Role of Ceramide-Containing Skin Care for the Improvement of Diabetes Mellitus–Related Xerosis

This article was sponsored by CeraVe^®.

Introduction

Diabetes mellitus (DM) is a prevalent disorder that affects more than 37 million adults in the United States.¹ Patients with DM can experience altered blood flow and volume; macro- and microvascular complications of DM include cardiovascular disease, peripheral artery disease, stroke, diabetic retinopathy, nephropathy, and neuropathy.^2-4 Vascular complications can promote a spectrum of skin conditions observed in patients with DM, including xerosis, acquired ichthyosis, pruritis, and cutaneous infection.^4-7 Appropriate skin care that reduces dry skin and pruritis and improves skin health and function may increase patient comfort and quality of life (QOL).⁴

Xerosis and Associated Skin Conditions in DM

Up to 70% of patients with DM experience skin disorders closely tied to glycemic control.^7,8 Skin manifestations may be an initial sign of DM in patients who are not diagnosed.^8,9 A prospective study assessed the relationship between skin diseases and noncutaneous complications in 750 patients with DM.¹⁰ A total of 38% of patients had diabetic neuropathy, whereas retinopathy or nephropathy was present in 23%. Among almost 80% of patients who had skin disorders, approximately 48% had cutaneous infections, 26% had xerosis, and 21% had inflammatory skin diseases.

Unfortunately, xerosis and other skin conditions are often ignored or undiagnosed in DM care.^7,8 Proper management of dry skin due to DM can improve patients’ skin condition, satisfaction, and scores on QOL measures.¹¹ Importantly, in early-stage skin disorders of xerosis and callus formation, identification of the dermal manifestation and effective therapy can reduce complications associated with DM.⁷

Appropriate Skin Care

Successful management of diabetic-related skin conditions may include the use of skin care regimens with gentle cleansers and moisturizers that contain ceramides 1, 3, and 6-II, the 3 essential physiologic lipids needed to build and preserve the epidermal barrier.^11,12 Ceramides make up 50% of the stratum corneum; they are needed to support the skin barrier and retain moisture.^13,14 Low ceramide levels can lead to dry skin.¹³

Skin care regimens for dry skin include cleansers to remove bacteria and pollutants and moisturizers with humectants (eg, hyaluronic acid), which hydrate the stratum corneum and improve skin elasticity, and physicologic lipids (eg, ceramides) to help restore the skin barrier.⁸ Examples of products that contain 3 skin identical ceramides are CeraVe Hydrating Facial Cleanser, CeraVe Moisturizing Cream, and CeraVe Diabetics Dry Skin Relief Moisturizing Cream.^15-17 Pharmacists can become familiar with DM-associated xerosis and these OTC products to educate patients with DM and help them to make an informed choice about skin care products.

Xerosis Pathogenesis and Complications

Numerous factors contribute to the development of xerosis in patients with DM. Dry skin results from abnormalities of the corneocytes. These cells stick together persistently, which leads to a thickening of the stratum corneum.⁷ In addition, the corneocytes take a longer amount of time to turn over within the stratum corneum. Xerosis in patients with DM also is attributed to reductions in both hydration in the most superficial layers of the stratum corneum and activity in the sebaceous glands.⁸ Changes in the functional properties of the stra­tum corneum resulting in a weakened skin barrier function, which leads to increased water loss and susceptibility to pathogens.^8,18 Further, a prolonged state of hyperglycemia is associated with decreased epidermal lipid synthesis, contributing to skin barrier dysfunction.¹⁸

The effects of xerosis can range from mild to severe, and they may be noticed by the patient and others.^8,19 The skin may feel tight, look shrunken or dehydrated, and appear rough.^8,19 Patients with dry skin may also experience itching, pain, erythema, and inflammation.^8,11 Xerosis, associated with scaling and peeling skin, can result in fine lines, cracks, and fissures.^8,19 Deep fissures, which are commonly noted on heels, may bleed and create a path of entry for pathogens and promote infection.^8,19

Efficacy and Safety Results With CeraVe Hydrating Facial Cleanser and CeraVe Moisturizing Cream for DM-related Xerosis

An international, multicenter, open-label cohort study assessed the benefits of a twice-daily regimen using the ceramide-containing products CeraVe Hydrating Facial Cleanser and CeraVe Moisturizing Cream on clinical symptoms and QOL measures in patients with DM-related xerosis.¹¹ The study was conducted at 62 sites that involved patients in 19 countries and 6 continents. A total of 531 men and women aged 18 to 75 years who had dry skin due to DM participated; the final sample included 528 patients.¹¹ The majority of patients were women (327 patients [61.9%]).¹¹ Further, 436 patients (82.6%) were diagnosed with type 2 DM; the other 92 patients (17.4%) were diagnosed with type 1 DM.¹¹

At baseline, physicians and patients scored skin condition and attributes using the Dry Skin Classification Scale (DSCS).¹¹ This measure was also assessed at the end of the study (EOS) on day 28 (range, day 23-day 33).¹¹ Physicians scored the Global Aesthetic Improvement Scale (GAIS) at the EOS (the primary efficacy measure), and patients reported on QOL at baseline and the EOS.¹¹ At the EOS, scores were also given to patient satisfaction with treatment outcomes, skin care use, and product features.¹¹ Adverse events (AEs) were reported at each visit.¹¹

