Skin ageing is a result of intrinsic factors, particularly a gradual decrease in the levels of oestrogen and progesterone, as well as extrinsic factors, principally ultraviolet (UV) irradiation that leads to photoaging (Papakonstantinou et al, 2012). Changes related to intrinsic aging are largely unpreventable as they are innate changes that result in structural and functional changes in the epidermis and dermis that places skin at increased risk of damage (Farage et al, 2013).
Effects of ageing on the epidermis
In relation to changes that occur within the epidermis, proliferation of keratinocytes reduces leading to a slower rate of epidermal turnover (Farage et al, 2013). The main role of keratinocytes is to produce new epidermis therefore a reduction in the number of these cells leads to thinning of the epidermis (Nigam and Knight, 2017). Simultaneously, epithelial extensions, known as rete ridges (or pegs), that help to anchor the epidermis to the dermis below flatten out (Parrish, 2017). Flattening of these ridges gives skin the typical wrinkled appearance associated with older individuals (Farage, 2013) (Figure 1).
Figure 1. Skin tear also showing wrinkles associated with older age
At the same time, there is a reduction in the levels of hyaluronic acid (HA) in the ground substance of the dermis (Ghersetich et al, 1994). HA facilitates moisture retention in the tissues, acting as a store to hydrate the skin as well as providing a filling substance to strengthen the skin; in addition, it facilitates the attachment of the epidermis to the dermis (Papakonstantinou et al, 2012). The consequences of rete ridge flattening and reduced levels of HA mean that the epidermis and dermis are more at risk of shearing against each other, increasing the risk of injuries such as skin tears, due to loss of protective cushioning provided by HA (Campbell et al, 2018) (Figure 1). In addition to the risk of skin tears, skin stripping and tension injuries/blisters can occur (McNichol and Bianchi, 2016). This triad of categories is referred to as medical adhesive-related skin injury (MARSI) (McNicol et al, 2013).
The epidermis acts a barrier and provides protection against invasion from micro-organisms (Flanagan, 2013). Within the epidermis Langerhans cells have an immune function protecting an individual from microbial invasion; however, with age the number of these cells reduces by approximately 50%, putting an individual at increased risk of infection from even small breaks in the skin (Fore, 2006). In addition, other co-morbidities such as diabetes can lead to peripheral neuropathy, increasing the risk of injury due to loss of protective pain and heat sensation (Wickremaratchi and Llewelyn, 2006). Use of topical steroids can also lead to thinning of the skin placing the individual at greater risk of tissue damage (Barnes et al, 2015).
Effects of ageing in the dermis
Within the dermis, there are cellular and functional changes that occur with age, for example there is a decrease in the number of fibroblasts. The main role of fibroblasts is to produce collagen, which is the most abundant protein that gives the skin its' structure and strength. With age collagen becomes denser and straighter, reducing the elasticity of the tissues, and making it less resilient to damage (Haydont et al, 2019).
Ageing also leads to an increase in proteinase activity in the dermis. In wound healing, proteinases, such as matrix metalloproteinases (MMPs), are responsible for the production and breakdown of damaged tissue, as well as facilitating blood vessel formation and migration of epidermal cells (Gibson et al, 2009). Increased levels of MMPs leads to granulation tissue being broken down quicker than it can be synthesised, as well as changes to the microcirculation and slower epithelialisation meaning that the process of wound healing is slower in older individuals (Wicke et al, 2009).
Sebaceous glands within the dermis produce sebum, which is the skin's natural moisturiser. The production of sebum decreases with older age, particularly after the menopause in women and after the age of 80 in men (Zouboulis and Boschnakow, 2001). Reduced levels of sebum leads to the skin drying out and becoming itchy which increases the risk of scratching and therefore minor trauma (Figure 2).
Figure 2. Dry skin associated with ageing
The combined effects of ageing on the epidermis and dermis are challenging to manage in clinical practice as many of the changes are intrinsic or innate, which means they are largely irreversible. However, with early recognition of skin changes associated with ageing and appropriate treatment, particularly of the periwound area, it may be possible to reduce the impact of the changes. Prevention is of vital importance, therefore awareness of these changes should aid the implementation of prevention strategies.
