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Care Homes: Tips to Improve Skin Care in Care Homes

Tips to Improve Skin Care and application of topical creams and ointments in Care Homes

For all staff involved in the care of the skin of elderly residents

 

  1. Good skin care is essential in everyone. If the skin looks dry, itchy, flaky, discoloured or changed then residents should have frequent skin assessments to prevent breakdown of the skin surface

 

  1. Itching is common in the older person – 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!

 

  1. Rinse skin well after washing as a combination of soap with hard water (such as water in the Chilterns) may produce a scum that can remain on the surface of the skin, which can cause irritation

 

  1. Residents with decreased fluid intake will often have dry skin – encourage a good fluid intake of at least 1600mL- 2000mL per day. This is 6-8 large glasses of fluid (unless care plan states the need for a reduced fluid intake). For more information on hydration please refer to our Keeping hydrated guidance

 

  1. “Emollients” are moisturisers for the skin – they are important in promoting skin health in the elderly. They 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. Resident choice should be considered when selecting emollient therapy. Avoid cosmetic products, that may contain fragrance & colours, which are of no therapeutic value

 

  1. Gels are similar to creams containing a higher water content; however they may be harder to wash off. They can be useful for areas such as the face or scalp

 

  1. The use of oral antihistamines such as chlorphenamine, promethazine and hydroxyzine, which may be prescribed for itch, 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 the older adult

 

  1. Aqueous cream can be used for washing instead of soap – it can be rubbed (gently) on the skin, or applied on a clean flannel/added to water – before rinsing off completely. Do not leave aqueous cream on the skin or use as an emollient as it may increase skin reactions, particularly in eczema

 

  1. 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 length of time to be applied (if not stated on the label/MAR chart)

 

  1. Barrier Creams for incontinent residents (e.g. Medi Derma-S, Cavilon). A small amount (pea –sized) should be applied to clean, dry skin after every 3rd 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

 

  1. Sudocrem should not be used for incontinent residents because it can block continence pads

 

  1. Make sure that continence pads are the appropriate absorbency and fitted correctly. These should be checked and changed regularly to prevent moisture damage

 

  1. Topical preparations that are non-medicated i.e. 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.
  2. The national patient safety agency (NPSA) and medicines and healthcare products regulatory agency (MHRA) have highlighted the danger of fire and serious injury for patients who smoke or go near naked flames when they are 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. More information can be found at Link

Best Practice Statement: Application to practice: management of dry, vulnerable skin**

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 (e.g. 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 (e.g. 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 – 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 & advice to promote good skin care in care homes is available from:

 

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

francoise.kupa@nhs.net

 

Care Homes Pharmacists

 

Buckinghamshire Clinical Commissioning Group (CCG)  

Medicines Management Team

bucks.mmt@nhs.net Tel: 01494 586714