Skin Matters: Impaired Skin Integrity in the Elderly
For years, clinicians across the continuum of care have focused on the development of programs for the prevention and treatment of chronic wounds. In many situations, clinician time and budgetary restraints have allowed the wound care arena to overshadow the need to develop similar programs for the prevention and management of actual or potential impaired skin integrity, especially in the geriatric population.
According to current US Census statistics,1 the population is getting older — 12% is >65 years and of this group, 5.6% is older than 75 years. As people age, their chances of developing skin-related disorders increase.
More than 70% of the older population has skin conditions.2 Clinicians need to focus on the assessment and management of the elderly with or at risk for impaired skin integrity. Geriatric skin care requires knowledge of the anatomy and physiology of the skin, physiological changes that occur with aging skin that play a significant role in common geriatric skin conditions, skin assessment techniques, and management of common skin care problems. Administrators in acute, subacute, and long-term care settings need to support the development and implementation of facility-wide skin care protocols and product formularies for prevention and management of geriatric skin care problems, as well as ways to maintain skin integrity.
This article addresses various aspects of the assessment and management of the most common alteration in elderly skin integrity: dry skin.
The Skin: Structure and Function
The skin is composed of two layers — the epidermis and the dermis, the latter secured to muscle and bone by connective tissue. The two layers have numerous functions.3 The primary function of the epidermis is to maintain skin integrity by presenting a physical barrier to micro-organisms, physical insults, and toxic agents. Skin pH (slightly acidic) and the Langerhans cells (functioning as macrophages by processing contact antigens before T lymphocyte assimilation) provide the micro-organism barrier. The melanin in the basal layer protects the skin from the physical insult of ultraviolet radiation.
The dermis, which provides strength, support, blood, and oxygen, is comprised of sweat glands, sebaceous glands, hair follicles, and small fat cells. Sebum, secreted by the sebaceous glands, maintains skin hydration by providing a protective lipid layer that minimizes fluid loss through the epidermis.
Subcutaneous tissue (the fatty layer) beneath the dermis functions as a shock absorber against trauma, provides high-calorie storage, and modulates conductive heat loss. It attaches the dermis to the underlying structures, facilitating its ongoing blood supply for regeneration.
Aging Skin and Moisture Retention
Aging has a significant impact on the structure and function of the skin and its ability to retain moisture. Changes in aging skin (eg, decreases in production of lipids, desquamation rate, and dermal proteins; changes in lipid composition; and prolonged epidermal turnover) decrease the skin’s ability to retain moisture.
One of the most common alterations in aging skin is the decreased ability of the epidermal barrier to prevent water loss. Healthy stratum corneum (the outermost layer) is essentially impermeable to water and serves to maintain the skin’s hydration and flexibility. A brick wall and mortar analogy has been used to describe the barrier function of the stratum corneum.4 Stratum corneum cells (corneocytes) are non-continuous, essentially proteinaceous, “bricks” embedded in the continuous matrix of specialized lipids (“mortar”). These lipids provide the water barrier and the corneocytes protect against the continuous abrasion by chemical and physical injury. Sebum and lipids, other natural oils, and natural moisturizing factors (NMFs) form the hydro lipid system. Aging affects this system —oil-producing sebaceous gland activity declines steadily in postmenopausal women and in men age 70 years and older (a paradox relationship exists in the elderly where enlarged sebaceous glands have significantly decreased secretory activity).
Aging also affects desquamation of the stratum corneum, which has a significant role in maintaining moisture of the skin. Because capacity for epidermal proliferation is decreased, more time is required for epidermal cells to migrate to the skin surface. Apoptosis (the process of cell death where keratinocytes differentiate, flatten out, become densely packed, lose their nucleus, and become corneocytes) also decreases significantly in the elderly, which impedes desquamation. As a consequence of prolonged epidermal turnover time and slowed desquamation, the top layer of corneocytes is thinned, creating a larger surface area for fluid loss.
