Hong Kong Med J 2015 Oct;21(5):417–25 | Epub 28 Aug 2015
Patient acceptability, efficacy, and skin biophysiology of a cream and cleanser containing lipid complex with shea butter extract versus a ceramide product for eczema
KL Hon, MD, FCCM1; YC Tsang, BSc1; NH Pong, MPhil1; Vivian WY Lee, PharmD2; NM Luk, FRCP3; CM Chow, FRCPCH1; TF Leung, FRCPCH, FAAAAI1
1 Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
2 School of Pharmacy, The Chinese University of Hong Kong, Shatin, Hong Kong
3 Hong Kong Dermatology Foundation, Hong KongFull paper in PDF
Corresponding author: Prof KL Hon (email@example.com)
Objectives: To investigate patient acceptability, efficacy, and skin biophysiological effects of a cream/cleanser combination for childhood atopic dermatitis.
Design: Case series.
Setting: Paediatric dermatology clinic at a university teaching hospital in Hong Kong.
Patients: Consecutive paediatric patients with atopic dermatitis who were interested in trying a new moisturiser were recruited between 1 April 2013 and 31 March 2014. Swabs and cultures from the right antecubital fossa and the worst eczematous area, disease severity (SCORing Atopic Dermatitis index), skin hydration, and transepidermal water loss were obtained prior to and following 4-week usage of a cream/cleanser containing lipid complex with shea butter extract (Ezerra cream; Hoe Pharma, Petaling Jaya, Malaysia). Global or general acceptability of treatment was documented as ‘very good’, ‘good’, ‘fair’, or ‘poor’.
Results: A total of 34 patients with atopic dermatitis were recruited; 74% reported ‘very good’ or ‘good’, whereas 26% reported ‘fair’ or ‘poor’ general acceptability of treatment of the Ezerra cream; and 76% reported ‘very good’ or ‘good’, whereas 24% reported ‘fair’ or ‘poor’ general acceptability of treatment of the Ezerra cleanser. There were no intergroup differences in pre-usage clinical parameters of age, objective SCORing Atopic Dermatitis index, pruritus, sleep loss, skin hydration, transepidermal water loss, topical corticosteroid usage, oral antihistamine usage, or general acceptability of treatment of the prior emollient. Following use of the Ezerra cream, mean pruritus score decreased from 6.7 to 6.0 (P=0.036) and mean Children’s Dermatology Life Quality Index improved from 10.0 to 8.0 (P=0.021) in the ‘very good’/‘good’ group. There were no statistically significant differences in the acceptability of wash (P=0.526) and emollients (P=0.537) with pre-trial products. When compared with the data of another ceramide-precursor moisturiser in a previous study, there was no statistical difference in efficacy and acceptability between the two products.
Conclusions: The trial cream was acceptable in three quarters of patients with atopic dermatitis. Patients who accepted the cream had less pruritus and improved quality of life than the non-accepting patients following its usage. The cream containing shea butter extract did not differ in acceptability or efficacy from a ceramide-precursor product. Patient acceptability is an important factor for treatment efficacy. There is a general lack of published clinical trials to document the efficacy and skin biophysiological effects of many of the proprietary moisturisers.
New knowledge added by this study
- Patient acceptability is an important factor for treatment efficacy.
- There is a general lack of published clinical trials to document the efficacy and skin biophysiological effects of many of the proprietary moisturisers.
Eczema or atopic dermatitis (AD) is a chronically relapsing dermatosis associated with atopy, and characterised by reduced skin hydration (SH), impaired skin integrity (transepidermal water loss [TEWL]), and poor quality of life as a result of deficient ceramides in the epidermis.1 Regular application of a moisturiser is the key step in its management. Moisturiser therapy for AD is significantly complicated by the diversity of disease manifestations and by a variety of complex immune abnormalities.1 Filaggrin (filament-aggregating protein) and related moisturising factors have an important function in epidermal differentiation and barrier function, and null mutations within the filaggrin gene are major risk factors for developing AD.2 3 4 5 6 Ceramides and related lipid products are also important components in skin barrier function.7 Recent advances in the understanding of the pathophysiological process of AD have led to the production of new moisturisers targeted at correcting the reduced amount of ceramides and natural moisturising factors in the stratum corneum with ceramides, pseudoceramides, or natural moisturising factors.7 Many proprietary products claim to have these ingredients, but have no or limited studies to document their clinical efficacy. Our group previously tested a number of these commercial products and found patient preference and acceptability may influence outcomes of topical treatment independent of the ingredients in these products.8 The purposes of this study were to investigate patient acceptability of a cream/cleanser combination containing lipid complex and shea butter extract with claimed antihistaminergic properties, and evaluate its efficacy in improving the clinical and biophysiological properties of the skin in AD patients. A MEDLINE search was also performed to evaluate whether evidence of efficacy of many of the proprietary moisturisers exists.
