Properly caring for residents’ skin always should be a priority, but it’s especially essential during summer months, when heat and sun are at their peak. Although sunburn is a notable concern — especially because up to half of all Americans aged 65 or more years will receive a diagnosis of non-melanoma skin cancer — experts warn that a host of other skin-related issues also should be on every caregiver’s radar.
“When caring for the elderly, skin-related issues can certainly present unique challenges, particularly in the hot summer months,” says Mitchell Manway, D.O., PGY-2, dermatology resident at Affiliated Dermatology. Those skin challenges can be compounded by many chronic illness and conditions, such as diabetes or vascular disease as well as certain medications that increase photosensitivity and dryness.
Proactive planning and proper care is essential for maintaining skin integrity and comfort. That involves assessing each resident’s specific risks, consistently applying the right products and ensuring proper care practices are adopted community wide.
A DELICATE BALANCE
A common caregiver mistake is assuming skin moisturizers aren’t necessary during hot months because of humidity and sweating; on the contrary, experts say excessive dryness is the most common skin problem seen in the elderly during summer. Not only does skin thin with age, oil production also diminishes, especially when skin is exposed to sun and heat.
“Air conditioning also is drying because it decreases the amount of water in the skin,” explains Peggy Brenner, MSN, RN, Northeastern regional director of nursing at Acts Retirement-Life Communities.
The same is true of overly hot water used during bathing, she adds: “This should be avoided because it can further dry skin and make it more susceptible to damage and irritation.”
Dry skin is not only uncomfortable, it can lead to eczema, rashes, excessive scratching, skin breakdown and subsequent infection. Yearlong, skin-care products that are free of dyes, perfumes and harsh detergents should be used. Daily moisturizing is prudent regardless of the season, but Manway recommends lighter lotions and creams instead of thick, barrier-restorative creams and ointments. Although heavy moisturizers commonly are used in cooler months, they can trap heat, cause sweat to accumulate and create a perfect environment for bacteria and yeast to grow when used in warmer months. Bacteria and yeast overgrowth most commonly are seen in skin folds where moisture from sweat more readily retained, such as underarms, underneath breasts, in-between digits or in leg or groin creases. These areas must be thoroughly cleaned and dried, and an absorbent antifungal powder can be applied twice daily, according to Adrienne Haughton, director of clinical & cosmetic dermatology at Stony Brook Medicine at Commack. “If that does not resolve or prevent infection, then a dermatologist should be seen for prescription medication,” she adds.
Whenever residents will be outdoors or exposed to sunlight, liberal sunscreen use becomes critical to prevent skin damage.
“Sunburn causes ultraviolet damage to skin cells, resulting in thinning of the skin. This thinning may lead to bruising of the skin and increase the risk of developing skin cancer,” says Ellen Thompson, BSN, RN, CWS, wound and product specialist for Gentell Corp.
Sun overexposure also damages DNA, collagen, proteins and lipids, adds Dan Beecher, RN, BSN, WCC, account manager and clinical educator for DermaRite Industries.
Caregivers routinely should check for any medications being used that might have a sun-exposure contraindication. They also should observe for any adverse reactions to sun exposure or products used on skin to prevent over-exposure.
“Several medications can cause sun-induced skin reactions, [so] check prescription drug bottles. The label may have a warning to avoid excessive or prolonged sun exposure,” says Steven Antokal, RN, BSN, CWCN, CCCN, DAPWCA, director of clinical education for DermaRite Industries. He warns that sunburns can lead to blisters and open areas, and healing may be delayed or complicated for someone with an acute or chronic medical condition such as diabetes.
Applying a broad-spectrum sunscreen of at least SPF 30 to all exposed areas of the body — including hands, feet, chest, face and ears (which sometimes are overlooked) — is essential, and some physicians recommend an SPF of 50 or higher. Neil Brody, a board-certified dermatologist in Manhasset, NY, prefers a zinc-based sunscreen that contains antioxidants and comes in a spray bottle for easy application. The introduction of antioxidants has been critical, he says, because some of the molecules in sunscreen are injured by ultraviolet light, which can render the product ineffective and add to oxidative damage from sunlight. “Having an antioxidant present protects both the skin and the sunscreen,” he says.
For Acts Retirement-Life residents, Brenner recommends using a water-resistant sunscreen with zinc oxide or titanium dioxide. She also educates employees on the importance of liberal and frequent application — approximately one ounce (two tablespoons) that then is reapplied at least every two hours or immediately after swimming or at times of profuse sweating. To protect delicate skin on lips, she says SPF 30 lip balm should be applied frequently and immediately after drinking.
Full-body hydration plays a pivotal role in skin health and its especially crucial any time residents are outdoors. Not only does dehydration decrease skin elasticity, making the skin more fragile and increasing the risk of skin breakdown, it also affects residents with wounds. According to Eula Reynolds, RN, MSN, CWS, director of clinical education for DermaRite Industries, dehydration can decrease the amount of oxygen and nutrients being delivered to the wound site and affect the skin’s ability to heal.
“On average, an individual needs eight to 10 glasses of water to remain hydrated, and warm weather increases that demand for seniors,” Reynolds says.
Caregivers should be aware of any constraints related to existing comorbidities that may limit fluid intake, Thompson adds. At Acts Retirement-Life Communities, hydration stations with fruit-infused water are strategically placed and easily accessible to all residents. Walks and other outdoor activities also are discouraged during prime time for sun and severe heat, typically between the hours of 10 a.m. and 4 p.m., Brenner says.
Proper attire plays a key role in sun-smart skin care. Brenner reminds employees, residents and their family members that lightweight, breathable cotton clothing is best in the summer because it is cooler, more comfortable and helps wick away moisture. Broad-brimmed hats that cover face, neck and ears offer additional protection from the sun and heat, and residents are encouraged to sit under umbrellas whenever possible.
Clothes should be changed as needed to prevent sweat accumulation, and skin should be observed and assessed throughout the day to proactively pinpoint irritation at its onset and prevent further skin damage. Incontinent residents are especially vulnerable to moisture-related skin irritation and require highly absorbent briefs and frequent changes to keep them dry. Acts Retirement-Life Communities recently trialed three new incontinence briefs, and Brenner says the difference in fluid absorption across the three products in the test pilot was surprising. Due to the successful pilot, a high-quality brief was selected that could hold a large amount of fluid. “This is so important, especially when we are encouraging more fluid intake,” she says.