Management of Patients with Dry Skin

CPD e-learning module

Developed alongside leading Dermatologist Dr Justine Hextall and Deborah Evans, Pharmacist and Managing Director of Pharmacy Complete

Upon completion of the module, you should have:

  • Updated your knowledge on the anatomy of the skin and dry skin formation.
  • Bettered your understanding of common dry skin causes and symptoms, as well as how to identify it.
  • Increased your awareness and clinical confidence on how to manage patients with dry skin and offer practical advice for self-care at home.
  • A sound understanding of the business opportunity that the skincare category presents for pharmacies.

Upon completion of the training, you will receive an e-certificate.

The free training takes approximately 45min to complete.

UK/2019-0213

After working through this training module, you should have:

  • 1 Updated your knowledge on the anatomy of the skin, dry skin formation, how to identify dry skin conditions and understanding of their causes and symptoms
  • 2 Increased your awareness and clinical confidence on how to manage patients with dry skin and offer advice for self-care

Continuing Professional Development


Revalidation

These e-learning modules can be used towards Continuing Professional Development for revalidation of registered pharmacy professionals with the General Pharmaceutical Council. This can either be a planned CPD learning record or unplanned depending on how you approached this learning. After completing this module, complete a CPD entry on www.mygphc.org and ensure that you detail how you have applied the learning and describe how it has specifically benefited people using your services, illustrated with an example.

You should download and store the e-certificate as evidence of your CPD and retain as a hard or e-copy.

We estimate this module should take 45 minutes to complete.


Module 1 – Introduction to dry skin

‘Management of patients with dry skin’ is an online educational resource for healthcare professionals (HCPs). The module is expected to take around 45 minutes, and counts towards your Continuing Professional Development (CPD).

Dry skin is very common in both adults and children and it is a topic patients will often wish to discuss with a HCP, such as their pharmacist. Some patients will be able to seek advice, treatment and solutions to ease their dry skin discomfort in pharmacy, while other patients will need assistance to find treatment advised by their GP or a specialist. Pharmacists will be able to alert patients to any skin conditions that need additional expert attention, i.e from a dermatologist. Good skin care advice improving dry irritated skin at an early stage, can prevent the development of some skin conditions.

For many, ‘dry skin’ is simply a skin type. But for others, it’s a condition that can genuinely affect their quality of life and drain their confidence. I’ve treated many patients who feel far from comfortable in their own skin as a result.

This training module has been designed to develop your knowledge of dry skin and associated dry skin conditions, which can often be self-managed effectively without the need to visit a dermatologist.

Enjoy learning about dry skin and the optimal dry skin treatment advice you can give to your patients.

Dr Justine Hextall,
Leading dermatologist

The physiology of dry skin

Skin becomes dry when it doesn’t produce enough oil (sebum), with time there is a loss of natural ceramides/ lipids and the skin barrier function is compromised, leading to moisture loss.1

Dry skin is known as xerosis, a common skin condition, which has been found to affect almost 30 per cent of the population.2 As we age the skin barrier atrophies (wastes away), there is a reduced capacity for repair after insult (physical injury), and the production of lipids declines. Soaps and shower gels that may have once been tolerated leave skin dry and irritated, requiring protective emollients. The skin barrier is less effective and as a consequence there is increased (trans-epidermal) water loss. Some studies show that that up to 70% of those over 70yrs suffer with dry skin.

Our skin comprises of three main dermal layers: the external, protective layer called the epidermis, the second ‘main’ skin layer called the dermis, and a bottom subcutaneous (lipid) layer.3

The epidermis itself has five strata (layers) of cells, which give skin its strength, flexibility and water resistance.4

The outermost layer, called the stratum corneum, we now realise plays the crucially protective role in maintaining optimal skin function.4 It constantly renews itself from cells made deeper in the epidermis. The statum corneum (the outermost layer of the skin) has a naturally acidic pH around 5.5. If we change that pH, for example when the skin comes into contact with soaps or chlorinated swimming pool water, the barrier function becomes compromised and can lead to dry irritated skin. The stratum corneum is formed of dead skin cells, which shed when skin is rubbed or exfoliated.4 It also contains ‘pores’ – small openings of the sebaceous (oil) glands attached to a hair follicle, which produce oily sebum to lubricate the top layer, contributing to maintaining the integrity of the skin barrier. 5

Importance of healthy skin/Itch scratch, infection cycle6

Damage to the skin’s outer barrier leads to dehydration and, if untreated, dry skin can become flaky and itchy. Depending on severity, this may lead to it cracking, bleeding and becoming inflamed, which prevents the skin from being able to shield itself, and the rest of the body, against external factors.4

A weakened protective layer increases exposure to allergens, bacteria and toxins, increasing the risk of infection.

