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Supplement to the May 2012

®

Advances in managing Hyperkeratotic Conditions A review of a new formulation to manage pilaris and damaged and cracked heels.

Supported by

May 2012 • Supplement to The Dermatologist ® 1 Advances in managing Hyperkeratotic Conditions A review of a new formulation to manage and damaged and cracked heels. Julia Ernst, MS, Assistant Editor

he new SA Renewing Lotion from CeraVe is The convex shape of the heel causes tension, which Tformulated with , ammonium lactate and contributes to the phenomenon of cracked heels (see vitamin D3 to repair, restore and renew , making the Figure 1), and is why the fingertips can also crack, Dr. product ideal for dry, cracked heels or keratosis pilaris. Bikowski explains. Keratosis pilaris (KP) (see Figure 2) This article reviews these two conditions, the new causes rough patches and small, -like bumps on the CeraVe SA Renewing Lotion and the ways in which skin — on the facial cheeks and, most commonly, on the the new lotion helps patients with these conditions. arms, and .3 KP is a of keratinization of follicles of the skin4 that can also Hyperkeratotic Conditions: Dry, Cracked Heels or be associated with dryness and, sometimes, perifollicular Keratosis Pilaris , according to Dr. Bikowski. is a condition marked by thickening Neither condition is associated with increased mor- of the outer layer of the skin.1 The condition’s etiolo- bidity or mortality.3,4 Effective treatment options are gies include eczema (chronic inflammation), X-linked limited, according to Dr. Bikowski. The primary treat- / (genetic disorders) and ment option is moisturizing. corns/ (normal use).1 Going barefoot and bio- “Moisturizing is key, with the ultimate goal, in the mechanical factors (increased body weight) also play case of dry, cracked heels, to restore hydration and important roles in its development. It occurs because of encourage proper barrier function,” Dr. Bikowski hypertrophy of the .2 says. “In the case of KP, topical help to Dry, cracked heels or keratosis pilaris are two types of hy- relieve the dry, rough feel often associated with the perkeratotic conditions. Dry, cracked heels occur for a num- condition. Application of moisturizers under occlu- ber of reasons, according to Joseph Bikowski, MD, FAAD, sion can also help enhance skin hydration. Patients of Bikowski Skin Care Center in Sewickely, PA, including apply a thick moisturizing agent to the affected areas, the anatomic features of the heels, skin dryness and trauma, then place a clean sock over top. This should be done which is often minor, or a combination of these factors. at bedtime.”

Figure 1. Dry, cracked heel. Figure 2. Keratosis pilaris. Photo courtesy of Bernard Cohen, MD.

2 May 2012 • Supplement to The Dermatologist ® Case Study

Joseph B. Bikowski, JR, MD, FAAD

A 39-year-old moderately obese Caucasian female presented with a many-year history of dry, painful heels. She reported that a num- ber of over-the-counter medications had been ineffective. A KOH preparation for dermato- phytes was negative and, on examination, the Figure 3a. Before weight-bearing sides of the heels were dry, flaking and cracked.

The patient was instructed to apply CeraVe SA Renewing Lotion to the affected area twice a day for 2 weeks. Upon her return visit after 2 weeks of twice-daily application of the lotion, the skin of the heels was essentially normal in appearance and feel (see Figures 3a and 3b).

Figure 3b. After two weeks

Both conditions may also benefit from the use of extremely dry skin.7 In the case of dry, cracked heels or , Dr. Bikowski explains. Keratolytics are KP, SA Renewing Lotion can serve a dual purpose, by used to soften skin and facilitate the removal of epi- helping to slough off damaged skin cells and encourage dermal cells; some examples include salicylic acid the growth of new, healthy skin.7 and .5,6 As with all CeraVe products, the new SA Renewing Keratolytics “desquamate the thick, keratinized skin of Lotion includes ceramides, which help to restore, repair the heels and increase suppleness, to withstand trauma,” and maintain the skin barrier.7 The new lotion is also Dr. Bikowski explains. “In KP, keratolytics can help to formulated with salicylic acid and ammonium lactate, unplug the pores and reduce the formation of bumps.” two key ingredients that help to loosen and exfoliate According to Dr. Bikowski, cracked heels and feet dead skin cells.7 This process lets the moisturizing agents may be mediated by other factors, such as dermato- penetrate the deeper layers of the skin for enhanced ef- phyte infections. In the case of infection, he explains, fectiveness.7 Also included in SA Renewing Lotion is inflammation and a compromised epidermal barrier , another key ingredient that helps to keep skin may heighten the likelihood of trauma and dryness. No looking smooth and hydrated.7 known factors for KP are within a patient’s control, Dr. Bikowski explains. How do the key ingredients work? Salicylic acid is a member of the beta hydroxy acid CeraVe SA Renewing Lotion family. This lipid-soluble agent is used for epidermal ex- What is the SA Renewing Lotion? foliation. Salicylic acid breaks up in hyperkera- The new SA Renewing Lotion from CeraVe is used totic conditions, enhances the shedding of thick skin and for extremely dry, rough, bumpy skin, making it a good softens newly growing skin.8 SA Renewing Lotion con- for patients with cracked heels or KP. The tains 3% salicylic acid. product was formulated in conjunction with derma- “Salicylic acid is one of the most commonly pre- tologists and is designed to exfoliate, smooth and soften scribed agents used to treat KP,” Dr. Bikowski explains.

