Introduction
Maintaining and improving skin health and integrity are major goals in acute and long-term care. Skin integrity is regarded as a quality indicator1 and maintaining skin integrity is widely accepted as being more cost-effective compared to wound treatment.2-4 Patients who are critically and chronically ill and those with immobility or incontinence are at risk for developing a broad range of adverse skin conditions such as pressure ulcers (PUs), incontinence-associated dermatitis (IAD), skin tears, or intertriginous dermatitis (intertrigo).5,6 Due to continuous changes in skin and underlying soft tissue structure and function,7 advancing age can also be regarded as an independent risk factor for developing skin problems. Dry skin (xerosis), fungal infections, and several forms of dermatitis are most prevalent in aged populations in care settings.8-12
Thousands of patients receive daily routine skin care, including washing, showering, and bathing with or without the use of skin cleansers. Cleansing is often followed by application of lotions, creams, and ointments. These personal hygiene and skin care activities are integral parts of nursing practice, but little is known about the benefits and clinical efficacy of these practices.5,13
We practice in a similar situation at the Charite-Universitatsmedizin Berlin, one of the largest university hospitals in central Europe. Multiple skin care products are used, and skin care routines are based on personal beliefs, preferences, and local care policies rather than current best evidence or consistent best practices. In order to reduce practice variations, we developed a basic skin care algorithm based on current best evidence and best practices. A quality improvement project was launched. This article reports results of a systematic literature review about the current best evidence regarding basic skin care. Review results and expert input were then used to create a clinical algorithm for basic skin care in care settings, which is introduced in the second part of this article.
Basic skin care was defined as skin cleansing and application of topical products in order to maintain and improve the skin's barrier function and integrity. Common practices include washing, bathing, showering with or without cleansing products, and application of leave-on products such as lotions creams or ointments. We placed special emphasis on a preventive approach to skin care.14 Application of administration of prescriptive agents was excluded from this project.
Methods
A systematic literature search was conducted to evaluate the empirical evidence supporting basic skin care interventions. The electronic databases MEDLINE, EMBASE, and CINAHL were searched ranging from 1995 to 2013. We also completed reference (ancestry) searches of selected publications. After inclusion of publications from the database and reference list searches, a forward search was conducted using Scopus and Web of Science. This technique allowed us to search forward in time of publication of key articles to ensure a more thorough review. There were no language restrictions.
We decided to cover a broad range of basic skin care interventions in our literature review. We therefore deemed the following article types eligible for inclusion: (1) systematic reviews; (2) intervention studies; and (3) clinical practice guidelines, consensus statements, and best practice standards. Many intervention studies have been included in previous systematic reviews already. If studies had already been included in a previous review, they were not included as a single study again. Instead we limited our review to randomized controlled trials (RCTs) reporting basic skin care treatment effects that were not included in previous systematic reviews. Editorials, comments, case-control studies, and studies focusing on the treatment of persons with IAD, skin tears, or PUs were excluded.
Study Selection and Data Extraction
Two reviewers (A.L. and A.H.) independently screened the results of the database search based on title and abstract. Potentially relevant articles were read in full text independently by the same 2 reviewers; disagreements were resolved by consensus. The results were methodologically clustered into (1) systematic reviews, (2) RCTs, and (3) clinical practice guidelines, consensus statements, and recommendations. The following characteristics were extracted: (1) Systematic reviews: authors, review topic, main inclusion criteria, summary of results, and included studies (Table 1); (2) RCTs identified during reference reviews: authors, topic/research question, sample, intervention, and main results (Table 2); and (3) Clinical practice guidelines, consensus statements, and recommendations: source, topic, conclusion, and recommendations about skin care (Table 3). Besides the different publication types identified, content was then iteratively classified into related topics.
