Skin integrity for people with long term conditions
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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
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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
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Plan:
Kathy Radley November 2014
• 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
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Structure of the skin
• Photo: American Skin Association.
Kathy Radley November 2014
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Functions of the skin:
Kathy Radley November 2014
• 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
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Kathy Radley November 2014
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The epidermis:
Kathy Radley November 2014
• 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
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The epidermis:
Kathy Radley November 2014
• 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)
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Stratum corneum:
Kathy Radley November 2014
• 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
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Brick wall analogy
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Kathy Radley November 2014
• Image source: http://www.epgonline.org/page.cfm/pageId/2621/type/print/ in collaboration with Astellas Pharma Europe Ltd
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Kathy Radley November 2014
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Skin hygiene
Kathy Radley November 2014
• 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
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Skin hygiene
Kathy Radley November 2014
• 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
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Skin hygiene
Kathy Radley November 2014
• 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
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Dry skin
Kathy Radley November 2014
• 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
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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).
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Emollients
• Formulations and greasiness:
• Ointments
• Creams
• Lotions
• Additives
• Quantities – BNF , Best practice statement
• Method of application
• Before or after other topical preparations?
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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!
Kathy Radley November 2014
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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
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Skin care related to pressure ulcer prevention
Kathy Radley November 2014
• 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
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Examination:
Kathy Radley November 2014
• 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!
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Record: body maps
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Intrinsic changes in older people’s skin
Kathy Radley November 2014
• 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)
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Extrinsic factors in skin changes in older people
Kathy Radley November 2014
• Environmental – pollutants, sun
• Smoking
• Reduced peripheral sensation
• Reduced mobility
• Incontinence
• Depression and dementia
• Polypharmacy
• Diabetes and vascular changes
• Poor nutrition
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Skin changes in patients with bariatric needs
Kathy Radley November 2014
• 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)
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Exogenous eczema
Kathy Radley November 2014
• Irritant contact dermatitis (ICD)
• Allergic contact dermatitis (ACD)
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ICD
Kathy Radley November 2014
• 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)
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ICD
Kathy Radley November 2014
• Mechanic – oil
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ACD
Kathy Radley November 2014
• 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)
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Patch tests applied
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Patch test readings
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ACD
Kathy Radley November 2014
• Nickel
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BCDS standard series pt 1
Kathy Radley November 2014
• 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.
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BCDS standard series pt 2
Kathy Radley November 2014
• 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
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Infections
Kathy Radley November 2014
• Bacterial – Impetigo (non-bullous, bullous), folliculitis,
cellulitis
• Fungal – tinea, candida
• Viral – herpes simplex (eczema herpeticum), varicella
zoster, molluscum contagiosum, viral warts
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Non bullous impetigo
Kathy Radley November 2014
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Tinea manum
Kathy Radley November 2014
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Eczema herpeticum
Kathy Radley November 2014
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Take-home messages!
Kathy Radley November 2014
• Soap is irritating and raises pH, drying gently but thoroughly
is best for skin barrier
• Do not use aqueous cream
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References:
Kathy Radley November 2014
• 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
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References (continued)
Kathy Radley November 2014
• 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