Measures of Skin Turgor in Humans: A Systematic Review of the Literature

Skin turgor is defined as the elasticity of the skin, as evidenced by the resistance of the skin when being pinched.¹ Good skin turgor is associated with young and healthy individuals whereas poor skin turgor is often seen in individuals who are aging, dehydrated, malnourished, or unhealthy. It is a common measurement that is often used to determine hydration status in the elderly and in children.¹ However, it is also used in various other settings, ranging from cosmetology to anesthesiology. Skin turgor may also be assessed to gauge healing of burns and skin grafts or to monitor electrolyte imbalance issues, such as hypovolemia (a condition in which the blood plasma volume is too low), hypernatremia (a condition in which the sodium level in the blood is too low), or hyperkalemia (a condition in which the potassium level in the blood is too high). Decreased skin turgor is evident when the skin “tents” or stays in the position from when it was pinched.¹ A natural occurrence during the process of aging due to the loss of subcutaneous fat, decreased skin turgor also commonly reflects dehydration-related issues or malnutrition. Dehydration is common in the elderly and in children. In the elderly, dehydration is often due to low intake of fluids (drinking) and is associated with increased morbidity and mortality.^2,3 In children, dehydration is often caused by diarrhea, vomiting, gastroenteritis, or other gastrointestinal-related issues leading to shifts in electrolytes and blood volume.⁴

Skin turgor is just one of the many measures used when determining dehydration. Often several tests and screening methods are used to determine a patient’s hydration status because individual tests alone are often insufficient to accurately diagnose dehydration.³ However, skin turgor is a common preliminary measure to screen for dehydration because health care providers can perform the assessment quickly and easily, especially in medical emergencies or time-sensitive situations.

One factor that plays a valuable role in the maintenance of skin turgor is hyaluronic acid (HA), a molecule synthesized inside the human body and mainly found in the extracellular matrix surrounding the skin. Given that HA is primarily located in the soft tissues, determination of its distribution would require numerous tissue samples and microscopic evaluation, but Papakonstantinou et al⁵ reported that 50% of the body’s HA is in the extracellular matrix surrounding the skin. Among its many roles, HA helps the structure of the skin form lipid barriers in the epidermis that maintain the water and electrolyte balances.⁶ As the body ages, HA is lost from the epidermis, resulting in a loss of the water and other nutrient balances in the skin. This effect can also be seen in skin damage from ultraviolet light and burns, which induce loss of HA. Consequently, skin turgidity is used as a measure for assessing healing in muscle flaps and skin grafts, common treatments for wounds and burns, because it can take several days for proper blood circulation to return to a flap.⁷ Skin turgor and pigmentation may take up to 6 months to return to normal for myocutaneous flaps.⁸ Lin et al⁹ state that the best measures for monitoring arterialized venous flaps are color, turgor, capillary refill, and pinprick.

Fluid balance is the ability to maintain balance between what fluid is lost and what fluid is gained. When the body becomes dehydrated due to excess fluid loss, it has been found that skin turgor is decreased.^10-12 Hypernatremia can be a result of fluid imbalance and dehydration. In a study to assess the sensitivity and specificity of the main clinical characteristics of elderly people with hypernatremia, skin turgor was measured at 4 sites: subclavicular fossa, anterior forearm, anterior thigh, and sternum. Skin turgor was found to be decreased if tenting lasted > 3 seconds following 3 seconds of skin pinching. The researchers found that abnormal subclavicular and anterior thigh skin turgor was significantly and independently associated with hypernatremia in patients.¹³

Hypovolemia may also occur due to blood loss during a surgical procedure. The anesthesiologist must maintain proper blood flow to perfuse the organs via intravenous fluids for volume resuscitation to counteract the blood loss. The European Society of Anaesthesiology has provided guidelines that suggest the use of repeated clinical inspection of the operative patient’s volume throughout a procedure, including skin turgor assessment.¹⁴

While decreased skin turgidity is currently used as sign of body fluid and electrolyte imbalance, research is lacking with respect to technique and parameters for skin turgor measurement and how these measures correlate with other assessment findings. According to Bunn and Hooper² and researchers at the University of Michigan,¹⁵ a blood serum analysis to evaluate the levels of sodium, potassium, and other electrolytes important for homeostasis remains the most accurate assessment of dehydration and electrolyte balance.

