Effects of loading and prophylactic dressings on the sacral and heel skin: An exploratory cross‐over trial

Pressure ulcers/injuries are caused by sustained loading and deformation of skin and underlying soft tissues. Prophylactic dressings are recommended as an adjunct to other preventive measures such as repositioning and offloading. The aim of this study was to investigate the effects of prophylactic soft silicone multi-layered foam dressings on the skin structure and function of the two most common pressure areas, sacrum and heel, with and without loading. An exploratory randomised cross-over trial using intra-individual comparisons was conducted. Eight healthy volunteers (mean age 27.5 years) were assigned to three groups and either spent 2.5 hours on a standard hospital mattress lying in supine position with and without dressings or spent 2.5 hours with dressings applied but without loading. Skin temperature, stratum corneum, and epidermal hydration increased in all groups irrespective of wearing a dressing and/or loading. Mean roughness decreased at the heels. Reactive hyperaemia and the release of interleukin 1 alpha were associated with loading only. Results suggest that the occlusive effects of dressings are similar or only slightly greater than those observed with non-loading or loading without dressings. Thus, a dressing does not cause additional irritation or skin changes during loading but it may reduce the inflammatory response

Dry skin and the use of leave-on products in nursing care: A prevalence study in nursing homes and hospitals

Aims: To describe the prevalence of dry skin in nursing homes and hospitals and to describe relationships between topical skincare interventions and dry skin. Design: Two multicentre descriptive cross-sectional prevalence studies. Methods: The studies were performed in German nursing homes and hospitals in 2015 and 2016. Data were collected by trained nurses based on a standardized data collection form. The severity of dry skin was measured using the Overall Dry Skin Score. Results: In total, 1,662 nursing home residents and 1,486 hospital patients participated. The prevalence of dry skin was 41.2% in nursing homes and 55.2% in hospitals. In case of skincare dependency, the proportions of participants with dry skin were higher, particularly in hospitals (70.2%). In both institutions, the application of leave-on products increased when dry skin was present but remained lower in hospitals. Considering the high amount of skin dryness in skincare-dependent participants, interventions seem not to be successful. Results indicate a need for skincare improvement in future

Disentangling Extrinsic from Intrinsic Biological Phenomena

Facial skin ageing is caused by intrinsic and extrinsic mechanisms. Intrinsic ageing is highly related to chronological age. Age related skin changes can be measured using clinical and biophysical methods. The aim of this study was to evaluate whether and how clinical characteristics and biophysical parameters are associated with each other with and without adjustment for chronological age. Twenty-four female subjects of three age groups were enrolled. Clinical assessments (global facial skin ageing, wrinkling, and sagging), and biophysical measurements (roughness, colour, skin elasticity, and barrier function) were conducted at both upper cheeks. Pearson’s correlations and linear regression models adjusted for age were calculated. Most of the measured parameters were correlated with chronological age (e.g., association with wrinkle score, ) and with each other (e.g., residual skin deformation and wrinkle score, ). After statistical adjustment for age, only few associations remained (e.g., mean roughness () and luminance (),  , ). Chronological age as surrogate marker for intrinsic ageing has the most important influence on most facial skin ageing signs. Changes in skin elasticity, wrinkling, sagging, and yellowness seem to be caused by additional extrinsic ageing

a multicentre prevalence study

Objectives: The aim of this study was to measure the prevalence of skin diseases in aged nursing home residents and to explore possible associations with demographic and medical characteristics. Design: Descriptive multicentre prevalence study. Setting and participants: The study was conducted in a random sample of ten institutional long-term care facilities in the federal state of Berlin, Germany. In total, n=223 residents were included. Results: In total, 60 dermatological diseases were diagnosed. The most frequently diagnosed skin disease was xerosis cutis (99.1%, 95% CI 97.7% to 100.0%) followed by tinea ungium (62.3%, 95% CI 56.0% to 69.1%) and seborrheic keratosis (56.5%, 95% CI 50.2% to 63.0%). Only few bivariate associations have been detected between skin diseases and demographic and medical characteristics. Conclusion: Study results indicate that almost every resident living in residential care has at least one dermatological diagnosis. Dermatological findings range from highly prevalent xerosis and cutaneous infection up to skin cancer. Not all conditions require immediate dermatological treatment and can be managed by targeted skin care interventions. Caregivers need knowledge and diagnostic skills to make appropriate clinical decisions. It is unlikely that specialised dermatological care will be delivered widely in the growing long-term care sector. Trial registration number: This study is registered at https://clinicaltrials.gov/ct2/show/NCT02216526

