Caring for older residents with skin conditions

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1 Caring for older residents with skin conditions Care home managers and care staff have a responsibility to ensure that their residents basic skin hygiene is maintained. This article examines two common skin conditions, eczema and psoriasis, and discusses how carers and residents themselves can best look after their skin. Principles of care Once a resident is admitted, a comprehensive baseline assessment must be carried out to establish their skin integrity. Staff can then agree and develop skincare strategies. Mangan (2002) suggests: The principles of a skincare strategy to be used in a care home should be to assess an individual client s need for help with hygiene and also the degree of risk of skin damage they face as a result of the state of their skin. The prime aim of the strategy should be to minimize irritation and damage of the epidermis by moisture and chemical irritants such as urine, and improve the quality and hydration of the skin. Personalized care planning The care plan will help all staff understand what is expected from everyone at specific times of the day. The resident should also be able to agree with, and sign up for, the plan. The plan should include the practical and physical aspects of care. It should also provide treatment details, such as the use of topical treatment and administering of drugs, plus adequate levels of resident Adrian Ashurst is NRC Consultant Editor. Beryl Caldwell is Home Manager, Ennerdale BUPA Nursing Centre, Liverpool. Correspondence: c/o NRC Adrian Ashurst and Beryl Caldwell discuss the development of a systematic approach to care and support for older residents with skin conditions. monitoring. In short, it should document all aspects of the care delivered. All care home staff are reliant on the individualized holistic care plan and each daily entry should be signed and dated. It is important to remember that the resident s care plan is a legal document. Staff should have up-to-date knowledge of age-related changes to skin (Table 1). They should also be aware of the current treatments for various skin conditions, specifically those affecting older residents. A healthy diet A healthy, well-balanced diet will help older residents to maintain good tissue viability. Nazarko (2007) suggests that: Nurses need to be aware of the changes that ageing and illness can cause if they are to provide highquality care and prevent the occurrence of wounds. Unfortunately, professionals are often unaware of the skincare needs of older people and receive little training on dermatology. A healthy diet will contain all the nutrients an individual needs, and should include a balance of vegetables, proteins and carbohydrates. All care home staff play an important part in the delivery of well-balanced menus for residents, and offering them choice. Residents should also have access to refreshing drinks throughout the day. If patients are not eating, or are malnurished, then dietary supplements are a good source of nourishment (Burch, 2007). Many are available through prescription and/or from pharmacies. Examples include: Build-up (Nestlé, Croydon) Ensure Plus (Abbott Nutrition, Berkshire) Fortisip (Nutricia, Wiltshire) Scandishake (SHS International, Liverpool) Fresubin (Fresenius Kabi, Cheshire) Fortical (Nutricia, Wiltshire). When dietary supplements cannot be taken, one way of providing calories is to offer the patient chocolate. This provides calories and vitamins A and D, and releases endorphins from the brain, making the resident feel good. Eczema Atopic eczema: is more usually found in children and young people, but may recur in old age. The skin becomes dry, itchy, red and inflamed. It can develop on a few small patches of skin or on the whole body. Atopic eczema is normally inherited but can be triggered by environmental factors and is linked to other conditions, such as asthma and hay fever. Discoid or nummular eczema: is characterized by coin-shaped lesions that can appear anywhere on the body but usually on the lower leg, trunk or forearms. The role of emollients Emollients are topical agents that have a moisturizing action which soothes the skin, and reduces dryness, itching and scaling associated with dry-skin conditions Emollients are available in a number of formulations, including creams, ointments, washes and bath oils. The choice of products depends on individual preference the best emollient for an individual is the one they prefer as they are more 128 Nursing & Residential Care, March 2010, Vol 12, No 3

The epidermis (outer layer) becomes thinner Table 1 AGE-RELATED CHANGES TO SKIN Loss of integrity between the epidermis and the dermis makes skin more vulnerable to trauma and shearing The dermis

This leads to decreased production of elastin, which gives the skin its elasticity Collagen, which gives the skin its strength, loosens and wrinkles The skin becomes dry (xerosis) Damaged skin is

