AACN P Part 1

UC Davis
UC Davis Previously Published Works

Title
Caring for Aging Skin

Permalink

Journal
Home Healthcare Now, 40(1)

ISSN
2374-4529

Authors
Kirkland-Kyhn, Holly
Zaratkiewicz, Sunniva
Teleten, Oleg
et al.

Publication Date
2022

DOI
10.1097/nhh.0000000000001046

Peer reviewed

eScholarship.org Powered by the California Digital Library
University of California

60 AJN ▼ February 2018 ▼ Vol. 118, No. 2 ajnonline.com

Caring for Aging Skin
Preventing and managing skin problems in older adults.

Family caregivers of older adults are commonly
involved in wound care. In a recent national
sample, 35% of caregivers were performing

wound care and found it to be one of the most chal-
lenging aspects of providing care.1

Intact skin is the first line of defense against infec-
tions, the environment, and trauma. As people age,
skin changes and becomes thinner, drier, and more
fragile.2 These changes can make skin more suscep-
tible to injury and infections. With age, it becomes
more important to take care of skin to prevent inju-
ries and infection.

The following is a discussion of common prob-
lems associated with aging skin, the risks of compro-
mised skin integrity, and the preventive actions nurses
can encourage family caregivers to take to promote
healthy skin.

DRY SKIN
Most older adults will experience xerosis, or dry
skin. Xeroderma creates a fine powdery scale and
accentuated creases in the palms of the hands and
soles of the feet. Dry skin can cause itching, scaling,
and cracking of skin, which allows bacteria to pen-
etrate and can result in infection. The itching that
accompanies dry skin can be localized or general-
ized, may interrupt sleep, and can cause scratching
that further excoriates skin and may lead to infection.
Skin dryness may be worse during the winter months,
in heated buildings, and in areas of the country that
have low humidity.3

As people age, the subcutaneous layer of the skin
becomes thinner and provides less protection from
trauma and thermal changes. During exercise or hot
weather, hyperpyrexia may occur owing to a reduced
ability to sweat.3, 4 In the deeper layers of the skin, se-
baceous gland function may be diminished, leading
to dry skin.3, 4 Aging also affects healing and a per-
son’s susceptibility to skin injuries and infections.

Prevention. Skin dryness and associated itching
can be prevented by limiting warm baths to three
times a week and restricting the use of soap to the
axilla, groin, scalp, and soles of the feet.5 The regu-
lar application of a skin emollient can aid with the
prevention of dryness. Skin emollients, such as pet-
rolatum, shea butter, or cocoa butter, in the form
of cream or ointment, should be applied while the
skin is still moist to hold in moisture. Lotions can
be used, but they evaporate and don’t hold moisture
in as well because of their high water content.5 Care
must be taken when applying an emollient, which
can be slippery and potentially cause a fall.

Environmental factors deplete the moisture of
the skin and exacerbate dryness and associated itch-
ing. Frequent use of harsh soaps or other personal
care products, like powders, can dry the skin and
cause itching, as can a low-humidity environment
and the use of heaters and fireplaces.6 Using a hu-
midifier to moisten room air may help prevent dry-
ness.

Treatment. Hydrating the skin is best accomplished
by immersion in a warm (not hot) bath followed by

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration
with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy
Institute’s No Longer Home Alone video project, supported evidence that family caregivers aren’t given the
information they need to manage the complex care regimens of family members. This series of articles and
accompanying videos aims to help nurses provide caregivers with the tools they need to manage their fam-
ily member’s health care at home.

