16 Nursing Times 04.12.12 / Vol 108 No 49 / www.nursingtimes.net

Nursing PracticeReviewSkin health

Keywords: Skin/Skin health/Ageing/Older people ●This article has been double-blind peer reviewed

Ageing affects skin’s barrier function

Author Fiona Cowdell is senior research fellow and graduate research director at the Faculty of Health and Social Care, University of Hull; Kathy Radley is lecturer in skin health and dermatology care at the Faculty of Health and Social Care, University of Hull, and clinical nurse specialist, dermatology at United Lincolnshire Hospitals Trust.Abstract Cowdell F, Radley K (2012) Maintaining skin health in older people. Nursing Times; 108: 49, 16-20.The article examines general skin care for older people, skin barrier function and the skin changes associated with the ageing process. Skin assessment and the use of washing products and emollients are discussed. Methods by which older people and nursing staff can help to promote and improve skin health are identified.

As the skin ages it becomes less able to perform its key barrier functions and skin breakdown becomes an increasing risk.

This can have a detrimental impact on quality of life with major economic impli-cations (Gardiner et al, 2008), so skin health is essential to the wellbeing of older people and a central component of nursing care. It is estimated that approximately 70% of older people in the UK experience skin problems, many of which are prevent-able (Associate Parliamentary Group on Skin, 2000).

This article summarises the structure and function of the skin, describes intrinsic and extrinsic changes to it in older age, and looks at skin assessment. It also explores evidence for use of washing products and emollients, and strategies to support patients to self-manage skin health.

5 key points 1 Age-related

changes reduce the ability of the skin to perform its barrier function

2Skin health is essential to the

wellbeing of older people

3Nurses are in the unique

position of having regular opportunities to assess older people’s skin

4Skin care regimens

should be individualised ensuring skin is clean and dry and that adequate emollients are used

5Older people should be

supported to self-manage their own skin care as much as possible

Structure and function of the skinThe skin is the largest organ of the body, covering approximately 2m2 (Penzer and Ersser, 2010). It performs a number of functions including: » Maintaining an effective barrier

between the environment and internal organs;

» Regulating temperature;» Storage;» Sensation; » Vitamin D synthesis.

This article focuses on the barrier func-tion and how it is affected by age.

The skin has two main layers: the epi-dermis (outer layer) and the dermis. These provide supportive structures allowing the epidermis to function (Fig 1). The stratum corneum provides the skin barrier. In normal skin it is resilient, protecting the underlying skin from the penetration of irritants and allergens and preventing the loss of water from the body.

The corneocytes are full of water; this results in a smooth barrier with no cracking between the corneocytes, which also contain high levels of natural moistur-ising factor (NMF) – a humectant. Normal skin is smooth and elastic and does not itch (Cork and Danby, 2009). The natural pH of the skin is slightly acidic – between 4 and 5.5 – providing protection from microbes (Cowdell, 2010). Damage to the skin barrier allows for water to be lost and irritants and allergens to be introduced, leading to inflammation (Cork et al, 2006).

Skin ageingAs we age the skin is affected both by intrinsic and extrinsic factors. Intrinsic ageing is the “programmed” true biolog-ical changes (Lawton, 2007), summarised

In this article... Skin care for older people Approaches to skin assessment Methods of promoting skin health in older people

Age-related changes in the skin mean older people are at increased risk of skin breakdown, and should be supported to maintain good skin health

Maintaining skin health in older people

18 Nursing Times 04.12.12 / Vol 108 No 49 / www.nursingtimes.net

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in Table 1. Extrinsic factors, such as damage from exposure to the environment (Lawton, 2007) and, in particular, the sun (ultraviolet exposure), also affect skin ageing. Other extrinsic factors include smoking, environmental pollutants (Lawton, 2007), reduced peripheral sensa-tion, reduced mobility, incontinence, depression and dementia, polypharmacy, diabetes and vascular changes, and poor nutrition (Finch, 2003). Although ageing cannot be prevented, strategies to enhance skin-barrier function can be used and the risk associated with extrinsic factors can be reduced.