Consecutive patients with AD who were interested in trying a new moisturiser were recruited from the paediatric dermatology clinic at a university teaching hospital in Hong Kong. Diagnosis of AD was based on the UK working group criteria.9 In this study, SH and TEWL in the right forearm (2 cm below the antecubital flexure), and disease severity (SCORing Atopic Dermatitis [SCORAD] index) were measured. We have previously described our method of standardising measurements of SH and TEWL.10 After acclimatisation in the consultation room with the patient sitting comfortably in a chair for 20 to 30 minutes, SH (in arbitrary units) and TEWL (in g/m2/h) were then measured according to the manufacturer’s instructions with the Mobile Skin Center MSC 100 equipped with a Corneometer CM 825 (Courage + Khazaka electronic GmbH, Cologne, Germany), and a Tewameter TM 210 probe (Courage + Khazaka electronic GmbH). We documented that a site 2 cm distal to the right antecubital flexure was optimal for standardisation. Oozing and infected areas were avoided by moving the probe slightly sideways.10 The clinical severity of AD was assessed with the SCORAD index.11 12 The SCORAD index also scores pruritus and sleep loss/disturbance on a scale of 0 to 10 (0 being not affected and 10 being most severely affected).
Patients were given a liberal supply of a trial cream containing lipid complex with shea butter extract for eczema (Ezerra [E]; Hoe Pharma, Petaling Jaya, Malaysia) and body wash (E, Hoe Pharma). The moisturiser contained STIMU-TEX AS (Centerchem Inc, Norwalk [CT], US) and saccharide isomerate. The wash contained STIMU-TEX AS and Amisoft (Amisoft Technologies Ltd, Brentwood, UK). The patients were instructed not to use any other moisturiser or topical treatment. Use of any medications such as topical corticosteroid or oral antihistamine was documented. Patients were encouraged to use the test moisturiser at least twice daily on the flexures and areas with eczema. In case the emollient effect was not satisfactory, they could use their usual emollient and medications, but the frequency of such use was to be reported and they must continue with the E moisturiser. The patients were reviewed at the end of 4 weeks. Measurements of SCORAD index, Children’s Dermatology Life Quality Index (CDLQI), SH, and TEWL were repeated. Patients’ global or general acceptability of treatment (GAT) was recorded as ‘very good’, ‘good’, ‘fair’, or ‘poor’.8 13 Approval was obtained from the Clinical Research Ethics Committee of the Chinese University of Hong Kong and written informed consents were obtained from the guardian and patient.
Continuous data were expressed as mean and standard deviation. Mann-Whitney U test was used for intergroup comparison and Wilcoxon signed rank test for within-group comparison as a small number of patients was included. Categorical data were presented in counts. Chi squared test or Fisher’s exact test where appropriate was used to compare intergroup categorical data, while McNemar’s test was used to compare within-group categorical data. Fisher’s exact test was used to determine the GAT of previously used proprietary products and E moisturiser and wash. All comparisons were two-tailed, and P values of <0.05 were considered to be statistically significant. The results were also compared with the data for an emollient (C) containing ceramide-precursor lipids and moisturising factors (n=24).14
Between 1 April 2013 and 31 March 2014, 34 patients (56% boys; mean [± standard deviation] age, 12.1 ± 4.4 years) with AD were recruited and treated with applications of a moisturising cream (E). Compliance was good and patients generally managed to use the moisturiser daily. Among the patients, 74% reported ‘very good’ or ‘good’ acceptability, whereas 26% reported ‘fair’ or ‘poor’ acceptability of the moisturiser (Tables 1 and 2).
There were no intergroup differences in pre-usage clinical parameters of age, objective SCORAD index, pruritus, sleep loss, SH, TEWL, topical corticosteroid usage, oral antihistamine usage, or GAT of prior emollient (Table 2). Following use of the E cream, pruritus score and CDLQI were lower in the ‘very good’/‘good’ group than in the ‘fair’/‘poor’ group. Mean pruritus score decreased from 6.7 to 6.0 (P=0.036) and mean CDLQI improved from 10.0 to 8.0 (P=0.021) in the ‘very good’/‘good’ group (Table 2).
