Daily Moisturization for Atopic Dermatitis: Importance, Recommendations, and Moisturizer Choices

Open AccessPublished:July 24, 2021DOI:https://doi.org/10.1016/j.nurpra.2021.06.003

      Highlights

      • Moisturization is the foundation of treatment guidelines for atopic dermatitis (AD).
      • Nurse practitioners and physician assistants are essential in the interprofessional AD care team.
      • Understanding moisturizer options is important when recommending effective therapeutic choices.

      Abstract

      Topical moisturizers are the core treatment for atopic dermatitis (AD), with treatment guidelines recommending at least daily thorough moisturization of both lesional and nonlesional skin. Ultimately, moisturizer selection is an individual, personal choice, but, surprisingly, few moisturizers have published efficacy and acceptability data to support decision making. This clinical feature emphasizes the value of daily moisturization for AD and summarizes the moisturizer types available. Nurse practitioners/physician assistants manage and educate patients and caregivers on optimizing this key aspect of disease management. Nurse practitioner/physician assistant interventions may lead to impressive increases in moisturizer use and reductions in chronic AD severity.

      Keywords

      There is a clear distinction between “dry skin” due to a lack of moisture (eg, reduced air humidity) that can be simply treated with basic moisturizers and atopic dermatitis (AD)/atopic eczema. AD is a common, chronic relapsing inflammatory skin disease that requires robust therapeutic moisturizers to help manage the many symptoms and signs. AD is characterized by itchy, dry, inflamed, and often cracked and flaking skin, with an underlying defect in the skin’s protective barrier that renders the skin prone to infection. In most countries worldwide, ~20% of children and 2% to 8% of adults are affected by AD
      • Wollenberg A.
      • Barbarot S.
      • Bieber T.
      • et al.
      Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I.
      ; many cases of AD resolve or improve as the child reaches adulthood. The pathogenesis of AD is complex and not completely understood but results from genetic, environmental, and immune factors.
      The impact of AD on patients and their families includes medical costs (visits to health care providers and prescription and nonprescription costs), absenteeism from work or school, decreased productivity, and decreased quality of life.
      • Avena-Woods C.
      Overview of atopic dermatitis.
      ,
      • Silverberg J.I.
      • Gelfand J.M.
      • Margolis D.J.
      • et al.
      Symptoms and diagnosis of anxiety and depression in atopic dermatitis in U.S. adults.
      Skin irritation and itching negatively impact the quality of life and are associated with mental distress and sleep disturbance (difficulty falling asleep and maintaining sleep). The physical appearance of the skin of a patient with AD can lead to embarrassment and decreased self-esteem.
      • Avena-Woods C.
      Overview of atopic dermatitis.
      Various complex measurement instruments are widely used in clinical research to record disease severity and assess the efficacy of therapeutic interventions. These instruments include the Eczema Area and Severity Index and the Severity Scoring of Atopic Dermatitis Index. Symptoms and the skin area affected are quantified according to standardized rating scales, resulting in severity indexes.
      • Chopra R.
      • Silverberg J.I.
      Assessing the severity of atopic dermatitis in clinical trials and practice.
      For clinical practice, the Atopic Dermatitis Severity Index is a simplified sum scoring of 5 symptoms on a target lesion, not a whole body assessment; this makes it easy to implement for disease monitoring.

