Download Skin Care 101 In Long Term Care

Understanding Skin
to Promote
Skin Wellness
for your Residents
Skin Care 101
In Long Term Care
2010 GOJO Industries, Inc. All rights reserved.
Training topics
 Skin and an aging population
 Understanding skin structure
and function
 Fundamentals of aging skin
 Understanding compromised
skin in the elderly
 Understanding skin regimen
principles*
*excluding wound care
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Skin Care 101 In Long Term Care
Skin and an aging population
In Memoriam
Albert M. Kligman, M.D. PH.D.
1916 - 2010
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No one dies of old skin! No matter how
decrepit the integument becomes after a
lifetime of assaults, it continues to perform
its primary protective role. But, although
skin diseases do not contribute importantly
to mortality statistics, skin problems
abound in the aged.
Skin Care 101 In Long Term Care
Skin and an aging population
 By 2050 one of every five people in the world will be older than
65 years
 By 2030 America’s population greater than 65y will grow by
30M to 70M people
 The vast majority of people above this age have at least one
skin problem
 Skin dryness (xerosis) and itching (pruritus) are the top two most
common problems
 Subjects older than 65y account for 88.2% of all reported
skin tears
 The elderly population has rapidly increasing needs for skin care
Norman RA. Aging: an overview. Dermatologic Therapy 16, 2003: 181-185. Norman RA. Xerosis
and pruritus in the elderly: recognition & management. Dermatologic Therapy 16, 2003: 254-259.
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Skin Care 101 In Long Term Care
What does your skin do?
 Provides protection against effects of
the environment especially sunlight
 Controls against excessive body water
loss but keeps itself moist
 Regulates body temperature through
sweating and blood supply
 Senses the environment through touch
and pressure but also pain
 Is a primary immunological organ
protecting against infections
 Is involved in vitamin D synthesis
for your body
 Excretes non-essential compounds
through sweating and cell loss
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Skin Care 101 In Long Term Care
Structure of the skin
Outer skin layer
Epidermis
Middle skin layer
Dermis
Deepest skin layer
Hypodermis
Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008
Mar;13(3):S26, S28, S30-2
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Skin Care 101 In Long Term Care
Function of skin layers
LAYER
7
STRUCTURE
FUNCTION
Stratum
Corneum
Corneocytes, lipids,
natural moisturizing factors
Physical, chemical and antimicrobial barrier.
Controls skin pH. Transduces touch to
epidermal nerve fibers.
Epidermis
Keratinocytes mature into
corneocytes to provide UV
protection via melanin.
Immune cells present.
Nerve fibers are present.
Forms stratum corneum natural moisturizing
barrier. Provides melanin pigment for skin
protection. First level of body immunity. Skin
feelings via nerve fibers and merkel cells.
Dermis
Fibroblasts making
collagen etc, hair follicles,
sebaceous glands, sweat
glands. Touch and
pressure sensing cells
present. Blood vessels.
Strength and elasticity of skin. Sebum and
sweat delivered to skin surface. Touch,
pressure and vibrations sensed.
Thermoregulation.
Subcutaneous
Layer
A dipocytes making fat
tissue and fibroblasts
making collagen etc.
Temperature insulation. Mechanical cushioning.
Energy reserve.
Skin Care 101 In Long Term Care
Stratum corneum (the top layers of skin)
Skin Care 101 In Long Term Care
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Rawlings AV et al. Stratum corneum moisturisation at the molecular level. J. Invest. Dermatol. 103:731-40; 1994
Dry skin occurs on all aged body sites
Dry skin or skin xerosis
http://www.health.com/health/gallery/0,,20307059_6,00.html
Bianchi et al. Assessment of skin integrity in the elderly. (Part 1)
Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2
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Skin Care 101 In Long Term Care
Aged dry skin: faulty desquamation
Normal photograph
High resolution micrograph
Healthy Skin
Smooth Skin
Dry Skin
Flaky Skin
Dry skin has less stratum corneum lipids, natural moisturizing factors
and desquamatory enzymes and has an itchy flaky skin surface
Rawlings et al. Stratum corneum moisturization at the molecular level: an update in relation to the dry skin cycle.