The methodological quality of all systematic reviews and the RCTs included in our review was independently rated by 2 reviewers (A.L. and A.H.); disagreements in quality were resolved by consensus. We used a validated instrument to evaluate systematic review quality (AMSTAR, Assessing the Methodological Quality of Systematic Reviews).15 This instrument consists of 11 items covering the design and the conduct of each systematic review, for example, whether a research question and inclusion criteria were stated a priori, or if a list of inclusion and exclusion criteria was provided. Other questions address, for example, the characteristics, the scientific quality of the included studies, or whether publication bias was assessed. All questions were answered with "Yes," "No," "Can't answer," or "Not applicable." Every "Yes-answer" was assigned one point, indicating that this quality criterion was met.
Randomized controlled trials included in this review were rated using the Cochrane Collaboration's tool for assessing risk of bias.16 Six possible bias categories (sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other potential threats to validity) were ranked using "Yes" for low risk of bias, "No" for high risk of bias, or "Unclear." Because of their heterogeneous nature, the methodological quality of the guidelines, consensus statements, and recommendations was not formally assessed.
Development of the Skin Care Algorithm
After evaluation and summary of empirical evidence, recommendations for care, along with consensus statements and a clinical algorithm for basic skin care in an institutional care setting, were developed. At first, review results were clustered into similar interventions and activities. These interventions were then ordered according to the general care process logic.17 The first draft of our algorithm was sent to colleagues with expertise in dermatology (U.B.P.), skin pharmacology/pharmacy (C.S.), nursing science, and basic skin care research (J.K., A.L.), clinical quality and risk management (A.H.). Based on feedback from these expert colleagues, the algorithm was revised and discussed in a subsequent face-to-face meeting. A second revision was reviewed again and finally approved.
Outcomes
Searches of the EMBASE, MEDLINE, CINAHL, Scopus, and other electronic databases retrieved 1007 records. A title search narrowed this number to 121 articles that were read in full text by 2 reviewers (A.L. and A.H.). Ultimately, 41 documents reporting 7 systematic reviews, 19 RCTs, and 15 guidelines/consensus statements were included in the data synthesis (Figure 1).
We retrieved 3 clinical practice guidelines based on consensus statements,18-20 4 systematic reviews,5,13,21,22 and 6 RCTs not included in systematic reviews23-27 that we used to generate recommendations and interventions for prevention of dry skin. We retrieved 3 clinical practice guidelines/consensus statements28-30 and 2 systematic reviews2,4 that were used to generate recommendations and interventions for prevention of IAD. We used 4 clinical practice guidelines/consensus statements31-34 and 1 systematic review5 to generate recommendations and interventions for prevention of skin injuries. Finally, we used 2 clinical practice guidelines35,36 and 6 RCTs37-40 to generate recommendations and interventions for prevention of the diabetic foot and foot xerosis. One expert symposium41 and 5 RCTs42-46 were extracted, which reported recommendations and results about basic skin care. Forty-three single studies covering the time period 1995 to 2012 were included in the 7 systematic reviews. Some studies were included 3 to 4 times,47-52 whereas others53-55 were included only once.
Methodological Quality
The methodological quality of the included publications varied. Four3-5,22 of 7 systematic reviews showed good methodological quality; they met 6 or more out of 11 quality criteria according AMSTAR. The most common reasons for the poor ratings were: (1) no protocol was published a priori,2,4,5,13,21 (2) excluded studies were not listed,2,4,5,13,21,22 or (3) a conflict of interest was not specified for the systematic review and for each of the included studies2-5,13,21,22 (Table 1).
Most of RCTs showed low methodological quality. Four24,40,56,57 of the 19 RCTs were deemed of high methodological quality. The main criteria associated with lower methodological quality were missing or inappropriate allocation concealment, no blinding of participants, personnel and outcome assessors, or sequence generation processes (Table 2). The main results of clinical practice, the guidelines/recommendations, and consensus statements are reported in Table 3. As noted earlier, their methodological quality was not assessed.