Inflammation and cracking can trigger pruritic (itchy) skin, which if scratched releases more histamine, increasing the desire to itch, the skin can become thickened and cracked leaving it vulnerable to irritants and infection. This is collectively known as the itch-scratch infection cycle.6

It’s essential to treat dry skin to keep it healthy, strong and prevent infection and exacerbation of dry skin conditions.

Dry skin symptoms

Dry skin symptoms often include:


  • 1 Dull or red/pink colour
  • 2 Flaky texture
  • 3 Peeling
  • 4 Inflammation
  • 5 Lichenification – skin is thickened often pink or darker depending on natural skin tone in areas scratched regularly
  • 6 Pruritus – itching, which worsens after scratching (known as the itch-scratch cycle)7

Common dry skin conditions

Dry skin conditions vary significantly in severity and from patient to patient. The most common dry skin conditions are listed here from mild to severe. Please note that this list is not definitive.

Dry skin or very dry skin – Dry skin incidence is on the increase.8 It can occur for many reasons and at any age, although it has a higher prevalence in the elderly.9 Parts of the body most affected include hands, elbows, heels of the feet and lips and if left untreated, the skin can become itchy, inflamed and uncomfortable.

Eczema – There are many forms, but the most common is, atopic dermatitis, a chronic condition often diagnosed in children. It causes skin to become dry, red, itchy and cracked and may appear in scaly patches, and it can lead to widespread inflammation. It most often affects the hands, insides of the elbows, backs of the knees and the face and scalp but can appear anywhere on the body. People with eczema will experience varying severities of the condition at different times. It can lead to flare ups, sometimes triggered by anxiety, stress and diet.10

Psoriasis – A condition that causes defined thick, red and scaly patches of dry skin, with silvery scales. It’s commonly found on the elbows, knees, scalp and lower back, although it can appear across the body. The severity of the condition varies considerably from person to person.11

Ichthyosis - There are at least 20 types of this dry skin condition, which can cause widespread and persistent thick, dry and scaly skin. The most common form, ichthyosis vulgaris appears as fine light-grey scales across the limbs. Unlike eczema and psoriasis, the face and bends of elbows and knees aren’t affected, although people with ichthyosis often have eczema too.12

Causes of dry skin

Dry skin can be caused by internal and external4 factors, as well as some health conditions.

Internal (physiological)

  • Dehydrated skin is often caused by a lack of sebum, leading to a compromised protective skin barrier, which causes water to evaporate from our body, and drying it out.
  • Age also plays a part – dry skin is common in the elderly.11

External

  • Not drinking enough water can lead to skin dehydration.
  • Dry skin often gets worse in winter when temperatures drop and air becomes drier.4
  • Exposing skin to heat, in the form of hot baths, showers and central heating can take moisture out of the skin.13
  • Harsh soaps and detergents can remove oil from the skin, causing it to dry out.

Health conditions

  • Dry skin is the main symptom of eczema13 and psoriasis14
  • Patients with diabetes14, hypothyroidism15 and kidney disease16 often experience dry skin.
  • The menopause and hormonal imbalances can dry out skin too.

References


Which of the following might be a physiological cause of dry skin?

  • The skin doesn’t produce adequate sebum, which compromises the natural barrier
  • The skin produces too much sebum, which dehydrates skin and compromises the natural barrier.
  • Dead skin cells rising up and compromising the natural barrier when they hit the air

What parts of the body does atopic dermatitis commonly affect?

  • Feet, hands and elbows
  • Hand, insides of elbows and knees, face and scalp
  • Hand, insides of elbows and knees and lower back

Tick all of the most common aggravators of dry skin

  • Cold weather
  • Hot baths
  • Spicy food
  • Soaps
  • Humidity

Which skin layer creates the skin’s protective moisture barrier?

  • Epidermis
  • Subcutaneous layer
  • Dermal papilla

Module 2 – Practical guidance for patients with dry skin

Caring for dry skin

Dry skin requires hydration to help support the protective barrier function. Moisturisers are a basic component of daily skin care, helping to keep it healthy.

Treating dry skin, very dry skin and dry skin conditions requires a combination of particular components to hydrate skin optimally.

