Evaluation of a Once-Daily Moisturizer Used to Treat Xerosis in Long-Term Care Patients
The body’s largest organ, the skin provides a barrier between an individual and the environment. The skin performs many functions — it protects against infectious micro-organisms, ultraviolet light, noxious substances, and excess fluid/electrolyte loss and provides the means for thermoregulation, sensation, metabolism, and communication.1 The stratum corneum (horny layer) is continuously exposed to the outside environment and provides the first line of protection, serving as a vital part of the body’s immune system.2
Xerosis (dry skin) is characterized by pruritic, erythemic, dry, scaly, cracked, or fissured skin (see Figure 1) and is a result of the loss of natural moisturization factors and barrier abilities, as well as epidermal water loss. Some bathing and skin treatment practices also are believed to contribute to or exacerbate dry skin.1,3-5 Xerosis occurs most often on the legs but may be present on the hands and trunk. It is a problem for 59% to 85% of people older than 64 years6; it is one of the most common dermatological conditions found in long-term care.7 Evidence suggests that xerosis increases the risk for additional clinical problems such as discomfort, pruritus, infection, skin tears, and pressure ulcers.8-11 The purpose of the product evaluation was to determine whether a new therapeutic moisturizing cream decreases the symptoms of xerosis.
Pathology. In healthy skin, skin cells called corneocytes detach from neighboring cells and are replaced by younger cells from the deeper layers. This orderly process of skin cell loss from the skin surface (desquamation) is controlled primarily by two intercellular components, corneodesmosomes and lipids, that provide for the maintenance of tissue thickness. Corneodesmosomes bind the corneocytes to maintain intercellular cohesion and tissue integrity and eventually must be broken down for desquamation to be effective. In healthy skin, this process, corneodesmolysis, eliminates the corneodesmosomes.12 In xerotic skin, corneodesmosomes persist and disturb the orderly desquamation process, resulting in the formation of visible, powdery flakes on the skin surface.13
Free water also is necessary to control the corneodesmolysis process. Adequate lipid content is required to retain the free water. Inadequately hydrated skin cannot provide this free water; therefore, deficits in both skin hydration and lipid content play a key role in xerosis.12 Consequently, the skin’s inability to retain moisture and provide an effective barrier directly affects the development of xerosis.14,15
A number of situations impact the skin’s moisture depletion. For example, xerosis tends to relapse in the winter when humidity is low.12 The daily use of cleansers and/or bathing without replacing natural skin emollients results in epidermal water loss and a depletion of skin lipids.16 Pre-existing disease states (ie, end-stage renal disease, nutritional deficiency, thyroid disease), therapies (eg, radiation), and medications render an individual more susceptible to xerosis.17
The link between xerosis and pruritus, infection, skin tears, pressure ulcers and pain.
Pruritus. Pruritus is the unpleasant sensation that elicits the urge to scratch. It has been cited as the most common and distressing anti-inflammatory skin condition.18 Although pruritus has several different causes, xerosis is thought to be associated with up to 85% of pruritus cases.3
Infection. The scratching and rubbing of pruritus produces excoriation, inflammation, or secondary lesions. Subsequently, environmental allergens and pathogens can easily penetrate the skin, increasing the risk of allergic and irritant contact dermatitis and infection.
Staphylococcus and streptococcus species are part of the normal flora of the skin but when the stratum corneum is compromised due to pruritus, these species become sources of infection such as impetigo. Scratching also can drive pathogens into a wound or lesion to cause infection.7
Pressure ulcers. Pressure ulcers are areas of localized tissue destruction caused by the compression of soft tissue over bony prominence and an external surface for a prolonged period of time. More than 1 million individuals develop pressure ulcers each year. In the US alone, approximately 1.5 to 3 million adults are living with pressure ulcers.19 The average hospital incurs $400,000 to $700,000 annually in direct costs to treat pressure ulcers.20 Dry stratum corneum generally is accepted as a precursor to pressure ulcer development. Pressure ulcer development can be partially offset by the use of moisturizers to facilitate stratum corneum hydration.9,19,21 This is particularly important for the elderly patient population; aging skin is drier, more prone to cracking, and slower to recover from the effects of cleansing products.22
Healthcare agencies that implement focused skin care protocols to prevent pressure ulcers and intervene as early as possible have been able to demonstrate reductions in the prevalence and incidence of pressure ulcers.23,24 Based on expert opinion and panel consensus, the AHRQ Pressure Ulcer Prediction and Prevention Guidelines recommend that dry skin be treated with moisturizers.9
An early study21 followed the occurrence of pressure ulcers over an approximately 10-year period using data from the first National Health and Nutrition Examination Survey (NHANES 1) Epidemiologic Follow-up Study. Individuals who developed pressure ulcers were identified through death certificates, discharge summaries, or self/proxy-report. Risk factors for pressure ulcer development were evaluated using the NHANES baseline data. Individuals with pressure ulcers were compared with the remainder of their cohort as well as a control group matched for age or length of hospital or nursing home stay. Dry or scaling skin was found to significantly increase the risk of pressure ulcer development.
