It is the body’s largest organ, yet the importance of protecting and maintaining our skin is often overlooked, writes Leanne Philpott
As accessible sources of healthcare advice, pharmacists are in a prime position to educate patients and help facilitate effective skin care and support those with long-term skin conditions.
The changes that occur in ageing skin can increase susceptibility to a range of skin disorders. Dehydration of the stratum corneum and impaired epidermal barrier function can lead to common skin conditions such as xerosis, asteatotic eczema, contact dermatitis and skin infections.
Xerosis is a common cause of pruritis and, according to The Royal Australian College of General Practitioners, pruritus is the most common skin complaint in patients over the age of 65 years, with symptoms being potentially incapacitating and dramatically affecting and impairing quality of life.
Dermatologist Dr Hope Dinh explains, “Dry skin is itchy skin and in aged skin we see an increase in factors leading to drier skin that doesn’t tend to “bounce back” like younger skin. Dry skin in the elderly is exaggerated with prior UV radiation. Factors like reduced epidermal cell turnover can lead to delayed wound healing and this is important in patients with pruritic dermatoses because we need to allow a longer time frame for the elderly to recover from itchy rashes compared with younger patients.
“The elderly are more likely to be on medications for other medical conditions and some medications can lead to exaggerated skin dryness, which will make pruritus worse. Such medications that can induce skin dryness include cholesterol lowering medications, diuretics and retinoids amongst others. The elderly can have more risk of chronic medical conditions that can also contribute to dry skin and hence itchy skin. These medical conditions include thyroid disorders, renal failure, for example. Some patients may also be on a fluid restriction due to other medical conditions, and this can lead to dry and dull skin that is not resilient. The elderly can sometimes not pay as much attention to nutrition as they should and this can have a negative impact on their skin health. Encourage those elderly patients on a “tea and toast” diet to have a more varied diet full of fresh fruit and vegetables and protein.”
Risk factors for xerosis include:
- Hereditary – history of atopy (eczema, asthma, hayfever in family history)
- Climate – dry climate in Melbourne is worse than hot and humid climates
- Medications can contribute to xerosis such as cholesterol lowering medications, retinoids, diuretics
- Ageing and in particular photo-ageing; post-menopausal women
- Overheating – shower, doona, electric blanket, sitting in front of the fire, central heating, synthetic clothing (which can lead to trapping of heat and overheating)
- Excess hand washing/wet work
- Using drying soaps on the skin
Dr Dinh adds, “Patients can often underestimate the external factors that can cause xerosis but once I clearly spell out these individual factors, patients usually understand and are keen to avoid them.
“Best practice treatment for pruritus should include ruling out a systemic medical reason. It would be reasonable to do a panel of blood tests including FBE, UEC, LFTs, serum protein electrophoresis, hepatitis serology, and thyroid function tests. To exclude contact allergy dermatitis you may consider patch testing, depending on the patient’s history.”
The mainstay of treatment in pruritis is the regular and ongoing use of emollients but lifestyle modifications, topical antipruritics and corticosteroids as well as antihistamines can also prove successful.
Other actions include:
- Use of soap substitutes
- Use of topical steroids if a rash is present
- Applying 0.5% menthol cream (best kept in the fridge) to soothe itchy areas
- Keeping nails short
- Encouraging patients to pat or rub the itchy areas, rather than scratch as scratching can lead to secondary bacterial infection, which can then independently drive the itch
- Use of H2 blockers
- Applying a good quality fragrance-free moisturiser
While the structural and physiological changes that occur in ageing skin can increase susceptibility to a range of skin disorders, youthful skin can have its fair share of concerns too.
It is believed that acne affects at least 85% of the population at some time during their lives and while acne isn’t just limited to teenagers, those aged 15 to 25 are most likely to suffer from the condition.
“Acne is very common, 90% plus of teenagers experience acne. When it becomes more inflamed and there’s the risk of scarring or it’s starting to interfere with quality of life then it has clearly become a problem that needs addressing,” says Associate Professor Chris Baker, President of the Australasian College of Dermatologist.
“The majority of acne is attributed to genetics and hormonal stimulation of oils glands. This accounts for 90%. Some people get acne from topical blockage of follicles caused by make-up use, oil application and people who work in environments where there’s a lot of oil in the air, such as kitchen workers,” he adds.
Sydney dermatologist Li-Chuen Wong explains, “Hormonal changes, such as puberty and pregnancy can lead to sebum overproduction and bacterial proliferation. When hair follicles then become blocked with sebum and dead skin cells, this creates blackheads, whiteheads and pimples. A sudden rise in blood sugar will lead to a surge of insulin. We now know that this burst of insulin will then trigger a flare of acne.”
Over-the-counter treatments for mild acne usually include benzoyl peroxide, salicylic acid or sulfur but some patients may show concern over the drying effects of these ingredients, in particular benzoyl peroxide.
Ms Wong advises, “The associated dryness and irritation seen with benzoyl peroxide usage occurs usually in the first few weeks of application. These side effects will eventually settle down, so encourage patients to persist with the treatment! In fact, the skin dryness seen is actually the benzoyl peroxide exfoliating the top layer of skin, allowing blackheads and whiteheads to become unplugged.”
A/Prof Baker says, “You can have oily skin but still have dry skin because the dryness relates to the barrier function, which irritants like benzoyl peroxide can damage or reduce as can excessive washing or exposure to soap.