2 The epidermis (outer layer) becomes thinner Table 1 AGE-RELATED CHANGES TO SKIN Loss of integrity between the epidermis and the dermis makes skin more vulnerable to trauma and shearing The dermis becomes thinner and less fl exible The dermis has fewer fi broblasts (the cells from which connective tissue develops). This leads to decreased production of elastin, which gives the skin its elasticity Collagen, which gives the skin its strength, loosens and wrinkles The skin becomes dry (xerosis) Damaged skin is replaced more slowly There are fewer Langerhans cells (specialized immune surveillance cells) The backs of the hands may develop keratotic nodules (thickened patches) Loss of functioning melanocytes reduces ability to tan. Skin protection is reduced and risk of skin cancer increased Pigmented areas develop as melanin clumps form, for example, on the face or hands Senile purpura (bruised hands and arms) may develop because of blood vessel changes Puritis may occur because of ageing, medication or chronic disease. Nazarko (2007) likely to use it regularly (Cork, 1998). It is worth encouraging residents to sample several types of emollient to find one that appeals to them. Aloe vera Hampton (2004) explains: The aloe plant is a native to Africa and is also known as lily of the desert, the plant of immortality and the medicine plant. The plant is about 96% water, with the rest being made up of active ingredients including essential oil, amino acids, minerals, vitamins, enzymes and glycoproteins. Aloe can help to keep the skin supple, and has been used in the control of eczema, acne and to relieve the symptoms (such as itching) of insect bites and allergies. It has also been shown to have beneficial effects on wounds and burn injuries (Mantle et al, 2001). The healing power of aloe vera dervies from its ability to increase the availability of oxygen to the skin and to enhance the synthesis and strength of tissue (Herbal Information Centre, 2004). Aloe-containing products include: The aloe vera plant is known for its healing properties. Discoid eczema. 130 Nursing & Residential Care, March 2010, Vol 12, No 3

3 Skin care Aloe Vera Gel (Banana Boat) Aloe vera suncream (for example, Expert Defence Daily Moisture Cream (Boots)) Aloe Blossum herbal tea (Forever Living Products) Sonya Aloe Balancing Cream (Forever Living Products). There are also dry-coated Aloe Vera Gloves (Seton) that gradually deliver aloe vera gel to the skin. A study found that these improved skin integrity, and decreased the appearance of fine wrinkling and erythema in dry skin and irritant-contact dermatitis (West and Zhu, 2003). Aloe Propolis Cream (Aloe Vera Company UK) is 100% stabilized aloe vera with the added benefit of bee propolis, which is a natural antibiotic product. This is collected by bees from tree buds and sap, and used to keep their hive sterile and free of infections. Aloe vera propolis can also be used in the treatment of eczema. Psoriasis Psoriasis is an inflammatory skin disorder characterized by red scaly areas usually on the knees, elbows, lower back and scalp. It is a chronic condition, with episodes of flare and remission. Psoriasis can occur at any time in life and affects males and females equally (Waugh and Grant, 2006). Lawton (2000) states that: Genetic factors are important in psoriasis and environmental factors such as skin trauma, streptococcal infection, certain medications, smoking, alcohol consumption and psychological stress may also play a role in disease expression (Table 2). Psoriasis can be painful, itchy and unsightly, but it is never infectious. Although it is rarely life-threatening, it can be disabling and have a significant impact on quality of life. When the skin is impaired, as in psoriasis, the resident s body image can be significantly affected, which can be debilitating. Following a clinical assessment, a general practitioner (GP) will perform a detailed clinical examination to identify the type of psoriasis present. The GP will then prescribe a topical treatment and a nurse will Table 2. TRIGGER FACTORS THAT MAY PRECIPITATE PSORIASIS Skin trauma: often known as Koebner phenomenon. Psoriasis lesions may appear at the site of trauma: scratches, surgical wound, sunburn or skin infection Medication: Lithium, beta-blockers and anti-malarials Anti-infl ammatory drugs: may exacerbate psoriasis Alcohol: there has been a reported association between psoriasis and a high intake of alcohol Climate: psoriasis tends to improve in warm climates and becomes worse in cold ones Sunlight: helps in many patients, but can exacerbate psoriasis in about 10% of cases Stress: although diffi cult to prove, residents report that emotional upset and stress aggravate or trigger fl are-ups Smoking: aggravates psoriasis and can also trigger palmoplantar pustular psoriasis. Lawton (2000) Box 1. PSORIASIS TREATMENT PLAN A common treatment plan is to start with a low-strength preparation of dithranol (coal tar). If there is no irritation then apply daily as directed (often for about 30 minutes each day) for a few days. The strength should be increased for a further few days before moving on to a higher strength, and so on. The aim is to gradually build up the strength (the % concentration) to the strongest preparation the person can tolerate. If irritation or burning occurs, stop using dithranol and apply a moisturiser until the skin has settled. Then start again at a lower strength. Some people are more sensitive to the irritating and burning effects than others, so different individuals end up using different strengths. Carry on with the treatment until the treated skin feels fl at and smooth like the nearby normal skin. Any staining of the skin will clear, usually in about two weeks. If there appears to be skin irritation, or if there is no improvement after three weeks at the highest strength a person can tolerate, residents should see a doctor for advice. (Sourced on 16 December 2009 by authors) be responsible for educating the resident about the condition. The nurse will also develop a care plan in conjunction with the resident. Some residents may feel great discomfort and embarrassment while experiencing a flare-up of psoriasis. The nurse therefore needs to recognize the signs of itchiness, soreness, dryness, bleeding, pain and discomfort as soon as they occur. The resident s quality of life is of paramount importance, and the more staff communicate with the resident and their family, the easier it will be for the individual to gain confidence in dealing with the effects of their skin condition and the treatment regimen associated with it. Topical treatments Emollients are the mainstay of any dermatological treatment and should be used regularly throughout the day in conjunction with active topical therapies (Lawton, 2000). They hydrate and soften the skin and prevent water evaporating from it. Emollients have several useful effects in the management of psoriasis: Soothing: if the psoriasis is itchy, emollients soothe and help relieve the irritation (anti-pruritic) Nursing & Residential Care, March 2010, Vol 12, No 3 131

