How to Assess and Assist Patients with Dry Skin

12.08.2021

It’s that time of year again—as the weather gets colder and drier, almost every patient coming into the pharmacy seems to be asking what to do about their dry, itchy skin! 

 

What Causes Dry Skin? 

Dry skin, also called xerosis or xeroderma, occurs when the surface of the skin loses too much water.1-4 Symptoms can include skin tightness, scaling, flaking, roughness, peeling, fine lines, and itching; it can also lead to dermatitis, with symptoms of redness, cracking and inflammation.1,4,5 

 

The top layer of skin is normally thick with natural fats and oils, acting as a barrier to retain moisture and prevent irritants and bacteria from entering.6 Our skin has three layers: the epidermis, dermis, and subcutaneous layer. The stratum corneum is the upper layer of the epidermis, and it helps protect the skin by acting as the primary barrier to water loss. It’s made of different components, including a lipid layer with ceramides, cholesterol, and free fatty acids. Healthy skin has a high concentration of ceramides, which protect the 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

 

Risk factors for dry skin include age, environment, occupation, personal products, medications, and medical conditions (see Table 1).

 

Table 1. Risk factors for dry skin.  

 

Age 

  • As age increases, particularly above 40 years old, skin becomes thinner, loses fats and oils, and moisture can more easily escape1,2 

 

Environment 

  • Cold weather and dry climates with low humidity1  
  • Excessive sun exposure4  
  • Heat, in the form of space heaters, fireplaces, central heating, or wood-burning stoves   
  • Hot showers and baths1  

 

Occupation 

  • Occupations that require frequent handwashing (e.g, healthcare workers and hairstylists)1,2  

 

Personal Products 

  • Harsh perfumes, soaps, shampoo, deodorant, and detergents, which are formulated to remove oil1 

 

Medications 

  • Examples include chemotherapy, anticholinergics, systemic retinoids, and niacin3,4 

 

Medical Conditions 

  • Atopic dermatitis (eczema), psoriasis, chronic kidney failure, diabetes, liver disease, and hypothyroidism can affect the skin barrier and predispose skin to being dry1,4 
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Treatment for General Dry Skin 

Often people with dry skin are not using a moisturizer. 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 oil-based moisturizers work best.5,6 Moisturizers should be applied 3-4 times a day, preferably while the skin is still damp. Applying a moisturizer within 3 minutes of bathing/washing hands helps trap moisture in the skin.2,4,5 If a patient is using any medicated creams/ointments, you can suggest they apply their 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 water-based gels, lotions, and creams, which can act as humectants, occlusives, or barrier repair agents.4,5 Emollient ointments can also be used as moisturizers since they create a barrier on the skin to reduce water loss.4 Thick creams or ointments offer the most protection against dry skin, but for patients who find these options too greasy, lotions may still be beneficial. 7 For moisturizer categories, see Table 2 below.  

 

Non-pharmacological treatment options to help with dry skin include limiting hot water exposure (showers should be <10 mins, using only warm water), avoiding harsh and drying soaps (suggest gentle skin cleansers with added moisture), and covering the skin on cold and windy days.1,2 Oatmeal baths may help soothe the skin.8 Caffeine, alcohol, and spices can cause dehydration when ingested in excess, so limiting these may help.4 Managing stress levels (which may cause flares of dry skin for people with eczema and psoriasis), reducing sun exposure, and drinking plenty of fluids can help alleviate dry skin. Quitting smoking may also be helpful since nicotine can reduce blood flow and dry out the skin.2 

 

Choosing a Moisturizer 

Help patients find a moisturizer labeled as non-comedogenic (won’t block pores), non-irritating, and hypoallergenic.4 For sensitive skin, make sure the product says fragrance-free and for sensitive skin.5 Mature skin has less protection from damage because it is thinner and drier, so a good option is an oil-based moisturizer containing petroleum jelly to hold in moisture.5 

 

Table 2. Categories of moisturizers.4 

 

Emollients 

  • Soften skin by filling in space between stratum corneum cells and sealing in moisture 
  • Stearic acid, stearyl alcohol, and cetyl alcohol in combination with emollients can improve the oil/water balance 
  • Examples include ceramides, cocoa butter, and various oils 

 

Humectants 

  • Draw water into the top layer of skin 
  • Often used with occlusives to improve the skin’s ability to retain moisture 
  • Examples include glycerin, hyaluronic acid, lactic acid in concentrations £12%, and urea in concentrations £10% 

 

Occlusives 

  • Physically block skin surface to prevent water loss and help with barrier repair 
  • Examples include lanolin, zinc oxide, petrolatum, and beeswax 

 

Barrier Repair Agents 

  • Replace ceramides to reduce TEWL, which in turn reduces triggers for inflammation  
  • Examples include combinations of ceramides, cholesterol, and free fatty acids  

TEWL= transepidermal water loss  

 

The use of herbal products (such as aloe vera) in moisturizers may irritate the skin and their value is unclear.4 Advise patients to be cautious of products labeled as “unscented”, as this does not mean fragrance-free—it means chemicals have been added to hide a scent.9

Rx Treatment

If over-the-counter moisturizers are not helping a patient’s skin heal, they may need to see a physician/dermatologist to have the severity of dry skin assessed. Prescription topical corticosteroids may be used for extremely dry skin, while severe cases may require oral or injectable medication.2 

 

Written by Chelsea Geen, BSc(H), MES, PharmD, RPh

 

References 
  1. Mayo Clinic. Dry skin. August 20, 2019. Retrieved 20Feb21 from https://www.mayoclinic.org/diseases-conditions/dry-skin/symptoms-causes/syc-20353885 
  2. Cleveland Clinic. Dry skin. Last reviewed May 2020. Retrieved 21Feb21 from https://my.clevelandclinic.org/health/diseases/16940-dry-skinitchy-skin 
  3. American Academy of Dermatology Association (AAD). Dry Skin: Overview. Retrieved 21Feb21 from https://www.aad.org/public/diseases/a-z/dry-skin-overview 
  4. Kleiman, Nancy. Dry skin. Canadian Pharmacists Association, CTMA. Last reviewed January 2018. Retrieved from CPS, 2Dec2021. 
  5. 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 
  6. 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 
  7. Howe, W. Treatment of atopic dermatitis (eczema). UpToDate. Last reviewed November 2021. Retrieved 2Dec21 from https://www.uptodate.com 
  8. American Academy of Family Physicians (AAFP). Pruritis. Last updated January 2020. Retrieved 21Feb21. https://familydoctor.org/condition/pruritus/ 
  9. 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