Medications CE National Continuing Education Program

Dry Skin Care and Colloidal Oatmeal March 2007

By Rhonda L. Dorren, B.Sc.Pharm Introduction Determining the best topical solutions for patients with skin that is scaly, dry, raw or itchy (dermatitis) can be challenging. Dermatitis, a term often used interchangeably with eczema, is superficial inflammation of the skin characterized by redness, edema, oozing, crusting, scaling, and sometimes vesicles. Pruritus is commonly associated with these syndromes. Amongst other solutions, supportive care includes topically applied colloidal oatmeal.1 Simply described, oil in the skin keeps skin from losing moisture and makes it soft. Washing skin strips away oil, creating a drying effect. When it’s humid, the skin retains moisture better. However, in reduced humidity environments, as in winter months, the skin loses the ability to moisturize itself. Most skin conditions, including atopic dermatitis, psoriasis and eczema, get worse in the winter because humidity is reduced in the outer layer of the skin. When the outer cells of the skin become dry, their edges curl up and the skin feels rough. Low humidity, coupled with heavier clothing and longer, hotter showers and baths, can leave skin feeling dry, irritated and itchy. The best way to prevent and treat skin problems in the winter is to moisturize.2 There are numerous pathologies for dry skin. Treatment is generally focused on hydration of the skin. This

lesson discusses the most common clinical conditions associated with dry skin, various forms of products and delivery methods to treat dry skin including the use of colloidal oatmeal.

Definition of Dry Skin, Dermatitis and Pruritus Dry skin (xeroderma) is a condition involving

the integumentary system (surface area comprising skin, hair, nails, sweat glands and their products, sweat and mucus), which in most cases can safely and effectively be treated with emollients and/or moisturizers. Dry skin can occur at any age and for many reasons. It occurs most commonly on the lower legs, arms, the sides of the abdomen and thighs. Symptoms generally associated with dry skin are scaling (the visible peeling of the outer skin layer), itching and cracks in the skin. In most cases, skin becomes drier as we age.3 Skin is not dry because it lacks oil, but because it lacks water. Therefore treatments are aimed at replacing water in the skin.4 Pruritus is an itch or sensation that causes a

person to want to scratch that area. It is distressing, causing discomfort and frustration. If severe, it can lead to sleeplessness, anxiety and depression. The cause of an itch is a complex process involving nerves that respond to various

The author, expert reviewers and Rogers Publishing have each declared that there is no real or potential conflict of interest with the sponsor of this lesson. Supported by an educational grant from:

APPROVED FOR 1.25 CE UNITS Approved for 1.25 CE units by the Canadian Council on Continuing Education in Pharmacy. File #521-0107. Not valid for CE credits after FEBRUARY 12, 2010.

Answering Options

A. For immediate results, answer online at www.pharmacygateway. ca, CE Online section, “More CCCEPApproved” area. B. Mail or fax the printed answer card to (416) 764-3937. Your reply card will be marked and you will be advised of your results within six to eight weeks in a letter from Rogers Publishing.

STATEMENT OF OBJECTIVES Pharmacists who successfully complete this lesson will be able to: 1. Describe the symptoms of dry skin (xeroderma), pruritus and dermatitis. 2. Describe the vehicles and topical agents for delivery of associated skin treatments. 3. Discuss the indications and uses for colloidal oatmeal. 4. Discuss the clinical evidence for the use of colloidal oatmeal. 5. Educate and counsel patients on the use of colloidal oatmeal in various indications.

Instructions 1. After carefully reading this lesson, study each question and select the one answer you believe to be correct. Circle the appropriate letter on the attached reply card. 2. To pass this lesson, a grade of 70% (14 out of 20) is required. If you pass, your CEU(s) will be recorded with the relevant provincial authority(ies). (Note: some provinces require individual pharmacists to notify them.)

This CE lesson is published by Rogers Publishing Limited (Pharmacy Group), One Mount Pleasant Rd., Toronto, Ont. M4Y 2Y5. Tel.: (416) 764-3916 Fax: (416) 764-3931. No part of this CE lesson may be reproduced, in whole or in part, without the written permission of the publisher. ©2007