The articles in this new installment of the series provide simple and useful instructions that nurses should
reinforce with family caregivers who perform wound care tasks. Each article also includes an informational
tear sheet—Information for Family Caregivers—that contains links to instructional videos. To use this series,
nurses should read the article first, so they understand how best to help family caregivers, and then encour-
age caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

SUPPORTING FAMILY CAREGIVERS
NO LONGER HOME ALONE

[email protected] AJN ▼ February 2018 ▼ Vol. 118, No. 2 61

By Holly Kirkland-Kyhn, PhD, FNP-BC, GNP-BC,
Sunniva Zaratkiewicz, PhD, RN, CWCN,

Oleg Teleten, MS, RN CWCN, and
Heather M. Young, PhD, RN, FAAN

the application of petrolatum or urea-based products,
which help to bind water to the stratum corneum.5, 7
Scaling of the skin can be controlled by using products
that contain alpha hydroxy or lactic acid; however, the
therapeutic value of using high concentrations of lactic
acid is unclear—although it enhances scale removal,
it can irritate inflamed, dry skin.5

SKIN TEARS
Skin tears can be of partial or full thickness and are
defined as wounds caused by shear, friction, or blunt
force, resulting in the separation of the epidermis from
the dermis.8 Although these are superficial wounds,
they are often very painful and can cause significant
bleeding and bruising.8 Skin tears can occur anywhere
on the body but are most often found on the arms,
legs, and back of the hands of older adults as a result
of trauma; for example, when bumping into an object
or sustaining a fall.9

Prevention. The prevention of skin tears in-
volves protecting the skin from shearing, friction,
or blunt force. Careful positioning and avoiding
the application of adhesives, which may cause tear-
ing of skin upon removal, are important factors in
preventing skin tears. Additional preventive strate-
gies include reinforcing the need for gentle care, en-
couraging those at risk to wear long sleeves and
long pants, keeping the skin well moisturized, and
creating a safe environment to prevent trips and
falls.9

Treatment. Skin tear treatment depends on the
tear type (type 1, 2, or 3), which varies according
to the depth of the injury.9 Early care involves con-
trolling the bleeding by pressing a dry clean cloth or
piece of gauze on the skin tear until bleeding stops.9
The area should be cleaned with saline or warm wa-
ter and patted dry. If a skin flap exists, replace and
realign the flap. Apply a nonadherent dressing to the
wound. Tape the dressing to itself to ensure the tape
is not in contact with the skin. An alternate method
is to secure the dressing with a wrap gauze and tie
the ends.

PRESSURE INJURIES
Pressure injuries, which are also known as decubitus
ulcers or bed sores, are injuries to skin or underlying
tissue that result from sustained pressure, shear, and
other factors.10, 11 Although often found over bony
prominences, they can occur in any anatomical lo-
cation. Pressure injuries present in a variety of ways,
ranging from intact skin with nonblanching erythema
to full thickness tissue loss down to the muscle or
bone.10, 11 These wounds can develop because of im-
paired mobility or the use of medical devices, such as
tracheostomy neck plates, wheelchairs, or orthopedic

splints, which can cause injuries at the point of con-
tact with the skin.

Prevention. It’s important to assess high-risk areas
of the skin at least daily and to check for any areas of
impairment (for example, nonblanching redness or dis-
coloration, skin breakdown, edema, a change in the
consistency of the tissue, or pain). If any are noted, the
caregiver should contact the health care provider for
prompt assessment while continuing to provide general
skin care, including regular bathing, moisturizing, and
timely incontinence care. For patients with impaired
mobility, make regular small shifts in positioning and
assess the skin under and around medical devices a
minimum of twice a day.11 Consider using air-filled or
high-specification foam mattresses or other support
surfaces, including off-loading devices, specialized seat
cushions, and turning support systems, for both the
prevention and treatment of pressure injuries.11

Fingernails and toenails should be trimmed and
filed to prevent skin damage from scratching or in-
advertent nicks. Nails tend to thicken or crumble
with age because of their slowed growth; in addition,
chronic, systemic disease, such as diabetes and vascu-
lar insufficiency, can compound physiologic changes
and make older adults more susceptible to fungal
infections, which can also thicken nails. Thick or
untrimmed toenails can prevent a person from wear-
ing appropriate footwear, making the feet more vul-
nerable to damage. Older adults can benefit from
regular visits to a podiatrist or, if no podiatrist is
available, a health care provider who can perform
a thorough foot, nail, and skin evaluation and has
access to specialty tools for trimming the toenails.

A nurse teaches the family caregiver how to assess and treat a skin tear. Photo cour-
tesy of the AARP Public Policy Institute.

