In long-term care (LTC) facilities, treatment of skin tears often takes a lot of nursing time, is costly and can negatively impact on the quality of life of residents. While skin tears may not be life-threatening, they are a painful injury that can also be disfiguring (Fleck, 2007). Skin tears can sometimes become infected, which can cause more suffering to the residents (Rayner et al, 2015). There is a general interest towards reducing skin tears, but often, what is seen as a reasonable action—for example the use of moisturisers—may not be supported by an evidence-base. There is an ongoing demand for LTC providers to practice using evidence-based guidelines to improve delivery of the quality of care.
Ageing is associated with structural and functional changes of the skin that result in increased vulnerability (Kottner et al, 2013). A healthy skin provides the primary protection for the body against external injuries and is essential in the maintenance of general homeostasis (Bonté et al, 2019). Thinning, reduced elasticity and other age-related changes of the dermis and epidermis (chronological ageing), as well as sun damage (photoaging), change the skin's ability to resist damage and injury, such as a skin tear (Koyano et al, 2016; Bonifant and Holloway, 2019).
Skin tears are the most common wounds in older adults. LeBlanc et al (2013) found skin tears most commonly occur in upper extremities (60%) and legs (40%). Skin tears may increase the length of hospitalisation (particularly if related to lower extremities and involving underlying pathology), increase healthcare costs and impact on quality of life (Carville et al, 2007; Clothier, 2014; LeBlanc et al, 2014; Rayner et al, 2015).
The most recent definition of skin tear from the International Skin Tears Advisory Panel (ISTAP) is: ‘A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. Severity may vary by depth (not extending through the subcutaneous layer’ (LeBlanc et al, 2018).
Prevalence of skin tears in LTC facilities is not known, but it has been estimated to vary between 10 and 54% (Everett and Powell, 1998; Carville and Smith, 2004; McErlean et al, 2004; Woo and LeBlanc, 2018).
Emollient products are available as moisturisers (creams, ointments and lotions), bath oils, gels and soap substitutes (National Institute for Health and Care Excellence (NICE), 2015). Simple emollients work by ‘trapping’ moisture into the skin and reducing water loss by evaporation, whereas emollients that include additional substances known as humectants (e.g. urea) work in a different way by actively drawing water from the dermis to the epidermis and compensating for the reduced levels of natural moisturisers in the skin (Wounds UK, 2015).
Aims
This review investigated whether moisturising with a lotion was beneficial for skin tear prevention in older adults residing in LTC facilities. The results may guide LTC facilities to adopt an evidence-based approach for reduction of skin tear risk in older adults.
Methods
A literature review was conducted on available evidence on moisturiser use for the prevention of skin tears in older adults over the age of 65 years. Search terms included: moisturiser, cream, ointment, lotion, skin tear/s, skin tear prevention, older adult/s, elderly, aged care, long-term care and nursing home. Studies investigating only moisturising soaps, body washes and other similar products were excluded, as were studies that only investigated the effects of moisturisers on skin dryness.
A systematic search using Boolean operators for publications using PubMed, CINAHL, SCOPUS, Cochrane and EMBASE databases was conducted in January 2023.
Findings
An initial search for studies resulted in 1860 articles, However, upon closer examination three studies (Bank and Nix, 2006; Carville et al, 2014; Finch et al, 2018) met the pre-defined inclusion criteria on moisturiser use for the prevention of skin tears in older adults over the age of 65 years in long-term care facilities. The patient, intervention, comparison, outcome and time (PICOT) criteria (Richardson et al, 1995) was used to extract relevant information from these three studies (Table 1). Table 1 lists the characteristics of the three included studies using this evidence-based approach.
Table 1. Characteristics of included studies
| Authors | Population | Intervention | Comparison | Outcome | Time | Findings |
|---|---|---|---|---|---|---|
| Bank and Nix (2006) | A total of 209 bed urban nursing and rehabilitation home (USA) | The preventive skin care strategies: staff education, skin sleeves and padded side rails for high-risk patients, gentle skin cleansers, and lotion | Pre-intervention vs post-intervention | Effect on skin tear rates | 13 months pre-intervention, 15 months post intervention | Following implementation of the prevention protocols, the number of skin tears changed from a mean of 18.7 to a mean of 8.73 per month (p <0.001) |
| Carville et al (2014) | Aged care residents in 14 Western Australian facilities (980 beds)Half of the facilities were randomly selected as an intervention group | Twice daily moisturising regimen (with commercially available, standardised pH neutral, perfume free moisturiser) | Compared with ‘usual’ (ad hoc) skincare. Half of the facilities were randomly selected as a control group | Effect on skin tear rates | 6 months | A total of 1396 skin tears on 424 residents were recorded during the study. In the intervention group, the average monthly incidence rate was 5·76 per 1000 occupied bed days as compared to 10·57 in the control group. The application of moisturiser twice daily reduced the incidence of skin tears by almost 50% in residents living in aged care facilities |
| Finch et al (2018) | 762 private hospital residents (>65) in Brisbane | Twice-daily moisturising regimen (with commercially available, pH neutral, perfume free moisturiser) | Compared with no intervention in 415 patients in the historical control group | Incidence of skin tears (average monthly rates) | 12 months | In total, 104 patients developed at least one skin tear (intervention group: n=60; the control group: n=44). An overall 185 skin tears were reported (mean=1.79 skin tears/patients; standard deviation=1.55, range=19). The average monthly incidence rate in the intervention group was 4.35 per 1000 occupied bed days (96 skin tears over 12 months), which was significantly lower (p=0.006) than those found in the historical control group of 6.61 per 1000 occupied bed days (89 skin tears over 6 months). The results indicate the efficacy of twice-daily application of moisturiser when applied to the extremities of elderly patients for the prevention of skin tears |
A total of two studies were conducted in Australia and one in the US. The studies were conducted between 2003–2018 and the patient population varied from 209–980 residents in LTC facilities. A twice-daily moisturising regimen with commercially available, pH neutral, perfume free moisturiser was used in all studies. In the Bank and Nix (2006) study, multi-disciplinary team were involved in planning the study. The interventions also included one-week in-service education for staff prior to study start, as well as application of skin sleeves and padded side rails for high-risk patients. In all three studies, comparisons were made between the intervention group (moisturiser) and the control group with no intervention or ‘ad hoc’ moisturiser users. All studies collected data on rates of skin tears.