Dry Skin Care and Colloidal Oatmeal

chemicals, such as histamine, that are released in the skin, and the processing of nerve signals in the brain. Pruritus can be a part of skin diseases, internal disorders, or due to faulty processing of the itch sensation within the nervous system. Scratching may cause breaks in the skin possibly resulting in infection. Itching can be related to anything from dry skin to undiagnosed cancer manifesting as generalized or localized itching.5 Often, scratching can intensify itching and even cause further damage to the skin, dubbed the “itch-scratch-itch cycle”.6 Dermatitis, generally synonymous with

eczema, is used loosely to define a common condition of any red, scaly, itchy rash that is a potentially debilitating condition and can compromise quality of life.This term does not discriminate between contact dermatitis, seborrheic dermatitis, atopic dermatitis, irritant dermatitis, nummular dermatitis, and a variety of other eczemas or dermatitides. Often at first evaluation, rashes can be difficult to precisely categorize, and in many instances, red, itchy, scaly rashes and lesions are designated as an “eczematous dermatitis.”These different types of dermatitis’ and disorders can have many causes and occur in many forms.7 Patients may feel uncomfortable and self-conscious. Attempts to relieve the itch by scratching simply worsen the rash, creating a vicious circle. A combination of self-care steps and medications can help with treatment of dermatitis, dry skin and pruritus.8 Treatment should be directed at limiting itching, repairing the skin and decreasing inflammation when necessary. Moisturizers, antihistamines and topical corticosteroids are the mainstays of therapy. When required, oral corticosteroids can be used. If pruritus does not respond to treatment, other diagnoses, such as bacterial overgrowth or viral infections, should be considered.Treatment options are available for refractory atopic dermatitis, but these measures should be reserved for use in unique situations and typically require consultation with a dermatologist or an allergist.8

Principles of Topical Dermatologic Therapy Topical dermatologic treatments include cleansing agents, absorbents, anti-infective agents, antiinflammatory agents, astringents (drying agents that precipitate protein, shrink and contract the skin), emollients (skin hydrators and softeners), and keratolytics (agents that soften, loosen, and facilitate



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exfoliation of the squamous cells of the epidermis).9 Table 1 provides information pertaining to the principles of dermatologic therapy.9 Vehicles

Delivery of topical therapies occurs in various vehicles including: • Liquids • Combination of liquid and oil • Powders9 A therapy’s effectiveness is influenced by the vehicle and may itself cause adverse effects (e.g.

contact or irritant dermatitis).9 • Aqueous preparations tend to be drying because the liquid evaporates º Utilized in acute inflammatory conditions.9 • Oil-based preparations are moisturizing. º Preferred for chronic inflammation.9

Categories and Indications Primary actions of topical agents include cleansing, moisturizing, drying, anti-inflammatory, antimicrobial, keratolytic, astringent, and antipruritic.9

TABLE 1 VEHICLES Powders

Recommended for lesions in moist or intertriginous areas. For use where opposing skin surfaces touch and may rub. May be mixed with active agents (e.g., antifungals) to deliver therapy.

Liquids

Baths and soaks For large areas, such as those with extensive contact dermatitis or atopic dermatitis.



Solutions Ingredients are dissolved in a solvent, usually ethyl alcohol, propylene glycol, polyethylene glycol, or water; easy to apply (especially to the scalp for disorders such as psoriasis or seborrhea); tend to be drying.



Lotions Water-based emulsions are easily applied; good for hairy skin, cool and dry acute inflammatory and exudative lesions, such as contact dermatitis, tinea pedis and tinea cruris.



Gels Ingredients are suspended in a solvent thickened with polymers; often more effective for controlled release of topical agents; commonly used in acne, rosacea, and psoriasis of the scalp.

Combination vehicles Generally comprised of oil and water but may also contain propylene or polyethylene glycol Creams Semi-solid emulsions of oil and water; used for moisturizing and cooling and when exudation is present; vanish when rubbed into skin. Ointments Oil-based (e.g. petrolatum) lubricants; may increase drug penetration due to occlusive nature; concentration of drug is generally more potent in an ointment; preferred for lichenified lesions (skin that has become thickened and leathery with an accentuation of the skin lines which often results from continuous friction on an area of skin) and those with thick crusts or heaped-up scales, including psoriasis and lichen simplex chronicus (skin disorder characterized by chronic itching and scratching wherein the constant scratching causes thick, leathery, brownish skin); Less irritating than creams for erosions or ulcers. Source: Merck. Principles of Topical Dermatologic Therapy.9

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Cleansing Agents

Astringents

The primary cleansing agents are soaps, detergents and solvents. Soap is the most popular cleanser, but synthetic detergents are also used. Organic solvents (e.g., acetone, petroleum products, propylene glycol) are very drying, can be irritating, and cause irritant or allergic contact dermatitis. Acutely irritated, weeping, or oozing lesions are most comfortably cleansed with water or isotonic saline rather than soaps, detergents and solvents. Water is the principle solvent for cleansing.9

Astringents are drying agents that precipitate protein and shrink and contract the skin. The most commonly used astringents are aluminum acetate (Burow’s® solution) and aluminum sulfate and Ca acetate (Domeboro®’s solution). Usually applied with dressings or as soaks, astringents are indicated for infectious eczema, exudative skin lesions, and pressure ulcers. Witch hazel is also a popular over-the-counter (OTC) astringent.9

Drying Agents Excessive moisture in intertriginous areas (e.g., between the toes, in the intergluteal cleft, axillae, groin, inflammatory areas) can cause irritation and maceration (the softening of a tissue from moisture). • Powders dry macerated skin and reduce friction by absorbing moisture; some powders have a propensity to clump and may irritate the skin if they become moist. º Cornstarch and talc are most often used; however, they may promote fungal growth. • Aluminum chloride solutions. • Methenamine (which hydrolyzes into formaldehyde and ammonia, Dehydral®) is often useful in hyperhidrosis.9

Anti-inflammatory Agents It is beyond the scope of this lesson to discuss anti-inflammatory agents.

