Original Paper

Skin Pharmacol Physiol 2014;27:208–216 Received: August 19, 2013

Accepted after revision: February 4, 2014
DOI: 10.1159/000360546
Published online: April 3, 2014

Children with Dry Skin and Atopic Predisposition:

Daily Use of Emollients in a Participant-Blinded,
Randomized, Prospective Trial
Marianne Schario a Lena Lünnemann a Andrea Stroux a, b Anett Reisshauer c
       

Torsten Zuberbier d Ulrike Blume-Peytavi a Natalie Garcia Bartels a 

     

a
  Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science, Charité-Universitätsmedizin
Berlin, and Departments of b Medical Statistics and Clinical Epidemiology, c Physical Medicine and Rehabilitation and
   

d
Allergy Center, Department of Dermatology and Allergy, Charité-Universitätsmedizin Berlin, Berlin, Germany
 

Key Words atopic predisposition may improve their skin condition dur-
Skin barrier · Emollient · Transepidermal water loss · ing daily emollient application. PIPJ-based formulations
Stratum corneum hydration · Skin pH · Atopic dermatitis · may be helpful to maintain skin barrier integrity.
Children · Dry skin · TEWL · Ice plant © 2014 S. Karger AG, Basel

Abstract
Background: Dry skin reflects a skin barrier defect which can
lead to atopic dermatitis. Little is known about the distinct
effects of emollient use in children with dry skin and atopic
predisposition. Objectives: We investigated the effects of
daily application of pressed ice plant juice (PIPJ)-based
emollients and petrolatum-based emollients. Methods:
Children aged 2–6 years with dry skin and atopic predisposi-
tion were randomized into 2 groups: group 1 received emol-
lients containing PIPJ and natural lipids, while group 2 re-
ceived petrolatum-based emollients. Skin condition and
biophysical properties of the skin barrier were assessed at
inclusion and weeks 4, 12 and 16. Results: Skin condition
improved significantly in all children. Comparing the groups,
children treated with emollients containing PIPJ showed
significantly higher stratum corneum hydration values and
significantly lower transepidermal water loss values at week
16 on the forearm and forehead. A significant decrease in
skin pH was noted in group 2 on the forearm and forehead;
group 1 showed a stable course. Conclusion: Early interven-
tion with emollients in children with dry skin condition and
Introduction
Dry skin has a high prevalence in children and is most
commonly a symptom of underlying atopic dermatitis
(AD) [1]. An impaired skin barrier function is typically
found in dry skin, which exhibits increased values of tran-
sepidermal water loss (TEWL) and skin surface pH (pH)
[2–5]. In addition, this epidermal barrier insufficiency is
reflected by a decrease in stratum corneum hydration
(SCH) and decreased amounts of natural moisturizing
factor (NMF) [6–10]. Compared with adult skin, the in-
fantile skin barrier is going through a process of matura-
tion as water-handling properties of the stratum corneum
(SC) are found to be less strongly developed [11]. Regard-
ing this continuous state of development, the skin of chil-
dren exhibits a pronounced susceptibility to various ex-
ternal and environmental factors, including inadequate
skin care, water hardness or infant swimming practices
[12, 13]. This can lead to a perturbation of the fragile skin
barrier homeostasis, resulting in a dry skin condition [9,
13–15]. Previous studies investigating infants with healthy

