Emollients
Emollients have been used for over 5,000 years and they form an essential part of the therapy for all dry skin conditions, including atopic and contact eczema.
Emollients are safe and effective and, in the majority of cases, mild to moderate eczema can be successfully treated by using emollient therapy alone.
Unfortunately, emollients are under used, as people often perceive them to be inactive moisturisers and do not understand why they are so important in controlling eczema. When used correctly as a daily skin care regime, emollients become effective ‘active treatments’. Emollient therapy is not just about products but understanding how and when to use them.
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Why are emollients so effective?
Dry skin is one of the main symptoms of eczema. Changes in skin moisture levels cause a reduction in the barrier function, which in turn increases water loss, thus allowing the penetration of irritants and allergens which trigger eczema.
Itching is another major and most distressing symptom of eczema and produces an itch-scratch-itch cycle. Scratching leads to the release of histamine, a chemical in the body, which makes the itching worse and leads to skin damage. This also allows entry for irritants, allergens and bacteria which trigger eczema.
Emollients soothe and relieve the itch, producing an oily layer over the skin surface which traps water beneath it. The resulting restoration of the skin’s barrier function by emollients prevents penetration of irritants, allergens and bacteria thereby reducing or preventing the development of eczema. A good skin care routine using emollients can soothe, moisturise, and protect the skin, thus helping to reduce the need for steroid preparations. In mild to moderate eczema, topical steroids and calcineurin inhibitors (e.g. Elidel and Protopic) should only be necessary intermitently for flare-ups of eczema.
What are emollients?
Emollient is simply the medical word for moisturiser. However, emollients are different from cosmetic moisturisers in that they tend to be unperfumed and do not have anti-ageing ingredients. Applying emollients can be very time consuming and tedious, but it helps to know what they do for your skin. Emollients help skin to feel more comfortable and less itchy. They keep the skin moist and flexible, helping to prevent cracks. There are many types of emollients and they can be classified according to how they are applied.
Lotions, creams and ointments: applied directly to the skin.
Bath and shower oils: added to the bath water or directly to the skin in the shower.
Soap substitutes: used instead of soap to cleanse the skin.
Lotions
Lotions contain more water and less fat than creams. They spread easily and are cooling, but are not very effective at moisturising very dry skin. They are useful for hairy areas or for quick absorbtion if time is short.
Creams
Creams contain a mixture of fat and water and feel light and cool on the skin. They are easier to spread over sore skin and are not greasy. All creams contain preservatives and people can become sensitised to them, although this is rare. Creams need to be used liberally and frequently so that the skin is not allowed to dry out.
Ointments
Most ointments do not contain water; therefore they do not need a preservative. This makes them ideal for people who react to preservatives. Ointments are often stiff and greasy and some people may find them cosmetically unacceptable. However, because they are very effective at holding water in the skin, they are useful for very dry and thickened skin, under wet wraps or if a heavier cream is required at night. Ointments should not be used on weeping eczema – use a cream or lotion instead. The absence of preservatives in ointments makes them vulnerable to contamination by bacteria transferred from your skin. It is very important not to put your fingers into the pots of ointment. Instead decant some of the ointment into another clean container before applying to your skin.
Bath oils
Bubble baths are extremely drying and potentially irritating to people with eczema. However, daily baths remove dirt and skin debris which could cause infection. Bath oils and warm water clean and hydrate the skin coating it with a film of oil to trap water in the skin.
Some bath oils are fully-dispersing while others are semi-dispersing, leaving more or less oil on the skin. As with emollients it can be a case of trial and error. Experiment to see which suits your or your child’s skin best. Some doctors prescribe emulsifying ointment for bathing. This needs to be dissolved with boiling water first and whisked with a fork. Some people find this helpful, while others find it messy and time-consuming. Discuss with your doctor to find an emollient regime
that works best for you.
Bath oils can be used in the shower, either on a sponge, or applied all over before showering off.
It is also possible to obtain emollients specially designed for the shower. If you find that entering the water stings the skin, apply a soap substitute or emollient all over before entering the water. Be careful not to slip – always use a bath/shower mat. Grab rails are also helpful. Placing a towel in the bath may also be helpful especially when bathing an active baby. Bath oils do make a mess of the bath. Wipe around the bath with paper towels or tissues – this will absorb excess oil and shine the bath. Warn other bath users that the bath or shower may still be slippery. The bath may be cleaned with a bath cleaner but be careful to rinse it thoroughly before use.
Soap substitutes
Soap is alkaline and very drying to skin with eczema. The hands are particularly at risk, as they are washed more frequently. Each wash degreases the skin. Detergent base soap-substitutes (liquid soaps/cleansers) and perfumed products should also be avoided as they tend to irritate eczematous skin.
Emollient soap-substitutes do not foam and may take a little while to get used to. It is not essential to have bubbles to clean the skin and emollient washing creams are very effective at cleaning the skin. Soap-substitutes can either be applied before bathing, showering or washing or scoop up a handful of cream and apply over the skin while in the water.
Choosing the right emollient
The best emollient is one which the patient prefers because then you, or your child, will use it more frequently. Dermatology nurses sometimes give out emollients for people to try. Always try new emollients on a small area of unaffected skin first to test for a reaction.
Once you have chosen your emollients they will need to be used frequently to have maximum benefit. Ideally this would be every few hours but it should be at least 3 to 4 times a day – getting through a 500g tub per week is not unusual.
It is important to use emollient products for the purpose for which they were designed. Aqueous cream was designed as an emollient soap substitute and for this purpose it is acceptable.
However if aqueous cream is used as a leave on emollient cream it can irritate the skin of children with eczema and make it worse rather than better. In an audit of children attending a paediatric dermatology clinic using aqueous cream caused irritant reactions in more than fifty percent of the children (Cork et al 2003).¹
When and how to apply emollients
When the skin is very dry, using a combination of the three types of emollients helps to give the best hydration and restore the skin’s barrier function to normal. Emollients can be used in combination with other treatments which your doctor may prescribe, such as topical steroids and topical calcineurin inhibitors.
There are no standard rules regarding whether to apply a topical steroid preparation after or before using an emollient. Some people are happiest using an emollient first to prepare the skin, followed by the steroid. However, whichever order of care you choose it is important that you leave as long a period as practical, approximately 1/2 to 1 hour, between the two treatments to avoid diluting the strength of the topical steroid preparation, and to prevent the spread of topical steroids and calcineurin inhibitors to areas not affected by eczema.
Emollient cream or ointment