Antimicrobials and Antifungals Topical antimicrobials include antibiotics, antifungals, insecticides and nonspecific agents. Antifungals are indicated for candidiasis, a variety of dermatophytoses and other fungal infections.9

Keratolytics Keratolytics soften and facilitate exfoliation of epidermal cells. Examples include 3% to 6% salicylic acid and urea. Salicylic acid is indicated for use in psoriasis, seborrhea, acne and warts. Adverse effects are burning and systemic toxicity if large areas are covered. It should rarely be used in children and infants. Urea is indicated for plantar keratodermas (skin thickening) and ichthyosis (scaling of skin). Adverse effects are irritation and intractable burning. It should not be applied to large surface areas.9

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Managing Dry Skin When skin loses moisture it may crack and peel, or become irritated and inflamed. Bathing too frequently, especially with harsh soaps, may contribute to dry skin.3 Suggested solutions generally include a change in bathing habits: shorten baths and showers, use warm water in place of hot water and use a minimal amount of soap. Limit the use of soap to face, armpits and genitals if possible.3 Use of mild cleansers such as Aveeno® or Cetaphil® or mild soaps such as Neutrogena® or Dove® are suggested. To increase skin and body moisture, use bath oils and moisturizers at least daily.3 Discussion of oral solutions and remedies is beyond the scope of this lesson.

Moisturizing Agents Moisturizers have been adapted to perform many important roles on the skin surface and are widely used in various dermatologic and cosmetic skin therapies. Moisturizers can serve as important adjunctive therapeutic modalities for patients with various dermatologic disorders, including acne vulgaris, rosacea, retinoid-induced irritant dermatitis, atopic dermatitis, psoriasis, and the skin dryness that appears to occur with intrinsic and extrinsic aging. Therapeutic moisturizers, defined as those proven in clinical trials to be both compatible with topical therapies and biocompatible with the skin, not only improve the signs and symptoms of dry skin but also, as research has demonstrated, help maintain hydration and overall integrity of the stratum corneum.10 The type of humectants and emollients contained in a therapeutic moisturizer can affect the overall tolerability of the formulation. Dermatologists recommend therapeutic moisturizers that are noncomedogenic, devoid of irritant ingredients, and compatible with many

Dry Skin Care and Colloidal Oatmeal

therapeutic regimens.10 Different classes of moisturizers are based on their mechanism of action, including occlusives, humectants, emollients and protein rejuvenators.11 The combination of occlusives and humectants are generally designed to enhance the water-holding capacity of the skin in moisturizers. Further diversity in moisturizer formulation is created through the addition of special ingredients, designed to enhance the functions of the skin. These agents mimic natural ingredients. Application of moisturizers can serve as important adjunctive therapy for patients with various dermatologic disorders.12 The addition of carefully selected emollients can influence the esthetic properties of the moisturizer and the stability of the active ingredients. The addition of sunscreens to moisturizers has created a new product category with an added skin function. Moisturizers are an important part of the dermatologist’s armamentarium.13 The principles of humectancy, emolliency and occlusion, all central to stratum corneum maintenance, continue to drive the development of novel moisturizing technologies. Humectants promote water retention within the stratum corneum, whereas occlusives generally minimize water loss to the external environment. The complementary occlusive activity of emollients contributes to stratum corneum hydration as well. Moisturization technologies, ranging from face care to hand and body care, vary in the types and levels of humectants, emollients (including lipids), and occlusives. Accordingly, their therapeutic effects differ as well. Emulsification of these components into a single formulation, the technologies of which are as varied as their individual components, is thought to enhance the aesthetics of the moisturizer and its overall moisturization efficiency.14 Moisturizers (emollients) restore water and oils to the skin and help to maintain skin hydration. They typically contain glycerin, mineral oil or petrolatum, and are available as lotions, creams, ointments and bath oils. Stronger moisturizers contain urea (2%), lactic acid (512%), and glycolic acid (10%); higher concentrations are used as keratinolytics (e.g. ichthyosis). They are most effective when applied to already moistened skin (e.g., after a bath or shower).9

