Effect of Sunflower Seed Oil Moisturizer Creams on Transepidermal

Water Loss in Atopic Dermatitis Pediatric Patients

Inne Arline Diana, Reiva Farah Dwiyana, Srie Prihianti Gondokaryono, Ineke Winda, Ayu Nur Ain,

Roni Aldiano, Imelda Pardede, Hendra Gunawan, Kristina Makarti

Faculty of Medicine Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung

Keywords: atopic dermatitis, sunflower seed oil, trans epidermal water loss

Abstract: Atopic dermatitis (AD) is a chronic disease associated with disruption of skin barrier. There is an increase of

transepidermal water loss (TEWL) in AD, therefore moisturizers application is essential. Sunflower seed oil

(SSO) is one of natural moisturizer contain essential fatty acid that has emollient and occlusive effect. The

aim of this study was to ascertain the effect of SSO on TEWL in AD pediatric patients. A hundred and twenty-

four pediatric subjects with and without history of AD recruited into one cross-sectional study and three

randomize-controlled studies, including the measurement of TEWL on six anatomical sites, the effect of 15%

SSO moisturizer cream in healthy skin, comparison of 15% SSO moisturizer cream to controlled, and

comparison of 20% SSO moisturizer to 5% urea moisturizer cream in AD patients, respectively. The

moisturizer was applied twice daily on forearm or lower leg for two weeks. The TEWL values was measured

by Tewameter® 300. The result showed that the highest TEWL values on the extensor part of lower leg (10.72

g/m2/h). The application of 15% SSO moisturizer showed a positive impact on skin barrier by reducing TEWL

value in healthy skin (average decrease 9.34 g/m2/h, p< 0.01). TEWL decrement value between 15% SSO

group compared to controlled group were not significant (p= 0.283). While, TEWL decrement value of 20%

SSO group had similar results compared to 5% urea group (p= 0.309). We concluded that 20% SSO can be

used as an alternative and can work as well as urea on AD pediatric patients.

1 INTRODUCTION

Atopic dermatitis (AD) is a common chronic

inflammatory skin condition marked by xerosis and

highly pruritic skin lesions.(Lyons et al., 2015) Data

from the International Study of Asthma and Allergies

in Childhood (ISAAC) revealed that the prevalence

of AD symptoms in the 6- to 7-year and the 13- to 14-

year age groups ranged from 0.7 to 18.4% and 0.8 to

20.5%, respectively.(Williams et al., 1999) Skin

barrier function can be assessed by non-invasive

measurement of transepidermal water loss (TEWL).

In children with a healthy skin, there is a full integrity

of the epidermis, presented with minimal TEWL,

while in children with AD, the TEWL is

increase.(Catherine MacK Correa and Nebus, 2012)

Current clinical guidelines recommend skin

hydration and the application of moisturizers as

nonpharmacologic interventions in AD

patients.(Catherine MacK Correa and Nebus, 2012;

Lyons et al., 2015) Emollients, is a type of

moisturizers which mainly contain lipids and oils that

enhance the skin softness and hydrate the dry

skin.(Sethi et al., 2016) There has been increasing

interest in using natural ingredients for skin care

product including moisturizing creams. It believes to

be safe and gentle by health-conscious

costumers.(Tobin, 2008) The discovery and

development of plant-based ingredients such as

inclusion of sunflower seed oil (SSO) in moisturizing

cream is become more compelling, because it shown

that the essential fatty acid (EFA) contain in the SSO

could treated and act as an anti-inflamatory in skin

disorders.(Eichenfield et al., 2009; Danby et al.,

2013) Hence this study was determined to assess the

effect of sunflower seed oil on TEWL in atopic

dermatitis pediatrics patients.

2 METHODS

Subjects. One cross sectional and three cohorts of

subjects were recruited. Subject with inflammed skin

on treatment sites, recently having a severe AD based

108

Diana, I., Dwiyana, R., Gondokaryono, S., Winda, I., Ain, A., Aldiano, R., Pardede, I., Gunawan, H. and Makarti, K.

Effect of Sunﬂower Seed Oil Moisturizer Creams on Transepidermal Water Loss in Atopic Dermatitis Pediatric Patients.

