It is well recognised that skin problems in older people can have a significant impact on all aspects of their daily living. The All-Party Parliamentary Group on Skin (APPGS) (2000) conducted a study on skin diseases in older people, which highlighted that:
- Older people were noted to suffer from a lack of sensitivity to their skin care needs and related problems
- Training was lacking for healthcare professionals to manage the skin care needs of older people
- Preventative interventions were inadequate
- Services were not planned with the needs of this group of people in mind.
Major skin changes are one of the many features occurring with ageing and it is estimated that 70% of older people have skin problems. The APPGS (2000) made a number of recommendations to improve the treatment and management of skin diseases in the older person. Measures need to be taken to improve both older peoples' and nurses' knowledge base and skills in caring for ageing skin. The APPGS (1998) have stated that with sufficient training and expertise, many skin disorders could be managed effectively at the primary care level. The enquiry highlighted a lack of basic skin care for people in nursing homes and residential homes, which often employ unqualified or under-qualified nursing staff. It also highlighted the importance of basic skin care, including the regular and correct use of emollients to prevent common skin problems such as dryness, itching and asteatotic eczema (also known as ‘eczema craquelé’, which is common in older people).
Carers may often be responsible for assisting the older person with skin hygiene and care and therefore, need to be trained to perform these tasks correctly and safely (APPGS, 2000). This is also addressed within the Essence of Care document (Department of Health (DH), 2010) which states that patients'/clients' personal hygiene needs are met according to their individual and clinical needs, and should include the physical act of cleansing the body to ensure that the skin, hair and nails are maintained in an optimum condition (DH, 2010). Certainly, nurses working in primary and secondary care need to know about basic skin care and promotion of healthy skin, common skin diseases, their treatments and nursing care. This further highlights the importance of educational opportunities.
Factors affecting skin ageing
Skin ageing is a continuous process that affects skin function and appearance and as people age, their chances of developing skin-related disorders increase. There are two types of skin ageing: intrinsic ageing, which include alterations in structure and function of the ageing skin and are due to normal maturity and occurs in all individuals, and extrinsic ageing (Table 1) (Norman, 2003; Burns et al, 2010).
Table 1. Factors affecting skin ageing
| Intrinsic | Extrinsic |
|---|---|
| Dryness | Smoking |
| Atrophy | Environmental pollutants |
| Laxity | Ultra Violet light |
| Wrinkling | Decreased mobility |
| Sparse grey hair | Drug induced disorders |
| Pigmented and other blemishes | Chronic illness |
Intrinsic ageing
Epidermis
As a person ages the epidermis becomes thinner on a structural level; there is flattening of the dermo-epidermal junction and the corneocytes become less adherent to one another, which reduces their water binding capacity and results in skin dryness. The number of melanocytes and Langerhans cells decrease, altering the immune response, increasing the risk of infection and skin cancer, and decreasing the ability to heal (Hill, 1994; Burns et al, 2010).
Dermis
The dermis becomes atrophic and it is relatively acellular and avascular. There are changes in the collagen and elastin fibres which degenerate, resulting in less bulk and structure to the dermis (laxity). The number of mast cells, which have a protective function, and fibroblasts, which have a role in wound healing, steadily decrease.
Subcutaneous tissue
The subcutaneous tissue is diminished in some areas, especially the face, shins, hands and feet, while in others, particularly the abdomen in men and the thighs in women, it is increased due to reduced insulation and protection (Hill, 1994).
Skin appendages
The number of eccrine glands are reduced and both the eccrine and apocrine glands (sweat glands) undergo shrinking which affects the thermoregulatory function as sweating is reduced. Sebaceous glands tend to increase in size but ironically, their secretory output (sebum) is lessened, which reduces the water retaining/waterproofing effect of the skin. The nail plate is generally thinned, the surface ridged and lustreless, and the lunula (half-moon shape at the very bottom of the nail) decreases in size (Burns et al, 2010). There is a progressive reduction in the density of hair follicles; the capacity to grow long hair decreases, scalp hair is thinner, chest and pubic hair peaks in the 5th decade and then declines. However, in areas such as the ears, nose and eyebrows of men the hair becomes bushy and in women hirsutism may occur due to hormonal changes (Burns et al, 2010).
Extrinsic ageing
A number of extrinsic factors often act together with the normal ageing process to prematurely age our skin. It results from the cumulative effects of exposure to a variety of environmental insults, changes in the environment decreasing occupational exposure and increasing leisure exposure to potential irritants and sensitizers (central heating, weather, soaps and bubble baths) (Burns et al, 2010). These lead to decreased sensory perception, increased dryness, and skin thinning, decreased vitamin D synthesis and a reduction in the skin's immune response. The thermoregulatory function is also decreased (Hill, 1994).