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Dry Skin Care and Colloidal Oatmeal

Functional Ingredients in Moisturizers Ingredients documented as having a potential biological effect and reducing the severity of dry skin include alpha hydroxyl acids (AHAs) and beta hydroxy acids (BHAs), including their salts, as well as retinoids. The hydroxy acids are classified according to the number of carboxylic acids on their configuration. Monocarboxylic acids are glycolic, lactic and mandelic acids. Dicarboxylic acids include malic and tartaric acids. Tricarboxylic acids embody citric acid found in citrus fruits. The BHAs encompass mostly salicylic acid and its derivatives. AHAs have been shown to exfoliate and may be useful in hyperkeratotic conditions. They act as humectants and have a normalizing effect on the stratum corneum, increasing its plasticity and flexibility. Retinoids have been shown to be beneficial on photo-aged skin. Clinically, they have been shown to reduce some of the stigmata of photodamaged skin. Vitamins have become ordinary ingredients in moisturizers. Their role in protection from oxygen radicals produced by exogenous (e.g., Ultra Violet [UV] light) and endogenous (e.g., inflammation) states has long been known. When topically applied, vitamins have shown to reduce cellular injury by these harmful insults.15 Colloidal oatmeal, backed by clinical evidence, has a been designated by Health Canada and the Food and Drug Administration as an active ingredient for dry and itchy skin.16-18

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that “provides temporary skin protection and relieves minor skin irritation and itching due to poison oak, poison ivy, poison sumac and insect bites.” The FDA also allows colloidal oatmeal as an active ingredient in skin protectants for use as a soak, compress or wet dressing.19 Clinical investigations have demonstrated the efficacy of topical colloidal oatmeal. Oatmeal is a potent antipruritic. The moisturizing properties of colloidal oatmeal alleviate itch due to dry skin, and these properties consecutively promote protection of barrier function.20 Oatmeal also works as a skin protectant and enhancer of barrier function as the proteins and polysaccharides bind to skin to provide a protective barrier, while proteins buffer both acids and bases. Further, oat flour has been shown to display antioxidant properties and oil emulsions prevent transepidermal water loss.21 Physicians routinely recommend using oatmeal products as a matter of course for the common indications of dermatitis, eczema and dry skin.9 The application of oatmeal helps to provide relief from the symptoms of these syndromes.

Clinical Evidence for Specific Indications and Topical Colloidal Oatmeal Although scientific evidence is limited, colloidal oatmeal has been shown in clinical trials to be effective in certain difficult-to-manage clinical conditions.

Colloidol Oatmeal

Treatment of Rosacea

Health Canada Drugs and Health Products classify colloidal oatmeal as a Natural Health Product (NHP) in the category of medicated skin-care products.16 Colloidal indicates the substance is comprised of very small, insoluble particles, usually 1 to 1000 nm in diameter, that are uniformly dispersed or suspended in a finely divided state throughout a continuous dispersion medium, not settling readily and can be solid, liquid or gas.17 The Health Canada medicated skin-care product monograph applies to colloidal oatmeal products in lotion, cream, jelly, oil, suspension or stick forms, which are intended to be applied to the skin to relieve the irritation of dry and itchy skin.18 The U.S. Food and Drug Administration (FDA) accepts the safety and efficacy of colloidal oatmeal (the powder resulting from the grinding and processing of whole oat grain) products, classifying them as a skin protectant ingredient

The utilization of colloidal oatmeal for rosacea is based on its anti-inflammatory properties. Rosacea is a common skin disease that causes redness and swelling on the face. Often referred to as “adult acne,” rosacea may begin as a tendency to flush or blush easily, progressing to persistent redness in the centre of the face that may gradually involve the cheeks, forehead, chin and nose.4 Rosacea is a chronic disease and many patients find prescription therapies unsatisfactory, and frequently turn to herbal ingredients such as colloidal oatmeal for relief of their persistent facial redness.The properties that make oatmeal useful for itchy and allergic conditions make it an especially efficacious ingredient for rosacea therapies. Moisturizing properties of colloidal oatmeal alleviate itch due to dry skin.These properties sequentially promote protection of barrier function, which is often impaired in rosacea patients.20



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Herpes Zoster Colloidal oatmeal is recommended as part of the symptom management regime for herpes zoster. Herpes zoster is an acute, localized infection caused by varicella-zoster virus, which causes a painful, blistering rash. Pain, tingling or burning sensations may be intense. Reddening of the skin (erythema) followed by the appearance of blisters of vesicles (grouped, dense, deep small blisters that ooze and crust). Herpes zoster usually disappears on its own, and may not require treatment except for symptom relief, such as pain medication. Cool wet compresses can be used to reduce pain. Soothing baths and lotions, such as colloidal oatmeal products and baths, starch baths, or lotions and calamine lotion, may help to relieve itching and discomfort.22