DOI: 10.5220/0008151901080112

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 108-112

ISBN: 978-989-758-494-7

on SCORAD score, known history of allergy to the

moisturizing cream ingredients used in this test, and

was using moisturizer 7 days before and during

participation were excluded from the study. The

subjects were refrained from using any other topical

products beside the given moisturizer. Informed

consent was obtained from each subject. The studies

were approved by the Health Research Ethics

Committee, Faculty of Medicine, Universitas

Padjadjaran-Dr. Hasan Sadikin Hospital Bandung,

West Java, Indonesia with ethical clearance. The

cross-sectional study consisted of 70 healthy children

(forty females and thirty males, ages 6-7 years) were

measured for TEWL value on six anatomical sites.

The Cohort 1 study consisted of 26 healthy children

(thirteen females and thirteen males, ages 6-7 years)

were treated with 15% SSO moisturizer cream on

lower leg for two weeks. The Cohort 2 study

consisted of 16 subjects (eight females and eight

males, ages 2-11 years) with previous history of AD,

diagnosed by Hanifin-Rajka criteria and recently not

in severe condition according to SCORAD score. The

Cohort 3 study consisted of 12 subjects (six females

and six males, age 2-9 years) with previous history of

AD, diagnosed by Hanifin-Rajka criteria and recently

not in severe condition according to SCORAD score.

Treatment. The cross-sectional study measured

the TEWL value of healthy childrens skin without

any treatment needed. The cohort 1 study was an

experimental analytical prospective study using

convenience sampling. According to pediatrics finger

tip unit (FTU), the subjects were given 20 g of 15%

SSO moisturizing cream per week for two weeks

application. Treatments were applied to lower legs

twice a day after bath. The cohort 2 study was a

double blind controlled study using consecutive

sampling. The subjects were given 20 g of 15% SSO

moisturizing cream per week for two weeks

application for one arm and 20 g of vehicle-controlled

moisturizer cream per week for two weeks

application for the other arm. Treatments were

applied twice a day after bath and leave skin

uncovered for at least 30 minutes after each

application. Both creams were labelled and blinded to

subjects and observer. The cohort 3 study was a

double blind controlled study using consecutive

sampling. The subjects were given 20 g of 20% SSO

moisturizing cream per week for two weeks

application for one leg and 20 g of 5% urea

moisturizing cream per week for two weeks

application for the other leg. Treatments were applied

to lower legs after bath and leave skin uncovered for

at least 30 minutes after each application. Both

creams were labelled and blinded to subjects and

observer. The moisturizer used in this study was

allocated in opaque container, labelled and was

undergone product testing using animal tests before

used with the formula presented in Table 1. While the

urea 5% moisturizer was using Extreme Dry Skin

Relief Hand Cream 5% urea, from Sebamed

(Sebapharma GmbH & Co. KG, Germany).

Table 1. Moisturizer Cream Formula

SSO 15%

moisturizer

Vehicle Only

moisturizer

SSO 20%

moisturizer

Refined

Sunflower Seed

Oil 15%

Cetostearyl

alcohol 10%

Cetomacrogol

10%

Petroleum jelly

Potassium sorbate

0,1%

Propilen glycol

7,5%

Citrus fragrance

q.s

Aquadest ad 100

Paraffin 15%

Cetostearyl

alcohol 10%

Cetomacrogol

Petroleum jelly

Potassium

sorbate 0,1%

Propilen glycol

7,5%

Citrus

fragrance q.s

Aquadest ad

100 gr

Refined

Sunflower

Seed Oil 20%

Cetostearyl

alcohol 10%

Cetomacrogol

10%

Petroleum

jelly 5%

Potassium

sorbate 0,1%

Propilen

glycol 7,5%

Citrus

fragrance q.s

Aquadest ad

100 gr

Biophysical Measurements. Measurements were

performed in a room maintained at 20-22°C and 40-

60% relative humidity. Subjects were asked to sit in a

resting position with their forearm or lower leg

exposed for 20 minutes before measurrements to

acclimatize the test areas. The last application of

creams was made 12 to 24 hours before the evaluation

to avoid interference of residues with the

measurement. TEWL was measured using a

Tewameter ® 300 (Courage and Khazaka electronic

GmbH, Germany).