62 AJN ▼ February 2018 ▼ Vol. 118, No. 2 ajnonline.com

SUPPORTING FAMILY CAREGIVERS

NO LONGER HOME ALONE



Information for Family Caregivers

General Skin Care

Cleansing.
• Use liquid, lotion, or foam cleansers to clean skin.
• Foam cleansers can be used in place of shampoo. Spray onto a moist washcloth, massage into
scalp for 30 to 60 seconds, and gently comb hair.

• Premoistened bathing cloths can be used to wash hair or can take the place of a shower or bath.
Regular use of these cloths, which should not be flushed, can be costly.

• Wear gloves while providing incontinence care, which includes prompt cleansing. Wash hands
before and afterward.

Skin protection.
• Protect skin from the harmful irritants found in stool and urine by applying skin protectants.
• Use products containing zinc, glycerin, petrolatum, or dimethicone.

Dry or calloused skin.
• For dryness, apply creams and ointments after cleansing (lotions may be used, but they don’t
hold moisture in the skin well because of their high water content). Avoid the application of
cream or ointment to skin folds.

• For very dry skin, use products containing alpha hydroxy acid. These products may cause a sting-
ing sensation during the initial application.

• For calloused skin on heels, use urea-based products. These products may cause a stinging sensa-
tion during the initial application.

Pressure Injury Prevention
• Surfaces. Ensure pressure redistribution over bony prominences by using air-filled overlays and
seat cushions and high-specification foam mattresses. The use of a specialty surface does not
eliminate the need for repositioning.

• Keep repositioning. Shift the person’s weight using wedges for positioning. It’s important to shift
weight to relieve pressure on any one area.

• Incontinence care. Wash hands before and after care, wear gloves, and avoid diaper use (use ab-
sorbent pads instead).

• Nutrition. Adequate hydration and a balanced diet are needed to maintain healthy skin. Assess
the person’s nutritional needs regularly.

Family caregiver instructional videos about skin care can be found on AARP’s website:

Treatment of Skin Tears

Pressure Ulcers: Prevention and Skin Care

For additional information and to access these videos in Spanish, visit AARP’s Home Alone Alliance
web page: www.aarp.org/ppi/info-2017/home-alone-alliance.html.

[email protected] AJN ▼ February 2018 ▼ Vol. 118, No. 2 63

Patients with incontinence are at risk for skin dam-
age owing to prolonged contact with moisture, and
further damage may occur because of exposure to the
enzymes present in stool.12 The contact of stool or
urine with skin may provoke skin breakdown, leading
to pain and skin infections. Although adult diapers
can be useful and practical, they should be avoided, if
possible, because they need to be changed often and
immediately after becoming wet or soiled. Prompt
cleansing and protection of the skin (by applying skin
protectants) may help to prevent skin breakdown.

Treatment. Pressure injuries can worsen quickly.
These wounds should always be assessed by a nurse,
physician, or other health care provider who can pro-
vide the caregiver with instructions on how best to
care for the wound. During each dressing change,
caregivers should use normal saline or potable water
for cleansing, gently pat the wound dry, and apply a
dressing recommended by the health care provider.11, 13
In addition, caregivers should avoid positioning the
patient directly on the pressure injury.

DIET FOR HEALTHY SKIN
A balanced diet plays an important role in maintain-
ing healthy skin. Eating poor-quality food can lead
to undernutrition, which is associated with the de-
velopment of pressure injuries.14

Protein is a macronutrient required for optimal skin
integrity and wound healing.15 Good sources of pro-
tein include dairy products, meat, poultry, seafood,
eggs, nuts, seeds, and legumes. Adequate hydration is
also essential for skin health and the prevention of skin
breakdown. Vitamins A and C contribute to epithelial
and collagen formation and wound healing.16 Fresh
fruits and vegetables, particularly yellow vegetables,
are good dietary sources of these vitamins. ▼

Holly Kirkland-Kyhn is the director of wound care in the Patient
Care Services Department of the University of California, Davis,
Medical Center in Sacramento, where Oleg Teleten is a wound
care specialist. Sunniva Zaratkiewicz is the director of clinical
education, nursing research, and accreditation at Harborview
Medical Center, University of Washington, Seattle. Heather M.
Young is dean of the Betty Irene Moore School of Nursing at the
University of California, Davis, and associate vice chancellor for
nursing at UC Davis Health. Contact author: Holly Kirkland-
Kyhn, [email protected]. The authors have disclosed
no potential conflicts of interest, financial or otherwise.

