Dry skin: more than an annoyance; Linda Zinn, Editor, shares a few practical tips gleaned from professional conferences and reports on managing this common disorder.

With winter almost upon us, it's prime time for reminding your frontline staff about the consequences of dry skin and instructing them in ways to prevent and manage it. In areas with cold winter climates, the humidity of the air is lower than at other times of the year, and forced-air heating systems dry the air even further. These conditions, along with other factors, such as individuals' predisposition to dry skin, contribute to its development, especially in elderly individuals whose skin is thinner, less elastic, more fragile, and less likely able to retain natural moisture.

Dry skin is not simply an irritation in older residents; in addition to causing them discomfort (e.g., itchiness and a feeling of tautness), it can increase their vulnerability to infections and other adverse skin conditions, which are more difficult to heal in people of advanced age. Therefore, it's important that their skin be monitored for signs of dryness, such as redness, roughness, scaling, flaking, itchiness (which can lead to scratching, causing further damage to skin), fine cracks (resembling those seen in old porcelain) and, if the dry skin becomes more advanced, fissures that can become deep and bleed.

No one sees more of your residents--and certainly not more of their bare skin!--than the CNAs who care for them every day. Because they often assist residents with bathing, showering, and toileting, it stands to reason that no one is in a better position to serve as your first line of defense in preventing and managing dry skin in your residents.

Because CNAs are relied on as the "eyes of the facility," and because high turnover rates among CNAs are so common, it's important that newly hired CNAs receive adequate training in caring for the skin of elderly residents, including the prevention and management of dry skin. Skin-care measures that might seem to be simple common sense to experienced staff might run counter to what a new hire believes is best, and even the most conscientious new CNA might be unaware of some of the steps that can be taken to prevent dry skin. As a matter of fact, a refresher for more seasoned staff probably wouldn't hurt, either, to remind them of the importance and benefits of taking the time to care for aging residents' skin.

Bathing: More Is Better, Right?

Wrong. Of course, bathing is a good thing, both in terms of hygiene and the feeling of freshness and well-being it provides. But we are obsessed in modern society with what our ancestors might well have considered excessive bathing--jokes about the "Saturday night baths" of old notwithstanding. Many experts, including geriatric dermatologist Robert A. Norman, DO, MPH, recommend that nursing home residents have a bath or shower every other day rather than daily. (1)

Also keep in mind that, although Mrs. Jones might love her heavily perfumed lavender soap, it's a good idea to try to steer her toward an unscented alternative that is less drying to her skin. Bubble baths, bath salts, and other fragrance-laced bathing products can be too harsh for older skin that is prone to dryness. (Also, residents' clothing should be laundered with soaps and detergents that are fragrance-free, and perfumed dryer sheets should be avoided, as well. (2)) Dr. Norman recommends the use of "antibacterial soaps or mild 'soapless soaps'" for elderly nursing home residents. (1) Soaps strip the skin of its natural lubrication, and even water alone, especially if it is hard water, washes off the oils that help skin retain its moisture. Many gentler, less drying alternatives to soap are available from suppliers of resident hygiene products.

Another issue related to bathing that might be overlooked involves exposure to chlorine: In facilities with swimming pools, residents should shower or bathe immediately after a swim or a session of water exercise. (2)

Fragile: Handle With Care

Although a brisk rubdown with a nubby Turkish towel after a steamy soak in a hot bath might be invigorating to a 25-year-old athlete after a workout, a 75-year-old resident's delicate, aging skin isn't up to the challenge of being dried so vigorously. Caregivers assisting residents with bathing and showering should, instead, gently pat the resident dry with a towel, and residents who bathe or shower without assistance should be instructed likewise. Vigorous scrubbing with a washcloth is also to be avoided--friction is not the friend of aging skin.

Extremely hot water is another thing to avoid. Not only does it have a drying effect on the skin, but for residents with diabetes mellitus or other conditions that diminish sensation in the extremities, it can be dangerous: If they can't feel that the water's too hot, they can't tell you so, and their sensitive skin can be scalded. Warm water is recommended, as is thorough rinsing.

Moisturize, Moisturize, Moisturize

Daily application of lotions and creams used to prevent and treat dry skin may seem time-consuming, but consider the alternative: the amount of time that would be involved in managing the consequences of not providing this care. Untreated dry skin that has become cracked or fissured can subsequently become ulcerated and/or infected.

When used after baths and showers, lotions or creams should be applied immediately after residents are patted dry, while the skin is still slightly moist. Again, many product choices are available from your suppliers, including emollients, which soften and smooth skin; moisturizers, which add moisture; humectants, which help the skin retain moisture; and combinations of these ingredients. Keep in mind that many commercially available moisturizers contain perfumes, so be sure the lotions or creams you're using are fragrance-free. For residents who already have moderate to severe xerosis, Dr. Norman recommends using ammonium lactate 12% lotion. (1) He reminds caregivers to wash their hands before applying lotions or creams, to avoid spreading bacteria between residents.

Watch That Itch

As anyone who has had poison ivy, a mosquito bite, an itchy rash, or extremely dry skin knows, not scratching the itch is easier said than done. Imagine how difficult it must be for residents with cognitive impairment who have dry, itchy skin to avoid the urge--or even cognitively intact residents who are inactive and, therefore, not distracted from the persistent sensation. Therefore, CNAs should check residents' fingernails regularly, to make sure there are no rough, jagged edges that could tear or cut the residents' skin, creating favorable conditions for an infection. To help ease the compulsion to scratch, caregivers can apply gentle pressure or a cold washcloth to the affected skin. (1) Residents also can be encouraged to gently rub the skin that itches rather than scratching it. (2)

Other Considerations

Some of the factors that contribute to healthy skin should already be part of every long-term care facility's standard care practices, such as providing adequate hydration and good nutrition. But keep in mind that spicy foods, alcohol, and caffeine should be avoided by people whose skin tends toward dryness. (2)

For facilities located in a hot, dry climate or in an area where the climate is cold and dry during the winter months, a humidifier connected to the HVAC system would help increase ambient humidity.

Finally, residents' clothing should be assessed for fit and fabric. Tight garments should be avoided, along with clothing made of wool or synthetic fabrics. Cotton--especially for undergarments--is much less irritating to the skin.

To summarize, although dry skin can't always be avoided, taking measures to protect residents from the factors that cause and exacerbate it can save them a great deal of discomfort and reduce their risk of developing more serious skin problems. The time required for proper skin care will pay off, and staff members need to be reminded of this.

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References

1. Norman RA. Caring for Aging Skin. Nursing Homes Long Term Care Management (April 2003);52:22-24.

2. University of Iowa Hospitals & Clinics. Health Topics for Aging: Skin problems in the elderly. www.uihealthcare.com/topics/aging/agin3400.html (accessed Sept. 27, 2005).