Chickenpox

Chickenpox is an acute, systemic infection that most commonly occurs during childhood and is caused by the varicella-zoster virus (human herpes virus type 3). It usually begins with mild constitutional symptoms that are followed shortly by skin lesions appearing in crops and characterized by macules, papules, vesicles, and crusting. Mild cases require only symptomatic treatment. Relief of itching and prevention of scratching, which predisposes to secondary bacterial infection, may be difficult. Wet compresses, colloidal oatmeal products and baths may help. For severe itching, systemic antihistamines may help.23

Reduction of itch during burn wound healing Colloidal oatmeal is valuable in the management of pruritus in burn patients. An assessor-blind clinical trial carried out in the Adult Burns Unit, Royal Brisbane Hospital (RBH), in Australia, demonstrated liquid paraffin with colloidal oatmeal reduced itching and antihistamine use in acute burn patients compared to liquid paraffin alone. The study investigated a method to reduce the itch experienced by patients who had sustained burn injuries, by using and comparing the effectiveness of two shower and bath oils. One product contained liquid paraffin with 5% colloidal oatmeal and the other contained liquid paraffin. Acute burn patients (n=35) rated their discomfort from itch and pain and recorded their daily amount of antihistamine consumption. Analysis of data supplied by patients showed that the group

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using the product with colloidal oatmeal reported significantly less itch and requested significantly less antihistamine than those using the oil containing only liquid paraffin.24 Treatment with colloidal oatmeal lotion is efficient in controlling the rash associated with epidermal growth factor (EGFR) and multiple tyrosine-kinase inhibitors (TKI), and allows continuation of the antineoplastic treatment. Colloidal oatmeal lotion demonstrates effective anti-inflammatory action in cancer patients with dermatological toxicity when treated with antineoplasic therapies. Current treatment modalities for EGFR-positive cancers have recently included the use of antibodies and small-molecule TKI. A significant limiting step in the use of these agents is dermatological toxicity, frequently in the form of an acneiform eruption. Present management modalities for this toxicity are largely ineffective. Colloidal oatmeal lotion demonstrates multiple anti-inflammatory properties with known effects on arachidonic acid, cytosolic phospholipase A2 and tumour necrosis factor-α pathways, along with an excellent side-effect profile. Treatment with colloidal oatmeal was applied to 11 patients with a rash induced by cetuximab, erlotinib, panitumumab and sorafenib. Of the 10 assessable patients, 6 had complete response and 4 had partial response, giving a response rate of 100% with no associated toxicities.25

Wound Care After Radiation Therapy Colloidal oatmeal products decrease itching in radiation-induced wounds. More than 50% of all cancer patients receive some form of radiotherapy for tumor control preoperatively, postoperatively, or as sole treatment.26 Radiation-induced wounds are a concern for patients and practitioners. Current research investigating alternative treatment strategies offers the hope of improved wound healing and enhanced quality of life for patients with these wounds. Dry desquamation during treatment occurs with the patient’s skin in the treated area, appearing red or tanned, dry, itchy and peeling.The products suggested for use in treating an erythematous reaction can be applied in this situation. Hydrophilic preparations (e.g., Eucerin®, Lubriderm®) protect and lubricate scaly or flaking skin resulting from the loss of sweat and sebaceous gland function.26 To decrease itching, products such as colloidal oatmeal (e.g., Aveeno®), cornstarch and mild steroids such as hydrocortisone cream 1% can be used.27

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Dry Skin Care and Colloidal Oatmeal

Figure 1

Source: Pharmacy Gateway. OTC Recommendations Survey 2005.28

What do Canadian Pharmacists Recommend? The Canadian OTC Recommendations Survey for 2005 reports that Aveeno® (including colloidal oatmeal) and Glaxal® Base (moisturizers) are the most frequently recommended products by pharmacists in Canada. Lubriderm® (shea and cocoa butter) and Moisturel® (moisturizers) are third and fourth. These moisturizers containing certain ingredients, including occlusives and humectants, are intended to repair damaged stratum corneum.28

Directions for Use of Colloidal Oatmeal Directions for use are described in the Health Canada Monograph (Category IV). Products may be in lotion, cream, jelly, oil, suspension or stick forms, intended for application to the skin to relieve the irritation of dry and itchy skin.18

Indications for Colloidal Oatmeal (Health Canada) • relieves and soothes chapped skin and lips • helps prevent and relieve chaffing and dry itchy skin • specially formulated for the treatment of dry skin • medicated skin-care product • therapeutic preparation for dry itchy skin