REFERENCES
1. Reinhard SC, et al. Home alone: family caregivers providing

complex chronic care. Washington, DC: AARP Public Policy
Institute; 2012 Oct.
research/public_policy_institute/health/home-alone-family-
caregivers-providing-complex-chronic-care-rev-AARP-ppi-
health.pdf.

2. Barr JE. Impaired skin integrity in the elderly. Ostomy Wound
Manage 2006;52(5):22-8.

3. Yaar M, Gilchrest BA. Aging of skin [chapter 109]. In: Gold-
smith LA, et al., editors. Fitzpatrick’s dermatology in general
medicine. 8th ed. New York, NY: McGraw-Hill Professional;
2012.

4. Burke MM, Laramie JA. Aging skin. In: Burke MM, Laramie
JA, editors. Primary care of the older adult: a multidisciplinary
approach. 2nd ed. St. Louis: Mosby; 2004. p. 155-63.

5. Berger TG, et al. Pruritus in the older patient: a clinical review.
JAMA 2013;310(22):2443-50.

6. Garibyan L, et al. Advanced aging skin and itch: addressing
an unmet need. Dermatol Ther 2013;26(2):92-103.

7. Danby SG, et al. The effect of an emollient containing urea,
ceramide NP, and lactate on skin barrier structure and func-
tion in older people with dry skin. Skin Pharmacol Physiol
2016;29(3):135-47.

8. LeBlanc K, et al. Skin tears: state of the science: consensus
statements for the prevention, prediction, assessment, and
treatment of skin tears. Adv Skin Wound Care 2011;24(9
Suppl):2-15.

9. Baranoski S, et al. Preventing, assessing, and managing skin
tears: a clinical review. Am J Nurs 2016;116(11):24-30.

10. Edsberg LE, et al. Revised National Pressure Ulcer Advisory
Panel pressure injury staging system: revised pressure injury
staging system. J Wound Ostomy Continence Nurs 2016;
43(6):585-97.

11. Haesler E, editor. Prevention and treatment of pressure ulcers:
quick reference guide. 2nd ed. Osborne Park, Western Austra-
lia: Western Australia National Pressure Ulcer Advisory Panel,
European Pressure Ulcer Advisory Panel, Pan Pacific Pressure
Injury Alliance; 2014.
uploads/2014/08/Updated-10-16-14-Quick-Reference-Guide-
DIGITAL-NPUAP-EPUAP-PPPIA-16Oct2014.pdf.

12. Bianchi J, Cameron J. Assessment of skin integrity in the el-
derly 1. Br J Community Nurs 2008;13(3):S26-S32.

13. Wound, Ostomy and Continence Nurses Society, Wound
Guidelines Task Force. WOCN 2016 guideline for preven-
tion and management of pressure injuries (ulcers): an execu-
tive summary. J Wound Ostomy Continence Nurs 2017;44(3):
241-6.

14. Thomas DR. Role of nutrition in the treatment and preven-
tion of pressure ulcers. Nutr Clin Pract 2014;29(4):466-72.

15. Stechmiller JK. Wound healing. In: Mueller C, et al., editors.
A.S.P.E.N. adult nutrition support core curriculum. 2nd ed.
Silver Spring, MD: American Society for Parenteral and En-
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16. MacKay D, Miller AL. Nutritional support for wound healing.
Altern Med Rev 2003;8(4):359-77.

Resources for Nurses

Treatment of Skin Tearsa

Pressure Ulcers: Prevention and Skin Carea

AJN’s resource page for supporting family care-
givers includes previous articles and videos in this
series.

a Family caregivers can access these videos, which are available in English
or Spanish, as well as additional information and resources, on AARP’s
Home Alone Alliance web page: www.aarp.org/ppi/info-2017/home-
alone-alliance.html.