“There’s an opportunity in pharmacy to pick the right strength for a person’s skin type. Strengths like 10% would be restricted for a person’s torso, 2.5% or 5% would be suitable for the face but someone with sensitive skin may only be able to tolerate 2.5% or they may need intermittent application, perhaps on alternate days. Judge from the patient’s past experience what strength and application they can take.”
“Acne is associated with a bacteria called Propriobacterium Acnes and benzoyl peroxide helps destroy this bacteria. However, it needs to be continuously used in order to maintain control of mild acne. Suggest patients avoid using benzoyl peroxide around the sensitive areas on the face, such as around the eyes, as sensitivity may result in them stopping use of the treatment,” says Ms Wong.
Lifestyle measures, avoiding simple carbohydrates like sugar, white rice, white bread and pasta, pastries and desserts, can help prevent an acne flare.
“There is evidence that a low GI diet improves acne. Low GI relates to insulin levels, high GI foods such as refined sugars and fast foods create an insulin spike, which is relevant in driving oil production,” says A/Prof Baker.
Ms Wong says other action that can help with acne include regular exercise, as this allows good blood circulation to the skin and stress reduction. Stress increases skin cortisol levels, which can exacerbate acne.
“Dermatitis is a condition that can affect people of all ages, yet typical ‘eczema’ or ‘atopic dermatitis’ usually has its onset in childhood. Whilst the majority of children will grow out of having active eczema, they are more likely to be predisposed to dry skin due to the genetic basis underling their condition,” says associate professor Saxon Smith, dermatologist and leading clinical researcher into atopic dermatitis.
“Eczema is the result of a genetic predisposition to drier skin and sensitive skin, environmental factors such as infection, irritants and allergies, and episodes of inflammation in the skin. It is important to consider all of these factors when managing eczema.
“The back bone of management is the use of soap-free washes, regular moisturiser, and short, lukewarm showers or emollients in the bath. This supports the skin to be adequately moisturised and helps it to be more resilient to environmental factors.
“An attempt should be made to manage or modify identified environmental factors, such as avoidance of demonstrated allergies and treating potential infections. When there is active eczema characterised by areas of red inflamed skin, topical corticosteroids (TCS) and calcinurin-inhibitors are used as anti-inflammatories.”
There’s the common concern that the inappropriate use of TCS can lead to skin thinning and pharmacists are in an ideal position to address this and alleviate the apprehension, especially amongst parents of children with eczema.
“Topical steroid products are essential in the treatment of eczema, in order to decrease the associated inflammation, redness and itch. If they are used intensively and regularly, to only the affected areas of eczema till completely resolved, no side effects will develop, such as skin thinning. On the other hand, if eczema is not adequately treated, then often the excessive scratching due to itch will lead to secondary infection and considerable discomfort,” says Ms Wong.
A/Prof Smith adds, “When parents use TCS under instruction from their dermatologist and with supervision you do not see ‘skin thinning’. This has been confirmed by research in Australia as well as the recently published consensus of safety and efficacy of TCS in paediatric dermatitis.
“Similarly, the use of the term ‘sparingly’ leads to confusion in parents and patients. It creates a negative message of risk or danger around the use of TCS despite their strong safety and efficacy. This can lead to parents or patients applying inadequate amounts or avoid applying TCS at all. The best guide on the amount to apply is based on the finger-tip-unit.”
One fingertip unit (FTU) is the amount of cream from the tip of an adult finger to the first bend in the finger. This quantity of cream will cover an area equal to two adult hands.
Pharmacist Nick Logan, of Nick Logan Pharmacist Advice in Artarmon, Sydney, advocates the need for consistent advice surrounding TCS application.
“Around 30% of Australian children are affected by atopic eczema which creates a huge burden on them and their families. Correct application of TCS is fundamental in supporting the health and wellbeing of these children, and pharmacists are at the forefront of providing consistent and correct advice on application. By increasing education about this core treatment and promoting universal use of the fingertip unit rule we can provide best practice care for our atopic eczema patients of all ages.”
“When patients and parents receive different and even conflicting messages it can lead to poor treatment adherence and ultimately poor treatment outcomes,” says A/Prof Smith.
A/Prof Smith and Mr Logan are part of a team (a collaboration between MSD & Medikidz) that has developed ‘Elliot’s Meditotz Adventure’, an educational storybook designed for parents and children with eczema.
“Like many parents with a child with eczema, I find the day to day challenge of trying to get my son to comply with his eczema treatments difficult. There are days when applying moisturises and TCS are easy, but other days feel like a complete battle. It was a wonderful opportunity to help create a book aimed at children and in their language. This was the best way to help the children, like my son, understand what eczema is and why their parents put their creams on every day.
“It’s hard work as a parent to constantly manage your child’s eczema. Furthermore, the associated stress, sleepless nights, and even poorer school performance can affect the whole family. It’s important for all of us as part of the multi-disciplinary team to help and support these parents, and adults with eczema, so that their children can enjoy the disease-controlled life they deserve,” says A/Prof Smith.
“As a pharmacist who sees many families battling eczema symptoms and a parent myself, it’s easy to see why this is a valuable resource for kids about eczema. Based on the real-life experiences of five-year-old Elliot, who lives with eczema, Elliot’s Meditotz Adventure is designed to explain the sometimes ‘more complex’ information about eczema in a format that children will easily understand and relate to,” says Mr Logan.
For a limited time, pharmacists and consumers can order a FREE copy of Elliot’s Meditotz Adventure from the Eczema Association of Australasia.
To order a copy, send an email to firstname.lastname@example.org with your full name and postal address or call 1300 300 182.