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ntact skin serves a vital role in maintaining homeostasis of the body and is regarded as the body's first line of defense against invading microorganisms. Obvious clinical manifestations of compromised skin integrity include pressure ulcers, venous ulcers, burns, and skin tears. Less apparent and yet more prevalent are manifestations of compromised skin integrity, such as xerosis, chapping, cracks, and erythema. Although these conditions may be less dramatic in appearance, they portend more serious skin problems, particularly in the elderly patient population.
       A common need of all patients in any healthcare setting is to maintain intact, healthy, moisturized skin. Unfortunately, many general bathing techniques and routines jeopardize the barrier function of the epidermis. Furthermore, when healthcare providers have damaged hands (i.e., cracks in the skin), their risk of being colonized with potential pathogens and then shedding these microorganisms to potentially vulnerable patients is increased.1,2 The frequency of cleansing and the formulation of the cleansing agent are important variables that influence the effect of the cleanser on the skin.

Skin: Structures and Functions
       The skin serves several functions: protection, sensation, metabolism, thermoregulation, and communication. The intact stratum corneum protects against excessive loss of fluid and electrolytes so that a homeostatic environment is maintained.3 The skin also provides protection against mechanical injury, such as stretching or pigmentation. The melanin present in the basal layer protects the skin from ultraviolet radiation.
       Several features of the epidermis work collectively to protect the skin from pathogens: an intact stratum corneum, sebum production, acid pH, normal skin flora, and the skin immune system. Sebum is a lipid-rich oily substance secreted by the sebaceous glands onto the skin surface. This substance creates an acidic environment on the skin in the pH range of 4.5 to 6.5. Referred to as the acid mantle, this environment helps reduce the potential for pathogen invasion or environmental irritants. In healthy intact skin, the normal microbial skin flora is comprised primarily of aerobic Gram-positive cocci (e.g., staphylococcus and micrococci), diphtheroids, and yeast; Gram-negative bacilli rarely are seen.4 Within the skin, the Langerhans cells, cell tissue macrophages, and mast cells constitute the skin immune system.

Moisture Retention in the Skin
       Several structures and processes within the dermis and epidermis are essential for fluid and electrolyte homeostasis-structures that play a role in moisture retention in the skin. In the epidermis, the stratum corneum is composed of a thin layer of densely packed anuclear keratinocytes. Keratinocytes at the basal layer are healthy and cube shaped; with the appropriate signals from calcium levels in the surrounding milieu, cellular structures, and chemotactic factors, keratinocytes begin to proliferate and migrate upward through the epidermis. En route, they receive new signals that trigger growth arrest and eventually differentiation. Through a genetically defined process of cell death known as apoptosis, the keratinocytes differentiate, begin to flatten out, become more densely packed, and lose their nucleus. This transformation into corneocytes occurs within one cell layer. This surface layer of densely packed corneocytes provides the essential barrier function in the skin. Thus, the upward migration of the keratinocytes is an orderly, regulated process-a balance of cellular proliferation and apoptosis. Prolonged epidermal turnover time (or decreased proliferation) results in aging of the epidermal cells (cells that are not removed in a timely fashion). Prolonged epidermal turnover time can be triggered by aging and other external factors. These aging cells are less adherent to each other and more vulnerable to mechanical stresses, such as trauma and friction.5 Similarly, any change in the rate of apoptosis can alter the thickness of the corneocytes, which impacts the effectiveness of the skin's moisture barrier function.
       Within the dermis, sebaceous glands produce natural oils, such as sebum, that lubricate the skin and provide a protective lipid layer that minimizes fluid loss through the epidermis. The predominant proteins present in the dermis (elastin and collagen), as well as the ground substance that is located in the dermis, contribute to moisture retention.6 Ground substance contains numerous proteins-primarily, proteoglycans (PGs) and glycosaminoglycans (GAGs). Although the proteins present in ground substance comprise a very small amount of the weight of the dermis (less than 0.5%), these large protein molecules are capable of binding up to 1,000 times their volume.3 As such, PGs and GAGs play an important role in regulating the water-binding capacity of the dermis and impact on dermal volume and compressibility.