© 2014 S. Karger AG, Basel Priv.-Doz. Dr. med. N. Garcia Bartels

1660–5527/14/0274–0208$39.50/0 Department of Dermatology and Allergy, Clinical Research Center for Hair and Skin Science
Charité-Universitätsmedizin Berlin, Charitéplatz 1
E-Mail karger@karger.com
DE–10117 Berlin (Germany)
www.karger.com/spp
E-Mail natalie.garcia-bartels @ charite.de
skin have suggested the use of emollients to increase SCH
and thus support skin barrier maturation [16, 17]. In ad-
dition, a protective effect of daily emollient use in neo-
nates at high risk of AD development has recently been
suggested [5]. Still, there is a lack of scientific data on the
impact of emollient use on skin barrier function in chil-
dren with dry skin and atopic predisposition. Barrier re-
covery patterns vary according to distinct anatomical
skin areas, which seems to be related to structural and
physiological differences. Therefore, anatomically specif-
ic skin care regimens appear interesting for dry skin at
risk of AD [18]. Plant extracts become increasingly popu-
lar in skin care products and self-medication, therefore
botanicals should be scientifically evaluated regarding
their effect on skin barrier properties [19, 20]. This study
aimed at investigating the effects of emollient application
on skin barrier integrity in children with dry skin and
predisposition to AD. In this study, different types of
emollients – plant-based emollients containing pressed
ice plant juice (PIPJ) and petrolatum-based emollients –
were evaluated regarding their clinical and biophysical
effects on skin barrier function by daily application.
Methods
Study Design
A prospective, participant-blinded, randomized study was
conducted from December 2011 to July 2012. The trial was ap-
proved by the local ethics committee and complied with the Dec-
laration of Helsinki guidelines. Children were examined at inclu-
sion (visit 0, V0), week 4 ± 4 days (V1), week 12 ± 4 days (V2) and
week 16 ± 7 days (V3). The active application phase lasted 16
weeks. The panelists participated in a weekly swimming course
for a total of 4 weeks (V1–V2). No additional swimming was al-
lowed during the study. The use of pimecrolimus, systemic or
topical corticosteroids for more than 3 consecutive days led to
dropouts. The full trial protocol can be assessed at the Clinical
Research Center for Hair and Skin Science, Department for Der-
matology and Allergy, Charité-Universitätsmedizin Berlin, Ber-
lin, Germany.
Population
Children aged 2–6 years (±4 weeks) with dry skin and atopic
predisposition were enrolled in the study. The definition of dry
skin in the present study comprised a rough, finely scaling ap-
pearance without clinical signs of inflammation [21]. Atopic pre-
disposition was evaluated by a modified Erlanger Atopy Score
(EAS) [22, 23]. The EAS represents a well-established method for
evaluating atopic diathesis and includes major and minor criteria
defined by Hanifin and Rajka [23, 24]. Inclusion criteria were:
EAS ≥4; clinically dry skin; one or both parents having current or
previous AD, allergic rhinitis, conjunctivitis or asthma; and par-
ents consenting to their children’s participation in the swimming
course. Exclusion criteria were: immunocompromised or severe-
Use of Emollients in Children with Atopic
Predisposition
Table 1. Modified daily dosage and application mode of emollients
to the body surface in both groups, adjusted by age of children
Lotion entire body surface Cream, fingertip units2
(except face), per pass1
face forearms
3–5 years 6 1.5 4
6 years 8 2 5
1 
1 pass = 1 g of lotion.
2 1 fingertip unit = 0.5 g of cream.
ly ill children; increased or decreased body temperature (≤35 ° C    
or ≥38.5 ° C); congenital and/or contagious skin disorders; skin
irritation affecting measurements; current treatment with topical
or systemic corticosteroids or macrolides; any topical or system-
ic therapy within 4 months prior to inclusion lasting longer than
3 days with corticosteroids, pimecrolimus or antihistamines; fur-
ther phototherapy; and participation in another study. Siblings
were not enrolled, to avoid unblinding of the study products.
After obtaining written informed consent from both legal
guardians, the eligible children (n = 47) were randomly assigned
to two different intervention groups, using concealed random al-
location [25] by a person not involved in the study. Randomization
was performed using block randomization with a block length of
4. Block randomization was generated by the trial statistician.
Intervention
Children in group 1 (G1; n = 24) received skin care with two
differently formulated emollients by Dr. Hauschka Med: Ice Plant
Body Care Lotion (aqua, mesembryanthemum crystallinum ex-
tract, glycerin, alcohol, simmondsia chinensis oil, persea gratissi-
ma oil, prunus amygdalus dulcis oil, manihot utilissima starch,
cera alba, lanolin, lysolecithin, mangifera indica seed butter, bu-
tyrospermum parkii butter, daucus carota extract, sucrose stearate,
sucrose distearate, chondrus crispus extract, glyceryl stearate, hec-
torite, xanthan gum, stearic acid, amyris balsamifera oil, rosmari-
nus officinalis extract, sodium stearoyl lactylate) and Intensive Ice
Plant Cream (aqua, mesembryanthemum crystallinum extract,
persea gratissima oil, glycerin, mangifera indica seed butter, alco-
hol, tricaprylin, prunus amygdalus dulcis oil, simmondsia chinen-
sis seed oil, sesamum indicum seed oil, lanolin, cetearyl alcohol,
bentonite, butyrospermum parkii butter, daucus carota sativa root
extract, rosmarinus officinalis leaf extract, amyris balsamifera bark
oil, lysolecithin, glyceryl oleate, xanthan gum); the latter had a
higher content of natural lipids and PIPJ than the lotion.
The children in group 2 (G2; n = 23) received a basic skin care
treatment with a petrolatum-based lotion and cream (German
Drug Codex basic cream: aqua, petrolatum, propylene glycol, ca-
prylic/capric triglyceride, glyceryl stearate, alcohol, cetyl alcohol,
PEG-20 glyceryl stearate), both adjusted in their lipid and ethanol
concentration to the Dr. Hauschka Med products. All study prod-
ucts were manufactured and labeled by WALA Heilmittel GmbH
(Bad Boll, Germany). The parents were blinded to the study prod-
ucts, and instructed about the dosage and application mode at in-
clusion (table 1). As a first step, the lotion was applied to the entire
Skin Pharmacol Physiol 2014;27:208–216 209
DOI: 10.1159/000360546
 Enrollment Screening: n = 50 Excluded: n = 3
Randomized: n = 47 ‡ molluscum contagiosum: n = 1
‡ TCS >3 days: n = 1
‡ examination refused: n = 1
Allocation
G1: G2:
allocated: n = 24 allocated: n = 23

Follow-up
Dropout: n = 1 Dropout: n = 1
V1: n = 23 V1: n = 22
TCS >3 days: n = 1 lost contact: n = 1
Follow-up
Dropouts: n = 2
Dropout: n = 1
V2: n = 22 V2: n = 20 ‡ withdrawn consent: n = 1
request of participant: n = 1
‡ time difficulties: n = 1
Follow-up
Dropouts: n = 2 Dropouts: n = 2
V3: n = 20 V3: n = 18
TCS >3 days: n = 2 TCS >3 days: n = 2
Analysis
Study completed regularily G1: n = 20 Study completed regularily G2: n = 18

Fig. 1. Flow diagram. In total, there were 3 dropouts in G1 and 2 dropouts in G2; those participants had used TCS
for >3 days. TCS = Topical corticosteroids.