Main Findings
Findings from our review were clustered into 3 topics: (1) skin care for prevention of dry skin; (2) skin care for prevention of IAD; and (3) skin care for prevention of skin injuries, including PUs, skin tears, and diabetic foot syndrome. This concept incorporates the various clinical pictures resulting from diabetic neuropathy, ischemia, and infection, leading to wounds and potential amputation.58
Skin Care for Prevention of Dry Skin
Recommendations for prevention of dry skin were based on a single report from an expert dermatology symposium,41 3 clinical practice guidelines and consensus statements,18-20 4 systematic reviews,5,13,21,22 and 6 RCTs not included in the systematic reviews.23-27 Because the pH of the surface of the skin is slightly acidic (pH 4.5-5.7), the use of mild cleansers with pH close to skin pH is recommended. Skin cleansing with natural soap is not recommended because the alkaline pH of these products (7-12) has the potential to damage the skin barrier. Key ingredients of cleansers are surfactants (surface active agents). These are molecules consisting of hydrophilic (water-soluble) and lipophilic (oil-soluble) parts. Therefore, they are able to dissolve in both phases, making them miscible. According to the charge of the hydrophilic head group of the molecule "amphoteric," "nonionic" or "anionic" surfactants are distinguished. Based on the available evidence, amphoteric and nonionic surfactants instead of anionic surfactants lower the irritation potential and should be preferred. In any case, mild cleansers are preferred.41
Evidence retrieved from our review revealed that topically applied dexpanthenol 2.5% and 5% demonstrated protective effects against skin irritation.26,27,59 Twice-daily application of moisturizers has the potential to improve the skin's barrier function, but the effectiveness depends on the composition of the moisturizers and emollients.42 The 2010 study by Williams and colleagues46 revealed that the application of moisturizers to healthy skin offers protective effects against exposure to irritants. Another study investigated cosmetic body moisturizers, including niacinamide and glycerin versus moisturizers containing only glycerin or glycerin with petrolatum or glycerin with mineral oil. The twice-daily application of a cosmetic body moisturizer with niacinamide and glycerin improved the integrity of the stratum corneum by diminishing skin dryness and transepidermal water loss.43
Frequent bathing or showering should be avoided and bathing time should be shortened when skin is dry. At least twice-daily application of emollients and moisturizers containing humectants such as urea or glycerin is recommended for prevention of dry skin.5,13,18,20
Skin Care for Prevention of IAD
Recommendations for prevention of IAD were based on 3 clinical practice guidelines/consensus statements and 2 systematic reviews.2,4,28-30 Gentle daily cleansing with no-rinse cleansers (pH 5.5) and cleansing after each incontinence episode is recommended for prevention of IAD. Soap and water were found to be less effective and more time consuming than non-rinse cleansers (eg, wipes) and barrier creams.4 The skin should be dried carefully and thoroughly, and scrubbing should be avoided because of its deleterious effects on the skin's moisture barrier. After cleansing, a skin protectant product should be applied. Products, including zinc oxide, petrolatum, dimethicone, or other skin sealant, may be used.28-30
Skin Care for Prevention of PUs, Skin Tears, and Diabetic Foot Syndrome
Recommendations for prevention of PUs, skin tears, and diabetic foot syndrome were drawn from multiple sources. Recommendations for the contribution of skin care to the prevention of PU were drawn from 4 of the 15 clinical practice guidelines, best practice, or consensus statements31-33,60 along with 1 systematic review3 and 1 additional RCT.57 One consensus statement was found with recommendations for skin tear prevention34 and one systematic review focused on skin injury prevention.5 Recommendations related to basic skin care for prevention of diabetic foot syndrome were drawn from 3 consensus statements,35,36,61 and 6 RCTs.37-40,56,62
The skin should be washed with lukewarm water and dried carefully but thoroughly, especially the toes and other areas where skin-to-skin contact is present (eg, submammary, inguinal, axilla). Irritating cleaning agents such as soap should be avoided. A clinical practice guideline from the Australian Wound Management Association recommended the use of pH appropriate skin cleansers and the application of emollients.31 The use of oils or creams is recommended for skin care in persons with diabetic foot syndrome, but the skin between the toes should be avoided.63 The application of emollients or a moisture barrier for skin protection in terms of PU prevention is also recommended.5,33 A best practice document for prevention of PUs and skin tears by Ayello and Sibbald32 suggested application of hypoallergenic moisturizers twice daily especially on arms and legs, combined with avoidance of rubbing the skin.
