1. Understanding Skin to Promote Skin Wellness for your Residents  2010 GOJO Industries, Inc. All rights reserved. Skin Care 101 In Long Term Care

2. Skin Care 101 In Long Term Care Training topics  Skin and an aging population  Understanding skin structure and function  Fundamentals of aging skin  Understanding compromised skin in the elderly  Understanding skin regimen principles* 2 *excluding wound care

3. Skin Care 101 In Long Term Care 3 Skin and an aging population In Memoriam Albert M. Kligman, M.D. PH.D. 1916 - 2010 No one dies of old skin! No matter how decrepit the integument becomes after a lifetime of assaults, it continues to perform its primary protective role. But, although skin diseases do not contribute importantly to mortality statistics, skin problems abound in the aged.

4. Skin Care 101 In Long Term Care Skin and an aging population  By 2050 one of every five people in the world will be older than 65 years  By 2030 America’s population greater than 65y will grow by 30M to 70M people  The vast majority of people above this age have at least one skin problem  Skin dryness (xerosis) and itching (pruritus) are the top two most common problems  Subjects older than 65y account for 88.2% of all reported skin tears  The elderly population has rapidly increasing needs for skin care Norman RA. Aging: an overview. Dermatologic Therapy 16, 2003: 181-185. Norman RA. Xerosis and pruritus in the elderly: recognition & management. Dermatologic Therapy 16, 2003: 254-259. 4

5. Skin Care 101 In Long Term Care What does your skin do?  Provides protection against effects of the environment especially sunlight  Controls against excessive body water loss but keeps itself moist  Regulates body temperature through sweating and blood supply  Senses the environment through touch and pressure but also pain  Is a primary immunological organ protecting against infections  Is involved in vitamin D synthesis for your body  Excretes non-essential compounds through sweating and cell loss 5

6. Skin Care 101 In Long Term Care Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2 Structure of the skin 6 Deepest skin layer Hypodermis Deepest skin layer Hypodermis Middle skin layer Dermis Middle skin layer Dermis Outer skin layer Epidermis Outer skin layer Epidermis

7. Skin Care 101 In Long Term Care 7 Function of skin layers

8. Skin Care 101 In Long Term Care Rawlings AV et al. Stratum corneum moisturisation at the molecular level. J. Invest. Dermatol. 103:731-40; 1994 Stratum corneum (the top layers of skin) 8

9. Skin Care 101 In Long Term Care http://www.health.com/health/gallery/0,,20307059_6,00.html Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2 Dry skin occurs on all aged body sites 9 Dry skin or skin xerosis

10. Skin Care 101 In Long Term Care Aged dry skin: faulty desquamation Normal photographHigh resolution micrograph Rawlings et al. Stratum corneum moisturization at the molecular level: an update in relation to the dry skin cycle. Journal Of Investigative Dermatology 124: 1099-1110, 2005. 10 Healthy Skin Smooth Skin Dry Skin Flaky Skin Dry skin has less stratum corneum lipids, natural moisturizing factors and desquamatory enzymes and has an itchy flaky skin surface

11. Skin Care 101 In Long Term Care Aged dry skin = more body itching  Increased body itching occurs in aged skin due to reduced skin moisturization and increased dry skin  Mechanical trauma induced by scratching further compromises barrier function leading to a dry skin cycle  Aged skin has a decreased sense of feeling and constant mechanical trauma can lead to increased risk of tissue injury  Longer wound repair times result in higher morbidity in the aged 11 http://www.health.com/health/gallery/0,,20307059_1,00.html Leveque et al. Changes in tactile spacial discrimination by skin hydration in the elderly. J Invest Dermatol. 115: 454-458, 2000. Farage et al. Degenerative changes in aging skin.. In: Skin Aging. Eds: Farage et al. Chapter 4: 25-35, 2009. Rawlings et al. Stratum corneum moisturization at the molecular level: an update in relation to the dry skin cycle. Journal Of Investigative Dermatology 124: 1099-1110, 2005.

12. Skin Care 101 In Long Term Care http://www.health.com/health/gallery/0,,20307059_6,00.html Problems of the aging foot  Generalized xerosis (dry skin)  Thickening of the stratum corneum (hyperkeratosis) leads to corns on toes or calluses on soles or heels  Itching, burning, numbness, cramp  Diabetes can make these worse 12 Generalized xerosis

13. Skin Care 101 In Long Term Care 30-40 KERATINOCYTES PER MELANOCYTES EPIDERMAL MELANIN UNIT 30-40 KERATINOCYTES PER MELANOCYTES EPIDERMAL MELANIN UNIT Melanocytes and skin aging 13 MELANIN EXFOLIATION WITH CORNEOCYTES MELANIN EXFOLIATION WITH CORNEOCYTES Aging skin makes less melanin but it becomes more concentrated in ‘age spots’ MELANIN SYNTHESIS IN MELANOCYTES MELANIN SYNTHESIS IN MELANOCYTES MELANSOMES TRANSFERRED TO KTs MELANSOMES TRANSFERRED TO KTs MELANIN DEGRADATION & OXIDATION MELANIN DEGRADATION & OXIDATION

14. Skin Care 101 In Long Term Care Dermis and skin aging 14 Flattening of the connections between the epidermis and dermis