body surface excluding the face, followed by application of the
cream to the face and to the entire forearm. No other emollients
were allowed except sunscreen; however, the parents were in-
structed to use physical sun protection [5]. The parents were ad-
vised to retain their routine bathing procedures with the usual
cleaning products. Last application of emollients was more than
12 h before measurements. Additionally, no bathing, use of sun-
screen or sports was allowed within 12 h prior to data collection.
Outcome Variables and Clinical Evaluations
The primary outcome variable was SCH on the forearm. Sec-
ondary outcome variables were TEWL, pH and Scoring Atopic
Dermatitis (SCORAD) [26–32]. TEWL, SCH and pH were as-
sessed noninvasively using a Tewameter® TM 300, Corneome-
ter® CM 825 and Skin-pH-Meter® PH 905 (Courage + Khazaka,
Cologne, Germany) according to standardized protocols [17] un-
der standardized ambient conditions (room temperature: 22–
26 ° C; relative humidity: 40–60%; adaption period: at least 10 min,
   
with the investigational areas not covered by clothing). Skin func-
tional parameters were assessed at each visit in 3 defined investi-
gational areas: (1) the forehead, (2) the right midvolar forearm
and (3) the right midlateral thigh. Measured skin sites were free
of eczematous involvement. If the right side of the body could not
be assessed at inclusion, the left side was chosen for all measure-
ments. Skin condition was evaluated at each visit by visual scoring
using SCORAD. Besides the criteria erythema, edema, crust, ex-
coriation and lichenification, this score also evaluates skin dry-
ness and subjective symptoms like pruritus and sleep loss. So far,
a validated clinical scoring for the target population is missing and
data are only available from children with AD. Therefore,
SCORAD was chosen to quantify dryness intensity and to com-
pare our results with others.
Statistical Methods
Descriptives included absolute and relative frequencies for cat-
egorial measurements, and mean, standard deviation (SD), medi-
an and range for quantitative measurements. Univariate between-
group comparisons were performed using the χ2 test for categorial
and the Mann-Whitney U test for quantitative variables. For be-
tween-visit comparisons with regard to skin functional parameters
and SCORAD, the Wilcoxon test was used. Correlation analyses
concerning associations between quantitative measurements were
done using Spearman’s correlation coefficient. p < 0.05 (two-sid-
ed) was considered significant. No Bonferroni correction was per-
formed. All statistical analyses were performed with the commer-
cially available software SPSS version 20 [33].
Sample size calculation, which was conducted with the com-
mercially available software nQuery Advisor 6.0, was based on
mean differences in development of the primary endpoint SCH
between V0 and V3 with n = 26 children per group. A power of
80% with a difference in means of 5 (SD = 8) could be shown on a
two-sided significance level of α = 0.05.
Results
In total, 38 children completed the study (fig. 1). The
baseline characteristics of both groups were comparable
except for age (table 2). Each body region represented an
application area for either cream (forehead) or lotion
(leg) or both preparations (forearm; table 1). Skin func-
tional parameters showed different values and develop-
ment depending on the body region investigated.

210 Skin Pharmacol Physiol 2014;27:208–216 Schario/Lünnemann/Stroux/Reisshauer/

DOI: 10.1159/000360546 Zuberbier/Blume-Peytavi/Garcia Bartels
 Table 2. Baseline characteristics of study participants

G1 G2 p
(n = 24) (n = 23) G1 vs. G2

EAS 8.88±2.6 8.83±3.04 0.996

Female, n 16 (66.7) 9 (39.1) 0.082
Male, n 8 (33.3) 14 (60.9)
Age, months 47.54±12.2 39.3±15.6 0.024
Body length, m 1.02±0.7 0.98±0.1 0.073
Weight, kg 16.0±2.7 15.2±2.7 0.069
BMI 15.2±1.4 15.7±1.6 0.278
History of possible allergic reactions,1 n 2 (8.3) 5 (21.7) 0.245
History of AD, n 2 (8.3) 2 (8.7) 1.000
Regular skin care performed prior to inclusion, n 22 (91.7) 22 (95.7) 1.000

Values denote means ± SD unless specified otherwise. Data in parentheses are percentages.
1 Information given by parents during anamnesis; represents a subjective interpretation of different reactions

and their correlation to a putative cause, without a known or proven allergy.

Table 3. Stratum corneum hydration (AU) Table 4. Transepidermal water loss (g/m2/h)

Group Baseline Week 4 Week 12 Week 16 Group Baseline Week 4 Week 12 Week 16

Forehead G1 43.9±9.5 46.3±8.4 49.3±10.8 49.8±9.9 Forehead G1 10.6±4.3 7.9±2.3 10.2±4.1 9.2±2.4
G2 41.7±10.3 40.8±12.8 44.6±11.7* 38.4±10.9 G2 12.2±6.3 14.9±8.2 12.5±6.6 11.4±3.5
G1 vs. n.s. n.s. n.s. p = 0.004 G1 vs. n.s. p < 0.001 n.s. p = 0.024
G2 G2
Forearm G1 36.3±9.1 42.4±7.1* 43.4±8.5* 40.6±7.3 Forearm G1 9.3±2.2 10.0±6.9 8.3±1.6* 8.6±2.2
G2 32.8±7.8 36.1±10.6 35.9±11.5 33.1±7.9 G2 10.7±4.1 10.5±3.7 10.7±3.2 10.0±2.8
G1 vs. n.s. p = 0.040 p = 0.033 p = 0.006 G1 vs. n.s. n.s. p = 0.008 p = 0.039
G2 G2
Leg G1 32.3±8.4 37.2±7.1* 39.0±7.0* 35.7±9.4 Leg G1 11.5±3.7 9.8±3.8* 10.6±2.3 11.7±3.6
G2 27.5±9.3 35.1±11.3* 33.7±8.6* 29.2±7.7 G2 11.0±2.9 10.6±3.4 12.4±8.1 11.9±3.8
G1 vs. p = 0.030 n.s. p = 0.046 p = 0.038 G1 vs. n.s. n.s. n.s. n.s.
G2 G2

Values denote means ± SD unless specified otherwise. n.s. = Values denote means ± SD unless specified otherwise. *  p  <
Not significant. * p < 0.05: significantly different from baseline. 0.05: significantly different from baseline.