Algorithm for Basic Skin Care
We developed our algorithm for basic skin care based on universal care process logic (assessment, diagnoses, interventions17), findings from our literature review, and expert review as described previously (Figure 2). The target groups for the algorithm are adult patients or residents in institutional and home care settings. The algorithm is intended for persons with intact skin that may exhibit signs of dryness such as scaling or hyperhydration such as maceration or other moisture-related changes. The algorithm is not indented to address severe inflammation, cutaneous lesions, infections, or wounds. The algorithm is not intended for persons with common dermatoses such as eczema, psoriasis, and candidiasis. Similarly, it is not intended for use in persons with atopic, contact, or seborrheic dermatitis.
The algorithm distinguishes between general and special basic skin care. General skin care is defined as all interventions and activities that patients or residents should receive. An assessment helps decide whether special skin care is needed or not. Skin care interventions always include cleansing followed by skin care. Skin cleansing usually includes the application of rinse-off products to remove unwanted substances on the skin (eg, dirt, bacteria, sweat, debris). Skin care is the application of leave-on products (eg, moisturizers, emollients) to protect and/or to enhance/restore the skin barrier.
General Assessment and Care
A thorough skin assessment is completed after patient admission as soon as possible. The clinician should assess the skin for integrity, scaling, redness, or cutaneous signs of pruritus. The assessment should take into account a history of comorbid conditions affecting the skin such as obesity, urinary or fecal incontinence, diaphoresis, diabetes mellitus, age 75 years or greater, immobility, or functional limitations. In case of the presence of skin problems or risk factors, special skin care is needed.
The skin should be cleansed once daily. Traditional alkaline soaps should be avoided when providing basic skin care. We recommend the use of a syndet cleansing product. Syndets, synthetic soap like products, should contain a milder synthetic surfactant when compared to traditional soaps and possess a pH of 4 to 5 that is compatible with the acid mantle of healthy skin. However, cleansing and the other caring procedures may follow individual preferences as long as no skin problems occur.
Special Skin Care
The skin of patients requiring special skin care is classified based on "dry" and "humid" skin areas. Dry areas include surfaces that are directly exposed to air and/or clothes such as the face, scalp, and back. Humid areas include areas where skin folds occur such as axillae, abdominal skin folds, under the breasts, groin, and skin between the toes. We acknowledge that this dichotomous division may not reflect subtle differences between various skin areas, but we believe it aids thinking and clinical decision making in relation to the 2 key challenges in basic skin care: enhancing the moisture barrier when the skin is "too dry" or "too moist."
Dry skin areas should be regularly assessed for the presence of scaling, roughness, redness, and cracks. Documentation and follow-up of these signs are especially important when evaluating the effectiveness of preventive interventions. In general, cleansing of dry skin areas should occur daily using lukewarm water. Severely dry skin should not be cleaned with soap and water; instead, mild lipid containing cleansers (syndets) with a pH near 4 to 5 should be used. Cleansers containing humectants (eg, urea, lactic acid, glycerin) are preferred. Lipid and humectant containing leave-on products should be applied to dry skin areas at least twice daily. In the case of severe dryness, products must be applied more often. The drier the skin, the more lipophilic the product should be.
Humid skin areas should be cleansed once daily and, if necessary, more frequently; these areas should be dried thoroughly but carefully. Full-body immersion should be avoided in order to limit exposure to additional moisture. For cleansing, mild syndet soaps should be used. Leave-on products should be avoided. If the patient has urinary or fecal incontinence, cleansing should be conducted after every incontinent episode to reduce exposure to urine and/or stool. A skin protectant should be applied after and before exposures to protect the skin.
