What advice can you offer on maintaining healthy skin or counselling on chronic skin conditions, such as eczema and psoriasis?
While you can’t change the weather, you can encourage people to revise their skincare regimen during the colder months. Dry skin is a widespread condition, affecting people of all ages. However, it’s typically more prevalent in winter due to external factors, for instance cooler temperatures and reduced humidity—as well as internal influences, such as indoor heating, hot showers and the use of soap.
Dermatologist Associate Professor Rosemary Nixon AM says dry skin and cold weather go hand in hand. “It’s very common for people to suffer dry skin in the colder months. Not only is the air drier and colder, but also homes are heated, which further dehydrates the skin.
“Dry skin is particularly common in older people. One feature of aged skin is a decreased rate of epidermal proliferation, which increases the susceptibility to dry skin. There is also less moisture and lipid content in older skin.”
She explains, “Dehydrated skin feels rough and most commonly affects the lower legs. However, people with a tendency for atopic dermatitis may develop generalised dry skin, which can also be very itchy.
Furthermore, itchy skin conditions are worse when you get hot. For example, some people overheat in bed because they’re using an electric blanket, or they have long hot showers—both of which increase the propensity for dry, itchy skin.”
Winter itch: how to assist
Pruritus hiemalis (or winter itch) is a type of dermatitis that affects the skin, most commonly the legs, during cold weather and is more prevalent among older people with dry skin. Symptoms include roughness, dryness and cracking, itchiness and irritation, as well as potential lesions as a result of scratching the skin.
Dermatologist Dr Chris Baker says, “Dry skin can affect people of all ages, however, older people are more prone to it. Furthermore, people who have a history of hayfever, asthma and eczema, as well as those on diuretics or cholesterol-lowering drugs are more likely to suffer from dehydrated skin.”
He explains that if dry skin is left untreated it can lead to more severe complications, such as eczema, fissures and secondary infection. “Once the skin is damaged it’s a bit like continuing to run on a sprained ankle; it won’t ever heal properly.
“It’s a similar scenario with winter itch. Once you get into an itching, scratching cycle it can take a very long time to break the sequence—even if the correct treatment regimen is followed. So, it’s important for pharmacists to manage people’s expectations and encourage them to adhere to the treatment.”
The aim of treatment for pruritus hiemalis is to provide symptomatic relief and help break the itching, scratching cycle. Emollients are the mainstay of treatment. However, it’s important to assist customers in finding the most appropriate type of emollient. “The best product is the one that people will use regularly!” says A/Prof Nixon.
“Typically, greasier moisturisers are most effective for dry skin conditions and are best applied after the shower and before bed. I recommend ointments and then creams over the use of lotions. However, compliance is a really important factor; some people don’t like the feel of greasy moisturisers. In this case, it’s important to help the person find a product that they like the feel of and will use frequently.
“When customers come into the pharmacy seeking a product for their dry skin, it’s a great opportunity to educate on the importance of treating and preventing dry skin. Many people just assume ‘moisturising’ is a term used for facial products, and are unaware of the importance of moisturising the whole body, particularly the legs.
“You can also provide some simple but useful self care tips, such as swapping out soap, which is alkaline and more drying, in favour of a soap-free, ph-balanced cleansing product, as this will be less irritating for the skin. You can also recommend taking shorter showers or baths and moisturising soon after washing to help trap moisture into the skin.”
Educating on emollients
“Skin conditions are very individual so, as pharmacists, we really want to spend the time understanding individual circumstances in order to provide the best possible care,” says Eric Chan, head of pharmacy, Blooms The Chemist.
“When someone comes into the pharmacy seeking assistance for a skin concern the first questions we need to ask are how long have you had the condition, what treatments have you tried and how long have you used the products for. This enables me to take the most holistic, patient-centred approach and this is where pharmacists can really help to assist and support people with their skin conditions.”
“The choice of emollient depends on the individual skin care needs and degree of moisturisation needed and also personal preference of the user. Ultimately if the patient does not like the preparation, they will not use it,” says Dr Annika Smith, consultant dermatologist and fellow of the Australasian College of Dermatologists.
“Generally speaking, if dealing with extremely dry skin and eczema-prone skin, ointments are best. Ointments are devoid of preservatives and additives that can irritate and sensitise. The thicker and greasier the product, for example white soft paraffin or liquid paraffin, the better it is in terms of moisturising capacity, repairing and reinforcing the skin barrier.
“When it comes to ingredients, pharmacists can urge people to look for products containing ceramides, as these help to repair and reinforce skin barrier function, as well as nicotinamide, which has humectant properties. Sensitive skin should avoid fragrances, preservatives and alcohol.”
