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Skin care problems account for billions in health care spending each year - most of it out-of-pocket expenditures by consumers. The costs associated with skin conditions are similar to those associated with other chronic conditions such as urinary incontinence, which costs the U.S. health care system approximately $16 billion annually.1
Despite a clear need for medical care, many skin care products to prevent skin irritation are not covered by insurers, including Medicare.2 In addition to financial cost, the price of human suffering due to skin care problems is tremendous: Lost workdays, general discomfort and altered appearance contribute to reduced quality of life, particularly for patients with skin and nail conditions that affect the feet.
Despite the availability of numerous prescription and over-the-counter products to treat common skin conditions of the feet, patients frequently turn first to their medicine and kitchen cabinets. Consumer publications and broadcasts, as well as the World Wide Web, are replete with information on "unique" uses of both household and OTC products for health care purposes - but the information can be misleading and potentially harmful. Dry, itchy feet and thick, discolored toenails are common skin conditions for which consumers frequently use household and OTC products.
As much as 80 percent of the adult population older than 50 will experience a foot problem at least once, and skin conditions will account for a significant portion of these foot difficulties.3 As the severity of problems increases, many patients seek treatment from health care providers. These professionals may recommend household remedies or couple the use of these remedies with more conventional approaches.
This article elucidates some of the therapies commonly used for dry skin, athlete's foot (tinea pedis) and toenail fungal infection (such as onychomycosis), focusing on four household products. The products are referred to as the four "Vs": vegetable shortening, Vaseline (petrolatum), vinegar and Vick's VapoRub.
Dry Skin
Environmental conditions, normal aging and various disease states can cause dry skin when protective oils in the stratum corneum are lost and water escapes. As the stratum corneum becomes dry and shrinks, small cracks or fissures develop.4 The skin becomes dull, scaly and often itchy. Dry skin is particularly common on distal lower extremities, where compromised circulation contributes to its severity.
Patients often seek relief by applying emollients, lotions, creams and oils. Emollients moisten, soften and lubricate the skin. The terms "emollient" and "moisturizer" are used interchangeably, and a variety of emollients are on the market. The oil in an emollient traps the water in the skin and the skin becomes softer and smoother, which results in decreased cracking and itching. Commonly used brand-name emollients are Neutrogena, Nivea and Burt's Bees creams.
Lotions are suspensions of oily chemicals in alcohol and water. Their moisturizing effect is not long-lasting, and the lubricating function is minimal. Lotions contain two major ingredients: humectants, which draw moisture to the skin's surface (glycerin), and a barrier-type ingredient that traps moisture on the skin (mineral oil). Over time, lotions can be drying due to the cumulative effects of the alcohol content.5 Commonly used brand-name lotions are Lubriderm, Moisturel and Curel.
Creams are semisolid emulsions of oil in water or water in oil that moisturize and lubricate more effectively than lotions. Examples of brand name creams are Vaseline Cream, Eucerin Cream and Moisturel Cream.
Ointments are oil-based emulsions that contain little water. They are the most effective choice for moisturizing, and tend to leave the skin greasy. Ointments are frequently used for chronic dry skin conditions. Aquaphor is a popular ointment.
Vegetable shortening and Vaseline (petrolatum) are also considered moisturizers, and they are relatively inexpensive.
Vegetable Shortening
Used chiefly for baking and cooking, vegetable shortening (e.g., Crisco) is made of hydrogenated soybean and cottonseed oil, along with mono- and diglycerides. Cosmetic experts often recommend vegetable shortening as a treatment for dry skin, and it has been used to make "moisturizing" soap for many years.6 Dialysis patients often apply it to chronically itchy skin. The potential for bacterial growth in shortening containers, as well as a potential for allergic dermatitis, are concerns associated with the use of vegetable shortening as a dry skin treatment.7
Little scientific evidence supports the benefits of using vegetable shortening for dry skin. However, data suggest that the use of natural vegetable fats from palm, palm kernel, rapeseed, sunflower, coconut and soy may protect the skin from irritants.8 In addition, patient education materials and patient anecdotes are rife with claims about the purported benefits of these products. Fats with higher melting points and viscosity, such as palm and rapeseed oil, may form a stable physical barrier by "shielding" the epidermis against irritants.8 Fats with lower melting points, such as coconut and sunflower seed oil, tend to offer less protection as they become liquid on warm skin.8 Vegetable products that offer protective qualities against contact irritants may also induce irritant or allergic dermatitis.9 Caution is therefore necessary when using these products on impaired skin.