Many studies use similar methods to measure skin turgor, such as pinching the skin and then measuring the time it takes the skin to return to normal. However, there is no gold standard method or parameter for using this measurement that is favored in clinics or hospitals. Data are lacking on what location(s) to use while measuring skin turgor, as well as the time cutoffs for increased, normal, or decreased skin turgor. For example, one study states that common sites for assessment include anterior thigh, subclavicular fossa, sternum, and dorsum of the hand with time variances ranging from 1 to 4 seconds.³ However, these specific areas differ from research on skin turgor measures performed on the dorsum of the hand as in the study previously mentioned.¹³ The purpose of the current systematic review was to determine if there is any consistent method to measure skin turgor in humans that is valid and reliable

Search strategy. A thorough search of the literature was performed. Structured search strategies were developed specifically for PubMed, ProQuest Medical, SPORTDiscus, PEDro, Web of Science Core Collection, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) Complete. A sample of search terms used for PubMed were as follows: ((“skin”[MeSH Terms] OR “skin”[All Fields]) AND “turgor”[All Fields]) OR “skin turgor”[All Fields]. All searches were completed with the assistance of a health professions librarian.

Inclusion and exclusion criteria. Inclusion criteria included studies with human participants aged 18 years or older, articles published originally in English, articles with a clear method and reasoning for skin turgor testing, and articles that ranked level 2, 3, or 4 on the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence scale. Exclusion criteria included: nonhuman subjects, such as animals, food, or bacteria; simulation studies; studies in children under 18 years of age; studies that lack a clear method and reasoning for measuring skin turgor; studies that ranked level 1 or 5 on the 2011 OCEBM Levels of Evidence scale¹⁶; and studies classified as literature reviews or systematic reviews. The authors initially reviewed inclusion and exclusion criteria by using only the article abstract and title. Each article was reviewed by 2 researchers, and any disagreements were settled by a third researcher. After the initial review was completed, a second review was performed using the full-text articles. Again, each article was reviewed by 2 researchers, and any disputes were resolved by a third researcher.

Evidence level. Level of evidence was determined using the 2011 OCEBM Levels of Evidence diagnosis category “Is this diagnostic or monitoring test accurate?”¹⁶ This scale ranks research from level 1 to 5, with 1 being the highest level of evidence as a systematic review and level 5 being the lowest level of evidence as a study based upon mechanism reasoning (see Table 1 for details).¹⁶ The 2011 OCEBM Levels of Evidence hierarchy was chosen because it offers a quick and easy heuristic system for evaluating the quality of evidence based on the style of research. Similar to inclusion and exclusion criteria, level of evidence was assessed through including and excluding articles, with two researchers independently determining the level of evidence and a third researcher managing any disputes.

Methodological rigor. Methodological rigor was assessed by using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS), which is a tool used in systematic reviews to determine the quality of primary studies of diagnostic accuracy.¹⁷ The QUADAS uses 14 questions to assess the rigor of each article. For each question, the article is awarded 1 point for the response of “yes” and 0 points for the response of “no” or “unclear.” The QUADAS was chosen to assess methodological rigor because it has been shown to be an excellent and objective tool to assess quality of studies in systematic reviews. To assess methodological rigor, 2 researchers independently reviewed the articles, and disputes were settled using a third researcher

Level of evidence and methodological rigor. Based on the authors’ original article search, a total of 373 studies were found. Of these, 149 were found to be duplicates, leaving 224 articles. From these, 90 articles were excluded upon review of the inclusion and exclusion criteria against the article abstract and title. From the 134 articles that remained, 121 were excluded. The full articles were reviewed against the inclusion and exclusion criteria (see Figure for details regarding why these articles were excluded).¹⁸ The remaining 13 articles chosen for review are provided in Table 2, Part 1 and Table 2, Part 2.

