How to treat dry and itchy skin

section anchor

Restoring the skin's barrier

Different dry- and itch-related skin conditions may present with similar signs and symptoms. A stepwise approach to managing a patient’s dry and itchy skin means the treatment can be stepped up or down, depending on how the patient responds.

section anchor

Step 1: Emollients

Emollients play an important role in basic skin care by supplying the skin with the constant moisture it needs.           

By helping to prevent transepidermal water loss (TEWL), emollients help improve the clinical signs and symptoms of dry skin conditions including atopic eczema and chronic plaque psoriasis. 1,2

Emollients can help to occlude the stratum corneum to help protect the skin from the daily impact of the environment and reduce moisture evaporation from the skin. 3,4

A skincare routine that uses complete emollient therapy (emollients for washing and moisturising) has been shown to be very helpful when managing skin disease states where the protective barrier function is not working effectively. 4

So it’s important to advise patients to use a complete emollient therapy skincare routine to help improve their dry and itchy skin, and work with them so they follow it. A complete routine can involve using a topical emollient along with soap substitutes. 

Emollients

Emollients come in several forms: 1,5,6

  • Ointments are greasy preparations which typically have a lower percentage of water in formulations compared to creams and lotions, making them less well tolerated by patients. However they are particularly suitable for night time use, or on very dry and thickened areas and are less likely to cause contact allergic dermatitis, as they do not contain preservatives
  • Creams and Gels are less greasy than ointments because they're a mixture of oil and water, making them easier to apply and more well tolerated by patients
  • Lotions have a high water content and so are the least greasy, which means they are often well tolerated but might not be suitable for severe itchy, dry or very dry skin conditions

Optimum usage of emollients is important to make sure a patient’s treatment is effective. 1,5-7

  • Emollients need to be used at the appropriate frequency – 34 times a day is recommended, but more frequent application may be required, depending on how dry the skin is
  • The appropriate amount needs to be applied as prescribed for the condition being treated; for example, in eczema cases it is recommended at least 500g for adults and at least 250g for children should be used every week, which is about one handful a day for adults and half an adult handful a day for children
  • When treating dry or itchy skin conditions such as eczema, emollients need to be applied using the appropriate technique dotted on the body area and smoothed downwards in the direction of hair growth to prevent folliculitis; if you’re able, take the time to demonstrate proper technique in the consultation, as this has been shown to significantly increase adherence 8
  • Non-steroid emollient can be used every day and continued even after the skin has shown improvement when treating eczema
  • Emollient products need to be used in the appropriate way for example, some emollients such as ointments are often available in tubs, but fingers should not be used to take the emollient out of the tub instead a scoop or, in the case of creams or lotions, a pump-action product should be used to reduce the risk of infection

Soap substitutes

  • Cosmetic bath and shower gels should be switched for emollient-rich alternatives
  • Advise patients to take warm, not hot, showers; their skin should then be patted dry and their emollient applied
  • Patients should try and use a soap substitute when washing their hands, and consider applying their emollient after they have washed their hands
  • Older or vulnerable patients should be advised to take care in the bath or shower when using these products as they might make the bath or shower more slippery

Your patients might benefit from a prescription prepayment certificate, which will cover all their prescriptions for either 3 or 12 months. More information can be found on the NHS website.

section anchor

Step 2: Topical treatments 

When more serious dry or itchy skin conditions, such as eczema or psoriasis are not being controlled by emollients alone, prescribing a topical treatment, such as a topical steroid can be the next step. 

Topical steroids are often used as a short-term therapy burst to treat inflamed, itchy or flaring skin in conditions such as eczema, seborrhoeic dermatitis, and psoriasis. Topical steroids however are not effective in treating ichthyosis 5,9

The optimum usage of steroids is based on: 1,10

  • Frequency: for most people steroids can be applied once or twice daily for a week or two
  • Amount: patients should use the fingertip unit measure – one fingertip’s worth of cream should cover an area of two measured hand areas (laid flat with their fingers together)
  • How: if patients use both topical corticosteroid and emollient, they should apply their steroid to the affected areas at least 30 minutes after applying emollient, so the emollient has time to soak in

When using topical steroids in the treatment of eczema, the steroid ladder can help guide your patient's therapy by stepping treatment up or down depending on how the skin is responding. It’s important to balance the risk and benefits when prescribing a steroid and ensure patients use the least potent topical steroid that will control the condition. For severe eczema cases, when there is no response to a mild steroid, moderate to potent topical steroids may be prescribed for short periods, under medical supervision. The patient can then be stepped down to a less potent treatment once the condition has been brought under more control. 11

Steroid ladder diagram adapted from National Eczema Society – Topical Steroid Factsheet and Bridgewater NHS advice – to be used in conjunction with the latest local formulary, BNF, BNFc and the Tier Two Eczema and Psoriasis Guidelines 11,12

In the case of psoriasis, a steroid treatment of moderate potency may be prescribed for localised acute psoriasis or subacute inflammatory psoriasis with hot spreading or itchy lesions. However a topical steroid is generally not suitable for long-term use, or as the sole treatment for extensive chronic plaque psoriasis. For long-term treatment of plaque psoriasis, a vitamin D and its analogues, such as Calcipotriol will normally be prescribed as a first line treatment option instead of steroids. 5

If you’re prescribing a patient with several products they’ll need to get regularly, a prescription prepayment certificate might be a more cost-effective way for them to get their prescription.

