Xerosis

Xerosis is extremely dry, cracked, and itchy skin. Xerosis is the most common skin problem experienced by older people. Xerosis occurs primarily in the extremities, especially the legs, but can affect the face and the trunk as well. The thinner epidermis of older skin makes it less efficient, allowing more moisture to escape. Inadequate fluid intake worsens xerosis as the body will pull moisture from the skin in an attempt to combat systemic dehydration.

Exposure to environmental elements such as artificial heat, decreased humidity, use of harsh soaps, and frequent hot baths or hot tubs contributes to skin dryness. Nutritional deficiencies and smoking lead to dehydration of the outer layer of the epidermis. Dry skin may be just dry skin, but it may also be a symptom of more serious systemic disease (e.g., diabetes mellitus, hypothyroidism, renal disease) or dehydration.

To prevent excessive loss of moisture and natural oil during bathing, only tepid water temperatures and super-fatted soaps or skin cleansers without hexachlorophene or alcohol should be used. Products such as Cetaphil, Basis, Dove, Tone, and Caress soaps or Jergens, Neutrogena, and Oil of Olay bath washes are effective in helping to prevent the loss of the protective lipid film from the skin surface. Most lubricants such as creams, lotions, and emollients work by trapping moisture and are most effective when applied to towel-patted, damp skin immediately after a bath. Bath oils and other hydrophobic preparations may also be used to hold in moisture. Light mineral oil is as effective and more economical than commercial brands of lotions and oils. However, oils poured directly into a tub or shower increase the risk for falls. It is safer and more effective to apply the oil directly to the moist skin. Water-laden emulsions without perfumes or alcohol are best.

Pruritus

One of the consequences of xerosis is pruritus, that is, itchy skin. It is a symptom, not a diagnosis or disease, and is a threat to skin integrity because of the attempts to relieve it by scratching. It is aggravated by perfumed detergents, fabric softeners, heat, sudden temperature changes, pressure, sweating, restrictive clothing, fatigue, exercise, and anxiety. If rehydration of the stratum corneum is not sufficient to control itching, cool compresses, or oatmeal or Epsom salt baths may be helpful. Failure to control the itching increases the risk for eczema, excoriations, cracks in the skin, inflammation, and infection. Pruritus also may accompany systemic disorders such as chronic renal failure, biliary or hepatic disease, and iron deficiency anemia. The nurse should be alert to signs of infection.

Scabies

Scabies is a skin condition that causes intense itching, particularly at night. Scabies is caused by a tiny burrowing mite called Sarcoptes scabiei. Scabies is contagious and can spread quickly through close physical contact in a family, child care group, school class, or other close communal living facilities such as nursing homes. To diagnose scabies, a close skin examination is conducted to look for signs of mites, including their characteristic burrows. A scraping may be taken from an area of skin for microscopic examination to determine the presence of mites or their eggs.

Scabies treatment involves eliminating the infestation with prescribed lotions and creams (Elimite, Lindane). Treatment is usually provided to family members, caregivers, and other close contacts even if they show no signs of scabies infestation. Medication kills the mites but itching may not stop for several weeks. The oral medication ivermectin (Stromectol) may be prescribed for individuals with altered immune systems, for those with crusted scabies, or for those who do not respond to prescription lotions and creams. All clothes and linen used at least three times before treatment should be washed in hot, soapy water and dried with high heat.

Purpura

Thinning of the dermis leads to increased fragility of the dermal capillaries and to blood vessels rupturing easily with minimal trauma. Extravasation of the blood into the surrounding tissue, commonly seen on the dorsal forearm and hands, is called purpura. These are not related to a bleeding disorder, and individuals who are prone to purpura should be advised to protect the skin against trauma and friction. Health care personnel must be advised to be gentle when handling the skin of older patients because even minor trauma can cause purpura. Long-sleeved shirts reduce shear and friction, and protect the skin against trauma. If a skin tear occurs, use nonadherent dressings secured with tubular retention bandages.

Keratoses

Herpes zoster

Herpes zoster (HZ), or shingles, is a viral infection frequently seen in older adults. HZ is caused by reactivation of latent varicella-zoster virus (VZV) within the sensory neurons of the dorsal root ganglion decades after initial VZV infection is established. HZ occurs most commonly in adults over 50 years of age, those who have medical conditions that compromise the immune system, or people who receive immunosuppressive drugs. HZ always occurs along a nerve pathway, or dermatome. The more dermatomes involved, the more serious the infection, especially if it involves the head. When the eye is affected it is always a medical emergency. Most HZ occurs in the thoracic region but it can also occur in the trigeminal area and cervical, lumbar, and sacral areas. HZ vesicles never cross the midline.

The onset may be preceded by itching, tingling, or pain in the affected dermatome several days before the outbreak of the rash. It is important to differentiate HZ from herpes simplex. Herpes simplex does not occur in a dermatome pattern and is recurrent. During the healing process, clusters of papulovesicles develop along a nerve pathway. The lesions themselves eventually rupture, crust over, and resolve. Scarring may result, especially if scratching or poor hygiene leads to a secondary bacterial infection. HZ is infectious until it becomes crusty. HZ may be very painful and pruritic.