Statistical Analysis. Results in the cohort 1 study

were analyzed using Wilcoxon test. Results in the

cohort 2 study were analyzed using Friedman test

(before and after treatment) and Mann-Whitney test

(comparison between two group). Results in the

cohort 3 study were analyzed using Repeated

ANOVA and Repeated ANOVA Comparisons

(comparison of decrement in TEWL from baseline)

and p < 0.05 was considered significant.

3 RESULTS

TEWL Value of Various Anatomical Sites in Healthy

Pediatric Skin. Seventy healthy children, were having

Effect of Sunﬂower Seed Oil Moisturizer Creams on Transepidermal Water Loss in Atopic Dermatitis Pediatric Patients

109

TEWL measurement on the cheek, forehead, extensor

part of lower arm, flexor part of upper leg, extensor

part of lower leg, and back, using Tewameter® 300.

The mean TEWL value in our study from the highest

to the lowest were as follows: the extensor part of

lower leg (10.72 g/m

/hour), forehead (8.53

g/m

/hour), extensor part of lower arm (7.56

g/m

/hour), cheek (7.05 g/m

/hour), flexor part of

upper leg (6.1 g/m

/hour), and the lowest value

obtained from the skin on back (5.46 g/m

/hour).

Effect of 15% SSO Moisturizer in Healthy

Pediatric Skin. Twenty-six healthy children applied

15% SSO moisturizer creams to the skin of legs twice

a day for 2 weeks. The TEWL measurement was

perfomed at baseline, evaluation week-1, and week-

2. Results from the study shown a decrease in TEWL

value on application of 15% SSO moisturizer creams

from baseline until week-2 evaluation in healthy

pediatric skin. The decrement was almost half of the

baseline value from 17.66 g/m

/hour to 8.32

g/m

/hour in week-2 evaluation (average decrease

9.34 g/m

/hour) or 47.11% decrease from baseline.

This result was statistically significant with p < 0.01

(p= 0.0001).

Effect of 15% SSO Moisturizer Compared to

Vehicle Controlled in AD Pediatric Skin. Sixteen

subjects with history of AD and curently in mild

condition based on SCORAD score applied 15% SSO

moisturizer creams twice a day to one arm and

vehicle-controlled moisturizer creams to the other

arm. In 15% SSO group after two weeks of

moisturizer application the average decrement of

TEWL was 6.16 g/m

/hour ± 1.51 g/m

/hour. While

in vehicle-controlled group after two weeks of

moisturizer application the average decrement of

TEWL was 6.18 g/m

/hour ± 1.59 g/m

/hour.

Statistically using Friedman test, TEWL decrement

value on both group were significant with p <0,001.

In 15% SSO group, after two weeks of moisturizer

application, TEWL decrement value was raised from

1.6 g/m

/hour (19.22%) to 2.26 g/m

/hour (26.78%).

While in vehicle-controlled group, after two weeks of

moisturizer application, TEWL decrement value was

also raised from 1.38 g/m2/hour (17.21%) to 1.75

g/m2/hour (21.43%). According to Mann-Whitney

analytical test with Confidence Interval 95%, the total

TEWL decrement value between 15% SSO group and

vehicle-controlled group was not statistically

significant (p= 0.283).

Effect of 20% SSO Moisturizer Compared to 5%

Urea Moisturizer in AD Pediatric Skin. Twelve

subjects with history of AD and curently in mild to

moderate condition based on SCORAD score applied

20% SSO moisturizer creams twice a day to one leg

and 5% urea moisturizer creams to the other leg. The

TEWL values between 20% SSO group and 5% urea

group were presented in Table 2. TEWL decrease in

both group from baseline to week-2 evaluation was

significant (p <0.001). The decrease of TEWL in 20%

SSO group (49.80%) was superior to 5% urea group

(42.75%). This result was not statistically significant

when compared 20% SSO group to 5% urea group

from baseline to week-2 evaluation (p= 0.309).