Most premature ageing is caused by sun exposure. ‘Photoageing’ is the term used to describe this type of ageing caused by exposure to the sun's rays and occurs over a period of years. With repeated exposure to the sun, the skin loses the ability to repair itself, and the damage accumulates. Repeated ultraviolet exposure breaks down collagen and impairs the synthesis of new collagen. The sun also attacks elastin, leaving the skin loose, wrinkled and leathery. Photoaged skin is coarse, wrinkled, pale–yellow in colour, telangiectatic, irregularly pigmented, prone to purpura and subject to benign and malignant neoplasms (DermNet, 2018). The amount of photoageing that develops depends on:
- A person's skin colour
- Their history of long-term or intense sun exposure
- Occupation
- Geographical location
Other influences on skin health include:
- Age-related disease in other organ systems
- Social circumstances (e.g. poor nutrition)
- Home care and mobility, which often contribute to the expression, perpetuation and failure to resolve skin problems
- Not being able to reach areas to apply treatments
- Reduced mobility
- Poor dexterity
- Physiological problems, such as dementia
- Increasing rigidity of attitude and cognitive decline
- Refusal to accept advice
- Increasing physical frailty, resulting in a relative incapacity to carry out tasks correctly
- Poor hygiene
- Neglect, unable to self-care (Burns et al, 2010).
Assessment
There are certain principles that should be considered when assessing the skin in older people. It cannot be assumed that older people are always aware of any skin conditions that may be relevant or treatable; many accept them as part of the ageing process, and without realising help may be available (Kirkup, 2006). When assessing any patient it is important to undertake a full assessment; this includes obtaining a detailed dermatological history as this may provide clues to diagnosis, the need for further laboratory investigations, management and nursing care of the existing problem, and should include: a general assessment; a history of the patient's skin condition (Box 1); a specific skin assessment with careful observation and meticulous description; consideration of the skin as a sensory organ; if the skin is sore, painful or itchy; and an assessment of the patient's knowledge about their skin condition (Lawton and Turner, 2020).
Box 1.History of skin condition
- How long has the condition been present for?
- How often does it occur or recur?
- Are there any seasonal variations?
- Is there a family history of skin disease?
- Does the patient have previous or current occupation and hobbies?
- Is the patient taking any medication, prescribed and over-the-counter products—orally or applied topically. Many patients self-treat before seeking further advice
- Are there any known allergies?
- Previous and present treatments and their effectiveness
- Are there any treatments, actions or behavioural changes that influence the condition?
Source: Lawton and Turner (2020)
Common skin conditions affecting the older person
Common conditions affecting the older person can be categorised into the following groups (Table 2): wounds, eczematous conditions, infections, infestations, lesions and others. However in many skin conditions, pruritus (itch) is often one of the main presenting features for patients and will be the area discussed in more detail.
Table 2. Skin ageing factors
| Categories | Skin disease |
|---|---|
| Eczematous | Eczematous conditions are very common in this age group and include:
|
| Infections |
|
| Infestations |
|
| Lesions |
|
| Others |
|
Pruritus
Skin disease in the older person encompasses a vast array of disease processes, the major players being xerosis (dryness) and pruritus (itch). The itch of pruritus induces scratching and is often linked to an underlying skin condition or systemic disease. It may also be due to a psychogenic cause and can provide healthcare teams with a real challenge (Norman, 2003). Persistent severe pruritus, like pain, is a dominating part of one's existence; from day to day it takes over one's life. It leads to sleepless nights, exhaustion and impacts on all activities and relationships and requires a comprehensive workup to establish a possible cause (Box 2) (Fitzpatrick et al, 2001).
Box 2.Pruritus
- Detailed history of pruritus; skin lesions, severity
- Constitutional symptoms: weight loss, fatigue, fever, malaise
- Recent emotional stress
- History of medication taken
- Assess for primary skin condition
- General physical examination
- If duration >2 weeks and no other cause established, laboratory investigations and screens will be required:
- Chest x-ray, full haematological screening and others dependent on assessment
- Dry skin present: avoid soap-based products and use emollients
- Arrange follow-up to review
Differential diagnosis
- Metabolic and endocrine conditions
- Haematological disease
- Malignant neoplasms
- Hepatic disease
- Drug induced
- Infestations
- Primary skin disease
- Psychogenic cause
- Dry skin (xerosis) exacerbated by environmental factors
Source: Fitzpatrick et al (2001)
Some practical measures that may help to relieve and minimise the symptoms, are:
- Keeping the environment cool and dust free
- Wearing loose cotton clothing and ensuring emollients are used to wash and moisturise the skin
- Avoiding products that may irritate the skin such as perfumes, bubble baths and talcum powder and soap based products (Moncrieff et al, 2013).
Other treatment interventions include sedating antihistamines, emollients and the use of topical anti-inflammatory treatment, topical antipruritics such as menthol in aqueous cream, to name a few (DermNetNZ 2016).
Conclusion
Skin disease in the older person can significantly affect their quality of life. They are often embarrassed about their condition and are reluctant to seek help. As nurses, we are well-placed to recognise skin problems when helping with personal hygiene needs or performing treatments. By integrating skin health promotion into our everyday practice, we are able to promote a more positive view of older people and to contribute to healthy ageing (Cowdell and Garrett, 2014). The development of more nurse-led services and prescribing opportunities requires the practitioner to have the competency required in this area of service provision. The competent community nurse should be able to demonstrate an understanding of the anatomy and physiological changes associated with ageing skin, be able to recognise and describe common dermatological conditions and assess the ability of older people (physically/mentally) to treat and manage their skin effectively and independently, providing advice on basic topical treatments for the care of ageing skin.
Further information
- DermNet NZ: http://www.dermnetnz.org/
- British Dermatological Nursing Group: www.bdng.org.uk
- British Association of Dermatologists: www.bad.org.uk
- British Skin Foundation: https://www.britishskinfoundation.org.uk/
- Primary Care Dermatology Society: https://www.pcds.org.uk/the-primary-care-dermatology-society