Dry Skin S.O.S.!
In the past week, I’ve had numerous patients come into the pharmacy asking about dry, itchy skin - so thought I should tackle this topic in a blog post!
Dry skin, also called xerosis or xeroderma, occurs when the skin loses too much water[1-4] This means dry skin is not related to a deficiency of oils, but to water loss from the surface[4]. Symptoms can include skin tightness, scaling, flaking, roughness, peeling, fine lines, and cracking; it can also lead to dermatitis, which includes redness and itching[1,4,5].
Our skin has 3 layers: the epidermis, dermis, and subcutaneous layer. The stratum corneum is the upper layer of the epidermis, and is the primary barrier to water loss and helps protect the skin. It’s made of different components, including a lipid component containing ceramides, cholesterol, and free fatty acids. Healthy skin has a high concentration of ceramides, acting as a barrier to protect skin and keep it hydrated. If the skin barrier is damaged, there is an increase in what is called “transepidermal water loss” (TEWL), and a decrease in skin lipids including ceramides. Research for dry skin treatment tends to focus on the decrease in ceramides and TEWL[4].
What Causes Dry Skin?
The top layer of our skin is normally thick with natural fats and oils, acting as a barrier to keep in moisture and prevent irritants and bacteria from entering[6]. Changes to this layer disrupt its natural defensive barrier and can result in dry skin. Here are some of the ways our skin is affected.
As we age (especially past 40), skin becomes thinner, it loses fats and oils, and moisture can escape[1,2,6]
Often dry skin is caused from the environment, such as hot/cold weather and dry climates with low humidity[1]
Excessive sun exposure, called photoaging, can dry out the skin[3]
Heat, in the form of space heaters, fireplaces, or hot water, can also dry out the skin[1]
Products such as harsh perfumes, soaps, shampoo, deodorant, and detergents strip moisture away from the skin[1,3]
Occupations such as healthcare workers and hairstylists (washing hands frequently) increase the risk of dry skin[2]
Genetics can also play a role[2]
Medication sometimes can be culprits - for example, chemotherapy, anticholinergics, systemic retinoids, and niacin often have side effects of dry skin[3,4]
Did you know that the most common cause of itchy skin is dry skin[6]? It doesn’t help that scratching damages the skin barrier even more, making us more susceptible to irritants and allergens that can cause inflammation like dyes, fragrance, plants, rubber etc[6]. As well, having medical conditions such as atopic dermatitis (eczema), psoriasis, chronic kidney failure, diabetes, liver disease, or hypothyroidism can also affect the skin barrier and predispose your skin to being dry[1,4].
Treatment
When it comes to dry skin, I think it’s safe to say most people know the key is to moisturize. But what products are the best for this? Why do some work better than others?
Let’s start with what a moisturizer does. Since the purpose of moisturizers is to hold water in the outer layer of skin and replace the fats and oils that have been lost, thicker moisturizers work the best[1,5,6]. Moisturizers protect sensitive skin, mask imperfections, and improve skin texture. You can get the best results by applying moisturizers 3-4 times a day while the skin is still damp - just blot skin dry and apply within 3 minutes of bathing/washing hands to help trap moisture in the skin[2,4-7]. If you are using any medicated creams/ointments, apply your moisturizer about 30 minutes AFTER the medication[5]. This allows for the drug to absorb into the skin before being diluted by a moisturizer.
Most moisturizers are serums, gels, lotions, creams, and ointments and include emollients, humectants, occlusives, and barrier repair agents[4,5]. Gels evaporate the quickest (least effective). Lotions are more cosmetically appealing than a cream/ointment, as they spread more easily (sometimes good for the face). However, they dry relatively quickly in comparison to creams, and can have more irritating ingredients[6,7]. Creams are my FAVOURITE! Creams are thicker, hold in moisture longer, and are not as greasy and unpleasant as ointments. Look for an oil-based cream so thick it comes in a jar, not a pump bottle[3]! Ointments are thick and greasy, sitting on the skin the longest and providing excellent protection. It’s because of its texture that ointments are usually reserved for severely dry skin, or used at night rather than during the day. For example, for extremely dry hands, petroleum jelly can be applied before bed, using cotton gloves on top[2].
Other treatment options to help with dry skin include limiting hot water exposure (showers should be <10 mins, and only warm), avoiding harsh and drying soaps (opt for gentle skin cleansers with added moisture), and covering your skin on cold and windy days[1,2]. Oatmeal baths may help soothe the skin[8]. Caffeine, alcohol, and spices can cause dehydration, so try to limit these[4]. Manage stress levels (these can cause flares of dry skin especially for people with eczema and psoriasis), reduce sun exposure, and drink plenty of fluid[5]! Smoking can also reduce blood flow and dry out the skin[5], so if you’ve been thinking about trying to quit - now is the time! Many pharmacists have smoking cessation training and are happy to help you kick the habit.
Choosing A Moisturizer
When searching for a moisturizer, look for key words such as non-comedogenic (won’t block pores), non-irritating, and hypoallergenic (safe for sensitive skin)[4]. Everyone’s skin is a bit different, so you may have to try several brands/different ingredients to find one that suits your skin type[5]. For sensitive skin, choose soothing ingredients like chamomile; avoid acids as these may irritate[5]. Also make sure it says fragrance free and for sensitive skin[5]. Mature skin has less protection from damage (it’s thinner and drier), so a good option is petroleum jelly to hold in moisture and decrease wrinkles and lines[5]. Itchy skin may benefit from ingredients like pramoxine and colloidal oatmeal. You'll also notice in the list below that some ingredients have multiple functions (eg as an emollient and a humectant) - which simply means more benefits for the skin! Also keep in mind how effective the formulation is at preventing water loss (least to most moisturizing): gels --> lotions --> creams --> ointments.
