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Pearls for Practice: Moisturization and Lubrication: A Proven Remedy for Dry, Scaly, Flaky Skin
The process of aging results in drier, thinner skin that has less natural moisturization and is prone to injury.1 Edema fluid inactivates oleic and linoleic acid in the skin, making it susceptible to streptococcal invasion and cellulitis.2 Epithelialization that closes full-thickness ulcers lacks dermis and dermal appendages such as sebaceous and eccrine glands.3 Diabetes mellitus causes dermopathy and micro-angiopathy that leads to less pliant and scaly skin.4 The dermal tissue in the pretibial area is not well vascularized and is difficult to heal, especially in the elderly patient.5 Each of these factors, or any combination of them, can result in dry, scaly, flaky skin. Such skin results in pruritus. Rubbing or scratching the pruritic dry skin can result in irritation and a secondary superficial infection. Depending on the degree of scabs, debris, and scales, a vigorous program is required to cleanse the area and get to the enveloping epithelial layer. Once that is achieved, a program to maintain the area in optimal condition is required. Although the scenarios mentioned can occur on any part of the body, the lower extremities are most commonly affected. They are more prone to edema, especially when impaired venous and/or lymphatic drainage is present. Also, the legs and feet may be the most difficult for the patient to care for. In the patient with diabetes mellitus, impaired vision may further impede the patient from performing proper skin care.
For the past 13 years, the clinicians at our wound clinic have utilized a skin care program including prevention, education, and compliance with skin hygiene to address the problems presented by the patient with dry, scaly, flaky skin. Moisturization and lubrication of the damaged skin are key components to achieving healing and maintaining skin long-term. We have used a concentrated melting moisturizing cream (Elta Crème Moisturizer, SteadMed Medical LLC, Fort Worth, TX) to moisturize, lubricate, and heal skin. We have reported this cream facilitates the removal of callous formations, scabs, other wound product residue, and dry flaky skin without causing tissue trauma so the skin surface can be properly visualized and assessed.6,7 In addition, the petrolatum and paraffin in the product provides lubrication to the skin. This is especially important if the patient is required to wear compression stockings. Healed, moisturized, lubricated skin facilitates application of the stockings.
The utility of our program of skin hygiene, moisturization, and lubrication are illustrated by the following cases.
Case 1. A 67-year-old man with Down’s Syndrome presented with severe dryness and flaky scaling of his legs (see Figure 1a). According to his group residential home’s staff, the condition had been present for 3 years. His past care instructions had been to apply mineral oil to his legs daily after bathing. Our initial treatment was to soak and remove crusts from the legs, scrub the legs with 4.0% chlorhexidine gluconate, and thoroughly massage in the moisturizing and lubricating cream (see Figure1b). The outpatient plan included showering, cleansing the legs, and applying the concentrated moisturizing cream. When the patient returned to the wound clinic 2 weeks after the start of the protocol, his legs had no scaling or flaking and were significantly improved (see Figure 1c).
Case 2. A 30-year-old man was treated in the Emergency Department for chemical burns to both pretibial areas sustained from kneeling in fresh concrete for multiple hours. The treatment consisted of copious flushing of the injured areas with saline, application of topical antibiotic ointment to the injured areas, and oral antibiotics and analgesics. He was referred to the Wound Clinic for evaluation 1 week later (see Figure 2a). The concentrated moisturizing and lubricating cream was applied to both extremities to loosen the crusts, dried blisters, and built-up dirt. The areas then were cleansed and copiously flushed with saline. Concentrated moisturizing melting cream then was applied to the intact skin and collagenase to the thick yellow slough. Following 2 days of treatment, the wounds were healing and the collagenase was discontinued (see Figure 2b). Daily application of the moisturizing, lubricating cream resulted in total healing of both legs by 21 days (see Figure 2c).
Case 3. A 53-year-old man with bilateral edema, venous disease, and periodic fungal issues was noncompliant to treatment. He arrived in the Wound Clinic with superficial eschars on his right leg post blistering due to his chronic edema (see Figure 3a). Our standard skin protocol was initiated; concentrated moisturizing melting and lubricating cream was massaged into the leg. After waiting a few minutes, the scabs and callous formations were lifted using gauze and a forceps, which caused no skin damage or pain. Intact skin was found beneath the debris (see Figure 3b). The patient was reeducated about leg elevation, compression hose, podiatric monitoring for toenail and fungal care, and daily skin care using the moisturizing, lubricating cream. A vascular surgical consult was obtained, and compliance with the skin protocol was monitored by the vascular service.
Case 4. A 63-year-old man with diabetes mellitus was seen in conjunction with the vascular surgery service. He had been aware of the skin protocol previously but had become noncompliant and had stopped using moisturization and lubrication on his legs and feet (see Figure 4a). After re-education, his legs and feet were massaged with the concentrated moisturizing and lubricating cream. His skin immediately was no longer dry, and the outer skin layer exhibited no flaking (see Figure 4b). His wife was shown the proper skin care and was asked to help with the patient’s compliance.
The four cases represent many cases we have treated during the 13 years our protocol has been in use. During that time, moisturization and lubrication provided by the concentrated melting cream largely eliminated problems with dry, flaky scaly skin seen secondary to a wide variety of conditions.
Pearls for Practice is made possible through the support of SteadMed Medical, LLC, Fort Worth, TX (www.steadmed.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of SteadMed Medical, LLC, OWM, or HMP Communications.
This article was not subject to the Ostomy Wound Management peer-review process.
1. Hayflick L. The cell biology of aging. Clin Geriatr Med. 1985;1:10–29.
2. Ricketts LR, Squire JE, Topley E, Lilly HA. Human skin lipids with particular reference to the self-sterilizing power of the skin. Clin Sci Mol Med. 1951;10:89–93.
3. Converse JM, Brauer RO. Transplantation of skin. In: Converse JM (ed). Reconstructive Plastic Surgery. Philadelphia, PA: WB Saunders Co;1967:21–80.
4. Al-Mutairi N. Skin diseases seen in diabetes mellitus. Bull Kuwait Inst Med Specialization. 2006;5:30–39.
5. Haertsch PA. The blood supply to the skin of the leg: a post-mortem investigation. Brit J Plast Surg. 1981;34:470–477.
6. Pattison P, Gordon J. Proper Skin Hydration Requires Assessment, Re-Assessment, and Hydration. Poster presented at the WOCN 36th Annual Wound/Ostomy/Continence Conference, Tampa, FL. June 2004.
7. Pattison P, DeRosa L,Holter B, Gordon J, Muto P, Mallen J. Utilizing Concentrated Melting Moisturizing Creme as the First Step to Achieve Proper Skin Hygiene. Poster presented at Symposium on Advanced Wound Care. Dallas, TX. April 2009.
