45 min. Name Assoc Prof presenter Bill McGuiness PhD, RN, FAWMA. xx College Month of 201x Science, Health & Engineering

Transcription

1 45 min Title Skin integrity of presentation the cellular level? Name Assoc Prof presenter Bill McGuiness PhD, RN, FAWMA Title Head of of presenter School School / of Faculty Nursing / Division & Midwifery xx College Month of 201x Science, Health & Engineering w.mcguiness@latrobe.edu.au latrobe.edu.au CRICOS Provider 00115M

2 Outline The cellular consortia of skin Insults to skin cells Cellular response to the insult Apply this knowledge to wound care 2

3 The skin Largest organ Continually replacing itself Important defence Essential for homeostatic balance 3

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6 Cellular components of each layer Keratinocytes Langerhans cells Melanocytes Barrier Moisture loss Fibroblasts Endothelial cells Smooth muscle cells mast cells Elasticity Mechanical integrity Adipose tissue Collagen Energy source Insulation 6

7 Stratum Corneum Often thought of as dead cells Keratinocytes to Corneocytes Approx. 4 weeks Major make over A number of physiological functions Regulate Transdermal Water Loss (TEWL) Immunity Antioxidant barrier Antimicrobial Photo barrier Intercellular lamellar lipid membrane Ceramides 40-50% Cholesterol 25% Fatty acids 10-15% 7

8 Intercellular lamellar lipid membrane Crucial in in maintaining the skin permeability barrier Able to detect subtle changes in its own hydration status bio-sensing In response to loss of permeability barrier; there is an increase secretion of lipids into the stratum corneum up regulation of the natural moisturising factor in the cells Del Rosso & Levin (2011) The clinical relevance of maintaining the functional integrity of the stratum cornea in both healthy and disease-affected skin, Clinical and Aesthetic Dermatology, September 16, 8

9 The insults

10 The Insults of time

11 Is it an accident that we see breakdown in skin integrity and chronic wounds in older clients? 11

12 Slow replacement of lipids Reduced melanocytes and langerhans Flattened dermoepidermal layer Thin dermis with decreased fibroblasts and melanoncytes Decreased vaculature 12

13 The insults of life style

14 External Changes to Ph Alkaline for 1 st few months Then acid mantel Acid = normal flora Alkaline pathogens - staph Over washing/bathing Stripping of lipids Removing NMF components Damage to SC proteins Topical products Alpha-hydroxy acids (Anti wrinkle, exfoliation, chemical peels) Astringents (Oatmeal, witch hazel, silver nitrate, cold water) Abrasive granules Retinol (Topical vit A, skin regeneration) Steroids Internal Statins Interfere with cholesterol production 14

15 Photodamage Dry skin (xerosis) Irregular pigmentation Pronounced wrinkling Fibroblasts produce elastin more susceptible to enzymatic degradation Decreased collagen Premalignant skin tumors 15

16 External irritants Moisture associated skin damage (MASD) Incontinence-associated dermatitis Creams and lotions Allergic reactions 16

17 Cosmetic enhancement 17

18 The insults of wounding

19 Wounding 19

20 Wounding 20

21 Wounding 21

22 Wounding 22

23 Response to the insults

24 Replace or Renovate 24

25 Rebuilding the cellular structures Regeneration Vs Repair Regeneration Development of the same tissue type Only select tissues regenerate Epithelium, liver, peripheral nerves, fetus Repair Replacement with other tissues 25

26 The three amigos of Wound healing Cellular migration Extracellular matrix organisation and remodeling Cellular proliferation 26

27 Healing wounded tissue the migration of cells Epithelial Fibroblasts Endothelial Macrophages Leukocytes cells cells From Recruited Phagocytose wound adjacent by from growth margins capillaries dead bone factors tissue and marrow hair & bacteria follicles Migrate Connective Form Stimulate Degrade new over blood and tissue granulation collagen destroy vessels matrix μm/minute non-viable - cytokines tissues Tissue remodeling 27

28 Neutrophil Macrophage Fibroblast Endothelial Epithelial 28

29 Migration of epithelum Full thickness wound margins Partial thickness margins and hair follicles Proliferation (regeneration) Spatial or distance difference Migration Epithelialisation takes longer than Granulation 29

30 Cells move on the Highwounds and Freewounds using Moisture 30

31 No basement membrane and disorganised extracelluar matrix Epithelial cells don t migrate from area of proliferation Repair not regeneration takes places substituting epithelial cells with connective tissue Scar formation 31

32 Cellular proliferation Necessary stem cell production Bone marrow and hair follicles Adequate nutrients Adequate perfusion Amendable environment Psychological support 32

33 How do we help the cells?

34 Assisting an overstressed Stratum Corneum Gentle cleansers Moisturisers Humectants (attract water from dermis), Occlusives (slow evaporation) Emollients ( lubricants that fill the gaps) (DelRosso 2003, Loden 2003, Del Rosso 2009, Rawlings 2004) Aged skin Lipid based moisturisers (Zettersten 1997, Torra et al 2005) Oral fluids Torra i Bou J-E, Segovia Gomez T, Verdu Soriano J, Nolasco Bonmati A, Rueda lopez J, Arboix i Perejamo M. The effectiveness 34 of a hyperoxygenated fatty acid compound in preventing pressure ulcers. Journal of Wound Care. 2005;14(3).

35 Moisturiser 35

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37 Control exudate Moist interface Prevent periwound maceration Remove external irritants to the epithelium 37

38 Why does skin maceration matter? Minematsu et al. (2011) examined the effect of maceration on aged skin Method Rat and human subjects. Rats were divided into young (9 wk) and old (6mths). Humans 3 males and 3 females (23 to 39 yrs). Heels used for all subjects 1% Agarose gel for maceration Measured trans-epidermal water loss (TEWL), skin moisture and ph, and florescence (rats only) Findings Disruption to the intercellular lip lamella More pronounced in the old rats. 38

39 Young rats Old rats 39

40 Preventing infection Wound hygiene Regular debridement Topical antimicrobials Hydration 40

41 Chronic Infection 41

42 In Summary Cells are our colleagues Recognize their capabilities Optimize their working conditions Reward their outputs Facilitate regeneration over repair Keep the wound interface Moist not wet Free of infection Prevent skin breakdown Keeping the skin hydrated Protecting from trauma Treating underlying pathology 42

43 Thank you latrobe.edu.au CRICOS Provider 00115M