Vaseline (Petrolatum)
Robert Augustus Chesebrough created Vaseline, an odorless, colorless jelly, in the mid-1800s. The word Vaseline is a combination of the German word for water and the Greek word for olive oil.10 At least four types of petrolatum are available, and the composition and purity depend on the petroleum stock and on production and packing methods. White and yellow petrolatum (Vaseline) are the most common types and are made from a mixture of semisolid hydrocarbons of the methane series.11 In the health care industry, petrolatum is used to treat dry skin and serves as an occlusive barrier to promote moist wound healing.
Petrolatum-based products have been identified as clinically effective and cost-effective. In a randomized, double-blind, controlled trial comparing white petrolatum with bacitracin ointment applied to post-procedure dermatologic wounds, the incidence of infection and allergic contact dermatitis was not significantly different.12 Compared with bacitracin ointment, white petrolatum was a safe, effective wound care ointment, did not decrease wound healing time, and did not contribute to increased incidence of infection or dermatitis. The investigators suggest that while further studies are needed, a switch from antibacterial ointments to white petrolatum by U.S. dermatologists would result in a health care cost savings of $8 million to $10 million annually.12
Conversely, infections have been attributed to petrolatum when it is used as an occlusive barrier to prevent transepidermal water loss (TEWL). A case-control study of 10 extremely low birthweight infants documented an increase in the incidence of systemic candidiasis after the use of topical petrolatum ointment (TPO) for skin care.13 The investigators speculate that TPO provided a milieu in which the colonizing yeast could proliferate.
The benefit of occlusion in chronic skin disorders has been well documented. However, research results about the benefits of occlusion in acute skin irritation, especially with petrolatum, are mixed. Previously, occlusion was thought to delay the repair of the epidermis by affecting TEWL.14 However, researchers found no significant difference among three types of occlusive treatments on TEWL in acutely irritated skin: pure white petrolatum, a semipermeable, non-adhesive occlusive dressing, and a nonpermeable, non-adhesive occlusive dressing.15 Occlusive treatment had no marked influence on healing after acute short-time irritation, and neither petrolatum nor occlusive dressings additionally irritated the skin or accelerated the repair process.
One final remark about petrolatum: Although rare, contact eczema, urticaria and contact sensitization to petrolatum have been documented.11,16 The mechanism by which this occurs is unexplained. However, reaction to petrolatum could mimic the clinical presentation of chronic dermatitis, hyperpigmentation of unknown origin, or sensitization to other allergens.
Use of Shortening and Vaseline
The goal of treatment for dry skin is to hydrate and lock in moisture.17 An occlusive moisturizer prevents water loss by providing an oily surface over the skin and attracts water from the inner skin layer. It is important to apply emollients to damp skin so that they trap moisture. If applied to dry skin, emollients will block moisture loss and act as a barrier. Therefore, emollients such as vegetable shortening and Vaseline have a dual purpose, depending on the indications for use: to treat dry skin and prevent allergen and irritant access.18 For maximum benefit, emollients should be applied at least three times a day and even more often if skin is very dry.
Informal discussions with numerous health care professionals in an academic medical center indicate that recommendations to use vegetable shortening and petrolatum vary widely. A consensus among these health care providers is that vegetable shortening and petrolatum should be applied to damp skin to trap moisture.
Consistent, daily use is indicated for best results. As with any skin care product, frequent application (three to four times per day or more) is advised. Applying a thin layer of vegetable shortening or petrolatum after a bath helps seal in moisture and reduce flaking, cracking and itching. Patients who do not like the greasy feeling created by application can apply the product at night and wear thin socks to bed. Anecdotally, frequent applications of a thin layer of vegetable shortening or petrolatum to damp skin has improved moisture retention and decreased cracking and flaking of the skin of patients with end-stage renal disease.19
Patients should wash their hands before applying shortening or petrolatum, since contaminated hands "dipped" into the containers could leave a residue of bacteria. Open-lid containers should be handled carefully to prevent contamination. Vegetable shortening used as a skin product should be stored away from other food substances and not used for cooking or baking. Advise patients to place the container in the bathroom, label it as "skin cream," and to refrain from sharing the product with others.
Some patients report that they scoop out the vegetable shortening with spoons or wooden sticks and smooth it on the skin. One patient's "recipe" for treating dry skin on the feet is to wash with a mild moisturizing soap (such as Camay, white Dove, pink Dove, Cetaphil bar or Aderma), rinse, gently pat dry, apply vegetable shortening, wrap feet with plastic wrap (leaving toes exposed), put on socks and leave in place for 30 minutes.19,20 The patient performs this procedure three times each week to prevent heel cracks and dry skin.