Prompt treatment with the oral antiviral agents acyclovir, valacyclovir, and famciclovir decreases the severity and duration of acute pain from zoster. Zoster vaccine (Zostavax) is recommended for all persons 60 years of age and over who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions. Before administration of the vaccine, patients do not need to be asked about their history of varicella or have serologic testing to determine varicella immunity.

Photo damage of the skin

Candidiasis (candida albicans)

The fungus Candida albicans (referred to as “yeast”) is present on the skin of healthy persons of any age. However, under certain circumstances and in the right environment, a fungal infection can develop. Persons who are obese, malnourished, receiving antibiotic or steroid therapy, or have diabetes are at increased risk. Candida grows especially well in areas that are moist, warm, and dark, such as in skinfolds, in the axilla and the groin, and under pendulous breasts. It can also be found in the corners of the mouth associated with the chronic moisture of angular cheilitis. In the vagina it is also called a “yeast infection.” If this is found in an older woman, it may mean that her diabetes either has not yet been diagnosed or is in poor control.

Inside the mouth a Candida infection is referred to as “thrush” and is associated with poor hygiene and immunocompromise, such as those with long-term steroid use, who are receiving chemotherapy, or who test positive for or are infected with human immunodeficiency virus (HIV) or have acquired immunodeficiency syndrome (AIDS). In the mouth, candidiasis appears as irregular, white, flat to slightly raised patches on an erythematous base that cannot be scraped off. The infection can extend down into the throat and cause swallowing to be painful. In severely immunocompromised persons the infection can extend down the entire gastrointestinal tract.

On the skin, Candida is usually maculopapular, glazed, and dark pink in persons with less pigmentation and grayish in persons with more pigmentation. If it is advanced, the central area may be completely red and/or dark, and weeping with characteristic bright red and/or dark satellite lesions (distinct lesions a short distance from the center). At this point the skin may be edematous, itching, and burning.

The best approach to managing fungal infections is to prevent them, and the key to prevention is limiting the conditions that encourage fungal growth. Prevention is prioritized for persons who are obese, bedridden, incontinent, or diaphoretic. Attention is given to the adequate drying of bodily target areas after bathing, the prompt management of incontinent episodes, the use of loose-fitting cotton clothing and underwear, the changing of clothing when damp, and the avoidance of incontinence products that are tight or have plastic that touches the skin.

One of the best ways to dry hard-to-reach, vulnerable areas is with a hair dryer set on low. A folded, dry washcloth or cotton sanitary pad can be placed under the breasts or between skinfolds to promote exposure to air and light. Cornstarch should never be used because it promotes the growth of Candida organisms. Optimizing nutrition and glycemic control is also important.

The goal of treatment is to eradicate the infection. This includes not only the use of prescribed antifungal medication, but also the active involvement of the nurse to reduce or eliminate the conditions that created the problem. The affected area of the skin must be cleansed carefully and dried thoroughly before antifungal preparations are applied. A mild soap or cleansing agent, such as Cetaphil, should be used. Antifungal preparations come as powders, creams, and lotions. Because the latter two trap moisture, the powder is recommended. They are usually needed for 7 to 14 days or until the infection is completely cleared.

Antifungal medications include miconazole (Micatin), clotrimazole (Lotrimin), nystatin (Mycostatin), and econazole (Spectazole). Treatment of oral Candida infection includes mouth swishing and swallowing with an antifungal suspension and/or sucking on antifungal troches. Angular cheilitis is treated by application of a topical antifungal ointment to the corners of the mouth. If the Candida cannot be eliminated in the usual course of therapy, it may be necessary to use ketoconazole or fluconazole systemically for a prescribed period.

Definition

The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) constitute an international collaboration convened to develop evidence-based recommendations to be used throughout the world to prevent and treat pressure-related wounds. According to this group, a pressure ulcer is “an injury to the skin and/or underlying tissue resulting from pressure or in combination with shear, usually over a bony prominence” (EPUAP & NPUAP, 2009). As tissue is compressed, blood is diverted and blood vessels are forcibly constricted by the persistent pressure on the skin and underlying structures; thus cellular respiration is impaired and cells die from ischemia and anoxia. Intervention at any point in this development can stop the advancement of the pressure ulcer.

Just how much pressure can be endured by tissue (tissue tolerance) is highly variable from body location to location and person to person. Tissue tolerance is inversely affected by moisture, amount of pressure, friction, shearing, and age and is directly related to malnutrition, anemia, and low arterial pressure.

Prevalence

Cost and regulatory requirements

Characteristics

Pressure ulcers can develop anywhere on the body but are seen most frequently on the posterior aspects, especially the sacrum, the heels, and the greater trochanters. Secondary areas of breakdown include the lateral condyles of the knees and the ankles. The pinna of the ears is another area subject to breakdown, as are the elbows and the scapulae. Heels are particularly prone to the development of pressure ulcers because they are small surfaces that receive a high degree of pressure. Older adults with diabetes are prone to the development of foot ulcers and are at higher risk of earlier death compared to those without diabetes (Brownrigg et al., 2012). Attention to foot care is essential when caring for an older adult with diabetes. More information on diabetes can be found in Chapter 17, and a discussion of foot care is included later in this chapter.

Classification