Common periwound issues
The periwound area is defined as skin within 4 cm of the wound edge, as well as any skin under a dressing (Dowsett et al, 2015a). Problems associated with the periwound area are relatively common and can lead to delays in wound healing (Bianchi, 2012). A survey by Cartier et al (2014) identified that 60−70% of patients (n=958) had unhealthy periwound skin. Complications of periwound issues include pain and discomfort, which can affect the patient's quality of life (Lawton and Langøen, 2009), as well as potentially triggering enlargement of a wound (Dowsett et al, 2015b). The most common peri-wound problems are summarised in Table 1.
Table 1. Common periwound problems
| Dowsett et al (2015a) | McNichol and Bianchi (2016) |
|---|---|
| Maceration | Skin stripping: mechanical adhesive related skin injury (MARSI) |
| Excoriation | |
| Dry skin | |
| Hyperkeratosis | |
| Callus | |
| Contact dermatitis | |
| Eczema |
Common periwound problems: definitions
Maceration
Maceration is a type of moisture associated skin damage (MASD) sometimes referred to as periwound moisture-associated dermatitis (Gray et al, 2011). Maceration is caused by an excess of moisture, which in wounds is often related to excessive levels of exudate or inadequate moisture vapour transmission rates of dressings (Rodgers and Watret, 2003). The tissue will appear as white in colour and ‘soggy’, and may be visible at the wound edge initially but can quickly extend to the periwound area if uncontrolled (Figure 3). Excessive exudate has a detrimental effect on the skin barrier function, reducing its effectiveness and placing it at risk of breakdown. Macerated tissue is also associated with an increased chance of contact dermatitis (Cameron, 2004).
Figure 3. Shows maceration of the wound edge and surrounding tissue
Excoriation
Excoriation in relation to wounds refers to a situation where the upper layers of the epidermis are stripped away by prolonged exposure to MMPs present in wound exudate (Dowsett et al, 2015a).
Dry skin
Dry skin presents as dry, scaling and flaky tissue that can become itchy and crack, predisposing an individual to infection if bacteria enter the break in the skin integrity (Nigam and Knight, 2017).
Hyperkeratosis
Hyperkeratosis is characterised by increased thickening of the stratum corneum (the outer layer of the epidermis). Hyperkeratosis is associated with an over-production of keratinocytes, which are responsible for producing keratin (International Lymphoedema Framework, 2012). This results in thickening of the epidermis and dermis (Jakeman, 2012), which presents as thick scaly skin (European Wound Management Association, 2005) (Figure 4).
Figure 4. Hyperkeratosis associated with lower limb venous disease
Callus
Callus refers to thickened and hardened skin particularly in an area that has been subjected to friction forces. It is most often associated with neuropathic diabetic foot ulcers (Arosi et al, 2016) and can be present at the wound edge as well as the surrounding tissue (Figure 5).
Figure 5. Callus in a diabetic foot ulcer
Contact dermatitis
Contact dermatitis is associated with a reaction to a substance, which could be a topical cream/ointment or a dressing/bandage (Alavi et al, 2016), leading to the skin becoming dry and itchy. The tissue can also blister and crack. Contact dermatitis is sometimes considered under the umbrella term of eczema, but unlike eczema will usually resolve once the irritant has been removed/discontinued. Irritant dermatitis can also be a consequence of incontinence-associated dermatitis (IAD) from faeces or urine (Ousey and O'Connor, 2017).
Eczema/gravitational eczema
Eczema causes the skin to become red, itchy and inflamed (Figure 6). When this occurs on the lower limb and is associated with chronic venous insufficiency, it is referred to as gravitational (venous) eczema (Patel et al, 2001).
Figure 6. Eczema
Skin stripping
Skin stripping can occur when adhesive dressings and tapes are removed, leading to removal of the upper layers of the epidermis. This type of damage is one type of MARSI (McNichol and Bianchi, 2016).