      Treatment of AD

      AD is generally recommended to be treated with a stepwise approach to therapy aligned with the severity of symptoms as shown in the Figure. Treatment aims are to soothe and help control pruritus and erythema, protect and heal the skin barrier, and re-establish its integrity. For steps 2 to 4, therapeutic options are shown and others possible, indicated as “+.” The foundational stepwise disease management requires that the basic step be used at each step regardless of disease severity and the drug or drug combinations prescribed. Basic treatment including bathing, daily moisturization, avoiding irritants, and triggers is the foundation of this stepwise disease management. Key education messages for patients with AD are listed in Box.
      Figure thumbnail gr1
      Figure 1Stepwise management of AD. For every step, additional therapeutic options are given. (Adapted with permission from Nicol.
      • Nicol N.H.
      Step-wise treatment of atopic dermatitis: basics and beyond.
      )
      Moisturization—Key Messages for Patients With Atopic Dermatitis (AD)
      Tabled 1
      • 1.
        Moisturizer should be applied liberally at least twice daily to reduce symptoms and minimize risk of AD worsening
      • 2.
        Consistent daily use and regular bathing help reduce symptom severity and the incidence of flare episodes
        • Regular bathing is helpful to reduce pathogenic bacteria and rehydrate skin; it is important to apply moisturizer immediately after bath or shower
      • 3.
        Moisturizers are not all equal; patients should follow nurse practitioner/physician assistant recommendations of a moisturizer with clinically proven benefits that suits the individual’s preferences to promote compliance
      Globally, published treatment guidelines consistently recommend moisturization as a key part of AD management. The skin of a patient with AD that is not actively flaring is still compromised, exhibiting an impaired barrier function and subclinical signs of inflammation
      • Biagini Myers J.M.
      • Sherenian M.G.
      • Kyzy A.B.
      • et al.
      Events in normal skin promote early-life atopic dermatitis – the MPAACH cohort.
      • Brunner P.M.
      • Emerson R.O.
      • Tipton C.
      • et al.
      Nonlesional atopic dermatitis skin shares similar T-cell clones with lesional tissues.
      • Lloyd-Lavery A.
      • Solman L.
      • Grindlay D.J.
      • Rogers N.K.
      • Thomas K.S.
      • Harman K.E.
      What’s new in atopic eczema? An analysis of systematic reviews published in 2016. Part 2: epidemiology, aetiology and risk factors.
      • Pavel A.B.
      • Zhou L.
      • Diaz A.
      • et al.
      The proteomic skin profile of moderate-to-severe atopic dermatitis patients shows an inflammatory signature.
      • Unger B.
      • Garcet S.
      • Gonzalez J.
      • et al.
      An integrated model of atopic dermatitis biomarkers highlights the systemic nature of the disease.
      compared with healthy individuals and thus requires moisturization on lesional and nonlesional sites.
      The appropriate use of nonprescription therapeutic moisturizers often reduces the need for more aggressive therapy
      • Harcharik S.
      • Emer J.
      Steroid-sparing properties of emollients in dermatology.
      and reduces the incidence of disease flare.
      • Wollenberg A.
      • Barbarot S.
      • Bieber T.
      • et al.
      Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I.
      ,
      • van Zuuren E.J.
      • Fedorowicz Z.
      • Christensen R.
      • Lavrijsen A.
      • Arents B.W.
      Emollients and moisturisers for eczema.
      Guidelines recommend liberally applying moisturizer 2 to 3 times daily,
      • Wollenberg A.
      • Barbarot S.
      • Bieber T.
      • et al.
      Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I.
      ,
      • LePoidevin L.M.
      • Lee D.E.
      • Shi V.Y.
      A comparison of international management guidelines for atopic dermatitis.
      resulting in the use of a minimum amount of 250 g moisturizer weekly for adults as part of foundation care regardless of AD intensity. Regular bathing is also recommended to reduce bacterial infection and to rehydrate skin; moisturizing immediately afterward is crucial to maintain hydration.
      • van Zuuren E.J.
      • Fedorowicz Z.
      • Christensen R.
      • Lavrijsen A.
      • Arents B.W.
      Emollients and moisturisers for eczema.
      ,
      • Boguniewicz M.
      • Fonacier L.
      • Guttman-Yassky E.
      • Ong P.Y.
      • Silverberg J.
      • Farrar J.R.
      Atopic dermatitis yardstick: practical recommendations for an evolving therapeutic landscape.

       Moisturizers

      Basic moisturizers, including those provided by popular brands such as Aquaphor (Beiersdorf Inc.), Eucerin (Beiersdorf Inc.), Vanicream (Pharmaceutical Specialties Inc.), CeraVe (L'Oréal Group), or Cetaphil (Galderma Laboratories), may be sufficient to help the dry skin of AD (step 1) or the “normal-appearing skin of AD”; however, subclinical inflammation and underlying defects persist. When skin shows mild to moderate symptoms of inflammatory disease and sensitivity manifest in AD (step 2), more effective therapeutic moisturizers may be needed to support the barrier, help reduce itch and sensitivity, and decrease inflammation (Table 1).
      Table 1Appropriate Moisturizers for Normal Skin, Escalating to Those for Use on Dry, Inflamed Skin
      Patient IndicationsMoisturizer Class, DescriptionClinical Evidence
      Dry, inflamed skinNonprescription over-the-counter drugs: FDA-regulated skin-protectant drugs with colloidal oatmeal active for eczema indication. Use for the temporary relief of itch and irritation due to eczema. Help to reduce mild symptoms; important adjunctive to drug therapy in moderate to severe AD.