Journal Of Investigative Dermatology 124: 1099-1110, 2005.
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Skin Care 101 In Long Term Care
Aged dry skin = more body itching
 Increased body itching occurs in aged
skin due to reduced skin moisturization
and increased dry skin
 Mechanical trauma induced by
scratching further compromises barrier
function leading to a dry skin cycle
 Aged skin has a decreased sense of
feeling and constant mechanical trauma
can lead to increased risk of tissue
injury
 Longer wound repair times result in
higher morbidity in the aged
http://www.health.com/health/gallery/0,,20307059_1,00.html
Leveque et al. Changes in tactile spacial discrimination by skin hydration in the elderly. J Invest Dermatol. 115: 454-458, 2000.
Farage et al. Degenerative changes in aging skin. . In: Skin Aging. Eds: Farage et al. Chapter 4: 25-35, 2009.
Rawlings et al. Stratum corneum moisturization at the molecular level: an update in relation to the dry skin cycle. Journal Of
Investigative Dermatology 124: 1099-1110, 2005.
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Skin Care 101 In Long Term Care
Problems of the aging foot
 Generalized xerosis (dry skin)
 Thickening of the stratum
corneum (hyperkeratosis)
leads to corns on toes or
calluses on soles or heels
 Itching, burning, numbness,
cramp
 Diabetes can make these
worse
http://www.health.com/health/gallery/0,,20307059_6,00.html
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Skin Care 101 In Long Term Care
Generalized xerosis
Melanocytes and skin aging
30-40 KERATINOCYTES
PER MELANOCYTES
EPIDERMAL
MELANIN UNIT
Aging skin makes
less melanin but
it becomes more
concentrated in
‘age spots’
MELANIN EXFOLIATION
WITH CORNEOCYTES
MELANIN DEGRADATION
& OXIDATION
MELANSOMES
TRANSFERRED TO KTs
MELANIN SYNTHESIS
IN MELANOCYTES
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Skin Care 101 In Long Term Care
Dermis and skin aging
Flattening of the
connections between
the epidermis and
dermis
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Skin Care 101 In Long Term Care
Normal skin aging
FEATURE
Clinical
appearance
INTRINSIC AGING
Smooth texture, unblemished surface.
Fine wrinkles. Some deepening of skin
surface markings. Some loss of
elasticity, redundant skin.
PHOTOAGING
Nodular, leathery surface, Sallow
complexion, yellowish mottled,
pigmentation. Coarse wrinkles.
Severe loss of elasticity.
Kafi R et al. Improvement of naturally aged skin
with vitamin A.Arch Dermatol. 2007
May;143(5):606-12.
Physiological variations during aging. Pierard et
al. In: Skin Aging.Eds: Farage et al. Chapter 6:
45-54, 2009
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Skin Care 101 In Long Term Care
Aging and skin problems
Thick, scaly skin / Hyperkeratosis
Acute Eczema
Blister, Bullae
Allergy
Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2
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Skin Care 101 In Long Term Care
Fragile aged skin: Dermatoporosis
Table 1. Proposed clinical staging of dermatoporosis: a basis
for further evidence-based quantitative definitions
Stage I
Stage II
Stage III
Stage IV






Skin
atrophy
Senile
purpura
Pseudoscar
Skin
laceration
Dissecting
hematoma
+
+
+
+
+
+
+
+
+
+
+
+
–
+
++
++
–
–
–
+
Skin thinning (Skin atrophy)
Skin bruising (Senile purpura)
Skin scarring (Pseudoscar)
Skin tears
(Skin laceration)
Skin ulcers
(Dissecting hematoma)
Decreased pain perception & tactile sensitivity
with aging leads to higher risk of trauma
Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome.