When analysed for the association of the rating of acceptability, the acceptability of E cleanser (P=0.526) and E cream (P=0.537) was not significantly associated with their respective pre-trial products (Table 1). Patients who preferred the trial moisturiser or wash might or might not have come from the group of poor/fair acceptability of their prior emollient or wash, and vice versa. Prior products included emulsifying ointment and various other proprietary products.
When compared historically with another product containing ceramide-precursor lipids (C) that we tested in a previous report,14 the present shea butter extract–containing cream showed similar efficacy and acceptability (Table 3). It appears that ceramide does not confer superiority in terms of acceptability and clinical efficacy.
Table 3. Comparative study of the cream containing lipid complex (E) with a proprietary emollient containing ceramide-precursor lipids (C)
A MEDLINE search was performed on selected common proprietary moisturisers/emollients for eczema using the following search terms in combinations: “eczema” OR “atopic dermatitis”, AND “emollient” OR “moisturizer” OR “barrier” OR “barrier repair” OR “natural moisturizing factor” OR “ceramide” OR “pseudoceramide”. We selected literature mainly from the past 10 years, but did not exclude commonly referenced and highly cited older articles. We included and described all randomised trials, case series, and bench studies in barrier repair therapy for eczema, with limits activated (Humans, Clinical Trial, Meta-Analysis, Randomized Controlled Trial, English, published in the past 10 years). Editorials, letters, practice guidelines, reviews, and animal studies were excluded. In addition, the bibliographies of the retrieved articles and our own research database were also hand searched. As of 23 April 2014, 18 articles were obtained (Table 413 27 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48). The common proprietary moisturisers were included. The publications generally provided limited evidence of efficacy and biophysical effects (such as SH and TEWL), but virtually no data on patient acceptability and effects on Staphylococcus aureus colonisation.
Table 4. Results of a MEDLINE search of studies of selected proprietary moisturisers13 27 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48
Atopic dermatitis is a chronically relapsing dermatosis characterised by pruritus, skin dryness, inflammation, secondary bacterial infection by S aureus, and poor quality of life.1 15 16 17 The stratum corneum normally consists of fully differentiated corneocytes surrounded by natural moisturising factor and a lipid-rich matrix containing cholesterol, free fatty acids, and ceramide. In AD, metabolism of lipid and filaggrin protein is abnormal, causing a deficiency of ceramide and natural moisturising factors and impairment of epidermal barrier function that leads to increased TEWL and abnormal skin integrity.1 4 7 18 19 20 21 Moisturisers form the first-line therapy as maintenance and therapeutic management in childhood-onset AD.1 22 23 Hydration of the skin helps to improve dryness, reduce pruritus, and restore disturbed barrier function. Bathing without the use of moisturiser may compromise SH.24 25 26
In this study, we explored clinical efficacy and acceptability of a proprietary moisturiser (E) containing shea butter extract. The cream was acceptable as ‘very good’ or ‘good’ in about three quarters of patients with AD who tried the moisturiser, and ameliorated their pruritus and improved their quality of life.
Compliance or adherence to usage of the moisturising cream was reflected by the GAT and reported frequency of usage (times per day).27 We did not calculate the amount of moisturising cream used because many parents/patients have discarded the tubes or failed to bring them back for weighing in previous trials. Topical steroid usage is also an important confounding factor in this study. We standardise treatment for all our patients by not changing their existing topical steroid (mometasone furoate) and other medications (ie oral antihistamine, topical immunomodulant, and Chinese medicine). In previous studies, we found that documentation of the exact amount of steroid usage (weight or frequency of usage) was difficult for similar reasons as those for moisturisers.28 Most parents are still concerned about topical steroid usage and tend to use the minimal amount of steroid as far as possible.29
Alternative explanations for the modest within-group changes in pruritus and CDLQI (Table 2) include regression to the mean, detection bias, or confounding by co-treatment with topical corticosteroid or usual emollients. Our study did not demonstrate any reduction in clinical severity or S aureus colonisation. When compared historically with another product (C) containing ceramide-precursor lipids that we tested in a previous report,14 although different patients were involved and the E or C products were not received by patients in the same period, the present E cream showed similar efficacy and acceptability with the use of a similar study protocol as the previous study. It appears that specific ceramide-precursor lipids do not confer superiority in terms of acceptability and clinical efficacy.
