Basics of dry & irritable skin, solutions for the same.

1. PRURITUS - CREAM
For Internal Use Only

2. What is skin?
 Skin is the largest organ in the body in surface area and weight)
 It consists of two layers:
 Epidermis: Superficial Layer made up of dead skin cells
 Dermis: made up of actual “Living” cells with melanin and nerve endings
 Beneath the dermis lies the subcutaneous fatty tissue

3. What are the layers of the Skin?

4. What are the functions of skin?
 Protection
 Oragnelles below
 Regulation of temperature
 Sweat etc.
 Sensation
 Pain, heat etc.

5. Why skin is to be protected?
Skin has to itself be protected and Hydration is very important
• Hydrated Skin looks smooth, radiant & even tone
• Dehydrated Skin looks flaky, dull & dry
• Symptoms of Dehydrated skin:
• Itchiness
• Redness
• Flaky skin
• Skin irritation

6. Which systemic diseases lead to skin manifestations?

7. Why does Chronic kidney diseases causes itch?
• Toxin build up
• Peripheral neuropathy
• Immune system dysregulation
• Opioid Dysregulation

8. What is the pathophysiology for itch?
Skin
Somatosensory Nerve Endings
Stimuli
Itch Pain
Histamine-dependent, slow-conducting,
unmyelinated C fiber
Non-histaminergic neurons
Neural pathways
Stimuli/Disease
Itch Pain

9. What is“ISI” cycle?
(Itch- Scratch-Itch)

10. Immune Dysregulation
Dehydration- Structural Changes
Additional Systemic Inflammation
Itch/Pain

11. How Severe can the Condition be ?

12. What are the postulated causes of itch?
 Less active sweat glands lead to itchy
and dry skin
 Altered skin barrier
• Deposits of calcium/phosphate crystals
in the skin may irritate the nerve endings
which can cause itching

13. What is the lifetime prevalence?
Acta Derm Venereol 2015; 95: 816–821

14. What is the incidence in India?
 Skin ailments:
 Xerosis (dry skin) >66%
 Pallor (45%)
 Pruritus (43%)
 Cutaneous pigmentation (33%)
The study concluded that xerosis and pruritus are
the most skin common conditions experienced by
CKD patients
Indian J Nephrol [serial online] 2012 [cited 2020 Oct 15];22:116-20

15. What is the management of Pruritus?
A, double-blind study; B, clinical trial containing 20 or more subjects; C, clinical trial containing fewer than 20 subjects; and D, case series containing 5 or more subjects
Am J Kidney Dis 50:11-20.

16. Anti-histamines
 Widely used medication to treat itching
 Classified into 2 categories:
 Histamine receptor antagonists e.g. Cetirizine
 Medications that prevent the release of histamine
 Side Effects: Confusion and Sedation
Most Studies found Steroids and Anti-histamine are not effective*
* Combs Seminars in Nephrology 2015; 35:4, 383-391

17. Nerve Fiber “relaxant”
Medications that blunt peripheral C-fiber nerve transmission and modulate pain and
itching have been used to treat Uremic Pruritus
E.g. Gabapentin, Pregabalin
Side Effects:
 Confusion
 Dry Mouth
 Visual change
 Angioedema
 Weight gain
 Increased suicide risk

18. Opioid Antagonist
 An imbalance between over-stimulation of central -opioid receptors or antagonism
of -opioid receptors systems lead to itching
 Central -opioid receptors antagonists e.g. naloxone, naltrexone are used to treat
CKD-aP
Adverse drug reactions:
 Insomnia
 Constipation

19. What is the step- wise escalation treatment?
Am J Kidney Dis 50:11-20.

21. What are emollients?
• Emollients are substances that soften and moisturize the skin and
decrease itching and flaking
• Emollients show least risk of side effects
• Emollient: Humectant + Occlusive
• Humectant: Increase the water holding capacity of the stratum corneum e.g.
Glycerine
• Occlusive: Oils of non-human origin, often mixed with water and an emulsifier.
Layer of oil on the surface of the skin to reduce water loss from the stratum
corneum e.g. Paraffin

22. How Paraffin and Glycerin benefit?
Paraffin:
• Provides a thin, oily, protective layer on the skin
• Additionally, locking moisture into the skin where it's needed
Glycerin:
• Natural humectant or a skin-conditioner
• It attracts moisture and keeps the skin hydrated keeping skin hydrated, soft
and supple

23. Reference Title Key Result
Clin J Am Soc Nephrol 6: 748–752,
2011
Randomized, Double-blind Study
with Glycerol & Paraffin in Uremic
Xerosis
n=99
Emollient therapy was highly effective in
patients (73%). Objective reduction in the
density and thickness of the scales on day
7 and a substantial improvement of the
uremic pruritus (75%) and quality of life of
the patients at study end
G Ital Dermatol Venereol.
2011;146(5):321–325
Efficacy of topical hydrating and
emollient lotion containing 10%
urea ISDIN® plus dexpanthenol
in the treatment of skin xerosis
and pruritus in hemodialyzed
patients: An open prospective
pilot trial
N=15
Itching Score(IS) at baseline was 1.0. URx
reduced IS significantly to 0.2 at week 2
and to 0.06 at week 4
Topical application of emollient shown to
improve pruritus in HD patients

25. Summary
• Skin has to itself be protected and its hydration is very important.
• Deposits of calcium/phosphate crystals in the skin may irritate the nerve endings
which can cause itching
• Xerosis and pruritus are the most common skin conditions experienced by CKD
patients
• Emollients are substances that soften and moisturize the skin and
decrease itching and flaking
• Emollient therapy has been very effective in managing the Uremic Pruritus

26. THANK YOU