  • Occlusive agents – substances, such as oils and butters, which form a protective layer on top of the skin.17
  • Humectants –draw moisture into the skin. Glycerin is an example of a humectant.18
  • Emollients –help to improve the appearance of dry skin by filling in open spaces left by flaky skin cells, leaving it feeling smoother.19

Other dry skin treatments

Topical corticosteroids – can be used to ease swelling and redness in eczema or psoriasis flare ups.

Antihistamines – help to reduce pruritus.

*Patients with severe eczema and psoriasis or other problematic skin conditions may require additional medication and may need to be referred to a specialist.20

Supporting patients with dry skin

Due to the variable nature of dry skin, it’s important to ask patients about their symptoms. Ask open-ended questions beginning with ‘what’ or ‘how’. Questions might include:


  • What is their current skincare regime?
  • How do they describe the feeling of their skin, is it itchy?
  • Have they noticed any triggers that make it worse?
  • What helps to relieve it and what aggravates it?
  • Is it a long-term problem or a new health condition?
  • Find out what other health conditions they have and the medications they are taking. Are there any new medications? Look particularly for diuretics, retinoids and statin medications.

Self-care advice for patients with dry skin

Drink water

Dry skin can develop from dehydrated skin. Drinking enough fluids daily will help reduce skin dehydration.

Emotional triggers

Flare ups can be triggered by anxiety and stress. If this is the case with your patient, recommend ways to relax and relieve stress, such as yoga, meditation and getting enough sleep, exercising, and doing activities they enjoy.

Try not to scratch

Scratching releases more histamine, worsening pruritus, which is referred to as the ‘itch-scratch cycle’. It can also introduce bacteria to cracked skin, or cause skin to lichenify.

Daily skincare regime

Recommend a daily skincare routine for patients. They should regularly apply an effective, long lasting treatment, such as Bio-Oil Dry Skin Gel, at least twice daily. It’s particularly important to apply product of choice after a shower or bath to lock in moisture, and before going to bed, so the product can work overnight without disruption.

Protect skin from aggravators

Remind patients dry skin is aggravated by extreme hot and cold temperatures. Avoid harsh skin cleaners that leave skin feeling tight and dry, hot showers and keep skin covered in cold weather. In particular, it’s important to wear gloves.

Avoid harsh products

Skincare products containing irritants e.g retinoids, heavy exfoliants, alcohol and fragrances, can strip the skin of natural oils. Patients should also be aware of harsh detergents. Recommend dry skin products which combine dry skin hydrators – humectants, emollients and occlusive agents.

Pre-existing conditions

Pre-existing health conditions such as hypothyroidism, kidney disease, malnutrition and hormonal changes can cause skin to dry out; as well as some medications. Ask the patient questions around these areas to access the correct course of action to treating their dry skin. You can find a list of questions to ask in a downloadable resource for HCPs.



References

  • 17 Schandra Purnamawati et al. The Role of Moisturizers in Addressing Various Kinds of Dermatitis: A Review 2017
  • 18 Teresa M Weber et al. Treatment of xerosis with a topical formulation containing glyceryl glucoside, natural moisturizing factors, and ceramide. 2012
  • 19 Runa Izumi et al. Efficacy of an emollient containing diethylene glycol/dilinoleic acid copolymer for the treatment of dry skin and pruritus in patients with senile xerosis. 2017
  • 20 https://www.nhs.uk/conditions/atopic-eczema/treatment/

What are the benefits of treating dry skin with an oil?

  • Soothing inflammation
  • Smoothing skin
  • Oils help create a protective film on the skin preventing moisture loss

What is the itch-scratch cycle?

  • Worsening of pruritus after scratching dry skin
  • Infection of skin after scratching
  • Calming of skin after scratching

Which of the below self-care management tips can you give patients with dry skin?

  • Daily skincare regime
  • Avoid potentially irritant products such as those containing SLS, alcohol and fragrances
  • Keep hydrated
  • Avoid hot showers
  • All of the above

Module 3 - Grow your business: How to create a skincare niche within pharmacy

In-store Business

In these times of NHS funding cuts and reduced margins, pharmacy is looking for growth areas to sustain their business and improve both revenue and profitability. Skincare is a growing category within pharmacy and presents a commercial opportunity for those who take advantage.

Pharmacists and their teams can play an important role when it comes to improving skincare, particularly dry skin, a common condition affecting many of their customers. This is even more relevant as GPs review patients on emollients and look to de-prescribe some products to reduce costs.21

Individuals diagnosed with a dry skin condition can often feel overwhelmed by the range of products available to them. Pharmacy teams are well placed to give extra support to keep individual’s skin healthy and provide effective solutions for those with skin complaints.

