The skin is the largest body organ, making up 15% of the total body weight. It provides protection from the environment and is the first line of defense against external injury and infection. It aids in temperature regulation and sensory perception. Care of the skin, therefore, is very important.
Children receive numerous knee and elbow abrasions as they are learning to ride bicycles or skate boards. Adolescents worry about acne, pimples, and that first important shave. Young women spend hours in the sun, trying to get a beautiful bronze tan. Women - young, middleaged, and old - spend millions of dollars each year on a large variety of cosmetics, trying to enhance, retain, change, and improve the skin of the face, neck, hands, arms, legs, and feet.
Like most other body organs, the skin changes with advancing age. Some skin conditions in the elderly are determined genetically (moles), some are caused by the environment (sun, wind, lack of care), some are due to organic disease (liver obstruction and tuberculosis), and some have no apparent cause. Nurses need to be aware of normal changes in the aging skin, how to assess the skin in the older individual, major problems of the skin in the elderly, and nursing implications for skin care of the older adult.
Common changes that affect the aging skin are loss of subcutaneous fat, loss of cells that affect pigmentation, atrophy of sweat and oilsecreting glands, and a decrease in blood vessels to the skin.' The sebaceous glands secrete less sebum, an oily substance that keeps the skin from becoming dry. Dryness of the skin is a major problem, therefore, that can lead to chapping, cracking, and infection. The epidermis, or outer layer of skin, becomes dry, less elastic, thinner, flatter, scaly, and rough in appearance. The skin becomes a great deal thinner over the backs of the hands and forearms, but not as much over the upper arms, trunk, and legs.2
When the amount of subcutaneous fat decreases and the skin becomes less elastic, wrinkles occur deep in the dermis,3 especially if there is sudden or excessive loss of weight. Some older individuals who retain their normal lifetime weight into old age develop no wrinkles at all. Wrinkles are less obvious in the slightly obese individual. Drying and wrinkling are less apt to occur in dark-skinned individuals; therefore, the skin of the face may retain a youthful appearance. There is also some evidence that degree of wrinkling is genetic, just like the aging process itself.
The hair becomes thin, fine, gray, and decreased in amount. The loss of hair color because of the decreasing number of functioning pigmentproducing cells.1 Body hair also diminishes or disappears. The absence of hair on the feet may indicate severe circulation problems.3
Nails, especially toenails, become brittle, striated, thickened, hardened, deformed, and misshapen. These conditions may have been caused by previous acute or chronic trauma, disease such as fungus, inherited nail abnormalities, or lack of adequate manicuring.4 A decreased blood supply also contributes to thickening of fingernails and toenails.1
Assessment of the Skin
Many diseases and internal conditions can be diagnosed by the appearance of the skin. Therefore, observation of the skin on a daily basis is very important to detect possible problems early. Adequate natural lighting is important when assessing the skin because artificial lights change the color of the skin. Lighting is often a problem in the long-term care facility or hospital room where there are few windows. The patient may need to be moved near a window for skin assessment.
A thorough assessment of the skin should be performed upon admission to the hospital, long-term care facility, or home care. If auxiliary nursing personnel are assigned to make this initial assessment, they need to be taught how to do the assessment and for what specific abnormalities to look. Reddened areas may be the early sign of decubiti. Black, brown, or yellow areas may indicate a previous fall or physical abuse.
Routine assessment of the skin by nursing personnel should be done daily, ideally during the bath or while helping the patient to dress. Nurses' aides should be taught to report promptly any sudden changes or unusual observations of the skin.
Major Skin Problems
Many skin conditions and diseases affect all age groups, but there are particular skin problems that occur in the older adult. Some of these are relatively harmless and others need special treatment and/ or care.
One of the first skin changes that many aging individuals (especially women) notice is a condition commonly known as "old-age freckles," "age spots," or "liver spots." These are round, irregular, brown spots larger than freckles that first appear on areas exposed to the wind and sun over many years. They occur on the face, neck, arms, and backs of the hands. Although they are called liver spots, "they are unrelated to the liver" and "properly identified as lentigo senilis.'"6 With advancing age, these spots may become larger in size, darker in color, thicker, and scaly. They rarely become malignant; however, if they become thick or develop crusts, there is a possibility they may become precancerous.3 Cancerous skin lesions are more apt to be shiny, flat, and black in color than brown and crusted. Senile freckles occur occasionally after age 50, but they are rare.1
Senile pruritis or itching occurs as a result of the loss of fluid and oil from the skin. Itching commonly occurs on the legs, but can be on any part of the body. Older people complain of this problem particularly in the winter because of low humidity, high room temperature, and warm woolen clothing.1 Severe itching of the skin, although usually due to excess skin dryness in old age, may be a symptom of disease. This itching may be caused by bile pigments deposited in the skin by way of circulation if there is obstruction of the hepatic ducts or other liver disease.
