Keratolytics and Emollients and Their Role in the Therapy of Psoriasis: a Systematic Review

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Abstract

Introduction

Psoriasis is a common chronic disease with significant impairment in quality of life. As there is no cure, it often requires lifelong disease control to minimize the development of skin lesions and to relieve symptoms. The aim of this publication is to systematically review the role of currently used emollients and keratolytics in the treatment of psoriasis.

Methods

A systematic literature search was conducted in Medline via PubMed regarding reviews, meta-analyses, and trials published from January 1983 to December 2013 dealing with topical administration of emollients and keratolytics in patients with psoriasis. A subsequent search in EMBASE regarding clinical trials published from 1983 to 2013 was performed to complement the findings.

Results

A total of 60 publications met the inclusion criteria for full-text evaluation. While current reviews, meta-analyses, and guidelines state that adjuvant therapy with emollients and keratolytics should be an obligatory part in the therapy of psoriasis to facilitate descaling and/or penetration enhancement, comprehensive trials on these agents are missing, with the exception of combination products containing salicylic acid and corticosteroids. In the mentioned trials, addition of salicylic acid was beneficial in inducing a more rapid onset of action as well as a reduction of severity parameters and the area affected. However, its use has substantial limitations in young children, in patients with renal/hepatic impairment, with widespread psoriasis, those undergoing phototherapy, or those concomitantly treated with calcipotriene/systemic salicylates.

Conclusion

In view of these shortcomings, there is a need for well-designed studies on suitable keratolytic alternatives to salicylic acid offering an indisputable positive benefit–risk ratio.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-015-0068-3) contains supplementary material, which is available to authorized users.

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Most cited references 59

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Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders.

Marie Lodén (2002)

Emollients and moisturizing creams are used to break the dry skin cycle and to maintain the smoothness of the skin. The term 'moisturizer' is often used synonymously with emollient, but moisturizers often contain humectants in order to hydrate the stratum corneum. Dryness is frequently linked to an impaired barrier function observed, for example, in atopic skin, psoriasis, ichthyosis, and contact dermatitis. Dryness and skin barrier disorders are not a single entity, but are characterized by differences in chemistry and morphology in the epidermis. Large differences also exist between moisturizing creams. Moisturizers have multiple functions apart from moistening the skin. Similar to other actives, the efficacy is likely to depend on the dosage, where compliance is a great challenge faced in the management of skin diseases. Strong odor from ingredients and greasy compositions may be disagreeable to the patients. Furthermore, low pH and sensory reactions, from lactic acid and urea for example, may reduce patient acceptance. Once applied to the skin, the ingredients can stay on the surface, be absorbed into the skin, be metabolized, or disappear from the surface by evaporation, sloughing off, or by contact with other materials. In addition to substances considered as actives, e.g. fats and humectants, moisturizers contain substances conventionally considered as excipients (e.g. emulsifiers, antioxidants, preservatives). Recent findings indicate that actives and excipients may have more pronounced effects in the skin than previously considered. Some formulations may deteriorate the skin condition, whereas others improve the clinical appearance and skin barrier function. For example, emulsifiers may weaken the barrier. On the other hand, petrolatum has an immediate barrier-repairing effect in delipidized stratum corneum. Moreover, one ceramide-dominant lipid mixture improved atopic dermatitis and decreased transepidermal water loss (TEWL) in an open-label study in children. In double-blind studies moisturizers with urea have been shown to reduce TEWL in atopic and ichthyotic patients. Urea also makes normal and atopic skin less susceptible against irritation to sodium laurilsulfate. Treatments improving the barrier function may reduce the likelihood of further aggravation of the disease. In order to have optimum effect it is conceivable that moisturizers should be tailored with respect to the epidermal abnormality. New biochemical approaches and non-invasive instruments will increase our understanding of skin barrier disorders and facilitate optimum treatments. The chemistry and function of dry skin and moisturizers is a challenging subject for the practicing dermatologist, as well as for the chemist developing these agents in the pharmaceutical/cosmetic industry.