       In the basement membrane zone (BMZ), also known as the epidermal-dermal junction, the epidermal rete ridges interdigitate with the dermal papillae of the dermis, thus anchoring the epidermis to the dermis. Fibronectin, laminin, type-II collagen, and heparin sulfate proteoglycans are the major proteins in the BMZ. Capillary loops are contained within the dermal papillae and serve to oxygenate and nourish the overlying epidermis. The intricate, wavy, cable-like formation of the capillaries increases the surface area in which fluid and electrolyte homeostasis is maintained. Hence, the loops of the capillaries are integral to maintaining moisture within the skin and, specifically, within the epidermis.3

Threats to Skin Integrity
       The skin, particularly the epidermis, provides numerous complex mechanisms for maintaining skin integrity and moisture within the skin. However, serious "natural" and "man-induced" threats exist that can compromise the skin's ability to retain moisture, jeopardizing skin integrity.
       Aging. The impact of the aging process on the structure and function of the skin is well described.3,7-10
       Oncotic pressure shifts as dermal proteins decrease with age, affecting the ability to retain moisture within the dermis and resulting in less pliable tissue vulnerable to minor trauma.11 As the rete ridge and dermal papillae flatten, the capillary loops become less curvaceous and straighten out. Thus, the surface area of the capillary loops decreases and the capacity for the capillaries to maintain homeostasis is reduced. With aging, the capacity for epidermal proliferation is decreased, so more time is required for the epidermal cells to migrate to the skin surface. In addition, apoptosis and the resulting desquamation rate slows by 30 to 50 percent by the eighth decade of life.12 As a consequence of prolonged epidermal turnover time and slowed desquamation, the top layer of corneocytes are thinned and a larger surface area for fluid loss is created. Compounding this process, the aging corneocytes are less adherent, therefore producing a less efficient barrier to the outside. Dermal proteins (elastin fiber bundles) degenerate and loosen, decreasing skin elasticity, so the skin is more easily deformed.13
       Finally, during the aging process, sebum production changes. Previously, clinicians believed that sebum production decreased with age. Now, shifts in sebum production are associated with changes in sebum composition.5 The sebum sebaceous wax ester secretion decreases after age 35; in addition, the fatty acid composition in aging sebum is altered. As a consequence, less water comes to the skin surface.
       Ultimately, changes that occur with aging are manifested as dry skin (xerosis). A common phenomenon of aging skin, dry skin affects as many as 59 to 85 percent of people over the age of 64.5,11,14,15 Dry skin also is associated with up to 85 percent of pruritis, the most common aging skin problem.16 At least 70 percent of hospitalized patients are older than 65 years, and almost 90 percent of the residents in long-term care are older than 65 years of age.17 Therefore, a vast majority of the people who enter acute and long-term care facilities have vulnerable skin and decreased resiliency.
       Skin tears. One of the more ubiquitous and under-appreciated threats to skin integrity for patients in long-term and acute care settings is skin tears. Malone and colleagues18 estimated that at least 1.5 million skin tears occur in institutionalized elderly alone each year. Many of the physiologic changes in the skin that occur with aging predispose for skin tearing, particularly the thinning of the dermis and flattening of the dermal-epidermal junction.
       Soaps. Beyond the natural aging process, several "man-induced" threats to skin integrity exist; among them are using certain cleansing agents. Cleansing products (also known as detergents) include soap or a synthetic detergent. Cleansers are formulated with surfactants (natural and synthetic) that facilitate removal of dirt and debris from within the lipids of the skin.19 Unfortunately, natural surfactants remove the natural lipid layer, thus compromising the natural barrier function of the epidermis.