Dermal proteins (predominantly elastin and collagen) and dermal ground substance (containing numerous proteins including primarily, proteoglycans [PGs] and glycosaminoglycans [GAGs]) decrease with age, affecting the ability of the dermis to retain moisture. Ground protein molecules are capable of binding up to 1,000 times their volume; hence, they play an important role in regulating the water-binding capacity of the dermis and impact on dermal volume.5 In fact, because of their capacity to hold water, GAGs may be responsible for the normal turgor of the dermis.
Alterations in Skin Barrier Functions
A multitude of factors (including disease, diet, hydration status, and the external environment) cause alterations in skin barrier function, potentially inducing dryness, irritation, and itching. The ability of the epidermis to restore its impaired barrier declines with age.6 In addition, seasonal variations in intercellular lipid levels and serum glucocorticoid levels within the stratum corneum may predispose the skin to winter dryness. Stress may exacerbate skin impairment.
Barrier function impairment initiates a series of events that stimulate a metabolic response within the underlying epidermis that are designed to restore the stratum corneum’s normal function. The principle response is a temporary increase in the biosynthesis of epidermal lipids (ie, cholesterol, fatty acids, and ceramides). Minor barrier disturbances remain local to the epidermis. However, repeated or severe barrier disruption stimulates response cascades involving not only the desired epidermal response, but also inflammatory events in the deeper layers of the skin and the endothelium. Such changes play a role in inflammatory dermatoses.7 Common skin alterations in the elderly are xerosis (dryness), pruritus, and complications of xerosis such as eczematous inflammatory dermatoses.
Common Geriatric Skin Care Problems
Xerosis. Xerosis, or dry skin, can occur at any age but is more commonly found in the elderly. The cause is unknown but appears to be related to several physiological changes in aging skin such as altered lipid composition of the stratum corneum, loss of NMFs, and decreased barrier ability to prevent epidermal water loss. Xerosis most commonly involves the anterolateral lower legs (especially the shins), back and flanks, abdomen and waist, and arms. The axilla, groin, face, and scalp are usually spared.
Occurrences of dry skin increase in cold, dry weather because cold air contains less moisture than warm air. Environmental conditions such as dry heat, use of fireplaces, and use of air conditioners precipitate occurrence of dry skin in the elderly. Excessive contact with water (eg, long, hot baths or showers) reduces the skin’s NMFs. Use of harsh soaps, detergents, solvents, and chemicals can worsen or cause the condition.
Clinical manifestations of xerosis vary.8 Intense itching without an obvious rash may occur sporadically. Mild presentation may include faint reticulate pinkness and fine scales (raised or uplifted skin edges) or cracks visible with tangential light. Moderate to severe skin changes present with dramatic deep erythema, cracking, and desquamation (flaking). Xerosis can progress to asteatotic eczema, where fissures and excoriation allow environmental irritants to penetrate the skin and cause inflammation, compromising the stratum corneum. Nummular eczema has a tendency to develop in areas of xerosis.
Keratolytics, moisturizers, and steroids are the foundation of topical xerosis management.9 Additional management includes interventions to add moisture to the environment (air humidification) and patient education regarding skin care protocols.
Eczemas (decreased moisture retention /hydration of skin).
Asteatotic eczema (eczema craquele). Asteatotic eczema occurs when skin moisture and oils are lost. Although any part of the body can be affected, this condition is found most commonly on the lower legs of older people. The affected skin is very dry and resembles cracked paving with fissures occurring between blocks of skin. The eczema often is exacerbated by spending time in overheated, dry rooms or sitting too close to a radiator or fireplace, all of which draw moisture from the skin. The overuse of soaps also can worsen the condition. Patients should be educated about proper skin care measures for the treatment of asteatotic eczema. After bathing or showering (with soap substitutes), the skin should be patted dry rather than rubbed vigorously with a towel. Emollients should be applied generously at regular intervals throughout the day to keep the skin moisturized. Humidifiers should be used to keep air moist.
