The management of dry skin in the elderly.
The skin is known as the Integumentary System [Science Links]. The skin is the outer covering of the body and is made up of 2 main layers. The epidermis is the outer layer of skin, while the dermis is the inner layer which lies on a layer of fatty tissue. The epidermis protects the body from injury and parasites, as well as preventing the body from becoming dehydrated. A combination of erectile hairs, sweat glands and capillaries within the skin forms part of the temperature control mechanisms of the body. The skin also acts as both an excretion organ--via secretion of sweat--and a sense organ, as it contains receptors that are sensitive to heat, cold, touch and pain. The layer of fat underneath the dermis acts as a reservoir of food and water for the skin (Concise Medical Dictionary 2002).
The epidermis is made up of layers or zones,
* The top or outer layer being known as the horny layer--stratum corneum.
* Granular (stratum granulosum) layer.
* Germative layer.
* Pickle cell (stratum spinosum).
* Basal layer (stratum basale).
These 5 layers make up the epidermis and cover the dermis and underlying subcutaneous tissue (Watson, R 2005).
The germative layer produces the main cells (keratinocyte) of the epidermis. These cells raise from the basal cell layer through each of the layers of the epidermis--stratum spinosum, gradulosum and lastly the stratum corneum the outer most layers. Once the cells have reached this outer most layer they have gone through a process of differentiation, which has transformed them into dead, flattened, anucleated cells called "coenocytes", which can take between 28 46 days to complete. This outer layer (stratum corneum) is where the barrier function of the skin occurs. Due to the high water content within these cells, it allows the cells to not only keep close to each other but also to form a tight but flexible seal (Bristow, I. 2013)
Cell turgidity is maintained through a natural moisturising process (NMF)--an intercellular humectant--which attracts water to itself. NMF is obtained from a substance called filaggrin, which breaks down into a range of NMF's--urea, amino acids, pyrolidoncaboxylic acid and latic acid. This process maintains the skins natural acidic PH (around 5.5). Lipids originating from the lamellar bodies in the stratum gradulosum, secrete into the epidermis, acting in a similar way to waterproof mortar between the coenocytes (flattered cells) of the horny layer This chemical and PH balance maintains the thickness of the epidermis (Cork, M.J et al 2009).
Between the epidermis and dermis a dermoepidermal junction forms to help anchor the epidermis and dermis together. The dermis makes finger like folds into the epidermis which are known as dermal papillae. These dermal papillae are complement by protrusions from the epidermis known as rete or epidermal ridges or pegs. Where there is an increase in mechanical stress a stronger attachment is formed between the dermal papillae and rete pegs (Dawber, R et al 2001). Collagen fibres account for up to 70% of the dermis giving both strength and toughness to the structure. Elastin fibres provide elasticity to the skin; these fibres are loosely arranged in all directions within the dermis (Gawkrodger, D.J. et al 2012).
The dermis is made of 2 layers, the papillary and reticular layer. The thin upper papillary layer contains most of the blood and lymphatic vessels, while the reticular layer is not as vascular, it does contain denser collagen and elastic fibres. T--Lymphocytes and mast cells of the immune system are present within the dermis (Dawber, R. et al 2001). Also present within the dermis there are numerous hair follicles and sweat glands (Gawkrodger, D.J. et al 2012).
The paper thin appearance of the skin associated with the elderly is due to an estimated 20% reduction in the thickness of the skin (Haroun, M.T. 2003). Thinning of the dermis sees a reduction in blood vessels, nerve endings and collagen. This causes a decrease in sensation, temperature control, rigidity and moisture retention (Barsnoski, S. et al 2004). A combination of reduced sweat glands and a lack of production of sebum make the skin difficult to keep hydrated leading to dryness and itching (Watkins, J. 2011). The ability to detect temperature changes via the skin makes the elderly prone to the cold and hypothermia. A reduced ability to regenerate, with a less efficient immune system, increases the risk of skin breakdown from even the slightest injury (Voegel, D. 2012). As the skin barrier fails it becomes dry (xerotic), scaly and loses elasticity, patients may complain of itching and stinging within the skin. Dry skin is often associated with ageing but is usually due to a combination of factors
* Young or elderly.
* Soaps, bubble baths and shower gels.
* Soaking the skin.
* Insufficient rinsing of the skin cleaning products.
* Vigorous drying with a towel.
* Temperature and humidity--air conditioning and central heating.
* Sun exposure
* Many skin conditions--eczema, psoriasis, and ecchymosis.
* Skin infection.
* Peripheral vascular Disease.
* Iron deficiency anaemia.
* Hypovitiamins (A, B, C, E).
* Renal failure.
* Thyroid Disease.
* Anorexia nervosa.
* Lymphoma and other internal malignancies.
