and facilitate skin barrier breakdown (Figure 1).45,59
Cleansers with an elevated pH can damage the stratum corneum or strip it of essential components, such as lipids, proteins, and natural moisturizing factors.45,59,62 Cleansers with a nearphysiological pH of 5.5 and the addition of hydrating agents can provide both hygiene and moisturization (Box 2).47,59,60,66
The past decade has seen considerable advances in understanding the role of moisturizers in AD management.15,19,20-38,67 According to various guidelines, clinical pathways, and consensus papers, skincare using gentle cleansers and moisturizers are the cornerstone of all AD regimens regardless of ethnicity. 15,19,20-38,67 An ideal moisturizer for AD patients would be safe, effective, affordable, fragrance, and sensitizing agent-free.59,60 Preferably, the product would be pleasant to use with a look, smell, and feel that invites consistent use.
Moisturizers reduce xerosis by combining ingredients that maintain skin hydration, such as emollients, occlusive agents that prevent water evaporation, and humectants that attract and hold water into the stratum corneum (Box 3).39,45,59 Increased knowledge of skin barrier dysfunction in AD has supported the development of moisturizers containing physiologic lipids such as ceramides, which may help replace the deficient lipids in ADaffected skin.45-48,59,60,66,68-72 Topical formulations that contain CERs mimic physiological lipids supporting homeostasis and reducing AD severity while improving general skin condition.59,60,66,68-72 Skincare use with a cleanser and moisturizer decreases pruritus and other symptoms, along with the severity of AD.59,60,66,68-72 Additionally, the number of AD flares is reduced and time periods of remission between flares are increased when CERcontaining skincare is frequently applied.59,60,66,68-72
Draelos et al (2020) showed that using a ceramide-containing moisturizing cream on dry lower leg skin of 49 women resulted in an 11% increase in total ceramide content, a 14% increase in free fatty acids, and an 11% increase in cholesterol.66 Most importantly, this increase in ceramide content was still demonstrable after 48 hours.66
A further study found that both the ceramide-containing cream and lotion significantly increased skin hydration and reduced skin dryness for at least 24 hours following a single application compared to an untreated control site.70,71 Compared to three reference emollient creams, the ceramide-containing cream and lotion were the only products capable of sustaining clinically meaningful improvements in skin moisturization for the full 24 hours.70,71
Many types of moisturizers are available; however, robust comparative studies are scarce, especially in SOC populations. Therefore, the clinician should consider AD patients' preferences in product choice, which may differ between gender, skin type, and racial/ethnic groups.73 According to the advisors, skin care practices have a profound cultural significance that must be respected to improve adherence to AD treatment and thus patient outcomes. Clinicians should integrate evidence-based recommendations with cultural norms, exploring creative ways of communicating information, focusing on the benefit to the patient or caregiver (eg, not hearing their child scratch at night). Additionally, incorrect advice from some social media may be addressed and scientific data translated into culturally sensitive messaging.
Finally, the advisors agreed on the importance of informing patients about promoting a healthy skin barrier using physiologic concentration of ceramides and the omission of irritating substances in skin care products to help them make the right choices when faced with the extensive array of options in the pharmacy or department store skincare section. Conversely, the wrong choice can derail an otherwise effective therapeutic approach, such as by adding irritating substances that can counter effective therapy for AD.
Limitations
A detailed discussion on genetic factors of AD is outside the scope of the review. Many OTC skincare products are available; however, robust comparative studies on skincare in AD in SOC are lacking and do not allow conclusive recommendations. There is an overall lack of prospective, evidence-based studies focusing on treatment of AD in SOC. However, the available data suggest that skincare strategies to improve AD patients' outcomes should consider racial/ethnic differences.
CONCLUSION
This review explored best clinical practices in treating AD
