Caring for aging skin: a geriatric dermatologist's expert advice on skin care for LTC residents. (Feature Article).

The skin of the elderly is prone to a number of diseases and disorders because of its decreased elasticity, thickness, and resilience and because of certain diseases (e.g., diabetes mellitus, human immunodeficiency virus, and congestive heart failure) that have a negative effect on the skin's ability to heal.

Some skin problems can be prevented, however, by adhering to a few commonsense principles. First, adequate nutrition is essential for healthy skin, and in the case of the elderly, the skin needs all the support it can get from a balanced diet.

It's important to keep in mind that some LTC residents manifest skin problems because of nutritional deficiencies that arise from underlying disease or develop as a side effect of drug therapy. These residents might need regular monitoring with laboratory tests. For example, patients with a blistering skin disease called bullous pemphigoid should have their serum protein levels checked regularly, to ensure that their protein intake is sufficient. The facility's dietitian or nutritional consultant should work with residents' physicians to determine which residents need regular testing, what type of testing is needed, and how often.

Another component of good skin care is the use of an assessment tool that takes into account all the factors that might influence skin health, such as mental status/sensory perception; mobility status; moisture, bowel, and bladder status; skin integrity and friction tear; activity status; nutritional fluid status; and predisposing medicalproblems/influencing health factors.

Preventable Skin Disorders

Some skin disorders are quite common in the elderly, both in community-dwelling elders and in those residing in long-term care facilities, but they can be prevented, and the methods for heading them off are quite simple and inexpensive. Some avoidable conditions frequently seen in nursing home residents are miliaria, xerosis/pruritus, scabies, and pressure ulcers.

Miliaria. We often think of miliaria, commonly known as "prickly heat," as an infant's problem that occurs in hot, humid weather or climates. The result of blocked sweat glands, it also occurs in adults, however. It appears as an itchy, acne-like rash. In residents of nursing homes, it typically occurs on residents' backs and on the backs of their legs.

Several measures can be taken to prevent the occurrence of miliaria in people residing in nursing homes. First, those residents who cannot change positions on their own need to be turned every two hours--a measure that should be taken to prevent decubitus ulcers anyway. Moving residents regularly will help prevent skin breakdown by preventing the build-up of moisture, bacteria, and yeast on their skin.

It also it important to keep residents dry to prevent miliaria, especially in a warm, humid climate where they might perspire excessively. Once miliaria occurs, dryness remains a prime concern. It might be necessary to place a fan in the resident's room to accomplish this. Loose-fitting clothing with high naturalfiber content is also recommended. In some cases, miliaria might also require the application of a topical antibiotic.

Xerosis. Xerosis, or dry skin, is extremely common in the elderly, because of the loss of sebaceous and sweat-gland activity. This condition is characterized bypruritic (itchy),cracked skin with scaling. It is seen most often on the legs of the elderly, but it also may occur on the hands and trunk. Sometimes the cracks in xerotic skin--which result from epidermal water loss--give it the appearance of cracked porcelain. If the cracks become deep enough to disrupt dermal capillaries, bleeding might occur. People with dry skin often complicate the problem further by scratching or rubbing it, clearing the way for bacterial invasion. Dry skin, if not properly prevented or treated, can lead to stasis dermatitis and, ultimately, to ulcers.

Preventing xerosis involves three key elements: keeping the environment amply humidified, which includes not keeping the temperature excessively high; making sure residents have good fluid intake, which should already be part of the care routine; and moisturizing the skin daily.

Moisturizing lotions should be mild; a good choice for moderate to severe dryness is ammonium lactate 12% lotion. Lotions or creams should be applied immediately after bathing, before all the water has been gently patted (not rubbed vigorously) off the skin. Caregivers should wash their hands after applying lotions or creams, to avoid spreading bacteria from one resident to another.

Bathing every other day is quite sufficient for nursing home residents and will not dry the skin as much as daily baths. It's important that the bathwater not be too hot, because of hot water's drying effect on the skin. Perfumed soaps should be avoided, because they can irritate dry skin. Instead, antibacterial soaps or mild "soapless soaps," such as Cetaphil(r), should be used. Sometimes facilities can encourage family members to provide the special soaps and moisturizers.

Scabies. Scabies occurs when microscopic mites burrow into the skin and cause an itchy allergic reaction that can resemble eczema. It spreads quickly in an environment such as a nursing home where many people live in close proximity, and prevention is tricky, since anyone--a resident transferring from a hospital, a resident's family member, or a staff member--can unknowingly start an outbreak.

I've often seen facility staff suffering a great deal of guilt over a scabies outbreak. Since prevention is nearly impossible, the next best thing is to be acutely aware of the possibility of scabies and treat it as soon as possible, to prevent further spread.

Decubitus ulcers. There are many products on the market for skin and wound care, but the most important factors in pressure-ulcer prevention are good nursing care and attention to details. Nothing substitutes for one-on-one care. CNAs are crucial to this process, because of their daily contact with residents and their ability to report to their nurse supervisors any rashes or other skin maladies, including early signs of decubiti. Also important in preventing pressure ulcers are proper bedding and support surfaces.

For residents who are incontinent, skin can be protected with barrier creams and ointments; these are inexpensive and effective. If possible, the incontinence should be addressed, but as long as it is occurring, caregivers must make certain that clothing and bedsheets are changed frequently enough.

Nonpreventable Skin Disease

CNAs and other frontline caregivers in nursing homes should have adequate training to enable them to identify suspicious, possibly cancerous, skin lesions. They should have at least enough familiarity to give them an index of suspicion. It's a good idea to post brochures from the American Cancer Society that show visible signs of skin cancer, or provide the URL of the organization's Web site (www.cancer.org) so that staff can go there to familiarize themselves with the appearance of possible skin malignancies.

Improving LTC Skin Care

The preventable skin conditions described earlier in this article are usually more severe when diagnosed in nursing home residents than in elders living in the community. This is simply because, too often, inadequate attention is paid to the skin in that setting. A delay in care causes these conditions to grow worse before they are noticed and can be addressed.

Another problem is that residents have little access to specialists, because of the high cost of specialized care compared with the low level of Medicare reimbursement for such services. To address this problem, I formed Dermatology Healthcare to provide more affordable dermatologic care to long-term care residents. Currently the company operates in Florida, but its services will be expanded nationwide within the next year.

Dermatology Healthcare relies on specially trained nurse practitioners and physicians' assistants to provide clinical services to nursing home residents. The consulting NPs or PAs provide routine skin care for a fraction of what it would cost to transport the resident to a dermatologist's office and pay his or her fees. If they see a resident who needs more extensive care than they are qualified to provide, they refer that person to the appropriate specialist.

To summarize, the key to good skin care is one-on-one attention to details. Most of the routine skin care nursing home residents require can be provided by the CNAs who care for them daily. Protocols and procedures for keeping residents dry, turning them regularly, and keeping their skin moisturized will go a long way toward preventing many of the skin conditions that beset the elderly.

Dr. Robert A. Norman is the chief physician and owner of Dermatology Healthcare, founded in 1994 to provide skin and wound care services. The company now cares for patients in more than 450 nursing homes and assisted living facilities. He has written 18 books and more than 100 articles; his book on Geriatric Dermatology, which includes skin care protocols, was published by Parthenon/CRC and can be ordered at www.crcpress.com. Dr. Norman can be reached at [e-mail]. To comment on this article, please send e-mail to [e-mail].