Stratum Corneum Hydration
At baseline both intervention groups showed compa-
rable values for SCH on the forehead and forearm (p  >
0.160; table 3). Skin hydration in the entire sample showed
anatomical variability, presenting the highest values on the
forehead (42.8 ± 9.9 AU), followed by the forearm (34.6 ±
9.5 AU; p = 0.001) and leg (29.9 ± 9.1 AU; p = 0.001), at
baseline (table 3). On the forearm, SCH significantly (p <
0.033) increased in G1 after 4 and 12 weeks, and remained
stable in G2 (table 3). On the leg, both groups showed a
significant increase in SCH until weeks 4 and 12 (p < 0.017;
table 3). On the forehead, SCH levels remained stable in
both groups when comparing week 16 with the baseline
(table  3). However, when comparing G1 with G2, a sig-
nificantly higher SCH was found at week 16 on the fore-
head (p = 0.004) and forearm (p = 0.006; table 3).
Transepidermal Water Loss
The baseline values for TEWL in each area of investiga-
tion were comparable (p > 0.23; table 4) between groups.
The entire sample showed significantly lower TEWL val-
ues on the forearm (10.0 ± 3.3 g/m2/h) compared with the

Use of Emollients in Children with Atopic Skin Pharmacol Physiol 2014;27:208–216 211
Predisposition DOI: 10.1159/000360546
leg (11.3 ± 3.3 g/m2/h; p = 0.012) at baseline (table 4). On Table 5. Skin pH
the forearm, a significantly lower TEWL was found in G1
after 12 weeks compared with the baseline (p = 0.023; ta- Group Baseline Week 4 Week 12 Week 16
ble 4). On the forehead and leg, TEWL remained stable at Forehead G1 4.5±0.4 4.5±0.4 4.3±0.3* 4.4±0.3
week 16 in both groups compared with the baseline (p > G2 4.5±0.4 4.4±0.3 4.2±0.3* 4.3±0.1*
0.353; table 4). When comparing both groups, G1 showed
Forearm G1 4.9±0.4 4.9±0.5 4.8±0.4 4.8±0.3
significantly lower TEWL values than G2 at weeks 12 and G2 4.9±0.4 4.8±0.4 4.7±0.3* 4.6±0.4*
16 (p = 0.008 and p = 0.039) on the forearm, and at weeks
Leg G1 4.9±0.4 4.9±0.5 4.9±0.5 5.0±0.5
4 and 16 (p < 0.001 and p = 0.024) on the forehead (table 4).
G2 5.0±0.5 4.8±0.3 4.7±0.3* 4.8±0.4

Skin Surface pH
Each body region presented similar values at baseline
when comparing both groups (p > 0.716; table 5). When
comparing the areas of the entire sample investigated,
their pH values differed significantly at baseline. A lower
pH was found on the forehead (4.5 ± 0.4) compared with
the forearm and leg (4.9 ± 0.4 and 5.0 ± 0.5; p < 0.045).
Children in G2 showed significantly lower pH values in
all areas investigated at week 12 compared with the base-
line (table 5). On the forehead and forearm, a decrease
was noted also at week 16 (p < 0.016; table 5). In G1, at
week 16 the pH was comparable with values at baseline
on the forearm (p = 0.121), forehead (p = 0.132) and leg
(p = 0.615; table 5). Only at week 12 did the pH decrease
on the forehead (p = 0.033).
Skin Condition
The SCORAD index and the dryness intensity assess-
ment of the SCORAD were comparable at baseline be-
tween groups (p > 0.911; table 6). The SCORAD index
dropped significantly in both groups comparing baseline
with weeks 4, 12 and 16 (p < 0.014; table 6). Dryness in-
tensity decreased significantly in G1 after 4, 12 and 16
weeks (p < 0.020), and in G2 after 4 and 16 weeks (p <
0.031; table 6). There were no statistically significant dif-
ferences between the groups.
Discussion
Dry skin is often linked to impaired skin barrier func-
tion as observed in AD skin [34, 35]. Several studies have
been performed to evaluate the effect of emollient therapy
on children with AD. Nevertheless, current awareness of
dry skin condition and effective treatment of children with
atopic predisposition is limited [36, 37]. Regular applica-
tion of emollients is discussed to exert a positive effect on
skin barrier function in infants [17, 38]. In order to scien-
tifically characterize the effect of the emollients applied, we
assessed the functional skin parameters SCH, TEWL and
Data are given as means ± SD. * p < 0.05: significantly different
from baseline; there were no significant differences between the
groups.
Table 6. SCORAD index and dryness intensity assessment
Group Baseline Week 4 Week 12 Week 16
SCORAD G1 10.7±8.8 6.8±8.3* 4.5±3.3* 3.8±4.3*
index G2 9.9±7.5 5.1±5.4* 5.4±5.3* 5.3±5.6*
Dryness G1 1.42±0.58 1.00±0.30* 0.91±0.29* 0.85±0.49*
intensity G2 1.43±0.66 0.96±0.37* 1.05±0.2 1.0±0.34*
Data are given as means ± SD. * p < 0.05: significantly different
from baseline; there were no significant differences between the
groups.
pH by established, noninvasive methods in three represen-
tative areas of investigation [39]. The previously reported
anatomical variability in infant skin has to be considered
when evaluating the effect of regular emollient application
on skin barrier function [14, 16, 17, 38, 40, 41]. Skin lesions
in AD are characteristically distributed in an age-related
pattern. While in infants, primarily the skin in the face is
affected, older children show lesions primarily in flexural
areas [42, 43]. At the end of the study, the forehead, which
had PIPJ cream applied, and the forearm, which received
PIPJ cream and PIPJ lotion, showed significantly higher
SCH values and lower TEWL values compared with chil-
dren receiving petrolatum-based emollients, or compared
with the leg, to which only the lotion was applied.
Hydration of the SC
The forehead and forearm showed lower SCH values
at study entry compared with values reported for non-
atopic children of the same age [44]. This might indicate
an impaired skin barrier function even in the absence of

