Is Moisturiser Withdrawal necessary for healing?

What is Moisturiser Withdrawal and do I have to do it?

Moisturiser Withdrawal is the cessation of the use of any kind of moisturisers on the skin. This is a common practice amongst people with TSW skin and has very promising results. People who do Moisturiser Withdrawal benefit from quicker recovery times, fewer inflammation cycles and reduction of elephant/hardened skin.

However, is this really necessary for healing? The answer is… yes and no. It is complicated and dependent on many factors, which will be explained below.

How do moisturisers work? 

There are 3 different types of moisturisers: Occlusives, Humectants and Emollients.

Humectants: Humectants work to hydrate the surface layers of the skin by drawing water from deeper layers of the skin or from the environment (if there is adequate humidity) up to the surface layers. Some examples are hyaluronic acid, glycerin, urea etc.

Occlusive: Occlusives create a physical barrier on top of the skin to reduce or prevent water from evaporating from the skin to the air. This is why they are also most effective when applied to wet skin or after showering. Some common occlusives are petroleum jelly/Vaseline/paraffin, lanolin, mineral oil, waxes such as beeswax, shea butter etc.

Emollients: Emollients smoothen the skin by filling in gaps between the skin cells, and are usually made of oils/lipids that are naturally present in the skin. Examples of emollients are argan oil, rosehip oil, grapeseed oil etc.

Some ingredients can act as one type of moisturiser alone, or can be a combination of any of the 3 types of moisturisers. An example would be coconut oil. When used infrequently and thinly, coconut oil is an emollient. However when used frequently and thickly, the oil acts as a barrier on the skin that prevents water or air from escaping, and acts as an occlusive moisturiser.

How is TSW skin affected by moisturisers?

It is important to note that moisturisers affect different skin types differently. Likewise, moisturisers affect TSW skin differently from healthy skin, because TSW skin cells are modulated by long term steroid use and thus weakened and unable to recover or regenerate as quickly as healthy skin.

When humectants are applied to TSW skin, water is drawn from the deeper layers of the skin to the surface. Prolonged usage causes the deeper layers of the skin to dry out and harden, causing hardened TSW skin. This is most easily observed on skin where the joints are: fingers, wrists, ankles, neck and decolletage, elbows and knees. Hardened skin can happen on any part of the body, but the joints are most obvious to notice. For an example of early signs of hardened skin, scroll to see pictures below.

The consistency of the humectant matters: creams and thicker consistencies would only be absorbed to the surface layers of the skin, and water will be drawn from the deeper layers to moisturise the surface layers. Gels and serums which are lighter would be better absorbed into the deeper layers of the skin, so the deeper layers are less likely to dry out and cause hardened skin.

Occlusives, which prevent water from evaporating away from the skin, also block air from entering the skin. This can delay the healing rate of the skin. One of the most commonly used occlusive is Liquid Paraffin/Petroleum jelly. Paraffin/petroleum jelly is a by-product of gas/petrol and is a major irritant to sensitive TSW skin. Many with TSW who use paraffin/petroleum/vaseline or any product containing this ingredient would usually notice that the skin becomes redder upon application. The constant redness and inflammation causes the skin to harden to protect itself. This is a natural protective response of the skin - when it is hardened, less of the product can penetrate it. Occlusives are thus the most harmful to TSW skin, causing hardened skin and prolonging flares.

Emollients are least harmful to TSW skin but can act as occlusives when frequently applied or thickly applied. Most emollients are made of natural oils, which contain plant sterols - this is not a negative thing and can be helpful in milder cases, however it can cause irritation/flare ups in more severe cases of TSW.

Across all three types of moisturisers, all contain various ingredients that are foreign to the skin. TSW skin, being extremely sensitive, detects these foreign substances. This is why TSW skin is often red/pink after application of a moisturiser or cream. When these foreign ingredients sink into the skin layers, the skin reacts and protects itself by proliferating. It generates layers of flakes underneath the skin’s surface to block the foreign substances from penetrating deeper. These layers of flakes form ridges and cause thickened and hardened skin. This is natural protective mechanism - just like how our skin forms calluses to protect itself from the constant friction it is exposed to.

Many products are a combination of many different ingredients which act as various types of moisturisers. Therefore it is difficult for people with TSW to figure out which products are safe for their use. There are simply too many ingredients that TSW skin cannot tolerate. This is why some doctors treating TSW resort to a blanket rule not to moisturise - it does not mean all skincare products are bad, it simply means most are not suitable for TSW skin or formulated with TSW in mind, and has a higher likelihood of causing flares or hardened/thickened skin.