To help your patients plan and manage their treatment, you can use our treatment planner.

Back to top

section anchor

Step 3: Other treatments

If the emollients you’ve tried haven’t worked for you, you could try an emollient specifically designed for itch. Other treatments that may be useful in addition to emollients and topical steroids to improve patients’ skin include:

  • Bandages and medicated dressings 1
    • These can be used on top of emollients and topical steroids for 7-14 days in the case of eczema flare ups, or for longer on chronic lichenified eczema
    • They should not be used on wet, infected eczema
  • Sedating antihistamines 5
    • These can be used at night in eczema flare up cases which cause marked sleep disturbance
    • They function by blocking the effects of histamine in the blood to relieve the itch associated with atopic eczema
  • Immunomodulators (eczema) 1
    • Tacrolimus ointment and pimecrolimus cream are calcineurin inhibitors
    • These do not contain steroids so should be used in preference to the regular use of topical steroids on the face
    • Immunomodulators can also be used in preference to regular use of topical steroids eczema treatment in the lower legs of elderly patients and others at risk of leg ulcers 
  • Coal tar 5
    • Coal tar can be useful in some cases of chronic eczema, and chronic stable plaque psoriasis
    • It has anti-inflammatory properties and antiscaling properties which can help relieve the symptoms of chronic plaque psoriasis
  • Dithranol (psoriasis) 5
    • This is effective in treating chronic plaque psoriasis, however its major disadvantages include irritation and staining of the skin and clothing
    • It should be applied to chronic extensor plaques only, carefully avoiding normal skin
    • It’s not suitable for widespread small lesions nor should it be used in the flexures or on the face
  • Retinoid formulations 5,7
    • Can be used to relieve the symptoms of psoriasis, however is also used in disorders of keratinisation and some forms of ichthyosis
  • Antibiotics 1
    • These may be needed if there's infection i.e. a widespread flare up and/or areas of weeping or crusted eczema

Back to top

section anchor

Step 4: Referrals

Patients should be referred to a specialist if:

  • Their condition is moderate to severe, and not controlled by the use of copious emollients and topical steroids appropriate for the site of the condition
  • Their skin is not responding to other treatment
  • If you're uncertain about the diagnosis
  • If you're concerned about the amount of topical steroid needed to effectively manage the skin
  • For possible cases of contact allergic eczema (which may be suggested by, for example, persistent eczema on the patient’s hands or face)

References

  1. Primary Care Dermatology Society (PCDS). (2017a). Eczema (Atopic eczema). [accessed April 2017] via http://www.pcds.org.uk/clinical-guidance/atopic-eczema
  2. Primary Care Dermatology Society (PCDS). (2017b). Psoriasis: an overview and chronic plaque psoriasis. [accessed April 2017] via http://www.pcds.org.uk/clinical-guidance/psoriasis-an-overview
  3. Verdier-Sévrain S, Bonté F. (2007). Cosmet Dermatol. 6(2): 75-82
  4. High W, Del Rosso JQ, Levin J. (2011). J Clin Aesthet Dermatol. 4(9): 22-42
  5. National Institute for Health and Care Excellence (NICE). (2017). 13 Skin. [accessed May 2017] via https://www.evidence.nhs.uk/formulary/bnf/current/13-skin
  6. National Eczema Society. (2016a). Emollients – Factsheet. [accessed May 2017] via http://www.eczema.org/emollients
  7. Primary Care Dermatology Society (PCDS). (2017c). Ichthyosis. [accessed April 2017] via http://www.pcds.org.uk/clinical-guidance/ichthyosis
  8. Cork M. el al. (2003). Br J of Dermatol. 149: 582-589
  9. British Association of Dermatologists (BAD). (2016). Ichthyosis. [accessed May 2017] via http://www.bad.org.uk/shared/get-file.ashx?id=167&itemtype=document
  10. NHS Choices. (2016). Topical Corticosteroids. [accessed April 2017] via http://www.nhs.uk/conditions/corticosteroid-preparations-(topical)/Pages/Introduction.aspx
  11. National Eczema Society. (2016b). Topical Steroids – Factsheet. [accessed May 2017] via http://www.eczema.org/corticosteroids
  12. Bridgewater Community Healthcare NHS Foundation Trust. (2015). Steroid Ladder. [accessed April 2017] via http://www.bridgewater.nhs.uk/wp-content/uploads/2012/11/Steroid-Ladder1.pdf

UK/E45-NHS/0317/0004b