May 2012 • Supplement to The Dermatologist ® 3 Figure 4. MVE absorption rate into the skin. “Its incorporation into a moisturizing, barrier-support- and help soften the new skin that is regenerated.7,8,12 The ing topical lotion is a benefit for patients.” MVE technology allows for a continuous dispensation Ammonium lactate is a combination of alpha hy- of products, which is crucial for patients with hyper- droxy acid (AHA) and lactic acid that is neutralized keratotic skin conditions. SA Renewing lotion is also with ammonium hydroxide.8 This component relieves non-comedogenic and non-irritating.7 dry skin by increasing the moisture content of the stra- “The unique combination of these exfoliating kera- tum corneum, the skin’s outermost layer.8 AHA acts as tolytic agents and humectants within a formulation a humectant and has a normalizing effect on the skin. containing barrier-supporting ceramides is expected Lactic acid has also been shown to reduce the thick- to optimize patient response and enhance healing,” Dr. ened stratum corneum that results from hyperkeratotic Bikowski says. n conditions.8 SA Renewing Lotion contains 3.5% am- 8 monium lactate. Disclosure: Dr. Bikowski is a consultant for Valeant. “Ammonium lactate also helps restore moisture while reducing skin thickness and roughness,” explains References Dr. Bikowski. 1. National Institute. Dictionary of cancer terms: hyperkera- Vitamin D3 helps to maintain healthy skin that is tosis. Available at www.cancer.gov/dictionary?cdrid:413928. Accessed firm and supple.8 Analogs of vitamin D3 such as calci- April 6, 2012. potriene and becocalcidiol have been shown to be effec- 2. Merriam Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: tive in ; it was particularly effective for resistant Merriam-Webster Inc; 2003. 9 3. Mayo Clinic. Keratosis pilaris. Available at http://www.mayoclinic. plaques and lesions on the . Vitamin D3 has also com/health/keratosis-pilaris/DS00769/METHOD=print. Accessibil- been effective for the treatment of , ity verified April 9, 2012. and .10 It’s said to have antipruritic, anti- 4. Medscape Reference: Drugs, and Procedures. Keratosis inflammatory and healing properties in psoriasis treat- pilaris. Available at http://emedicine.medscape.com/article/1070651- ment.11 All these factors may play a role in the use of overview. Accessed April 9, 2012. 9–11 5. Merck Manual Professional. Principles of topical dermatologic vitamin D3 for skin conditions. therapy. Available at http://www.merckmanuals.com/professional/ dermatologic_disorders/principles_of_topical_dermatologic_ther- The role of multivesicular emulsion technology apy/principles_of_topical_dermatologic_therapy.html. Accessed CeraVe skincare products feature multivesicular emul- April 9, 2012. sion (MVE) technology (see Figure 4), a patented pro- 6. Skin & Aging. Management of seborrheic . Available at http://www.the-dermatologist.com/article/9049. Accessed cess that delivers CeraVe products into the skin over a April 9, 2012. 12 period of time, rather than all at once. This delivery 7. When your skin hits a bumpy patch, change direction with new method also “locks in” moisture.12 CeraVe SA Renewing Lotion! [press release]. New York, NY: The “The MVE technology facilitates slow release of ce- Lane Communications Group; February 6, 2012. ramides over time, which means continuous skin mois- 8. New CeraVe SA Renewing Lotion Key Ingredients [press release]. New York, NY: The Lane Communications Group; February 6, 2012. turization,” Dr. Bikowski explains. “This is a practical 9. Mayo Clinic. Vitamin D. Available at http://www.mayoclinic.com/ benefit for both cracked heels or KP, as patients are health/vitamin-d/NS_patient-vitamind. Accessed April 9, 2012. unlikely to remove their shoes or clothing to re-apply 10. Medline Plus. Vitamin D. Available at http://www.nlm.nih.gov/ moisturizer multiple times throughout the day.” medlineplus/druginfo/natural/929.html. Accessed April 9, 2012. 11. Kuravi A. Effect of parenteral vitamin D3 in skin diseases. Indian J Dermatol Venereol Leprol 1998;64:251-252. Additional benefits for patients with cracked heels or KP 12. CeraVe. The role of MVE technology. Available at http://cerave. The ingredients in CeraVe SA Renewing Lotion com/cerave-resources/the-role-of-mve-technology/. Accessed April work together to exfoliate and remove dead skin cells 5, 2012.

4 May 2012 • Supplement to The Dermatologist ®