Dry skin can result in itching (pruritus), burning, and cracking of the skin (Figure 17-2). Many older people develop a habit of scratching or picking at dry or cracked skin, increasing their risk for further tissue damage and infection. Skin irritation can be severe and can cause intense discomfort to older adults. In fact, it may be so distracting that affected individuals cease to participate in social activities.

Rashes and skin irritation can be caused by factors other than dryness. Medications, communicable diseases, and contact with chemical substances are common causes of skin rashes and pruritus (Figure 17-3).

One communicable source of skin irritation and severe pruritus is scabies. Scabies is a superficial infection caused by a parasitic mite (Sarcoptes scabiei var. hominis) that burrows under the skin (Figure 17-4). Older adults, especially individuals who suffer from chronic illness, dementia, or a depressed immune system, are particularly vulnerable to scabies infections. Signs of scabies include intense itching and fine, dark, wavy lines at the flexor surface of the wrist or elbow, the webbed area of the fingers, the axilla, and the genitals. Recognition of scabies may be difficult in older adults because it has an asymptomatic incubation period of 4 to 6 weeks and because atypical presentations are common. When infestation is suspected, skin scrapings should be examined to determine the presence of ova or mites.

Changes in skin pigmentation are common with aging. These changes are discussed in Chapter 3. Many of the changes are cosmetic and do not cause problems unless they are located on the face or arms, where they may be distressing to the affected person. Common conditions such as acne rosacea can be treated with topical medications, which help heal the skin and reduce redness, whereas others can be concealed by appropriate use of cosmetics. Changes in the size or pigmentation of moles are of greater significance because these changes may indicate the presence of a precancerous or cancerous condition that needs immediate medical attention.

Pressure ulcers are a particular risk to older adults who suffer from compromised circulation, restricted mobility, altered level of consciousness, fecal or urinary incontinence, or nutritional problems (Table 17-2). Studies estimating the occurrence of pressure ulcers vary widely, but one consistent point is that they occur in all settings. Although most studies show that the incidence of pressure ulcers has declined, there is still much work to be done. Pressure ulcers have negative effects on the overall health of an elderly person. They can lead to infection, pain, loss of function, and even death. Furthermore, incidence of pressure ulcers can leave care facilities and nurses vulnerable to lawsuits for negligence. They strain the health care system with treatment costs estimated at $11 billion per year. New Medicare rules specify that a hospital will not be reimbursed for the care of a patient who develops a pressure ulcer after being admitted to a hospital. This should be a great motivator for hospitals to institute pressure ulcer prevention programs.

Excessive pressure on tissues, particularly over bony prominences, can quickly lead to skin breakdown (Figure 17-5). Ulcer development depends on the amount of pressure, the length of time pressure is exerted, and the underlying status of the tissues involved. Tissue that is subjected to excessive pressure does not receive adequate oxygen or nutrients. This can result in ischemia and increased susceptibility to breakdown. When tissue is deprived of necessary nutrients for a longer period, necrosis and tissue destruction result. Tissue that is fragile because of poor nutrition or circulation is most susceptible to breakdown. Early danger signs indicating a risk for breakdown include pale or reddened tissue. Pressure ulcers are categorized or staged based on their appearance and the depth of tissue penetration (Figure 17-6).

Individuals who have had one pressure ulcer are at greater risk for future development of additional ulcers. Additional factors that contribute to development of pressure ulcers include the following:

Rather than wait for skin breakdown to occur, most health care agencies perform a formal risk assessment at the time of admission and then at regular intervals. The most common tools used for this assessment are the Braden and Norton Scales (see Tables 17-3 and 17-4). Nurses use the information from this assessment to develop a plan of care that minimizes risk factors and promotes skin integrity.