212 Skin Pharmacol Physiol 2014;27:208–216 Schario/Lünnemann/Stroux/Reisshauer/

DOI: 10.1159/000360546 Zuberbier/Blume-Peytavi/Garcia Bartels
visible erythema. In addition, former studies revealed
similar, reduced SCH values in lesional skin of children
suffering from AD [6, 45, 46].
In general, the water content of the SC is essential for
normal skin physiology [47]. Diminished SCH levels lead
to impaired activity of proteases involved in SC desqua-
matory processes [48–50]. Consequently, corneodesmo-
somes are degraded insufficiently, resulting in an accu-
mulation and aggregation of corneocytes on the skin sur-
face [51]. The clinical equivalent is a dry flaky skin
appearance [52].
During the study, the children in the PIPJ group (G1)
showed significantly increasing SCH values on the fore-
arm, where lotion and cream were applied, in contrast to
the children receiving the basic emollient compositions.
Application of both formulations, lotion and cream in
G1, as well as the amount of PIPJ and natural lipids may
have influenced the course of SCH, since no significant
changes in SCH were found in G2 [53]. The SCH values
in G1 were comparable with SCH values in AD children
of the same age treated with an emollient [54, 55]. How-
ever, the SCH levels in both groups were lower than the
SCH values reported for nonatopic children [44]. In ad-
dition, group-specific findings on barrier function were
not reflected in dryness intensity. Furthermore, applica-
tion of PIPJ cream to the forehead was followed by sig-
nificantly higher SCH at the end of the study comparing
G1 with G2. Hence, daily application of PIPJ cream may
augment the water content of the SC. The overall lowest
SCH was assessed on the leg and corroborates previously
reported lower NMF levels when compared with the fore-
arm. As the NMF is a major factor in adequate water re-
tention in the SC, this may be clinically correlated with an
increased incidence of dry skin on the leg [7, 48]. Regard-
less of whether the emollient was plant based or petrola-
tum based, both groups profited from daily application of
lotion to the leg as SCH increased during the study.
At week 12, significantly lower TEWL rates were mea-
sured on the forearm of children treated with PIPJ emol-
lients compared with those treated with the petrolatum-
based emollients, possibly indicating an improved skin
barrier function. The different effects of the emollients
used in G1 on TEWL values might be related to the lipid
formulation and the water-binding properties of PIPJ-
containing emollients [53, 56].
Skin Surface pH
Baseline pH assessment revealed lower values in our
cohort compared with previously reported ranges in
healthy children of 4.67–5.37 [57]. While pH levels
Use of Emollients in Children with Atopic
Predisposition
remained low as found at baseline in G1, a further
significant decrease in pH was observed in G2 (forehead
and forearm; week 16) through the study period.
An acidic SC is essential for the correct functioning
of  diverse enzymes, e.g. acid sphingomyelinase or
β-glucocerebrosidase, which have a decisive role in epi-
dermal barrier maturation and skin repair processes
[48, 58]. Besides this, an acidic pH functions as a de-
fense against pathogens while encouraging the growth
of normal skin flora [59]. On the contrary, a condition
connected with perturbation of the skin acid mantle –
hence displaying elevated skin pH levels while patho-
genic bacteria (e.g. Staphylococcus aureus) grow – is AD
[6, 57, 60]. In vivo, lactic acid increased levels of SC
ceramides, and resistance to the appearance of skin xe-
rosis was observed [61]. Consequently, impairment of
the cutaneous barrier function is observed in patients
with atopic eczema [57]. In this context, hyperacidifica-
tion has been suggested by experimental studies to be
helpful in maintaining barrier homeostasis, by stimu-
lating the maturation of extracellular lamellar mem-
branes [60]; moreover, a possible preventive effect on
AD development was indicated [62]. Based on these re-
sults, the low skin surface pH and the decrease in pH
values in our study may be helpful to maintain skin bar-
rier integrity in children with dry skin and atopic pre-
disposition.
Clinical Condition of the Skin
Both skin care regimes improved the skin condition.
Regular treatment with emollients may be a vital factor
in the management of this skin condition in children
with dry skin and atopic predisposition [4, 5]. The clini-
cal evaluations revealed a similar course of the skin con-
dition in both groups. However, the biophysical mea-
surements indicated a difference between effects exerted
by the use of PIPJ emollient and those exerted by the
petrolatum-based lotion or cream. Thus, biophysical pa-
rameters represent an important adjunct in the compre-
hensive evaluation of emollient effects on skin barrier
function [4]. Comparing our results with earlier results
of studies investigating patients with definite AD, no sig-
nificant correlations between SCORAD and TEWL or
SCH were observed in our patients with dry skin and
predisposition to AD [63]. In this study, SCORAD was
used as an interesting tool to quantify the parameter
‘dryness intensity’ and overall skin condition in children
with atopic predisposition, even if SCORAD is validated
only for AD.
Skin Pharmacol Physiol 2014;27:208–216 213
DOI: 10.1159/000360546
 Environmental Factors
Additionally, environmental skin barrier break-
down might be influenced by chlorine in swimming
pools, which frequently is not well tolerated and is sup-
posed to alter skin barrier permeability [64]. A positive
effect of using lotion after baby swimming on skin
functional parameters was shown by recent findings
[38]. As no deterioration in skin physiological param-
eters and clinical scoring was found in this study, it can
be assumed that adequate skin care may be helpful in
protecting the skin barrier in children with dry skin
and atopic predisposition following a once-weekly
swimming course.
Plant Extract
The number of patients and consumers asking for
plant-based therapeutic products as a complementary
dermatologic therapy is increasing [19, 20]. Traditionally,
some plants have been used for the treatment of AD for a
long time as botanical compounds display interesting
skin barrier-reinforcing properties [65, 66].
The ice plant, a vegetable found in semi-arid climate
zones, is traditionally consumed as salad or spinach [67].
The species Mesembryanthemum crystallinum is charac-
terized by antioxidant and antibacterial properties and is
of pharmacological and dermocosmetic interest [68]. The
plant was widely used in traditional medicine for the re-
spiratory or urinary system and has been used as an anti-
diabetic agent in Japan [13, 69–71]. The pressed juice of
the plant influences the cell physiology of human kerati-
nocytes and fibroblasts and improves skin hydration in
atopic patients [72, 73].
Nevertheless, several botanicals hold the risk of pro-
voking allergic reactions or of sensitization [19]. How-
ever, ice plant has been a nutritional compound in sev-
eral countries for many years, and no allergic reactions or
sensitizations have been reported so far [73]. However,
the risk of sensitization in long-term treatment with plant
extracts cannot be ruled out.
Dry skin requires adequate intervention; if left un-
treated, it may lead to a flare of the underlying condition
such as atopic eczema [9]. Our study indicates that ap-
propriate daily emollient application, even with a PIPJ
formulation, stabilizes the susceptible skin barrier func-
tion of children with dry skin and atopic predisposition.
Thus, increasing awareness of dry skin condition in chil-
dren may lower the risk of developing AD. Anatomy-spe-
cific regimes, the mode of application and the type of
emollient should be considered when investigating skin
barrier properties [17, 18]. The present results contribute
to an improved understanding of the effects of emollient
application on skin barrier function in children with dry
skin and atopic predisposition.
Limitations
A control group of children of the same age with ab-
sence of dry skin would have helped to compare skin bar-
rier parameter values with those of healthy children in
parallel.
Acknowledgment
We thank the European Centre for Allergy Research Founda-
tion Institute GmbH, Berlin, for providing the logistics to conduct
this study. The study was supported by WALA Heilmittel GmbH.
Disclosure Statement
None declared.