Use liberally and frequently – every hour if the skin is very dry, but at
least 3 times a day.

Apply gently in the direction of hair growth. Never rub up and down vigorously as this could trigger itching, block hair follicles or create more heat in the skin.
Apply emollients after bathing, while water is still trapped in the skin, for extra hydration.
Avoid putting hands into large tubs of emollient cream. Use a spatula to take out the correct amount each time and replace the lid immediately.
Alternatively, ask your doctor or pharmacist about pump dispensers for emollients.
Continue to use the emollient, even when the eczema has improved, this will help prevent flare-ups.
Apply the emollients to all of your skin
Storage depends on whether you prefer your emollient warm or cold – try either the airing cupboard or fridge.

Bath oil

Adding oil to warm, not hot, bath water cleanses and hydrates the skin., Pat (do not rub) the skin dry. Apply emollient.

Emollient soap substitutes
Use whenever you would use soap, but particularly on the hands and
while bathing or showering.

¹ An audit of adverse drug reactions to aqueous cream in children with atopic eczema: M.J Cork
et al Pharmaceutical Journal, Vol 271 29 November 2003,
The National Eczema Society is grateful to Dr. Michael Cork, Head of Academic Dermatology, University of Sheffield Medical School and Honorary Consultant dermatologist at Sheffield Childrens and Royal Hallamshire Hospitals for his
help in the preparation and review of this sheet.
Disclaimer
These details are only as a general guide. Individual circumstances differ and the National Eczema Society does not prescribe, give medical advice or endorse products or treatments. We hope you will find the information useful, but it does not replace and should not replace the essential guidance given by your general practitioner, dermatologist and dermatology nurse..
Updated and revised 04/06
©National Eczema Society 2006