Cole and Nesbitt11 conducted a multiphase project to measure the effects of skin integrity interventions on the incidence of pressure ulcers in a 154-bed hospital in Canada. In one phase of the study, researchers found that implementing an all-body liquid skin cleanser, longer lasting lotion, no-rinse perineal cleanser, and a perineal skin protectant cream significantly reduced the incidence of pressure ulcers from 17.9% to 5.2% (Z score of 2.50).
One quasi-experimental pre-test/post test study10 assessed the effectiveness of adding moisturizing skin care products and perineal barriers to the prevention protocols used with residents of two long-term care facilities (N = 136). Results showed a statistically significant (P = .000) decrease in pressure ulcer incidence from 19.9% to 8.1%.
Skin tears. Malone and colleagues25 estimated that at least 1.5 million skin tears occur annually in institutionalized elderly. Skin tears cause pain and increase the cost of care for residents in long-term care facilities. One study26 examined the expense of dressing changes for skin tears in a long-term care facility and found that one skin tear cost $19.26 per month in dressing costs and 24 minutes per month in nursing time.
Mason’s27 4-month prospective study found that a 173-bed long-term care facility decreased its rate of skin tears by 34.8% after switching from using a non-emollient to an emollient cleanser.
White et al28 conducted a 6-month retrospective review of incident reports involving lacerations and abrasions in a 120-bed, long-term care facility. The study revealed that, on average, 14% of the population sustained a skin tear each month. A 12-month concurrent evaluation of incident reports found that dry skin was among the many risk factors for developing skin tears. When moisturizing the arms and legs twice a day was incorporated into a standardized care plan to minimize risk for skin tear development, the incidence of skin tears decreased 50%.
Hunter et al’s10 quasi-experimental pre-test/post test study found that skin tears were the most common type of skin breakdown identified by study participants. Researchers noted a decrease in the prevalence of skin tears from 32 (47%) to 17 (42%) after implementing moisturizing skin care products and barriers.
Pain/discomfort. Patient comfort and pain control are important concerns in today’s healthcare environment. It is generally accepted that pruritus is uncomfortable29 and that wounds are painful.19 The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released revised standards for the assessment and management of pain for all patients in healthcare institutions; accreditation is provided only if institutions demonstrate processes are in place to assess and manage pain appropriately in all patients.30
Treatment of xerosis. To treat the symptoms of severe cases of xerosis and pruritus, short-term use of topical corticosteroids and antipiretics may be necessary. However, an effective skin care routine can prevent or break the xerotic cycle before secondary complications occur.31 Moisturizing products have been shown to be an important part of xerosis prevention and treatment and range from lotions to therapeutic creams (see Table 1).32
According to product labels, general moisturizers and lotions require at least twice-a-day application for the prevention of dry skin.
An exfoliating product that contains urea and lactic acid to remove or exfoliate dry stratum corneum also adds moisture. Most exfoliating products require a prescription and twice-a-day use is recommended.32 In a 40-patient prospective, randomized, controlled double-blind study,32 one over-the-counter product containing 10% urea and 4% lactic acid resulted in a statistically significant (P = 0.007) decrease in the severity of xerosis.
Super moisturizers, a term coined by the industry to describe moisturizers used to prevent and treat xerosis, contain a potent humectant and provide continuous moisture while preventing moisture loss. According to the product labels, a once-a-day application of a super moisturizer is considered sufficient for preventing and treating xerosis.
Methods and Materials
Purpose/product description. A 5-day prospective study was conducted to determine if a new therapeutic moisturizing cream decreases the symptoms of xerosis (dry skin, erythema, and pruritus) when applied once a day for 5 days. The product evaluated (Sween® 24, Coloplast Corp., Marietta, Ga.) is an over-the-counter fragrance-free, lanolin-free moisturizing skin protectant cream containing dimethicone 6%. Manufacturer directions state that the cream can be applied as often as desired; however, the product label states that “only one application a day is needed to prevent and treat xerosis.”
Ethical review. Permission to conduct the evaluation was obtained by the wound care specialist from the facility administrator and the Director of Nursing. Because the product was already on the market and skin assessments regarding moisturization did not exceed regular patient care standards, the study did not require written participant consent or Institutional Review Board approval. Patients provided verbal consent to participate in the evaluation. Data collected were/are kept confidential in a secure area.
Subjects/setting. The evaluation was conducted in a 300-bed, long-term care facility with on-site dialysis and high acuity due to its proximity to a trauma center. The patient unit was chosen for participation in the evaluation because of an 18% prevalence of xerosis.
Inclusion criteria included 1) the presence of flaking on at least one extremity and 2) verbal consent to participate in the evaluation.
