A common sense approach: keeping aging skin clean and healthy.

Preventing breakdown is at the top of every nursing home's list of skin care priorities. But the skin problems that most often plague the elderly are pruritis (itching) and over-drying.

The solutions to those problems involve the use of mild, pure cleansing products, and in many cases, less frequent and cooler baths or showers and bath oils after bathing. Despite those principles, Mrs. Smith's 60-year routine of daily, hot showers with heavily-perfumed soaps and monthly hair coloring with harsh chemicals is a source of pleasure and comfort in the nursing home environment. Unless her skin becomes very dry or she begins to itch constantly, there is no reason to change that routine simply to conform to preconceived standards of care.

The fundamentals of keeping aging skin clean and healthy aren't very different from those of caring for young skin, with a few exceptions. Decreased oil production makes aging skin highly susceptible to over-drying. Because skin becomes thinner and more fragile as it ages, it is also more vulnerable to potential irritants. Because most of the elderly have limited exposure to the extrinsic dirt (grease, soil) associated with a more active lifestyle, accomulated dirt poses less of a problem than harsh soaps that over-dry.

For the "average" nursing home resident, a mild, nonperfumed, cream or lotion-style soap (such as unscented Dove or Neutrogena) or even water-rinsing alone is sufficient to clean the skin and remove perspiration and any accumulated residual bacteria. The same is true for more active residents who may use a mild antibacterial soap (such as Lever 2000) if they desire.

The same principle applies to shampoos and shaving products. Baby shampoos are safe and effective, and men who develop a shaving rash can use products such as Cetaphil, a non-soap, less-drying cleanser that serves as a shaving soap.

While somewhat climate-dependent, the use of lotions and creams is a fact of life for a large subset of the elderly population. Bath and baby oils, and even Vaseline, effectively solve generalized pruritis problems and are far preferable to alcohol-based products that dry the skin or prescription medications. The oils should be applied to the hands, feet, arms, legs, and back after bathing and light towel-drying while the skin is still moist. This also minimizes the risk of applying the oils while the resident is in the tub. Residents with an aversion to these "greasy" products can be reassured that a light coat of oils attracts dirt only in dusty environments.

For wheelchair or bed bound residents, daily bathing is neither practical nor necessary. Twice or preferably three times weekly bathing is sufficient.

In all cases, anticipating and preventing breakdown is considerably easier than trying to heal an existing pressure ulcer. Frequent position changes and appliances should be coupled with daily, or at least twice-weekly, visual inspection of pressure points. Washing or bathing provide an excellent opportunity to identify and document any skin problem and should be a routine part of the bathing routine. Once breakdown occurs, skin care becomes wound care and infection, especially staph, become the primary concern. Because of the fragility of aging skin, caregivers should be reminded that contact that wouldn't harm a younger person's skin (such as use of a band-aid, for example) can literally tear that of the elderly resident. This risk is most pronounced in the chronically sun-exposed areas, such as the backs of the hands and forearms, usually when an arm is grabbed to assist a resident to a sitting position or out of a tub.

A frequently overlooked but critical aspect of aging skin care is sun protection. The current skin cancer epidemic includes increasing rates of all forms of the disease in the elderly. Residents who spend even limited time outdoors should be protected with a sunscreen with an SPF of at least 15.

Ultraviolet light is both a cancer promoting agent and an immunosuppresant. Of course, an 80-year-old need not worry about sun exposure initiating cancers that can take 10 to 30 years to appear. But even fairly small amounts of UV exposure can, in a matter of weeks, bring out otherwise quiescent cancers that were initiated decades ago. Nursing handbooks used by the staff should include skin cancer prevention and identification materials, as well as the information needed to identify non-cancerous skin growths of no medical consequence. Organizations such as the American Skin Cancer Foundation, Box 561, Dept. SR, New York, NY 10156, provide such written information.