Regarding intra-group comparisons, the C cream reduced objective SCORAD index (P=0.027) and increased SH (P=0.015), whereas the E cream reduced pruritus and improved CDLQI only in the ‘very good’/‘good’ group (Table 3). Regarding intergroup comparisons, overall there were no significant differences between the pretreatment and post-treatment parameters for the two moisturisers. We note that in the subgroup analysis, pruritus and CDLQI could be the possible contributing factors for the acceptability in the ‘very good’/‘good’ group for the E cream.
Many proprietary emollients/moisturisers are available in the market.7 22 30 31 Despite claims about their efficacy, little evidence has demonstrated the short- or long-term usefulness of many of these proprietary products. Ceramides, pseudoceramides, or filaggrin protein products have been studied and added to commercial moisturisers to mimic natural skin lipids and moisturising factors.32 Anxious parents often consult their physicians for recommendation as to the choice of an ideal or perfect moisturiser for their child with AD. Physicians need to have some evidence-based understanding about these moisturisers in order to address issues raised by the parents. We performed a MEDLINE search and found that only a few of these products have published clinical data (Table 413 27 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48). The majority either do not have patient acceptability or clinical efficacy data in the scientific literature. The efficacy of ceramides and natural moisturiser factors is generally not scientifically documented. Larger-scale, properly conducted randomised controlled trials with recruitment of more study participants may validate subtle differences in clinical efficacy between different emollients. It is likely that there will be similar outcomes in efficacy if the tested emollient is compared with any other traditional emollient such as aqueous cream or Vaseline (Unilever, London, England). Commercial pharmaceutical companies are often unwilling to supply free samples of their product to compare with an inexpensive product, even if more validated and conclusive results may be obtained by increasing the sample size in clinical trials. That is perhaps why there are so few comparative clinical studies in the medical literature.
In a wider context, AD is a complex multifactorial atopic disease. Monotherapy targeting merely at replacement of ceramides, pseudoceramides, or filaggrin degradation products at the epidermis is often suboptimal. In particular, colonisation with S aureus must be adequately treated before emollient treatment can be optimised.17
The major hindrance to the efficacy of a moisturiser is the patient’s perception as to what an ideal moisturiser should be.8 Indeed, it is often not the product, but the patient’s acceptability that determines whether it may be used consistently. Therefore, the physician caring for a patient with AD must educate and guide the parents and the patient to choose the most acceptable formulation to ensure optimal compliance.
This open-label series confirms our previous experience in emollient research. First, patient acceptance of the strengths, types, and formulations of any novel products need to be studied, preferably in randomised controlled trials. Second, holistic efficacy studies of all clinical parameters (namely severity scores, quality-of-life indices, SH, TEWL, S aureus colonisation, and patient acceptance) must be included. Third, as AD is not a simple epidermal skin disease but rather a complex atopic disease, emollient alone is bound to be suboptimal in efficacy.
Well-designed, large-scale, randomised, placebo-controlled trials to document therapeutic effects on disease severity, skin biophysiological parameters, quality of life, and patient acceptability are needed. Patient’s acceptability of a certain product is pivotal for compliance and clinical outcome. Only few of the many proprietary moisturisers for AD have undergone clinical trials to evaluate clinical efficacy and patient acceptability.
Drs KL Hon and TF Leung have performed research on eczema therapeutics, and written about the subject matter of filaggrin, ceramides, and emollients.
We thank Hoe Pharma in Hong Kong for freely supplying the studied materials. The company, however, was not involved in the design or analysis of the research data. The products used in the present study could be examples of other similar products containing shea butter.
1. Leung AK, Hon KL, Robson WL. Atopic dermatitis. Adv Pediatr 2007;54:241-73. CrossRef
2. Sandilands A, Terron-Kwiatkowski A, Hull PR, et al. Comprehensive analysis of the gene encoding filaggrin uncovers prevalent and rare mutations in ichthyosis vulgaris and atopic eczema. Nat Genet 2007;39:650-4. CrossRef
3. Sandilands A, Smith FJ, Irvine AD, McLean WH. Filaggrin’s fuller figure: a glimpse into the genetic architecture of atopic dermatitis. J Invest Dermatol 2007;127:1282-4. CrossRef
4. Enomoto H, Hirata K, Otsuka K, et al. Filaggrin null mutations are associated with atopic dermatitis and elevated levels of IgE in the Japanese population: a family and case-control study. J Hum Genet 2008;53:615-21. CrossRef
5. Chamlin SL, Kao J, Frieden IJ, et al. Ceramide-dominant barrier repair lipids alleviate childhood atopic dermatitis: changes in barrier function provide a sensitive indicator of disease activity. J Am Acad Dermatol 2002;47:198-208. CrossRef
6. Maintz L, Novak N. Getting more and more complex: the pathophysiology of atopic eczema. Eur J Dermatol 2007;17:267-83.
