skin integrity for people with long term conditions

Skin Integrity for people with long-term conditions

Kathy Radley, Lecturer in Skin Health and Dermatology Care,

University of Hull and Project Coordinator, Eczema Education

Project, GSTT

Intended learning outcomes:

Kathy Radley November 2014

• By the end of the session delegates will:

– Understand the role of the skin as barrier and the effect

skin hygiene practices have on this

– Review the evidence underpinning skin hygiene practices

– Utilise knowledge of skin health and skin hygiene to

enhance evidence-based practice

– Consider promotion of skin integrity for people with MS

Plan:


• Skin structure and function

• Stratum corneum

• Maintaining skin integrity

– Skin hygiene– Dry skin– Pressure

• Skin changes in older people

• Skin changes in people with bariatric needs

• Contact dermatitis

• Infection

• Take home messages

Structure of the skin

• Photo: American Skin Association.


Functions of the skin:


• Prevents loss of essential body fluids

• Protects against entry of toxic environmental chemicals and microorganisms

• Protects against damage from ultraviolet radiation

• Regulates body temperature

• Immunological function

• Vitamin D synthesis

• sensation

• Sexual attraction and social interaction

The epidermis:


• Stratum basale

– Unique ridges – fingerprints– Melanocytes distributed through this layer

• Stratum spinosum

– 8 - 10 layers of keratinocytes bound together by desmosomes

– Langerhans cells – immune function

• Stratum granulosum

– Cells stopped dividing– Make large amount of keratin– Dehydrate, thicken and interlock tightly

The epidermis:


• Stratum lucidum

– Clear layer in thicker skin (palms and soles)– Densely packed cells filled with keratin

• Stratum corneum

– Exposed surface– Thickness varies with site, 15 – 30 layers of keratinised

cells– 7 – 10 days from stratum basale to stratum corneum– 14 days more before shedding– Water resistant but not waterproof– ~ 500ml water lost per day (not including sweating we are

aware of)

Stratum corneum:


• Prevents water loss

• Barrier to penetration of external agents

• Filaggrin binds with keratin to help provide barrier

• Gene mutations in atopic eczema and some ichthyoses for filaggrin leads to compromised barrier function

• Natural moisturising factor (NMF) has a major component derivative of filaggrin

• Acid mantle (pH 5.4-5.9) – natural protection against microbes

Brick wall analogy



• Image source: http://www.epgonline.org/page.cfm/pageId/2621/type/print/ in collaboration with Astellas Pharma Europe Ltd

http://www.epgonline.org/page.cfm/pageId/2621/type/print/

http://www.epgonline.org/terms-of-use-ape.cfm

Skin hygiene


• Search on Cinahl complete and medline with terms ‘skin barrier’ and ‘wash*’ = 120 results

• Many involved neonates

• Several sponsored studies

• Voegeli (2008) – study experimental cohort design and healthy volunteers

• Compared washing with just water, and soap and water

• Both increased TEWL and increase in pH with soap

• Comparing drying by patting with towel, gentle rubbing and no drying –patting and no drying increase TEWL

• Some evidence to suggest cumulative effect of damage with increase of frequency of washing

Skin hygiene


• Ersser et al 2005

• Hot water causes dry skin due to removing skin oils and accelerating water loss by evaporation

• Surfactants in soaps (commonly SLS) are potent irritants

• Soaps raise pH of skin leading to increase of p. acnes and s. aureus

• Studies comparing skin cleansers and soap/water – most have small samples or design weakness

• Study with soap and water, cleanser (not alkali and including an emollient), cleanser plus barrier cream and soap/water plus barrier cream looking at TEWL – cleanser better than soap and water, soap and water plus barrier cream better than cleanser but cleanser and barrier cream (combined product) gave best outcome

Skin hygiene


• Ersser et al (2005) report some small studies looking at

patient preference, nursing time and cost

• Implication from studies that if staff had better knowledge of

products available and their benefits then skin care would

improve

• Take-home message: soap is irritating and raises pH, drying

gently but thoroughly is best for skin barrier

Dry skin


• Associated with underlying skin disease eg eczema,

psoriasis

• Associated with ageing

• Associated with oral or topical treatments

• Neonatal skin

• Use of emollients help restore skin barrier

Emollients

• Emollient and moisturiser often used synonymously

• Best practice statement (BDNG 2012)

• Moisturiser: something that actively adds moisture to the

skin.