• helps relieve dry itching and minor skin irritations • therapeutic emollient • for the protection, relief and/or treatment of diaper rash Dosage: The product should be applied as

and where needed. For bath oil, approximately 15 to 30 millilitres (the quantity recommended will depend on the concentration of the medicinal ingredients) of the product should be added to the bath water.18 Warnings: The product is intended for

external use only. Contact with the eyes should be avoided - if this happens, rinse thoroughly with water. Use should be discontinued if rash or irritation occurs or worsens.18

Conclusion The moisturizing properties of colloidal oatmeal alleviate itch due to dry skin and promote protection of barrier function. Colloidal oatmeal lotion demonstrates multiple anti-inflammatory properties with known effects on arachidonic acid, cytosolic phospholipase A2 and tumour necrosis factor-α pathways, along with an excellent side-effect profile. Patients can be counseled to be cautious when using bath oil and exiting the tub, as the bath oil can make the

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Dry Skin Care and Colloidal Oatmeal

tub surface quite slippery. The clinical evidence of efficacy makes colloidal oatmeal a predictable and effective solution for various causes of dry skin. Dry skin is the major indication of use.

Pharmacist’s Role Investigating the patient history is necessary to ascertain the status of a patient’s complaint of dry skin. Product selection and recommendations must be made in consideration of each patient’s unique needs and should incorporate such variables as the individual’s skin, the desired effect, the consistency and texture of the preparation, its cost, and acceptability to the patient. The recommendation for the use of colloidal oatmeal in cases of dry skin of various etiologies can be made with confidence of its efficacy.



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References

1. Merck. Puritis. http://www.merck.com/mmpe/sec10/ ch114/ch114b.html. Accessed December 8, 2006. 2. American Acedemy of Dermatologists. Dermatology Insights. Scaling back on winter skin problems. Fall 2001:p24. http://www.aad.org/NR/rdonlyres/529273A8-FD17-4C5994FB-2097D436DBE4/0/DIfall01.pdf#page=24. Accessed December 9, 2006. 3. Medline Plus. Medical Encyclopedia. Dry Skin. http:// www.nlm.nih.gov/medlineplus/ency/article/003250.htm. Accessed December 8, 2006. 4. American Acedemy of Dermatology. www.aad.org. Accessed December 8, 2006. 5. Medline Plus. Medical Encyclopedia. Itching. http:// www.nlm.nih.gov/medlineplus/ency/article/003217.htm. Accessed December 8, 2006. 6. Wikipedia Encyclopedia. http://en.wikipedia.org/wiki/ Main_Page. Accessed December 6, 2006. 7. Correale CE, Walker C, Murphy L. et al. Atopic Dermatitis: A Review of Diagnosis and Treatment. Am Fam Physician 1999;60:1191-210. 8. Mayo Clinic.com. Dermatitis/Eczema. http://www. mayoclinic.com/health/dermatitis-eczema/DS00339. Accessed December 8, 2006. 9. Merck. Principles of Topical Dermatologic Therapy. http://www.merck.com/mmpe/sec10/ch110/ch110a.html. Accessed December 8, 2006. 10. Bikowski J. The use of therapeutic moisturizers in various dermatologic disorders. Cutis. 2001 Dec;68(5 Suppl):3-11. 11. Lynde CW. Moisturizers: What they are and how they work. Skin Therapy Lett. 2001 Dec;6(13):3-5. 12. Lipozencic J, Pastar Z, Marinovic-Kulisic S. Moisturizers. Acta Dermatovenerol Croat. 2006;14(2):104-8. 13. Draelos ZD. Therapeutic moisturizers. Dermatol Clin. 2000 Oct;18(4):597-607. 14. Rawlings AV, Canestrari DA, Dobkowski B. Moisturizer technology versus clinical performance. Dermatol Ther. 2004;17 Suppl 1:49-56. 15. Schwartz R. Moisturizers. eMedicine from WebMD. Available at www.emedicine.com. Accessed January 5, 2007. 16. Health Canada. Drugs and Health Products. http:// www.hc-sc.gc.ca/dhp-mps/prodnatur/applications/licen-prod/ monograph/list_mono4_e.html. Accessed December 8, 2006. 17. Merck Source. Resource Library. Dorlands Medical Dictionary. www.mercksource.com.Accessed December 8, 2006. 18. Health Canada. Category IV Monograph. Medicated skin-care products. http://www.hc-sc.gc.ca/dhp-mps/ prodpharma/applic-demande/guide-ld/cat-iv-mono/sk_sp_ med_cat4_e.html. Accessed December 8, 2006. 19. Food and Drug Administration. Skin protectant drug products for over-the-counter human use; final monograph. Fed Regist. June 4, 2003;68(107):33362-33381. 21 C.F.R. §§ 347.10(f) and 347.50(b)(4). 20. Wu J. Treatment of rosacea with herbal ingredients. J Drugs Dermatol. 2006 Jan;5(1):29-32. 21. Webster FH. Oat utilization: Past, present, and future. In: Webster FH, ed. Oats: Chemistry and Technology. St Paul, Minn: American Association of Cereal Chemists. Inc; 1986:413-26. 22. Medline Plus. Herpes zoster. http://www.nlm.nih.gov/ medlineplus/ency/article/000858.htm.Accessed December 8, 2006. 23. Merck. Chicken Pox. http://www.merck.com/mmpe/ sec14/ch189/ch189b.html. Accessed December 8, 2006. 24. Matheson JD, Clayton J, Muller MJ. The reduction of itch during burn wound healing. J Burn Care Rehabil. January-February 2001;22(1):76-81. 25. Alexandrescu DT,Vaillant JG, Dasanu CA. Effect of treatment with a colloidal oatmeal lotion on the acneform eruption induced by epidermal growth factor receptor and multiple tyrosine-kinase inhibitors. Clin Exp Dermatol. 2006 Oct 11; [Epub ahead of print]. 26. Mendelsohn FA, Divino CM, Reis ED, et al. Wound care after radiation therapy. Adv Skin Wound Care. 2002;15:216,218-24. 27. Ratliff C. Impaired skin integrity related to radiation therapy. J Enterostomal Ther 1990;17(5):193-8. 28. Pharmacy Gateway. OTC Recommendations Survey 2006. Available at http://www.pharmacygateway.ca/otc/ products/product_37.html. Accessed January 7, 2007.