7. Hon KL, Leung AK. Use of ceramides and related products for childhood-onset eczema. Recent Pat Inflamm Allergy Drug Discov 2013;7:12-9. CrossRef
8. Hon KL, Wang SS, Pong NH, Leung TF. The ideal moisturizer: a survey of parental expectations and practice in childhood-onset eczema. J Dermatolog Treat 2013;24:7-12. CrossRef
9. Williams HC, Burney PG, Pembroke AC, Hay RJ. The U.K. Working Party’s Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation. Br J Dermatol 1994;131:406-16. CrossRef
10. Hon KL, Wong KY, Leung TF, Chow CM, Ng PC. Comparison of skin hydration evaluation sites and correlations among skin hydration, transepidermal water loss, SCORAD index, Nottingham Eczema Severity Score, and quality of life in patients with atopic dermatitis. Am J Clin Dermatol 2008;9:45-50. CrossRef
11. Severity scoring of atopic dermatitis: the SCORAD index. Consensus Report of the European Task Force on Atopic Dermatitis. Dermatology 1993;186:23-31. CrossRef
12. Kunz B, Oranje AP, Labreze L, Stalder JF, Ring J, Taieb A. Clinical validation and guidelines for the SCORAD index: consensus report of the European Task Force on Atopic Dermatitis. Dermatology 1997;195:10-9. CrossRef
13. Hon KL, Wang SS, Lau Z, et al. Pseudoceramide for childhood eczema: does it work? Hong Kong Med J 2011;17:132-6.
14. Hon KL, Pong NH, Wang SS, Lee VW, Luk NM, Leung TF. Acceptability and efficacy of an emollient containing ceramide-precursor lipids and moisturizing factors for atopic dermatitis in pediatric patients. Drugs R D 2013;13:37-42. CrossRef
15. Leung DY, Boguniewicz M, Howell MD, Nomura I, Hamid QA. New insights into atopic dermatitis. J Clin Invest 2004;113:651-7. CrossRef
16. Hon KL, Lam MC, Leung TF, et al. Clinical features associated with nasal Staphylococcus aureus colonisation in Chinese children with moderate-to-severe atopic dermatitis. Ann Acad Med Singapore 2005;34:602-5.
17. Hon KL, Wang SS, Lee KK, Lee VW, Fan LT, Ip M. Combined antibiotic/corticosteroid cream in the empirical treatment of moderate to severe eczema: friend or foe? J Drugs Dermatol 2012;11:861-4.
18. Hanifin JM, Rajka RG. Diagnostic features of atopic dermatitis. Acta Derm Venereol (Stockh) 1980;2:44-7.
19. Hanifin JM. Atopic dermatitis. J Am Acad Dermatol 1982;6:1-13. CrossRef
20. Candi E, Schmidt R, Melino G. The cornified envelope: a model of cell death in the skin. Nat Rev Mol Cell Biol 2005;6:328-40. CrossRef
21. Leung DY, Nicklas RA, Li JT, et al. Disease management of atopic dermatitis: an updated practice parameter. Joint Task Force on Practice Parameters. Ann Allergy Asthma Immunol 2004;93(3 Suppl 2):S1-21. CrossRef
22. Hon KL, Leung AK, Barankin B. Barrier repair therapy in atopic dermatitis: an overview. Am J Clin Dermatol 2013;14:389-99. CrossRef
23. Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics 2008;122:812-24. CrossRef
