Skin integrity: selection of topical agents.

Guidelines for product selection to assist in individualized skin care

Maintaining the skin integrity of elderly residents is a continuous challenge. The elderly tend to share common characteristics of aging skin, such as a tendency toward drying, thinning and greater susceptibility to shearing-type injuries. Yet, although they share the common denominator of "elderly," each resident is an individual, with his or her own skin type. Factors such as skin type, present skin integrity, environmental conditions, bathing schedules, ease of product application and removal, and cost need to be taken into consideration when developing an individualized plan of care. Selecting a "universal" preparation for cleansing and moisturizing is not in the resident's best interest.

Based on recent research and the clinical practice guidelines published by the Agency for Health Care Policy and Research (AHCPR), here are suggestions for selecting and utilizing topical agents, i.e., cleansers, moisturizers and topical barriers, to assist caregivers in developing a comprehensive approach to skin care.

Cleansing. AHCPR guidelines recommend the following interventions for skin cleansing:

* Cleansing should occur at the time of soiling and at routine intervals.

* Frequency of cleansing should be individualized according to need and/or patient preferences.

* Hot water should be avoided; instead use warm water to prevent skin dryness. In cases involving very dry skin, using warm water without a cleansing agent may be appropriate.

* Mild cleansing agents should be used to minimize irritation and dryness; a mild cleanser should be non-alkalinic to maintain the skin's protective acid mantle.

* Force and friction applied to the skin during the cleansing process should be minimized.

Moisturizers. Because moisturizing the epidermis maintains the skin's suppleness and pliability, moisturizers are an important part of skin care. Treatments that promote skin dryness, such as antacids or heat lamps, are not appropriate. Moisturizers are available in lotion and cream formulas.

Lotions, primarily made of water, are not occlusive and therefore must be applied more frequently to maintain hydration. Lotions are more cooling (because of the water content), easy to apply and non-greasy. They are effective for residents in low-humidity environments.

Creams are preparations of oil in water. Because their main ingredient is water, the consistency of creams is thicker than that of lotions yet thinner than ointments. Because of their oil component, creams tend to be more occlusive than lotions. Creams therefore need to be applied less frequently than lotions.

Recent research has found that moisturizers incorporating essential fatty acids - specifically, linoleic acid extracted from sunflowers - are particularly effective in maintaining moisture levels, texture and elasticity of dry skin, since they replenish the epidermal barrier lipids that are lost as skin dries with aging.

Again, none of this implies that moisturizers should be used on the same schedule for all residents. Though skin drying does increase with age, there are residents who have relatively oily skin and are in less need of this type of attention. Individualizing care according to skin type is always recommended.

Occlusive barrier preparations. These petroleum-based products both moisturize and protect against irritation by unwanted moisture, i.e., from incontinence. Because of their occlusive properties, however, they should not be used in the presence of infection (i.e., yeast infection), unless they are medicated ointments. Further, topical medications used in perineal areas should always be in ointment form, not in powders or creams. Powders and creams will simply wash away with the next incontinent episode.

Though dry skin is in large measure a normal consequence of aging and is found in as many as 80% of the elderly, AHCPR notes that there are environmental conditions that predispose to dry skin and thus require particular vigilance. Low humidity (less than 40%) and cool air are among these, and prevalence of these conditions should alert staff to pay particular attention to residents' skin care needs.

The elderly resident is also at risk for shearing injuries and skin tears due to skin aging. Staff should be instructed in taking particular care in the positioning and transferring of residents; the gentler, the better. Residents can be further protected by regular application of lubricants (i.e., cornstarch and creams), protective films (i.e., transparent film dressings and skin sealants), and protective dressings (i.e., hydrocolloids) to high-risk skin areas most likely to experience friction, and by protective padding applied specifically to heels and elbows.

In sum, there is an array of skin care products available today that are effective in maintaining residents' skin integrity (see Table, p. 50). The key is to match the products with the appropriate conditions as they vary from resident to resident.

Cathy Thomas Hess, BSN, RN, CETN, is the founder of Wound Care Strategies, Inc. (WCS), Harrisburg, PA. An independent consulting firm, WCS customizes and supports wound care systems, and provides education, management and treatment expertise. Ms. Hess is a frequent contributor to Nursing Homes. For further information, [phone].