Fungal Infections
Onychomycosis is a common fungal infection of the nails, most often the toenails. Risk factors include increasing age, male gender, diabetes, nail trauma, hyperhidrosis, peripheral vascular disease, poor hygiene, tinea pedis, immunodeficiencies and chronic exposure of nails to water.21 Recent research documented a relationship among smoking, peripheral arterial disease and onychomycosis.22 Studies have reported the prevalence of onychomycosis to be 8 percent to 9 percent in the general population.23,24 Data obtained from a multi-center survey suggest that 26 percent of diabetics have evidence of toenail onychomycosis.25 The prevalence among 40- to 60-year-olds is 15 percent to 20 percent, with men being more likely to have onychomycosis than women.26
Dystrophic changes of the nail include thickness, discoloration and loosening of the nail plate from the nail bed. Nail discomfort also is a feature of onychomycosis. However, only 50 percent of dystrophic nail changes can be attributed to fungal infection. Therefore, a nail culture is necessary to rule out other nail disorders.26
Onychomycosis is often chronic and recalcitrant to treatment. Treatment can include palliative or conservative care such as proper footwear, mechanical de-bridement such as nail trimming, and the use of topical agents such as ciclopirox (Penlac). Other topical antifungal agents often prescribed for toenail fungus are butenafine (Mentax) and terbinafine (Lamisil). These two products do not have an FDA indication for the treatment of toenail fungus.
Examples of systemic agents to treat onychomycosis include terbinafine (Lamisil), itraconazole (Sporanox), and griseofulvin (Fulvicin, Grisactin, Grifulvin V). A combination of palliative care, topical and systemic agents may also be used.
Systemic and prescription topical preparations are expensive, and some are not covered by insurance. The use of certain systemic agents may require monitoring of liver function tests, and patients with liver disease often cannot take these medications. For Sporanox, monitoring is required only with pre-existing liver disease or when liver toxicity has developed with other drugs. Consider ordering liver function studies in all patients prior to prescribing Sporanox. For Lamisil, check serum transaminases before initiating therapy. Patients with liver disease often cannot take these medications. Because many patients with onychomycosis are not considered good candidates for systemic treatment due to finances, age or underlying health conditions, more conservative measures may be considered.
Vinegar and Vicks VapoRub ointment are two agents that are frequently mentioned as home remedies for fungal conditions of the nails and skin. However, the efficacy of these products, particularly Vicks VapoRub, is unclear. Some research has examined the use of vinegar to prevent or treat various skin conditions and produced positive results.
Vinegar
Vinegar, or acetic acid, is produced by the fermentation of natural sugars to alcohol and then secondary fermentation to acetic acid. Apple cider vinegar is a weak acid and usually contains 4 percent to 8 percent acetic acid. For centuries, vinegar has been touted as a cleanser and sanitizer. Hippocrates expounded on its medicinal properties, and the Bible contains references to its soothing and healing qualities.27 Research shows that 2 percent to 3 percent acetic acid in vitro inhibits the growth of Pseudomonas aeruginosa, Staphylococcus aureus, Proteus mirabilis and Streptococcus pyogenes, the most common bacterial pathogens in otitis media and otitis externa.28 For years, pediatricians recommended this solution as a treatment for minor ear infections.
Direct visualization of the cervix after the application of a 5 percent acetic acid solution is an effective primary screening test for cervical cancer in low-resource populations.29 Acetic acid (0.25 percent) has also proven effective in reducing S. aureus and gram-negative rods in patients with exudative, sloughing venous leg ulcers larger than 1 cm.30
These data suggest that vinegar in varying dilutions is effective in reducing or eliminating growth of certain bacteria, although it is unclear how long the effect persists and whether long-term use produces irritating, toxic or allergic reactions. Data that address the efficacy of vinegar against fungi are lacking.
Nonetheless, a diluted white vinegar solution is mentioned descriptively in medical and nursing literature as a treatment for toenail fungus, athlete's foot, and for use as an exfoliant for dry, flaky skin.31 The most often recommended mixture is one part vinegar to two parts warm water. Instruct patients to soak their feet for 15 to 20 minutes daily, rinse well and pat dry. Long-term use is contraindicated due to the potential for skin irritation.