Management of periwound issues
Interventions to manage the periwound area should be based on an accurate diagnosis and assessment (Dowsett and Allen, 2013) and should include:
- Treat underlying cause
- Implement a structured skin care regimen
- Base dressing selection according to exudate volume and wound bed preparation
- Moisturise and protect using emollient and or skin barrier products
- Involve patient in decision-making process.
Maceration
The management of maceration is primarily associated with the management of exudate. In normal wound healing, exudate is produced as part of the inflammatory process. Factors that can increase the volume of exudate include the size of the wound, presence of sloughy tissue which can perpetuate the inflammatory reaction, as well as bacterial infection. Increased levels of exudate can also be associated with dependency of the leg, usually related to the presence of a venous leg ulcer, where the higher levels of exudate are usually an indication that the patient is not elevating their limbs sufficiently. In turn, an increased level of moisture is a risk factor for wound infection (International Wound Infection Institute, 2016).
Therefore, it is paramount that the choice of primary dressing should facilitate adequate management of excess exudate to maintain a balance of moisture (Table 2). Dressing selection should be based on the following factors:
- Availability on local formulary
- Able to manage exudate without strike through
- Comfortability to the wound bed
- Ease of use
- Cost-effective
- Suitability for use under compression
- Will dressing require secondary fixation.
Table 2. Dressings and exudate management
| Type of dressing | Exudate level | Mode of action | Considerations for use |
|---|---|---|---|
| Foams | Low-medium exudate | Uses capillary action to draw up fluid |
|
| HydrofiberAlginates | Low-medium exudate | Absorb exudate to form a gel |
|
| Super-absorbents | Medium-high exudate | Absorb and trap bacteria in the dressing |
|
Excoriation
Excoriation, in relation to wounds, is often associated with maceration (Beldon, 2016). The patient may describe an itching or burning association associated with this. The presence of dry skin or eczema can lead to further irritation causing the patient to scratch the affected area. Excoriation can also be associated with skin-stripping as a consequence of dressing removal. Therefore, management of excoriation should follow the guidance for controlling dry skin and avoidance of MARSI (Dowsett et al, 2015a). The use of barrier creams and films, such as Cavilon™ (3M) Medi Derma-S Barrier Cream/film(Medicareplus); LBF® Barrier Cream/film (CliniMed), can be considered to help maintain moisture and reduce the risk of irritants entering the skin (Bianchi and Hardy, 2012).
Some key considerations include:
- Avoid acrylic-based adhesive tapes and dressings
- If there is likely to be oedema or distension consider a product that will stretch to accommodate the oedema
- Consider silicone adhesives as an alternative in high-risk patients with fragile skin.
Dry skin
Dry skin is fragile skin that requires moisturisation in order to reduce the risk of further skin breakdown (Moncrieff et al, 2013). The use of emollients will assist in restoring barrier function and protect against further skin damage (Montcrieff et al, 2013). There are many different emollients available and each product may vary both in ingredients and moisture reliving properties (Moncrieff et al, 2013). Selection of the correct product will depend on patient preference and availability on local formulary. Petroleum-based ointments and creams provide an occlusive layer and increase skin hydration. However, practitioners should be mindful that paraffin is a flammable substance and therefore should be used with caution should a patient be a smoker. Products containing sodium laryl sulfate such as aqueous cream should be avoided as this can act as a skin irritant (Danby et al, 2011). Ensuring the patient is well-hydrated will also help to maintain healthy skin.
Contact dermatitis and eczema
Allergic contact dermatitis can occur as a reaction for a number of reasons, but products such as dressings, creams or lotions are a common cause. It is characterised by redness and a rash, or in the case of a dressing it could be a well-demarcated area of red skin (that mirrors the shape of the dressing). It is therefore important to remove the source of the allergic reaction (Ewart, 2015). Management of contact dermatitis follows the same guidance for dry skin.
Eczema can present as a wet or dry condition and is generally associated with venous ulcers (Patel et al, 2001). Wet eczema usually requires the use of a topical corticosteroid once or twice daily for a number of weeks. Dry eczema typically requires the use of emollients and moisturisers to keep the skin clean and dry (Patel et al, 2001).