      ++++
      Therapeutic or emollient plus (eg, NMF and ceramides): Formulations designed to treat diseased skin with xerotic symptoms. A blend of emollients to soften and smooth, occlusives to decrease water loss, humectants to bind water, and other ingredients including itch and pain relievers, anti-inflammatories, pH modifiers, and antimicrobials. Help to reduce mild symptoms; important adjunctive to drug therapy in moderate to severe AD.+++
      Dry, noninflamed skinOcclusives (eg, dimethicone, mineral oil, and petrolatum): Protective formulations that decrease water loss and protect from external irritants, especially for very dry, cracked skin. Greasy or waxy in consistency, leaving a hydrophobic layer that remains on the skin.

      ++
      Normal to dry skinHumectant light duty (eg, glycerin, sodium lactate, and lactic acid): Moisturize skin with humectants that attract and bind water. Generally, emulsions of oil droplets suspended in an aqueous water phase that absorbs quickly.

      +
      Normal skinEmollient dominant (eg, oils, lipids, and lanolin): “Pleasurable” formulas that smooth and soften skin; lack therapeutic, skin-restorative effects.

      AD, atopic dermatitis; FDA, Food and Drug Administration; NMF, natural moisturizing factor.
      +, open studies, expert opinion; ++, case-control studies; +++, cohort studies/randomized clinical trial; ++++, systematic reviews/randomized clinical trials.
      Adapted with permission from Wollenberg et al.
      • Wollenberg A.
      • Barbarot S.
      • Bieber T.
      • et al.
      Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I.
      The marketplace offers a broad range of moisturizers, including simple carriers of pleasurable fragrances, emollient-dominant formulations that smooth and soften the skin but lack protective or skin-healing properties, occlusives that provide barrier protection, products that offer hydration (humectant-enriched formulations), and therapeutic moisturizers whose compositions address specific skin conditions. Within this therapeutic group, Food and Drug Administration–regulated over-the-counter drugs with defined active ingredients and specific disease indications are available without prescription. For eczema, only the active ingredients colloidal oatmeal (under the skin protectant monograph) or hydrocortisone (under the external analgesic monograph) are permitted to make label claims of a therapeutic benefit for eczema.
      Therapeutic formulations are not restricted to any formulation type but are engineered with key ingredients to counteract the underlying causes or disease symptoms and have been clinically assessed with validated clinical measures. As well as their efficacy, therapeutic moisturizers are developed to be esthetically pleasing to improve compliance and consequent outcomes. For AD, therapeutic moisturizers include ingredients that repair the disrupted skin barrier function, diminish itch and inflammation, and lack irritants that can provoke AD patients who have heightened sensitivity to perfumes and other allergens; furthermore, true therapeutic moisturizers have been clinically evaluated in patients with AD.

       Compliance With Treatment

      Despite overwhelming evidence of benefit, compliance with topical therapy for chronic skin conditions is often poor among patients and/or their caregivers.
      • Akdis C.A.
      • Akdis M.
      • Bieber T.
      • et al.
      Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report.
      Recently, a large-scale United Kingdom study found real-world emollient use 4-fold lower than the amount recommended in the current guidelines.
      • Bass A.M.
      • Anderson K.L.
      • Feldman S.R.
      Interventions to increase treatment adherence in pediatric atopic dermatitis: a systematic review.
      For total body coverage, an average-sized adult requires 15 to 30 g (1/2-1 oz) for each total body application (front and back, from head to toe).
      • Fleischer D.M.
      • Udkoff J.
      • Borok B.S.
      • et al.
      Atopic dermatitis: skin care and topical therapies.
      Some nonadherence may be because patients are unclear about the specific instructions for their skin care and are confused by the plethora of nonprescription products available.
      • Choi J.Y.
      • Dawe R.
      • Ibbotson S.
      • et al.
      Quantitative analysis of topical treatments in atopic dermatitis: unexpectedly low use of emollients and strong correlation of topical corticosteroid use both with depression and concurrent asthma.
      Indeed, a 2019 UK study reported over 100 emollient formularies,
      • Ridd M.J.
      • Wells S.
      • Edwards L.
      • et al.
      Best emollients for eczema (BEE) – comparing four types of emollients in children with eczema: protocol for randomised trial and nested qualitative study.
      with the comprehensive Cochrane review on moisturizers for AD unable to recommend one product over another.
      • van Zuuren E.J.
      • Fedorowicz Z.
      • Christensen R.
      • Lavrijsen A.
      • Arents B.W.
      Emollients and moisturisers for eczema.
      A comparative study found that repeated nurse-led patient education and demonstrations of topical therapies have resulted in impressive (89%) reductions in the severity of chronic eczema and an 800% increase use of emollients.
      • Cork M.J.
      • Britton J.
      • Butler L.
      • Young S.
      • Murphy R.
      • Keohane S.G.
      Comparison of parent knowledge, therapy utilization and severity of atopic eczema before and after explanation and demonstration of topical therapies by a specialist dermatology nurse.
      A similar study noted significant improvement in mean moisturizer use, a decrease in sleep disturbance, and an improved feeling of control among caregivers who underwent a multifaceted educational support program.
      • Mason J.M.
      • Carr J.
      • Buckley C.
      • et al.
      Improved emollient use reduces atopic eczema symptoms and is cost neutral in infants: before-and-after evaluation of a multifaceted educational support programme.
      A decrease in disease severity and a reduction in sleep disturbance were also reported in a pilot study of 1,638 parents who underwent individually tailored nurse consultations in 22 centers;
      • Rolinck-Werninghaus C.
      • Trentmann M.
      • Reich A.
      • Lehmann C.
      • Staab D.
      Improved management of childhood atopic dermatitis after individually tailored nurse consultations: a pilot study.
      the value of nurse practitioners (NPs)/physician assistants (PAs) in the management of severe AD has also been shown in a 2019 publication.
      • Brar K.
      • Nicol N.H.
      • Boguniewicz M.
      Strategies for successful management of severe atopic dermatitis.
      Besides the exceptional improvement of compliance rates, this type of intervention has been shown to be cost-effective.
      • Schuttelaar M.L.
      • Vermeulen K.M.
      • Coenraads P.J.
      Costs and cost-effectiveness analysis of treatment in children with eczema by nurse practitioner vs. dermatologist: results of a randomized, controlled trial and a review of international costs.
      Engagement, time with patients, and education are all key to improved rates of treatment adherence. Thus, NPs and PAs have a central role within a multidisciplinary team, supporting patients and caregivers of patients with AD and providing advice to patients who have difficulty in finding an emollient regimen that suits their individual needs and preferences.
      • van Os-Medendorp H.
      • Deprez E.
      • Maes N.
      • et al.
      The role of the nurse in the care and management of patients with atopic dermatitis.