Vicks VapoRub
Vicks VapoRub is available as both an ointment and a cream, and has active ingredients including 4.8 percent camphor, 2.6 percent menthol and 1.2 percent eucalyptus oil.32 The inactive ingredients include cedar leaf oil, nutmeg oil, special petrolatum, thymol and turpentine oil.32 Both camphor and eucalyptus oil are rubefacients or skin irritants. When applied to the skin, menthol dilates the blood vessels, causing a sensation of coldness followed by an analgesic effect.33
Vicks VapoRub is indicated for the temporary relief of cough and nasal congestion due to the common cold. It also is indicated for the temporary relief of minor aches and pains in people older than 2 years.32 The mechanism of action for Vicks VapoRub in the treatment of toenail fungus is unclear.
Information gathered anecdotally from nursing and medical colleagues suggests that recommendations for how to use Vicks VapoRub vary widely. Some patients report applying the product directly to the nail with a cotton tip applicator once or twice each day, avoiding contact with skin. Other patients report that they spray their feet with a vinegar solution after showering, then apply Vicks VapoRub to the nails.
Bedtime application of Vicks VapoRub to the toenails can be followed by wearing thin socks to "seal" in the product and keep sheets from rubbing against the nails. Some patients wipe the affected toenail with white vinegar using a cotton ball, then rub Vicks VapoRub onto the nail.
Little scientific data is available in the medical literature to support the use of Vicks VapoRub for toenail problems. As with any household remedy, care should be exercised when using products for purposes other than that intended. Patients considering the use of any home remedies or products should seek advice from health care providers. The length of treatment necessary to reduce or eradicate fungal infection is unknown and seems to be individually determined.
Research Needed
Home remedies continue to be used for foot care, both individually and in conjunction with traditional health care interventions. Anecdotal sharing of information about these remedies is a common practice among health care providers. There is evidence to suggest that some of the four Vs are effective for certain conditions, such as the use of vinegar to treat bacterial contamination of the skin. However, little evidence supports the use of vinegar for fungal infections of the nail or skin. Furthermore, no studies have been published about the use of Vicks VapoRub for the treatment of fungal infections of the skin or nails.
If any of your patients use the four Vs for foot care, be sure to caution them against using the products on mucous membranes or on ulcers, wounds or other breaks in the skin.
In our opinion and based on clinical experience, the four Vs are readily available and economical alternatives for treating dry skin or fungal infections of the toenails and feet for patients who have limited finances and whose health condition may contraindicate the use of more potent and expensive prescription drugs. These patients may find familiar household products more appealing and convenient to use.
As with all treatments, weigh the risks and benefits of each product for each patient and discuss all issues. Caution patients to watch for adverse effects and stop using the product immediately if any occur. Research is needed about the use of vegetable shortening and Vicks VapoRub, which may have promise for recalcitrant skin and nail problems that affect the feet.
References
1. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. Overview: Urinary Incontinence in Adults, Clinical Practice Guidelines Update. Available online at: http://www.ahcpr.gov/clinic/uiovervw.htm.
2. Vinson J, Proch J. Inhibition of moisture penetration to the skin by a novel incontinence barrier product. Journal of Wound, Ostomy and Continence Nursing. 1998;25(5):256-260.
3. Bryant JL, Beinlich NR. Foot care: focus on the elderly. Orthopaedic Nursing.1999;18(6):53-60.
4. Duffill M. New Zealand Dermatological Society. Emollients and moisturizers - Information for Patients. Available online at: http://www.dermnetnz.org/dna.emoll/emoll.html.
5. Sontheimer Rd. Skin disease in dermatomyositis - what patients and their families often want to know. Dermatology Online Journal. Available online at: http://www.dermatology.cdlib.org/DOJvol8num1/information/dermatomyositis/sontheimer.html.
6. Dry skin and winter itch. Ten cold-weather options. The Doctor's Book of Home Remedies. Available online at: http://www.mothernature.com/Library/Bookshelf/Books/47/49.cfm.
7. Joe Lenczowski, MD, personal communication, Feb. 18, 2003.
8. Schliemann-Willers S, Wigger-AlbertiW, Kleesz P, et al. Natural vegetable fats in the prevention of irritant contact dermatitis. Contact Dermatitis. 2002;46:6-12.
9. Guin J. Occupational contact dermatitis to plants. In: Kanerva P, Wahlbert E, Maibach HI, eds. Handbook of Occupational Dermatology. New York: Springer; 2002:730-66.
