What are the differences between cream, ointment, and gel formulations for treating skin conditions, and how do I choose the most appropriate one for a patient?

Differences Between Cream, Ointment, and Gel Formulations

Ointments are generally most effective for dry, irritable skin conditions because they provide superior hydration through improved lipid barrier function, while creams and gels are better suited for moist or hairy areas where cosmetic acceptability matters more than maximal occlusion. 1

Key Physical Properties and Composition

Ointments

• Highest lipid content (often 100% lipid base with minimal to no water), providing maximum occlusion and barrier support 2
• Examples include petrolatum-based products, white/yellow soft paraffin, and emulsifying ointment 2
• Greasy consistency that some patients find cosmetically unacceptable, which can reduce compliance 2
• Most effective for dry, scaly, hyperkeratotic conditions requiring intensive moisturization 1

Creams

• Water-in-oil or oil-in-water emulsions with moderate lipid content 3
• Less occlusive than ointments but more cosmetically acceptable 3
• Can further dry the skin in some cases, particularly water-based formulations 1
• Suitable for general application on most body areas where greasiness is undesirable 3

Gels

• Water-based or alcohol-based formulations with minimal lipid content 3
• Non-greasy, quick-drying, and cosmetically elegant 3
• Ideal for hairy areas (scalp), mucosal surfaces, and acute weeping lesions 1
• May increase risk of folliculitis when very greasy emollients are needed 1

Clinical Selection Algorithm

Step 1: Assess Skin Condition Characteristics

For dry, scaly, hyperkeratotic skin:

• Choose ointments as first-line for maximum hydration and barrier repair 1, 2
• Particularly recommended for elderly patients with pruritus 2
• Apply at least twice daily, ideally after bathing (usage: 200-400 grams per week for adults) 2

For moist, weeping, or inflamed areas:

• Choose creams for moderate occlusion without excessive greasiness 3
• Avoid very greasy formulations that may worsen folliculitis 1

For hairy areas or mucosal surfaces:

• Choose gels for scalp disease or mucosal involvement 1
• Solutions may also be appropriate for scalp application 1

Step 2: Consider Anatomic Location

• Face and flexures: Creams or gels preferred for cosmetic acceptability 1, 3
• Scalp: Gels or solutions to avoid matting hair 1
• Trunk and extremities: Creams or lotions for ease of application over large areas 1
• Palms, soles, elbows (thick scale): Ointments or high-concentration urea preparations (20-40%) 4

Step 3: Factor in Patient Preference

Patient preference is decisive for long-term adherence, as emollient therapy is time-consuming and demanding 2

• In a large randomized trial of 550 children with eczema, all four formulation types (lotion, cream, gel, ointment) showed equal effectiveness over 16 weeks, with no difference in eczema severity scores 5, 6
• Overall satisfaction was highest for lotions and gels, though opinions about creams and ointments varied most 5
• Stinging was less common with ointments (9%) compared to lotions (20%), creams (17%), or gels (19%) 6

Common Pitfalls and How to Avoid Them

Pitfall 1: Assuming Greasier is Always Better

• While ointments provide superior occlusion, poor cosmetic acceptability leads to non-adherence 2
• Solution: Offer a range of formulation types and allow patients to choose based on their lifestyle and preferences 5, 6

Pitfall 2: Using Water-Based Creams for Very Dry Skin

• Water-based creams can paradoxically worsen dryness in severely xerotic skin 1
• Solution: Use ointments with 50-100% lipid content for maximum hydration in dry conditions 2

Pitfall 3: Applying Greasy Emollients to Acne-Prone or Hairy Areas

• Very greasy emollients may increase folliculitis risk 1
• Solution: Use non-comedogenic gels or light lotions for acne-prone skin and hairy areas 1, 3

Pitfall 4: Ignoring Specific Active Ingredient Requirements

• Some medications are formulated in specific vehicles for stability or penetration reasons 1
• For example, nitrogen mustard 0.02% gel was non-inferior to ointment for mycosis fungoides, providing a more practical alternative 1
• Solution: When prescribing active medications, verify that the vehicle type is appropriate for the specific drug formulation 1

Special Considerations by Disease State

For EGFR-TKI Related Skin Toxicity

• Ointments are generally more effective for dry, irritable rashes from EGFR inhibitors 1
• Very greasy emollients may increase folliculitis risk in this population 1

For Lichen Planus and Lichenoid Reactions

• High-potency topical steroids: Consider gel for mucosal disease, solution for scalp, and cream/lotion/ointment for other areas 1

For Actinic Keratosis Treatment

• Diclofenac 3% in 25% hyaluronic acid gel applied twice daily for 60-90 days 1
• 5-FU cream formulations for field treatment 1

For Acne Vulgaris

• Gels and solutions preferred for oily, acne-prone skin 1
• Retinoids available in cream, gel, or microsphere gel vehicles with slight differences in tolerability 1