• Emollient: something that smoothes and softens the skin,

usually via occlusion.

• Definition: substances whose main action are to occlude the

skin surface and to encourage build up of water within the

stratum corneum (Best practice statement 2012).


Emollients

• Formulations and greasiness:

• Ointments

• Creams

• Lotions

• Additives

• Quantities – BNF , Best practice statement

• Method of application

• Before or after other topical preparations?


Emollients - side effects:

• Stinging / discomfort

• Irritant contact dermatitis (ICD) / allergic contact dermatitis

(ACD)

• Climatic effects

• Flammability

• Aqueous cream (SLS) (Cork and Danby 2011) and olive oil

(high oleic acid) (Danby et al 2013)

• Take home message: Do not use aqueous cream!


Emollients – practical tips for patients

• Wash off regularly

• Take out / away with you

• Apply for further supply before you run out

• Ask for assistance in applying your emollient

• Chill in fridge


Skin care related to pressure ulcer prevention


• EPUAP (2014)

• Strong evidence for:

• Avoid repositioning on an area of erythema

• Use a pH balanced skin cleanser

• Develop and implement an individualised continence management plan

• Cleanse skin promptly following episodes of incontinence

• Some evidence for:

• Do not massage or vigorously rub skin at risk of pressure ulcers

• Protect skin from excessive exposure to moisture with a barrier product

• Consider a moisturiser to hydrate dry skin

Examination:


• Look at general skin as well as lesions:

– Elasticity

– Moisture

Consider other sites including nails, hair/scalp

Touch:

Temperature

Scale

Solidity of lesion

• Good light is essential!

Record: body maps


Intrinsic changes in older people’s skin


• Reduction in cell turnover – skin more fragile as epidermis

thins and integrity between epidermis and dermis decreases

• Blood vessels become more fragile and blood supply to the

skin decreases

• Collagen fibres stiffen and elastic fibres thicken

• Production of sebum decreases

• Sweat glands become smaller and secrete less sweat

• Cowdell and Radley (2012)

Extrinsic factors in skin changes in older people


• Environmental – pollutants, sun

• Smoking

• Reduced peripheral sensation

• Reduced mobility

• Incontinence

• Depression and dementia

• Polypharmacy

• Diabetes and vascular changes

• Poor nutrition

Skin changes in patients with bariatric needs


• WHO data from 2008 – 35% adults overweight with 11% obese

• Change in epidermal barrier – increased TEWL and dry skin

• More pronounced erythema

• Reduced microvascular activity

• Collagen changes

• Skin folds – heat rashes (blocked and inflamed sweat glands), environment for bacteria and fungi

• Heavy adipose tissue, equipment (IVI, catheters)

• Mobility and equipment issues

• Cowdell and Radley (2014)

Exogenous eczema


• Irritant contact dermatitis (ICD)

• Allergic contact dermatitis (ACD)

ICD


• Irritants

– Acids– Alkalis– Detergents– petroleum

• Strong irritant – immediate effect

• Weaker irritant – cumulative effect

• Occupational – hairdresser (shampoos), engineer (cutting fluid), cleaner (cleaning products), nurses (soaps)

• Incontinence associated dermatitis

• Treatment – avoid irritant and use emollients (use of barrier creams)

ICD


• Mechanic – oil

ACD


• Delayed hypersensitivity reaction (type IV) – cell-mediated allergic response

• Common allergens

– Nickel– Colophony (adhesive plasters)– Rubber– Chromate (leather, cement)– Topical medicaments (neomycin, antihistamines,

preservatives), plants (primula, poison ivy, feverfew)

• Diagnosis – by patch testing for delayed hypersensitivity

• Treatment – avoid allergen and treat eczema

• Graham-Brown (2011)

Patch tests applied


Patch test readings


ACD


• Nickel

BCDS standard series pt 1


• 1 potassium dichromate 0.50% pet.

• 2 neomycin sulphate 20.00% pet.

• 3 thiuram mix 1.00% pet.

• 4 p-phenylenediamine 1.00% pet.

• 5 cobalt chloride 1.00% pet.

• 6 caine mix III 10.00% pet.

• 7 formaldehyde 1.00% aq

• 8 colophony 20.00% pet.

