Effectiveness and safety of moisturizing wash and cream in the treatment of elderly xerosis cutis

To the Editor: As one of the most vulnerable groups of patients during the era of coronavirus disease 2019 (COVID-19), the geriatric population must adhere to specific guidelines to reduce their chance of contracting this potentially fatal virus. Older patients who implement measures, such as frequent handwashing and sheltering in place, benefit most from the perspective of viral infectivity; however, paradoxically, this group is also the most vulnerable to dermatologic consequences associated with these preventative measures. The use of hand sanitizer and handwashing have become particularly important during COVID-19. Guidelines provided by the Centers for Disease Control and Prevention (CDC) recommend frequent handwashing multiple times a day and suggest the use of an alcohol-based hand sanitizer that contains at least 60% alcohol when soap and water are not readily available.1 Frequent handwashing and alcohol-based hand sanitizers are a common cause of dry skin and irritation in the general population, and skin changes associated with the aging process further predisposes older patients to these conditions. Barrier function and recovery in aged skin (aged >80 years) is more readily disrupted than is young skin (aged 20–30 years), resulting in transepidermal water loss and altered permeability to chemical substances.2 Increased handwashing can further exacerbate this problem, leading to xerosis (i.e., skin dryness; Figure 1A) and increased susceptibility to irritant contact dermatitis (ICD) (Figure 1B). Xerosis is a common dermatologic problem in the older population, characterized by rough, flaky, and scaly skin, and is the most common cause of pruritus in older people.3 ICD occurs on contact with an irritating chemical or physical substance to the skin, and patients present with a pruritic rash characterized by erythema, papules, fissures, and scaling. Pruritus characteristic of these dermatologic conditions is thought to occur secondary to abnormalities in cytokine levels, skin pH, keratinization, and surface lipid components.4 The mainstay of treatment for prevention of ICD is avoidance of the offending agent; however, this option is not feasible in the current climate, and emphasis should be placed on prevention. As a functional, protective cutaneous barrier exists at an acidic pH (4.0–6.0), prevention of barrier dysfunction characteristic of xerosis and ICD should include the use of low pH cleansers and moisturizers.5 Alkaline bar soaps can be irritating to the skin and should be avoided. Other preventative measures include the use of barrier creams containing dimethicone and moisturizers rich in ceramides.6 Treatment of ICD can be achieved through the use of topical corticosteroids; however, the clinician should be weary of increased risk for steroid-induced atrophy in the geriatric population, in whom the skin is thin. Itch relief can be obtained with use of cold compresses. The CDC and federal government have also recommended that Americans “shelter in place” as an emergency preparedness and response measure to COVID-19. Individuals across the country are remaining inside their homes and being discouraged from engaging in outside activity due to risk for viral exposure. Older patients who are becoming more sedentary due to these measures are at risk for exacerbation of stasis dermatitis, a common condition seen in the geriatric population that results from aberrant venous drainage from the legs (Figure 1C).7 Stasis dermatitis is a common cause of chronic pruritus in the lower extremities of older patients and can be extremely uncomfortable for patients.8 To improve symptoms of this condition, geriatric patients should use elastic stockings and frequently elevate the legs to improve venous circulation. The stress of surrounding COVID-19 and social isolation can have significant negative effects on mental stress in older people. Psychological stress has an impact on many skin diseases and can play a substantial role in exacerbating disease activity.9 One of the most common skin conditions in which psychological factors play a central role is seborrheic dermatitis (SD). SD is common in the older population, and especially in those with Parkinson's and Alzheimer's disease.10 To help abate symptoms of SD, we recommend the use of topical antifungal shampoos, such as ketoconazole, as well as mild-to-moderate topical corticosteroids. Dr. Yosipovitch is Scientific Board Member of Menlo, Trevi, Sanofi Regeneron, Galderma, Pfizer, Novartis, Kiniksa, Eli Lilly, Leo, and Bellus; and has received research support from Pfizer, Sun Pharma, Leo, Novartis, and Kiniksa. The other author has no conflicts of interest. Rachel Shireen Golpanian and Gil Yosipovitch were involved in study concept and design, acquisition and interpretation of data, and preparation of the article. Hong Liang Tey, from the National Skin Center in Singapore, contributed to providing the figure in this article. None.

