59: Eczema Regimens

Eczema Regimens

Zoe Diana Draelos

Dermatology Consulting Services, PLLC, High Point, NC, USA


Eczematous skin disease is one of the most commonly treated dermatologic conditions. While topical prescription corticosteroids and calcineurin inhibitors are the mainstay of therapy, cosmeceutical moisturizers are key to the treatment and prevention of disease. Moisturizers enhance the skin barrier, decreasing stinging and burning from a sensory standpoint and improving the look and feel of the skin. Moisturizers can also smooth desquamating corneocytes and fill corneocytes gaps to create the impression of tactile smoothness. This effect is temporary, of course, until the moisturizer is removed from the skin surface by wiping or cleansing. From a functional standpoint, moisturizers can create an optimal environment for healing and minimize the appearance of lines of dehydration by decreasing transepidermal water loss. Transepidermal water loss (TEWL) increases when the “brick and mortar” organization of the protein‐rich corneocytes held together by intercellular lipids is damaged. A well‐formulated cosmeceutical moisturizer can decrease the water loss until healing occurs (Table 59.1).


Eczema is characterized by barrier disruption, which is the most common cause of sensitive skin. The barrier can be disrupted chemically through the use of cleansers and cosmetics that remove intercellular lipids or physically through the use of abrasive substances that induce stratum corneum exfoliation. In some cases, the barrier may be defective because of insufficient sebum production, inadequate intercellular lipids, or abnormal keratinocyte organization. The end result is the induction of the inflammatory cascade accompanied by erythema, desquamation, itching, stinging, burning, and possibly pain. The immediate goal of treatment is to stop the inflammation through the use of topical, oral, or injectable corticosteroids, depending on the severity of the eczema and the percent body surface area involved. In dermatology, topical corticosteroids are most frequently employed with low potency corticosteroids (desonide) used on the face and intertrigenous areas, medium potency corticosteroids (triamcinolone) on the upper chest and arms, high potency corticosteroids (fluocinonide) on the legs and back, and ultra‐high potency corticosteroids (clobetasol) used on the hands and feet. Newer topical options for the treatment of eczema‐induced sensitive skin include the calcineurin inhibitors, pimecrolimus, and tracrolimus.

However, the resolution of the inflammation is not sufficient for the treatment of eczema. Proper skin care must also be instituted to minimize the return of the conditions that led to the onset of eczema.

Moisturizer mechanism of action

Moisturizers are incorporated into eczema treatment regimens to reduce transepidermal water loss. There are three cosmeceutical ingredient categories that can reduce transepidermal water loss: occlusives, humectants, and hydrophilic matrices [1]. The most common method for reducing transepidermal water loss is the application of an occlusive ingredient to the skin surface. These are oily substances that create a barrier to water evaporation. The more commonly used occlusive ingredients in current formulations and their chemical category are listed in Table 59.2 [2].

Table 59.1 Moisturizer mechanisms of action.

Moisturizer benefit Mechanism of action
Enhance skin barrier Ingredients such as waxes, petrolatum, and oils can place a protection film over the skin surface functioning as a temporary skin barrier to retard TEWL
Create optimal environment for healing Healing is optimized in a moist environment, moisturizers decrease TEWL to enhance healing
Decrease noxious sensory stimuli Temporary moisturizer barrier covers exposed nerve endings decreasing sensory stimuli, such as stinging, burning, itching, and pain
Decrease fine lines of dehydration Reduction in TEWL hydrates skin with increased water minimizing fine lines, especially in thin skin areas, such as around the eyes
Increase skin smoothness and softness Friction reducing film, usually containing dimethicone, smooths down desquamating skin scale and reducing friction thereby improving tactile skin properties
Improve skin radiance and luminosity Film forming polymers, such as silicone elastomers, put a smooth light reflective coating thereby improving optical skin properties

Table 59.2 Occlusive moisturizing ingredients to inhibit transepidermal water loss.

1. Hydrocarbon oils and waxes: petrolatum, mineral oil, paraffin, squalene
2. Silicone oils
3. Vegetable and animal fats
4. Fatty acids: lanolin acid, stearic acid
5. Fatty alcohol: lanolin alcohol, cetyl alcohol
6. Polyhydric alcohols: propylene glycol
7. Wax esters: lanolin, beeswax, stearyl stearate
8. Vegetable waxes: carnauba, candelilla
9. Phospholipids: lecithin
10. Sterols: cholesterol

The most popular and effective occlusive ingredient is time‐tested petrolatum, which blocks 99% of water loss from the skin surface [3]. This remaining 1% transepidermal water loss is necessary to provide the cellular message for barrier repair initiation. If the transepidermal water loss is completely halted, the removal of the occlusion results in failure to repair the barrier and water loss quickly resumes at its preapplication level. Thus, the occlusion does not initiate barrier repair [4]. Petrolatum does not function as an impermeable barrier, rather it permeates throughout the interstices of the stratum corneum allowing barrier function to be re‐established [5]. Moisturizers for eczematous disease must contain several occlusive moisturizing ingredients.

In addition to occlusive ingredients, a therapeutic moisturizer for eczema must contain humectants. Humectants are substances that attract water to the viable epidermis and stratum corneum from the dermis. They function as a sponge to hold and release water as necessary. Examples of humectants include glycerin, honey, sodium lactate, urea, propylene glycol, sorbitol, pyrrolidone carboxylic acid, gelatin, hyaluronic acid, vitamins, and some proteins [2, 6].

Humectants only draw water from the environment when the ambient humidity exceeds 70%. In environmentally controlled spaces, this does not occur, thus humectants pull water from the deeper epidermal and dermal tissues to rehydrate the stratum corneum. A therapeutic moisturizer for eczema must trap the water in the skin with an occlusive film placed on top of the stratum corneum [7]. Humectants also allow the skin to feel smoother by filling holes in the stratum corneum through swelling [8, 9]. Therefore, a moisturizer recommended for eczema must combine both occlusive and humectant ingredients for optimal efficacy and patient aesthetics. Occlusive and humectant moisturizers are the formulations most beneficial in the treatment of eczema and include the majority of those found in the dermatologic sample closet (Eucerin Cream and Lotion, Beiersdorf; Aveeno Cream and Lotion, Johnson & Johnson; Olay Daily Facial Moisturizer, Procter & Gamble; Cetaphil Cream and Lotion, Galderma; CeraVe Cream and Lotion, L’Oreal).

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Nov 13, 2022 | Posted by in Dermatology | Comments Off on 59: Eczema Regimens

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