It is estimated that at least 70% of older people will have a skin problem (APGS, 2000) and skin conditions are one of the most common reasons for primary care consultations (Schofield et al, 2011). Davies (2008) identified skin conditions that com-monly affect older people, including eczema, psoriasis, infections and infesta-tions, and pruritus. Many of these are asso-ciated with dry skin and itching.

Skin assessment There is evidence of under-reporting of skin problems in older people (Kirkup, 2006) possibly because they see skin deteri-oration as an inevitable part of ageing and believe no help is available. Fanos and Laird (2001) also note that clinicians may see con-cerns as trivial. It is therefore important that nurses routinely enquire about skin health in older people, and undertake accu-rate and thorough skin assessment to iden-tify problems (Nazarko, 2009).

Assessment is not a one-off activity but an ongoing process, involving monitoring change and response to treatment. It should include: » Listening to the patient;» A detailed visual inspection of the skin; » Touching the skin to assess texture,

moisture, turgor and temperature;» Smelling to check for distinctive

odours (Cowdell, 2010). Finch (2003) gave a detailed explanation

of skin assessment. If any skin problems are identified on general assessment, fur-ther assessment, investigation and com-pletion of risk assessment tools should be undertaken as required.

Skin care Skin care is one of the cornerstones of nursing practice but the importance of general skin care is an area of practice that is often overlooked (Castledine, 2003). However, maintaining or improving skin health is generally neither costly nor diffi-cult. Simple, low-cost interventions can have a positive impact on quality of life and help to prevent skin breakdown.

Skin hygiene is essential for skin health and important in promoting personal wellbeing. For older people with dry skin it is particularly important to achieve a bal-ance between cleanliness and over-washing, which may damage the barrier function (Voegeli, 2008a). Use of appro-priate washing products and emollients can contribute to maintaining skin health.

Washing products The lack of evidence base for bathing prac-tices means they are frequently guided by ritual (Voegeli, 2008b). Both nurses and older people may be reluctant to relinquish tried and tested practices.

Washing with soap and water remains the standard method of skin cleansing (Ersser et al, 2005) and is recommended in many nursing texts (for example, Downey and Lloyd, 2008; Dougherty and Lister, 2008). However, this can cause an increase in skin pH (Korting et al, 1987), which can alter the skin’s normal bacterial flora, increasing the likelihood of colonisation

with more pathogenic organisms (Cooper and Gray, 2001). The increase in pH can also damage the skin barrier and cause irri-tation (Kirsner and Froelich, 1998). Soap also removes lipids from the surface of the skin and overwashing removes NMF (Pe ters, 2001), resulting in further skin dry-ness. If acceptable to the individual, using emollient and soap-substitute products rather than soap will help to maintain skin health.

EmollientsEmollients increase the amount of water held in the stratum corneum, either by occlusion (trapping the water in and pre-venting evaporation), or by actively drawing water into the stratum corneum from the dermis (Ersser et al, 2009). They play a crucial but often undervalued role in skin health and are the mainstay of thera-peutic treatment for older patients with dry and itchy skin. Although their benefits are widely acknowledged in the field of dermatology, they have tended to be undervalued and underused in general care (Lawton, 2010). Adverse effects from emollients are rare, although occasionally sensitisation to an ingredient may occur.

There are many formulations of topical emollients including ointments, creams, lotions, gels and sprays. Ointments are the greasiest preparations and often contain paraffin; creams are an emulsion of oil and water; lotions are the least greasy, making them less effective as an emollient. Cos-metic acceptability is, however, an impor-tant consideration. Some products contain humectants such as urea or lipids (NMF), which provide excellent moisturisation (Lawton, 2010). Emollients alone may be sufficient to alleviate skin dryness but can be considered as adjuvant therapy along-side other topical or systemic treatments in chronic skin conditions such as eczema or psoriasis (Ersser et al, 2009).