Dry skin is a common dermatological condition that frequently affects the elderly. A contributing cause to dry skin is a reduced concentration of hyaluronic acid (HA) in both the epidermis and dermis. The effectiveness of moisturizer containing HA as a therapy for dry skin is impacted by its specific molecular weight. Low molecular weight HA (LMWHA) is believed to be more effective in replenishing skin hydration in aging skin compared to High Molecular Weight HA (HMWHA) due to its ability to penetrate the stratum corneum. However, there is a lack of clinical research supporting this claim. A double-blind, randomized controlled trial was conducted on 36 residents of a nursing home in Jakarta. The participants, aged between 60 and 80 years, had been diagnosed with dry skin. Each test subject was administered three distinct, randomized moisturizing lotions (LMWHA, HMWHA, or vehicle), to be topically applied to three separate sites on the leg. Skin capacitance (SCap), transepidermal water loss (TEWL), and specified symptom sum score (SRRC) were measured at weeks 0, 2, and 4. After four weeks of therapy, area that was treated with LMWHA showed greater SCap values compared to the area treated with HMWHA (56.37 AU vs. 52.37 AU, p = 0.004) and vehicle (56.37 AU vs. 49.01 AU, p < 0.001). All groups did not show any significant differences in TEWL and SRRC scores. No side effects were found in all groups. The application of a moisturizer containing LMWHA to the dry skin of elderly resulted in significant improvements in skin hydration compared to moisturizers containing HMWHA and vehicle. Furthermore, these moisturizers demonstrated similar safety in treating dry skin in the elderly. ClinicalTrials.gov Identifier NCT06178367, https://clinicaltrials.gov/study/NCT06178367 .

Atopic dermatitis (AD) is characterized by impaired epidermal barrier function. Portable devices are available to measure stratum corneum hydration (SCH) and transepidermal water loss (TEWL). These could be incorporated into clinical practice to measure barrier function to define treatment success in AD. Despite the importance, there is minimal evidence for objective biophysical measurements to assess treatment success. The aim of this study was to evaluate the role of SCH and TEWL in distinguishing treatment efficacy between methotrexate and topical treatments and their correlation with Eczema Area and Severity Index (EASI), Patient-Oriented Eczema Measure (POEM) and Dermatology Life Quality Index (DLQI). Patients with AD (n = 16) were recruited from a specialist eczema clinic, as well as healthy controls (n = 10). All cases were recruited when the current therapy switch was planned, namely at the point of treatment failure. Of the patients with AD, 56% (9 of 16) had not responded to topical therapy, and 44% (7 of 16) had not responded to methotrexate. EASI scores did not differ significantly between the groups with lack of response to topical treatment or methotrexate (mean 20.7, SD 10.9 vs. mean 18.2, SD 15.1, respectively; P = 0.70). Furthermore, DLQI and POEM scores did not significantly differ between topical or methotrexate treatment (P = 0.24 and P = 0.89, respectively). As expected, healthy control samples showed significantly better barrier function than both lesional (TEWL, P &amp;lt; 0.001; SCH, P = 0.002) and nonlesional skin (TEWL, P = 0.004; SCH, P = 0.02). EASI positively correlated with TEWL values in both lesional and nonlesional skin (r &amp;gt; 0.5, P &amp;lt; 0.05). However, SCH did not correlate well with EASI for lesional and nonlesional skin (r = 0.075 and 0.029, respectively). Interestingly, with topical treatment, lesions could be distinguished from nonlesions by both TEWL (P = 0.008) and SCH (P = 0.003), even in treatment failures. However, with methotrexate treatment, barrier function measures were equivalent between lesions and nonlesions for TEWL (P = 0.44) and SCH (P = 0.55). Skin barrier function correlated very weakly with patient-reported outcomes for both TEWL and SCH, with POEM (lesional r2 = 0.15 and 0.04, respectively; nonlesional r2 ≤ 0.005 and r2 = 0.04) and DLQI (lesional r2 = 0.11 and 0.22; nonlesional r2 = 0.06 and 0.21). In conclusion, barrier function, as defined by TEWL and SCH, was significantly impaired in AD compared with healthy controls, but only TEWL scores correlated with EASI. In the patients, SCH did significantly distinguish lesions from nonlesions, as did TEWL. However, unlike topical-treated cases, in those with methotrexate treatment, no difference was shown between lesional and nonlesional TEWL and SCH. These data suggest that systemic therapy with methotrexate may improve lesional skin barrier function to that of nonlesional skin, even in those who are deemed to have not responded to treatment. Therefore, additional measures may be required to automate the definition of therapeutic treatment success or failure.

