understanding skin to promote skin wellness for your residents 2010 gojo industries, inc. all...

Understanding Understanding

Skin Skin

to Promote to Promote

Skin WellnessSkin Wellness

for your for your

ResidentsResidents

2010 GOJO Industries, Inc. All rights reserved.

Skin Care Skin Care 101101In Long Term CareIn Long Term Care

Skin Care 101 In Long Term CareSkin Care 101 In Long Term Care

Training topicsTraining 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*

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*excluding wound care

Skin Care 101 In Long Term Care3

Skin and an aging populationSkin and an aging population

In MemoriamAlbert M. Kligman, M.D. PH.D.

1916 - 2010

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 and an aging populationSkin 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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What does your skin do?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

Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2

Structure of the skinStructure of the skin

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Deepest skin layerHypodermis

Deepest skin layerHypodermis

Middle skin layerDermis

Middle skin layerDermis

Outer skin layerEpidermis

Outer skin layerEpidermis


Function of skin layersFunction of skin layers


Rawlings AV et al. Stratum corneum moisturisation at the molecular level. J. Invest. Dermatol. 103:731-40; 1994

Stratum corneum (the top layers Stratum corneum (the top layers of skin)of skin)

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http://www.health.com/health/gallery/0,,20307059_6,00.htmlBianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2

Dry skin occurs on all aged body sites

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Dry skin or skin xerosis


Aged dry skin: faulty Aged dry skin: faulty desquamationdesquamation

Normal photograph High resolution micrograph

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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Healthy Skin Smooth Skin

Dry Skin Flaky SkinDry skin has less stratum corneum lipids, natural moisturizing factors

and desquamatory enzymes and has an itchy flaky skin surface


Aged dry skin = more body Aged dry skin = more body itchingitching 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

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http://www.health.com/health/gallery/0,,20307059_1,00.htmlLeveque 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.


http://www.health.com/health/gallery/0,,20307059_6,00.html

Problems of the aging footProblems 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

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Generalized xerosis


30-40 KERATINOCYTESPER MELANOCYTES

EPIDERMALMELANIN UNIT

30-40 KERATINOCYTESPER MELANOCYTES

EPIDERMALMELANIN UNIT

Melanocytes and skin agingMelanocytes and skin aging

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MELANIN EXFOLIATIONWITH CORNEOCYTES

MELANIN EXFOLIATIONWITH CORNEOCYTES

Aging skin makes less melanin but it becomes more concentrated in ‘age spots’

MELANIN SYNTHESISIN MELANOCYTES

MELANIN SYNTHESISIN MELANOCYTES

MELANSOMESTRANSFERRED TO KTs

MELANSOMESTRANSFERRED TO KTs

MELANIN DEGRADATION& OXIDATION

MELANIN DEGRADATION& OXIDATION


Dermis and skin agingDermis and skin aging

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Flattening of the connections between the epidermis and dermis


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

Normal skin agingNormal skin aging

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Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2

Aging and skin problemsAging and skin problems

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Thick, scaly skin / Hyperkeratosis Acute Eczema

Blister, Bullae Allergy


Fragile aged skin: Fragile aged skin: DermatoporosisDermatoporosis

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 traumaKaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294

I

II

III

IV

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Skin atrophy

Senilepurpura

Pseudo-scar

Skin laceration

Dissecting hematoma

Stage I + + + – –Stage II + + + + –Stage III + + + ++ –Stage IV + + + ++ +

Table 1. Proposed clinical staging of dermatoporosis: a basis for further evidence-based quantitative definitions


Dermatoporosis and skin tear Dermatoporosis and skin tear gradinggrading

http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/PublishingImages/01-Fig3.JPG


Fragile aged skin: Fragile aged skin: DermatoporosisDermatoporosis

Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294

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.

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Old Young


Aging and loss of collagenAging and loss of collagen

Old

Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294

Histologically aged skin shows:A decrease in collagen (less red staining)

Young

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Skin aging summarySkin 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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Causes of elderly skin damageCauses 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

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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


Poor nutrition: more aged skinPoor 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

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Physiological variations during aging. Pierard et al. In: Skin Aging. Eds: Farage et al. Chapter 6: 45-54, 2009Nutrition & skin aging. Cosgrove et al. In: Aging Skin. Eds: Rhein et al. Chapter 13: 377-390, 2010


Well-conditioned skin is the basis of Well-conditioned skin is the basis of preventionprevention

Maintaining healthy skin barrier is the best way to prevent many aging skin problems

Healthy skin

Apply this concept to the elderly

Dry skin

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Recommended Care = Gentle Contact + Mild Cleansing + Regular Moisturizing


Preserving and Protecting the Preserving and Protecting the Skin of Long-term Care Skin of Long-term Care ResidentsResidents 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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Preserving and Protecting the Preserving and Protecting the Skin of Long-term Care Skin of Long-term Care ResidentsResidents 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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understanding skin to promote skin wellness for your residents 2010 gojo industries, inc. all...

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