Deborah Evans,
FFRPS FRPharmS FFRPS,
Managing Director of Pharmacy Complete

The skincare opportunity for UK pharmacists

Skincare comprised almost a quarter (24 per cent) of UK cosmetics sales in 2016.22 Meanwhile, the UK health and beauty market is forecast to grow 21 per cent in the next five years23, which includes dry skincare products, such as moisturisers and cleansing soaps.

Pharmacies are responsible for almost 50 per cent of skincare sales.23

Combining forecasted growth and the profession’s ability to provide detailed advice, it puts pharmacists in a strong position to use skincare to help grow their business while also improving customer skin health.

Promoting skincare

Apply the principles of Healthy Living Pharmacies (HLPs) - these pharmacies proactively engage with their communities around a range of health and wellbeing topics24. Raising awareness about causes of dry skin, lifestyle advice to support a healthier skin and treatment options can all fit within the HLP ethos.

Engagement- pharmacies play a key role in assisting customers who are diagnosed with skin conditions and who are seeking specific products recommended by their GP or specialist. Pharmacy staff can assist customers to seek out the right product for their skin, remind them of their new skincare regime and answer any questions they might have in relation to their condition. In addition, additional product recommendations can be made to support those supplied on prescription, for example, washes and moisturisers to support someone who has been prescribed a product for acne.

Raising awareness of dry skin - use the health promotion zone to promote non-promotional information and leaflets about dry skin and use off-location displays to feature best-sellers in each brand. These can be focused specifically on a skin condition, for example general dry skin, or specific conditions such as eczema and psoriasis. This display will highlight the issue to customers, enabling them to self-select and prompts them to ask you for dry skin advice.

Seasonality - skincare changes with the seasons, as cold weather can dehydrate skin further and in hot weather sun damage can dry out skin. Creating promotional displays seasonally is another opportunity for the pharmacy to provide customers with advice in this area and increase sales.

Sampling - consider offering the pharmacy team products to use so that they can act as experienced advocates and encourage customers to use ‘tester’ products, so they can try before they buy. This provides an enhanced customer shopping experience and increasing customer confidence in your team and the product.

Develop pharmacy team knowledge

Educate the whole team - train the team on the symptoms of dry skin and common skin conditions and ensure they are aware of the most effective and up-to-date treatment solutions available in store.

Create a dry skin ‘champion’ - make a team member a dry skin hero - someone who is fully trained on dry skin conditions and the dry skin product category. They will be able to provide further support to customers who have specific needs and information over and above the basics.

Provide outstanding customer service - arms the whole team with relevant patient resources/leaflets/and samples as part of their advice in order to enhance the reputation of the pharmacy and to further enable them to offer an outstanding customer experience. Once the customer has been guided to the right product, and it is proven effective, they are likely to return to the pharmacy to not only repeat-purchase but to also benefit from the specialist knowledge in the pharmacy team. Once you have made a recommendation, ask the person to return in perhaps 2-3 weeks to tell you how they have got on.

Understand your customer’s dry skin needs

Sales growth can be achieved in the skincare category with existing customers by engaging them in the dry skincare conversation:


  • Prevention – pharmacy teams can support individuals with everyday skincare, educating them on the importance of moisturising their skin with the right product to prevent dry skin and irritation. It’s also important to make customers aware that their skincare needs will change with the seasons.
  • Maintenance – people with dry skin conditions need to look after their skin properly every day to help minimise symptoms, discomfort and the emotional impact of dry skin conditions.
  • Enhance treatment – provide helpful advice on topical products prescribed by the GP, so use the opportunity to offer skincare advice to patients based on their prescriptions. This is particularly important for people with conditions proven to result in dry skin, such as diabetes.

Sales growth can also be achieved in this category by identifying new customer groups who’s needs may not be met:


  • Demographics – consider the population you serve for example young parents will need skin care support through pregnancy and with babies and children.
  • Diversity - consider the diversity of your community and their different skin care needs, understanding where they may access specialist skin care products.
  • Men – the male skincare category, whilst significantly smaller than women’s, is growing faster. This may be a significant area for growth.


Practical tools and resources for pharmacy teams

In order to help pharmacists feel confident discussing skin conditions such as dry skin with their patients, Bio-Oil has created a suite of complimentary resources including an educational Dry Skin leaflet with support and advice for pharmacy staff managing patients with dry skin. As well as a direct to patient leaflet [Supporting You: To understand and Care for Dry Skin] with advice from a dermatologist, to help educate and empower patients to self-care and better manage their dry skin at home.