Nummular eczema (discoid eczema). Nummular eczema is characterized by pruritic, coin-shaped lesions that may develop into scales. These lesions are found most commonly on the lower legs, upper extremities, dorsum of the hands, and the trunk. Patches begin with a slightly bumpy surface and rough edges; within a few days, the patches often begin to weep and become itchy, crusted, and infected. Eventually, the surface becomes scaly and the centers of the discs clear, leaving the skin dry and flaky. Treatment includes use of medium- or high-potency topical steroids and emollients. Secondary infections are treated with antibiotics that address staphylococci. Discoid eczema tends to recur, although the intervals between attacks vary. Regular use of emollients and avoiding soap and conditions likely to dry the skin can make the skin more comfortable and reduce incidence.10
Clinicians treating the elderly should secure a general skin health history at the initial patient assessment, including:
• History of skin cancers or other chronic skin conditions
• Excessive dryness, itching, or increased bruising tendency
• Increased healing time
• Chronic, long-term sun exposure
• Frequency of bathing and products used for bathing
• Use of home remedies or local applications of any kind used on the skin
• Occupational hazards (eg, skin contact materials, radiation, abnormal lighting).
Further questions can help identify the type of dry skin problem or eczema the patient is experiencing:
• Is the skin itchy? For how long?
• What is the normal skin care routine?
• Is the dryness worse at certain times of the day (eg, at night)?
• Does scratching interfere with daily life?
All areas of the patient’s skin should be examined to identify lesions and to note variation in skin quality in different areas of the body. The clinician should observe the patient’s skin color and note lesions, erythema, vascularity, bruising, odors, and hygiene. The skin should be palpated to assess temperature, texture, thickness, turgor, edema, and degree of moisture. Lesions, lumps, and nodules should be palpated for pain, depth, and size.
Skin Integrity Management
Management of skin with or at-risk for xerosis and various forms of eczema related to a decreased ability of the stratum corneum to maintain skin moisture involves replacing the lost water and oils from the skin and maintaining adequate skin hydration. Skin care products, cleansers, and moisturizers are the foundation of topical management. Corticosteroids are indicated for inflammatory dermatoses. Eliminating or addressing provocative environmental conditions (temperature, humidity), physical factors (constrictive clothing), and skin care practices (cleansing/appropriate use of emollients) is critical to dry skin management in the elderly. The clinician’s role includes health promotion, education, and implementing quality skin care. Patients need to be taught criteria for selection of products (cleansers and moisturizers) and how to adjust topical management based on skin condition and environmental factors (eg, appropriate use of moisturizing lotion or cream — ie, thinner consistency/application in the summer and thicker, oilier products in the winter).
Skin Care Product Formulary for Management of Dry Skin
Clinicians use topical skin care products to prevent, treat, and maintain skin integrity. When managing various degrees of dry skin, cleansers and moisturizes should be selected based on patient skin type, degree of dryness, desired outcome, application, removal of product, and cost. Topical cleansers and moisturizers have indications based on their composition and their added ingredients to assist in product choice in terms of skin protection, maintenance, or integrity restoration.
Skin cleansing and cleansers. Patients with xerotic skin should avoid soaps and deodorants because they can change the skin surface pH and irritate the skin,11 especially elderly patients whose skin is thinner and less able to reverse the alkalinization induced by some soaps. Cleansing creams and lotions with ingredients such as phospholipids, humectants, amino acids, vitamins, and a balanced pH that falls between 4 and 7 are most useful for xerotic and sensitive skin.12 Stender et al13 studied the effects of oil and water baths on the hydration state of the epidermis and found that the direct hydration of the skin following an oil bath is of short duration and comparable to a tap water bath. Oil baths, which promote general lipidization of the skin with some improvement in dryness and scaling, resulted in an increase in skin surface lipids lasting for about 3 hours. However, because of the short duration of benefits, a daily oil bath does not replace the need for frequent moisturizer application.
When establishing cleansing protocols, patients must be included. Education is an important aspect of dryness control. Skin care education should include teaching good cleansing practices:
• When bathing, use only lukewarm water and limit bath time to up to 30 minutes per day or every other day. Shower or bath water that is too hot causes vasodilatation and increases the evaporation of water from the corneocytes. Bathing too frequently or for long periods of time will remove the natural oils from the skin.
• Adding oil at the end of the bath may be helpful in replacing lipids to the skin.
• Wash at night. This gives skin time to recover the sebum and natural moisturizing factors cleansers can strip away from the skin.
• When toweling, blot skin gently to leave some water on the skin.
• Apply moisturizers immediately after the bath to slightly damp skin.
