remedies for dry skin acc to andrews, fitzpatrick
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Remedies for Dry Skin (Xerosis)
According to Fitzpatrick's Dermatology
Definition & Causes
Xerosis (dry skin) is extremely common, especially in the elderly, and frequently affects the legs. It is multifactorial - age-related reduction in sebaceous and sweat gland activity, altered lipid composition, impaired filaggrin production, and intrinsic changes in keratinization all contribute. Systemic associations include chronic renal failure, liver disorders, lower-limb atherosclerosis, autoimmune diseases, and hepatitis C infection.
- Fitzpatrick's Dermatology, Vol. 1-2, Ch. 106
Treatment Approach
1. Environmental / Behavioral Modifications
- Avoid excessive washing, which exacerbates xerosis (particularly winter xerosis)
- Improve environmental temperature and humidity (cold, low-humidity environments worsen the condition)
- Reduce cold exposure
2. Emollients (cornerstone of treatment)
- Emollients are the primary topical treatment for both xerosis and its complication, asteatotic eczema (eczema craquelé)
- For dry skin types: use non-foaming cleansers (oils, creams, milk cleansers) that deposit fatty acids on the skin and repair the barrier
- Stearic acid (in shea butter) - straight hydrophobic tails that stack closely, giving optimal barrier repair
- Linoleic acid (in safflower oil, argan oil) - good antiinflammatory properties
- Avoid oleic acid (olive oil) - disrupts the lipid bilayer membrane
3. Moisturizers - Ingredients for Dry Skin
Fitzpatrick's classifies moisturizer ingredients for dry skin into:
| Category | Examples |
|---|---|
| Barrier Repair | Ceramides, cholesterol, fatty acids, MLE technology |
| Occlusives | Petrolatum, argan oil, safflower oil, grape seed oil, mineral oil, jojoba, flaxseed, lanolin, silicones, squalene, soybean oil, propylene glycol, wax |
| Humectants | Glycerin, hyaluronic acid, urea, alpha-hydroxy acids, heparan sulfate, propylene glycol, sugars |
4. Cleanser Choice
- Dry skin types need a neutral or acidic pH cleanser (high-pH soap cleansers perturb the skin barrier)
- Non-foaming cleansers are preferred over foaming/surfactant-heavy products
5. Exfoliants (adjunctive)
- Alpha-hydroxy acids (lactic acid, glycolic acid) - have humectant properties in addition to exfoliant action
- Avoid over-use; must combine with barrier-repair moisturizers
Summary from Fitzpatrick's:
Dry skin types should be treated with lipid-sparing cleansers (non-foaming) and barrier repair moisturizers. Humectant-, occlusive-, and exfoliant-containing products can be added for other issues (pigmentation, wrinkles) or to improve compliance.
- Fitzpatrick's Dermatology, Vol. 1-2, Ch. 207 (Skin Care)
According to Andrews' Diseases of the Skin (Dermatology 2-Volume Set, 5e)
Dry Skin and Pruritus - Practical Recommendations
- Use soapless, fragrance-free cleansers
- Apply emollients frequently, especially ointments and thicker creams (not thin lotions)
- Avoid tight-fitting or abrasive clothing; wear cool, breathable fabrics
- Avoid antihistamines if dryness of the eyes or mouth is also present (sicca syndrome)
- Dermatology 2-Volume Set 5e, Ch. 52 (Patient handout)
Cleansers for Dry Skin (Andrews)
- Lipid-free, non-foaming cleansers - applied to dry or moistened skin, wiped or rinsed away; important in persons with barrier disruption
- Cold creams - classic cleanser for dry, dermatitic skin; combines a lipid solvent (wax or mineral oil) with detergent action from borax
- Body washes with occlusive and emollient components (petrolatum + soybean oil) - cleanse while leaving moisturizing substances behind after rinsing
Moisturizer Types and Mechanism (Andrews)
Moisturizers work by retarding transepidermal water loss (TEWL) and creating an optimal environment for stratum corneum barrier restoration. Optimal stratum corneum water content is 10-30%.