Seborrheic keratosis manifests itself as a yellow or brown wart covered witha greasy scale. It seldom becomes malignant.6 Senile keratosis, a thickening of the skin, frequently is found on the face, hands, arms, trunk, scalp, and neck. These raised brown or gray areas become scaly and can become malignant.6 The incidence of skin cancer increases with age, so skin abnormalities bleed, become hard or infected, or grow rapidly in size should be referred to a dermatologist for diagnosis and treatment. The various types of malignancies and other specific diseases of the skin are beyond the intent of this paper.
Future generations of older adults likely will have more skin problems because of the recent emphasis on sun-bathing among the young. Many older women of today were taught by their mothers and grandmothers to wear bonnets that shaded the face and neck, and gloves and long sleeves that protected the hands and arms. Some of these women have retained beautiful skin into their 70s and 80s. The very obvious effects of the sun can be seen readily when comparing the face or backs of the hands with the buttocks of an 85-year-old. The hands appear dark, rough, dry, scaly, and irritated, while the skin on the buttocks is pinkish, smooth, soft, supple, and warm.
Corns and calluses on the feet are common in the elderly. They often are due to wearing ill-fitting shoes over many years. Because of their low incomes, some older people continue to wear worn-out shoes that have become distorted and have worn heels, therefore contributing to the formation of blisters and other foot problems. Also, callus formation continues in the bedridden patient.4
Care of the Skin
Since the skin is more dry and fragile in the older adult than in younger people, it is very important to touch the skin with special care. When lifting or turning older patients, the nurse should use the palm of the hand, rather than the fingers, when grasping the patient's arm or leg. Extremities should be handled very carefully to prevent trauma and/orinjury. Fingernails of nursing personnel should be short and clean. Nail polish may be used if it is not chipped; in fact, it may protect the patient from rough or irregular nails.
Friction injuries can occur when a patient is pulled across the bed or off a bedpan. If these movements are necessary but difficult without adequate assistance, a small amount of powder or cornstarch sprinkled on the linen or bedpan may be helpful.3
Tepid rather than hot water and as little soap or detergent as possible should be used when bathing the older adult, since aging skin is more subject to injury and irritation. Soaps that contain some cream or emollient are better than are deodorant-type soaps, which may be irritating to the skin. All soap used on the skin should be rinsed off thoroughly, since soap causes more drying. Bath oils may be used if the skin is very dry, but they can be hazardous if placed in the bathtub.
Care should be taken to rinse and dry the skin well, especially under the arms, under pendulous breasts, at the groin, at the genital region, and between the toes. A complete bath is not absolutely necessary every day, even for the bed patient, since bathing dries the skin even more. A partial bath daily with special emphasis on the face, hands, axillae, genital region, and feet should be adequate, with a complete bath two or three times a week. The daily bath is probably more important for excercise, diversion, and conversation for the older bed patient than for cleansing the skin. A good back rub with an emollient lotion is important several times a day for the patient who must remain in bed. However, the nurse should not rub, scrub, or pull on the skin because of the danger of trauma and injury.8
Emollient creams do not add moisture to the skin but they help to prevent normal moisture evaporation.3 Lotions and creams help to relieve excessive dryness but alcohol and powder should not be used. Alcohol, by the way of rapid evaporation, increases dryness. Powder absorbs some of the moisture on the skin and also produces excessive dryness. When powder is used in the genital area to absorb moisture because of urinary incontinence, perspiration, or other drainage, the powder serves as a medium for bacterial growth and is very difficult to remove. Powder may mask an odor temporarily but it does not prevent or remove the odor. Careful cleansing is the best method of keeping the skin free from odor and infection. If the patient desires powder, the nurse should place a very small amount on a dry wash cloth or in the patient's hand, and then apply it to the skin. Excess powder should be dusted off the skin.
Adequate care of the skin also includes all of those other important nursing measures that help to prevent decubitus ulcers in the bed patient. Frequent turning (at least every two hours); a clean, smooth, tight, wrinkle-free bed; and an alternating air mattress, water bed, or other mechanical device for the bed to reduce pressure on the skin arejust as important as the cleansing and massaging of the skin areas where decubitus ulcers are most likely to occur. When reddened areas begin to form, gentle massaging in a circular manner around the reddened area, not directly over the area, is important. If an air mattress is used, it is important that a minimum amount of linen be placed on top of the mattress so that the effectiveness of the alternating air currents, which rotate pressure on the skin, will not be diminished.
Decreased sensory perception in the elderly is also important to remember when applying heat or cold to the skin. Injury can occur before the person is aware of any discomfort.
Wrinkling of the skin is not a major problem physically but it may be a psychologic and social problem for some people. A few middle- and older-aged adults have surgery to remove wrinkles from around the eyes, cheeks, mouth, and neck. Despite much advertising to the contrary, commercial creams that contain vitamins and hormones are not effective in removing wrinkles.
Increasing the humidity of the environment of older patients should help, at least in part, to prevent the loss of moisture on the skin into the air and prevent extreme drying. The author checked the humidity in a number of patient rooms in one nursing home and found the humidity to range from 25% to 40%. Room humidifiers could be utilized to increase the humidity in an attempt to prevent the loss of excess fluid from the skin. Increased room humidity also can prevent drying of the mucous membranes of the respiratory tract to facilitate breathing.
