CLINICAL REVIEW íkin

Ageing skin: focus on tlie useof emoiiients

The effects of ageing are most visiblydemonstrated in the largest humanorgan, the skin. Skin impairment

and disease is commonly seen in the olderperson and a large tnajority of people overthe age of 70 years will present with at lea.stone skin condition (Norman, 2003). Nursesin care homes must have an understandingof the changes that occur in ageing skin andthe importance of this organ in maintaininghomeostasis of the body.

Homeostasis refers to the body's ability tomaintain 'normal' functioning, adjusting toexternal and internal changes to maintain'normal life' (Clancy and Smith, 2010), Theskin is integral to homeostatic functioning.

Skin care in the elderly is a recognisedarea of priority for all nurses and should beconsidered as a first-line nursing interven-tion in all residential and nursing hotneswith no exceptions. The nursing manage-ment objective is to ensure early interven-tion, with simple therapeutic agents suchas emollients, placing a heavy emphasis onappropriate resident education (Ersser, 2000;Haynes, 2008). Staff should also endeavourto obtain accurate and timely diagnosis ofskin conditions which, if misdiagnosed orignored, wül impact on resident wrellbeing,quality of life and NHS resources.

This article aims to identify the changesseen in elderly skin as a re,sult of pathologi-cal changes associated with ageing and theimportant homeostatic role the skin plays.The focus on emollient therapy is to in-crease awareness of the importance of pro-tecting the skin barrier fimction using a bestpractice approach, which can be adaptedto any skin care protocol and is based onbest practice guidance from the Internation-al Skin care Nursitig Group and the British

:= Carrie Wingfieldr Deimatology Nurse'^' " tTt,Noribikand

h University Rxindation^ W p t a l ; President, British

^= Detmartdogical Nursing Group;"^= Aeenr-igte University Lecturer,

»tyofEastAnglia

All nurses in carehomes play a major role

in ensuring adequateassessment of the older

person's skin and advisingon dry skin management.Carrie Wingfield provides

tips for best practice

Dermatological Nursing Group (Ersser et al,

2009).

Homeostasis and pathophysiologyThe integrity of the skin barrier is subject todeterioration and altered fimction as peopleage. As a consequence, the skin loses upto 20% of its thickness, making it .suscep-tible to damage, injury, dryness and skindisease (Nazarko, 2007). The thinning ofthe epidermis means loss of collagen andreduced blood and nerve supply, decreas-ing the skin's ability to regenerate, heal, andretain moisture and elasticity (Baranoski andAyeUo, 2004). Eunctionally, immune respon-siveness is comprotnised in the older skin,contributing to a higher incidence of malig-nant tumours and infections.

Previous lifestyle, comorbidities and familyhistory also play a part in how the skinbehaves in tlie older person. These factorsinclude (Bianchi and Cameron, 2008);H Chronic skin disease (eczema, psoriasis)f- Incontinence'̂ Decreased mobility* ImmunosuppressionS Diabetes• Renal disease• Thyroid disease• Iron deficiency• Changes in mental health• Poor dietary intake• Poor hygiene as consequence of other

impairments• Sun damage.

One of the major accelerating factors in

ageing skin is where lifestyle has causedexcessive photo damage/sun damage. Thiscan manifest in skin changes, such as (Rittieand Eisher, 2002):• Xerosis (dry skin/asteatotic eczema)• Thickened leathery skin• Increased wrinkles (solar elastosis)• Irregular and increased pigmentation

(freckles, lentigines).In addition, a -wide variation of pre-can-

cerous lesions and benign skin lesions eanappear, including (Wingfield, 2012; Ginardand Gaputy, 2012):• Seborrhoeic keratosis (warty benign le-

sion, ofien multiple in presentation) {Fig-ure T)

• Acrochordons (skin tags)• Sebaceous gland hyperplasia (benign

condition of sebaceous glands)• Actinic keratosis (a sun induced scaling

lesion with the potential to become ma-lignant) (Figure 2)

• Bowen's disease (pre-cancerous sundamaged skin with potential for invasivemalignancy) (Figure 3).