       Informing Recommendations for a Nonprescription Therapeutic Moisturizer for AD

      Making clinical recommendations on which of many therapeutic moisturizers to use should be based on objective data. Only a small number of available therapeutic moisturizers that are available without prescription have such data.
      This article builds on a recent publication by this group,
      • Hebert A.A.
      • Rippke F.
      • Weber T.M.
      • Nicol N.H.
      Efficacy of nonprescription moisturizers for atopic dermatitis: an updated review of clinical evidence.
      which presented details of nonprescription therapeutic moisturizers marketed in the United States with objective, proven benefits in patients with AD (extending the time to eczema skin flare and retaining moisture in both lesional and nonlesional skin). Studies on the use of single ingredients for skin barrier function and water loss (eg, petrolatum or virgin coconut oil) are not included. Here, we provide data on price, medication adherence, cosmetic acceptability, and impact on measures of quality of life for the therapeutic moisturizers highlighted by Hebert et al.
      • Hebert A.A.
      • Rippke F.
      • Weber T.M.
      • Nicol N.H.
      Efficacy of nonprescription moisturizers for atopic dermatitis: an updated review of clinical evidence.

       Nonprescription Therapeutic Moisturizers With Clinical and Preference Data

      Seven individual products (Atoderm Intensive Cream [Bioderma Laboratories]; Cetaphil Restoraderm Lotion and Wash Regime [Galderma Laboratories], used together or separately; Dermacare Atopic Lotion [Dermacare USA]; Eucerin Eczema Relief Body Cream [Beiersdorf, Inc. ]; Eucerin Eczema Relief Flare-up Treatment [now Eczema Relief Flare-up Treatment; Beiersdorf, Inc.]; Physiogel AI Cream [Stiefel, Inc.]; and Receutics Intense Hydration and Repair Treatment [Receutics Active Skin Repair, Inc.]) supported by 10 publications
      • de Lucas R.
      • García-Millán C.
      • Pérez-Davó A.
      • Moreno E.
      • Redondo P.
      New cosmetic formulation for the treatment of mild to moderate infantile atopic dermatitis.
      • Draelos Z.D.
      A pilot study investigating the efficacy of botanical anti-inflammatory agents in an OTC eczema therapy.
      • Gayraud F.
      • Sayag M.
      • Jourdan E.
      Efficacy and tolerance assessment of a new type of dermocosmetic in infants and children with moderate atopic dermatitis.
      • Hon K.L.
      • Pong N.H.
      • Wang S.S.
      • Lee V.W.
      • Luk N.M.
      • Leung T.F.
      Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients.
      • Ma L.
      • Li P.
      • Tang J.
      • et al.
      Prolonging time to flare in pediatric atopic dermatitis: a randomized, investigator-blinded, controlled, multicenter clinical study of a ceramide-containing moisturizer.
      • Simpson E.
      • Dutronc Y.
      A new body moisturizer increases skin hydration and improves atopic dermatitis symptoms among children and adults.
      • Simpson E.
      • Trookman N.S.
      • Rizer R.L.
      • et al.
      Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study.
      • Weber T.M.
      • Babcock M.J.
      • Herndon Jr., J.H.
      • et al.
      Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life.
      • Weber T.M.
      • Herndon Jr., J.H.
      • Ewer M.
      • et al.
      Efficacy and tolerability of steroid-free, over-the-counter treatment formulations in infants and children with atopic dermatitis.
      • Weber T.M.
      • Samarin F.
      • Babcock M.J.
      • Filbry A.
      • Rippke F.
      Steroid-free over-the-counter eczema skin care formulations reduce risk of flare, prolong time to flare, and reduce eczema symptoms in pediatric subjects with atopic dermatitis.
      were identified by Hebert et al
      • Hebert A.A.
      • Rippke F.
      • Weber T.M.
      • Nicol N.H.
      Efficacy of nonprescription moisturizers for atopic dermatitis: an updated review of clinical evidence.
      as having peer-reviewed published data on efficacy or outcome measures (Table 2). Online searches revealed the cost of each product, starting with Walmart pricing (available to most consumers throughout the country). If not available at Walmart, a price was found from other retailers or directly from the product website. Prices were converted to dollars per fluid ounce for ease of comparison and were based on prices for the largest available package (ranging from 8-16.7 fl oz). Atoderm Intensive Cream, Cetaphil Restoraderm Lotion, and Eucerin Body Cream were similarly priced per fluid ounce and considerably lower in price than Physiogel AI Cream and Receutics Intense Hydration and Repair Treatment (Table 2).