Created in collaboration with clinical experts, the materials can be viewed and downloaded by visiting www.bio-oilprofessional.co.uk/resources or via the below links:

Dry Skin Support and Advice for Patients – Educational leaflet for healthcare professionals with information on how to support and advise patients with dry skin, also includes product information with benefits, application, user trials and clinical trials. Download.

Supporting You: To understand and Care for Dry Skin – Leaflet designed to be given direct to patients to empower them to self-care for their dry skin. Go.

What percentage of skincare sales go through pharmacies in the UK?

  • Almost 30 per cent
  • Almost 40 per cent
  • Almost 50 per cent

What can be done in pharmacy to promote the skincare category?

  • Engage proactively with customers about their skin care needs
  • Raising awareness about dry skin
  • Seasonal displays that reflect the different impact seasons have on skin health
  • Sampling using tester products
  • All of the above

Why are pharmacy teams well placed to provide customers with dry skincare advice?

  • Because the UK health and beauty market is forecast to grow 21 per cent in the next five years
  • Pharmacy teams can provide post-diagnosis treatment support for dry skin conditions, engage existing customers in tackling dry skin and provide treatment advice for conditions and medication that can dehydrate skin, such as diabetes
  • Pharmacy teams are not well placed to provide customers with dry skincare advice

Congratulations

You have successfully completed the module. Please complete the information below to receive your e-certificate, and remember that this module can be used towards your CPD. Your details will only be used for the purpose of providing you with your certificate, unless you state otherwise.

If you are interested in learning more about managing dry skin, please visit www.bio-oilprofessional.co.uk.

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Bio-Oil Dry Skin Gel

Our new Bio-Oil Dry Skin Gel replenishes the skin’s barrier and deeply moisturises. The new gel-to-oil texture absorbs easily and creates a protective film to resist moisture loss. With just 3% water, this highly potent formulation blends emollients such as shea butter; humectants like urea; along with vitamin B3 for an exceptional moisturising result.

    User trial results:

  • 62% agreed that ‘Bio-Oil Dry Skin Gel is better than any product they have ever used before to combat dry skin’1
  • 86% agreed that ‘their dry skin improved over the course of a two-week period’1
  • Clinical trials:

  • 82% agreed that ‘they saw a difference in just two days’2

Application advice for patients using Bio-Oil Dry Skin Gel

Dry Skin Gel can be used all over the body. Apply a small amount to dry skin as required and massage in circular motions until fully absorbed. Use less than you would applying a cream.

It’s non-comedogenic3 (doesn’t block pores) and gentle enough to use on sensitive skin4. Not suitable for children under the age of 3.

Your e-certificate

Thank you for completing the training.

Please check your email, we have emailed you a link to your certificate.

Introducing a new way to improve dry skin:

Bio-Oil Dry Skin Gel

Our new Bio-Oil Dry Skin Gel replenishes the skin’s barrier and deeply moisturises. The new gel-to-oil texture absorbs easily and creates a protective film to resist moisture loss. With just 3% water, this highly potent formulation blends emollients such as shea butter; humectants like urea; along with vitamin B3 for an exceptional moisturising result.

    User trial results:

  • 62% agreed that ‘Bio-Oil Dry Skin Gel is better than any product they have ever used before to combat dry skin’1
  • 86% agreed that ‘their dry skin improved over the course of a two-week period’1
  • Clinical trials:

  • 82% agreed that ‘they saw a difference in just two days’2

Application advice for patients using Bio-Oil Dry Skin Gel

Dry Skin Gel can be used all over the body. Apply a small amount to dry skin as required and massage in circular motions until fully absorbed. Use less than you would applying a cream.

It’s non-comedogenic3 (doesn’t block pores) and gentle enough to use on sensitive skin4. Not suitable for children under the age of 3.


References

  • 1 ProDERM Institute for Applied Dermatological Research, Germany, randomized and controlled trial on 24 participants. Data on file.
  • 2 Stephens & Associates (2018), A Split-Body, Evaluator-Blinded, Controlled Clinical Trial to Assess the Efficacy of a Moisturizing Product. Stephens Study Number: C17-D127. Data on file.
  • 3 Non-comedogenic study, 2018, proDERM Institute for Applied Dermatological Research, Hamburg, Germany.
  • 4 Sensitive skin test study, 2017, proDERM Institute for Applied Dermatological Research, Hamburg, Germany.