The skin is the largest organ in the human body and has five main functions: protection, sensation, heat regulation, storage and absorption. It provides a barrier to prevent harmful bacteria from entering the body and protects the internal organs from damage. It also prevents the leakage of vital chemicals and fluids. As the skin ages, its barrier function deteriorates, which affects immune function and increases the risk of the older person developing skin problems. Its lipid and water content decreases, and the skin becomes dryer (Nigam and Knight, 2017). Ageing skin is more prone to a range of conditions, including infections, infestations, eczema and psoriasis and has increased vulnerability to skin damage, such as pressure ulcers, leg ulcers and skin tears, as well as having decreased healing ability (Kottner et al, 2013; Stojadinovic et al, 2013).
How lifestyle factors and illness affect the skin
Certain factors accelerate skin ageing. The skin is easily damaged by ultraviolet light, and excessive sun exposure can cause dryness, irregular pigmentation, loss of collagen and deep wrinkling. Areas of the body exposed to the sun, such as the hands and forearms, age more rapidly that areas normally covered, such as the abdomen and buttocks (Vierkötter and Krutmann, 2012). Smoking deprives the skin of oxygen and accelerates the ageing process (Okada et al, 2013). Poor general health, poor nutrition and inadequate fluid intake can also accelerate skin ageing (Posthauer et al, 2013). Table 1 illustrates how ageing, lifestyle factors and illness affect the skin.
Table 1. Summary of NICE (2018) guidance on emollient prescribing
| Change | Consequence |
|---|---|
| Skin thins | More easily damaged, increased risk of bruising and skin tears |
| Replacement rate slows | Takes longer to heal |
| Reduced melanocytes | Burns more easily |
| Loss of collagen | Saggy wrinkly skinIncreased risk of skin tears, increased healing time, wounds more prone to breaking down |
| Loss of fat | Prominent veins, increased risk of bruisingReduced protective layer, increased risk of skin damage, increased risk of pressure sores |
| Loss of lipids and water | Dry skin, cracks easilyIncreased risk of infection |
The principles of maintaining healthy skin in older people are to maintain the barrier function, prevent dryness and replace lost moisture.
What is eczema?
Eczema was first described over 2000 years ago. The term eczema is derived from the Greek, ekzein, meaning ‘to boil out’. Ancient physicians considered that eczema made the skin look red and inflamed as though it were boiled. Today, the term eczema is often used loosely to describe any type of inflammatory skin condition (Van Onselen, 2012). Eczema is common at both ends of the age spectrum and predominately affects older people and young children.
The skin in those with eczema becomes red, inflamed, itchy and scaly. When infected, it can be red, crusting and weeping. Chronic eczema causes skin changes, such as dryness and thickening, the latter known as lichenification (Kim et al, 2016; Yew et al, 2019). Older people may develop different types of eczema such as atopic, seborrhoeic, discoid and venous eczema.
Atopic eczema
Beiber (2015:61) defined atopic dermatitis (AD) as ‘a chronic, relapsing pruritic skin disease involving allergic inflammation and skin barrier defects in relation to environmental stimuli and the patient's genetic background’. Figure 1 shows atopic eczema in an adult.
Figure 1. Atopic eczema on the hands
Knowledge of atopic eczema in older people is far from complete, although it is known that there are types of atopic eczema that affect older people: one that is associated with allergies, one that is not associated with allergies and another type that falls between the allergic and non-allergic types (Tanei, 2020). Atopic eczema may be associated with a history of allergies or asthma and tends to run in families. The skin of those with this condition becomes extremely itchy and inflamed, resulting in redness, swelling, vesicle formation (minute blisters), cracking, weeping, crusting and scaling. Almost all older people with atopic eczema have dry skin.
It is clear that age-related changes that affect the skin barrier function contribute to the development of atopic eczema. It also thought that there is a genetic component, and further research is required to help clinicians to diagnose and treat atopic eczema in older people (Bieber et al, 2017; Williamson et al, 2020).
Treatment of atopic eczema
Treatment consists of three measures. These are reduced exposure to triggers whenever possible, applying emollients to the skin and using topical steroids intermittently to deal with flare ups. If the person has an identified allergen, then exposure to this should be avoided whenever possible. The person will require regular application of emollients to the skin to maintain hydration. Steroid creams, such as dermovate, betamethasone, valerate and 0.1% eumovate are used to manage flare-ups.