The remaining articles were individually assessed for level of evidence and methodological rigor. Levels of evidence for the articles included in the study are shown in Table 3. Four of the articles were found to have level 2 evidence, 1 article had level 3 evidence, and 8 articles had level 4 evidence. The methodological rigor of the final articles included in this systematic review are shown in Table 4.

Study summary

Dehydration. Cumming et al²¹ compared the effectiveness of physical examination versus bioelectric impedance analysis for determining the volume status of elderly individuals with hyponatremia. The physical examination measures included: skin turgor, capillary refill time, mouth moistness, axillary moistness, and jugular venous distention. Skin turgor was measured by using 2 fingers to gently grasp the skin over the antecubital fossa and dorsum of the hand. Turgor was considered normal if the time for the skin to return to the hand was less than 2 seconds and considered decreased if > 2 seconds. Skin turgor had slight suggested utility compared with bioelectric impedance analysis, which had moderate suggested utility.

Vivanti et al²⁹ assessed the strongest indicators of dehydration in older individuals who have been admitted to the hospital. Turgor was assessed in this study by “pinching tissue on the dorsum of the hand and over the sternum and recording the seconds elapsed for tissue fold to return to normal.” Abnormal tissue turgor was considered anything > 2 seconds. To validate dehydration status, skin turgor as a clinical assessment was compared with short-term weight changes. The study found that participants with mild dehydration had a greater chance of decreased skin turgor over the sternum compared with well hydrated individuals. However, the findings were not statistically significant.

Feyens and de Jager²³ assessed skin turgor on the anterior leg of a 61-year-old volume-depleted individual. The skin remained elevated for > 10 minutes, indicating abnormal turgor. In a patient with normal hydration levels, the skin would return to its original state immediately. Stating that skin turgor does decrease with age, the authors acknowledge that there is no widely accepted threshold value for abnormal skin turgor.

Johnson and Hahn²⁰ assessed the incidence of a high fluid retention index (FRI) in patients living in a long-term care unit and evaluated the possible relationships between FRI and plasma osmolality and how these measures correlate with clinical examinations commonly used to diagnose dehydration. The FRI uses 4 urinary markers: specific gravity, osmolality, creatinine, and color. Each of the 4 urinary indices of dehydration is given a score depending on the measured value in each patient. This created a composite index that includes several urinary markers. Each of the 4 markers are scored individually on a 6-point scale. The FRI is the mean of the 4 indidivual scores. An FRI score of 4.0 is classified as dehydration. Of the 60 patients from the age of 64 to 103 who were evaluated, 49% were classified as dehydrated with an FRI score of 4.0 or above. Clinical examination measures used to diagnose dehydration included observation of mucous membranes of the mouth, presence of furrows across the tongue, sunken eyes, and skin turgor. Skin turgor was assessed on the dorsal part of the hand and rated as either normal = 0 or impaired = 1. Regarding skin turgor, 85% of patients had impaired skin turgor, and skin turgor was found to correlate only with age (mean age of patients with normal turgor, 78 years; mean age with impaired turgor, 85 years; P < .4).

Liu et al²⁸ sought to determine whether hydration state could be detected by analyzing the skin’s mechanical properties. Participants were evaluated in dehydrated state (no water 1 hour before the test and no smoking, drinking alcholic beverages, or medications for 1 week before the test) and in a hydrated state (immersing hands in water for 20 minutes). A mobile phone camera was used to capture and quantify the dynamic processes of skin stretching and relaxing by 2 methods: 1) tracking a mark drawn on the skin, and 2) capturing the natural skin texture change during the skin turgor test. Both methods were performed while the participant stretched the skin in the middle of the dorsum of their left hand toward their middle finger with the thumb of their right hand. The participant held this position for over 2 seconds and then released the skin. Then, the skin was allowed to relax in its original position for at least 8 seconds. For the skin mark method, a black dot was drawn on the dorsum of the left hand; in the skin texture method, the skin stretching was analyzed by the stretch finger (the thumb) and the skin relaxation was analyzed by detecting the skin texture change during skin relaxation.

