrophilic index.”12 oils determines their effect on the skin. Positive effects are
This index is based on a physical assay that measures the generally associated with low OA and high LA ratios.18 High
amount of water retained by a sample of moisturizer or LA concentrations have been shown to accelerate skin bar-
excipient, in order to approximate the “greasiness” of a par- rier development and repair, hydrate the skin, and, as a result,
ticular formulation. reduce the severity of atopic dermatitis and be steroid spar-
Beyond these, moisturizers can be categorized based on ing.18 Some natural oils with the highest LA/OA ratios are
their pH. Topical products that fall within the physiological safflower oil, sunflower seed oil, and sea buckthorn seed oil.
skin pH range of 4 to 6 may stabilize or improve the protec- In contrast, olive oil, with its relatively low LA/OA ratio, can
46 PRACTICAL DERMATOLOGY may 2013
Clinical Focus: pediatrics
The Hydrophilic Index for Moisturizers
Moisturizers, particularly modern ones, are highly complex and can affect the skin in multiple ways. However, they all strive to
do similar things: keep water in the skin, keep allergens and irritants out of the skin, make the skin feel soft, and, when appropri-
ate, help carry medicines or other treatments that can strengthen or treat the skin. In general, greasy ointments do the best job
of occluding the skin: locking water in and keeping irritants and allergens out. These also tend to be ones that do not sting or
burn when applied, even to open skin, and they tend to need fewer or no preservatives, all of which are favorable attributes.
However, they are greasy and cosmetically inelegant, which means that some patients will not use them, or they will use them less
frequently than recommended. Increasing water in a greasy preparation creates emulsions, which can be creams or lotions. These
are less occlusive, may feel cooling when applied, and absorb more readily into the skin, increasing compliance for many patients.
However, these can sting or irritate inflamed or open skin and often require preservatives, which can be allergens and may be
undesirable to some patients.
I recently co-authored a study that examined some physicochemical properties of various moisturizers, including heavier and
greasier agents, such as Aquaphor Ointment (Beiersdorf), as well as Eucerin Original Dry Skin Cream and Lotion (Beiersdorf). We
also examined lighter agents such as Dove Day Lotion SPF 15 (Unilever), CeraVe Moiturizing Cream (Valeant Pharmaceuticals),
and Neosalus Cream (Quinnova), as well as agents that fall somewhere in between, such as Cetaphil Restoraderm (Galderma) and
Aveeno Advanced Care Moisturizing Cream (Johnson & Johnson).1 Our goal was to determine how much water each moistur-
izer “hung on to,” so to speak, and this way we could layer out the oil from the water layer to measure it. The index we created
(hydrophilic index) can help guide patients to how “greasy” a preparation might feel, and perhaps to lead them to something
more suitable given what has worked for them in the past. In general, however, there is no perfect moisturizer; just a range that
may be helpful for certain patients, and even that can change depending on their skin at the time and the season.
We found that the greasier ointments were generally more hydrophobic, as one might expect. These tend to be great at “lock-
ing the skin down” and keeping water in, but often feel heavy and greasy. Those that held on to more water tended to be more
hydrophilic, which could mean that they are less occlusive but perhaps are able to bring some water and lipids deeper into the
skin, rather than just sit on top. Clinically, I find that a combination of both types often is the best recipe: a lighter cream during
the day when the skin is dry to bring water and fats into the skin, and a heavy, occlusive ointment at night after a bath to lock the
water in.
—Peter Lio, MD
1. Shi VY, Tran K, Lio PA. A comparison of physicochemical properties of a selection of modern moisturizers: hydrophilic index and pH. J Drugs Dermatol. 2012;11(5):633-6.
significantly damage the skin barrier and induce erythema by properties of parabens, depending on the compound, are
disrupting the lipid structure of stratum corneum and inhibit- up to one million times less than estradiol, and they also
ing homeostasis.18 Further research is necessary on the safety possess aromatase-inhibiting properties, thereby reducing
and efficacy of natural oils for the prevention and treatment the conversion of testosterone to estrogen. Parabens are
of dermatologic conditions. not officially identified or listed as an endocrine disrupt-
ing chemical by any governmental or regulatory agency,
Preservatives but public pressure has influenced some countries to
Preservatives are commonly added to moisturizers to introduce regulations on the use of parabens in consumer
inhibit the growth of bacteria, yeast, fungi, or algae. They products. Furthermore, parabens are added to cosmet-
stabilize the products and give them a cosmetically elegant ics in very small amounts that do not exceed 1% of total
feel, as well as extend the shelf life. Some of the most com- weight, making the possibility of systemic absorption
mon preservatives in cosmetics include parabens, form- miniscule.21 Additionally, the study author herself (Dr.
aldehydes, and benzyl alcohol. Recent controversy with Darbre) stated in reply to concerns raised about the paper:
the use of parabens stems from a 2004 study that found “Nowhere in the manuscript was any claim made that the
increased levels of parabens in the tissue of patients with presence of parabens had caused the breast cancer, indeed
breast cancer.19 Even though parabens have estrogenic the measurement of a compound in a tissue cannot pro-
properties, it should also be noted that the European vide evidence of causality.” Despite these points, there has
Cosmetic Toiletry and Perfumery Association (COLIPA) been a growing consumer push to avoid parabens in all
found that parabens are hydrolyzed in the skin and that forms, and a compensatory upswing in products touting
they do not enter the bloodstream.20 The estrogenic “parabens free” from many manufacturers.
48 PRACTICAL DERMATOLOGY may 2013
Conclusion
Moisturizers continue to be an important adjunct therapy
for a variety of dermatologic conditions, especially atopic
dermatitis. As we learn more about skin barrier function and
mechanisms leading to barrier dysfunction, new technolo-
gies lead the way in our search for the perfect moisturizer.
With such a vast array of options, it can be challenging for
an average consumer to choose the best option for their
skin type, condition, and budget. This underscores the
importance for dermatologists to keep abreast of new com-
mercially available as well as prescription products, their
efficacy, safety profile, and cost-effectiveness. n
Lidia Shettle, PA-C is a board-certified Physician
Assistant at Dermatology and Aesthetics of Wicker
Park in Chicago. She is a member of the American
Academy of Physician Assistants and the Society of
Dermatology Physician Assistants.
Peter A. Lio, MD is a Clinical Assistant Professor
in the Department of Dermatology & Pediatrics
at Northwestern University, Feinberg School of
Medicine.
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may 2013 PRACTICAL DERMATOLOGY 49
