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People present to their pharmacists with a range of skin conditions, from mild irritations to chronic disorders requiring specialised care. Steve Titmarsh reports…

Independents are well placed to advise on formulation choice, correct application and potential side effects to help patients adhere to their regimens – essential for optimal outcomes.

Dermatology makes up a significant part of community pharmacists’ workload – in 2020 it was estimated that about 38 per cent of requests for advice were for skin conditions. Indeed, just over half the population (around 54 per cent) will have some type of skin condition each year and at any point up to one in three people with have a skin disease that needs medical attention.

Community pharmacists are regularly consulted on a range of conditions such as eczema, dermatitis, general rashes, allergies and acne.1

Topical antihistamines are commonly used for allergic reactions to a range of allergens.

Antihistamine creams occasionally cause contact allergic dermatitis

However, antihistamine creams can occasionally cause contact allergic dermatitis so they should not be applied to large areas, and should be discontinued if they result in a rash. They should be avoided on broken skin.2

Emollients are the mainstay of eczema treatment. There are numerous formulations – creams, ointments, gels, lotions, sprays, washes and bath and shower additives – so choosing the right one based on individual circumstances is important.

Indeed, there is no controlled trial evidence to suggest one emollient is better than another.3

One person may need several different emollients for different areas of skin or different stages of a flare. For example, creams and lotions are generally better for red, inflamed skin because the evaporation of water-based products is thought to have a cooling effect.

Ointments are more effective than creams for dry non-inflamed skin. However, they are less well tolerated than creams, which may affect their acceptability and therefore adherence.

Emollients with active ingredients are associated with a higher risk of a reaction so are not generally used.3

Emollients are often under-prescribed and under-used: in general, around 10 times more emollient should be used than other topical treatments.

Emollients should be applied liberally (200–500g every week) and frequently – every two to three hours. They should be used during or after washing while the skin is moist.

Aqueous cream should be avoided for eczema

They should be smoothed into the skin along the line of hair growth, not rubbed in. Some people may find it beneficial to use creams or lotions during the day because they tend to be better tolerated, with ointments used at night because they may be less well tolerated.3

Aqueous cream should be avoided for eczema because of the risk of sensitization reactions.

The Medicines and Healthcare products Regulatory Agency says aqueous cream may cause local skin reactions, such as stinging, burning, itching and redness, when it is used as a leave-on emollient, especially in children with atopic eczema.

Reactions typically occur within 20 minutes of application and are not usually serious.3

Topical corticosteroids are also useful to help manage conditions such as atopic eczema, particularly for a short time to control flares.

The amount of topical corticosteroid needed to treat a flare-up of eczema for once daily application for two weeks by an adult is:3 

-             Face and neck, or both hands, or scalp, or groin and genitalia: 15–30g

-             Both arms: 30–60g

-             Both legs or trunk: 100g

In terms of formulation, most people prefer a cream, particularly for the face and hands. Ointments are greasy and so may be preferred for use at night.

Other formulations have been developed for specific areas such as scalp applications. 3

The amount of topical corticosteroid to apply can be gauged by using the so-called fingertip unit, which is around 500mg – enough to treat an area about twice that of a flat hand with fingers together.

A fingertip unit is the amount of cream or ointment expressed from a standard 5mm diameter nozzle that covers a finger from the base of the index finger to the tip. 3

Topical corticosteroids should not be applied more often than twice a day for eczema flares and treatment should be continued for 48 hours after eczema has cleared.

However, if a person’s skin has not improved after two weeks they should seek medical advice.3

There is no firm evidence as to whether topical corticosteroid or emollient should be applied first if both are being used together – it is down to personal preference.

The risk of side effects

Some suggest there should be an interval of at least half an hour between applications but that may not always be possible.3

The risk of side effects when using topical corticosteroids is greater with longer duration of treatment, large areas being treated, when skin is thin and inflamed, if a dressing is place over the area where the corticosteroid is applied and in children and older people.3

Local reactions are the most common adverse reactions, including:3 

-             Transient burning or stinging — especially in the first two days of application on untreated, inflamed skin. Changing treatment is not usually necessary because it improves in response to treatment.