For the skin mark method, the researchers found there was a faster skin relaxation rate in the hydrated state, although the rate of change varied among subjects. The skin texture method also showed a faster skin relaxation rate in the hydrated state, although there was larger variability with this method. This is consistent with observations that the skin texture method has lower accuracy but is easier to perform.

Fortes et al¹⁹ examined correlations between hydration status and 7 commonly used physical signs of dehydration in 138 participants taken within 30 minutes of being admitted to the hospital: tachycardia, low resting systolic blood pressure (SBP; defined as <100 mm Hg), dry mucous membrane lining of the inner cheek, axillary moisture level (moist or dry), poor skin turgor, sunken eyes (as determined by the research fellow), and capillary refill time of >2 seconds when the arm was held at heart level. The mean age of participants was 78 years. Skin turgor was “measured by pinching the skin on the dorsum of the hand and observing if the tissue fold returned to normal immediately.” This study also evaluated saliva and urine samples This study found that skin turgor had a poor correlation with hydration status.

Bunn and Hooper² aimed to assess the diagnostic accuracy of clinical signs or symptoms of dehydration including: subjective information about the dryness levels of the participants’ eyes and tongue; reports of feeling thirsty, tired, or “out-of-sorts”; objective observation of the mouth, tongue, and mucous membranes; presence and consistency of saliva; lip cracking, dryness, and color; eye moisture and rating of sunken or not; dryness, crinkling, and dimpling of the skin at the axilla, palms, cheeks, arms, and calves; skin turgor in 2 planes at 4 sites; capillary refill in the index finger nail; foot vein filling; temperature taken at the ear; pulse and blood pressure at sitting and standing; and weight and height. Skin turgor was assessed as “measuring time taken for a skinfold to return to normal” and was taken 2 times for each condition. The researchers found that skin turgor was “excellent” at the sternum and forearm, and was “fair” or “poor” at the other locations. This indicates that skin turgor seemed normal at the sternum and forearm and not at other indicated locations so was not a reliable indicator of skin turgor.

Skin integrity. Lassus²⁷ used skin turgor to assess the effectiveness of colloidal silicic acid for the treatment of aged skin, fragile hair, and brittle nails. Skin turgor was measured with Dermaflex A (Cortex Technology, Hadsund, Denmark) suction-based equipment using a negative pressure of 250 mm Hg. A 4-point scale was used to rate changes in skin turgor and thickness: 0 = absent, 1 = mild, 2 = moderate, 3 = severe. There were no significant changes in skin turgor or skin thickness with this treatment.

Brandt et al²² injected small-gel-particle HA into the hands of women with prominent vasculature, bony prominences and tendons, and poor skin turgor, all ranked on a visual scale of: 0 = undetectable, 1 = mild, 2 = moderate, and 3 = severe. Injections happened at visit 1 with a touch-up injection at visit 2. Mean scores on all visual severity rating scales improved from before treatment (visit 1) to visit to with 26.3 % loss of skin turgor. At 1 year, scores for the aesthetics of the hands retained improvements; however, the skin turgor was no different than pretreatment.¹³

Kerscher et al²⁶ used a single-center, prospective, pilot study to evaluate the effects of a stabilized HA-based gel of nonanimal origin (NASHA) on skin elasticity and skin turgor. The NASHA was injected into the mid dermis of both cheeks of 20 women (19 completed the study, and the mean age of patients was 54 years). Injections happened at V = visits 1, 2, and 3, each separated by 4 weeks, with follow-up visits at 12 weeks and 24 weeks (visits 4 and 5, respectively). There was a statistically significant improvement in skin elasticity, and 85% of participants rated the therapeutic treatment to be “good” or “very good” for the physical alterations seen.