      Table 2Overview of Studies Identified Evaluating Nonprescription Therapeutic Moisturizers Used for Mild to Moderate Atopic Dermatitis Available in the United States
      ProductPublished Data on Skin Barrier in Children (TEWL or Corneometry)Published Data on Skin Barrier in Adults (TEWL or Corneometry)Time to Flare StudySymptom Assessment Using EASI, SCORAD, or ADSIProduct Evaluation by InvestigatorProduct Evaluation by Parent/PatientSkin Irritation/Dryness/Itch Evaluated Outside of Standard MeasuresQuality of LifePrice per fl oz, April 2020
      Atoderm Intensive Cream
      Gayraud et al, 2015.28
      Gayraud et al, 2015.28
      Gayraud et al, 2015.28
      Gayraud et al, 2015.28
      Gayraud et al, 2015.28
      $
      Price from Walmart.com US website.
      Cetaphil Restoraderm Lotion and Wash
      Hon et al, 2013.29
      ,
      Simpson et al, 2012.32
      Ma et al, 2017.30
      Hon et al, 2013.29
      ,
      Ma et al, 2017.30
      Simpson et al, 2012.32
      Hon et al, 2013.29
      ,
      Ma et al, 2017.30
      ,
      Simpson et al, 2012.32
      $
      Price from Walmart.com US website.
      Cetaphil Restoraderm Wash
      Ma et al, 2017.30
      Ma et al, 2017.30
      Hon et al, 2013.29
      ,
      Ma et al, 2017.30
      $
      Price from Walmart.com US website.
      Dermacare Atopic Lotion
      De Lucas et al, 2019.26
      De Lucas et al, 2019.26
      De Lucas et al, 2019.26
      De Lucas et al, 2019.26
      De Lucas et al, 2019.26
      $$
      Price from Amazon.com.
      Eucerin Eczema Relief Body Cream
      Weber et al, 2015.34
      Weber et al, 2014.33
      Weber et al, 2015.35
      Weber et al, 2014.33
      ,
      Weber et al, 2015.35
      Weber et al, 2014.33
      ,
      Weber et al, 2015.34
      ,
      Weber et al, 2015.35
      Weber et al, 2015.34
      Weber et al, 2014.33
      ,
      Weber et al, 2015.35
      $
      Price from Walmart.com US website.
      Eucerin Eczema Relief Flare-up Treatment
      Weber et al, 2015.34
      Weber et al, 2014.33
      Weber et al, 2015.35
      Weber et al, 2014.33
      ,
      Weber et al, 2015.34
      ,
      Weber et al, 2015.35
      Weber et al, 2014.33
      ,
      Weber et al, 2015.34
      ,
      Weber et al, 2015.35
      Weber et al, 2015.34
      Weber et al, 2014.33
      ,
      Weber et al, 2015.35
      $$
      Price from Walmart.com US website.
      Physiogel AI cream
      Simpson et al, 2011.31
      Simpson et al, 2011.31
      Simpson et al, 2011.31
      Simpson et al, 2011.31
      Simpson et al, 2011.31
      Simpson et al, 2011.31
      $$$
      Price from Walmart.com US website.
      Receutics Intense Hydration and Repair Treatment
      Draelos, 2016.27
      Draelos, 2016.27
      Draelos, 2016.27
      $$
      Price from eBay, excluding US tax.
      $, less than $2/fl oz; $$, less than $3/fl oz; $$$, more than $3/fl oz; ADSI, Atopic Dermatitis Severity Index; EASI, Eczema Area and Severity Index; SCORAD, Scoring Atopic Dermatitis; TEWL, transepidermal water loss.
      Unit prices based on largest available size up to 16.7 oz.
      a De Lucas et al, 2019.
      • de Lucas R.
      • García-Millán C.
      • Pérez-Davó A.
      • Moreno E.
      • Redondo P.
      New cosmetic formulation for the treatment of mild to moderate infantile atopic dermatitis.
      b Draelos, 2016.
      • Draelos Z.D.
      A pilot study investigating the efficacy of botanical anti-inflammatory agents in an OTC eczema therapy.
      c Gayraud et al, 2015.
      • Gayraud F.
      • Sayag M.
      • Jourdan E.
      Efficacy and tolerance assessment of a new type of dermocosmetic in infants and children with moderate atopic dermatitis.
      d Hon et al, 2013.
      • Hon K.L.
      • Pong N.H.
      • Wang S.S.
      • Lee V.W.
      • Luk N.M.
      • Leung T.F.
      Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients.
      e Ma et al, 2017.
      • Ma L.
      • Li P.
      • Tang J.
      • et al.
      Prolonging time to flare in pediatric atopic dermatitis: a randomized, investigator-blinded, controlled, multicenter clinical study of a ceramide-containing moisturizer.
      f Simpson et al, 2011.
      • Simpson E.
      • Dutronc Y.
      A new body moisturizer increases skin hydration and improves atopic dermatitis symptoms among children and adults.
      g Simpson et al, 2012.
      • Simpson E.
      • Trookman N.S.
      • Rizer R.L.
      • et al.
      Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study.
      h Weber et al, 2014.
      • Weber T.M.
      • Babcock M.J.
      • Herndon Jr., J.H.
      • et al.
      Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life.
      i Weber et al, 2015.
      • Weber T.M.
      • Herndon Jr., J.H.
      • Ewer M.
      • et al.