       Soap, a natural surfactant, is made of sodium or potassium alkali salts of fatty acids. Because of its alkalinity, soap has poor rinsing qualities and can leave a film residue on the skin. In the process, soaps remove not only transient bacteria (which is desirable) but also resident bacteria (which is not desirable) and may impair bacterial resistance.3 In addition, soaps decrease the natural skin lubricants, interfere with the water-holding capacity of the skin, thin the layers of the stratum corneum, and increase the skin pH.20 The skin pH requires at least 45 minutes to return to normal following ordinary washing with even a limited amount of soap.21
       Synthetic detergents are a milder alternative to soap and contain synthetic surfactants. Using synthetic surfactants avoids many of the disadvantages associated with natural soaps.
       Bathing. A daily bath is the norm in many acute and long-term care settings. However, as potential threats to skin integrity (particularly the potentially harmful use of certain soaps) are examined, the merit of the function, frequency, and form of bathing deserves more scrutiny.22-24
       Bathing serves three functions: health benefits, social benefits, and patient comfort. Health functions include cleansing the skin, controlling infection, and stimulating tissue and muscles. From a clinical perspective, bathing also provides an opportunity to conduct a skin inspection and to test range of motion. The social functions of a bath are to control body odor and enhance the overall well being of the patient. Finally, bathing serves a comfort function that provides relaxation and positive sensory stimulation. The question regarding the function of bathing hospitalized patients, however, is how dirty are they? If body odor is a concern, is a shower or tub bath the solution, or would another bathing technique be easier, effective, and more "skin friendly?"
       American custom is to bathe once daily. However, considering the threat soap can present to the skin, as well as the vulnerability of the older patient's skin, the continued acceptance of this tradition for institutionalized patients must be challenged. An individualized approach to bathing frequency provides an opportunity to respect the patients' personal preferences and weighs time constraints of the nursing staff.
       The third parameter to consider regarding bathing is the form of the bath. Many techniques for maintaining skin hygiene exist. The bedside or basin bath is commonly employed when the individual is unable to shower or take a tub bath; however, the basin bath, and in some situations, the shower or tub bath, can pose a risk to the patient.
       Nosocomial mycobacterial outbreaks caused by contaminated water have been described.25,26 Neutropenic patients and individuals with HIV are at greatest risk for this life-threatening infection. Extensive warm-water distribution systems present in building complexes may provide excellent growth condition for Mycobacterium, a nonenteric, Gram-negative rod that is highly resistant to chlorination.
       A key disadvantage of the basin bath is the potential for bath water contamination and cross-contamination of the immediate environment and healthcare personnel.4 Patient bath water has been identified as a potential source of Gram-positive and Gram-negative bacterial contamination.25,27 Because bathing the forearms and forehead alone removes 60 to 95 percent of the aerobic flora from that area, the microbes are subsequently relocated to the bath water and gloves of the healthcare provider. Objects handled by the care provider wearing gloves during the bathing process also become contaminated. In addition, the caregiver's hands may become contaminated due to the poor fit of the gloves or holes in the glove.
       Another disadvantage of the basin bathing technique is that the soothing or relaxing nature of the bath is quickly diminished as the water cools in the basin. Shower and tub baths are refreshing yet potentially dangerous and anxiety-producing for the debilitated patient or the patient with venipunctures or wounds. Basinless baths provide an often under-recognized alternative. Premoistened, disposable washcloths can be warmed to a comfortable temperature and, when kept properly packaged, maintain their temperature for the duration of the bath. In contrast, basin bath water cools quickly and must be rewarmed during the bathing procedure. In addition, the basinless bath technique is hygienic because one cloth is used for each major body part. Finally, the cleanser used in the basinless bath product is skin friendly and contains moisturizers to help keep the skin well hydrated.