Di Taranto et al²⁴ assessed skin turgidity and tonicity while exploring free flap techniques used in lymphedema surgery in patients who displayed delayed wound healing, recurrent ulcerations and infections, and fibrosis of subcutaneous tissue. Ten patients with secondary severe lymphedema of the lower limbs and a history of a chronic ulcer (> 1 year) underwent excision of the ulcer and reconstruction with an omentum flap. Follow-up assessments included clinical examination, wound circumference measurement, lymphoscintigraphy, skin tonicity, and skin turgidity; patient progress was documented by photograph. Skin turgor was measured by observation through clinical examination and photography. Skin tonicity was measured by tonometer with a central plunger (diameter 10 mm) weighing 30 g (0.38 g/mm², 0.37 cN/mm²) at 2 displacement levels. Researchers found that skin tonicity decreased over time at 24 months postoperatively and skin turgor improved. Specific sites where tonicity was measured were not provided in this study.

Habib et al²⁵ measured skin turgor in their investigation of free flap survival in patients undergoing maxillofacial reconstruction. Patients in group A received a continuous paravertebral block at T1 and T2 with bupivacaine infusion, whereas patients in group B served as controls. Measurements included skin temperature and perfusion of the flap, which was assessed by analysis of skin color, turgor, and capillary refill. Skin turgor was measured every 4 hours for 48 hours postoperatively. The type of testing, such as pinch test, was not indicated. The specific sites of testing were not indicated. Testing was performed using a 3-point scale in which 1 = flat, 2 = bulging, and 3 = full/soft. Patients in group A had significantly higher scores for skin turgor at 16 and 20 hours postoperatively (P = .031 and P = .031, respectively).

Fluid/electrolyte balance. Chassagne et al¹³ compared the effectiveness of skin turgor assessment versus serum sodium measurement for determining hypernatremia and hydration status. Skin turgor was assessed at 4 locations: subclavicular fossa, anterior forearm, anterior thigh, and sternum. The skin was pinched for 3 seconds, and tenting lasting >3 seconds was considered abnormal. Abnormal subclavicular and forearm skin turgor was present in more than 60% of the patients with hypernatremia. Only abnormal findings at the subclavicular and thigh were significantly and independently associated with hypernatremia.

The primary purpose of this study was to conduct a systematic review to determine if there is a consistent method in the literature to measure skin turgor in humans. A secondary purpose was to determine if that method is valid and reliable. The index test of skin turgor was compared with the reference standard of flow index for free flaps, serum osmolarity for electrolyte imbalance, HA for skin integrity, and serum level for dehydration.

For the 7 studies included in the final review that measured dehydration, 6 used the traditional method for the skin turgor pinch test, while 1 study analyzed the skin’s mechanical properties through photography with a mobile phone camera. Within those 6 studies that used the traditional method, all had different protocols for where and how to measure, and all used different scales to interpret the findings. This highlights the lack of consistency in research and clinical practice. For example, Johnson and Hahn²⁰ measured skin turgor on the dorsum of the hand but did not specify a precise location or how much skin to pinch. Additionally, these researchers rated skin turgor as either normal = 0 or impaired = 1 but offered no explanation of the scale, so it was unknown if the values were indicative of time in seconds for recoil or a qualitative factor. On the other end of the spectrum, Bunn and Hooper² described a very detailed methodology in which skin turgor was assessed in 2 planes at 4 sites. Measurements were performed twice within each assessment according to the following instructions: “Use the resident’s dominant hand resting on knee, with fingers gently flexed at a 30 degree angle to the hand, gently pinching skin and assessing in 2 planes. Assess between third and fourth digit parallel to the fingers, then at 45 degrees to this, angled toward the little finger. Using a stopwatch, record how long skin takes to return to its normal position, round down to the largest whole digit.” However, the authors did not offer details on scoring or interpreting these measurements or provide a scale to determine normal and abnormal turgor. This study further highlights the inconsistent approaches to interpreting the results of skin turgor testing for determining dehydration.