Both allergic contact dermatitis and eczema are sometimes confused with cellulitis because they all lead to erythema/redness (Beasley, 2011). Therefore, it is important to differentiate between the presentations to ensure appropriate management (Salmon, 2015). Cellulitis is associated with warmth, pain and tenderness, with spreading redness in the tissues that usually requires systemic antibiotics. Lipodermatosclerosis (LDS) refers to changes in the skin of the lower legs. LDS is usually associated with venous disease and occurs bilaterally (Newton, 2010). LDS is often mistaken for cellulitis,; however, generally, cellulitis is confined to one leg only (Wingfield, 2009).
Practitioners should also be aware of the potential presence of MASD, particularly IAD, and ensure that vulnerable skin is assessed and treated appropriately (Browning et al, 2018).
Hyperkeratosis
Hyperkeratosis describes thickened, scaly skin (All Wales Tissue Viability Nurse Forum, 2014). It is often associated with venous disease and can be a consequence of venous eczema, which is a term used to describe the presence of eczema on the lower limb (Nazarko, 2016). Careful skin hygiene including moisturisation can help to prevent the condition. Where hyperkeratotic skin scales are present, emollients can also help to soften the tissue prior to gentle washing. Monofilament debridement pads are also available and are recommended by the National Institute for Health and Care Excellence (2014). The emollient should be removed prior to the use of the pad. Topical preparations of salicylic acid (3% or 6%) can be used (in the absence of diabetes) to soften the thickened skin. Other methods recommended for removing hyperkeratosis include debridement cloths containing a surfactant or monofilament debridement pads (Atkin et al, 2019).
Callus
The presence of callus tissue at the wound edge can delay wound healing. Callus is typically associated with neuropathic diabetic foot ulcers and requires careful sharp debridement with a scalpel by a competent practitioner. A scope of practice for podiatrists in relation to debridement of the diabetic foot has been developed (Chadwick et al, 2014). It is important that practitioners understand their own level of competency when making a decision on whether callus debridement is required.
Skin stripping
The selection of the appropriate dressing is key, as is ensuring careful application and removal to avoid the risk of skin stripping. Careful consideration should be given to the risk factors associated with MARSI, particularly older age, as well as any of the dermatologic conditions discussed in the previous section. The use of skin barriers (wipes, foams or sprays) can help to minimise the risk of skin stripping when a product with a medical adhesive is being used (McNichol and Bianchi, 2016). Additional considerations include:
- Consider using a medical adhesive remover
- Remove dressing/tape gently and slowly, keeping a low profile with the wound
- Remove in direction of the hair growth
- Observe skin for damage at each dressing change/adhesive removal.
It is vitally important to evaluate the effect of any treatment intervention to identify signs of both improvement but also deterioration. If symptoms are not improving, practitioners must consider a referral to an appropriate specialist team for advice.
Conclusion
Skin changes associated with intrinsic (innate) ageing are irreversible and include structural and functional alterations in the epidermis and dermis. Changes include flattening of the junction between the epidermis and dermis, reduced production of cells that are responsible for new epidermis, as well as decreased levels of substances that moisture the skin and ensuring its integrity. In an older individual with a wound, careful management of the periwound area is required in order to optimise wound healing and prevent deterioration, or in some cases enlargement, of the wound.
Of particular importance is management of excess exudate, debridement of callus and hyperkeratinised skin, choosing the most appropriate dressings and also products that may lead to contact dermatitis. Furthermore management of dry skin is important to improve skins' resilience, as is treatment of inflammatory conditions such as eczema. Importantly, the management of an individual needs to take into account their underlying history, co-morbidities and preferences to ensure they are at the centre of clinical decisions.
KEY POINTS:
- Skin changes are a natural consequence of intrinsic/innate ageing
- Skin changes associated with ageing often present with common features such as thin, dry, flaky, itchy and irritated skin as well as thickened and macerated tissue
- Differential diagnosis of the presenting periwound condition(s) is vital to ensure appropriate management
CPD reflective practice:
- What are the main effects of ageing on the epidermis and dermis?
- What are the most common periwound complications associated with ageing?
- What are the key principles of skin management that could help to reduce the risk of periwound complications?
- Reflecting on your practice, how will this article change how you approach periwound skin care?