Tips to improve skin care in care homes
This information is for all staff involved in the care of the skin of elderly residents.
Background
The skin is the largest organ in the human body, acting as a protective barrier against the outside environment. As people get older, their skin naturally changes. For example, as people age, their skin gets less oily, less elastic, thinner, and more prone to bruises.
As a result, the elderly may experience skin changes or issues that they did not have when they were younger (1). Skin care is therefore essential for care home
residents as it contributes significantly to their general health and wellbeing (2).
Aim or purpose
To support safer management of skin care. Highlight key issues to consider when care homes staff apply topical creams and ointments.
Recommendations and tips to improve skin care of care home residents
Follow these tips to ensure the safe management and improvement of skin care.
Good skin care is essential in everyone
If the skin looks dry, itchy, flaky, discoloured or changed, residents should have frequent skin assessments to prevent breakdown of the skin surface.
Itching is common in older people
It can cause discomfort and in severe cases it can cause disturbed sleep, anxiety and depression. Constant scratching can damage the skin, reducing its effectiveness as a protective barrier. Ensure nails are trimmed to minimise/avoid skin damage during scratching. Remember, dry skin is itchy skin!
Rinse skin well after washing
A combination of soap with hard water (such as water in the Chilterns) may produce a scum that can stay on the surface of the skin which can cause irritation
Residents with decreased fluid intake will often have dry skin
Encourage a good fluid intake of at least 1600mL to 2000mL per day. This is 6 to 8 large glasses of fluid (unless the care plan states the need for a reduced fluid intake). For more information on hydration please refer to our keeping hydrated guidance.
Emollients are moisturisers for the skin
They’re important in promoting skin health in the elderly and should be applied TWICE daily, ideally after bathing.
Apply directly to the skin in a downward motion in the direction of the hair growth – this will reduce the risk of blocking the hair follicles.
Consider resident choice when selecting emollient therapy. Avoid cosmetic products that may contain fragrance and colours, which are of no therapeutic value. See our emollient guideline
Gels are similar to creams containing a higher water content
But they may be harder to wash off. They can be useful for areas such as the face or scalp.
Review the use of oral antihistamines such as chlorphenamine, promethazine and hydroxyzine
They may be prescribed for itching but should be reviewed regularly by the prescriber with consideration to stopping.
This is because they can cause drowsiness and confusion which may contribute to falls in older adults.
Aqueous cream is no longer recommended as an emollient
It contains an ingredient called sodium lauryl sulphate (SLS) which can cause skin irritation such as burning, stinging, itching and redness. Some people still find it helpful as a soap substitute (3).
Prescribed compound preparations
If residents are prescribed compound preparations such as Canesten HC, Daktacort, Fucidin H these should be used regularly for a short period (typically twice daily for no more than 2 weeks). Check the length of time to be applied (if not stated on the label/MAR chart).
Barrier creams for incontinent residents
For example, Medi Derma-S, Cavilon) A small amount (pea sized) should be applied to clean, dry skin after every 3rd wash. If the skin feels oily – too much has been
applied. A 28g tube should contain 90 applications if the correct quantity is used. Do not apply to broken skin – seek advice on treatment
Sudocrem should not be used for incontinent residents
It can block continence pads.
Make sure the continence pads are properly fitted and have the appropriate absorbency
Regular checks and changes are necessary to prevent moisture damage.
Topical preparations that are non-medicated
For example, emollients or soap substitutes that need to be applied during personal care can be kept safely in the resident’s room alongside the topical MAR
chart.
Paraffin-based emollients
The national patient safety agency (NPSA) and medicines and healthcare products regulatory agency (MHRA) have highlighted the danger of fire and serious injury. This is for patients who smoke or go near naked flames when using paraffin-based emollients on their skin which is then covered with a dressing or clothing.
Clinicians should weigh up the benefits and risks of using emollients before prescribing. See the guidance on the safe use of emollient skin creams to treat dry skin conditions.
Best Practice statement |
Reason for Best Practice statement |
How to demonstrate best practice |
| All individuals should be assessed to determine the condition of the skin (for example, dry*, flaky, excoriated (scratch marks), discoloured, etc). | Assessment enables the correct and suitable preventative measures to be initiated and maintained | Document skin assessment findings in the health records |
| All individuals with dry, vulnerable skin should avoid skin irritants (for example, soaps). Dry skin conditions require the application of a moisturiser at least twice daily as part of a therapeutic treatment regimen. | Application of a moisturiser rehydrates the skin and reduces the irritant effects of perfumes and additives. Very dry skin is best treated with an ointment, moderately dry skin with a cream or gel, and slightly dry skin with a lotion. Patient preferences and lifestyle should be taken into consideration. | Document in the health records which moisturiser was prescribed and how often it should be applied. |
| Soap substitutes (or skin cleansers) should be used to wash the skin of individuals with dry, vulnerable skin, or skin determined to be vulnerable when washing/cleansing during routine personal hygiene. | Washing skin with a soap substitute reduces the drying effects associated with soap and water. Bath additives leave a layer of oil over the skin after bathing and prevent excessive moisture loss during washing. These preparations make skin and surfaces slippery so particular care is needed when bathing. | Document in the health records the skin cleansing regime used. |
| Skin should be dried gently to prevent further dehydration, before applying a topical ‘leave on’ moisturiser. Drying should involve light patting and not rubbing, as rubbing may lead to abrasion and/or weakening of the skin. | If the skin is left damp it is at risk from bacterial and fungal contamination. Application of a topical ‘leave on’ moisturiser after washing will help maximise its hydrating effect. | Document in the health records that the individual’s skin was dried in an appropriate manner. |
| Application of the moisturiser should follow the direction of the body hair, and be gently smoothed into the skin | Continuously rubbing moisturiser into the skin can lead to irritation. Rubbing against the lie of the hair can aggravate the hair follicle causing folliculitis, particularly if greasy emollients are used. | Ensure staff are trained in the application of moisturisers and show individuals how to do this properly as part of a self-management education programme. |
* Dry skin in the elderly is different to dermatological conditions such as eczema, psoriasis and underlying skin sensitivities. Individuals with eczema, psoriasis and underlying skin sensitivities are likely to benefit from the above guidance but should be referred for specific, appropriate treatments.
** Adapted from Best Practice Statement: Care of the Older Persons Skin (2nd edition) 2012, Wound UK
Support and advice to promote good skin care in care homes
Tissue Viability Nurses, Buckinghamshire Hospitals NHS Trust
Tissue viability team, Bht.tissue.viability@nhs.net
Julie Sturges, Tissue Viability Nurse
Julie.sturges@nhs.net 01296 316761
Continence Team, Buckinghamshire Hospitals NHS Trust
Specialist advice on continence care
bht.buckscontinenceteam@nhs.net
Françoise Kupa, Continence Support Nurse
Care Homes Pharmacists
Buckinghamshire Clinical Commissioning Group (CCG)
Medicines Management Team
bucks.mmt@nhs.net 01494 586714
References
1. The importance of elderly skin care (with tips)
2. Aqueous cream: may cause skin irritation
3. Oxford Health NHS Foundation Trust – Skin Care
4. Wonds UK 2012, Best Practice Statement: care of older persons skin (2nd edition)
5. PrescQIPP – Care homes: emollients and barrier preparations, 240, August 2020