Ingredients to Look For:
Emollients smooth and soften the skin by filling in space between stratum corneum cells and sealing in moisture; apply 3-4 times daily as needed. Stearic acid, stearyl alcohol, and cetyl alcohol in combination with emollients can improve the oil/water balance. Using emollients with occlusives is a power combo to reduce water loss[4,5,7]!
Cocoa butter
Ceramides
Oils (coconut, castor, sunflower, mineral, palm, jojoba)
Fatty acids
Lipids
Vitamins (A, E)
Shea butter
Humectants draw water into the top layer of skin; apply 2-3 times daily as needed[4,5].
Glycerin (high concentrations may increase water loss, avoid if sensitive skin)
Lactic acid (LESS than 12% concentration to moisturize)
Urea (LESS than 10% concentration to moisturize)
Acids (Alpha-hydroxy acid (AHA), glycolic acid)
Sodium hyaluronate
Hyaluronic acid
Sorbitol
Shea butter
Occlusives physically block the skin surface to prevent water loss and help with barrier repair; apply 3-4 times or more daily[4].
Beeswax
Dimethicone (silicones are often found in products labeled “oil-free”)
Lanolin (avoid if sensitive skin - may cause contact dermatitis)
Oils (mineral, soybean)
Paraffin
Petrolatum (greasy, hard to spread)
Zinc oxide
Shea butter
Barrier Repair Agents replace ceramides, which reduces transepidermal water loss, which in turn decreases triggers for inflammation[4]. These are usually a combination of ceramides/cholesterol/free fatty acids that help treat dry skin and its itch in atopic, radiation, and irritant dermatitis[4].
Bath Oils layer oil on top of the skin to prevent moisture from evaporating - best used at the end of a bath or shower.
Coal Tar
Colloidal oatmeal (for itching, enhances barrier function of skin)
Liquid paraffin
Ingredients to Avoid
The following may irritate the skin (especially if you have sensitive skin/are elderly)[1,4].
Lanolin (may cause contact dermatitis in sensitive skin)
Propylene glycol
Fragrance
Vitamin E
Aloe vera
Alcohols
Dyes
Preservatives
Glycerin (at high concentrations in sensitive skin)
Lactic acid (MORE than 12% concentration)
Urea (MORE than 10% concentration)
Herbal products (such as aloe vera) as a moisturizer may irritate the skin and their value is unclear[4]. Also be careful about products labeled “unscented”, as this does NOT mean fragrance free - it actually means chemicals have been added to hide a scent[7].
Rx Treatment
If over-the-counter moisturizers are not helping your skin heal, you may need to see a physician/dermatologist. They can assess the severity of your dry skin and prescribe different creams or ointments, usually containing topical corticosteroids for the inflammation, itch, and flaking. Another option that is steroid-free are “calcineurin inhibitors”, which work to reduce the inflammatory response your skin is having and include tacrolimus (Protopic ointment) and everolimus (Elidel cream). Treatment for more severe forms of dry skin such as psoriasis may include UV light therapy, or oral/injectable steroids if very severe[2,6].
Summary
Well, that was a lot of information about dry skin. Hopefully you found some of it helpful. Here are some key points to remember:
Try to apply a moisturizer as often as possible throughout the day, preferably when skin is moist.
My favourite pick is a CREAM over lotions/ointments - you may have to try different products to find one that helps your skin type the most.
I always recommend that a moisturizer should contain CERAMIDES.
Take note of ingredients to avoid, especially if you have sensitive skin.
Now what are you waiting for - reach for that cream!
References
Mayo Clinic. Dry skin. August 20, 2019. Retrieved 20Feb21 from https://www.mayoclinic.org/diseases-conditions/dry-skin/symptoms-causes/syc-20353885
Cleveland Clinic. Dry skin. Last reviewed May 2020. Retrieved 21Feb21 from https://my.clevelandclinic.org/health/diseases/16940-dry-skinitchy-skin
American Academy of Dermatology Association (AAD). Dry Skin: Overview. Retrieved 21Feb21 from https://www.aad.org/public/diseases/a-z/dry-skin-overview
Canadian Pharmacists Association. Dry skin. CTMA. Retrieved from RxFiles, 2021.
Mayo Clinic. Moisturizers: Options for softer skin. October 18, 2019. Retrieved 21Feb21 from https://www.mayoclinic.org/diseases-conditions/dry-skin/in-depth/moisturizers/art-20044232
Harvard Health Publishing: Harvard Medical School. Is that dry skin really something more serious? Harvard Health Letter, Feb 2018. Retrieved 21Feb21 from https://www.health.harvard.edu/diseases-and-conditions/is-that-dry-skin-really-something-more-serious
American Academy of Dermatology Association (AAD). Dermatologists’ top tips for relieving dry skin. 2021. Retrieved 25Feb21 from https://www.aad.org/public/everyday-care/skin-care-basics/dry/dermatologists-tips-relieve-dry-skin
American Academy of Family Physicians (AAFP). Pruritis Retrieved 21Feb21. https://familydoctor.org/condition/pruritus/
DISCLAIMER: The contents of this blog are for educational purposes and are not intended as medical advice. I enjoy researching but the information is general and not comprehensive. Please seek the advice of your healthcare provider (pharmacist/physician etc) with any questions you may have regarding your personal health. Never disregard professional medical advice or delay in seeking it because of something you have read online. Any mention of specific products or personal recommendations are my opinion and not to be taken as medical advice.
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