Evidence-based skin care in the context of age and care dependency

Hintergrund: Der Anteil der älteren Bevölkerung nimmt stetig zu. Damit einhergehend steigt die Morbidität. Altersbedingte, häufig chronisch verlaufende Erkrankungen führen zu einer Zunahme der Pflegebedürftigkeit. Die Haut als das menschlich größte Organ ist ebenfalls von altersbedingten Um- und Abbauprozessen betroffen. Physiologische Veränderungen der Haut im Alter führen häufig zu trockener Haut und zu einer erhöhten Vulnerabilität gegenüber einer Vielzahl von Einflüssen. Methode: Die vorliegende Dissertation untersuchte anhand von vier Teilprojekten, wie viele Menschen in institutionellen Settings von Hauttrockenheit (Xerosis cutis) betroffen waren, wie eine „gesunde“ Hautbarriere in Bezug auf den Parameter Transepidermaler Wasserverlust (TEWL) zu definieren ist, ob sich dieser Parameter im Alter verändert, welche Hautpflegestrategien in der täglichen Pflegepraxis angewendet werden, welche Einstellungen Pflegende zum Thema Hautpflege haben sowie die empirische Evidenz, um Empfehlungen für die Praxis ableiten zu können. Mit Hilfe einer multizentrischen, deskriptiven Querschnittsstudie wurde 2014 in deutschen Krankenhäusern und Pflegeheimen eine Erhebung durchgeführt, die unter anderem die Prävalenz von Hauttrockenheit bei Patienten und Pflegeheimbewohnern evaluierte. Die Untersuchung des Parameters TEWL wurde mittels einer systematischen Übersichtsarbeit und Meta-Analyse durchgeführt. Eingeschlossen wurden alle Primärstudien, die Baseline-, Kontroll- oder andere Messungen an gesunden Erwachsenen ohne Intervention durchführten. Mit Hilfe einer deskriptiven Studie an der Charité - Universitätsmedizin Berlin wurde untersucht, welche Hautpflegestrategien in der Praxis angewendet werden, und welche Einstellungen Pflegende haben. Zur Erfassung der empirischen Evidenz zum Nutzen von präventiven Hautpflegeinterventionen zum Erhalt und zur Stärkung der Integrität der Haut und der Funktion der Hautbarriere im Alter, wurde eine systematische Übersichtsarbeit angefertigt. Ergebnisse: Fast die Hälfte aller untersuchten Krankenhauspatienten und Pflegeheimbewohner hatten Anzeichen von Hauttrockenheit. Die Beine und Füße waren am häufigsten betroffen. Die stärksten Prädiktoren für das Auftreten von Hauttrockenheit waren höheres Lebensalter, Pruritus, onkologische und muskuloskeletale Erkrankungen und Abhängigkeit von der Hautpflege. Der Parameter TEWL zeigte intraindividuelle Differenzen in Abhängigkeit von der Körperstelle. In der Altersgruppe ab 65 Jahren waren die TEWL-Werte niedriger als in der jüngeren Altersgruppe. Es gab keine standardisierten Hautpflegestrategien auf den untersuchten Stationen. Die Auswahl und Anwendung von Hautpflegeprodukten schien stark von individuellen Präferenzen und persönlichen Erfahrungen der Pflegenden abzuhängen. Internationale Evidenz zu Empfehlungen von Hautpflegestrategien und Produkten ist selten vorhanden. Abgeleitete Empfehlungen dienten als Grundlage zur Entwicklung eines klinischen Hautpflege-Algorithmus. Schlussfolgerungen: Hauttrockenheit tritt im institutionellen Pflegesetting häufig auf. TEWL als Parameter zur Charakterisierung einer gesunden Hautbarriere ist schwer zu interpretieren, da ein niedriger Wert nicht zwangsläufig für eine gesunde Hautbarriere beim Älteren steht. Zum Thema Hautpflege bestehen Wissenslücken bei den Pflegenden. Der entwickelte Algorithmus dient als Hilfestellung und muss implementiert werden.Background: The world´s population is aging. The occurrence of aging associated chronic diseases also increases and often results in care dependency. The skin as the largest organ of the human body is also affected by age-related remodeling and degradation processes. Physiological skin alterations can lead to skin dryness and an increased vulnerability. Method: The present dissertation was split in four projects. It investigated how many patients are affected by dry skin in institutional care settings, how a healthy skin barrier can be defined in terms to the skin barrier parameter Transepidermal Water Loss (TEWL) and if this parameter changes during aging. It was further investigated which skin care strategies are applied in an institutional hospital setting. In addition, systematic searches for international evidence-based skin care interventions were performed for developing skin care recommendations. The prevalence of skin dryness was measured as part of an annual multicentre descriptive cross-sectional study. A systematic review and meta-analyses covering primary studies which investigated baseline and control measurements of TEWL in healthy adult humans without applying any interventions was conducted. A descriptive study was conducted at the Charité - Universitätsmedizin Berlin to evaluate skin care practices and beliefs of nurses in a clinical setting. Systematic literature reviews were conducted to synthesize empirical evidence about the efficacy and effectiveness of basic skin care interventions for maintaining skin integrity. Results: Nearly half of all hospital patients and residents were affected by skin dryness. The skin of feet and legs were most often affected by dry skin. The strongest predictors for the occurrence of skin dryness were age, pruritus, oncological and musculoskeletal diseases and skin care dependency. TEWL showed large intraindividual differences between skin areas. TEWL in 65-year and older individuals seems to be generally lower compared to middle aged individuals. Standardized skin care interventions were not available at the investigated wards of the Charité. Selection and application of skin care products appeared to depend on personal beliefs and preferences of care givers. International evidence for recommendations of skin care strategies and products was rare. Based on the international literature review a clinical skin care algorithm was developed. Conclusion: Skin dryness often occurs in hospitals and long-term care. TEWL as a parameter to define a healthy skin barrier is difficult to interpret. A lower TEWL cannot be interpreted as healthy skin barrier as a low TEWL does not stand for healthy barrier function in elderly. Nurses have knowledge gaps regarding skin care. Therefore the clinical algorithm can fill this gaps and after implementation it can serve as guidance