Finch et al (2018) compared 762 residents in the intervention group versus no intervention in 415 residents of the historical control group. In total, 104 patients developed at least one skin tear (intervention group: n=60; the control group: n=44). Overall, 185 skin tears were reported (mean=1.79 skin tears/patients; standard deviation (SD)=1.55; range=19). The average monthly incidence rate in the intervention group was 4.35 per 1000 occupied bed days (96 skin tears over 12 months), which was significantly lower (p=0.006) than those found in the historical control group of 6.61 per 1000 occupied bed days (89 skin tears over 6 months). These results indicate the efficacy of twice-daily application of moisturiser when applied to the extremities of elderly patients for the prevention of skin tears.
Carville et al (2014) randomly divided 14 facilities’ (n=980) residents into two groups—one with intervention using twice-daily moisturiser and another with the usual skincare. A total of 1396 skin tears on 424 residents were recorded during the study lasting 6 months. In the intervention group, the average monthly incidence rate was 5.76 per 1000 occupied bed days as compared to 10.57 in the control group. The application of moisturiser twice daily reduced the incidence of skin tears by almost 50% in residents living in LTC facilities.
The US study by Bank and Nix (2006) compared the skin tear rates of 209 bed urban nursing and rehabilitation home residents before and after the implementation of interventions. This study compared 13 months of pre-intervention rates with 15 months of post-intervention rates. Following implementation of the prevention protocols, the number of skin tears changed from a mean of 18.7 per month to a mean of 8.73 per month (p<0.001).
A systematic review by Le Blanc et al (2016) reported that the results from some of the studies (Bank and Nix, 2006; Carville et al, 2014) could have sampling, as well as methodological issues and therefore, should not be generalised. This included participant selection and reporting of outcome measures (Carville et al, 2014), and it was also unclear what defined ‘regular skin care’ compared to the intervention group (Bank and Nix, 2006).
Discussion
Only three original studies were available that involved older adults (>65yrs) on the use of moisturisers in LTC facilities and its impact on skin tears. Included studies recommend moisturisers that are pH neutral, contain a non-irritating humectant (e.g. glycerine) and an occlusive agent (e.g. paraffin or plant oil). Furthermore, the evidence suggests that moisturiser should be used minimum twice daily to achieve 50% reduction in skin tears.
The included studies contained some issues regarding attrition, performance, and detection bias. As other methods were also used to prevent skin tears in the included studies, such as skin sleeves and padded side rails (Bank and Nix, 2006), it is unclear how these interventions may have reduced the risk of skin tears with moisturising.
It is apparent that more standardised clinical trials would be beneficial in determining the effectiveness of moisturisers for skin tear prevention. There was also limited information available on how the residents themselves perceived the interventions. Therefore, future studies should include resident-centred outcome measures.
Conclusion
There are only a few studies available that have examined how effective the use of moisturiser is in reducing skin tears in older adults. However, evidence from all three studies included in this review (Bank and Nix, 2006; Carville et al, 2014; Finch et al, 2018) suggests certain types of emollients are more effective in reducing skin tears compared to no intervention or standard care in LTC facilities. Available studies found that the use of topical preparations significantly reduced the incidence of skin tears in older people by at least 50% when applied on skin twice daily. Based on the results, routine skin moisturising is recommended as one component of a skin tear prevention programme for older adults residing in LTC facilities. LTC facilities should include twice-daily moisturising as part of their daily care plan for residents to help minimise risk of skin tears.
There should also be education for healthcare staff and the residents about the benefits of moisturiser use in aged care. Previous studies have shown that staff education regarding skin tear assessment, prevention and management can dramatically reduce risk (Lopez et al, 2011).
Given the paucity of published studies, more research is needed to investigate the benefits of daily moisturiser use in LTC facilities. Randomised controlled trial design may be preferred due to possible confounders such as age, genetics, nutrition, trauma and other protective measures affecting skin integrity. The use of specific machines that measure skin integrity may also be useful to confirm objective benefit (Koyano et al, 2016). Future studies should also include qualitative measures from both residents and staff on daily moisturiser use. These could include quality of life measures as well as staffs' perception of benefits. Hunter et al (2003) showed that skin protectants may also decrease skin breakdown (including pressure injuries). Therefore, any future studies may also need to consider including use of skin protectants in LTC facilities.
Evidence from this clinical review has shown a clear benefit of using moisturisers by significantly reducing skin tears in residents living in LTC facilities. Use of moisturisers should thereby be included in the care plan for all residents to help minimise risk of skin tears.
Key points
- Clinical practice should be guided by evidence where possible
- Skin tears are not only painful and disfiguring but also consumes a lot of nursing time
- Use of moisturisers twice daily can reduce skin tears by 50%.
CPD reflective questions
- Why is it important to try to reduce skin tears in older adults?
- What type of moisturisers do all available studies recommend?
- Based on current knowledge, how effective is moisturiser use in prevention of skin tears in older adults?
- What were the issues/what issues could be expected when studying moisturiser effectiveness in aged care facilities?