4 Softening: emollients lubricate and soften the plaques (a broad, raised area of skin that is palpable), keeping them more flexible and comfortable, so they are less likely to crack Hydrating: by hydrating the plaques, scale removal is achieved. This allows easier application and enhanced penetration of other topical therapies Anti inflammatory: emollients may slow down the rate of cell turnover but further research is required Steroid sparing: using emollients may reduce the need for topical corticosteroids. Topical dithranol (commonly known as coal tar) has been used to treat psoriasis for for over 100 years (see Box 1 for a common treatment plan). It is thought to have an anti-mitotic effect (preventing cell division) but exactly how it works is still unknown. Corticosteroids are also used in the treatment of psoriasis. These are derived Further Information National Eczema Society Hill House Highgate Hill London N19 5NA Helpline: The Psoriasis Association Dick Coles House 2 Queensbridge Northampton NN4 7BF Tel: mail@psoriasisassociation.org.uk Further Information on Aloe Vera Contact Sarah Naidini Tel: from natural corticosteroid hormones produced by the adrenal glands, which have many important functions in the body, including control of inflammatory responses. Corticosteroid medications include: Alphaderm cream: this contains Hydrocortisone 1% and has a moderate potency. Betnovate RD cream/ointment: contains Betamethasone valerate 0.025% and has a moderate potency. Canesten HC cream: contains Hydrocortisone 1% and has a mild potency. ( Topical corticosteroids should not be used regularly for more than four weeks without clinical review. Potential side-effects include skin thinning, changes in pigmentation, easy bruising and redness. Furthermore, steroids can be absorbed through the skin and affect internal organs when used over long periods of time or applied too thickly. The use of potent preparations should be under dermatological supervision. Conclusion Psoriasis has a wide spectrum of clinical presentations, and residents differ in how they cope with, tolerate and respond to various treatments. Treatments should therefore be tailored to individual residents. Residents, relatives and staff should be encouraged to learn as much as possible about skin conditions and their treatment. Concordance with treatment relies heavily on staff and residents working closely together to identify the most successful form of treatment for each individual. Providing a nutritious and well-balanced diet remains pivotal to maintaining older residents wellbeing. People with eczema or psoriasis should be treated with dignity and respect as the care staff treat the affected areas. Nurses should always ensure that the resident is allowed to stay dressed, exposing only the area where the treatment is to be applied. Residents care plans should provide staff with an accurate record of what treatment has been agreed with the medical staff, and how and when the care should be delivered. Nurses and carers play a special role in the care of residents with skin conditions, giving not just treatment, but also the support and reassurance they need. NRC Burch J (2007) Dietary needs for care home residents with a stoma. Nursing & Residential Care (8): Cork MJ (1998) Complete emollient therapy, In: Todd D, ed. The National Association of Fundholding Practices Yearbook. Scorpio Publishing, London Hampton S (2004) Caring for the skin of older residents: a practical guide. Nursing & Residential Care (7): Herbal Information Centre (2004) Aloe (aloe vera). (Accessed 11 December 2009) Lawton S (2000) Psoriasis. Nursing & Residential Care (5): Mangan P (2002) The importance of good skin care. Nursing & Residential Care (6): Mantle D, Gok MA, Lennard TW (2001) Adverse and beneficial effects of plant extracts on skin and skin disorders. Adverse Drug Reaction Toxicol Rev 20(2): Nazarko L (2007) Maintaining the condition of ageing skin. Nursing & Residential Care 2007, 9(4): KEY POINTS Residents, relatives and staff need to be educated in the different types of treatment available for skin conditions such as eczema and psoriasis. The provision of care plans will enable staff to deliver treatment in a systematic way. Residents differ in how they cope with, tolerate and respond to various treatments, so these must be tailored to individual needs. Waugh A, Grant A (2006) In: Ross JS, Wilson K (eds) Anatomy and physiology in health and illness. Churchill Livingstone, Edinburgh West DP, Zhu YF (2003) Evaluation of aloe vera gel gloves in the treatment of dry skin associated with occupational exposure. Am J Infect Control 31(1): (Accessed 8 Feb 2010) 132 Nursing & Residential Care, March 2010, Vol 12, No 3

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What is Psoriasis? Common Areas Affected. Type Who Does it Affect Characteristics

What is Psoriasis? Common Areas Affected. Type Who Does it Affect Characteristics What is? is a term derived from the Greek word psōra which means itch and is a common, long lasting, inflammatory skin condition which affects 1-3% of the UK population and about 80 million people worldwide.