Maintaining barrier function
There is a protective oily layer on the skin's surface known as the acid mantle, made up of lactic acid and amino acids secreted from the sweat glands, free fatty acids from sebum and amino acids and carboxylic acid produced by the skin. This layer activates enzymes responsible for synthesising lipids, helps form lipids and restores the epidermis if it is damaged by mechanical or chemical damage (Schmid-Wendtner and Korting, 2006). Normal skin has a pH of 5.5 and is slightly acidic. However, soap is alkaline and has a pH of around 9. Thus, washing with soap strips the skin of its acid mantle and impedes its barrier function (Kirsner and Froelich, 1998). When the pH of the skin is altered, the skin can become colonised with bacteria, including virulent strains of Staphylococcus aureus (Rippke et al, 2004). Further, pH changes increase the risk of skin diseases such as irritant contact dermatitis, atopic dermatitis and Candida albicans infections (Schmid-Wendtner and Korting, 2006). Therefore, the skin should be cleansed using soap substitutes, which are effective cleansers but which do not lather like soap does. These include emulsifying ointments, Cetraben, Diprobase cream, Wash E45, Hydromol ointment, Epaderm and Dermol 500 (which contains an antibacterial). There also specific preparations for showering, such as Dermol shower, Oilatum shower and E45 Shower (British National Formulary, 2020; NHS, 2020).
The older person may have used soap all their lives and may not feel clean without it. If they wishes to continue using soap, they can be advised to use a mild non-perfumed soap, such as Simple soap, that maintains pH balance. Dove soap is a superfatted emulsion that has also been recommended for older skin (Hardy, 1996). Robertson and Brown (2011) worked with cancer patients and recommended that those receiving use mild soap. They asked patients to identify soaps that they considered mild and tested the soaps. Patients identified Johnson's baby soap, E45, Dove, Pears, Simple Soap and Imperial Leather. When tested, it was found that only Simple soap and Johnson's baby soap had a pH of around 5.5. All were fragranced except Simple and E45. If the skin is very dry, it is best to use emulsifying ointment. If the skin is sore, then plain water can be recommended until the soreness subsides.
Many older people enjoy using bubble baths and shower gels. Supermarket value ranges are often very harsh on older skin. If the skin is not too dry or sensitive, a cream bubble bath or a pH-balanced shower gel can be used.
Emollients
Emollients aim to restore the barrier lipid function and to enable the skin to regain its ability to resist damage from irritants, allergens and infection. These are available as lotions, creams and ointments. The grease, shine, stickiness and thickness of an emollient is a good guide to its lipid content. Lotions have the lowest lipid content. These are light and easily absorbed. Creams have higher lipid content. Ointments have the highest lipid content, but some people consider them greasy. There is no robust evidence to support the use of one emollient over another (van Zuuren et al, 2017). Guidance from the National Institute for Health and Care Excellence (NICE) (2018) guidance recommended that prescribers are guided by patients in which preparation is most effective for that person's skin (Tables 2 and 3).