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Adherence in the Treatment of Psoriasis: A Systematic Review

M. Augustin, B. Holland, D Dartsch … (2011)

Background: Medication adherence and compliance are essential for disease management and can significantly improve outcomes and quality of patient care. The literature suggests that up to 40% of patients do not use their medication as intended. Objective: To elucidate current knowledge on adherence/compliance in psoriasis. In particular, methods of adherence/compliance evaluation and influencing factors were to be identified. Methods: Systematic literature review based on a protocol-rooted search in online databases, followed by a structured critical appraisal and consecutive descriptive report. Results: Thirty-five original publications on adherence/compliance in psoriasis were identified, addressing the extent and quality of adherence/compliance in topical, systemic and UV treatments. Estimates of compliance varied considerably between 27 and 97%. Age, sex, psychosocial, disease-specific and treatment-specific factors were identified as predictors of adherence/compliance. Conclusion: A better understanding of the determinants of adherence can improve the outcomes of psoriasis treatment and lead to higher patient satisfaction and quality of care.

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S3 - Guidelines on the treatment of psoriasis vulgaris (English version). Update.

Alexander Nast, Wolf-Henning Boehncke, Ulrich Mrowietz … (2012)

Psoriasis vulgaris is a common and often chronic inflammatory skin disease. The incidence of psoriasis in Western industrialized countries ranges from 1.5% to 2%. Patients afflicted with severe psoriasis vulgaris may experience a significant reduction in quality of life. Despite the large variety of treatment options available, surveys have shown that patients still do not received optimal treatments. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologi sche Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. They were first published in 2006 and updated in 2011. The Guidelines focus on induction therapy in cases of mild, moderate and severe plaque-type psoriasis in adults including systemic therapy, UV therapy and topical therapies. The therapeutic recommendations were developed based on the results of a systematic literature search and were finalized during a consensus meeting using structured consensus methods (nominal group process).

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Author and article information

Contributors

Arnd Jacobi: a.jacobi@uke.de

Journal

Journal ID (nlm-ta): Dermatol Ther (Heidelb)

Journal ID (iso-abbrev): Dermatol Ther (Heidelb)

Title: Dermatology and Therapy

Publisher: Springer Healthcare (Heidelberg )

ISSN (Print): 2193-8210

ISSN (Electronic): 2190-9172

Publication date (Electronic): 21 January 2015

Publication date PMC-release: 21 January 2015

Publication date Collection: March 2015

Volume: 5

Issue: 1

Pages: 1-18

Affiliations

Institute for Health Services Research in Dermatology and Nursing (IVDP), German Center for Dermatological Research (CeDeF), University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Article

Publisher ID: 68

DOI: 10.1007/s13555-015-0068-3

PMC ID: 4374065

PubMed ID: 25604924

SO-VID: 2a777f7a-f498-401c-83c4-5c39d0ed85be

History

Date received : 29 August 2014

Custom metadata

ScienceOpen disciplines: Dermatology

Keywords: alpha-hydroxy acids,emollients,keratolytic agents,keratolysis,poly-hydroxy acids,psoriasis,salicylic acid,skin-peeling agents,skin peeling,urea

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ScienceOpen disciplines: Dermatology

Keywords: alpha-hydroxy acids, emollients, keratolytic agents, keratolysis, poly-hydroxy acids, psoriasis, salicylic acid, skin-peeling agents, skin peeling, urea

Keratolytics and Emollients and Their Role in the Therapy of Psoriasis: a Systematic Review

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Abstract

Introduction

Methods

Results

Conclusion

Electronic supplementary material

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Karger: Dermatology

Most cited references 59

Role of topical emollients and moisturizers in the treatment of dry skin barrier disorders.

Adherence in the Treatment of Psoriasis: A Systematic Review

S3 - Guidelines on the treatment of psoriasis vulgaris (English version). Update.

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Contributors

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