In addition to presenting inconsistent approaches to measuring skin turgor, the studies had little value for showing whether turgidity assessments can be used to accurately diagnose dehydration. Fortes et al¹⁹ concluded that “individually, all clinical physical signs performed poorly in terms of detecting dehydration with sensitivity ranging from 0% to 44%.” Diagnostic accuracy for skin turgor in this study was 0.55 (95% confidence interval, 0.45–0.65), indicating no correlation between findings. Bunn and Hooper² also validated this finding. In their study, none of the commonly used clinical signs and symptoms were able to discriminate between participants with or without low-intake dehydration. The authors went so far as to recommend these commonly used clinical tests not be used in practice for fear of false-negative results leading to misdiagnosis and consequently, elderly patients not receiving the required increased fluids to return to a normal hydration state.

In regard to skin integrity, the authors found that the literature described a wide variety of ways to define, measure, and quantify skin turgor. Brandt et al²² measured skin turgor via a 4-point visual scale of 0 = undetectable, 1 = mild, 2 = moderate, and 3 = severe with no further explanation of how to use this visual scale other than to look at the body part. In contrast, Kerscher et al²⁶ measured skin elasticity but not turgor, using a Cutometer MPA 580 (Courage + Khazaka, Köln, Germany) suction-based skin elasticity meter. Lassus²⁷ measured skin turgor with similar suction-based equipment set to a negative pressure of 250 mm Hg. It should be understood that skin elasticity and skin turgor may be measuring the same qualities of skin. This leads to several conclusions: 1) A visual scale can be biased and subjective based on researcher and patient report, 2) there is overlap of the definition of skin turgor and skin elasticity in research in skin integrity studies, 3) using a tool to measure skin elasticity could potentially be an objective method compared to a visual scale, and 4) there is inconsistency with how to measure and quantify skin turgor in skin integrity studies. All these conclusions suggest that there is currently not a consistent, reliable method to measure skin turgor in skin integrity studies.

With regard to using skin turgor as a measurement for free flap perfusion and success, this systematic review only included 2 studies that provided few details about how they measured skin turgor. Di Taranto et al²⁴ did not specify how they performed their assessment; however, it was assumed that turgidity was evaluated via observation only with no scale provided to interpret the findings. This study additionally measured skin tonicity with a skin tonometer, which could potentially be an objective manner to measure skin turgor for a free flap. Habib et al²⁵ did not specify how they measured skin turgor, but it was implied that measurements were performed via palpation. The researchers used a 3-point scale of 1 = flat, 2 = bulging, and 3 = full/soft. Skin turgor that was graded as soft postoperatively was found more likely to lead to a greater success rate of the free flap. The differences in methods for measuring skin turgor postoperatively, however, leads to inconclusive data regarding the reliability and validity of current skin turgor tests with respect to free flap perfusion and survival.

In the fluid/electrolyte balance category, this systematic review only included 1 study in which Chassagne et al¹³ described a clear method for measuring skin turgor. The authors specified multiple locations to measure, how long to pinch the skin, and clear cutoff times for determining whether skin turgor was abnormal. Their methods for measuring skin turgor were similar to those used in the majority of the dehydration studies; however, the measurement sites varied from study to study, with only the dorsum of the hand being a constant for this study and 4 of the dehydration studies is the dorsum of hand. This difference could be due to the different purposes of each study, but the exact reason is unknown. Additionally, the cutoff times specified in this study varied from those of all the dehydration studies, again highlighting the inconsistencies in clinical practice.

The results of the current study are in agreement with the findings of Hooper et al³ that indicated skin turgor as an index test is not accurate at individually assessing dehydration in the elderly. This may be due, in part, to the fact that the pinch test for skin turgor has no standard method of application or interpretation. Another explanation could be the natural change in cellular makeup during the aging process.

Measuring skin turgor is even variable across age groups due to the difference in tissue integrity. This could also be attributable to the fact that the traditional skin turgor measurement is not appropriate for all types of studies. For example, the traditional assessment would not be appropriate for evaluating patients who have undergone free flap surgery because it involves pinching of the skin on a postoperative site.

