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Skin Matters: Concepts in Skin Care Product Formulation
Skin Matters is published as an occasional column that addresses the multidisciplinary challenges of maintaining skin integrity.
The role of skin care products in institutional settings is a subject of much discussion and comment.1-4 Although it is understood that most institutionally associated or acquired skin-related problems can be managed with a robust regimen of cleansing, moisturization, and barrier provision, certain serious skin problems can escalate to life-threatening scenarios.4 For example, institutionally acquired pressure ulcers present a stubborn problem that seems to evade eradication, despite the focused attention of practicing clinicians, researchers, regulatory agencies, and top policymaking panels of the Centers for Medicare and Medicaid Services (CMS).5-7 Similarly, skin tears in the geriatric patient are commonly encountered, consume resources, and potentially preventable.8,10 Recently, a micronutrient-containing skin care regimen (the Remedy® family of skin care products, Medline Industries Inc., Mundelein, IL) has been used widely in the US and elsewhere as part of a coordinated program of cleansing, moisturization, and protection. Micronutrients for the skin surface, including antioxidants, are incorporated into the formulation to sustain and nourish the patient/resident’s skin surface. This formulation concept largely avoids the use of petrolatum as the primary barrier/moisturizer component, replacing the petrolatum with silicone polymers. Synthetic sulfate-based detergents also are avoided in favor of gentler, more naturally derived, phospholipid-type amphophilic ingredients designed to reduce detergent-associated harshness on skin. The formulation also includes natural oils and odor-masking agents instead of mineral oils (and their derivatives) and synthetic fragrances. In addition, chlorhexidine gluconate (CHG) compatibility has been explored and established for key product components.9 This compatibility information is important to infection control specialists who would want to ensure that the antimicrobial properties of CHG are not somehow rendered ineffective by skin care products being used in conjunction with CHG.
The benefit of these formulation principles has been studied in prospective and retrospective clinical trial models.10-12 Although links connecting novel formulation techniques and clinical benefits are difficult to establish with full certainty, and numerous study limitations are reported, clinical data seem to show that a carefully executed skin care regimen can yield appreciable clinical benefits. Examples include reduction of skin tears over a 6-month period10 (see Table 1), reduction of pressure ulcer incidence11 (see Figures 1 and 2), or decreased hand washing-related erythema in nurses working in institutional settings.12 Specifically, institutionally acquired pressure ulcers have large financial and legal liability costs11; the estimated national average cost of a hospital-acquired pressure ulcer (HAPU) is $37,800.5,7,11 A skin care regimen that includes micronutrient-containing skin care products was associated with a 50% reduction of pressure ulcers in 3 months, leading to a per-patient cost savings of $6,677.11 Finally, a prospective, controlled trial12 with nurse subjects working in a children’s hospital who experienced erythema issues related to meticulous and repetitive handwashing showed that the combination of micronutrients, silicone, and natural oil emollients provided a statistically significant reduction (P = 0.03) in skin surface erythema on nurse’s hands. Additional research13 has reported on the mechanism of action associated with reduction of skin erythema in response to the introduction of micronutrient-containing emollients and the potential (see Figure 3) of the formulation concept to manage undesirable conditions on the skin surface.
Skin Matters is made possible through the support of Medline Industries, Inc., Mundelein, IL. The opinions and statements of the clinicians providing material for Skin Matters are specific to the respective authors and are not necessarily those of Medline Industries, Inc., OWM, or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.
1. Bale S, Tebble N, Jones V, Price P. The benefits of implementing a new skin care protocol in nursing homes J Tissue Viabil. 2004;14(2):44–50.
2. Byers PH, Ryan PA, Regan MB, Shields A, Carta SG. Effects of incontinence care cleansing regimens on skin integrity J WOCN. 1995;22(4):187–192.
3. Cooper P, Gray D. Comparison of two skin care regimes for incontinence Br J Nurs. 2001;10(6 suppl):S6–S10.
4. Buraczewska I, Berne B, Lindberg M, Torma H, Loden M. Changes in skin barrier function following long-term treatment with moisturizers: a randomized controlled trial Br J Dermatol. 2007;156(3):492–498.
5. Number of patients with pressure sores increasing. Agency for Healthcare Research and Quality (AHRQ), Rockville, Maryland. Available at: http://hcup.ahrq.gov/HCUPnet.asp. Accessed October 4, 2011.
6. Langemo D. Quality of life and pressure ulcers: What is the impact? WOUNDS. 2005;17(1):3–7.
7. Lyder CH. Implication of pressure ulcers and its relation to Federal Tag 331. Annals Long-Term Care. 2006;14(4):19–24.
8. Baranoski S. Skin tears: the enemy of frail skin. Adv Skin Wound Care. 2000;13(3 PT 1):123–126.
9. In vitro laboratory data. On file at Medline Industries, Inc.
10. Groom M, Shannon RJ, Chakravarthy D, Fleck CA. An evaluation of costs and effects of a nutrient-based skin care program as a component of prevention of skin tears in an extended convalescent center J WOCN. 2010;37(1):46–51.
11. Shannon RJ, Coombs M, Chakravarthy D. Reducing hospital-acquired pressure ulcers with a silicone-based dermal nourishing emollient-associated skincare regimen Adv Skin Wound Care. 2009;22(10):461–467.
12. Visscher M, Davis J, Wickett R. Effect of topical treatments on irritant hand dermatitis in health care workers Am J Infect Control. 2009;37(10):842.e1–842.e11.
13. Davis JA, Visscher MO, Wickett RR, Hoath SB. Influence of tumour necrosis factor-alpha polymorphism-308 and atopy on irritant contact dermatitis in healthcare workers Contact Dermatitis. 2010;63(6):320–332.
