Taking It Back to Basics: Re-emphasizing the Role of Moisturization in Atopic Dermatitis

J Clin Aesthet Dermatol. 2024;17(2):30–31.

by Raj Chovatiya, MD, PhD

Dr. Chovatiya is with the Center for Eczema and Itch, Clinical Trials Unit at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

FUNDING: No funding was provided for this article.

DISCLOSURES: Dr. Chovatiya has served as an advisor, consultant, speaker, and/or investigator for AbbVie, Apogee Therapeutics, Arcutis, Argenx, ASLAN Pharmaceuticals, Beiersdorf, Boehringer Ingelheim, Bristol Myers Squibb, Cara Therapeutics, Dermavant, Eli Lilly and Company, FIDE, Galderma, Genentech, GSK, Incyte, Janssen, LEO Pharma, L’Oréal, Nektar Therapeutics, Opsidio, Pfizer Inc., Regeneron, RAPT, Sanofi, and UCB.

ABSTRACT: Atopic dermatitis (AD) is a common, burdensome inflammatory skin disease. In recent years, multiple safe and effective monotherapy treatments directly targeting immune dysregulation in AD have been approved and integrated into clinical practice. Although the etiopathogenesis of AD is complex, it is widely recognized that alongside immune dysregulation, skin barrier disruption also plays an essential role in disease pathophysiology. For this reason, regular moisturization has been a foundational mainstay of therapy, consistently recommended by treatment guidelines regardless of disease severity or therapeutic approach. It is vital for healthcare providers to continuously educate patients and caregivers about the importance of optimizing skin barrier function by maintaining proper moisturization as part of their treatment plan and help them make data-driven decisions to navigate the wide array of available products. Keywords: Atopic dermatitis, moisturizers, skin barrier; inflammation

Atopic dermatitis (AD) is a chronic, inflammatory cutaneous disease characterized by pruritus, erythema, and edema, affecting approximately 18 million Americans, including 1 in 5 children.¹ Poor quality of life is common in most patients with itch, skin pain, sleep disturbance, and/or mental health symptoms interfering with school or work performance.²

Until recently, topical corticosteroid (TCS) and topical calcineurin inhibitors (TCI) were the main options for patients with mild-to-moderate AD; however, concerns about cutaneous and systemic side effects with long-term use, tolerability on sensitive skin, and rebound effects with discontinuation (TCS), and limited efficacy, general tolerability, and a black box warning (TCI) left a major unmet gap for treatment options.^3,4 Among patients with moderate-severe disease, treatment was limited to either phototherapy, which is often limited by time, access, and/or efficacy, and conventional oral immunosuppressants, which have historically been used off-label for AD management but are associated with myriad immune and systemic side effects.^5–7 In the past few years, however, there have been an influx of novel, targeted treatment options for mild, moderate, and severe AD in topical, oral, and injectable formulations that have given health care providers and their patients multiple safe and effective approaches for AD treatment.⁸

AD pathophysiology is mediated by the complex interplay between intrinsic (i.e., genetic) and extrinsic (i.e., environment) factors leading to disrupted skin barrier function and complex immune dysregulation.^9,10 The breakdown of the epidermal barrier is associated with enhanced protease activity, decreased synthesis of lipid lamellae, increases in stratum corneum pH, increased susceptibility to microbial infections, and increases in transepidermal water loss (TEWL), which further perpetuate AD pathogenesis.¹¹ While most novel and emerging advanced therapies directly target immune dysregulation, which can secondarily improve barrier function, few directly target skin barrier optimization.¹² Given the key role of barrier dysfunction in AD, regular moisturization remains a foundational mainstay of therapy regardless of disease severity or therapeutic approach, and it is consistently recommended by both U.S. and international treatment guidelines (Figure 1).^1,6,8 In fact, concurrent use of moisturizers and emollients is permitted and often routinely required in AD clinical trials for both topical and systemic therapies.^13–16 It is essential for health care providers to continuously remind their patients and patient’s caregivers of the importance of protecting the skin barrier by maintaining proper moisturization. 

With hundreds of moisturizers commercially available, the selection process can be overwhelming for AD patients and their caregivers. Understanding the importance of key ingredients can aid providers in guiding their patients through the barrage of options. Essential for AD is utilization of a therapeutic moisturizer which contains ingredients to correct underlying deficits (i.e., skin protectants, barrier lipids, anti-oxidants, anti-inflammatory) or relieve specific symptoms (i.e., anti-pruritic) associated with AD.¹⁷ Topical moisturizers function in part by increasing barrier protection, minimizing TEWL, improving the stratum corneum hydration, reestablishing physiological pH of skin, and replenishing key components of the skin (i.e., natural moisturizing factors and ceramides), resulting in a reduction in signs, symptoms, and inflammation associated with AD.¹ This can directly lead to an improvement in disease severity scores, increasing the time of relapse, reduce the time of flares and even increase time between disease flares (Figure 2).^18,19 Key therapeutic ingredients for AD moisturizers include colloidal oatmeal, ceramides, licochalcone A, natural moisturizing factors (i.e., urea, lactate/lactic acid, amino acids, pyrrolidone carboxylic acid), shea butter, petrolatum, glycine, and glycyrrhetinic acid; in fact, only products containing 0.007-2% colloidal oatmeal are allowed to make claims about over-to-counter (OTC) skin protectant effects on AD symptoms.^19,20

Encouraging daily moisturization is an essential part of overall AD management for all patients. No matter the therapeutic approach – steroidal or non-steroidal, topical or systemic, biologic or JAK inhibitor, moisturization should be emphasized when counseling AD patients. By encouraging regular moisturization in combination with their prescribed treatment regimen, healthcare providers can maximize patient outcomes and quality of life improvement. 

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