Improvement of Chronic Venous Insufficiency Related Leg Xerosis and Dermatitis With Ceramide-Containing Cleansers and Moisturizers: An Expert-Based Consensus

February 2024 | Volume 23 | Issue 2 | 61 | Copyright © February 2024


Published online January 24, 2024

Robert S. Kirsner MD PhDa, Anneke Andriessen PhDb, Jason R. Hanft DPM FACFASc, Shasa Hu MDa, William A. Marston MDd, Lee C. Ruotsi MD ABWMS CWS-P UHMe, Gil Yosipovitch MDa

aDr. Phillip Frost Department of Dermatology & Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL 
bRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands
cFoot & Ankle Institute of South Florida, South Miami, FL; South Miami Hospital, South Miami, FL
dUNC Hospitals Heart and Vascular Center at Meadowmont, Chapel Hill, NC; Wound Management Center, Chapel Hill, NC
eSaratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, FL

hyperkeratosis leading to colonization or infection.34  If left untreated, lesions occur, and there is a risk for invasive infections such as cellulitis.34-37 

Gentle skin cleansing, exfoliation, and moisturizers as adjuncts to compression or medical treatment should be part of the prevention, treatment, and maintenance of VLD. Hyperkeratosis and papillomatosis should be removed to maintain or restore skin barrier function.8,9,34 Compression therapy, the standard treatment for patients with VLD, is less effective when hyperkeratosis is left untreated.34,35 Exfoliation may reduce hyperkeratosis, scabs, and scales in patients with VH and associated VLD.6-9 Removal of nonvital tissue is an accepted method to decrease biofilms and stimulate healing.34-37 

There are various methods available for skin cleansing, including mild cleansers with a physiological pH (4-7), scrubbing, or skin massage using monofilament fiber debridement pads.34-37 In choosing the right cleanser and cleansing device, it is important to consider aspects such as pathophysiology, skin condition, cleansing efficacy, patient tolerance, and interaction between skin condition, skin type, and the cleanser.34 Further factors to consider are adherence to the treatment, the optimal time and method of cleansing and moisturizing, and the patient's cosmetic perception.34

Statement 4: Maintaining an intact skin barrier by preventing and treating xerosis using gentle cleansers and ceramide-containing moisturizers may improve the skin sequelae of CVI.

Ceramides, cholesterol, and free fatty acids are essential constituents of the SC.33,40 They form highly ordered lipid lamellae and fill the space between the corneocytes.33,40 The composition and structure of the lipid lamellae are critically important to the permeability barrier function of the skin and form an effective waterproof barrier.33,40 Reductions in SC lipid content may be due to chronic inflammation leading to VLD.7,8,9,33,40 A healthy skin with good elasticity facilitates an improved surface for compression and exercise in patients with CVI.34-37 Skin care is important to address the issues associated with inflammation, xerosis, pruritus, and VLD.8,9,12,31-37 Xerosis and VLD are often associated with pruritus, mainly involving the lower extremities.18,19,23,31 Pruritus significantly impacts the quality of life and is reported by patients to be equally bothering as skin pain or even worse.39 Skin changes triggered by CVI make the leg more susceptible to the entry of irritants and allergens through the skin, leading to inflammation and pruritus.31,40 Scratching can lead to secondary infections, ulcerations, and chronic wounds.31

Skincare using cleansers and moisturizers and exfoliation of dry and scaly skin in atopic dermatitis has been reported in an algorithm as a standard measure for AD and may be applicable for VLD.38 Topically applied steroids combined with moisturizers may be of benefit in acute VLD disease, as is the use of topical nonsteroidal medications such as tacrolimus.8,9,31 Skin lipids containing moisturizers such as ceramides combat xerosis, restoring skin barrier function and may reduce pruritus.31,40-45

Statement 5: Skincare is frequently lacking or overlooked as part of the treatment of patients with CVI and venous dermatitis. This skin treatment is an unmet need that can be addressed with ceramides-containing pH balanced cleansers and moisturizers.

Ceramides are essential to the epidermal barrier and help maintain the skin's barrier function.40 A disturbed composition of ceramides in the epidermis of patients with inflammatory disorders such as AD affects epidermal water loss and reduced water holding capacity.40,45 It is evident from studies that the qualitative and quantitative difference in ceramide metabolism precipitates cutaneous inflammatory conditions such as dermatitis.40,45 

Ceramide-containing moisturizers can decrease AD flares, via activation of peroxisome proliferator-activated receptor alpha, downregulation of inflammatory cytokines, and elevated antimicrobial peptides expression.46 Ceramides delivered through a multi-vesicular topical product have shown clinically significant results for the management of xerosis.41-44 Studies demonstrated that ceramide-containing skincare restored skin barrier function, reducing irritation, and was an effective and safe choice for those with xerosis or AD.41-45
 
Currently, skincare for VLD is underused.5,31 Educating healthcare providers on the pathophysiology of CVI and related VLD is important to promote effective therapy with compression and skin care, improving patient outcomes.5,18 Training medical assistants and nurses to assess patients for CVI on initial office visit intake may support early intervention.18 During patient visits, handouts should be given, confirming the information on CVI and the risk of developing it due to comorbid conditions.18 

LIMITATIONS

Although many studies have looked at atopic dermatitis and the benefits of skincare using gentle cleansers and moisturizers, robust studies on combining compression treatment with skincare for CVI, VLD, and related xerosis are lacking. Moreover, skin treatment is an unmet need for CVI, VLD, and related xerosis that can be addressed with ceramides-containing pH balanced cleansers and moisturizers and should be part of guideless and addressed in education for clinicians and patients as a standard measure. 

CONCLUSION

Compression therapy is the standard CVI and VLD and should be combined with good-quality skincare to enhance adherence to treatment. Maintaining an intact skin barrier by preventing and treating xerosis using gentle cleansers and ceramide-containing moisturizers may reduce friction and help avoid skin trauma while putting on compression garments. A ceramide-containing moisturizer sustained significant improvements in skin moisturization for 24 hours and may offer synergistic benefits together with compression treatment improving adherence to treatment and patient outcomes. 

DISCLOSURES

This work was supported by an unrestricted educational grant from CeraVe US.

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AUTHOR CORRESPONDENCE

Anneke Andriessen PhD ti016762@telfort.nl
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