References
1 Böhme M, et al: Hanifin’s and Rajka’s minor
criteria for atopic dermatitis: which do 2-year-
olds exhibit? J Am Acad Dermatol 2000; 43:
785–792.
2 Cork MJ, Danby S: Skin barrier breakdown: a
renaissance in emollient therapy. Br J Nurs
2009;18:876–877.
3 Flohr C, et al: Filaggrin loss-of-function mu-
tations are associated with early-onset ecze-
ma, eczema severity and transepidermal wa-
ter loss at 3 months of age. Br J Dermatol 2010;
163:1333–1336.
4 Proksch E, Lachapelle JM: The management of
dry skin with topical emollients: recent perspec-
tives. J Dtsch Dermatol Ges 2005;3:768–774.
5 Simpson EL, et al: A pilot study of emollient
therapy for the primary prevention of atopic
dermatitis. J Am Acad Dermatol 2010; 63:
587–593.
6 Seidenari S, Giusti G: Objective assessment
of the skin of children affected by atopic der-
matitis: a study of pH, capacitance and
TEWL in eczematous and clinically unin-
volved skin. Acta Derm Venereol 1995; 75:
429–433.
7 Horii I, et al: Stratum corneum hydration and
amino acid content in xerotic skin. Br J Der-
matol 1989;121:587–592.
8 Berry N, et al: A clinical, biometrological and
ultrastructural study of xerotic skin. Int J Cos-
met Sci 1999;21:241–252.
9 Moncrieff G, et al: Use of emollients in dry-
skin conditions: consensus statement. Clin
Exp Dermatol 2013;38:231–238.
10 Pons-Guiraud A: Dry skin in dermatology: a
complex physiopathology. J Eur Acad Der-
matol Venereol 2007;21(suppl 2):1–4.