Surgical tape should be applied sparingly, removed carefully, and moved from one place to another, if possible, when dressings are changed. If there is a slight irritation due to tape, a very small amount of baby powder, lightly dusted on the irritation, will help to dry and heal the area. This procedure also is effective under pendulous breasts and a sagging abdomen to prevent irritation from skin rubbing against skin.
Nail care is also a major part of skin care in the elderly. The primary goal is to maintain cleanliness and prevent injury and infection. Fingernails should be checked daily and cleaned with an orange stick or cotton applicator. Even though the patient is confined to bed, the nails become dirty. Feces often can be found under the nails of patients who have great concern about constipation. Most older people cannot care for their own toenails because the nails are thick and hard to cut. They cannot see well enough to cut them safely and cannot reach their feet easily. 'The cutting of long, hard, brittle nails, care of ingrown toenails, and the trimming of corns and calluses should be done by a physician or podiatrist because circulation to the feet of most elderly persons is diminished and a severe infection could easily occur. The author remembers well an elderly diabetic patient who had trimmed a com with a razor blade and eventually required an amputation because of the resulting infection.
Fissures occur between the toes and on the heels. Frequent washing, careful drying, and the use of lotions will help to prevent this condition. Care must be taken to assure that sheets are not too tight over the feet.
A nutritious diet, with special emphasis on the adequate intake of a variety of fluids, vitamin A (a deficiency causes rough dry skin), niacin (a deficiency can cause dermatitis), and vitamin C (a deficiency can cause capillary leakage and dermatitis), is extremely important for the older patient. Good sources of vitamin A are liver, eggs, butter, milk, and dark green and yellow vegetable. Niacin is found in liver, wheat germ, and leafy vegetables. Good sources of vitamin C are citrus fruits, tomatoes, strawberries, and green vegetables.7
Older women either are expected not to use cosmetics or to use them to cover up, rather than enhance, the skin. The author asked about cosmetics for older women at cosmetic counters in several large department stores. Hormonal creams, thick powder bases, and bright red lipsticks were suggested, the combination of which gives a hard, artificial appearance. Creams advertised to remove wrinkles often make the skin feel tight and uncomfortable. Special cosmetics for older women have not been produced by the beauty industry even though specialized make-up has become available for those in early adolescence and for those who have dark-pigmented skin. Cosmetics that enhance the beauty of older skin rather than hide it should be chosen.8
Physical appearance and body image are very important to selfesteem at any age. The older woman should be assisted in applying cosmetics in such a way that they will enhance her appearance. Older women cannot see well and use too much powder and rouge, or go beyond the lip line when applying their lipstick because their hands are not steady.
Cleanliness and grooming of the hair also enhance feelings of selfesteem. The hair should be brushed daily and washed every one to two weeks, more often if the patient desires. Braids or a short, curly haircut are best for the bed patient. However, if braids are used, the hair should be braided loosely rather than tightly and discrimination should be used in applying hair ornaments. For example, bright pink ribbons or barrettes are not appropriate for an 85-year-old woman, unless she has been wearing them all of her life. These are ornaments for children and should not be used on the elderly unless they desire them.
Many elderly women, especially those in their 80s and 90s, are not accustomed to shaving their legs or under their arms, so this should not be done without their consent. However, they may want to have long hairs on their chins plucked or shaved to enhance the appearance of their faces.
Careful assessment and effective care of the skin in the elderly is very important. Not only will an intact and healthy skin prevent major infections and complications that can be hazardous to the elderly physically, but healthy skin improved by special care can enhance the older person's feelings of self-worth. The professional nurse has a responsibility to see that this special kind of skin care is provided.
- 1. Kart S MetressS, Metress SP: Aging and Health: Biologic and Social Perspectives, Menlo Park, CA, Add ison- Wesley Publishing Co. 1978, pp 32-43.
- 2. Caird FI, Judge TG: Assessment of the Elderly Patient. London: Pitman Publishing, Ltd, 1974, pp 22-24.
- 3. Fucrst V, Wolff LV, Weitzcl MH: Fundamentals of Nursing, ed 5. Philadelphia, JB Lippincott Co, 1974, pp 245247, 292.
- 4. McGregor RR: Geriatric foot care, Nws Clin North Am 1968; 687-695.
- 5. Bates B: A Guide 10 Physical Assessment. ed 2. Philadelphia, JB Lippincott Co, 1979, pp 46-47.
- 6. Saxon SV, Etten MJ: Physical Change and Aging. New York, The Tiresias Press, 1978, pp 18-22.
- 7. Robinson NB; Dietary needs in later life, in Hogstel MO (ed): Nursing Care of the Older Adult. New York, John Wiley and Sons, Inc, 1981, pp 219-223.
- 8. Palmer MH: Assisting the older woman with cosmetics. Journal of Gerontologicai Nursing 1982; 8(6):340-342.