-             Worsening and spreading of untreated infection.

-             Skin-thinning (improves after stopping treatment).

-             Permanent striae.

-             Allergic contact dermatitis.

-             Acne vulgaris (or worsening of existing acne) or acne rosacea.

-             Mild depigmentation (usually reversible).

-             Excessive hair growth at the site of application (hypertrichosis).

Making it personal

In the digital age people can access seemingly endless information, including that about skin care regimens. Community pharmacists can guide customers as to what might be the best regimen for their situation and skin type.

They can also help people guard against overuse of products containing retinol, for example. Restricted use of products such as topical corticosteroids is also important to reduce side effects.

And strict adherence to treatment regimens for eczema, for example, is key to successful outcomes.

Keep it simple

Simplification is often the key to resolving issues people may have from overzealous use of skin care products that may have damaged the skin barrier resulting in irritation.5

Achieving and maintaining healthy skin is very much related to maintaining a healthy lifestyle. Sun protection is recognised as fundamental to healthy skin, reducing damage and the risk of skin cancer.

Not smoking and a healthy diet will also help maintain healthy skin. Treating skin gently by limiting bath times, avoiding strong soaps and detergents, shaving carefully and patting the skin dry as well as moisturising all contribute to healthy skin.6

Role for the microbiome?

As in so many areas of medicine the microbiome is thought to play a role in the health of our skin.

Some research suggests, for example, that supplementation with probiotics such as Bacillus indicus (HU36), Bacillus subtilis (HU58), Bacillus coagulans (SC208), Bacillus licheniformis (SL307), and Bacillus clausii (SC109) and precision prebiotics such as fructooligosaccharides, xylooligosaccharides, and galactooligosaccharides may have beneficial effects for people with psoriasis already receiving conventional therapy.

It was noted that after 12 weeks supplementation patients’ gut microbiota had a more favourable anti-inflammatory profile.7

Similarly, products formulated to encourage improvement in the skin microbiome through barrier repair may have a role in treating conditions such as eczema and sensitive skin where dysbiosis is thought to be a contributing factor.

For example, an open-label study found that after applying a moisturiser containing colloidal oatmeal, Ophiopogon japonicus root extract (AD-Resyl®, SILAB, France), and a patented filaggrin protein byproduct to their cheeks twice a day for 21 days there was an increase in bacterial species richness in 10 of 12 participants in the study.8 

References

1. Harvey J, Shariff Z, Anderson C, et al. How can community pharmacists be supported to manage skin conditions? A multistage stakeholder research prioritisation exercise. BMJ Open 2024;14(1):e071863.

2. Dermnet. Antihistamines (https://dermnetnz.org/topics/antihistamines; accessed April 2025).

3. Clinical Knowledge Summaries. Eczema (https://cks.nice.org.uk/topics/eczema-atopic/prescribing-information/emollients/#usage-instructions; accessed April 2025).

4. National Institute for Health and Care Excellence. Atopic eczema in under 12s: diagnosis and management. Clinical guideline [CG57] (www.nice.org.uk/guidance/cg57/chapter/Recommendations#education-and-adherence-to-therapy; accessed March 2025).

5. Messaro L. The Flawless Fallacy: A Pharmacist’s Guide to Skin Care in the Digital Age (www.drugtopics.com/view/the-flawless-fallacy-a-pharmacist-s-guide-to-skin-care-in-the-digital-age; accessed March 2025)

6. Mayo Clinic. Skin care: 5 tips for healthy skin (www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/skin-care/art-20048237; accessed March 2025).

7. Buhaș MC, Candrea R, Gavrilaș LI, et al. Transforming Psoriasis Care: Probiotics and Prebiotics as Novel Therapeutic Approaches. Int J Mol Sci 2023;24(13):11225.

8. Whiting C, Abdel Azim S, Joly-Tonetti N, et al. Effects on the Skin Microbiome by a Moisturizer Formulated for Eczema-Prone and Sensitive Skin. J Drugs Dermatol 2025;24(3):275-80.