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Questions

Dry Skin Care and Colloidal Oatmeal

Answer by return card, fax or online at www.pharmacygateway.ca, CE Online section, “More CCCEP-Approved” area.

1) Which statement about dry skin is TRUE? a) Dry skin only occurs in individuals of advanced age. b) Skin is drier in summer months. c) Skin is dry because it lacks water. d) Dry skin occurs most commonly on the face. 2) Which statement best describes pruritus? Pruritus is: a) Never related to sleeplessness, anxiety or depression. b) An itch or sensation that is unrelated to scratching. c) A complex process involving nerves, the chemicals they respond to, and the processing of nerve signals in the brain. d) Scratching that calms itching as part of the “itch-scratch-itch cycle.” 3) Which statement is CORRECT regarding dermatitis? Dermatitis is: a) A red, scaly, itchy rash that is a potentially debilitating condition that can compromise quality of life. b) A rash that is precisely categorized. c) A term that is synonymous with eczemas or dermatitides. d) a and c e) All of the above. 4) P  atient R.K. presents at your pharmacy with a skin rash and inquires about the consequences of her ongoing attempts to relieve the itch of this rash by scratching. Which statement is TRUE? a) Limited options for treatment of itching are available. b) Scratching simply worsens the rash, creating a vicious circle. c) There are no self-care options or medications for itching. A physician must be consulted. d) Topical remedies are not effective, only oral dosage forms are useful. 5) P  atient P.M. has an acute inflamed patch on her skin and wants to know if she should use a waterbased product or an oil-based

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product. Which statement is TRUE? a) A combination of oil-based and waterbased products are used in acute conditions. b) O  il-based preparations are preferred for acute inflammatory skin conditions. c) Aqueous preparations are used in acute inflammatory skin conditions. d) Suspension preparations of oil with water are used for acute skin inflammation.

d) a and b e) a and c

6) Which vehicles are suggested for use in moist or intertriginous areas of dry skin? a) Oils b) Baths and soaks c) Liquids d) Powders

11) Dr.T.R. wants to know what the mechanism of action of colloidal oatmeal in rosacea patients is.The statement that best describes this is: a) The skin lightening properties of oatmeal are useful for facial redness. b) The anti-inflammatory and moisturizing properties of oatmeal alleviate itch from dry skin and promote barrier function. c) The immune modulating properties of colloidal oatmeal eliminate rosacea. d) Colloidal oatmeal is not useful for patients with rosacea.

7) Dr. P.K calls about patient R.B. asking which topical vehicle is most suitable for lichen simplex chronicus. Which answer is most accurate for lichen simplex chronicus? a) Creams are less irritating than ointments. b) O  intments are oil-based lubricants and most effective. c) Gels are most effective. d) Lotions are the best selection. 8) Patient K.P. has an acute case of contact dermatitis that is inflammatory and exudative. He wants a topical product to apply and asks you what type of product to use. Your suggestion for his condition is: a) Solutions of ethyl alcohol, propylene glycol, polyethylene glycol, or water are most helpful. b) Gels are often more effective. c) Powders are generally prescribed. d) L otions that are water-based emulsions will cool and dry acute inflammatory and exudative lesions, such as contact dermatitis. 9) The important properties of therapeutic moisturizers as defined in clinical trials is/are: a) To be biocompatible with the skin. b) Improve signs and symptoms of dry skin. c) Maintain elasticity and partiality of the stratum corneum.