• 9 quinoline mix 6.00% pet

• 10 Myroxylon pereirae (Balsam of Peru) 25.00% pet.

• 11 N-isopropyl-N-phenyl-4-phenylenediamine 0.10% pet.

• 12 lanolin alcohol 30.00% pet.

• 13 mercapto mix 1.00% pet.

• 14 epoxy resin 1.00% pet.

• 15 parabens mix 16.00% pet.

• 16 p-tert-butylphenol formaldehyde resin 1.00% pet.

• 17 fragrance mix I 8.00% pet.

• 18 quaternium 15 1.00% pet.

• 19 nickel sulphate 5.00% pet.

• 20 methylchloro & methyl isothiazolinone 0.02% aq

• 21 mercaptobenzothiazole 2.00% pet.

BCDS standard series pt 2


• 22 amerchol L101 50.00% pet.

• 23 sesquiterpene lactone mix 0.10% pet.

• 24 p-chloro-m-Cresol 1.00% pet. 25 2-bromo-2-nitropropane-1,3-diol 0.50% pet.

• 26 Cetearyl alcohol 20.00% pet.

• 27 sodium fusidate 2.00% pet.

• 28 tixocortol-21-pivalate 1.00% pet.

• 29 budesonide 0.10% pet.

• 30 imidazolidinyl urea 2.00% pet.

• 31 diazolidinyl urea 2.00% pet.

• 32 methyldibromoglutaronitrile 0.30% pet

• 33 ethylenediamine dihydrochloride 1.00% pet.

• 34 p-chloro-meta-xylenol 0.50% pet

• 35 carba mix 3.00% pet

• 36 fragrance mix II 14.00% pet

• 37 disperse Blue mix 106/124 1.00% pet.

• 38 hydroxyisohexyl 3-cyclohexene carboxaldehyde 5.00% pet

• 39 Compositae Mix 2.50% pet

• 40 methylisothiazolinone 0.20% aq

• 41 sodium metabisulphite 1.00% pet

Infections


• Bacterial – Impetigo (non-bullous, bullous), folliculitis,

cellulitis

• Fungal – tinea, candida

• Viral – herpes simplex (eczema herpeticum), varicella

zoster, molluscum contagiosum, viral warts

Non bullous impetigo


Tinea manum


Eczema herpeticum


Take-home messages!


• Soap is irritating and raises pH, drying gently but thoroughly

is best for skin barrier

• Do not use aqueous cream

References:


• BDNG (2012) Best practice in emollient therapy http://www.bdng.org.uk/documents/EmollientBPG.pdf accessed 21 01 14

• Cork M and Danby S (2011) Aqueous cream damages the skin barrier. British Journal of Dermatology 164 (6) 1179-1180

• Cowdell F, Radley K (2012) Skin health in older people. Nursing Times 108 (49) 16-20

• Cowdell F, Radley K (2014) What do we know about skin hygiene care for patients with bariatric needs? Journal of Advanced Nursing 70 (3) 543-52

• Danby SG, AlEnezi T, Sultan A et al (2013) Effect of olive and sunflower seed oil on the adult skin barrier: implications for neonatal skin care. Pediatric Dermatology Vol. 30 (1), pp. 42-50;

• D@nderm – An atlas of clinical dermatology. http://www.danderm-pdv.is.kkh.dk/atlas/index.htmlaccessed May 2013

• EPUAP (2014) Prevention and treatment of pressure ulcers: quick reference guide. http://www.epuap.org/guidelines/ accessed October 2014

http://www.bdng.org.uk/documents/EmollientBPG.pdf

http://www.danderm-pdv.is.kkh.dk/atlas/index.html

http://www.epuap.org/guidelines/

References (continued)


• Ersser S, Getliffe K, Voegeli D and Regan S (2005) A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. International Journal of Nursing Studies vol 42 pp823-835

• Graham-Brown R and Burns DA (2011) Lecture notes: Dermatology. Wiley-Blackwell, Chichester

• Martini F, Nath J and Bartholomew E (2012). Fundamentals of anatomy and physiology. 9th edition. Pearson education, San Francisco

• Penzer R and Ersser SJ (2010). Principles of Skin Care. Wiley-Blackwell, Chichester

• Voegeli D (2008) The effect of washing and drying practices on skin barrier function. Journal of Wound, Ostomy and Continence Nursing vol35(1) pp84-90

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