Cancerous lesions are also more preva-lent, presenting as basal and squamous cellcarcinomas (Figures 4), to name the twomo.st commonly seen CWingfield, 2012), Allof these factors may have an impact in ac-celerating the deterioration of the individu-al's skin integrity and homeostatic function-ing. The ageing process reduces this abilityto adjust, putting the skin in a vulnerableposition.

One of the important areas where home-ostatic control is tlireatened is in the skinmanagement of urinary and faecal inconti-nence. Incontinence associated dermatitis(IAD) commonly presents as skin redden-ing, broken skin, loss of barrier function,blistering and is prone to bacterial (Staphy-lococcus) and fungal infection (Candidaalbicans) (Sibbald et al, 2003; Gray et al,2007), Impact to chemically irritated skin isincreased where pres.sure and shear factorsare combined, such as from pads, bedding,clothing and chair surfaces. It is important tobe able to identify IAD and not misdiagnose

194 Nursing & Residentiai Care April 2013, Vol 15, No 4

CLINICAL REVIEW

Figure 1. Seborrhoeic keratosis Figure 2. Actinic keratosis Figure 3. Bowen's disease Figure 4. Basai ce// carcinoma

as pressure ulcers as preventative measuresdiffer.

Educational tools need to be in place tohelp nurses define skin presentation andsymptoms. Simple use of emollients as soapsubstitutes has demonstrated a significantreduction of IAD, therefore, cleaning andmoisturising the skin of residents with in-continence problems is of paramount impor-tance in any skin care protocol. Moisturisingskin protectants are recommended for resi-dents with high-volume or frequent inconti-nence, with faecal incontinence demonstrat-ing the most risk factors for IAD (Beeckmanet al 2010). Beeckman at al (2010) identifiesthat more research is required as there islimited evidence on the effectiveness of skinregimens; much of the evidence is anecdo-tal. However, the use of emollients and skinprotectants should not be overlooked as thebenefits to residents having clean, protectedand weU-hydrated skin is visibly apparent.

Dry skin managementDry skin is a common feature of ageing,and contributes to other secondary associ-ated conditions, such as eczema, nodularpmrigo, infection, cellulitis, pruritus (itch-ing) and ulcération. As the skin ages, thedecreased thickness and changing anatomyof the epidermis and dermis results in re-duced efficacy of sweat glands, increasingdryness. Untreated, this can lead to cracksand fissuring in the skin, leaving portals forbacterial colonisation, skin breakdown andfurther damage.

The loss of collagen in the dermisreduces the skin's strength and elasticity.Blood vessels in the dermis are more frag-ile and present changes in the skin, such asbruising (senile purpura) and cherry angi-omas. Loss of subcutaneous fat reduces nor-mal insulation and padding. This increasesrisk of skin injury and reduces the ability tomaintain body temperature. Other changes

Box 1. Summary of adverse events and advice of emollients '» stinging/discomfort, dry or broken skin. Apply gently without vigorous rubbing; consider changing

emollient if discomfort persists

M Ailergic/sensitivity reactions/irritation to preservatives used in product. If suspected change

treatment; apply a small test patch first, or if there are multipie product problems refer for patch

testing _-• Foiliculitis—blockage of hair follicles forming pustules and irritation. Lighter emollients/lotions *

recommended for hair bearing areas. Apply in downwards fashion going in direction of hair, avoid

vigorous rubbing in

:" Reduction of heat loss from skin. Hot weather occlusive emollient can affect thermorégulation of

the skin. Lighter emollient and not paraffin based recommended

•!• Fire risk. Paraffin products when soaked into dressings and clothing are flammable.