Table 2. TEWL Values between 20% SSO Group and 5% Urea Group

Cream Time Average

TEWL

(g/m2/hour)

TEWL

decrease

(%)

p value TEWL

decrement

Baseline-

week-2

p value

20%

SSO

Baseline 15.20± 3.498

49.80 <0.001

Week-1 10.93 ± 2.56 7.57 ±

3.33

Week-2 7.63 ± 2.43 0.309

Urea

Baseline 14.55± 1.945

42.75 <0.001

Week-1 11.18± 1.947 6.22 ±

3.00

Week-2 8.33 ± 2.65

4 DISCUSSION

Measurement of TEWL is useful to evaluate the

physical barrier function of stratum corneum. The

TEWL value differs, depends on anatomical location

and affected by the environment, as well as the size

and amount of corneocyte.(Machado et al., 2010) A

study by Rougier et al. concluded that the larger

corneocytes size corelated with the longer route for

the permeation, which presented in lower TEWL

value.(Rougier et al., 1988) Our study found the

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110

highest mean TEWL value were from the skin on

extensor part of lower leg (10.72 g/m

/hour) and the

lowest mean TEWL value were from the skin on back

(5.46 g/m

/hour). Comparative assessment of TEWL

by Fluhr et al. showed a difference in the baseline

values, with the highest TEWL value from the skin

on forehead (22.4 g/m2/h) and the lowest TEWL

values from the skin on the lower leg (7.7

g/m2/h).(Fluhr et al., 2002) The difference of these

studies results maybe due to the subject of our study

included children aged 6-7 years only, with

presumably high contact and friction of the lower legs

from trauma and their daily activity. It is supported

with one study showed that the reciprocating sliding

and contact between skin and working implements,

sports appliances, improper footgear, and textile

materials, etc. may lead to skin damage.(Chen et al.,

2015)

Linoleic acid was the major essential free fatty

acid (EFA) content found on SSO. Linoleic acid

contain in SSO can converts to arachidonic acid, a

precursor to prostaglandin E2 (PGE2), which was a

known modulator of cutaneous

inflammation.(Eichenfield et al., 2009) One study in

Bangladesh, using topical SSO on preterm infants

showed that SSO reduced the passage of pathogens

from the skin surface into the bloodstream compared

with untreated controlled group.(Darmstadt et al.,

2007) Our study supported the theory that topical use

of 15% SSO inclusion in moisturizing cream has the

positive impact on healthy pediatric skin, with

reducing the total TEWL value compare to baseline.

Pediatric skin with history of atopy and presented

with AD showed a different physical barrier compare

to the healthy pediatric skin. In human keratinocytes,

PPAR-α activators, including linoleic acid, showed a

regulatory effect by increasing involucrin,

transglutaminase protein and mRNA levels.(Hanley

et al., 1998; Eichenfield et al., 2009; Danby et al.,

2013) Our study revealed that 15% SSO moisturizer

significantly reduce the TEWL value in AD pediatric

skin, and similar results to vehicle-controlled group.

This results maybe due to the moisturizing effect of

the vehicle-controlled moisturizer used in this test,

contain paraffin and petroleum jelly which were

occlusive type of moisturizer.(Sethi et al., 2016)

While propilen glycol which was also add in the

vehicle is the mixture of emollient, humectant, and

occlusive moisturizer.(Sethi et al., 2016) According

to this result we consider a higher concentration of

SSO to have the better effect compared to controlled

moisturizer.

Five percent urea cream was often used as

moisturizer in AD, which act as humectant by

attracting water from the environment and retains it

within the cells. On one study comparing 5% and

10% urea moisturizer, both improved atopic

dermatitis skin lesion using scoring atopic dermatitis

severity index (SCORAD).(Bissonnette et al., 2010)

The 5% urea moisturizer was preferred by subjects

over the 10% urea lotion using the cosmetic

acceptability questionnaire.(Bissonnette et al., 2010)

In this cohort study we compare the 20% SSO

moisturizer with 5% urea moisturizer in AD pediatric

skin. To our knowledge there were no study

comparing urea and SSO in AD pediatric skin before.

The result showed that both 20% SSO moisturizer

and 5% urea moisturizer significantly reduce the

TEWL value on week-2 application compare to

baseline. Comparation analysis of the 20% SSO

moisturizer to 5% urea moisturizer was not

significant, but the TEWL decrement value in 20%

SSO group (49.80%) was superior to 5% urea group

(42.75%).