      Efficacy and tolerability of steroid-free, over-the-counter treatment formulations in infants and children with atopic dermatitis.
      j Weber et al, 2015.
      • Weber T.M.
      • Samarin F.
      • Babcock M.J.
      • Filbry A.
      • Rippke F.
      Steroid-free over-the-counter eczema skin care formulations reduce risk of flare, prolong time to flare, and reduce eczema symptoms in pediatric subjects with atopic dermatitis.
      k Price from Amazon.com.
      l Price from eBay, excluding US tax.
      m Price from Walmart.com US website.
      Few data were available for medication adherence. Ma et al
      • Ma L.
      • Li P.
      • Tang J.
      • et al.
      Prolonging time to flare in pediatric atopic dermatitis: a randomized, investigator-blinded, controlled, multicenter clinical study of a ceramide-containing moisturizer.
      used patient diary information to report ≥75% compliance with Cetaphil Restoraderm Lotion and Wash Relief, and Hon et al
      • Hon K.L.
      • Pong N.H.
      • Wang S.S.
      • Lee V.W.
      • Luk N.M.
      • Leung T.F.
      Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients.
      reported good compliance with the same products but without detail other than patients generally used the product once daily. Draelos
      • Draelos Z.D.
      A pilot study investigating the efficacy of botanical anti-inflammatory agents in an OTC eczema therapy.
      mentioned use of diaries for compliance but did not report results.
      Sleep disturbance due to itching was recorded by Weber et al
      • Weber T.M.
      • Babcock M.J.
      • Herndon Jr., J.H.
      • et al.
      Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life.
      as affecting 61% of adult patients with AD at baseline, which reduced to just 24% after 14 days of therapy with Eucerin Eczema Relief Instant Therapy. Sleep disturbance was also reported by Hon et al
      • Hon K.L.
      • Pong N.H.
      • Wang S.S.
      • Lee V.W.
      • Luk N.M.
      • Leung T.F.
      Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients.
      for Cetaphil Restoraderm Lotion and Wash but was mentioned among several general measures of product acceptability rather than addressed separately. Acceptability was rated “good/very good” for combined use of the lotion and wash in 16 of 24 of patients and for the wash alone in 13 of 24 patients.
      The effect of moisturization on skin irritation, skin dryness, and itch (outside parameters reported in standardized AD clinical scales) was reported in 4 studies (Table 2). The assessments are subjective but are fundamental to AD and are important measures of efficacy. Each of the moisturizers was beneficial for these outcomes, in both children and adults with AD. Only 1 study reported itch resolution relative to time
      • Weber T.M.
      • Babcock M.J.
      • Herndon Jr., J.H.
      • et al.
      Steroid-free emollient formulations reduce symptoms of eczema and improve quality of life.
      ; Eucerin Eczema Relief Instant Therapy effectively reduced itch in approximately two thirds of patients within 1 minute of application, with slightly more patients experiencing itch relief after 15 minutes. The frequency, intensity, and functional impact of itch were all reduced with this cream at day 14 (end of study), with itch absent/mild in 88% of subjects compared with baseline.
      Overall product assessment by the investigator was an outcome measure in 6 moisturizers. In all studies, the investigators reported subjective improvement in patient symptoms. Patients or caregivers assessed 8 products by responding to questionnaires or scoring an assessment scale (Table 2). Responses were subjective (eg, whether the product worked and whether it was pleasant to use). Because reporting varied across the studies, no comparison between products could be made, but all products received high ratings.
      Three studies
      • de Lucas R.
      • García-Millán C.
      • Pérez-Davó A.
      • Moreno E.
      • Redondo P.
      New cosmetic formulation for the treatment of mild to moderate infantile atopic dermatitis.
      ,
      • Gayraud F.
      • Sayag M.
      • Jourdan E.
      Efficacy and tolerance assessment of a new type of dermocosmetic in infants and children with moderate atopic dermatitis.
      ,
      • Simpson E.
      • Dutronc Y.
      A new body moisturizer increases skin hydration and improves atopic dermatitis symptoms among children and adults.
      looked at quality of life measures (Table 2), but each used a different measure and study durations varied, making qualitative comparisons difficult. However, all 3 products, Dermacare Atopic Lotion, Atoderm Intensive Cream, and Physiogel AI Cream, improved patient quality of life.