^ Tachyphylaxis—products become less effective/resistance. Change of emollient made be

needed, resistance usually temporary, can return to original product at some point if required

« Slipping—flooring surfaces, bath and shower

« Cross contamination. Open tubs, warm environment (e.g. bathroom) multiple users, growth of

bacteria in tubs and lids. Advise decanting where possible into smaller receptacle, discourage

multiple users. If secondary skin infection is a problem, ensure all tubs are replaced to prevent

further cross infection

From: Wingfíetd, 2011.

involve the sebaceous glands, which pro-duce less oil with age. This can make itharder to keep the skin moist, resulting indryness and itchiness.

Skin assessment should factor in anyexamination of a resident. In some con-ditions, such as lower limb cellulitis, theprimary cause may well be dermatological,such as tinea pedis (athlete's foot), varicoseeczema and dry skin (Wingfield, 2009).Simple therapeutic intervention, such asemollient treatment, can improve the skinbarrier function and reduce associated risks.The National Institute for Health and ClinicalExcellence (NICE), (2007) supports the evi-dence that emollients should be consideredas first-line treatment for dry skin conditions,regardless of age group.

Using emollients as soap substitutes is auseful therapeutic method in the treatmentof conditions presenting as dry, itchy andscaling, such as eczema. There is a largeselection of emollients to choose from, al-

though there is litde evidence to suggest oneis any better than another, in terms of effi-cacy. Adverse events in the use of emollienttherapy are often down to the choice of thewrong product for the individual's skin con-dition and incorrect application technique,although sensitisation and allergy can occur.Discussing emollient choice with the resi-dent, to find the most acceptable product,can encourage regular and repeated use(Loden, 2003).

Choosing the right emollientNew emollient products regularly launchinto the market. It is worth knowing thecomponents and functions of the differenttypes of emollients to enable the correctchoice to be made for the individual.

Aqueous cream is well known and is apopular choice as a cost-effective emollienttherapy. In the past, it has been advocated asboth a soap substitute and direct skin appli-cation product. Being a water-based prod-

196 Nursing & Residential Care April 2013, Vol 15, No 4

CLINICAL REVIE Skin

Table 1 . Common petroleum-based emollients (beavy duty)Petroieum Quantity Soap Disadvantages Advantages

emoiiient substitute

Liquid paraffin/soft paraffin BP(50/50)

500gtub

Emollin Spray 240 ml

Hydromol 500 g •/Ointment

Epaderm 500g v'Ointment

Emulsifying 500g -/Ointment BP

From Wingfieid, 2011.

uct, it requires a number of preservativesto prevent bacteria contamination. Thesepreservatives can lead to skin sensitivity andstinging in some people (Cork et al, 2003).

Aqueous cream is not always the bestchoice for dryer older skin, as decreasedskin integrity means that a heavy-dutyemollient will give a quicker and sustainedresult, providing it is used in sufficient quan-tity and frequency (Britton, 2003; Wingfieid,2011). It is recommended that, •where ap-propriate, the resident is involved in mak-ing this decision, to improve likelihood ofconcordance and encourage independence.The choice may be influenced by the healthprofessional's knowledge and the informa-tion and education provided.

Research into tiie use of aqueous crearnby Tsang and Guy (2010) identified skinthinning and irritation over a period of4 weeks connected to the sodium laurylsulphate content, a detergent agent. This isacknowledged as a small study and requiresfurther research to support; however, inmo.st dermatology circles, the use of aque-ous cream as a direct emollient has beendiscontinued (Cork et al, 2003). Aqueouscream is not intended as a direct emollient;

Inflammable whensoaked throughdressings andclothing; avoid nakedflames

Can reduce heat lossthrough the skin;warning if resident isin hot climate or wherethere is extensive skininfection and redness.Poor complianceissues due to greasynature; marks clothingand bedding.Folliculitis risk in hairbearing areas

As above

Excellent hydration underocclusive bandages/suits/dressings/paste bandagingespecially in management ofsurrounding skin in leg ulcermanagement

Minimal preservatives, lesschance of sensitivity issues.Poor uptake of bacterialcontamination in tub and spray.Spray easy to use for thosepatients with difficult areas toreach when self-caring.Spray useful in the treatmentof eczema where occlusionis used in combination withtopical steroids, avoidsspreading around of steroid togood skin

As above

Excellent for washing legs tohelp hydrate and loosen deadskin for removal

although, where it suits individual use, it isstill recommended as a soap substitute (NHSInform, 2011).