       In many respects, traditional bathing presents a quadruple threat to the skin. The cleansers used are often drying, remove resident bacteria, and alter the skin's pH. Washcloths are harsh and rough (because of frequent washing in bleach and hot water). The excess heat of hot water used for baths has a drying effect on the skin. Finally, bathing is often performed with an element of force and friction as the cloth is lathered up with soap and the skin rubbed in an attempt to achieve cleanliness. Certainly, bathing is essential when the skin is soiled. The challenge is to consider the form, function, and frequency of traditional bathing and re-evaluate bathing so moisture retention and the barrier function of the skin is not jeopardized.
       Frequent handwashing. Maintaining skin integrity and an intact barrier function is also important for healthcare providers. Handwashing presents detrimental effects to the skin of otherwise healthy care providers.28,29 Significant evaporation water loss and shedding of large aggregates of desquamating stratum corneum cells have been associated with frequent handwashing over a short period of time.28 Consequently, the microbial flora change and the risk of transmission of microorganisms is increased. Damage to the skin of care providers as a result of handwashing is common. As many as 42.5 percent of 367 healthcare workers examined in a one-day prevalence survey had red, dry skin with flaking and small cracks.1

Reducing Threats to the Skin
       To reduce threats to skin integrity, identifying factors that have the potential for damaging the skin, particularly by causing dry skin, is essential. Dry skin (the loss of moisture from the stratum corneum) results in a mechanically less pliable epidermis that is vulnerable to cracking, scaling, desquamation, and increased transepidermal water loss.9 Therefore, preventing dry skin is an important issue for patients as well as healthcare providers.
       In terms of patient care, the AHCPR Pressure Ulcer Prediction and Prevention Guideline30 enumerates several recommendations intended to protect the integrity of the skin. These recommendations address the water temperature, bathing frequency, cleansing solution, bathing technique, and moisturizer use.
       Many of these recommendations have been restated and expanded over time by other experts. In an interview with dermatologists,5 recommendations to manage xerosis included:
- Patting the skin dry rather than rubbing
- Eliminating harsh skin care products
- Incorporating the use of mineral oil in hygiene practices.
       Weinstein31 reiterates these salient recommendations but also addresses hydration needs of the patient and the technique used for cleansing:
1. Utilize protectant products and hand degermers, barrier creams, and new delivery mechanisms
2. Maintain the individual's hydration
3. Avoid rough skin scrubbers
4. Minimize contact with soap and solvents.
       In addition, cleansing agents used in patient bathing should be neutral in pH and contain or enhance moisturizers. To reduce the risk of dry skin, emollient cleansers are recommended.9,13,22
       Good hand hygiene is indisputably related to reduced transmission of infections. Unfortunately, negative consequences of good hand hygiene affect the healthcare provider. Recommendations include using waterless alcohol-based products rather than detergent-based antiseptics, modifying lengthy surgical scrub protocols, and incorporating moisturizers into skin care regimens for healthcare providers. According to APIC,32 the use of an antimicrobial hand cleanser should be based on the degree of hand contamination and whether counts of resident flora must be reduced. Based on this guideline and several research studies, an antimicrobial cleanser is recommended for healthcare providers who require frequent (eight or more times per day) handwashings.

Conclusions
       Promoting skin integrity and minimizing the potential threats to skin integrity are important goals in all healthcare settings. A key first step is to recognize that based on age alone, patients over 60 years of age have less resilient skin. Many routine practices employed in acute care as well as long-term care may have a cumulatively detrimental effect on the skin and subsequently increase the risk of skin dryness or skin tears. Traditional bathing techniques constitute one particular practice that may present considerable potential harm. Wound care nurses have a long history of advocating for appropriate care for patients with wounds; the type of cleansers used for general bathing, bathing technique, and hand hygiene all present additional opportunity for advocacy.


Excerpted and adapted with permission from HMP Communications. Bryant RA, Rolstad BS. Examining threats to skin integrity. Ost/Wound Manag 2001;47(6):18-27. Copyright © 2001 HMP Communications.