5 CONCLUSIONS

From this result, we concluded that 20% SSO can be

use as an alternative and can work as well as urea on

AD pediatric patients.

REFERENCES

Bissonnette, R., Maari, C., Provost, N., Bolduc, C., Nigen,

S., Rougier, A., Seite, S., 2010. A double-blind study of

tolerance and efficacy of a new urea-containing

moisturizer in patients with atopic dermatitis. Journal

of Cosmetic Dermatology 9, 16–21.

Catherine MacK Correa, M., Nebus, J., 2012. Management

of patients with atopic dermatitis: The role of emollient

therapy. Dermatology Research and Practice.

Chen, C.-Y., Yu, C.-A., Hong, T.-F., Chung, Y.-L., Li, W.-

L., 2015. Contact and frictional properties of stratum

corneum of human skin. Biosurface and Biotribology 1,

62–70.

Danby, S.G., Alenezi, T., Sultan, A., Lavender, T.,

Chittock, J., Brown, K., Cork, M.J., 2013. Effect of

olive and sunflower seed oil on the adult skin barrier:

Implications for neonatal skin care. Pediatric

Dermatology 30, 42–50.

Darmstadt, G.L., Saha, S.K., Ahmed, A.S.M.N.U., Choi,

Y., Chowdhury, M.A.K.A., Islam, M., Law, P.A.,

Ahmed, S., 2007. Effect of Topical Emollient

Treatment of Preterm Neonates in Bangladesh on

Invasion of Pathogens Into the Bloodstream. Pediatric

Research 61, 588–593.

Eichenfield, L.F., McCollum, A., Msika, P., 2009. The

benefits of sunflower oleodistillate (SOD) in pediatric

Effect of Sunﬂower Seed Oil Moisturizer Creams on Transepidermal Water Loss in Atopic Dermatitis Pediatric Patients

111

dermatology. Pediatric Dermatology.

Fluhr, J.W., Dickel, H., Kuss, O., Weyher, I., Diepgen,

T.L., Berardesca, E., 2002. Impact of anatomical

location on barrier recovery, surface pH and stratum

corneum hydration after acute barrier disruption.

British Journal of Dermatology 146, 770–776.

Hanley, K., Jiang, Y., He, S.S., Friedman, M., Elias, P.M.,

Bikle, D.D., Williams, M.L., Feingold, K.R., 1998.

Keratinocyte differentiation is stimulated by activators

of the nuclear hormone receptor PPARalpha. The

Journal of investigative dermatology 110, 368–375.

Lyons, J.J., Milner, J.D., Stone, K.D., 2015. Atopic

Dermatitis in Children: Clinical Features,

Pathophysiology, and Treatment. Immunology and

Allergy Clinics of North America.

Machado, M., Salgado, T.M., Hadgraft, J., Lane, M.E.,

2010. The relationship between transepidermal water

loss and skin permeability. International Journal of

Pharmaceutics 384, 73–77.

Rougier, A., Lotte, C., Corcuff, P., Maibach, H.I., 1988.

Relationship between skin permeability and corneocyte

size according to anatomic site, age, and sex in man. J

Soc Cosmet Chem 39, 15–26.

Sethi, A., Kaur, T., Malhotra, S., Gambhir, M., 2016.

Moisturizers: The slippery road. Indian Journal of

Dermatology 61, 279.

Tobin, D.J., 2008. Human hair pigmentation--biological

aspects. International journal of cosmetic science 30,

233–57.

Williams, H., Robertson, C., Stewart, A., Ait-Khaled, N.,

Anabwani, G., Anderson, R., Asher, I., Beasley, R.,

Bjorksten, B., Burr, M., Clayton, T., Crane, J., Ellwood,

P., Keil, U., Lai, C., Mallol, J., Martinez, F., Mitchell,

E., Montefort, S., Pearce, N., Shah, J., Sibbald, B.,

Strachan, D., von Mutius, E., Weiland, S.K., 1999.

Worldwide variations in the prevalence of symptoms of

atopic eczema in the International Study of Asthma and

Allergies in Childhood. J Allergy Clin Immunol 103,

125–138.

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

112