Sex-specific differences in prevention and treatment of institutional-acquired pressure ulcers in hospitals and nursing homes

Introduction: Gender and/or sex have a major impact on staying healthy, becoming ill, or care dependent. Differences between men and women have been described for socioeconomic positions, health behaviors, courses and severities of diseases and mortality rates. Consequently, sex and/or gender need to be adequately taken into account while developing and implementing evidence-based healthcare. Evidence regarding differences between men and women in pressure ulcer care is limited. Our research aim was to measure possible differences between male and female hospital patients and nursing home residents in prevention and treatment of institutional-acquired pressure ulcers. Methods: A secondary data analysis was conducted including data sets collected in nursing homes and hospitals in Germany annually from 2001 to 2016. Relevant variables were compared according to biological sex (men/woman). Results: The study included 38,655 nursing home residents (mean age 85.4 years women, 77.3 years men) and 58,760 hospital patients (mean age 66.7 years women, 63.4 years men). More women were underweight and at pressure ulcer risk in both settings. The proportion of institutional-acquired pressure ulcers was higher for men in hospitals. Slightly more men had a PU category 2 to 4 (OR 0.87, 95% CI 0.76 to 0.99) in nursing homes or developed an institutional-acquired pressure ulcers category 2 to 4 in both settings (OR 0.85, 95% CI 0.76 to 0.95). Special mattresses were more often used by women at PU risk. More men with an institutional-acquired pressure ulcer in hospitals received counseling of relatives (OR 0.53, 95% CI 0.39 to 0.72). Conclusion: Although slightly more men had institutional-acquired pressure ulcers than women, overall differences regarding pressure ulcer occurrence were minor. Gender and/or sex can rather not be considered as an independent risk factor for pressure ulcer development and differences regarding pressure ulcer prevention interventions seem to be minor

Measuring the quality of pressure ulcer prevention : a systematic mapping review of quality indicators

The aim of this study was to provide a systematic overview of available pressure ulcer prevention quality indicators and to evaluate the underlying empirical evidence. A systematic mapping review was conducted with combined searches in Embase and Medline, and websites of relevant institutions and organisations. The eligibility criteria were clear use of the term “quality indicator” regarding pressure ulcer prevention; English or German language; and all settings, populations, and types of resources, including articles, brochures, and online material. In total, n = 146 quality indicators were identified. Most indicators were published in the United States (n = 50). The majority of indicators was developed for the hospital setting (n = 102). Process indicators were the most common (n = 71), followed by outcome indicators (n = 49). Less than half of identified indicators appeared to be practically used. Evidence supporting the validity and reliability were reported for n = 25 and n = 30 indicators respectively. The high number of indicators demonstrate the importance of measuring pressure ulcer prevention quality. This is not an indicator of our ability to accurately measure and evaluate this construct. There is an urgent need to develop evidence-based and internationally comparable indicators to help improve patient care and safety worldwide