1. Occlusive Moisturizers - place an oily substance on the skin to prevent evaporative water loss:
- Hydrocarbon oils and waxes: petrolatum (reduces TEWL by 99% - most effective occlusant), mineral oil, paraffin, squalene
- Silicones: cyclomethicone, dimethicone
- Vegetable oils: castor oil, corn oil, grape seed oil, soybean oil
- Animal oils: mink oil, emu oil
- Fatty acids: lanolin acid, stearic acid
- Fatty alcohols: lanolin alcohol, cetyl alcohol
- Polyhydric alcohols: propylene glycol
- Wax esters: lanolin, beeswax, stearyl stearate
- Vegetable waxes: carnauba wax, candelilla wax
- Phospholipids: lecithin
- Sterols: cholesterol, ceramides
Note: Total occlusion is undesirable - TEWL is the cellular signal that initiates barrier repair and lipid synthesis. Petrolatum is preferred because it reduces TEWL by 99% while still allowing barrier repair by permeating throughout the interstices of the stratum corneum.
2. Humectants - attract moisture into the stratum corneum:
- Glycerin, honey, sodium lactate, urea, propylene glycol, sorbitol, pyrrolidone carboxylic acid (PCA), gelatin, hyaluronic acid, vitamins, proteins
Available Moisturizer Formulations:
| Type | Key Ingredients | Examples |
|---|---|---|
| Oil only | Petrolatum | Vaseline Petroleum Jelly |
| Oil-in-water emulsion | Water + petrolatum | Eucerin Original Healing Cream, Vanicream |
| Polymer-based | Water + polyglycerylmethylacrylate + petrolatum | Cetaphil Moisturizing Cream |
| Vegetable oil/wax | Castor oil, corn oil, beeswax, paraffin | Neutrogena Lip Moisturizer |
| Glycerin-rich | Water + glycerin + petrolatum | Neutrogena Norwegian Formula Hand Cream |
Key Take-Aways from Both Texts
| Aspect | Recommendation |
|---|---|
| Cleanser | Soapless, fragrance-free, non-foaming, neutral/acidic pH |
| Moisturizer | Ointments > thick creams > lotions for dry skin |
| Best occlusant | Petrolatum (99% TEWL reduction) |
| Humectants | Glycerin, urea, hyaluronic acid, lactic acid |
| Barrier repair | Ceramides, cholesterol, fatty acids (stearic > linoleic; avoid oleic) |
| Environment | Increase humidity, reduce cold exposure, avoid excessive bathing |
| Clothing | Breathable fabrics, avoid abrasive/tight-fitting garments |
| Exfoliants | AHAs (lactic/glycolic acid) as adjuncts; avoid overuse |
| Avoid | High-pH soaps, antihistamines in sicca syndrome, oleic acid (olive oil)-based products |
brand name of barrier repair products
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Brand Names of Barrier Repair Products
What is a Barrier Repair Moisturizer?
According to Fitzpatrick's Dermatology, dry skin types should use a barrier repair moisturizer containing ceramides, fatty acids, and cholesterol in the correct ratio of 1:1:1. This ratio mimics the natural 3-dimensional lamellar structure of the stratum corneum. Unlike humectants and occlusives (which give quick but temporary results), barrier repair ingredients correct the underlying defect in skin - though they may take 4 or more days to yield noticeable results.