      Discussion

      Daily moisturization is key to skin health and treatment outcomes in AD. Because of the underlying barrier defects and subclinical inflammation, even when not flaring, moisturization of lesional and nonlesional sites is indicated.
      Objective tests of skin barrier function in these studies revealed that moisturization (typically twice daily) significantly improved the skin barrier, demonstrated by increased skin hydration and decreased transepidermal water loss, in both adults and children with AD. Longer-term flare studies showed that daily moisturization extended the time to flare and reduced the total number of flares. Proactive moisturization of infants at high risk of developing AD may reduce its manifestation
      • Horimukai K.
      • Morita K.
      • Narita M.
      • et al.
      Application of moisturizer to neonates prevents development of atopic dermatitis.
      (although this finding was not confirmed in all studies,
      • Simpson E.L.
      • Chalmers J.R.
      • Hanifin J.M.
      • et al.
      Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention.
      • Chalmers J.R.
      • Haines R.H.
      • Bradshaw L.E.
      • et al.
      Daily emollient during infancy for prevention of eczema: the BEEP randomised controlled trial.
      • McClanahan D.
      • Wong A.
      • Kezic S.
      • et al.
      A randomized controlled trial of an emollient with ceramide and filaggrin-associated amino acids for the primary prevention of atopic dermatitis in high-risk infants.
      • Schachner L.A.
      • Hebert A.A.
      • Andriessen A.
      • et al.
      A global review on the risk factors and management of early atopic dermatitis in children ages 0 to 2 years old.
      • Skjerven H.O.
      • Rehbinder E.M.
      • Vettukattil R.
      • et al.
      Skin emollient and early complementary feeding to prevent infant atopic dermatitis (PreventADALL): a factorial, multicentre, cluster-randomised trial.
      perhaps reflecting differences between products). A 2021 Cochrane review assessing skin care interventions in infants for preventing eczema and food allergy reported that emollients during the first year of life in healthy infants were probably not effective for preventing eczema, and their impact on food allergy risk was uncertain.
      • Kelleher M.M.
      • Cro S.
      • Cornelius V.
      • et al.
      Skin care interventions in infants for preventing eczema and food allergy.
      The specific recommendation from Hebert et al
      • Hebert A.A.
      • Rippke F.
      • Weber T.M.
      • Nicol N.H.
      Efficacy of nonprescription moisturizers for atopic dermatitis: an updated review of clinical evidence.
      was for the use of clinically tested moisturizers, evaluated using objective, validated skin assessments in AD.
      This evaluation found that few moisturizers had published data reporting key product attributes. From the peer-reviewed relevant publications, Dermacare Atopic Lotion, Atoderm Intensive Cream, and Physiogel AI Cream improve patient quality of life; Cetaphil Restoraderm Lotion and Wash Relief are associated with good compliance rates under trial conditions; and Eucerin Eczema Relief Flare-up Treatment provides fast and lasting relief of itch and improved sleep quality for patients. Only Cetaphil and Eucerin have more than 1 publication with these outcome measures.
      Therapeutic moisturizers are available without prescription, and their cost is similar to other nonprescription products that have no supporting data. The price of therapeutic moisturizers is markedly less than prescription barrier creams despite several studies that show that efficacy does not differ between the 2 types of product
      • Miller D.W.
      • Koch S.B.
      • Yentzer B.A.
      • et al.
      An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.
      ,
      • Draelos Z.D.
      An evaluation of prescription device moisturizers.
      but exhibit vastly different cost:efficacy ratios,
      • Miller D.W.
      • Koch S.B.
      • Yentzer B.A.
      • et al.
      An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial.
      challenging the choice of the prescription treatment. Interestingly, the products with the most data to support their use are among the cheapest to buy (Cetaphil and Eucerin).
      Producing this practical guide for the NP/PA involved assessing which studies have physical, subjective, and objective data to support their use and those positively rated by patients or caregivers. Products cannot be compared directly, and the studies described in this article used different outcome measures for the same attribute. Furthermore, no direct comparisons were made between products in the original articles; each article described 1 or 2 products from the same manufacturer, and studies and publications may have been subject to bias as they were written or sponsored by the company producing the moisturizer under investigation. Instead, attention has been drawn to products that are therapeutic and validated by peer-reviewed published data.
      With so many products available, a recommendation by a health care provider is an important factor in moisturizer selection.
      • Joergensen K.M.
      • Jemec G.B.E.
      Use of moisturizers among Danish atopic dermatitis patients-which perceived product characteristics associate with long-term adherence?.
      ,