To help achieve the best results, Dr Smith offers the following application tips:
- Ointment: good for full body application on dry, scaly, eczematous, and eczema-prone skin
- Cream: if ointment is aesthetically displeasing (i.e. too thick or greasy) or less moisture needed
- Lotion: good for scalp and hair bearing sites.
She adds, “pump packs and tubes can help keep things hygienic and avoid incidental contamination of tubs of emollient.”
“We know that there is a high rate of noncompliance with topical therapy among patients, which partly comes down to how taxing a daily regimen can be, but also the aesthetics and “feel” of a product and how this interferes with clothing and function can also play into this. With topical therapy I encourage an active treatment plan and then a maintenance regimen, which is individualised according to the patient,” says Dr Smith.
“Whether it’s assisting with preventative, treatment or recovery measures, pharmacists can offer practical advice and tips. This might involve simply explaining what order the creams and topical treatments should be applied. Or we might recommend a non-prescription item as an adjunct treatment if we feel it will help manage the person’s individual skin condition.”
“Certainly, it’s not about replacing the advice of GPs and dermatologists, it more about giving practical advice, offering individual care and taking the opportunity to follow up with people,” Eric Chan says.
A proactive approach to psoriasis treatment
While psoriasis is an immune system disorder, the condition can be aggravated by cold, dry weather – which is typical in winter. Certainly, external factors can draw moisture away from the skin, but indoor heating can exacerbate the problem, causing cracked skin and even bleeding.
The most widespread form of psoriasis is chronic plaque psoriasis. This presents as raised red patches (plaques) covered with silvery-white skin cells (scales). It is most commonly found on the elbows, knees and lower back.
Karen Risdale, president of Psoriasis Australia, says, “Australians have a strong sense of trust in their pharmacist and, as such, people will often approach their pharmacist first to ask if there is something they can use on a patch of red, itchy, dry skin. It’s important to note that many of these people have not seen a GP, let alone a skin specialist, for this issue. So, I believe this is where the pharmacist can be of great help.
“It’s important to discourage the belief that it’s just ‘dry, itchy skin’. Pharmacists can help encourage people to see psoriasis for the complex and debilitating disease it can be for many, especially if it isn’t managed correctly.”
Dr Smith advises, “Topical therapy for psoriasis will, of course, depend on the severity and location of the psoriasis. For mild to moderate chronic plaque type psoriasis (i.e. extensor surface involvement (knee/elbow) and trunk), combination topical therapy (for example, betamethasone dipropionate and calcipotriol) is considered most effective.
“There are certain locations, such as genital or inverse psoriasis, where topical combination therapy can irritate (the calcipotriol component in particular) and a potent steroid is inappropriate for prolonged periods at these sites. The choice of topical therapy, including the type of topical steroid, is based on clinical judgment. This will take into account erythema, scale and thickness of the psoriatic lesion along with extent of involvement and location on the body.
“However, in cases where there is a suspected diagnosis of psoriasis, I strongly recommend the person is referred to their GP or a dermatologist for a more thorough evaluation. We now know psoriasis is not just skin deep, but a systemic inflammatory disease. Ensuring the correct diagnosis, clarifying the presence of associated comorbidities (i.e. psoriatic arthropathy) and ensuring appropriate and sufficiently potent therapy from the outset is key.”
Certainly, we know that high-level care and education can help people to better manage their psoriasis and may help prevent its progression and severity.
A study by pharmacist Rod Tucker in the UK (and reported in the International Journal of Pharmacy Practice in 2017) looked at the role of pharmacists in supporting self-management in patients with psoriasis. Participating pharmacists recruited patients both opportunistically, when they presented at the pharmacy with a prescription for a topical treatment for psoriasis, and by searching through script histories and directly contacting patients.
A short consultation was had with patients, which incorporated the use of the Person-Centred Dermatology Self-care Index (PeDeSI) tool involving a set of 10 questions. Additionally, patients were asked to complete a Self-Administered Psoriasis Area Severity Index (SAPASI) to understand the severity of their disease, and the Dermatology Life Quality Index (DLQI). Pharmacists also arranged a follow-up appointment after six weeks.
The findings reveal that the quality and appropriate advice offered by pharmacists increased patients’ understanding of their psoriasis and led to notable reductions in disease severity. Indeed, 51% of patients said that gained a greater understanding of their condition and how to treat it and, overall, 84% believed their psoriasis had improved due to the advice and support given by the pharmacist.
This article appeared in our June AJP magazine. See the issue, or the e-magazine, for the full article including tables and advice points.