Brand Names from the Textbooks
Directly Listed in Andrews' Dermatology 5e (Table 153.3)
| Moisturizer Type | Key Ingredients | Brand Name |
|---|---|---|
| Oil only | Petrolatum | Vaseline Petroleum Jelly (Unilever) |
| Oil-in-water emulsion | Water + petrolatum | Eucerin Original Healing Cream (Beiersdorf) |
| Oil-in-water emulsion | Water + petrolatum | Vanicream (Pharmaceutical Specialties) |
| Polymer-based | Water + polyglycerylmethylacrylate + petrolatum | Cetaphil Moisturizing Cream (Galderma) |
| Vegetable oil and wax | Castor oil, corn oil, beeswax, paraffin, carnauba wax | Norwegian Formula Lip Moisturizer (Neutrogena) |
| Glycerin-rich | Water + glycerin + petrolatum | Norwegian Formula Hand Cream (Neutrogena) |
| Glycerin-rich | Water + glycerin + petrolatum | Curél Daily Moisture Original Lotion (Kao Corporation) |
| Dimethicone + ceramides | Water + petrolatum + dimethicone + ceramides | CeraVe Moisturizing Cream (L'Oréal) |
| Dimethicone + ceramides | Water + petrolatum + dimethicone + ceramides | EpiCream / EpiCeram (Primus Pharmaceuticals) |
The table note also mentions additional prescription moisturizers:
- Atopiclair® Cream (glycyrrhetinic acid + shea butter)
- Promiseb™ Cream (castor oil-based)
Also Mentioned in Goldman-Cecil Medicine (for xerosis/eczema)
- Eucerin Skin Calming Crème
- CeraVe Itch Relief Moisturizing Cream
- Aveeno Eczema Therapy Moisturizing Cream
Mentioned in Campbell-Walsh Urology (for xerosis specifically)
- CeraVe - noted as particularly useful for skin conditions characterized by xerosis due to its ceramide-containing formulation
The Key Technology: MLE (Multilamellar Emulsion)
Fitzpatrick's notes that newer pseudoceramide formulations in a multilamellar emulsion (MLE) technology mimic the skin's natural 3D lamellar barrier. This is the basis of products like CeraVe and EpiCream. The classic ceramide:fatty acid:cholesterol ratio of 1:1:1 is what distinguishes true barrier repair from simple occlusion or humectancy.
Practical Summary
| Product | Best For | Contains |
|---|---|---|
| Vaseline | Severe xerosis, occlusion | Petrolatum only |
| CeraVe Moisturizing Cream | Barrier repair (xerosis, eczema) | Ceramides + dimethicone + petrolatum |
| EpiCream | Prescription barrier repair | Ceramide lipid complex |
| Eucerin Original/Calming | Dry to very dry skin | Petrolatum-based emulsion |
| Cetaphil Moisturizing Cream | Sensitive, dry skin | Polymer + petrolatum |
| Vanicream | Sensitive + dry skin | Petrolatum emulsion, fragrance-free |
| Neutrogena Norwegian Formula | Dry/cracked hands | Glycerin-rich |
| Atopiclair | Atopic dermatitis, barrier dysfunction | Glycyrrhetinic acid + shea butter |
systemic therapy
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Systemic Therapy for Dry Skin (Xerosis)
An important framing point from both textbooks: pure xerosis is primarily managed with topical and environmental measures - there is no dedicated systemic drug for xerosis itself. Systemic therapy comes into play in three situations: (1) treating the underlying systemic cause, (2) managing the associated pruritus, and (3) treating severe/refractory complications like asteatotic eczema or ichthyosis.