Table 2. Summary of NICE (2018) guidance on emollient prescribing
| Consideration | Recommendation |
|---|---|
| Dryness of skin | Mild to moderately dry: use creamsModerate to severely dry: use ointments |
| Weeping dermatitis | Use creams as ointments will tend to slide off, becoming unacceptably messy |
| Frequency of application | Creams are better tolerated but need to be applied more frequently and generously to have the same effect as a single application of ointment |
| Choice and acceptability | Take account of the individual's preference, determined by the product's tolerability and convenience of use |
| Efficacy and acceptance | Only a trial of treatment can determine if the individual finds a product tolerable and convenient |
| One size does not fit all | More than one kind of product may be required. The intensity of treatment required and the area to be treated should guide treatment choice |
| Balancing acceptability and effectiveness | The individual (and the prescriber) need to balance the effectiveness, tolerability and convenience of a product |
Table 3. Standard emollients in order of efficacy
| Name | Type | Comments |
|---|---|---|
| White Soft Paraffin/Liquid Paraffin 50:50 | Greasy but very effective 500 gm | Can soak into clothing and is a fire hazard in those who smoke or approach naked flames |
| Epaderm | Greasy but very effective 500 gm | Useful when it is only possible to apply once or twice daily |
| Unguentum Merck cream | 500 gm | Creams are less effective than ointments but patients may prefer them. They need to be applied more frequently than ointments |
| Neutrogena Dermatological cream 100 gm | 100gm | |
| Doublebase gel | 500g | Breaks down in contact with the skin and coats the skin. Has some water resistance so good for hands |
| Hydromol cream | 500g | |
| Diprobase cream | 500g | |
| Aveno lotion | Made with oatmeal, requires frequent application. Popular with some people, especially younger people whose skin is not very dry |
NICE (2018) recommended that, whenever possible, prescribers recommend an emollient with a pump dispenser to minimise the risk of bacterial contamination. If prescribing emollients that come in pots, they should advise using a clean spoon or spatula (rather than fingers) to remove the emollient. Further, aqueous cream should not be prescribed as it is thought to cause a disproportionate amount of skin reaction. Similarly, emollients containing active ingredients are not generally recommended, because they increase the risk of skin reactions. However, NICE (2018) guidance stated that they can be useful in some people. Table 4 provides details of emollients with active ingredients.
Table 4. Emollients containing active ingredients
| Ingredient and action | Brand names |
|---|---|
| Urea (a keratin softener and hydrating agent | Aquadrate, Balneum Plus, Calmurid, E45 Itch Relief Cream, and Eucerin Intensive |
| Lauromacrogols (have local anaesthetic properties, and soothes and relieve itchy skin) | Balneum Plus and E45 Itch Relief Cream |
| Lanolin or lanolin derivatives | Hydrous ointment, E45 cream and lotion, and Oilatum emollient bath additive |
| Antiseptic | Dermol preparations (cream, lotion, shower, and bath emollient), Emulsiderm liquid emulsion, and Oilatum Plus bath additive |
Flare-ups
Eczema can develop because of infection or non-infective inflammation. Infected eczema may be treated with oral or topical antibiotics. Inflammatory eczema is treated with a short-term dose of steroid cream (Ventura et al, 2015). Harding et al (1989) developed a practical way to measure how much steroid cream is required. The fingertip unit (FTU) is 0.5 g of ointment and is sufficient to cover both palms. An adult lower leg requires three FTUs. Topical steroids (other than mild steroids) can be applied once or twice daily. They should be applied for 10–14 days, as discontinuing early can lead to a recurrence of flare-ups. Steroids should be used episodically rather than long term. Long-term use of steroids can lead to problems such as skin thinning and reduced efficacy. Figure 2 illustrates how eczema can develop, and Figure 3 shows the potencies of steroid creams.
Figure 2. How eczema can develop 
Figure 3. Potencies of steroid creams
In some cases, management may also require antibiotic or antihistamine therapy. If the person's eczema does not respond to treatment, they require referral to a dermatologist (Van Onselen, 2012).
Seborrhoeic eczema
Gomez (2017) described seborrhoeic dermatitis as ‘a common, chronic or relapsing form of eczema or dermatitis that mainly affects the sebaceous, gland-rich regions of the scalp, face and trunk’. The causes of seborrhoeic dermatitis are not fully understood. Oily skin can lead to the proliferation of Malassezia species, a type of yeast that constitutes the normal skin flora. Malassezia species most commonly associated with seborrhoeic eczema are M. globosa and M. restricta, both of which thrive in oily skin (Gupta et al, 2003). An overgrowth of this yeast can lead to an inflammatory reaction that leads to seborrhoeic dermatitis (Zisova, 2009), characterised by dry skin plaques (Swartz et al, 2013). Seborrheic dermatitis is also linked to abnormalities in the immune system (Gomez, 2017). Figure 4 illustrates seborrheic dermatitis of the melolabial fold characterised by pink erythema and fine scaling.
