Psoriasis and Skin Barrier Dysfunction: The Role of Gentle Cleansers and Moisturizers in Treating Psoriasis

August 2023 | Volume 22 | Issue 8 | 773 | Copyright © August 2023


Published online July 31, 2023

Leon Kircik MD FAADa, Andrew F. Alexis MD MPH FAADb, Anneke Andriessen PhDc, Collin Blattner MD FAADd, Brad P. Glick MD DO MPH FAADe, Charles W. Lynde MD FRCPCf, Linda Stein Gold MD FAADg

aIcahn School of Medicine, Mount Sinai, New York, NY, Dermatology, Indiana University Medical Center, Indianapolis, IN, Physicians Skin Care, PLLC, Louisville, KY, DermResearch, PLLC, Louisville, KY
bWeill Cornell Medical College, New York, NY
cRadboud UMC, Nijmegen and Andriessen Consultants, Malden, The Netherlands 
dDepartment of Dermatology, Clear Choice Dermatology LLC & Great Skin Medical Consulting LLC, Portland, OR 
eAAD Board of Directors, Dermatology Residency Program Director Larkin Palm Springs Hospital PI, GSI Clinical Research, ASDS Advocacy Ambassador, Miami, FL
fDepartment of Medicine University of Toronto, Toronto, ON, Canada; Lynderm Research, Markham, ON, Canada gClinical Research, Department of Dermatology, Henry Ford Health, Detroit, MI

Moisturizers have shown benefits when used as adjunctives to prescription treatment. A study of a ceramide-containing moisturizer applied in combination with topical prescription treatment with mometasone furoate 0.1% cream demonstrated less psoriasis relapse than topical therapy alone.34 

Although the benefits of adjunctive skincare application have been reported in small studies and clinical reviews, the panel recognized the need to develop a more robust body of evidence to influence clinical practice in a meaningful way. Nevertheless, the panel members agreed that incorporating skincare principles into the psoriasis paradigm may evolve into the standard of care and be included in future treatment guidelines.

Statement 5: Studies applying ceramides-containing skincare showed an overall improvement in the appearance of the skin and provided relief for psoriasis. These results suggest that improvements in epidermal function with topical emollients can prevent/attenuate the development of psoriasis. 

A common clinical feature of psoriasis is the scaling typically associated with hyperkeratosis, pruritus, inflammation, and xerosis.9,15,24 Moisturizers promote moisture retention in the stratum corneum and can help reduce pruritus and desquamation.15

Topical moisturizers in psoriasis have been reported to increase hydration, decrease desquamation, improve the skin's overall appearance, improve Psoriasis Area and Severity Index (PASI)-50 in conjunction with topical steroids, and delay relapse. In a randomized controlled study of 106 patients with psoriasis, the treatment group (T1) received a combination of linoleic acid-ceramide moisturizer and mometasone furoate 0.1% cream) and the control group (C1) received mometasone furoate monotherapy.34 Improvement in pruritus was observed in both groups after 4 weeks. The treatment group reported superior PASI-50 results at week 8 compared with the control group. Higher water content and earlier reduction of lesional transepidermal water loss (TEWL) were observed in T1 vs C1. Subsequently, T1 patients were randomized for another year to 2 groups: T2 received a combination of linoleic acid-ceramide moisturizer and mometasone furoate 0.1% cream, and the control group (C2) did not receive a moisturizer. After one year, less relapse of psoriasis was observed in T2 compared with C2.34 Lesional TEWL, water content, and PASI measurements remained stable in T2 patients.34 In a second multicenter, randomized, controlled trial of 178 patients with psoriasis, treatment with mometasone furoate combined with a linoleic acid-ceramide-containing moisturizer for 4 weeks resulted in decreased rates of relapse.39 

Maintenance therapy with linoleic acid-ceramide-containing moisturizer demonstrated continuous improvement in body surface area (BSA) involvement, PASI score, investigators’ xerosis and desquamation assessment, Physician Global Assessment of Psoriasis score, and patient QoL.39

Patients with mild plaque psoriasis, seborrheic dermatitis, sebo-psoriasis, or persistent post-psoriasis sequelae may experience some symptom improvement even without prescription therapy when compliant with a rigorous moisturization regimen.39

In a study of psoriasis relapse prevention with ceramide-based adjunctive skincare, 2 cohorts of patients with psoriasis (n=30 and n=60) were treated topically with a proprietary emollient ceramide-based cream applied twice daily to one forearm.40 The same sites on the contralateral arm served as the untreated control. A delayed relapse on the treated arm was observed in 54.5% of patients in the first cohort (20 days of use) and 71% of patients in the second cohort (30 days of use).40 These results suggest that using moisturizers to promote a healthy skin barrier may prevent or attenuate psoriasis flares.

Limitations 
A detailed discussion of the pathophysiology of psoriasis is outside this review's scope. 

Despite the widespread availability of nonprescription skincare products, there are few robust evidence-based studies on skincare for psoriasis patients. 

CONCLUSION

The literature published on skincare in psoriasis is limited compared with other common skin conditions with known barrier defects. Topical moisturizers have shown several benefits in psoriasis, such as improved hydration and overall skin appearance, increased attainment of PASI-50, decreased desquamation, and delayed relapse.

Clinicians and patients would benefit from increased awareness of the importance of skincare in psoriasis. Early initiation and maintenance of well-tolerated treatment regimens and the use of carefully selected adjunctive skincare are potential considerations for increasing patient compliance and outcomes.

DISCLOSURES

The authors disclose receipt of an unrestricted educational grant from CeraVe Global for support with the research of this work and also received consultancy fees for their work on this project. 

All the authors developed the manuscript, reviewed it, and agreed with its content.

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AUTHOR CORRESPONDENCE

Anneke E. Andriessen PhD anneke.a@tiscali.nl
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