214 Skin Pharmacol Physiol 2014;27:208–216 Schario/Lünnemann/Stroux/Reisshauer/

DOI: 10.1159/000360546 Zuberbier/Blume-Peytavi/Garcia Bartels
11 Nikolovski J, et al: Barrier function and wa-
ter-holding and transport properties of in-
fant stratum corneum are different from
adult and continue to develop through the
first year of life. J Invest Dermatol 2008; 128:
1728–1736.
12 Chaumont A, et al: Interactions between do-
mestic water hardness, infant swimming and
atopy in the development of childhood ecze-
ma. Environ Res 2012;116:52–57.
13 Seyfarth F, et al: Dry skin, barrier function,
and irritant contact dermatitis in the elderly.
Clin Dermatol 2011;29:31–36.
14 Seidenari S, et al: Thickness and echogenici-
ty of the skin in children as assessed by 20-
MHz ultrasound. Dermatology 2000; 201:
218–222.
15 Stamatas GN, et al: Infant skin physiology
and development during the first years of
life: a review of recent findings based on in
vivo studies. Int J Cosmet Sci 2011; 33: 17–
24.
16 Garcia Bartels N, et al: Influence of bathing or
washing on skin barrier function in newborns
during the first four weeks of life. Skin Phar-
macol Physiol 2009;22:248–257.
17 Garcia Bartels N, et al: Effect of standardized
skin care regimens on neonatal skin barrier
function in different body areas. Pediatr Der-
matol 2010;27:1–8.
18 Fluhr JW, et al: Impact of anatomical location
on barrier recovery, surface pH and stratum
corneum hydration after acute barrier disrup-
tion. Br J Dermatol 2002;146:770–776.
19 Reuter J, Merfort I, Schempp CM: Botanicals
in dermatology: an evidence-based review.
Am J Clin Dermatol 2010;11:247–267.
20 Ring J, et al: Guidelines for treatment of atop-
ic eczema (atopic dermatitis). Part II. J Eur
Acad Dermatol Venereol 2012;26:1176–1193.
21 Serup J: EEMCO guidance for the assessment
of dry skin (xerosis) and ichthyosis: clinical
scoring systems. Skin Res Technol 1995; 1:
109–114.
22 Diepgen TL, Fartasch M, Hornstein OP: Cri-
teria of atopic skin diathesis. Derm Beruf Um-
welt 1991;39:79–83.
23 Diepgen TL, Sauerbrei W, Fartasch M: Devel-
opment and validation of diagnostic scores
for atopic dermatitis incorporating criteria of
data quality and practical usefulness. J Clin
Epidemiol 1996;49:1031–1038.
24 Hanifin JM, Rajka G: Diagnostic features of
atopic dermatitis. Acta Derm Venereol 1980;
92(suppl):44–47.
25 Turner L, et al: Consolidated Standards of Re-
porting Trials (CONSORT) and the com-
pleteness of reporting of randomised con-
trolled trials (RCTs) published in medical
journals. Cochrane Database Syst Rev 2012;
11:MR000030.
26 Kunz B, et al: Clinical validation and guide-
lines for the SCORAD index: consensus re-
port of the European Task Force on Atopic
Dermatitis. Dermatology 1997;195:10–19.
27 Severity scoring of atopic dermatitis: the
SCORAD index. Consensus Report of the
Use of Emollients in Children with Atopic
Predisposition
European Task Force on Atopic Dermatitis.
Dermatology 1993;186:23–31.
28 Charman C, Chambers C, Williams H: Mea-
suring atopic dermatitis severity in random-
ized controlled clinical trials: what exactly are
we measuring? J Invest Dermatol 2003; 120:
932–941.
29 Schmitt J, et al: What are the best outcome
measurements for atopic eczema? A system-
atic review. J Allergy Clin Immunol 2007;120:
1389–1398.
30 Oranje AP, et al: Practical issues on interpre-
tation of scoring atopic dermatitis: the
SCORAD index, objective SCORAD and the
three-item severity score. Br J Dermatol 2007;
157:645–648.
31 Schram ME, et al: EASI, (objective) SCORAD
and POEM for atopic eczema: responsiveness
and minimal clinically important difference.
Allergy 2012;67:99–106.
32 Schmitt J, et al: Assessment of clinical signs of
atopic dermatitis: a systematic review and rec-
ommendation. J Allergy Clin Immunol 2013;
132:1337–1347.
33 Zeger SL, Liang KY, Albert PS: Models for
longitudinal data: a generalized estimating
equation approach. Biometrics 1988; 44:
1049–1060.
34 Lodén M: Role of topical emollients and
moisturizers in the treatment of dry skin bar-
rier disorders. Am J Clin Dermatol 2003; 4:
771–788.
35 Proksch E: The role of emollients in the man-
agement of diseases with chronic dry skin.
Skin Pharmacol Physiol 2008;21:75–80.
36 Fluhr JW, et al: Infant epidermal skin physiol-
ogy: adaptation after birth. Br J Dermatol
2012;166:483–490.
37 Guenther L, et al: Pathway to dry skin preven-
tion and treatment. J Cutan Med Surg 2012;
16:23–31.
38 Garcia Bartels N, et al: Effect of baby swim-
ming and baby lotion on the skin barrier of in-
fants aged 3–6 months (in English, German). J
Dtsch Dermatol Ges 2011;9:1018–1025.
39 Fischer TW, Wigger-Alberti W, Elsner P: As-
sessment of ‘dry skin’: current bioengineering
methods and test designs. Skin Pharmacol
Appl Skin Physiol 2001;14:183–195.
40 Yosipovitch G, et al: Skin barrier properties in
different body areas in neonates. Pediatrics
2000;106:105–108.
41 Garcia Bartels N, et al: Standardized diaper
care regimen: a prospective, randomized pilot
study on skin barrier function and epidermal
IL-1α in newborns. Pediatr Dermatol 2012;
29:270–276.
42 Leung DY, Bieber T: Atopic dermatitis. Lan-
cet 2003;361:151–160.
43 Abramovits W: Atopic dermatitis. J Am Acad
Dermatol 2005;53(suppl 1):S86–S93.
44 Fluhr JW, Pfisterer S, Gloor M: Direct com-