There is little scientific evidence on how to apply emollients, although it is gener-ally agreed they should be applied using a gentle stroking motion following the lie of the hair on the body (Penzer and Ersser, 2010). This rationale is based on the prin-ciple that rubbing with a greasy emollient may lead to an irritated or blocked hair fol-licle and subsequent folliculitis. Ersser et al (2009) recommend application of emol-lients during the day at times convenient to the individual – this may be as fre-quently as every 2-3 hours, and at bedtime. A more greasy emollient may be accept-able for use overnight, so it is important that an adequate supply and several prepa-rations are available.

fig 1. STrucTure Of The SKiN

Hair shaft

Sweat pore

Sensory nerve ending

EPIDERMIS

DERMIS

SUBCUTANEOUS LAYER (hypodermis)

VeinArtery

Sweat gland

Hair follicle

Stratum granulosum

Stratum corneum

Pigment layer

Stratum spinosumStratum basale

Nursing PracticeReview

20 Nursing Times 04.12.12 / Vol 108 No 49 / www.nursingtimes.net

Self-careSelf-care and self-management are central to UK health policy (Department of Health, 2005) and undoubtedly the majority of older people would prefer to meet their own skin-care needs as far as they are able. Nurses should facilitate self-care wherever possible to ensure effective skin care and minimise deterioration in condition (Burr, 2007).

Many older people can care for their own skin provided they have sufficient know- ledge, skills and confidence to do this (Ban-dura, 1997). They may face difficulties such as reduced mobility and dexterity, cognitive impairment, increased frailty and difficult social circumstances but these can often be minimised or overcome if the multidisci-plinary team is involved and they are advised on different techniques or enabled to use appropriate aids. Concordance with skin care regimens can be enhanced using a range of strategies summarised in Box 1.

conclusionSkin health is essential to the wellbeing of older people and a fundamental aspect of nursing care. Nurses should regularly assess the skin health of older patients, promote self-care and encourage the use of appropriate products. NT

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Burr S (2007) How to assess and manage older people’s skin. Dermatological Nursing; 6: 4, 28-32.Castledine G (2003) Forgotten importance of giving a bed bath. British Journal of Nursing; 12: 8, 519.Cooper P, Gray D (2001) Comparison of two skin care regimes for incontinence. British Journal of Nursing; 10: 6 (suppl) S6-S10.Cork M et al (2006) New perspectives on epidermal barrier dysfunction in atopic dermatitis: gene-environment interactions. Journal of Allergy and Clinical Immunology; 118: 1, 3-21.Cork MJ, Danby S (2009) Skin barrier breakdown: a renaissance in emollient therapy. British Journal of Nursing; 18: 14, 872-877.Cowdell F (2010) Promoting skin health in older people. Nursing Older People; 22: 10, 21-26.Davies A (2008) Management of dry skin conditions in older people. British Journal of Community Nursing; 13: 6, 250-257.Department of Health (2005) Supporting People with Long-term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. London: DH.Dougherty L, Lister S (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.Downey L, Lloyd H (2008) Bed bathing patients in hospital. Nursing Standard; 22: 34, 35-40.Ersser S et al (2009) Best practice in emollient therapy: a statement for healthcare professionals. Dermatology Nursing; 8: 3 (suppl): S1-22.Ersser S et al (2005) A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies; 42: 823-835.Fanos N, Laird R (2001) Management of common skin disorders in the elderly. Family Practice Recertification; 23: 10, 15-30.Finch M (2003) Assessment of skin in older people. Nursing Older People; 15: 2, 29-30.Fore J (2006) A review of skin and the effects of aging on skin structure and function. Ostomy Wound Management; 52: 9, 24-37.Gardiner L et al (2008) Evidence-based best practice in maintaining skin integrity. Wound Practice and Research; 16: 2, 5-15.Gradwell C, McGarvey S (2006) Patients with a dry skin condition receiving seamless care throughout their journey. Dermatology Nursing; 5: 2, 8-10.Joint Formulary Committee (2011) BNF 61. London: Pharamceutical Press.