The degree of impact that each of these moisturisers have on TSW skin, and how likely you will develop hardened skin depend on several factors:
1) How weak/damaged the skin is: the weaker your skin, the greater the effect
2) The amount and frequency of application
3) The consistency of some formulas e.g. serum vs cream/ointment
4) The formula itself: having moisturising ingredients in a product is not harmful to TSW skin if they are counteracted with other positive ingredients

The moisturiser-inflammation cycle

The skin heals by flaking (proliferation). Flaking is an important stage in the healing of damaged skin. This is explained at length in my other post ‘‘Stages of Skin Healing’’. However most people with TSW mistake the flaking for a ‘‘flare’’ or the skin ‘‘getting worse’’. The skin is not flaring or getting worse but actually doing what it is meant to do, healing!

When the skin starts proliferating, it is dry, uncomfortable, tight and flaky and we naturally look for something to soothe the discomfort. However applying moisturisers cause the skin to go back to the inflammation stage. The cycle then repeats.

Thus it is best to stay off moisturisers as much as possible, by tapering off them, switching to a gel/serum type product, or stopping them completely. I have written some tips on how you can do Moisturiser Withdrawal at your own pace here.

Is it necessary to do MW to heal from TSW?

In conclusion, whether moisturiser withdrawal is truly necessary for healing is very dependent on the 4 factors above. Whether you have used moisturiser when your skin is extremely damaged vs when you have healed up a bit more, whether you have used a gel or an oil, how much you and how frequent your application is… this is why some people can still heal using moisturisers and some on the contrary, get worse on moisturiser. If you have used moisturiser without much knowledge about the skin or product formulation and healed, you probably listened well to how your skin was responding and used a good product!

In general, because us laymen have a limited knowledge and understanding of moisturisers and their ingredients, and limited understanding of TSW skin, it is best for those with TSW to use a gel or serum over other thicker consistencies, spot moisturise rather than apply it in large areas, and use it only when necessary, to avoid any possibility of hardened skin or delayed healing.

I personally would not recommend using them because once you begin to feel a little relief from them, it is easy to rely on them, just like topical steroids. It is understandable that sometimes it is just really too painful and uncomfortable and we all need to function in our daily lives, and so spot moisturising on the cracks or extra painful areas is okay.

Here is Dr. Fukaya’s take on moisturising for TSW skin: http://mototsugufukaya.blogspot.com/2013/06/is-moisturizing-really-help-to-cure.html

Jay generally does not encourage moisturising, but when some patients are desperate for relief, he suggests Physiogel AI Soothing Cream applied thinly.

Dr. Sato advocates drying out the skin and even goes so far to say that covering the skin or picking off scabs is a moisturiser!

My personal journey 

It is my 8th year of being in TSW in 2020. During the first 4 years of my TSW journey, I was on Traditional Chinese Medicine and solely relied on herbs and acupuncture. The TCM helped to manage my flares even though it took some time to work, and the acupuncture helped to relieve the pain and itch and helped me feel better in terms of general well-being. I did not apply any moisturisers on my skin and I had some good periods which I would call a “break”.

I relapsed into a full body flare when I was 21, it came back gradually, and then suddenly. Gradually because I noticed my face getting flaky and irritated, starting from my eyelids, and to my whole face. And suddenly because my hand started getting patches too, and I panicked and it went downhill from there very quickly. I went back to TCM but it did not seem to have an effect anymore. I was lost and turned to the Facebook groups for help.

This was then I begun experimenting with various creams that others recommended. I started with Lemongrass balm, then emu oil, then a lavender/olive oil/beeswax mixture. They helped my skin feel better. However, as I continued using them, I discovered that I needed them more and more. I used a jar every 1.5 weeks, and my skin became painful when I did not apply them on. I developed anxiety whenever I am out and I discovered I had left my moisturiser at home.

I noticed that my skin was getting harder, and my skin was always redder whenever I applied them. I developed hardened skin everywhere.

Upon finding out about the concept of Moisturiser Withdrawal, I was terrified. I could not live without it, and I did not wish to accept that MW would be helpful. It was only after 3 years of applying moisturiser daily, several times in the day, that I finally recognised that it has worsened my condition. I began the very painful process of MW.

I could not do it all at once, because it hurt everywhere. I started with areas which were less painful and did not require that much movement, like my back and my tummy. Slowly I stopped it on my legs and feet, and lastly my face and my arms. My skin stopped being bright red , but was white and flaky (good signs of no inflammation and skin cell regeneration). Over time I did not feel the need for moisturisers, but I did have to put up with a lot of flaking.

Hardened skin takes a lot of time to be reversed, but it is possible. I am not there yet, as you can tell I still have a bit more to go. If you notice yourself having hardened skin as well, I hope this gives you the courage to do Moisturiser Withdrawal. You will come out on the other side with smoother and softer skin.

Please read Stages of Moisturiser Withdrawal Healing for detail information on the healing process.