479

52 Barrier Creams and Emollients

Hongbo Zhai, Howard I. Maibach

Contents called skin protective creams (SPCs)”or protective creams (PCs), as well as protective ointments, 52.1 Introduction . . . 479 invisible glove, barrier, protective or prework 52.2 Barrier Creams . . . 479 creams and-/or gels (), antisolvent gels, and 52.2.1 Definition and Terms . . . 479 so on [7, 12–14]. Frosch et al. [7] consider “skin 52.2.2 Reasons for Using Barrier Creams . . . 479 protective creams” a more appropriate term since 52.2.3 Mechanism of Action and Duration . . . 480 most creams do not provide a real barrier, at least 52.2.4 Application Methods and Efficacy . . . 480 not comparable to stratum corneum. BCs may share 52.2.5 U.S. Food and Drug Administration Monograph Skin Protectants . . . 480 characteristics with . The target of BCs 52.3 Emollients . . . 480 is in the prevention of external noxious substances 52.3.1 Definition and Terms . . . 480 penetrating skin, and moisturizers are frequently 52.3.2 Mechanism of Action . . . 480 used for “dry” skin conditions as well as to maintain 52.3.3 Efficacy . . . 480 healthy skin [15]. Recently, it has become clear that 52.4 Conclusion . . . 483 some moisturizers prevent and ameliorate ICD from References . . . 483 surfactants [15, 16].

52.2.2 Reasons for Using Barrier Creams 52.1 Introduction Avoiding certain irritants or allergens may not be Contact (CD) occurs as a result of contact practical for persons whose occupation or activi- with external factors (irritants and allergens) and ties mandate their working in certain environments. comprises 90%–95% of work-related dermatoses [1]. Protective clothing as well as other personal devices From etiological grounds, it is divided into irritant may provide protective effects in industry [17, 18]. (ICD) and allergic contact derma- However, protective clothing may trap moisture and titis (ACD). ICD results from contact with irritants, occlude potentially damaging substances next to the while ACD is an immunological reaction in response skin for prolonged periods and increase the likeli- to contact with an allergen in sensitized individuals hood that dermatitis will develop [17, 18]. In practice, [1]. In order to reduce the risk of developing such CD, BCs are recommended only for low-grade irritants various prophylactic measures are used [1–6]. Barrier (water, detergents, organic solvents, cutting oils) [2, creams (BCs) as well as emollients may play an im- 19–22]. The first line of defense against hand derma- portant role in this strategy. BCs are used prior to or titis is to wear gloves, but in many professions it is during working [2–10], whereas emollients are used impossible to wear gloves because of the loss of dex- after work [6, 11] terity. In some instances, an alternative could be to apply BCs. BCs are also used to protect the face and neck against chemical and resinous dust and vapors 52.2 Barrier Creams [23]. Many workers prefer a barrier cream instead of gloves because they do not want their hands continu- 52.2.1 Definition and Terms ously sealed inside gloves. Furthermore, gloves can inhibit skin barrier function [2]. Additionally, gloves BCs, in theory, are designed to prevent or reduce the often do not resist the penetration of low-molecular- penetration of harmful agents [2–10]. BCs are also weight chemicals. Some allergens are soluble in rub- 480 Hongbo Zhai, Howard I. Maibach