Petroleum-based emollientsPetroleum-based emollients are often re-ferred to as 'heavy duty' (Table 1), becausethe petroleum content can reduce loss ofwater from the skin by 98% compared withother emollient products with only 20-30%retention (Rawlings et al, 2004). Additionally,they can be u.seful under bandages for treat-ment of varicose eczema. However, theyare greasy and not user-friendly, which canencourage poor concordance. For some in-dividuals, it is considered good practice tooffer two emollient products, a lighter creamfor daytime use and heavy duty for nighttime to improve concordance and cosmeticacceptability.

Lotions, creams and gelsCosmetic acceptance can be important forany age group where emollients are recom-mended. The lighter, more fluid nattire oflotions, creams and gels means they canbe packaged in pump dispensers, makingit easier for residents to apply and reduc-

ing the risk of bacterial contamination. Theycan double as soap substitutes or for directapplication, and can be mixed with otliersubstances, such as antimicrobials, mentholand anti-pruritic agents. In hair-bearing ar-eas lighter preparations can reduce the riskof folliculitis (Table 2).

Antimicrobial preparationsAntimicrobial emollients are useful inreducing bacterial colonisation, such asStaphylococcus aureus, in skin conditions,e.g. eczema, where symptoms have includ-ed secondary infection. From the author'sexperience, it is beneficial in the washingand moistitrisation of lower limbs, in condi-tions such as chronic oedema, lymphoede-ma, cellulitis and varicose eczema, with orwithout ulcération. It is not good practice touse antimicrobial emollients in place of oralantibiotics where infection is extensive or isdiagnosed, but they can be used in conjunc-tion with oral antibiotics (Wingfieid, 2009;Bjomsdottir et al, 2005).

Humectant preparationsPetroleum and creams work by trappingwater into the skin, and humectant prepara-tions differ in their action by attracting waterinto the skin either from the aDnosphere orby drawing water up from the dermis intothe epidermis. They are often used in thetreatment of dry thickened skin seen in ec-zema. They contain urea as the active in-gredient, which sometimes causes irritation.

EducationEducation of staff and residents can ensurecorrect usage and good results (Holden,2002). This includes the education of healthprofessionals in application and emollientpreparation choice. Inadequate prescriptionamounts, poor choice of product and pooradvice can quickly lead to ineffective use.

Regular application of up to i-A times aday should be recommended, but not to thedetriment of the resident's lifestyle. Compro-mise is often needed and it is important todemonstrate how to apply and how much,which can pay dividends in terms of skinresponse. It may be that only on or two ap-plications a day is possible and, if so, a moreheavy-duty emollient can be beneficial.The person applying the emollient shouldwear gloves and maintain short fingernailsto reduce risk of infection and trauma. An

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CLINICAL REVIEW

adult using emollients therapy will average500-600 g a week, possibly more if using asdual soap and emollient application. Thiswill vary depending on the severity and dry-ness of die individual's skin (Britton, 2003).Check prescriptions have not been automat-ed in error to prescribe 30 g aibes, as this isa common mistake.

OcclusionUsing bandages can help the emollient tostay in place and prevent it aibbing off ontoclothing or bedding. Paste bandages areoften used in the management of varicoseeczema, and it may well be that these areonly applied once or twice a week. Takeadvantage of die coverage and apply largeramounts; there is no need to rub in vigor-ously, just leave on the skin surface andcover. Where leg ulcération is concerned,emollients should be used to improve skinintegrity and provide barrier fLinction to thesurrounding skin. This will help in reducingdryness and irritadon to skin where skin tis-

sue infections, such as cellulitis, are prone(Wingfieid, 2009).