24. Lancaster W. Atopic eczema in infants and children. Community Pract 2009;82:36-7.
25. Tarr A, Iheanacho I. Should we use bath emollients for atopic eczema? BMJ 2009;339:b4273. CrossRef
26. Hon KL, Leung TF, Wong Y, So HK, Li AM, Fok TF. A survey of bathing and showering practices in children with atopic eczema. Clin Exp Dermatol 2005;30:351-4. CrossRef
27. Hon KL, Ching GK, Leung TF, Choi CY, Lee KK, Ng PC. Estimating emollient usage in patients with eczema. Clin Exp Dermatol 2010;35:22-6. CrossRef
28. Hon KL, Leung TF, Ng PC, et al. Efficacy and tolerability of a Chinese herbal medicine concoction for treatment of atopic dermatitis: a randomized, double-blind, placebo-controlled study. Br J Dermatol 2007;157:357-63. CrossRef
29. Hon KL, Kam WY, Leung TF, et al. Steroid fears in children with eczema. Acta Paediatr 2006;95:1451-5. CrossRef
30. Roos TC, Geuer S, Roos S, Brost H. Recent advances in treatment strategies for atopic dermatitis. Drugs 2004;64:2639-66. CrossRef
31. Baumer JH. Atopic eczema in children, NICE. Arch Dis Child Educ Pract Ed 2008;93:93-7.
32. Park KY, Kim DH, Jeong MS, Li K, Seo SJ. Changes of antimicrobial peptides and transepidermal water loss after topical application of tacrolimus and ceramide-dominant emollient in patients with atopic dermatitis. J Korean Med Sci 2010;25:766-71. CrossRef
33. Mohammed D, Matts PJ, Hadgraft J, Lane ME. Influence of Aqueous Cream BP on corneocyte size, maturity, skin protease activity, protein content and transepidermal water loss. Br J Dermatol 2011;164:1304-10. CrossRef
34. Tsang M, Guy RH. Effect of Aqueous Cream BP on human stratum corneum in vivo. Br J Dermatol 2010;163:954-8. CrossRef
35. Simpson E, Böhling A, Bielfeldt S, Bosc C, Kerrouche N. Improvement of skin barrier function in atopic dermatitis patients with a new moisturizer containing a ceramide precursor. J Dermatolog Treat 2013;24:122-5. CrossRef
36. Laquieze S, Czernielewski J, Baltas E. Beneficial use of Cetaphil moisturizing cream as part of a daily skin care regimen for individuals with rosacea. J Dermatolog Treat 2007;18:158-62. CrossRef
37. Simpson E, Trookman NS, Rizer RL, et al. Safety and tolerability of a body wash and moisturizer when applied to infants and toddlers with a history of atopic dermatitis: results from an open-label study. Pediatr Dermatol 2012;29:590-7. CrossRef
38. Miller MA, Borys D, Riggins M, Masneri DC, Levsky ME. Two cases of contact dermatitis resulting from use of body wash as a skin moisturizer. Am J Emerg Med 2008;26:246.e1-2.
39. Miller DW, Koch SB, Yentzer BA, et al. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. J Drugs Dermatol 2011;10:531-7.
40. Draelos ZD. The effect of ceramide-containing skin care products on eczema resolution duration. Cutis 2008;81:87-91.
41. Madaan A. Epiceram for the treatment of atopic dermatitis. Drugs Today (Barc) 2008;44:751-5. CrossRef
42. Palatty PL, Azmidah A, Rao S, et al. Topical application of sandal wood oil and turmeric based cream prevents radiodermatitis in head and neck cancer patients undergoing external beam radiotherapy: a pilot study. Br J Radiol 2014;87:20130490. CrossRef
43. Wang S, Kislalioglu MS, Breuer M. The effect of rheological properties of experimental moisturizing creams/lotions on their efficacy and perceptual attributes. Int J Cosmet Sci 1999;21:167-88. CrossRef
44. Boffa MJ, Beck MH. Allergic contact dermatitis from quaternium 15 in Oilatum cream. Contact Dermatitis 1996;35:45-6. CrossRef
45. Garfield SS. The beneficial effects of oilatum cream on hyperhydrosis. J Am Podiatry Assoc 1966;56:22-4. CrossRef
46. Yilmaz E, Borchert HH. Effect of lipid-containing, positively charged nanoemulsions on skin hydration, elasticity and erythema—an in vivo study. Int J Pharm 2006;307:232-8. CrossRef
47. Kemeny L, Koreck A, Kis K, et al. Endogenous phospholipid metabolite containing topical product inhibits ultraviolet light–induced inflammation and DNA damage in human skin. Skin Pharmacol Physiol 2007;20:155-61. CrossRef
48. Dizon MV, Galzote C, Estanislao R, Mathew N, Sarkar R. Tolerance of baby cleansers in infants: a randomized controlled trial. Indian Pediatr 2010;47:959-63. CrossRef