Purpose: The study aimed to investigate the effects of a sugar-based structure, i.e. XAX (Xylitylglucoside-Anhydroxylitol-Xylitol) on skin barrier function and moisturization, both in vitro and in vivo, and to compare its efficacy with that of glycerin.Methods: Expression of genes was investigated by RT-qPCR analysis on topically-treated human reconstructed epidermis. Ceramide neosynthesis was measured by chromatography in topically-treated human skin explants. Production of essential proteins was monitored in primary cell cultures: Chondroitin sulfate and hyaluronic acid in fibroblasts, using chromatography; hyaluronic acid in keratinocytes, using ELISA. In vivo, epidermal microrelief, skin capacitance and transepidermal water loss (TEWL) were measured on 25 female volunteers with dry skin. Skin capacitance and TEWL were also measured, on hands, comparing hydroalcoholic gels.Results: XAX increased the expression of key moisturizing-related genes, such as enzymes, structural components or regulators of inter-keratinocytes junctions, cornified layer, desquamation process, as well as skin barrier function and hydration. It also increased the contents of ceramides, hyaluronic acid and chondroitin sulfate. In vivo, XAX treatment at 3% decreased TEWL and increased skin capacitance, skin microrelief and desquamation. The combination of XAX+glycerin (1.5%+1.5%) showed interesting effects compared to glycerin alone.Conclusion: XAX promoted effects on the biological pathways involved in skin barrier function; epidermal and dermal water reserves; and epidermal water circulation. Its effectiveness, confirmed in vivo, alone and in combination with glycerin, makes it an interesting alternative to basic emollients, humectants and occlusives.

Moisturising creams are useful treatment adjuncts in inflammatory dermatoses and have beneficial effects in the treatment of dry, scaly skin. The effects on dryness and skin permeability of a new moisturising cream with 20% glycerine was compared with its placebo and with a medicinally authorised cream with 4% urea (combined with 4% sodium chloride) in the treatment of dry skin. Patients (n=109) with atopic dermatitis were treated for 30 days with a moisturiser in a randomised, parallel and double-blind fashion. Transepidermal water loss (TEWL) and skin capacitance were assessed instrumentally, and changes in the dryness of the skin were assessed by the dermatologist. No difference in TEWL was found between glycerine treatment and its placebo, whereas a lower value was found in the urea-treated area compared to the glycerine-treated area. No difference in skin capacitance was found. The clinical assessment of dryness showed urea to be superior to glycerine in treating the condition. Moisturising creams are different, not only with respect to composition but also with respect to their influence on skin as a barrier to water in patients with atopic dermatitis.

No studies have been performed evaluating skin barrier alterations in humans exposed to ultra-low humidity (ULH) in spite of several lines of evidence from animal experiments suggesting that the skin barrier is altered on exposure to ULH. The objectives of this study were to assess barrier function changes in workers occupationally exposed to ULH (relative humidity 1.5%), and to evaluate whether the exposure duration shows a dose-response relationship with transepidermal water loss (TEWL) and skin capacitance. A total of 49 male workers exposed to ULH for 12 h per working day were classified into five subgroups based on their ULH exposure duration (<0.5 months, 0.5-1.0 month, 1.1-10.0 months, 10.1-20.0 months, and >20.0 months). A group of 12 age-matched male laboratory workers from a normal humidity environment were recruited as a control group. TEWL and skin capacitance were measured to evaluate their skin barrier function. TEWL measurements showed a significant decline (8.3+/-0.4 vs 10.0+/-0.4 g m(-2) h(-1), P < 0.05) but no differences were found in skin capacitance (39.7+/-1.3 a.u. vs 45.0+/-2.4 a.u., P = 0.68) between the whole ULH exposure group and the control group. Maximum decreases in TEWL and skin capacitance were seen in the subgroups exposed for <0.5 months and 0.5-1.0 month, respectively. Almost completely natural recovery occurred in skin capacitance after 20 months ULH exposure, in contrast to less than 90% recovery in TEWL. Three stages were defined according to the pattern of alterations in TEWL and skin capacitance in relation to ULH exposure duration. A positive association between TEWL and skin capacitance occurred in the control group and stage I but a negative correlation in stage II. No correlation was found in stage III. Our study demonstrated that workers exposed to a ULH environment could exhibit skin barrier alterations. Both TEWL and skin capacitance decreased within 2 weeks of ULH exposure. The maximum alterations in TEWL and skin capacitance occurred during 0.5-1.0 months and 2 weeks, respectively. TEWL recovered partially and more slowly than skin capacitance which recovered earlier and almost completely.