1. Treat the Underlying Systemic Cause
Andrews (Dermatology 5e) lists the following systemic conditions that cause or worsen xerosis - treating these is the first step:
| Underlying Cause | Targeted Treatment |
|---|---|
| Hypothyroidism | Thyroid hormone replacement |
| Chronic kidney disease / hemodialysis | Manage renal disease; dialysis optimization |
| Malnutrition / marasmus | Nutritional rehabilitation |
| HIV infection | Antiretrovirals |
| Hepatic cirrhosis / nephrotic syndrome (edema-related) | Treat the primary liver/renal condition |
| Drug-induced xerosis (retinoids, targeted therapies) | Dose reduction or discontinuation |
2. Systemic Antipruritic Therapy (for Xerosis-Associated Itch)
Since pruritus is the major symptom driving patients to seek treatment, systemic agents are used primarily for itch control. Andrews' Diseases of the Skin covers these in detail:
Antihistamines
- First-generation H1 antihistamines (hydroxyzine, diphenhydramine) - may help with nocturnal itch; their direct antipruritic efficacy is disappointing in most disorders except urticaria and mastocytosis
- Doxepin (tricyclic with potent H1 + H2 antihistamine + anticholinergic action) - useful in several pruritic disorders; also reduces anxiety and depression; caution in elderly due to sedation and impaired cognition
- Non-sedating antihistamines and H2 blockers - only effective in urticaria and mast cell disease; not useful for xerosis-associated itch
Opioid-Modulating Agents
Activation of μ-opioid receptors stimulates itch; κ-opioid receptor stimulation inhibits itch. The following agents exploit this:
| Agent | Route | Notes |
|---|---|---|
| Naltrexone | Oral | μ-opioid antagonist; evidence in cholestatic and uremic pruritus |
| Naloxone | IV | μ-opioid antagonist |
| Nalfurafine | Oral | κ-opioid agonist; approved in Japan for uremic pruritus |
| Butorphanol | Intranasal | Mixed opioid agonist-antagonist |
Andrews cautions: "Initial reports of benefit in one condition are often followed by conflicting reports on further study."
Phototherapy
- UVB (narrowband or broadband), UVA, PUVA - useful for a variety of pruritic disorders including xerosis-associated pruritus, particularly in elderly patients and those on hemodialysis
- Andrews' Diseases of the Skin, Clinical Dermatology, Ch. 4
Systemic Corticosteroids
- Reserved for asteatotic eczema with secondary inflammation (short-course only); not for uncomplicated xerosis
3. Oral Retinoids (for Severe/Ichthyotic Forms)
When xerosis is severe enough to resemble ichthyosis or when the underlying diagnosis is an ichthyotic disorder, oral retinoids are used:
- Acitretin - best results in autosomal recessive congenital ichthyoses (e.g. lamellar ichthyosis); also used in Darier-White disease
- Side effects relevant to skin: paradoxically causes mucocutaneous xerosis, peeling, cheilitis, and fissuring - which must be managed with emollients alongside therapy
- Monitoring: lipid profile (hypercholesterolemia, hypertriglyceridemia), liver enzymes, musculoskeletal symptoms
- Fitzpatrick's Dermatology, Ch. 229 (Oral Retinoids)
4. Emerging / JAK Inhibitor-Based Therapies
For xerosis in the context of atopic dermatitis with significant pruritus, newer systemic agents target the neuro-immune interface:
- Dupilumab (IL-4/IL-13 blocker) - reduces itch by blocking type-2 cytokine signaling
- JAK inhibitors (baricitinib, abrocitinib, upadacitinib) - inhibit JAK1/2, decreasing IL-4, IL-31, and TSLP signaling
- Nemolizumab (anti-IL-31 receptor) - directly targets the key itch cytokine
- Andrews' Dermatology 5e, Ch. 5 (Treatments for Pruritus)
Summary Table
| Indication | Systemic Agent | Class |
|---|---|---|
| Xerosis-associated nocturnal itch | Hydroxyzine, diphenhydramine | H1 antihistamine (sedating) |
| Itch with anxiety/depression | Doxepin | Tricyclic / H1+H2 blocker |
| Uremic/cholestatic pruritus | Naltrexone, naloxone, nalfurafine | Opioid modulators |
| Refractory pruritus | UVB / PUVA phototherapy | Phototherapy |
| Ichthyotic xerosis | Acitretin | Oral retinoid |
| Atopic-type itch | Dupilumab, JAK inhibitors | Biologics / targeted |
| Hypothyroid xerosis | Levothyroxine | Hormone replacement |
| Drug-induced xerosis | Dose reduce/stop offending drug | - |
Bottom line from Andrews: "Treatment of the associated dermatologic condition, e.g. moisturization of dry skin, or the underlying systemic cause remains the most effective method of alleviating pruritus." Systemic drugs are adjunctive and symptom-directed. - Dermatology 2-Volume Set 5e, Ch. 5
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