Kirsner R, Froelich C (1998) Soap and detergents: understanding their composition and effect. Ostomy/Wound Management; 44: (3A suppl) 62S-70S.Kirkup M (2006) The National Service Framework for Older People. British Journal of Dermatology Nursing; 10: 1, 5-7.Korting H et al (1987) Influence of repeated washings with soap and synthetic detergents on pH and resident flora of the skin of forehead and forearm. Results of a crossover trial in health probationers. Acta Dermato-Venereologica; 67: 1, 41-47.Lawton S (2010) Addressing the skin-care needs of older people. Nursing and Residential Care; 12: 4, 175-181.Lawton S (2007) Addressing the skin-care needs of the older person. British Journal of Community Nursing; 12: 5, 203-210.Nazarko L (2009) Caring for older skin: preventing and treating dryness. Nursing and Residential Care; 11: 7, 333-337.Nazarko L (2005) Part one: consequences of ageing and illness on skin. Nursing and Residential Care; 7: 6, 255-257.Penzer R, Ersser SJ (2010) Principles of Skin Care. Chichester: Wiley-Blackwell.Peters J (2001) Caring for dry and damaged skin in the community. British Journal of Community Nursing; 6: 12, 645-651.Schofield JK et al (2011) Skin conditions are the commonest new reason people present to general practitioners in England and Wales. British Journal of Dermatology; 165, 1044-1050.Secker J et al (2005) Theories of change: what works in improving health in mid-life. Health Education Research; 20: 4, 392-401.Voegeli D (2009) The management of dry skin conditions in older adults. Nursing and Residential Care; 11: 4, 182-188.Voegeli D (2008a) LBF ‘no-sting’’ barrier wipes: skin care using advanced silicone technology. British Journal of Nursing; 17: 7, 472-476.Voegeli D (2008b) The effect of washing and drying practices on skin barrier function. Journal of Wound, Ostomy and Continence Nursing; 35: 1, 84-90.Ward S (2005) Eczema and dry skin in older people: identification and management. British Journal of Community Nursing; 10: 10, 453-456.

Nursing PracticeReview

TAble 1. iNTriNSic chANgeS iN AgeiNg SKiNintrinsic skin change effect on skin

Reduction in skin cell turnover – skin gradually becomes more fragile as the epidermis thins and integrity between epidermis and dermis reduces

● Papery appearance ● Less-effective barrier ● More prone to mechanical injury and damage from moisture, friction and trauma

Blood vessels become more fragile – blood supply to the skin is reduced

● Skin becomes more prone to bruising and damage

Collagen fibres that provide structural support stiffen – elastic fibres thicken

● Creases and wrinkles form● More prone to tearing and shearing

Production of sebum decreases ● Skin becomes drier● Vulnerable to splitting, cracking and infection ● Sensitivity to irritants increases

Sweat glands become smaller and secrete less sweat

● Skin becomes more dry ● Less-effective temperature control

Sources: Ersser et al (2009); Fore (2006); Nazarko (2005); Ward (2005); Finch (2003)

● Products should be readily available (Lawton, 2007)● Products should be chosen by users and be acceptable to them (Gradwell and McGarvey, 2006)● Instruction should be provided (written where appropriate) (Bleiker and Graham-Brown, 2000) and should be precise, including quantities to use (Voegeli, 2009)● Regimens should be individualised (Secker et al, 2005)● Lifestyle should be considered when agreeing care plans (Bianchi and Cameron, 2008)● If using emollients in the bath or shower, individuals should be advised of the danger of slipping ● If using paraffin-based products, individuals should be aware of fire risk (Joint Formulary Committee, 2011)

box 1. STrATegieS TO SuppOrT Self-cAre