The skin care algorithm provides general guidance for basic skin cleansing and caring and broad functional product categories. Nevertheless, we acknowledge that it does not address all possible special conditions and risks. Furthermore, we recognize a continuum between intact healthy and severely damaged skin. Targeted basic skin care is effective in managing dry scaly, (mildly) inflamed or even macerated skin. In case of severe deterioration of the skin condition and in case of infection or apparent wounds, a specialist (eg, a wound specialist, dermatologist) should be consulted.
Discussion
Skin care is an integral part of nursing practice in every care setting. The majority of skin care guidance addresses specific problems such as PU prevention,3,31-33, diabetic foot care,35,36 and management of dry (xerotic) skin.5,18-20 Nevertheless, a comprehensive guide addressing multiple skin care needs is not available. Our contribution is designed to fill this gap.
This work is based on a comprehensive appraisal and summary of existing literature. While previous reviews focused on special skin care areas, we provided a broad summary of available evidence. The systematic reviews we used for generating recommendations and designing our basic skin care algorithm incorporated approximately 40 studies (Table 1). In addition, we identified another 20 RCTs not incorporated into the systematic reviews (Table 2). We found that the methodological quality of most RCTs was poor, and interventions and outcomes are generally not comparable. In order to capture best practices where evidence was missing or lower quality, we also summarized recent guidelines and recommendations about diabetic foot care, dry skin, PU, and skin tear management.
Variability in the terms used to describe skin care provided a significant challenge for interpreting results. For instance, one resource recommended "mild"41 but failed to define what this term actually means. Another problem is the mixing of product functions (eg, moisturizing) and ingredient function (eg, glycerin as humectant, petrolatum as skin protectant). These difficulties are also observed for procedures. For instance, cleansing or application frequencies and durations are often not well described. Irrespective of these conceptual inconsistencies and different clinical areas, skin care recommendations and guideline statements were broadly similar. This suggests that there is a kind common state-of-the-art agreement, which is reflected in our algorithm.
The main therapeutic goal of the proposed skin care algorithm is the maintenance of a healthy and intact cutaneous barrier. In certain conditions such as mild inflammation or dryness, the proposed algorithm is also expected to improve barrier function. Applying a 2-step approach is considered useful to identify special skin care needs early. As long as the skin is intact and there are no other risk factors, "General skin care" interventions are considered appropriate. We acknowledge that personal hygiene and skin care procedures rely on tradition, personal beliefs, and preferences, but found no evidence signaling a need to change these behaviors as long as the integrity or barrier function of the skin is not compromised. On the other hand, patients with certain risk factors such as advanced age or incontinence will be led to the "special skin care" of the algorithm section that provides interventions to counteract the increased vulnerability to inflammation, maceration, and infection.
Product selection remains a major challenge in the field of basic skin care. For example, variable labeling of cleansing and skin care products renders it difficult to determine product performance.64,65 In addition, existence of a specific ingredient does not determine product performance; instead, performance must be determined based on the cumulative formulation and its proper application.66 Because of these difficulties, we provided general advice about what each product category should look like. For instance, we propose lipophilic leave-on products for dry skin conditions. This might include high lipid-containing creams or lotions.
Conclusions
This is the first clinical algorithm created for basic skin care in nursing care settings published internationally. It will be implemented at the Charite-Universitatsmedizin in Berlin and revised as indicated based on feedback from clinicians. During implementation, the number of skin cleansing and caring products will be reduced and the skin care approach standardized.
KEY POINTS
* A comprehensive basic skin care algorithm for use in clinical settings is proposed.
* In dry skin, frequent bathing or showering should be avoided and exposure to water should be reduced to a minimum.
* Lipophilic products including humectants should be used for treating dry skin.
* Skin should be protected against exposures to urine and/or feces.
* Skin care product selection is difficult due to heterogeneous labeling and claimed performance.
ACKNOWLEDGMENT
This project was partly funded by the Stiftung Charite.
References