A scientific committee including 2 dermatologists with over 30 years of experience prepared the questionnaire, addressing controversial aspects or uncertainties regarding moisturizers. A total of 5 topics were covered: (1) concept; (2) characteristics; (3) frequency; (4) quantity, method of use, and application areas; (5) special populations.

The degree of agreement for each item, presented as a statement, was assessed using 4 categories: strongly or somewhat disagree, and somewhat or strongly agree.

The questionnaire was distributed online to 22 dermatologists from the Spanish Research Working Group on Contact Dermatitis and Cutaneous Allergy (GEIDAC). The 1st round occurred from October to November 2022, and the 2nd one in December 2022.

The results of each item were presented as the percentage of responses in each of the 4 categories. Consensus was defined as ≥70%, and majority agreement as 60–70% (same criteria for both rounds).

After the first round, the scientific committee reviewed the responses. If a lack of consensus was attributed to unclear item wording, it could be reformulated and reintroduced as a new statement in round #2. The second-round questionnaire included reformulated items and those without consensus from round #1 (Table 1 and Fig. 1).

Figure 1.

Global result of the Delphi after 2 rounds (N=50 items).

(0.23MB).

Results were analyzed by an agency independent of the scientific committee and the expert panel. The scientific committee then prepared and approved the final manuscript.

Recommendation 1: The information provided by health care professionals about the product and its use should be clear. It is appropriate to use “moisturizing cream” with patients, limiting the use of “emollient” and “hydrating” as synonyms among professionals,10,14 as reflected in the use of both terms in the questionnaire items.

The terms “hydrating” and “humectant” are not interchangeable, in accordance with their mechanisms of action: creating a protective layer/barrier to prevent evaporation or attracting water to the skin, respectively.3,4,10,14

Recommendation 2: To improve the efficacy of new moisturizers, brands include non-pharmacological active ingredients (e.g., plant extracts), targeting various mechanisms involved in the pathogenesis of AD (e.g., inflammation and skin barrier disruption).18 However, clinical evidence is still lacking,10 as well as studies comparing products with different ingredients, to demonstrate the efficacy of each.18

Recommendations 3 and 4: There is insufficient evidence to determine whether the amount of product applied to the skin is smaller with those that are rinsed off vs those applied directly.19 However, both dermatologists and most AD guidelines recommend using leave-on moisturizers. The lack of recommendation for rinse-off products as the sole measure may be justified by the absence (or minimal) benefit observed when adding bath-time moisturizers to the standard treatment for children with AD (BATHE study).20

Recommendation 5: The water content in the skin significantly increases when applying doses of moisturizers >1mg/cm2/application, being appropriate to up titrate this depending on the dryness of the skin and the patient's preferences.21

Recommendation 6: Using moisturizers immediately after bathing/showering is justifiable due to the increase in transepidermal water loss at that time.21 There was no consensus on applying them to dry skin (item 4.4), although this does not imply that they must be used on damp skin.

Recommendation 7: Moisturizers are considered adjuvant therapy. Numerous guidelines recommend applying these products after an appropriate pharmacological treatment to reduce inflammation, to improve skin barrier dysfunction.6,22 Moisturizers may help reduce inflammation, decreasing corticosteroid use.19

Recommendations 8 and 9: Health care professionals prefer products with fewer ingredients, fragrance-free, and without known allergenic preservatives. Fragrances offer no benefit and may lead to contact dermatitis due to sensitization.23

Recommendation 10: Other factors that most experts would consider, though no consensus was reached: (A) Price. Despite the high cost for patients, moisturizers1,16 have proven to be a cost-effective strategy in managing AD16; (B) Age. Specific products for those under 16 are not recommended; (C) Patient preferences/experiences; and (D) Time of year. Patient preference may be influenced by external climate and time of day.24

Recommendations 11–13: Guidelines state that moisturizers should be applied regularly, without specifying frequency, and in some cases, as needed by the patient.25 A recent study demonstrated that in patients with AD and xeroderma, skin water content was significantly higher when moisturizers were applied twice a day (after showering, in the morning and at night).21 This suggests that for patients with dry skin, the optimal application regimen should be, at least, twice a day.21 However, no consensus was reached on the need for more than 1 application per day in patients with active AD, which may be justified by the potential negative impact on patient adherence.

Consensus on the use of moisturizers in skin without active lesions, not visibly dry, is supported by the recommendation for proactive AD treatment that involves their use across the entire body (affected and unaffected skin) after lesions have been successfully treated with anti-inflammatory therapy.26 Additionally, using them without active lesions may be justified by preventing relapses.16

European clinical practice guidelines indicate that the direct use of moisturizers on inflamed skin is often poorly tolerated, so it is advisable to treat the flare first,26 which would justify not recommending their use on inflamed areas.

Recommendations 14 and 15: Similar to AD, although it has been demonstrated that in patients with dry skin, moisturizers should be applied, at least, twice a day,21 experts did not reach consensus on whether they should be applied more than once a day in patients with xeroderma. Also, although there was no consensus, there was disagreement about restricting their application to itchy areas.

Recommendation 16: These products are already included in the skincare routine for patients with stasis dermatitis.27

Two of the 3 items where consensus or majority was not reached (3.1 b and 3.1 h) referred to the frequency of emollient use in individuals with healthy skin or active AD. More evidence is needed in these situations to achieve dermatologists’ positioning. On the other hand, the failure to reach consensus or majority on item 5.6 (use of emollients as adjuvant therapy for diaper dermatitis), beyond the lack of evidence, may be influenced by the absence of pediatric dermatologists among the expert participants.

The reduction in consultation rates, hospitalizations, loss of productivity, and other medical costs described as a result of the preventive use of moisturizers16 positions it as a cost-effective strategy. It also reduces and delays flare-ups and the use of other topical treatments (corticosteroids), in addition to enhancing their efficacy when combined with them.28

Although there was no consensus, most experts would recommend preventive use in the elderly and children at high risk of AD. A recent meta-analysis in children concluded that they do represent a preventive strategy for AD, pending confirmation from larger studies.29 Preventive use in children without AD risk has not been determined, justifying the majority (but not unanimous) agreement not to use them as a preventive method for AD in all children.

In the elderly, despite the lack of evidence on the role of moisturizers in maintaining skin integrity,30 they would recommend preventive use, which is consistent with the negative opinion of using them only when xeroderma and pruritus are present.

Other preventive uses that most experts would recommend include the appearance of stretch marks during pregnancy (currently, topical products used to treat and prevent stretch marks contain emollients), complications in the areolas during lactation, and diaper dermatitis. Although moisturizers may create favorable conditions for optimal skin health under the diaper and promote faster recovery from diaper dermatitis, experts did not reach consensus on their use as adjuvant therapy for this condition.

This study confirms the lack of evidence on the use of moisturizers and the significant variability in their management in clinical practice. To help mitigate the negative impact that this lack of evidence may have on routine clinical practice, consensus-based recommendations are provided to aid in the unification of criteria for all health care professionals. Further studies are still needed to reduce discrepancies and improve evidence on the use of moisturizers.