      Kunkiel K, Natkańska A, Nędzi M, Zawadzka-Krajewska A, Feleszko W. Patients’ preferences of leave-on emollients: a survey on patients with atopic dermatitis. J Dermatolog Treat. 2020 Jun 9 [Epub ahead of print], https://doi.org/10.1080/09546634.2020.1772452.

      The NP and PA are key patient advisors who can help patients find a product they like using that is also validated by scientific studies. Their ongoing support of patients is vital to ensure proper product use (ie, applying moisturizers generously at least twice daily, especially after a bath or shower).
      • Nicol N.H.
      Step-wise treatment of atopic dermatitis: basics and beyond.
      • Cardona I.D.
      • Kempe E.E.
      • Lary C.
      • Ginder J.H.
      • Jain N.
      Frequent versus infrequent bathing in pediatric atopic dermatitis: a randomized clinical trial.
      • Eichenfield L.F.
      • Ahluwalia J.
      • Waldman A.
      • Borok J.
      • Udkoff J.
      • Boguniewicz M.
      Current guidelines for the evaluation and management of atopic dermatitis: a comparison of the Joint Task Force Practice Parameter and American Academy of Dermatology guidelines.
      A supported and motivated patient is more likely to continue treatment regularly and for longer. Ultimately, the selection of moisturizer for each patient should be individualized, but given the plethora of products from which to select, patients appreciate specific provider recommendations to be assured of selecting an efficacious product.
      • Nicol N.H.
      Step-wise treatment of atopic dermatitis: basics and beyond.

      Conclusion

      NPs/PAs have a leading role to play in the management of AD and in recommending moisturizing products to patients. Not all moisturizers are equal; therapeutic moisturizers with peer-reviewed clinical efficacy data for improving skin barrier function that are rated favorably by end users and are low cost make excellent recommendations for patients with AD.

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      Biography

      Noreen Heer Nicol, PhD, FNP, NEA-BC, is an associate professor and interim associate dean of academic programs at the University of Colorado College of Nursing in Aurora and can be contacted at [email protected] .
      Teresa M. Weber, PhD, is the director of US R&D for Derma Brands, Beiersdorf Inc, in Wilton, CT.
      Frank Rippke, MD, is the chief medical scientist at Beiersdorf AG in Hamburg, Germany.
      Adelaide A. Hebert, MD, is a professor of dermatology and pediatrics at UTHealth McGovern Medical School in Houston, TX.