Hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings New
Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence.Objectives
To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.Search methods
We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers.Selection criteria
Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings.Data collection and analysis
We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence.Main results
We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave‐on body lotion; bed bath with “wash gloves” containing numerous ingredients; and application of a hot towel after usual care bed bath.
In five studies, treatment duration ranged from five days to six months; only one study had post‐treatment follow‐up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel.
Three studies each had high risk of attrition, detection, and performance bias.
Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice‐daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed‐days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin‐moisturising regimen) (P = 0.004), but this is based on very low‐quality evidence, so we are uncertain of this result.
Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave‐on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water‐in‐oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low‐quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid‐volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low.
One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low‐quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable.
Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow‐up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low.
Outcomes of erythema and clinical score of itch were not assessed in any included studies.Authors' conclusions
Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low‐quality evidence.
Low‐quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care.
Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient‐reported outcomes, such as comfort and acceptability.
Fiona Cowdell, Yuri T Jadotte, Steven J Ersser, Simon Danby, Sandra Lawton, Amanda Roberts, Judith Dyson
Plain language summary
What effects do washing and moisturising practices have on the skin health of older people in hospital and residential care settings?
We reviewed evidence about the effects of different washing practices and emollients (moisturisers) when compared with usual care or no treatment on maintaining healthy skin in people aged 60 years or older in hospitals or care homes.
With age, skin becomes drier; this may lead to discomfort, itching, and skin damage. Good hygiene and moisturising practice supports healthy skin ageing. However, research is limited, and current care is largely based on custom and practice.
We included six studies (1598 participants), all completed in care homes. When reported, most participants were female and aged 80 years or older.
Two studies included only people with diagnosed dry skin. Studies compared usual care or no treatment against differing cleansing and moisturising skin care regimens (a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave‐on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath). Length of treatment ranged from a single application for 10 seconds to six months of twice‐daily moisturiser use. Only one study assessed participants post treatment (one to eight days post treatment), and participants in the hot towel study were measured 15 minutes after their skin was wiped with a dry towel. When reported, four studies had received external funding, in two cases from commercial sponsors.
The evidence is current to January 2019.
Our main outcomes were skin damage and treatment side effects. Only one study reported frequency of skin damage (skin tears), finding fewer tears per month (5.76 per 1000 occupied bed‐days) with usual care plus twice‐daily application of a commercially available, pH‐neutral moisturising lotion (for six months) compared with usual care (i.e. no standardised skin‐moisturising routine) (10.57 tears). However, this is based on very low‐quality evidence, so we are uncertain about this result.
Only one study measured side effects of treatments, comparing care as usual (i.e. usual personal hygiene and care products) against the use of two different types of moisturising body wash plus body lotion (application was twice daily for eight weeks) in two groups of participants. Four side effects were reported in the treatment group (assessment occurred approximately 56 days after treatment started): itch (mild), redness (mild/moderate), irritation (severe), and mild skin dryness. No side effects were reported in the care‐as‐usual group. However, this finding is based on very low‐quality evidence, meaning that we are uncertain about this result.
The same study assessed water loss from the skin of the forearm and lower leg and found there may be no difference between usual care and treatment. A different study compared a hot towel applied for 10 seconds after a usual care bed bath versus usual care bed bath only, finding there may be little or no difference in water loss between groups. Both studies are based on low‐quality evidence.
Three studies, which assessed different skin care regimens for eight weeks; use of wash gloves for 12 weeks; and single application of a hot towel, showed no clear difference in hydration of the stratum corneum (the outermost layer of the skin) when compared with usual care. However, evidence quality was very low, so we are uncertain of this result.
Three studies measured skin dryness and there may be improvement with the following treatments compared to standard care or no intervention: different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days (all low‐quality evidence).
No included studies assessed skin redness and clinical score of itch.
Quality of the evidence
Evidence quality for outcomes of skin damage, side effects, and moisture in the outermost skin layer was very low. For remaining measured outcomes (i.e. water loss from the skin and skin dryness), evidence quality was low. We had concerns about how the studies were designed and undertaken, and about this review's small numbers of studies and participants.