ber gloves, and may penetrate the glove and produce 52.2.5 U.S. Food and Drug Administration severe dermatitis [2, 23, 24]. Another reason to avoid Monograph Skin Protectants wearing gloves is the fact that an allergic reaction to rubber latex has become a growing problem [23, 24]. The US Food and Drug Administration (FDA) de- Furthermore, due to continuous glove wearing, work- fines 13 skin protectants for over-the-counter (OTC) ers can develop serious symptoms of contact urticaria products [38]. These ingredients are: allantoin (0.5%– syndrome, including generalized urticaria, conjuncti- 2%), aluminum hydroxide gel (0.1%5–5%), calamine vitis, rhinitis, and asthma, etc. [2, 25]. (1%–25%), cocoa butter (50%–100%), dimethicone (1%–30%), glycerin (20%–45%), kaolin (4%–20%), petrolatum (30%–100%), shark liver oil (3%), white 52.2.3 Mechanism of Action and Duration petrolatum (30%–100%), zinc acetate (0.1%–2%), zinc carbonate (0.2%–2 %), and zinc oxide (1%–25%). There is little information on the mechanisms of BC’s In addition, an OTC (containing quater- action. The frequently quoted general rule is that nium-18 bentonite) against poison ivy, oak, or sumac water in oil (W/O) emulsions are effective against has been approved by the FDA and commercialized. aqueous solutions of irritants and oil in water (O/W) emulsions are effective against lipophilic materials [7, 8, 17, 18]. Some studies have demonstrated 52.3 Emollients exceptions to this rule [26, 27]. BCs may contain active ingredients that are presumed to work by 52.3.1 Definition and Terms trapping or transforming allergens or irritants [8, 27]. Most believe they interfere with absorption and Emollients are designed to smooth the skin and in- penetration of the allergen or irritants by physical crease water content indirectly by creating an occlu- blocking – forming a thin film that protects the skin sive film on the skin surface, thereby trapping water [8, 27–29]. in the upper layers of the stratum corneum [6]. They In order to avoid frequent interruptions for reap- are often used after work. There is little information plication, BCs are expected to remain effective for 3– to describe the definition and term of emollient in the 4 h. Most manufacturers claim that their products last literature. In fact, the term “emollient” is synonymous around 4 h. Others suggest using them “as often as with “” in the dermatological or cosmetic necessary” [18]. Several studies document duration products [39]. Their mode of action may be the same of action – with varying results [19, 22, 30, 31]. or similar to moisturizers [6, 39]. However, some emollients may contain anti-inflammatory or epithe- lial growth-promoting substances and hence may ac- 52.2.4 Application Methods and Efficacy celerate wound healing [6].