10) The indications for colloidal oatmeal as recognized by Health Canada are: a) Eliminate skin rash. b) Relieve the irritation of dry and itchy skin. c) Relieve pain. d) Relieve erythema.

12) Patient P.Q. has herpes zoster and is suffering with symptoms of a painful, blistering rash. He is taking pain medication and wants to know what form of colloidal oatmeal may help alleviate his discomfort. a) Gel or ointment application. b) Propylene glycol preparations. c) Blended soap preparations. d) Bath or lotions. 13) Patient T.R. is recovering from a burn injury and suffering from itching.T.R. takes antihistamines and wants to add a topical product.Which of the answers is most CORRECT? a) A 15% colloidal oatmeal in liquid paraffin solution my help relieve the itch. b) There are no studies on the effective use of topical preparations in burn patients. c) A 5% colloidal oatmeal in liquid paraffin solution my help relieve the itch. d) Topical preparations of colloidal oatmeal used with an antihistamine will not help relieve the itch.

March 2007



Promoting Protection: The Broad Spectrum of Sun Damage

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Questions (continued) 14) T.R. also wants to know if this topical preparation may help reduce the quantity of antihistamine he takes for the itching. Which statement is TRUE? a) 1 0% colloidal oatmeal in liquid paraffin has been shown to be helpful. b) 5% colloidal oatmeal in liquid paraffin has been shown to be helpful. c) Topical preparations are contraindicated in burn patients taking antihistamines. d) A liquid paraffin solution alone is the most helpful. 15) D  r. D.C. wants to know the mechanism of action for topically applied colloidal oatmeal.The answer that is most correct is that colloidal oatmeal has known effects on: a) Arachidonic acid, cytosolic phospholipase A2 and tumour necrosis factor-α pathways. b) Arachidonic acid, cytosolic phospholipase A2 and tumour necrosis factor-β pathways. c) Arachidonic acid, cytosolic phospholipase A4 and tumour necrosis factor- α pathways. d) Arachidonic acid, cytosolic phospholipids and tumour necrosis factor-β pathways. 16) D  r. D.C. also asks for information on the use of colloidal oatmeal for



dermatological toxicity in the form of an acneiform eruption.“In one study, patients receiving various chemotherapeutic agents demonstrated a: a) 60% response rate with associated toxicities.” b) 1 00% response rate with associated toxicities.” c) 100% response rate with no associated toxicities.” d) 6 0% response rate with no associated toxicities.”

17) Patient M.N. has a radiation-induced wound as a result of his cancer therapy with presenting symptoms including desquamation that is red, dry, itchy and peeling. M.N. finds the itching is quite intolerable and wants a topical preparation for relief from itching. Which statement is most CORRECT? a) Mild steroids are contraindicated for itching skin. b) C  olloidal oatmeal (e.g., Aveeno®) helps with itching. c) Eucerin® is very helpful with itching. d) Lubriderm® is best for itching.

19) Patient B.C. is suffering from chaffing and dry itchy skin and wants a bath oil to help relieve her discomfort. Which of the volumes for use of bath oil is most CORRECT? a) 5 ml b) 15-30 ml c) 250 ml d) 500 ml 20) Mrs. W.M. has a daughter who is 4years-old and suffering from the itching due to chicken pox. Which remedy would you suggest? a) P  ropylene glycol preparations applied directly to the skin is the best suggestion. b) Strong soap solutions in bath water is the best suggestion. c) Wet compresses, systemic antihistamines and colloidal oatmeal products and baths may help. d) Combination salicylic acid and urea products is the best suggestion.

18) Colloidal oatmeal is categorized as a category IV Natural Health Product (NHP) for use in which indications?

CE Faculty  honda Dorren has developed a consultation practice in R natural medicine pharmacy that includes private consultations for patients seeking protocols for complementary therapies. She has extensive practical experience and training in herbs, botanicals, nutraceuticals, nutritional supplements, homeopathy, homotoxicology and functional medicine. She utilizes a unique blend of allopathic and biological medicines for clients to maximize their outcomes. Rhonda regularly lectures to professional and

a) Anti-erythema product. b) Anti-acne products. c) Itching due to poison oak, poison ivy, poison sumac and insect bites. d) Relieve the irritation of dry and itchy skin.

CE COORDINATOR contributes to health magazines, most recently Alive, Vista, Natural Pharmacy Magazine and RX Press.

Reviewers

Heather Howie Toronto, Ont.

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Ramos at (416) 764-3879, fax (416) 764-3937 or

completeness and relevance to current pharmacy practice.

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non-professional groups on natural medicines. She also



March 2007

OTC Medications CE

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