What Should I Recommend for Severe Dry, Cracking Skin?

Posted 04/24/2003

  http://www.medscape.com/viewarticle/452575

from Medscape Nurses

Question

Especially in the winter months, many patients will complain of severe pain and cracking in the skin of the hands and feet. What practical recommendations might be suggested to ease their discomfort? Are particular ointments, creams, or special gloves more effective than others? What about the use of a topical analgesic to ease the pain?

Response

from Margaret A. Fitzgerald, MS, APRN, BC, NP-C, FAANP, 04/24/2003

The skin protects the body from outside substances, chemicals, and bacteria and contributes to temperature maintenance and other homeostatic functions. The outermost epidermal layer is only 1/250th of an inch, with the dermis is only 1/50th to 3/25ths of an inch thick. The skin's protective function can be easily interrupted through exposure to the elements, such as dry air, whether accompanied by cold or heat, leading to drying of the skin and microscopic cracks.

In addition, cold changes blood flow at the skin surface and leads to loss of sensation and increased risk of skin damage from trauma. Since healthy skin has a slightly acid pH, exposure to substances with an alkaline pH, such as many commercial cleansers and hand soaps, also contributes to interruptions of skin integrity. Once the skin integrity is disturbed, a homeostatic repair mechanism is stimulated that causes the rapid repair of barrier function. Continued exposure to alkaline substances will slow down repair by inhibiting normal skin acidity when there is continued exposure to unfavorable environmental factors.

The best treatment for severely dry, cracking skin is prevention. The hands should be protected from any factors that can interrupt skin integrity. Physical barrier protection, such as reusable kitchen rubber gloves, is needed whenever the hands might come in contact with cleansers. Creams that are touted as forming a protective skin barrier afford significantly less protection than a physical barrier. Remind patients that most cleansers are developed to cut through grease and will do this efficiently, depleting the natural protective oils on the hands.

When outdoors, the hands need to be protected with mittens or gloves adequate for the weather. When hand washing is needed, a pH-balanced skin cleanser such as Dove or Cetaphil in small amounts should be used. The use of a hand cream should always follow hand washing and must also be applied as often as possible during the day and before bedtime. Most commercially prepared hand creams contain lipids and humectants while many contain urea and alpha hydroxy acids. Lipids help protect the skin from outside influences while limiting transepidermal water loss. This yields more complete hydration of the skin and a mild anti-inflammatory effect.

Humectants bind water and thus attract water to the skin and temporarily hold it there. Urea enhances this activity while alpha hydroxy acids help with exfoliation. Petrolatum (Vaseline) is an inexpensive option for skin protection but not fully occlusive as once thought; while usually too messy for daytime use, petrolatum is well suited for use at bedtime. Bag Balm, a veterinary product touted to protect cow udders, has been used for human skin protection and contains petrolatum, lanolin, and an antiseptic (8-hydroxyquinoline sulfate 0.3%). While Bag Balm has not been approved for human use, there are no FDA reports of adverse effects with humans.

If dry, cracking skin does occur, a pumice stone after bathing can be used to gently remove excess callused and dead skin, followed by a program of skin protection. Covering skin fissures with an antimicrobial cream and a Band-Aid may help accelerate healing and relieve pain.

Topical anesthetic creams such as Lanacane are available over-the-counter and may be helpful for temporary relief of itch associated with dry skin, but are not of sufficient strength to relieve pain. Concerns about anesthetic sensitization with the use of these products is likely minimal, but remains an area of concern.

If deep fissures form, closure with a medical or commercial-grade glue (Dermabond, Superglue) is helpful in both controlling pain and accelerating healing. The glue usually wears off in about 1 week.