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52 Barrier Creams and Emollients 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 (lotions), 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 moisturizers. 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 dermatitis (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]. contact dermatitis (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 lotion (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 “moisturizer” 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.
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