BC effectiveness may be influenced by application methods [32–34]. Wigger-Alberti et al. [33] deter- 52.3.2 Mechanism of Action mined which areas of the hands were likely to be skipped on self-application using a fluorescence tech- Since emollients share the same characteristics as nique at the workplace; BC application was incom- moisturizers, they can restore, retain, or increase plete, especially on the dorsal aspects of the hands. moisture in the stratum corneum and therefore en- Most manufacturers suggest rubbing thoroughly onto hance barrier function [39]. Besides the effects of skin, paying special attention to cuticles and skin un- common moisturizers, emollients may also supply der the nails, letting it dry approximately 5 min, and the missing basic components of damaged skin and applying a thin layer of BC to all appropriate skin stimulate barrier function repair [6]. surfaces three or four times daily. Presumably, these controlled experiments are indicated. BC efficacy in preventing or reducing ICD and 52.3.3 Efficacy ACD has been documented in many experimental en- vironments. Reviews are found in references [2–10]. Goh [40] evaluated the effect of two after-work emol- However, some reports document that inappropriate lient creams on eight guinea pigs’ skin repeatedly BC application may exacerbate rather than ameliorate treated with cutting oil. He reported that the two-test the condition [7, 8, 22, 26, 35–37]. after-work emollient creams did not alleviate the irri- 52 Barrier Creams and Emollients 481 tant effect but appeared to aggravate the irritant effect and scaling noted at all time points. Conductance was of the cutting oil. Latter, Goh and Gan [11] compared significantly increased on days 8 and 11. the effects of a BC and an after-work emollient cream Ramsing and Agner [45] tested the effect of a mois- on machinists who handled cutting fluid (neat min- turizer on experimentally irritated human skin. In a eral oil) during work over 6 months; the test BC and therapeutic study, both hands of 12 volunteers were after-work emollient cream did not have a significant immersed in a 0.375% SLS solution, 10 min twice effect against cutting fluid dermatitis. However, the daily for 2 days. After the last immersion, one hand after-work emollient cream reduced the prevalence of was treated with the moisturizer for 5 days; the other cutting fluid irritation. hand served as control. A significant therapeutic ef- Lane and Drost [41] examined the effect of a water- fect was observed on the treated hand, while TEWL in-oil emollient moisturizer on 34 premature new- was significantly increased and electrical capacitance borns. Half of the neonates were treated twice daily was significantly decreased on the control hand on with test moisturizer for up to 16 days, and the other day 8. half served as controls. They demonstrated improved Zhai et al. [46, 47] utilized two human models in grading scores on the hand (day 2 through day 11), vivo to examine the efficacy of a restoration cream. In feet (day 2 through 16), and abdomen (day 7 through an acute acetone irritant dermatitis model, skin test day 11) at moisturized sites. sites were rubbed with acetone-soaked cotton balls Loden and Andersson [42] observed the effect of until elevated rates of TEWL occurred (>20 g/m2/h). topically applied lipids on surfactant-irritated skin One site was treated with test cream when the other in 21 healthy subjects, showing that canola oil and site treated with placebo control. The test cream sig- its sterol-enriched fraction reduced the degree of so- nificantly accelerated barrier recovery, especially dium lauryl sulfate (SLS) -induced irritation. Neither within the first 72 h. In the SLS irritant dermatitis fish oil (rich in eicosapentaenoic acid) nor borage oil model, the skin test area was damaged by occlusive (rich in GLA and linoleic acid) influenced the degree patch with SLS solution for 24 h. One site was treated of SLS-induced inflammation. with test cream and the other site with placebo con- Hannuksela and Kinnunen [43] developed a wash- trol. Results showed that the test cream produced ing test to determine the effect of moisturizers on rapid improvement in barrier function, in particu- 12 healthy female students. The participants washed larly within the first 48 h. their upper arms with a liquid dishwashing detergent Lodén [48] tested a moisturizing cream for its in- for 1 min twice daily for 1 week. Eight commercial fluence both on barrier recovery in surfactant-dam- moisturizers were applied on the left upper arm just aged skin and on the susceptibility of normal skin to after each washing, while the other upper arm was exposure to the irritant SLS. The surfactant-damaged left untreated. During the 2nd study week, the left up- skin was treated with the test cream for 14 days and per arm only was treated with the moisturizers twice promoted barrier recovery. The test cream acceler- daily. Transepidermal water loss (TEWL) increased ated the rate of recovery of surfactant-damaged skin during the washing period by 13 g/m2/h in the un- and decreased the degree of SLS-induced irritation in treated arm, while the increase in the treated areas normal skin. was only 3 g/m2/h. Visible dermatitis appeared on the Schleicher et al. [49] conducted a pilot study utiliz- untreated arm, while the treated areas remained ob- ing a new skin barrier-protectant cream (SBR-Lipo- jectively and subjectively free of symptoms and signs. cream) on 25 patients with hand dermatitis. All par- Blood flow also increased significantly in the washed, ticipants were treated with the test cream three to four untreated arm, but did not change in the arm treated times daily for an average period of 17.5 days. Results with moisturizers. Using moisturizers also enhanced suggested 96% patients considered that this cream the healing process significantly. helped their condition and 51% believed that this Gammal et al. [44] assessed the efficacy of mois- cream improved their symptoms of scaling, cracking, turizers by a soap-induced xerosis human model. The or fissuring. lower legs of 22 women were washed daily for 10 days Lodén et al. [50] investigated the influence of treat- with soap to induce the xerosis. After washing, one ment with a urea-containing moisturizer on the bar- side received a moisturizer, the other served as an rier properties of atopic skin. One of their forearms untreated control. The values of clinical scaling, elec- was treated with a moisturizing cream twice daily for trical conductance, and D-Squames were compared 20 days. On day 21, the skin was exposed to SLS and on each evaluation day. The moisturizer-treated legs on day 22 the irritant reaction was measured nonin- demonstrated a significant decrease in dryness grades vasively. Skin capacitance was significantly increased 482 Hongbo Zhai, Howard I. Maibach

Table 1. Brief data on after-work emollient efficacy

Study design Irritants Emollients Results Authors and references

Guinea pigs’ skin Cutting oil Two after-work Test after-work emollient creams did not al- Goh [40] emollient creams leviate the irritant effect of the cutting oil but rather appeared to aggravate the irritant effect Machinists‘ skin Cutting One BC and Test BC and after-work emollient cream did Goh and Gan [11] fluid (neat an after-work not appear to have any significant effect against mineral emollient cutting fluid dermatitis. But after-work emol- oil) lient cream appeared clinically to help reduce the prevalence of cutting fluid irritation Premature Water-in-oil Less dermatitis on the emollient-treated side Lane and Drost [41] newborns‘ skin emollient Surfactant-irri- SLS Topically ap- Canola oil and its sterol-enriched fraction Lodén and An- tated human skin plied lipids reduced the degree of SLS-induced irritation dersson [42]