Fiona Cowdell, Yuri T Jadotte, Steven J Ersser, Simon Danby, Sandra Lawton, Amanda Roberts, Judith Dyson
Implications for practice
This review collates evidence from six trials. Given the ageing population (United Nations 2017), increasing recognition of the importance of maintaining skin health in older people, and the fact that maintaining skin hygiene and comfort is one of the cornerstones of care provided in residential and hospital settings (Cowdell 2015), it is surprising that there is not more evidence to underpin best practice.
We do not have sufficient evidence to determine the effects of hygiene and emollients in maintaining skin integrity among older people in residential and hospital settings. Reporting of harm from these interventions was poor. Only one study reported side effects: four instances (mild itch, mild to moderate redness, mild skin dryness, and severe irritation) were reported across two intervention groups.
We are not certain of the effects of the assessed interventions on frequency of skin damage, side effects, and stratum corneum hydration (SCH) due to the very low quality of the evidence provided for these outcomes.
In residential care settings for older people, we found low‐quality evidence for the following interventions and outcomes.
- When compared with usual care (continuing with usual personal hygiene and care products), washing using moisturising cleansers containing ingredients that have emollient or humectant properties, or both, alongside the use of moisturising body lotion, may improve skin dryness on certain parts of the body but may make no apparent difference in transepidermal water loss (TEWL).
- Mean TEWL may be similar when a hot towel is applied to the body area for 10 seconds after a usual care bed bath and when a usual care bed bath alone is provided.
- A moisturising soap bar with an added emulsifier and humectant may improve skin dryness compared with a soap bar without these added ingredients.
- Lotion alone or water soak or oil soak (with or without the addition of lotion) may improve skin dryness when compared with usual care no treatment.
The following outcomes were not assessed by any of the included studies: erythema and clinical score of itch.
Firm conclusions cannot be drawn from the included studies due to methodological weaknesses and absence of information on effect sizes and precision in the study reports.
Implications for research
A small number of studies met our inclusion criteria, and these all had some methodological weakness. There is therefore a significant opportunity to improve research design to evaluate the effectiveness of hygiene and emollient interventions for maintaining or improving skin integrity among older people in residential care and hospital settings.
Future randomised controlled studies should focus on pragmatically deliverable interventions such as use of disposable bed bath/wet wipes, which obviate the need to towel‐dry skin, and use of differing emollient formulations such as gels and aerosols. The study awaiting classification ‐ NCT02984527 ‐ is assessing the effects of intimate hygiene with soap and water versus intimate hygiene with pre‐packaged disposable bed bath/wet wipes in a randomised cross‐over trial.
There is a need to agree upon and use a set of core outcome measures, so that in the future, meta‐analysis of studies will be possible. Vital outcomes including clinical measures of skin integrity (skin dryness, erythema, and skin tears, for example) and objective measures of skin barrier function, namely, stratum corneum hydration and transepidermal water loss, are now available, accompanied by clear guidelines for using these instruments in real‐world settings (du Plessis 2013). Self‐reported scores of itch should be measured and side effects must be assessed in all future studies.
Research is needed on the effects of hygiene and emollient interventions among persons of different ethnicities and skin types, including participants in a variety of settings (e.g. countries with different climates and hospital settings, as well as residential settings).
Future studies should be designed more robustly. In particular, researchers must use and accurately report adequate methods of random allocation, allocation concealment, and methods to ensure blinding. It is important that these studies include appropriate controls (i.e. standard care) and report sufficient information related to the precision of group difference estimates (e.g. standard deviation). Because attrition bias was high, future studies should try to minimise the number of dropouts and report reasons for dropouts. Many of the included studies had a small sample size, resulting in imprecise results. Further studies should ensure that researchers perform sample size calculations to adequately detect important differences between groups.
Such studies should develop a standardised language of skin care and skin care products that can be used when clinical research is planned and undertaken. In addition, we suggest the need for common definitions of terms such as 'skin damage' and 'skin breakdown', which are frequently seen in publications. This will support the development of evidence‐based guidelines for providing skin care to our ageing population (Kottner 2016).
In conclusion, there is much scope to undertake intervention studies to evaluate skin hygiene and emollient regimens with the potential to maintain and promote skin health among older people living in residential and hospital settings.Get full text at The Cochrane Library
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