15. Skin Care 101 In Long Term Care Kafi R et al. Improvement of naturally aged skin with vitamin A.Arch Dermatol. 2007 May;143(5):606-12. Physiological variations during aging. Pierard et al. In: Skin Aging.Eds: Farage et al. Chapter 6: 45-54, 2009 Normal skin aging 15

16. Skin Care 101 In Long Term Care Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2 Aging and skin problems 16 Thick, scaly skin / HyperkeratosisAcute Eczema Blister, Bullae Allergy

17. Skin Care 101 In Long Term Care Fragile aged skin: Dermatoporosis  Skin thinning (Skin atrophy)  Skin bruising (Senile purpura)  Skin scarring (Pseudoscar)  Skin tears (Skin laceration)  Skin ulcers (Dissecting hematoma)  Decreased pain perception & tactile sensitivity with aging leads to higher risk of trauma Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294 I II III IV 17 Skin atrophy Senile purpura Pseudo- scar Skin laceration Dissecting hematoma Stage I +++–– Stage II ++++– Stage III +++++– Stage IV ++++++ Table 1. Proposed clinical staging of dermatoporosis: a basis for further evidence-based quantitative definitions

18. Skin Care 101 In Long Term Care 18 Dermatoporosis and skin tear grading http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Sep3(3)/PublishingIma ges/01-Fig3.JPG

19. Skin Care 101 In Long Term Care Fragile aged skin: Dermatoporosis Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294 Aged skin shows: skin thinning (atrophy) i.e. more transparent skin, bruising (senile purpura) and scarring (linear white pseudoscars). These occur because of repetitive mechanical trauma to the skin and the lack of skin integrity due to the thinning if the skin. 19 Old Young

20. Skin Care 101 In Long Term Care Aging and loss of collagen Old Kaya G & Saurat JH. Dermatoporosis: A chronic cutaneous insufficiency/fragility syndrome. Dermatology 2007, 215: 284-294 Histologically aged skin shows: A decrease in collagen (less red staining) Young 20

21. Skin Care 101 In Long Term Care Skin aging summary  Drier, rougher and flaky skin  Less SC water, lipids, NMF and enzymes  Decreased cell turnover  Increased age spots  Weakened epidermal/ dermal connections  Decreased skin feeling  Presence of dermatoporosis –Skin atrophy (thinning and less collagen) –Senile purpura or bruising –Pseudoscars –Skin tears –Skin ulcers 21

22. Skin Care 101 In Long Term Care Causes of elderly skin damage  Weather and air conditioning –Especially cold and/ or dry  Physical insult and friction  Irritation from chemicals  Use of aggressive soaps  Prolonged occlusion  Lessened hygiene habits  Insufficient skin moisturization 22 Bianchi et al. Assessment of skin integrity in the elderly. (Part 1) Br J Community Nurs. 2008 Mar;13(3):S26, S28, S30-2. Bianchi et al. Management of skin conditions in the older population. Br J Community Nurs. 2008 Sep;13(9):S6, S8, S10. Ratliff et al. Skin teas: A review of the evidence to support prevention & treatment. Ostomy Wound Manage. 2007 Mar;53(3):32-4, 36, 38-40

23. Skin Care 101 In Long Term Care Poor nutrition: more aged skin  The elderly can have a substandard diet especially in protein  Increased fat and carbohydrate intake increases risk of skin thinning or atrophy  Insufficient intake of fruit and vegetables can lead to increased risk for skin bruising (purpura) and more skin photodamage  Higher intake of vitamin C leads to less aging appearances  Iron deficiency can result in anemia and skin itching (pruritus)  Zinc deficiency and vitamin deficiency can impair wound healing  Essential fatty acids and vitamin A deficiencies lead to increased risk of skin dryness (xerosis) and skin thinning (atrophy)  Poor fluid intake can lead to poor skin hydration 23 Physiological variations during aging. Pierard et al. In: Skin Aging. Eds: Farage et al. Chapter 6: 45-54, 2009 Nutrition & skin aging. Cosgrove et al. In: Aging Skin. Eds: Rhein et al. Chapter 13: 377-390, 2010

24. Skin Care 101 In Long Term Care Well-conditioned skin is the basis of prevention Maintaining healthy skin barrier is the best way to prevent many aging skin problems Healthy skin Apply this concept to the elderly Dry skin 24 Recommended Care = Gentle Contact + Mild Cleansing + Regular Moisturizing

25. Skin Care 101 In Long Term Care Preserving and Protecting the Skin of Long-term Care Residents  Encourage nutritious food and adequate fluid intake  Use a gentle touch, warm water and mild cleansers for routine bathing  Cleanse immediately if incontinent of urine or stool and use a barrier ointment routinely  Use absorbent pads or briefs to wick moisture away from the skin  Apply moisturizers often and minimize environmental factors such as exposure to low humidity and cold.  Avoid massage over bony prominences 25

26. Skin Care 101 In Long Term Care Preserving and Protecting the Skin of Long-term Care Residents  Include mental status and the ability to respond to pain or discomfort when assessing for risk of skin breakdown  Promote mobility and range of motion exercises  If confined to bed, change position at least every 2 hours  Minimize friction and shearing by using proper technique when positioning, transferring and turning  Encourage resident and family involvement in the plan of care for skin preservation 26