Topical corticosteroid treatmentTopical corticosteroid therapy is the maintreatment in the management of inflam-matory dennatoses, such as eczema.Emollients alone cannot control chronicinflamtnatory skin disease effectively. Ifprescribing both emollient and topical cor-ticosteroids, it is worth writing down theorder of application.

It is not uncommon in clinical practice tofind that the two therapies have been con-fused. With side effects such as skin thin-ning, this is a detrimental issue to residentsif the two are mixed up. Although there isno firm evidence as to which should beapplied first, it is recommended that sev-eral tninutes should be left between ap-plications (NHS Choices, 2011). Guidancefor the use of the fingertip method for ap-propriate steroid application should be fol-lowed (Findlay and Long, 1991).

the healing power of menthol A

. 0

o

the gentle menthol in aqueous crea

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Conclusion and recommendationsAll nurses in care homes play a major role inensuring adequate assessment of the olderperson's skin and advising on dry skin man-agement. Educating residents and healthprofessionals is essential to achieve bestresults in itnproving skin barrier fiinctionand resident cotiifort (Gradwell et al, 2002).

The older person's skin is susceptible tohomeostadc imbalance and requires timelydiagnosis and access to therapeutic agentsto reduce the risk of uncomfortable symp-toms, disease and infection. The use ofemollient tlierapy can accelerate the regen-eradon of the skin barrier funcdon (Held etal, 2001) and should not be underestimat-ed as a first-line treattnent. Nurses need toencourage best practice and, where possi-ble, give residents a choice of products toprotiiote concordance. Ensuring that thesepracdces are incorporated as mandatoryin any skin care protocol for nursing andresidential homes is essendal if we are toprovide intervendon that reduces the itnpact

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Nursing & Residential Care April 2013, Vol 15, No 4 199

CLINICAL REVIE Skin

Table 2. Creams, lotions and gel emollients (light duty)

Emoiiient

Creams

Cetraben Cream

Zerobase cream

Aquamol

Diprobase

Quantity

500g pump

500g pump

500g

500g

Soap

substitute

Disadvantages

Irritation/sensitivity

Humectants

Calmurid cream 500g pump x

Eucerin intensive 100ml / x

cream/lotion 250ml

Otiiers

Balneum Plus 500g pump •/cream

Dermol cream 500g pump •

Eczmol 1% w/w 250ml bottle •/cream

Aqueous cream 500g tub xmenthol 1%

Geis and iotion

Doublebase gel 500g pump

Dermol lotion 500ml pump •/

Irritation/sensitivity

Can sting on brokenskin

Irritation/sensitivity

Irritation/sensitivitySting on broken skinCross contamination

Irritation/sensitivity

Irritation/sensitivityMay need extragreasier emollient,antimicrobial candry skin

From: Wingfielä, 2011.

of skin disease, incontinence and enhancesresident wellbeing.

Acknowledgements: All images are includ-ed with consent of patients seen at Norfolkand Norwich University Hospital

Baranoski S, Ayello EA (2004) Wound Care Es-sentials, Practice Principles. Lippincott. Williamsand Wilkins, Springhorn PA

Beeckman D, Defloor T, Verhaeghe S et al (2010)Wliat is the mast effective method of preventingand treating incontinence associated dermatitis?http://www.nursingtimes.net/nursing-practice/clinical-zones/continence/ (accessed 8 March2013)

Bianchi J, Cameron J (2008) Assessment of skinintegrity in the elderly 1. Brf Community Nurs13(3): S26-32

Advantages/usage

Reduced risk ofcontaminationEasy to use

Maximized hydration

Emollient moisturizingaction

Reduced risk ofcontamination

Easy to useApply thinly

Contains lacromycrol;relief in itching

Antimicrobial; use ininfected eczema. ReducesS. aureus bacteria

Menthol has coolingeffect on skin-short termNight time use if wokenup with itching