Figure 4. Seborrhoeic eczema
Adult seborrhoeic eczema is more common in men than in women. It may be associated with oily skin, a family history of seborrhoeic eczema or psoriasis and neurological or psychiatric illness, such as depression, Parkinson's disease and epilepsy. It tends to worsen when a person is tired or stressed (Gomez, 2017). Seborrhoeic dermatitis affects the scalp, face (creases around the nose, behind the ears and within the eyebrows) and upper trunk. The clinical features are as follows:
- Worsens in winter and improves in summer
- Minimal itch
- Patient has combination skin with oily patches
- Salmon-pink, thin, scaly and ill-defined plaques in skin folds on both sides of the face
- Petal or ring-shaped flaky patches on hair-line and on anterior chest
- Rash in armpits, under the breasts, in the groin folds and genital creases
- Superficial folliculitis (inflamed hair follicles) on the cheeks and upper trunk.
Treatment of seborrhoeic eczema
As in the case of atopic eczema, treatment for seborrhoeic eczema consists of three measures: the use of keratolytics, that is, substances to soften the build-up of keratin that causes scaly skin, such as sulphur and salicylic acid; the use of antifungals to control the Malassezia yeast; and the use of topical anti-inflammatory drugs, such as corticosteroids and calcineurin inhibitors, to the treat the inflammation (Kastarinen et al, 2014; Clark et al, 2015).
Discoid eczema
Discoid eczema is a common type of eczema/dermatitis, in which there are scattered, roundish plaques of eczema (Oakley, 2014) (Figure 5).
Figure 5. Discoid eczema
Discoid eczema is associated with damage to the barrier function of the skin (British Association of Dermatology (BAD), 2019). It causes distinctive circular or oval patches of eczema. It can affect any part of the body, although it does not usually affect the face or scalp. In adults, it is more common in men than women and can occur with atopic eczema (NHS, 2019). There are two forms of discoid eczema, that is, exudative or wet discoid eczema and dry discoid eczema. Exudative acute discoid eczema manifests as small papules, blisters and plaques and can be associated with a S. aureus infection. Dry discoid eczema manifests as dry plaques (Oakley, 2014).
Treatment of discoid eczema
The main aims of treatment for discoid eczema are to protect the skin from injury, maintain skin health (using emollients), treat flare-ups with topical steroids and treat infections with oral antibiotics. Discoid eczema often develops following a minor skin injury, so people are advised to protect the skin by using gloves when washing up or gardening. Soap substitutes should be used to maintain the skin's barrier function. Emollients should be applied to eczema as frequently as required to relieve itching, scaling and dryness. In the case of flare-ups, topical steroids are prescribed and applied as prescribed usually once or twice daily for 2–4 weeks to settle inflammation and reduce irritation. Mild steroids such as hydrocortisone are safe for daily use if necessary. Oral antibiotics, usually flucloxacillin, unless the patient has a penicillin allergy, are prescribed for infected eczema. If the eczema is itchy, antihistamine tablets may be helpful (Oakley, 2014; BAD, 2019; NHS, 2019).
Venous eczema
Venous eczema is a non-infective inflammatory condition that affects the skin of the lower legs (Gawkrodger, 2006). It is part of a continuum of venous disease and is caused by failure of the valves in the superficial and deep veins (Eklof et al, 2004). Normally, during walking, the leg muscles pump blood upwards, and valves in the veins prevent pooling. A clot in the deep leg veins (deep venous thrombosis) or varicose veins may damage the valves. As a result, back pressure develops and fluid collects in the tissues and an inflammatory reaction occurs. Venous eczema is most often seen in middle-aged and older people and affects 20% of those aged more than 70 years (Nazarko, 2016). Clinical features include itchy red, blistered and crusted plaques; or dry fissured and scaly plaques on one or both lower legs and reddish, orange brown pigmentation. The pigmentation is caused by blood leaking from capillaries; haemosiderin is produced from haemoglobin and stains the skin. This is known as haemosiderin staining or simply staining. Complications of venous eczema include the development of infected weeping venous eczema, leg ulceration and lipodermatosclerosis (Figure 6).
Figure 6. Venous eczema
Lipodermatosclerosis is a term used to describe skin changes in the lower legs as a consequence of venous insufficiency and venous stasis. It typically presents as redness, swelling, increased pigmentation and skin induration with an inverted champagne bottle appearance. Venous disease leads to intravascular fluid leaking into tissues. This causes tissue damage, and fibroblasts cause granulation tissue to develop in the skin. The skin feels tight and wood-like.