Washing test Liquid Eight commercial Test products enhanced the heal- Hannuksela and dish- products (three ing process significantly Kinnunen [43] washing O/W creams; detergent one skin oil; four double emulsions) Soap-induced xe- Soap Vaseline Intensive Significantly decreased dry- Gammal et al. [44] rosis human skin Care Lotion ness grades and scaling Immersion of SLS Locobase A significant therapeutic effect was ob- Ramsing and both hands served on the treated hand Agner [45] Acute irritant Acetone One restoration Test cream significantly en- Zhai et al. [46, 47] dermatitis models and SLS cream with its hanced barrier recovery in human skin placebo control Surfactant-dam- SLS One moistur- Test cream accelerated rate of recovery of Lodén [48] aged human skin izing cream surfactant-damaged skin and the lower degree of SLS-induced irritation in normal skin Patients with Work- SBR-Lipocream Results suggested 96% patients considered Schleicher et al. [49] hand dermatitis ing field that this cream helped their skin condition and 51% believed that this cream ameliorated their scaling, cracking, or fissuring conditions Patients with SLS Canoderm Test cream improved skin bar- Lodén et al. [50] atopic skin rier function in atopics and reduced skin susceptibility to irritants Patients with Four creams Results showed that all four creams re- Gånemo et al. [51] lamellar ich- duced xerosis. In particular, two formula- thyosis (LI) tions containing lactic acid and propylene glycol were significantly more effective for clinical improvement. But, both of these formulations also caused a slight irritation Nurses with Occupa- A test BC or Results showed no significant differ- Berndt et al. [52] mild signs of tional risk its vehicle ences between BC and its vehicle. In both skin irritation exposures groups, clinical skin status improved and stratum corneum hydration increased sig- nificantly during the study period SLS-damaged SLS Several commer- One test lotion was able to improve De Paepe et al. [53] human skin cially available skin barrier repair in comparison body lotions with physiological barrier repair 52 Barrier Creams and Emollients 483 by the treatment, indicating increased skin hydration. high-risk substances as well as corrosive agents. How- As reflected by TEWL and superficial skin blood flow ever, wet workers utilizing water, soaps, and deter- values, skin susceptibility to SLS was significantly gents daily may benefit by applying BCs frequently. reduced. They concluded that certain moisturizers Furthermore, BCs may also shield skin from chemi- could improve skin barrier function in atopics and cals, oils and other substances and make them easier reduce skin susceptibility to irritants. to clean at the end of the workday [18]. To achieve Gånemo et al. [51] evaluated the efficacy of four optimal protective effects, BCs should be used with creams on 20 patients with lamellar ichthyosis (LI). careful consideration of the types of substances they Each test cream was treated on each of the four ex- are designed to protect against based on a specific ex- tremities twice daily for 4 weeks; all creams reduced posure conditions; also, the proper education in use that xerosis. In particular, two formulations contain- is essential [33, 34]. Inappropriate BC application ing lactic acid and propylene glycol were significantly may exacerbate irritation [7, 8, 22, 26, 35–37]; using more effective clinically; both of these formulations BCs on diseased skin may lead to increased irritation also caused a slight irritation. [8, 17]. Berndt et al. [52] measured the efficacy of a BC Emollients provide benefits when used after work. and its vehicle in a work setting; two panels of 25 The function of emollients on enhancing wound heal- hospital nurses with mild signs of skin irritation used ing or recovery of damaged skin is important. Obvi- one of the test products (BC or its vehicle), especially ously, we cannot simply include emollients in skin before contact with skin irritants over 4 weeks. Both care products, but they may also have characteristics preparations were studied weekly by clinical exami- of restoration creams such as topical agents. However, nation and bioengineering measurements. Results their irritant effect should be minimized [51]. showed no significant differences between the BC There are no perfect BCs or emollients. The ideal and its vehicle. In both groups, clinical skin status BC and emollient should be nontoxic, noncomedo- improved and stratum corneum hydration increased genic, nonirritating, nongreasy, and colorless. They significantly during the study period. They concluded should be highly efficacious, but not interfere with the vehicle alone is capable of positively influencing user’s manual dexterity or sensitivity. They should skin status. be easy to apply and remove, cosmetically acceptable, De Paepe et al. [53] tested several commercially and economical. They may be combined with each available body lotions for its potential recovery effects other or cosmetic benefits, and contain a high pro- on SLS-damaged skin. The forearms skin of 13 young portion of fatty materials (lipids) and can, therefore, women was patched with SLS for 24 h; one test lo- also be used for skin care, especially for rough, dry, or tion improved skin barrier repair in comparison with chapped skin. physiological barrier repair. The efficacy of after-work emollients is briefly sum- marized in Table 1. References

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