Skin assessment. Clinical indicators used to assess dry skin included:
• redness — inflammation varying from pink to bright red in area of xerosis
• flaking — appearance of dandruff-like flakes when fingers are lightly rubbed over skin surface
• scaling — fish-like scales on skin surface that easily rub off the skin surface with fingers
• cracking — parched appearance of skin that resembles dry earth.33
The presence of erythema and dry, scaly skin was identified visually by the Certified Wound and Ostomy Nurse and rated according to severity using a four-point ordinal scale where 0 = absence of symptom and 3 = severe symptom. Presence or absence of pruritus was identified if the wound care specialist observed the patient scratching the skin.
Procedure. Before conducting the 5-day product evaluation, the Certified Wound and Ostomy Nurse provided inservice training to the nursing staff about the product and the study. The Certified Wound and Ostomy Nurse performed the assessments and documented findings for each resident on the clinical record form. Data collection took a total of 8 hours each assessment day. Photographs and patient comments were recorded at each assessment visit. Assessments were recorded on Day 1 before the first product application and on Day 5 after four daily applications. To minimize variables and ensure consistency, all moisturizing products were removed from the resident’s rooms. The study moisturizer was kept and applied by the Certified Wound and Ostomy nurse, the treatment nurse, or the latter’s nursing assistant. The product was applied the same time each day.
Data entry/analysis. The data were entered into a spreadsheet and analyzed using SPSS 11.5 (SPSS Inc., Chicago, Ill.). Because the data involved a 4-point ordinal scale, a non-parametric paired-sign test was chosen. Day 1 data were compared to Day 5 data to determine improvement in dry, scaly skin, erythema and scratching.
Sixteen (16) people (6 men, 10 women; 18% of the total population of the unit) with end-stage renal disease and xerosis took part in the evaluation. Average age of the participants was 76 years (range 60 to 84 years). Participants included African Americans (N = 8), Caucasians (N = 5), Hispanics (N = 2), and Asians (N = 1) with multiple diagnoses that included congestive heart failure, diabetes, dementia, cerebral vascular accident, Alzheimer’s Disease, end-stage renal disease, and cancer. Of the 16 patients enrolled, 15 completed the evaluation; the subject not completing the evaluation was transferred out of the facility before the end of the study. No adverse events were reported during the evaluation.
All 15 subjects showed a statistically significant reduction of dry, scaly skin (P < 0.001) and erythema (P < 0.001). Ten subjects were observed scratching and almost half of the subjects showed improvement (P = 0.016) (see Table 2).
Both staff and residents were pleased with the skin condition improvements observed. Examples of patient comments obtained by the wound care specialist included:
• “I don’t know what you did but my foot doesn’t hurt anymore.”
• “My skin is softer.”
• “It feels good.”
• “Look at my legs, don’t they look great?”
This evaluation included residents from multiple ethnic origins (African American, Caucasian, Hispanic, and Asian) with diverse medical diagnoses (see Table 2). Product use was controlled by removing non-study skin preparations from the room and by having only the wound care team apply the product (not the patients).
The significant decrease of symptoms of xerosis after introduction of a new 24-hour moisturizer has important implications for practice. Hunter et al10 and Cole and Nesbitt11 found a statistically significant drop in the incidence of pressure ulcers after implementing moisturizing and protectant skin care products. Hunter et al10 and White29 used moisturizing agents along with other interventions to prevent skin breakdown and observed reductions in skin tears. These findings emphasize the importance of moisturizing in care plans to maintain skin integrity.
Treating xerosis to help prevent skin tears, pressure ulcers, and infection has important economic implications in today’s healthcare environment.23,27 This evaluation provides further evidence that some moisturizers only need to be applied once a day to decrease xerosis. In addition to the economic advantage of increased cost-effectiveness and reduced caregiver time, once-daily intervention is important because it is believed that better compliance is achieved when interventions are simplified and accepted by the caregiver.4
The AHRQ guidelines address prevention and treatment of dry skin but the recommendation was based on expert opinion.9 More studies are needed to strengthen the level of evidence linking xerosis to other important clinical conditions such as pressure ulcers, skin tears, infection, and discomfort so caregivers will be more likely to recognize that moisturizing is a critical, not optional, intervention.
The small number of subjects and range of comorbid conditions are limiting factors in this study. In addition, blinded assessments and a controlled study design would have strengthened the validity of the findings. Patients could have served as the control — eg, one side of body could have been treated with Product A and the other with Product B or treatment could have been limited to one side to show the effectiveness of the product.
A 24-hour moisturizer significantly decreased dry, scaly skin, erythema, and pruritus in 15 residents with xerosis secondary to end-stage renal disease. Though not specifically examined in this evaluation, implications of using a product that is effective with a once-a-day application may result in a reduction in caregiver time and an increase in caregiver receptiveness to the product, leading to improved compliance with moisturization.
The authors wish to thank the following people for their assistance with various aspect of this project: Stephen E. Bohnenblust, EdD, Professor, Department of Health, Minnesota State University, Mankato, Minn., for providing the statistical analysis; Cathy Garvin, RN, CWOCN, Senior Manager, Clinical Development, Coloplast Corp., Skin Care Business Unit; and the administration, staff, and residents at First Health Associates, Crestwood Care Center, Chicago, Ill.