To determine whether consuming heat-killed Lactiplantibacillus plantarum L-137 (HK L-137) influences skin functions, we performed a randomized, placebo-controlled, double-blind study in healthy participants who were conscious of dry skin. A total of 80 healthy participants (20 men, 60 women; mean age, 47.3 years) were assigned to receive a tablet containing HK L-137 or a placebo tablet daily for 12 weeks. Every 4 weeks, the skin water content and transepidermal water loss (TEWL) were measured at the forearm and face, and participants completed two skin-related questionnaires, the Dermatology Life Quality Index and a self-evaluation. The HK L-137 group tended to show greater increases from baseline of water content at the forearm and larger decreases of TEWL at the face. The total scores of both questionnaires improved significantly more in the HK L-137 group. Water content and TEWL improved significantly in participants in the HK L-137 group who were above the median age of study participants or had relatively dry skin. These findings suggest that daily HK L-137 intake can improve dry skin, thereby contributing to skin satisfaction.

Objectives: The morbidity of dry and itchy skin was high during a person’s lifetime and it had a significant negative impact. This study aimed to investigate the positive effect of silk fibroin moisturizing cream on dry skin pruritus induced by acetone/ether-water (AEW) method in mice. Method: We established a dry skin model in mice with AEW treatment, and the control group was treated with ultrapure water. The mice in AEW model group were locally administrated with silk fibroin moisturizing cream (SilkArmor)®. The transepidermal water loss (TEWL), scratching behavior, condition of skin erythema, skin histology (by hematoxylin-eosin staining) and the results of electron microscopy were measured to evaluate the positive effect of SilkArmor on dry and itchy skin in mice. Results: The TEWL value, spontaneous scratching behavior and erythema score were significantly increased after AEW modeling compared with the control group. There was no significant difference in the TEWL value, scratching behavior and erythema score between the SilkArmor group and the control group (P > 0.05). Compared with the AEW group, the value of TEWL, scratching behavior and the erythema score of mice in the AEW + SilkArmor group were improved, with statistically significant differences (P < 0.05). Skin histopathology and electron microscopy also showed that SilkArmor had certain improvement and repairment on AEW-induced skin pathological changes. Conclusions: A dry skin model was successfully established in this experiment, showing that SilkArmor brought an obvious alleviation to AEW-induced dry and itchy skin in mice.

SKIN BARRIER FUNCTION ALTERATIONS AMONG WORKERS IN AN ULTRA-LOW HUMIDITY ENVIRONMENT

Objectives Among Traditional Korean Medicine approaches, needle-embedding therapy is used in various fields and consistently studied; however, there have been no clinical studies of the treatment of adult atopic dermatitis (AD) with needle-embedding therapy. Thus, there is a need to investigate the effects of needle-embedding therapy for treatment of AD. This study was performed to identify possible effects of needle-embedding therapy at Quchi acupoint (LI11) on AD and to compare these effects with those of acupuncture therapy. Methods A total of 14 participants were enrolled in this study. Participants received acupuncture or needle-embedding treatments for 4 weeks and then were followed for an additional 2 weeks because of safety assessment. The participants were divided into 2 groups: the acupuncture group, receiving treatment at Quchi acupoint (LI11) 3 times per week, and the needle-embedding group, receiving treatment at Quchi acupoint (LI11) once per week. The groups were compared on the basis of the SCORing Atopic Dermatitis (SCORAD) index, Transepidermal Water Loss (TEWL), skin hydration, and Dermatology Life Quality Index (DLQI) at baseline and 1 week after treatment was completed (5th week). Results The SCORAD index, TEWL, Skin hydration, and DLQI at 1 week after treatment were significantly improved in both groups (p<0.05). However, there were no significant differences between the acupuncture and needle-embedding groups in any of the main evaluation indices (p>0.05). The study participants received a total of 84 acupuncture treatments or 28 needle-embedding treatments. No adverse events occurred during the study period. Conclusions Based on changes in the SCORAD index, TEWL, skin hydration, and DLQI value, we found that both needle-embedding and acupuncture treatments at the Quchi acupoint (LI11) were effective in decreasing the symptoms of AD and exhibited similar therapeutic effects, which suggests that needle-embedding treatment may be more clinically convenient than acupuncture, with longer effects and fewer treatments.