Results

More than 83% of the patients were adherent to the twice-daily skin care regimen.¹¹ Based on GAIS scores at the EOS, more than 98% of patients experienced improvement in their skin condition.¹¹ The skin care regimen with ceramide-containing CeraVe Hydrating Facial Cleanser and CeraVe Moisturizing Cream was associated with significant improvements from baseline to the EOS in all components of the DSCS scores by physicians (roughness/scaling, erythema, and fissures) and patients (roughness/scaling, pruritus, pain, erythema, and fissures [P < .001]).¹¹

Patients reported that all 3 measures of QOL (xerosis‑associated embarrassment, impacts on social life, and work/studying) significantly improved from baseline to the EOS (P < .001).¹¹ On day 28, 99.6% of patients were satisfied with skin care outcomes, 99.4% with product features, and 99.6% with moisturizing ability.¹¹ No product-related AEs were reported.¹¹

The results of this study demonstrated that a skin care regimen with CeraVe Hydrating Facial Cleanser and CeraVe Moisturizing Cream supported patient satisfaction and improved the severity of DM-associated xerosis and QOL. Most patients (91.5%) stated they would continue to use this regimen to improve their diabetes-related dry skin.¹¹

Patient Education and Product Recommendations for Diabetes-Related Xerosis

Patients with DM can experience challenges with adhering to a skin care regimen. Pharmacists can educate patients on the importance of cleansing and moisturizing their skin as part of a comprehensive DM care plan and recommended easy-to-use products with high satisfaction.⁸

Pharmacists can become familiar with information on 3 CeraVe skin care products that contain the skin identical ceramides 1, 3, and 6-II and that are endorsed by the American Diabetes Association as Better Choices for Life (Table).^12,15-17,20 CeraVe products are developed with dermatologists and formulated using MultiVesicular Emulsion (MVE) technology, which provides continual release of ingredients for long lasting hydration.^12,15-17,20

Resources

Details about products designed to improve diabetes‑related skin conditions with ceramide-containing skin care can be viewed at https://www.cerave.com/skincare/diabetic-skin-ada-seal. Additional skin health resources may be found at the Pharmacy Corner at https://www.lorealdermatologicalbeauty.us/pharmacy. Visit these web resources and register to enjoy all the free benefits of being a member, such as being sent product kit announcements and updates on educational resources and events.

References

1. Prevalence of both diagnosed and undiagnosed diabetes. Centers for Disease Control and Prevention. Reviewed September 30, 2022. Accessed March 30, 2023. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html
2. An Y, Kang Y, Lee J, Ahn C, Kwon K, Choi C. Blood flow characteristics of diabetic patients with complications detected by optical measurement. Biomed Eng Online. 2018;17(1):25. doi:10.1186/s12938-018-0457-9
3. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008;26(2):77-82. doi:10.2337/diaclin.26.2.77
4. Piérard GE, Seité S, Hermanns-Lê T, Delvenne P, Scheen A, Piérard-Franchimont C. The skin landscape in diabetes mellitus. Focus on dermocosmetic management. Clin Cosmet Investig Dermatol. 2013;6:127-135. doi:10.2147/CCID.S43141
5. Piérard GE, Piérard-Franchimont C, Scheen A. Critical assessment of diabetic xerosis. Expert Opin Med Diagn. 2013;7(2):201-207. doi:10.1517/17530059.2013.728585
6. Craiglow B. Ichthyosis. BMJ Best Practice. Updated January 11, 2022. Reviewed April 12, 2023. Accessed March 30, 2023. https://bestpractice.bmj.com/topics/en-us/584
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8. Kirsner RS, Yosipovitch G, Hu S, et al. Diabetic skin changes can benefit from moisturizer and cleanser use: a review. J Drugs Dermatol. 2019;18(12):1211-1217.
9. Duff M, Demidova O, Blackburn S, Shubrook J. Cutaneous manifestations of diabetes mellitus. Clin Diabetes. 2015;33(1):40-48. doi:10.2337/diaclin.33.1.40
10. Demirseren DD, Emre S, Akoglu G, et al. Relationship between skin diseases and extracutaneous complications of diabetes mellitus: clinical analysis of 750 patients. Am J Clin Dermatol. 2014;15(1):65-70.doi:10.1007/s40257-013-0048-2
11. Kirsner R, Andriessen A. An international evaluation of a ceramide-
    containing hydrating cleanser and moisturizing cream for the improvement of diabetes mellitus-related xerosis. J Drugs Dermatol. 2023;22(1):65-73. doi:10.36849/JDD.7168
12. Developed with dermatologists. CeraVe. Accessed March 30, 2023.
    https://www.cerave.com/about-cerave/developed-with-dermatologists
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15. Hydrating facial cleanser. CeraVe. Accessed March 30, 2023.
    https://www.cerave.com/skincare/cleansers/hydrating-facial-cleanser
16. Moisturizing cream. CeraVe. Accessed March 30, 2023.
    https://www.cerave.com/skincare/moisturizers/moisturizing-cream
17. Diabetics’ dry skin relief moisturizing cream. CeraVe. Accessed March 30, 2023. https://www.cerave.com/skincare/diabetic-skin/
    diabetics-dry-skin-relief-moisturizing-cream
18. Park HY, Kim JH, Jung M, et al. A long-standing hyperglycaemic condition impairs skin barrier by accelerating skin ageing process. Exp Dermatol. 2011;20(12):969-974. doi:10.1111/j.1600-0625.2011.01364.x
19. Guenther L, Lynde CW, Andriessen A, et al. Pathway to dry skin prevention and treatment. J Cutan Med Surg. 2012;16(1):23-31. doi:10.1177/120347541201600106
20. Urea. CeraVe. Accessed April 10, 2023. https://www.cerave.com/ingredients-in-cerave/urea