Colloidal Oatmeal use in Dermatology (Supplement)

Carrie Lynde MD FRCPC
Lynde Institute for Dermatology, Markham, ON, Canada

Introduction

Patients often seek natural approaches to treating skin disease. Colloidal oatmeal has been used for decades to improve atopic dermatitis and soothe other pruritic and xerotic dermatologic conditions.¹ Although initially developed because of historical use, data is growing supporting its myriad benefits.

Background

Oats have long been used as treatment for skin disorders and to beautify the skin. The oldest oat grains were found in Egypt around 2000 BC^2,3 and the nutritional value of oatmeal and its topical benefits have been recognized since Roman times.^2,3,4 Oats were introduced into North America in the 17th century.² In 1945 a ready to use colloidal oatmeal for skin care became available.³ Colloidal oatmeal is produced by grinding fine granules of oatmeal and subsequently boiling it to extract the colloidal material. A colloid is a substance microscopically dispersed evenly throughout another substance.

Colloidal oatmeal was approved by the Food and Drug Administration (FDA) as a skin protectant agent for over-the-counter use in 2003.⁵ One of its approved listings is that it “temporarily protects and helps relieve minor skin irritation and itching”.⁵ It is recognized as a natural health product skin protectant ingredient by Health Canada.⁶

Atopic dermatitis (AD) is a common, chronic, pruritic skin condition with a high prevalence in children. Although AD has a complex pathogenesis there is substantial evidence that a genetically impaired skin barrier plays a role in its development.^1,7,8 The defective barrier allows irritants and antigens to penetrate leading to inflammation.⁹ Decreased stratum corneum hydration also leads to skin inflammation.¹⁰ This results in the eczematous pruritic lesions of AD.

Thus, restoration of skin barrier and stratum corneum hydration, soothing of itch and reduction of inflammation are critical for improvement of AD and quality of life for the patient and their families.¹ Moisturization and barrier protection play a central role in the treatment of AD. They are recommended as first line and adjunctive agents for the management of AD. ^11,12

Oatmeal Properties

Colloidal oatmeal has multiple properties that make it ideal for managing AD and other xerotic and pruritic skin conditions. The small particles of the oat proteins form an occlusive barrier, protecting the skin from external agents^1,13 and preventing moisture loss. It contains high concentrations of starches and beta-glucan that create an occlusive film and exhibit water-absorbing properties.¹⁴ It also has antioxidant (e.g. avenanthramides, vitamin E, ferulic acid, caffeic acid)^3,4,15 and anti-inflammatory properties.^16,17 Aventhramides are phenolic compounds with potent anti-inflammatory activity, through inhibition of NFKB in keratinocytes and inhibition of the release of the proinflammatory cytokine IL-8.¹⁸ The level of anti-inflammatory effect is similar to that of topical 1% hydrocortisone.¹⁸ Colloidal oatmeal can also act as a skin buffer, restoring the pH of the skin to normal.⁴

Efficacy

The benefits of colloidal oatmeal have been known for decades and several studies as early as the 1950s have reported the hydrating, soothing, protective and anti-irritant properties in AD.^1,19-21

In the study by Nebus et al.,²² twenty-five patients aged 12 to 60 years were enrolled in the 8-week study. Inclusion criteria included mild to moderate AD with at least 5% body surface area (BSA). They used a topical regimen of twice-daily oat-based occlusive cream and a once-daily oat-based body wash. Patients were permitted to continue their topical prescription AD treatments, however, patients on systemic medications for their AD were excluded. The results demonstrated that daily use of the adjunctive oat-based regimen significantly improved AD outcomes at all time points compared to baseline: Investigators Global Assessment (IGA), Eczema Area and Severity Index (EASI), and itching. Dermatology Life Quality Index (DLQI) was significantly improved from baseline at weeks 4 and 8. Some patients became clear of eczema as early as week 2 of use and over 45% of patients were clear or almost clear by week 8. Safety assessments revealed the regimen was well tolerated and compatible with various topical prescription medications.