Treatment of venous eczema
Treatment of venous eczema is similar to that of discoid eczema, with a few special considerations. In people with venous eczema, the skin can become dry and covered in scale (Figure 7). Special pads and cloths are available to remove this scale. An active debridement pad (Debrisoft (Activa Healthcare)) uses a fleece-like contact layer to mechanically remove debris, necrotic tissue, slough and exudate (Gray et al, 2011). This has been shown to be effective in 94% of cases in patients treated on three occasions, approximately 4 days apart (Bahr et al, 2011). In the authors' experience, a single treatment is often sufficient to remove scale in some people. The Prontosan Debridement Pad (B Braun) and CleanWnd (Regen Medical) are similar to the Debrisoft pad. Similarly, the UCS debridement cloth—a pre-moistened single-use cloth—from Medi UK can also be used to debride wounds and remove scales from the skin. It has a mild cleansing agent that moistens and softens, making debridement more effective (Downe, 2014). A single treatment can provide significant debridement and does not cause pain or discomfort.
Figure 7. Skin scales in venous eczema
Venous disease occurs because of increased venous pressure. NICE (2013) guidance recommended that people who have primary or symptomatic recurrent varicose veins, lower-limb skin changes, such as pigmentation or eczema, superficial vein thrombosis and suspected venous incompetence, venous ulcers or a healed venous leg ulcer should be referred for assessment and treatment in a vascular service. It also recommended a range of treatment, dependent on the severity of the varicose veins, including endothermal ablation, endovenous laser treatment of the long saphenous vein, ultrasound-guided foam sclerotherapy and surgery.
NICE (2013) guidance also stated that compression hosiery should not be offered to treat varicose veins unless interventional treatment is unsuitable. People who have venous leg ulcers may have conditions that affect their suitability for these treatments or may decline the treatment. In these cases, compression can be helpful. Compression therapy improves the return of blood to the heart, reduces swelling and venous pressure and improves venous circulation. These changes prevent further deterioration of the veins, relieve aching and throbbing and help venous ulcers to heal. Compression therapy increases venous ulcer healing rates by more than 200% (O'Meara et al, 2012). It can also be used preventatively, to avoid leg ulcers.
A handheld Doppler ultrasound is used to check blood flow to the legs and to ascertain if the person can have full compression, modified compression or if compression is unsafe (Beldon, 2010). Compression can be provided by bandaging or stockings. Assessment enables the nurse to determine the appropriate type and level of compression (Ashby et al, 2013; Chi and Raffetto, 2015).
The person should be advised to avoid standing for long periods, to take regular walks, to elevate the legs when sitting and to elevate the foot of the bed so that legs are elevated at night. If the person is overweight, they should be advised to lose weight.
Conclusion
At present, providing effective skin care in older people is based not only on science but on the art of nursing and is informed by experience. Kottner et al (2013) conducted a review of the evidence in relation to skin care for older people. They examined 187 published articles and concluded that the evidence base for basic skin care among older adults is weak. Community nurses are well placed to help their clients maintain a healthy skin care regimen and guide them in treating their eczema.
KEY POINTS
- Skin problems are common in older people, and up to 70% of older people have a skin condition
- Age-related changes lead to a deterioration of the skin's barrier function, increased vulnerability to skin damage and decreased healing ability
- The principles of maintaining healthy skin in older age are to maintain the barrier function, prevent dryness and replace lost moisture
- A robust evidence base in skin care for older people is lacking, and care should be based on evidence and informed by experience
- It is vital that the nurse works with the patient to determine what emollients are most effective and acceptable to the individual.
CPD REFLECTIVE QUESTIONS
- Mrs Jones has extremely dry skin and will require assistance to apply an emollient. You are considering prescribing 50/50 liquid soft paraffin. What do you need to determine before you prescribe?
- Miss Kerridge is 70 years old and works as a volunteer in a kitchen at a day centre. She is constantly washing up and washing her hands. She has eczema of her hands and asks for advice on how best to maintain skin moisture. What kind of emollient would you advise and why?
- Mr Singh has venous eczema and complains that his legs are hot, swollen and heavy. You consider that he might benefit from compression hosiery. What checks must you make before using compression hosiery?