10. Jelly cure. Readers Digest. February 2003:124-125.
11. Conti A, Manzini BM, Schiavi ME, et al. Sensitization to white petrolatum used as a vehicle for patch testing. Contact Dermatitis. 1995;33:201-202.
12. Smack DP, Harrington AC, Dunn C, et al. Infection and allergy incidence in ambulatory surgery patients using white petrolatum versus bacitracin ointment. JAMA. 1996;276(12):972-977.
13. Campbell R, Zaccaria E, Baker C. Systemic candidiasis in extremely low birth weight infants receiving topical petrolatum ointment for skin care: a case-control study. Pediatrics. 2000;105(5):1041-1045.
14. Proksch E, Feingold KR, Mao-Quiang M, et al. Barrier function regulates epidermal DNA synthesis. J Clinical Investigation. 1991;87:1668-1673.
15. Welzel J, Wilhelm KP, Wolff HH. Skin permeability barrier and occlusion: no delay in repair in irritated human skin. Contact Dermatitis. 1996;35:163-168.
16. Grin R, Maibach HI. Long-lasting contact urticaria from petrolatum mimicking dermatitis. Contact Dermatitis. 1999;40:110.
17. Evans Army Community Hospital Site. Pediatric Clinic Patient Education Handouts: Treating Dry Skin. Available online at: http://www.evans.amedd.army.mil/Peds/PDF/dryskin.pdf.
18. The use of emollients in dry skin conditions. MeReC Bulletin, National Prescribing Centre. Available online at: http://www.npc.co.uk/MeReC_Bulletins/1998Volumes/pdf/vol9n12.pdf.
19. Kristin Larson, NP, personal communication, March 17, 2003.
20. Baranda LR, Gonzalez-Amaro R, Torres-Alvarez B, et al. Correlation between pH and irritant effects of cleansers marketed for dry skin. Int J of Derm. 2002;41(8):494-499.
21. Doctor Fungus. Onychomycosis. Available online at: http://www.doctorfungus.org/mycoses/human/other/ony%20chomycosis_general.htm.
22. Gupta AK, Gupta MA, Summerbell RC, et al. The epidemiology of onychomycosis: possible role of smoking and peripheral arterial disease. J Eur Acad Dermatol Venereol. 2000;14:466-469.
23. Gupta AK, et al. Prevalence and epidemiology of unsuspected onychomycosis in patients visiting dermatologists' offices in Ontario Canada. A multicenter survey of 2001 patients. Int J Dermatol. 1997;36:783-787.
24. Elewski BE, Charif MA. Prevalence of onychomycosis in patients attending a dermatology clinic in northeastern Ohio for other conditions. Arch Dermatol. 1997;133(9):1172-1173.
25. Gupta AK, et al. Prevalence and epidemiology of toenail onychomycosis in diabetic subjects: a multicentre survey. Br J Derm. 1998;139:665-71.
26. Gupta AK. Onychomycosis in the elderly. Drugs and Aging. 2000;16:397-407.
27. Vinegar as a cleaner and sanitizer. Available online at: http://www.versatilevinegar.org/bodwhatisvin.html.
28. Thorp MA, Kruger J, Oliver S, et al. The antibacterial activity of acetic acid and Burrow's solution as topical otological preparations. J Laryngology Otology. 1998;112:925-928.
29. Denny L, Kuhn L, Pollack A. Direct visual inspection for cervical cancer screening: an analysis of factors influencing test performance. Cancer. 2002;94(6):1699-1707.
30. Hansson C, Faergemann J. The effect of antiseptic solutions on microorganisms in venous leg ulcers. Acta Dermato Venereologic. 1995;75:31-33.
31. Gupta AK, Ryder J. Latest advances in onychomycosis treatment. Clinician Reviews. 2000;May(suppl):4-10.
32. Vicks VapoRub Web page. Available online at: http://www.vicks.com/products/vapor_rubointment.shtml.
33. Sweetman S, E. Martindale: The Complete Drug Reference. Greenwood Village, Colo.: Micromedix; 2004.
Teresa Kelechi is gerontologic clinical nurse specialist with a PhD and certification as a wound care nursing specialist. She is an assistant professor in the college of nursing at the Medical University of South Carolina in Charleston and practices clinically at the university's diagnostic center, where she specializes in geriatrics and foot and lower extremity wound care. Sally Stroud is an adult nurse practitioner with an EdD who specializes in foot care at the University Diagnostic Center at the Medical University of South Carolina.
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