The importance of skin care and assessment

Review of the safety of application of cosmetic products containing parabens

Cosmetics are a source of lifetime exposure to various substances including parabens, being the most popular synthetic preservatives. Because the use of cosmetics shows an increasing trend and some adverse health outcomes of parabens present in these products have been reported, the present review focused on the safety of dermal application of these compounds. Special attention has been paid to the absorption of parabens and their retention in the human body in the intact form, as well as to their toxicological characteristics. Particular emphasis has been placed on the estrogenic potential of parabens. Based on the available published data of the concentrations of parabens in various kinds of cosmetics, the average ranges of systemic exposure dose (SED) for methylparaben, ethylparaben, propylparaben, and butylparaben have been calculated. Safety evaluations [margin of safety (MoS)] for these compounds, based on their aggregate exposure, have also been performed. Moreover, evidence for the negative impact of methylparaben on skin cells has been provided, and the main factors that may intensify dermal absorption of parabens and their impact on the skin have been described. Summarizing, the use of single cosmetics containing parabens should not pose a hazard for human health; however, using excessive quantities of cosmetic preparations containing these compounds may lead to the development of unfavorable health outcomes. Due to the real risk of estrogenic effects, as a result of exposure to parabens in cosmetics, simultaneous use of many cosmetic products containing these preservatives should be avoided.

Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings

BACKGROUND

Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence.

OBJECTIVES

To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers.

SELECTION CRITERIA

Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence.

MAIN RESULTS

We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave-on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath. In five studies, treatment duration ranged from five days to six months; only one study had post-treatment follow-up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel. Three studies each had high risk of attrition, detection, and performance bias. Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice-daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed-days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin-moisturising regimen) (P = 0.004), but this is based on very low-quality evidence, so we are uncertain of this result. Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave-on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water-in-oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low-quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid-volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low. One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low-quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable. Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow-up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low. Outcomes of erythema and clinical score of itch were not assessed in any included studies.

AUTHORS' CONCLUSIONS

Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low-quality evidence. Low-quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care. Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient-reported outcomes, such as comfort and acceptability.

A review of the effects of ageing on skin integrity and wound healing

It is well known that advancing age is a factor that affects the normal course of wound healing. The population over the age of 65 years is increasing globally, and this may be accompanied by an increase in the number of individuals experiencing delayed wound healing. There is a breadth of research to show that age-related changes in the epidermis and dermis change the skin's ability to resist damage and injury. In particular, the dermoepidermal junction becomes flattened, which predisposes the tissue to shear and friction forces. Within the dermis, alterations in the amount and structure of collagen also mean that the tissue is much more rigid. Prompt assessment of the skin to identify existing conditions as well as preventive measures is therefore essential. This article discusses the anatomy of the skin and the effects of ageing on the tissues. It also offers some guidance on skin assessment and the basics of skin care.

The impact of care practices and health demographics on the prevalence of skin tears and pressure injuries in aged care

AIMS AND OBJECTIVES

To determine whether differences in care practices and demographics between two long-term aged care facilities affected the incidence of residents' skin wounds.

METHODS

A retrospective analysis of care plans and clinical outcomes was conducted for a 6-month period in 2016 at two aged care facilities, N = 39 Home 1 and N = 45 Home 2. Skin tears, pressure injuries and usual care practices and associated health demographics were recorded.

RESULTS

Over the 6-month period, 84 residents were found to have a total of 206 aged care acquired skin wounds (skin tears, pressure injuries, haematomas, rashes, infections). The frequency of skin tears or total wounds did not differ between the homes. Several factors were identified that influenced the skin wounds. A reduction in skin tears was associated with the use of heel protectors and antiembolic stockings, whilst a diagnosis of vascular dementia was associated with increased prevalence of skin wounds. Pressure injuries were significantly higher at Home 2. Increased use of strategies to moderate-risk activities, such as tray tables and bed rails, and impaired cognitive function were associated with higher pressure injury prevalence.

CONCLUSION

A number of care factors and health demographics influenced the rate of skin wounds. A holistic approach to skin management is needed.

RELEVANCE TO CLINICAL PRACTICE

Practices, such as repositioning and skin hygiene, are well known to reduce the incidence of pressure injuries and skin tears; however, there are other care practices that take place in homes as part of usual care that also impact skin wounds that have been largely ignored. This study highlights those care practices, as well as resident characteristics and comorbidities that may increase the risk of skin wounds, requiring further monitoring/mitigating strategies.

Older people and skin: challenging perceptions

In this article we set out to challenge perceptions about older people and skin. We examine current portrayals of older people and skin, both in the media and in the nursing literature. We describe the ‘normal’ process of skin ageing and highlight the importance of maintaining skin integrity and effective barrier function for health and wellbeing, particularly in older people. One element of maintaining skin integrity is ensuring that personal hygiene and emollient needs are met. Effective skin hygiene and emollient care will reduce the risk of breakdown, with all its burdensome and costly consequences. We therefore offer a summary of the current evidence base for skin-hygiene practice. We make a case for nurses considering skin health from a wider societal and human perspective, and identify opportunities to enhance nursing practice through skin-care advice and health education for all older people.

Introducing a new skin-care regimen for the incontinent patient

Maintaining skin integrity and preventing skin breakdown and moisture lesions in the incontinent patient is an everyday challenge for nurses in the acute setting. The management of incontinence is often a socially or culturally prohibited topic Fletcher (2008); it is frequently attributed to ill health, the aging process or hospitalization, and often overlooked. The concept of cleansing should be commonplace, but it is complicated by the ritualism that underpins this ordinary yet fundamental aspect of patient care (Voegeli, 2010). The use of traditional methods of cleansing with soap and water in the management of skin integrity consumes significant amounts of nursing time. However, this procedure conflicts with infection control measures and predisposes the patient to further skin breakdown. This article looks at the use of an evaluation of a skin-cleansing emollient product in an elderly-care setting to provide evidence enabling an innovation that would lead to a change in practice. It highlights the importance of the implementation of a skin-care regimen as part of basic nursing care for the incontinent patient within the acute setting, and challenges ritualistic practice with evidence-based care.

Characterization of health status with regard to tissue integrity and tissue perfusion in patients with venous ulcers according to the nursing outcomes classification

Nurses are active participants in caring for people with wounds and use their systematic knowledge to plan care. However, to apply adequate treatment, nurses need efficient tools to assess their patients' conditions. The purpose of this study was to characterize the tissue integrity and perfusion of the lower limbs of patients with venous ulcers based on Nursing Outcomes Classification (NOC) indicators. This cross-sectional, exploratory and descriptive study consisted of questionnaire information and physical examination of 49 patients with venous ulcers monitored in an outpatient clinic in the metropolitan region of Maracanaú. The statistical software package SPSS v. 13.0 was used to store and process data. Female patients were predominant; most were 60 years old or older and most were retirees or pension holders living with their partners. Growth of hair and peripheral edema were the most critical operational indicators. The nursing outcome indicators for tissue integrity and perfusion were shown to be moderately compromised. The variable representing age was shown to be inversely related to tissue integrity. The presence of heart disease was also shown to influence tissue integrity. The diastolic blood pressure variable showed a negative correlation with tissue perfusion. The assessment of tissue integrity and perfusion based on NOC indicators presented as advantages the possibility of examining several characteristics of the skin from the many operational indicators, the adaptation of parameters according to the study's results and the quantification of the compromise of these outcomes.