parison of skin physiology in children and
adults with bioengineering methods. Pediatr
Dermatol 2000;17:436–439.
45 Szczepanowska J, Reich A, Szepietowski JC:
Emollients improve treatment results with
Skin Pharmacol Physiol 2014;27:208–216
DOI: 10.1159/000360546
topical corticosteroids in childhood atopic
dermatitis: a randomized comparative study.
Pediatr Allergy Immunol 2008;19:614–618.
46 Hon KL, et al: The ideal moisturizer: a survey
of parental expectations and practice in child-
hood-onset eczema. J Dermatol Treat 2013;
24:7–12.
47 Fluhr JW, Darlenski R, Surber C: Glycerol and
the skin: holistic approach to its origin and
functions. Br J Dermatol 2008;159:23–34.
48 Harding CR, et al: Dry skin, moisturization
and corneodesmolysis. Int J Cosmet Sci 2000;
22:21–52.
49 Crowther JM, et al: Measuring the effects of
topical moisturizers on changes in stratum cor-
neum thickness, water gradients and hydration
in vivo. Br J Dermatol 2008;159:567–577.
50 Scott IR, Harding CR: Filaggrin breakdown to
water binding compounds during develop-
ment of the rat stratum corneum is controlled
by the water activity of the environment. Dev
Biol 1986;115:84–92.
51 Rawlings AV, Matts PJ: Stratum corneum
moisturization at the molecular level: an up-
date in relation to the dry skin cycle. J Invest
Dermatol 2005;124:1099–1110.
52 Sator PG, Schmidt JB, Hönigsmann H: Com-
parison of epidermal hydration and skin sur-
face lipids in healthy individuals and in pa-
tients with atopic dermatitis. J Am Acad Der-
matol 2003;48:352–358.
53 Patzelt A, et al: In vivo investigations on the
penetration of various oils and their influence
on the skin barrier. Skin Res Technol 2012;18:
364–369.
54 Boralevi F, et al: Long-term emollient therapy
improves xerosis in children with atopic der-
matitis. J Eur Acad Dermatol Venereol 2013,
Epub ahead of print.
55 Evangelista MT, Abad-Casintahan F, Lopez-
Villafuerte L: The effect of topical virgin coco-
nut oil on SCORAD index, transepidermal
water loss, and skin capacitance in mild to
moderate pediatric atopic dermatitis: a ran-
domized, double-blind, clinical trial. Int J
Dermatol 2014;53:100–108.
56 Lodén M: Effect of moisturizers on epidermal
barrier function. Clin Dermatol 2012;30:286–
296.
57 Rippke F, et al: Stratum corneum pH in atop-
ic dermatitis: impact on skin barrier function
and colonization with Staphylococcus aureus.
Am J Clin Dermatol 2004;5:217–223.
58 Rippke F, Schreiner V, Schwanitz HJ: The
acidic milieu of the horny layer: new findings
on the physiology and pathophysiology of
skin pH. Am J Clin Dermatol 2002; 3: 261–
272.
59 Harder J, Schröder JM, Gläser R: The skin sur-
face as antimicrobial barrier: present concepts
and future outlooks. Exp Dermatol 2013; 22:
1–5.
60 Hachem JP, et al: Acute acidification of stra-
tum corneum membrane domains using
polyhydroxyl acids improves lipid processing
and inhibits degradation of corneodesmo-
somes. J Invest Dermatol 2010;130:500–510.
215
61 Rawlings AV, et al: Effect of lactic acid iso-
mers on keratinocyte ceramide synthesis,
stratum corneum lipid levels and stratum cor-
neum barrier function. Arch Dermatol Res
1996;288:383–390.
62 Hatano Y, et al: Maintenance of an acidic stra-
tum corneum prevents emergence of murine
atopic dermatitis. J Invest Dermatol 2009;129:
1824–1835.
63 Chamlin SL, et al: Ceramide-dominant, barri-
er-repair lipids improve childhood atopic
dermatitis. Arch Dermatol 2001; 137: 1110–
1112.
64 Morren MA, et al: Atopic dermatitis: trigger-
ing factors. J Am Acad Dermatol 1994; 31:
467–473.
65 Reuter J, et al: Which plant for which skin dis-
ease? Part 1. Atopic dermatitis, psoriasis,
acne, condyloma and herpes simplex. J Dtsch
Dermatol Ges 2010;8:788–796.
216 Skin Pharmacol Physiol 2014;27:208–216
DOI: 10.1159/000360546
66 Casetti F, et al: Dermocosmetics for dry skin:
a new role for botanical extracts. Skin Phar-
macol Physiol 2011;24:289–293.
67 Romojaro A, et al: Nutritional and antioxi-
dant properties of wild edible plants and their
use as potential ingredients in the modern
diet. Int J Food Sci Nutr 2013;64:944–952.
68 Ibtissem B: Antioxidant and antibacterial
properties of Mesembryanthemum crystalli-
num and Carpobrotus edulis extracts. Adv
Chem Eng Sci 2012;2:359–365.
69 Lee BH, Lee CC, Wu SC: Ice plant (Mesembry-
anthemum crystallinum) improves hypergly-
cemia and memory impairments in STZ-in-
duced diabetic Wistar rats. J Sci Food Agric
2013, Epub ahead of print.
70 Bouftira I, Abdelly C, Sfar S: Characterization
of cosmetic cream with Mesembryanthemum
crystallinum plant extract: influence of for-
mulation composition on physical stability
and anti-oxidant activity. Int J Cosmet Sci
2008;30:443–452.
71 Hanen F, et al: Interspecific variability of an-
tioxidant activities and phenolic composition
in Mesembryanthemum genus. Food Chem
Toxicol 2009;47:2308–2313.
72 Deters AM, Meyer U, Stintzing FC: Time-de-
pendent bioactivity of preparations from cac-
tus pear (Opuntia ficus indica) and ice plant
(Mesembryanthemum crystallinum) on hu-
man skin fibroblasts and keratinocytes. J Eth-
nopharmacol 2012;142:438–444.
73 Wende K, et al: Dank Trockenstress zum
Hautpflegemittel. Pharmazeutische Zeitung
2006;151:322–324.
Schario/Lünnemann/Stroux/Reisshauer/
Zuberbier/Blume-Peytavi/Garcia Bartels
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.