Moisturizers. Moisturizers help maintain skin hydration and barrier integrity by blocking transepidermal water loss (TEWL), impeding moisture from evaporating from the skin. Moisturizers are composed of an oil-and-water combination with additional ingredients that may help combat specific skin problems. The oil applied to the skin surface traps moisture and smoothes dry, scaly, crusty skin to prevent flaking and subsequent itching. Moisturizers come in a variety of preparations such as lotions, creams, and ointments.
Water is the only true moisturizer; therefore, moisturizers are best applied after bathing when the skin has the appropriate moisture (water) content and swollen stratum corneum cells minimize skin cracks/fissures. Moisturizers should be reapplied frequently throughout the day (five or six times) if used to replace the lipid barrier and to prevent the loss of water through evaporation. Wilson and Nix14 evaluated a once-daily moisturizer used to treat xerosis and found it decreased symptoms of xerosis, including dry scaly skin, erythema, and pruritus.14 Moisturizers should be applied in smooth downward strokes following the natural flow of the hair so hair follicles do not become blocked. A soft touch should be used to avoid irritating the skin’s surface and stimulating itch response.15
Moisturizer types. Lotions are comprised of powder crystals dissolved in water and held in suspension by surfactants. Of all moisturizers, lotions have the highest water content; because they evaporate the quickest of all moisturizers, they need to be reapplied the most frequently. They may be more aesthetically pleasing than creams or ointments because they are easy to apply, have a cooling effect, are non-occlusive, and do not leave a greasy film on the skin. Lotions are best used in a low-humidity environment because high water content adds more moisture to the skin.
Creams are preparations of oil in water (water as the main component yields a thinner consistency than ointments). Because creams are less viscous, they also are less occlusive than ointments and must be applied much more frequently (four times daily) to maintain their effectiveness.
Ointments are comprised of a water-in-oil (typically lanolin or petrolatum) base. Ointments are generally characterized by their occlusive properties. Petrolatum is more effective on dry skin than lanolin. Ointments provide a longer-lasting effect on skin moisture than either lotions or creams.
Additional ingredients. Numerous ingredients are added to moisturizers to help protect, maintain, or repair skin integrity. Some of the more common ingredients include protective barriers, humectants, lipids, exfoliating agents/keratolytics, proteins, vitamins, collagen, elastin, and fatty acids.
Protective barriers or coating agents (most commonly, petrolatum and mineral oil) are added to moisturizers to prevent water from easily evaporating from the skin surface. Various oils and waxes also are used to improve water-trapping capabilities. In many advanced skin care moisturizers, oils are used as the coating agents instead of occlusive agents like petrolatum because they have the advantage of adding lipids to the skin.16
Humectants (eg, glycerin, propylene glycol, lactic acids) are oil-free, attract water, and bind to the skin. Humectants draw moisture from the air and trap it next to the skin. They are especially effective in more humid climates.
Ceramides and lipids occur naturally in the skin. In normal skin, they trap water; in chronic skin conditions (eg, eczema), these natural moisturizing agents are lacking. Using formulas that contain ceramides and lipids helps replenish the skin’s supply, restoring its ability to trap moisture on its own.
Keratolytics/exfoliating agents (eg, alpha hydroxy acids —glycolic acid, lactic acid) help dry skin by 1) increasing cell turnover to help rid the skin of dry, flaky skin cells at the stratum corneum and replacing them with younger cells and 2) increasing the hyaluronic acid, a natural moisturizer, in the skin.
Preservatives are added to moisturizers to protect the product from spoilage caused by micro-organisms.
Amino acids, vitamins, lipids, and antioxidants nourish the skin and help protect the cells against free-radical damage, supplying basic building blocks for collagen deposition (see “Skin Care Protocol”).
Dry skin, alone and as part of a sequel of many alterations in skin integrity, is a major problem that clinicians need to address when managing the geriatric population. All skin care products, including cleansers and moisturizes, are not the same. Cleansers and moisturizers are chosen based on the capacity of their ingredients to manage the alterations/clinical manifestations identified. Clinicians need to be familiar with concepts of advanced skin care in order to provide quality care to elderly patients.