IntroductionPatients with atopic dermatitis (AD) have impaired barrier function, which decreases skin hydration, weakens their defense against microorganisms, and culminates in increased inflammatory responses. Here, we conducted a clinical trial to evaluate the efficacy of a multi-lamellar emulsion (MLE) containing the pseudoceramide PC-9S and a synthetic sphingosine kinase 1 (SPHK1) activator, Defensamide™, in improving mild-to-moderate atopic dermatitis.MethodsForty patients aged ≥ 2 years were randomized into a combined-therapy group treated with the MLE containing PC-9S and Defensamide™ plus a topical corticosteroid and a topical-corticosteroid-only group. Assessments based on therapeutic methods included the Eczema Area and Severity Index (EASI), the Investigator Global Assessment (IGA), transepidermal water loss (TEWL), stratum corneum hydration (SCH), skin dryness, a visual analogue scale (VAS) of itchiness, a VAS of sleep disturbance, patient satisfaction, and the Dermatology Life Quality Index (DLQI).ResultsThirty-eight patients completed this study. In the combined-therapy group, significant improvements in clinical and instrumental measures such as EASI scores, skin hydration, and skin dryness were noted at 4 weeks compared to baseline, but such improvements were not noted in the topical corticosteroid-only group. Subjective assessments of itching and sleep disturbance and DLQI scores also showed significant improvements in the combined-therapy group.ConclusionCombined therapy with the MLE containing Defensamide™ and PC-9S and with topical corticosteroid demonstrated superior clinical outcomes compared with topical corticosteroid monotherapy. Our findings underscore the potential of MLE-containing formulations as effective adjunctive therapies for AD, offering both objective and subjective symptomatic relief and enhancing patients' quality of life.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13555-024-01254-5.

Introduction: Aging is a progressive process of decrease in organs functions and capacity, including the skin. Photoaging is extrinsic aging mainly occur due to ultraviolet (UV) exposure. Methods: This study is a clinical trial research design with one group pre-post test. All subjects who were exposed to UV for approximately 3-4 hours. All subjects signed an informed consent and were interviewed accordingly. Photoaging was diagnosed clinically by three dermatologists according to Glogau type II classification such as dynamic wrinkles, palpable keratosis, visible lentigo senilis, and smiley line. SOD 250 IU was given to all subjects twice daily for 60 days. Laboratory examinations such as TAS, TEWL, and sebum concentration were done pre and post-intervention. Results: A total of 25 subjects, Fitzpatrick skin type 4 were included in this study. There were 14 males and 11 females with 20 subjects age 30-40 years old and 5 subjects age 25-29 years old. Fourteen (56%) out of 18 subjects from low TAS group have normal TAS post-treatment with SOD. McNemar test showed a significant increase in TAS value pre and post-treatment with SOD (p&lt;0.05). TEWL measurement on cheek showed 9 out of 10 subjects from the strained group have normal TEWL post-treatment, while all 3 subjects from the critical group have normal TEWL value. Measurement on the forehead showed 7 subjects from the strained group have a normal TEWL. Sebumeter on the forehead showed 17 subjects from dry skin group 14 (56%) subjects have normal skin, 1 (4%) subject becomes oily, and 2 subjects remains dry post-treatment with SOD for 60 days. All subjects with dry skin on U zone become normal skin post-treatment. Conclusion: SOD significantly increased TAS value, decreased TEWL, and improvement of skin dryness post-treatment with SOD for 60 days.