* Drugs--statins, cimetidine, retinoid. (Bristow, I. 2013).
The major function of health skin is to act as a buffer between the body and the environment. As the skin ages the turnover of the skin slows down along with the production of NMF's. It results in various levels of dryness, along with the inability to retain water (Tangam, H. 2008). Other changes noted with age are fine to coarse wrinkling of the skin, mottled hyperpigmentation, yellowing and actinosis (skin plaques) (Lorimer, D. et al 2006).
Lifestyle and family history play a large role in how the skin behaves in the older person:
* Decreased mobility.
* Changes in mental health.
* Poor dietary intake/ poor hygiene due to a consequence of other impairments.
Signs of potential failure of the skin barrier include:
* Red sore skin--due to incontinence, obesity or reduced mobility.
* Itching, scratch marks (excoriation).
* Pressure areas, skin breaks, ulceration.
(Wingfield, C. 2012).
Dry skin--xerosis--conditions reflect the distruption of the normal function of the skin. As the skin becomes dry it is more vulnerable to splitting/ cracking, causing an increase in water loss, tissue breakdown and infection (All Wales Tissue Viability Nurses Forum 2011). Dry skin is often associated with the aging process, environmental factors and systematic diseases.
A common dermatological problem associated with dry skin is an "itch" pruritus. The incidences of pruritus increases with age, with those over 60 having chronic pruritus (classified as longer than 6 weeks duration) accounting for roughly 20% of the population. Damage to the skin caused by the patient scratching reduces the effectiveness of the skins natural protective barrier. Discomfort caused by the itch can lead to disturbed sleep, anxiety and depression (Best Practice Statement 2012). There are numerous reasons for pruritus ranging from:
* Allergic contact dermatitis.
* Medication--both topical and systematic (i.e. opioids, aspirin).
* Environmental agents--irritants i.e. soaps.
* Systematic disease--diabetes, CKD (Chronic kidney disease), cholestasis, thyroid dysfunction, anaemia.
Investigations are required to establish the cause of the pruritus, if no cause is found the patient often responses well to treatment for dry skin (Cowdell, F. 2009).
The use of emollients is important in promoting the health of the skin in the elderly. They are seen as the first line treatment for all dry scaling disorders, regardless of age group (NICE 2004).
Moisturisers or emollients work in 2 different ways, by either blocking the escape of water from the skin (occlusion) or by drawing water to the epidermis from the dermis (humectants). These products are the main element of treatment; they can either be used alone or with other topical treatments such as steroids (Best Practice Statement 2012.).
Moisturisers available include creams, ointments, lotions, bath oils and soap substitutes. Therapeutic preparations differ from cosmetics as the latter contain fragrances and colours which have no therapeutic value (Best Practice Statement 2012). Emollients are effective in the management of dry skin as part of routine foot care (Bristow, I. 2013).
Emollients, often called moisturisers have a number of functions; they soften and raise the moisture content within the epidermis, increase the skins resistance to irritation from outside irritants and improve pliability (Lorden, M. 2005). Emollients contain a lipid base of fat, wax or oil with varying degrees of water content. Ointments tend to have the lowest water content, while creams and gels have increased water content. Lotions feel lighter and are less occlusive due to their low lipid content which can cause increased dryness (Hon, K.A. et al 2013).
Urea is a naturally occurring substance within the skin, and when added to an emollient has demonstrated an effectiveness to hold water within the epidermis and contains antimicrobial properties (Bristow, I. 2013). Loden et al (2013), in recent work have noted that a 15% urea based formulation quickly improves dryness, thinning of hyperkeratosis on the foot without detriment to the water retaining capability of the epidermis.
Latic acid within an emollient has been noted to improve barrier function and reduced susceptibility to both infection and irrigation of the skin (Rawlings, A.V. et al 1996). Petroleum based products act as a barrier when applied to the skin, reducing the amount of evaporation of water from the skin, but do not rehydrate the skin (Rawlings, A.V. et al 2004).
Aqueous cream is best used for its intended purpose as a soap substitute due to the sodium lauryl sulphate content (detergent agent) which has been noted to cause skin thinning and irritation. The number of preservatives in aqueous cream has led to skin sensitivity and stinging in some patients (Wingfield, C. 2012).
Patients with dry skin are advised to apply a moisturiser regularly to the skin, at least twice a day. With very dry skin especially on the feet, once the emollient has been applied it is advised to cover the feet with a damp sock, followed with a dry sock over this, to help improve the effectiveness of the emollient (Bristow, I. 2013).
Patient compliance and emollient preference is required in order to improve and maintain skin integrity. Once dry skin has improved it is important that regular emollient use is maintained.
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Michelle Taylor MInstChP BSc
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|Title Annotation:||TECHNICAL ARTICLE|
|Date:||Mar 1, 2014|
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