In another study by Nebus et al.,²³ twenty-three babies and children (3 months to 5 years of age) were enrolled in a 4-week study. Similarly, patients must have mild to moderate AD and at least 5% BSA involvement. Patients applied an occlusive colloidal oatmeal cream twice daily on the entire body and a colloidal oatmeal-based glycerin cleanser for all routine bathing. Patients could continue any topical prescription AD medication already in use but must discontinue any previous cleansers or moisturizers. The oat-based regimen was well tolerated and significantly reduced itching by over 45% (mean) as early as week 2 of use. IGA and EASI were significantly improved from baseline at both week 2 and 4. Over 60% of patients were categorized as clear or almost clear by the end of the study. Baby/Child Quality of Life Index was also significantly improved by week 4.

In another clinical study,²⁴ 21 patients age 15 to 60 years with mild to moderate AD and at least 5% BSA were entered in this 14-day study. Patients used the oatmeal-based body wash once daily and applied the oatmeal-based therapeutic cream to the body twice daily. They were permitted to continue prescription topical treatments for AD. Itching was significantly improved at weeks 1 and 2, with over 40% improvement in the mean itch score at week 1. Investigator evaluations showed a significant improvement in the mean eczema severity score after 2 weeks of regimen use, with 62% of patients showing improvement from baseline.

In a 6-week randomized, controlled study involving 173 infants under 12 months of age with moderate to severe AD, an emollient containing colloidal oatmeal was shown to reduce the use of topical steroids.²⁵ High-potency topical steroid usage significantly decreased by 42%. The SCORAD index, and infants’ and parents’ quality of life significantly improved (p < 0.0001) in both groups.

Microbiome

The microbiome has been implicated in many different dramatological conditions. In AD the microbiome of lesional skin differs from that of non-lesional skin.²⁶ In lesional skin there tends to be less microbial diversity and we see this as lesions which are often colonized preferentially with staph aureus. A 14-day study with 65 adult subjects (mean age=34.5y) was conducted to look at the effects of a colloidal oatmeal cream versus a moisturizing lotion without oatmeal.²⁶ Subjects used assigned product to the body twice daily. The study showed significant improvement in transepidermal water loss (TEWL), skin hydration as well as itch. As expected, non-lesional skin had greater microbial diversity than lesional skin at both groups at baseline. Over the course of the study, subjects treated with the oatmeal-based cream had increased microbial diversity of lesional skin that approached that of non-lesional skin. This diversity was lost when the product was discontinued. The product that did not contain oatmeal did not improve microbial diversity of lesional skin at any point during the study.

Safety

Products containing colloidal oatmeal are very well tolerated. Although more than 8 million oat-based cosmetics are sold yearly, there are very few reports of allergic contact dermatitis or contact urticaria.²⁷ In the very few patients with cutaneous adverse effects to topical oats the reactions are generally very mild and did not recur with repeat application.²⁸

In a series of studies, the safety of topical products containing oatmeal were assessed for irritant and allergenic potential on repeat insult patch testing, in safety-in-use and ocular studies using subjects with non-sensitive and sensitive skin.²⁸

Low-level reactions were documented in 1.0% of subjects during the induction phase of repeat insult patch testing; one of 2291 subjects developed a persistent but doubtful low-level reaction involving edema during the challenge phase in repeat insult patch testing.²⁸ No allergies were reported by 80 subjects after patch testing after in-use application.²⁸

Conclusion

Moisturizers are essential in the management of AD. Nonprescription ingredients such as colloidal oatmeal have been used for years as an adjunct to provide further benefits. There is mounting evidence that colloidal oatmeal can safely enhance skin hydration and even help resolve clinical lesions through anti-inflammatory effects and by modulation of the microbiome. Currently, there are oat-based skin products available OTC, including Aveeno by Johnson & Johnson.

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