Post-acne erythema (PAE) is one of the most common inflammatory sequelae of acne. Although various therapeutic approaches are currently available, many are limited by suboptimal efficacy, poor tolerability, or high costs. This trial aims to evaluate the clinical efficacy and safety of non-cross-linked hyaluronic acid (HA) mesotherapy for the treatment of PAE. A total of 25 patients aged 18-35 years with clinically diagnosed PAE and bilaterally symmetrical facial lesions were enrolled. Three treatment sessions were performed at 4-week intervals. The primary outcome was the Clinician Erythema Assessment Scale (CEAS) score assessed at baseline and week 12. Secondary endpoints included the Dermatology Life Quality Index (DLQI), Patient Self-Assessment (PSA), VISIA skin analysis (red areas, pores, texture), CK measurement parameters (erythema index, melanin index, skin hydration, transepidermal water loss), dermoscopic imaging, adverse effects, and relapse. Finally, 23 patients completed all treatment sessions. By week 12, the mesotherapy group showed significantly lower CEAS scores compared to the control group. In addition, patients in the mesotherapy group reported higher satisfaction levels. Improvements in red areas, pores, texture, erythema index, skin hydration, transepidermal water loss, and dermoscopic imaging were also more marked in the mesotherapy group. There was a significant change in the DLQI score, too. No serious adverse events or erythema flares occurred during the study. Among the 23 patients who completed the trial, only one experienced acne relapse. According to the results of this study, non-cross-linked HA mesotherapy is a promising and useful therapeutic option for PAE.

Atopic dermatitis (AD) is characterized by dryness of the skin, pruritus and involvement of the skin flexures. Skin hydration (SH) and integrity, as measured by transepidermal water loss (TEWL), are important parameters for objectively quantifying AD research. To evaluate if sites in the forearm are equivalent to the antecubital fossa for standard SH and TEWL measurements; and to determine the correlations among these measurements and scores of disease severity and quality of life. We evaluated SH and TEWL under standardized conditions at three common measurement sites in the forearm (antecubital flexure, 2 cm below the antecubital flexure, mid-forearm), and determined the SCORing Atopic Dermatitis (SCORAD) score, Nottingham Eczema Severity Score (NESS), and Children's Dermatology Life Quality Index (CDLQI). Significant correlations between clinical scores, SH, and TEWL were obtained at a site 2 cm below the antecubital fossa (r = -0.553, p < 0.001 for SH and SCORAD; r = 0.596, p < 0.001 for TEWL and SCORAD). SH and TEWL were also correlated with long-term severity of AD as measured by NESS (r = -0.494, p = 0.001 for SH; r = 0.430, p = 0.004 for TEWL), while TEWL was significantly correlated with CDLQI (r = 0.323, p = 0.035). Overall, similar significant correlations were obtained at the mid-forearm, but less so at the antecubital fossa. In AD research, three sites on the forearm appear to be convenient for determination of SH and TEWL. This is the first report to demonstrate that significant correlations are obtained among acute and chronic scores of AD disease severity, quality of life, and the bioengineering parameters.

Background: Xerosis and pruritus (XP) are the most common skin conditions in the elderly, manifesting clinically as roughness, scales, fissures, and mild-to-severe itching. Vitamin D improves skin hydration, transepidermal water loss (TEWL), and regulates the immune system. We aimed to determine the efficiency of topical 7-dehydrocholesterol (DHC)-vitamin D3 complex cream in elderly patients with XP. Methods: An experimental phase III study was performed on elderly women with XP from December 2021 to March 2022 at the Geriatric Dermatology Clinic of Dr. Mohammad Hoesin General Hospital, Palembang. Inclusion criteria were age older than 55 years, healthy or with comorbidity. The exclusion criteria include the use of moisturizer within two weeks before the study. DHC-vitamin D3 cream was applied on subject’s volar arms once a day. Overall dry skin score (ODSS), visual analog scale (VAS) for pruritus and adverse effects, skin hydration, TEWL, sebum level, serum vitamin D level, and dermatology life quality index (DLQI) were assessed at baseline and after 4 weeks. Statistical analysis was done with Wilcoxon and paired T-test. Results:Eighteen elderly women were included. Most subjects were 60 to 74 years old (83,3%). Half the subjects (50%) had comorbidity. There was a significant difference in skin hydration (p Conclusion: Topical 7-DHC vitamin D3 complex cream is proven to improve skin barriers, increase serum vitamin D levels, well-tolerated, and provided satisfaction and comfort in elderly women with XP.