Dermatology 2007, 215: 284-294
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Skin Care 101 In Long Term Care
I
II
III
IV
Dermatoporosis and skin tear grading
http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/PublishingIma
ges/01-Fig3.JPG
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Skin Care 101 In Long Term Care
Fragile aged skin: Dermatoporosis
Young
Old
Aged skin shows:
skin thinning (atrophy) i.e. more transparent skin, bruising (senile purpura)
and scarring (linear white pseudoscars). These occur because of repetitive
mechanical trauma to the skin and the lack of skin integrity due to the
thinning if the skin.
Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome.
Dermatology 2007, 215: 284-294
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Skin Care 101 In Long Term Care
Aging and loss of collagen
Old
Young
Histologically aged skin shows:
A decrease in collagen (less red staining)
Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous
insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294
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Skin Care 101 In Long Term Care
Skin aging summary
 Drier, rougher and flaky skin
 Less SC water, lipids, NMF
and enzymes
 Decreased cell turnover
 Increased age spots
 Weakened epidermal/
dermal connections
 Decreased skin feeling
 Presence of dermatoporosis
– Skin atrophy (thinning and
less collagen)
– Senile purpura or bruising
– Pseudoscars
– Skin tears
– Skin ulcers
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Skin Care 101 In Long Term Care
Causes of elderly skin damage
 Weather and air conditioning
– Especially cold and/ or dry






Physical insult and friction
Irritation from chemicals
Use of aggressive soaps
Prolonged occlusion
Lessened hygiene habits
Insufficient skin moisturization
Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2.
Bianchi et al. Management of skin conditions in the older population.
Br J Community Nurs. 2008 Sep;13(9):S6, S8, S10.
Ratliff et al. Skin teas: A review of the evidence to support prevention & treatment. Ostomy Wound Manage. 2007
Mar;53(3):32-4, 36, 38-40
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Skin Care 101 In Long Term Care
Poor nutrition: more aged skin
 The elderly can have a substandard diet especially in protein
 Increased fat and carbohydrate intake increases risk of skin
thinning or atrophy
 Insufficient intake of fruit and vegetables can lead to increased
risk for skin bruising (purpura) and more skin photodamage
 Higher intake of vitamin C leads to less aging appearances
 Iron deficiency can result in anemia and skin itching (pruritus)
 Zinc deficiency and vitamin deficiency can impair wound healing
 Essential fatty acids and vitamin A deficiencies lead to increased
risk of skin dryness (xerosis) and skin thinning (atrophy)
 Poor fluid intake can lead to poor skin hydration
Physiological variations during aging. Pierard et al. In: Skin Aging. Eds: Farage et al. Chapter 6: 45-54, 2009
Nutrition & skin aging. Cosgrove et al. In: Aging Skin. Eds: Rhein et al. Chapter 13: 377-390, 2010
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Skin Care 101 In Long Term Care
Well-conditioned skin is the basis of prevention
Maintaining healthy skin barrier is the best way
to prevent many aging skin problems
Apply this concept
to the elderly
Healthy skin
Dry skin
Recommended Care = Gentle Contact + Mild Cleansing + Regular Moisturizing
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Skin Care 101 In Long Term Care
Preserving and Protecting the Skin of
Long-term Care Residents
 Encourage nutritious food and adequate fluid intake
 Use a gentle touch, warm water and mild cleansers for
routine bathing
 Cleanse immediately if incontinent of urine or stool and
use a barrier ointment routinely
 Use absorbent pads or briefs to wick moisture away
from the skin
 Apply moisturizers often and minimize environmental
factors such as exposure to low humidity and cold.
 Avoid massage over bony prominences
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Skin Care 101 In Long Term Care
Preserving and Protecting the Skin of
Long-term Care Residents
 Include mental status and the ability to respond to pain
or discomfort when assessing for risk of skin breakdown
 Promote mobility and range of motion exercises
 If confined to bed, change position at least every 2
hours
 Minimize friction and shearing by using proper
technique when positioning, transferring and turning
 Encourage resident and family involvement in the plan
of care for skin preservation
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Skin Care 101 In Long Term Care