Maintaining skin integrity in the aged : a systematic review

Background: In aged nursing care receivers, the prevalence of adverse skin conditions such as xerosis cutis, intertrigo, pressure ulcers or skin tears is high. Adequate skin care strategies are an effective method for maintaining and enhancing skin health and integrity in this population. Objectives: The objective was to summarize the empirical evidence about the effects and effectiveness of non-drug topical skin care interventions to promote and to maintain skin integrity and skin barrier function in the aged, to identify outcome domains and outcome measurement instruments in this field. Design: An update of a previous systematic review published in 2013 was conducted. Data sources: Databases MEDLINE and EMBASE via OvidSP and CINAHL (original search January 1990 to August 2012, update September 2012 to May 2018) and reference lists were searched. Forward searches in Web of Science were conducted. Methods: A review protocol was registered in Prospero (CRD42018100792). Main inclusion criteria were primary intervention studies reporting treatment effects of basic skin care strategies in aged people with a lower limit of age range of 50 years and published between 1990 and 2018. Primary empirical studies were included with experimental study designs including randomized controlled trials and quasi-experimental designs. Methodological quality of included randomized controlled trials was evaluated using the Cochrane Collaboration's Tool for assessing risk of bias. Levels of evidence were assigned to all included studies. Results: Sixty-three articles were included in the final analysis reporting effects of interventions to treat and/or to prevent skin dryness, pruritus, general skin barrier improvement, incontinence-associated dermatitis, skin tears and pressure ulcers. Skin cleansers containing syndets or amphotheric surfactants compared with standard soap and water improved skin dryness. Lipophilic leave-on products containing humectants decreased skin dryness and reduced pruritus. Products with pH 4 improved the skin barrier. Application of skin protectants and structured skin care protocols decreased the severity of incontinence-associated dermatitis. Formulations containing glycerin and petrolatum reduced the incidence of skin tears. Thirty-five outcome domains were identified with nearly 100 different outcome measurement instruments. Conclusion: Included studies showed substantial heterogeneity regarding design, interventions and outcomes. Basic skin care strategies including low-irritating cleansers and lipophilic humectant-containing leave-on products are helpful for treating dry skin and improving skin barrier in the aged. Lower pH of leave-on products improves the skin barrier. The number of different outcome domains was unexpectedly high. We recommend to identify critical outcome domains in the field of skin care to make trial results more comparable in the future and to measure possible performance differences between different skin care strategies and products

Characterizing Facial Skin Ageing in Humans: Disentangling Extrinsic from Intrinsic Biological Phenomena

Facial skin ageing is caused by intrinsic and extrinsic mechanisms. Intrinsic ageing is highly related to chronological age. Age related skin changes can be measured using clinical and biophysical methods. The aim of this study was to evaluate whether and how clinical characteristics and biophysical parameters are associated with each other with and without adjustment for chronological age. Twenty-four female subjects of three age groups were enrolled. Clinical assessments (global facial skin ageing, wrinkling, and sagging), and biophysical measurements (roughness, colour, skin elasticity, and barrier function) were conducted at both upper cheeks. Pearson’s correlations and linear regression models adjusted for age were calculated. Most of the measured parameters were correlated with chronological age (e.g., association with wrinkle score, r=0.901) and with each other (e.g., residual skin deformation and wrinkle score, r=0.606). After statistical adjustment for age, only few associations remained (e.g., mean roughness (Rz) and luminance (L*),  β=-0.507, R2=0.377). Chronological age as surrogate marker for intrinsic ageing has the most important influence on most facial skin ageing signs. Changes in skin elasticity, wrinkling, sagging, and yellowness seem to be caused by additional extrinsic ageing

Evidence-Based Skin Care: A Systematic Literature Review and the Development of a Basic Skin Care Algorithm

Patients in acute and long-term care settings receive daily routine skin care, including washing, bathing, and showering, often followed by application of lotions, creams, and/or ointments. These personal hygiene and skin care activities are integral parts of nursing practice, but little is known about their benefits or clinical efficacy. The aim of this article was to summarize the empirical evidence supporting basic skin care procedures and interventions and to develop a clinical algorithm for basic skin care. Electronic databases MEDLINE, EMBASE, and CINAHL were searched and afterward a forward search was conducted using Scopus and Web of Science. In order to evaluate a broad range of basic skin care interventions systematic reviews, intervention studies, and guidelines, consensus statements and best practice standards also were included in the analysis. One hundred twenty-one articles were read in full text; 41documents were included in this report about skin care for prevention of dry skin, prevention of incontinence-associated dermatitis and prevention of skin injuries. The methodological quality of the included publications was variable. Review results and expert input were used to create a clinical algorithm for basic skin care. A 2-step approach is proposed including general and special skin care. Interventions focus primarily on skin that is either too dry or too moist. The target groups for the algorithm are adult patients or residents with intact or preclinical damaged skin in care settings. The goal of the skin care algorithm is a first attempt to provide guidance for practitioners to improve basic skin care in clinical settings in order to maintain or increase skin health