See through pump; cansee when running out

Antimicrobial; use ininfected eczema. ReducesS. /Aureus bacteria

Bjornsdottir S, Gottfredsson M, Thorisdottir AS(2005) Risk factors for acute cellulites of thelower limb. A prospective case-controlled study.Clin Infect Dis 41: 1416-22

Britton J (2003) The use of emollients and theircorrect application, f Community Nurs 17(9):22-5

Clancy J, Smith S (2010) Psoriasis: A homeostaticapproach to care. Dermatological Nurs 9(3):16-22

Cork MJ, Timmins J, Holden C, et al (2003) Anaudit of adverse drug reactions to aqueouscream in children with atopic eczema. Pharma7271: 747-8

Ersser S (2000) Pmdtus (Itching). In: Encyclopediaof Care in the Elderly. Springer, New York

Ersser SJ, Maguire S, Nicol NH, Penzer R, PetersJ (2009) Be.st practice in emollient therapy; astatement for health care professionals. DermatolNurs 8(3): 1-22

Finlay AY, Long M (1991) The finger-tip unit - a

new practical measure. Clin Exp Dermatol 16(6):44-47

Ginard H, Gaputy G (2012) Benign Skin LesionsOverview of Benign Skin Lesions. http://emedi-cine.medscape.com/article/1294801-overview(accessed 8 March 2013)

Gradwell C, Thomas KS, English JS, Williams HC(2002) A randomised controlled trial of nursefollow up clinics- do they help free up consult-ants time. Brf Dermatol 147(3): 513-7

Gray M et al (2007) Incontinence- associated der-matitis: A consensus, f Wound Ostomy Cont Nurs34(1): 45-54

Haynes M (2008) The management of eczema inolder adult. In: Eczema from Birth to Old Age.Dermatolog Nurs 17(7 Supp)

Held E, Lund H, Agner T (2001) Effects of differentmoisturisers on SLS-irritated human skin. ContDerm 44(4): 229-34

Holden C, English J, Hoare C et al (2002) Advisedliest practice for the use of emollients in eczemaand other dry skin conditions./Dermato/og7reat 13(3): 103-6

Loden M (2003) Role of topical emollients andmoisturisers in the treatment of dry skin-barrierfunction. 4(11): 771-88

Madhulika A, Gupta MD, Gilchrest BA (2005)Psychosocial aspects of aging skin. DermatologyClinics 23(4): 643-8

Nazarko L (2007) Maintaining the condition of age-ing skin. Nurs Residential Care 9(4): 160-3

National Institute for Health and Clinical Excellence(2007) Atopic Eczema in Children. Managementof atopic eczema in children from birth to tl-ieage of 12 years. NICE clinical guidelines 57.NICE, London.

NHS Choices (2011) Contact dermatitis, www.nhs.uk/Conditions/Eczema/(contact-dermatitis)/Pages/Treatment.aspx (accessed 12/9/2011)

NHS Inform (2011) Emollients Introduction/HealthLibrary http://www.nhsinform.co.uk/health-library/articles/e/emollients/introduction.aspx(accessed 8 March 2013)

Norman RA (2003) Geriatric dermatology. DermatolTherap 16: 260-8

Rawlings AV, Canestrari DA, Dobkowski B (2004)Molstudser technology versus clinical perform-ance. 7 Derma/o/o Therapy 17(suppl 1): 49-56

Rittié L, Fisher G (2002) llV-light-induced signal cas-cades and skin aging. Aging Res Rev 1: 705-20

Sibbald R et al (2003) Intact skin - an integrity notto be lost. Ostomy/Wound Management 49(6):27-33

Tsang M, Guy RH (2010) Effect of Aqueous CreamBP on human stratum corneum in-vivo. Brfour-nal of Dermatology 163(5): 954-8

Wingfield C (2009) The importance of .skin care inchronic oedema. Wound Essentials A: 26-34

Wingfield C (2011) Skin Care: Managing Dry SkinConditions. Wound Essentials 6\ 104-111

Wingfield C (2012) Skin cancer: an overview ofassessment and management . Primary HealthCare lliS): 28-37

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