Potential other assessment methods. This systematic review has shown that skin turgor assessment is commonly used for a variety of reasons and performed using a variety of methods. Some studies have suggested other techniques or findings may be more reliable than skin turgor for gauging hydration status, skin integrity, and fluid/electrolyte balance.

Di Taranto et al²⁴ measured skin tonicity with a tonometer. This is a device that employs a 10-mm central plunger that records tissue compressibility. Kerscher et al²⁶ measured skin elasticity with a cutometer, a noninvasive suction-based skin elasticity meter. This device uses negative pressure to draw the skin into the probe. The measurement is based on penetration of light into the skin as the intensity of the light will vary depending on the amount of skin drawn into the probe. The skin is then released and associated with a curve that is then translated into an elasticity measurement from a computer software. Lassus²⁷ also used a suction-based device to measure skin turgor; however, these authors did not detail the procedure for how they used the device, and they used a 4-point scale to rate skin thickness and turgor but did not give values to the ratings.

Metheny³⁰ reported that the tongue should have 1 longitudinal furrow in a person who is euvolemic. A hypovolemic person would have more longitudinal furrows as well as a smaller tongue. Instead of skin turgor to assess hydration status, the tongue may be more reliable since its state reflects body condition and not age. Fortes et al¹⁹ assessed hydration status and found that a low SBP of < 100 mm Hg had high diagnostic correlation to water and solute loss dehydration in the elderly. They also found that saliva osmolarity was greater in dehydrated elders, offering the ability to differentiate between water loss and water and solute loss dehydration.

Implications of clinical practice and future research. In this systematic review, no consistent method was found to assess skin turgor, nor reason to assess or interpretation of results. Since there is no consistency, there cannot be reliability or validity. While Hooper et al³ explicitly stated that skin turgor should not be used to assess hydration levels in the elderly, the present systematic review concludes that skin turgor assessment should not necessarily be dismissed broadly because there is so much variability between methods, purposes, and populations. In the future, other methods should be utilized to assess the health of the overall person as well as that of the person’s skin. A low SBP, for example, indicates a decrease in blood volume and is an easy objective measure to obtain. Suction-based devices provide a more objective measure of the skin’s elasticity, which is related to age and risk of injury to the skin. Other categorical labels should be ascribed to skin flaps for more consistency, similar to assessing circulation at the hands by compressing the nail bed. This process would require more research to develop a safe, accurate, and reliable method to assess the sensitive tissue.

A limitation of this study was that only 13 studies were included in the final review. There cannot be strong evidence interpreted from this study when the inclusion of articles was limited. A majority of the studies included were level 4 evidence on the 2011 OCEBM Levels of Evidence scale,¹⁶ which reflects a poor or nonindependent reference standard. Several of the reference standards that the studies used also lack clinical validity and reliability. Additionally, the search included 6 databases; these databases were limited to those subscribed to by the university libraries (ProQuest Medical, SPORTDiscus, Web of Science Core Collection, and CINAHL Complete) and 2 freely available databases (PubMed and PEDro). As such, the search may have excluded important studies from other databases and written material. The search also only included studies originally published in English, which may have created a language bias.

Skin turgor is frequently used by clinicians in a wide variety of settings, for a wide variety of applications. It has been commonly used for dehydration, skin flap perfusion, skin integrity, and fluid/electrolyte imbalance assessments. However, there is a lack of consistent technique between these categories as well as within the individual categories. The current study completed a systematic review of the literature to determine if there is a valid and reliable method to the utilization of “skin turgor.” The articles demonstrated a wide variety of methods and interpretation for the results associated with skin turgor findings. Individually, researchers describe wide range of locations of assessment, durations of skin pinching, and interpretations of normal rebound values. Furthermore, many studies stated that skin turgor assessments were used but provided details regarding the methodology used. The findings revealed there is no consistent, reliable, valid method for assessing skin turgor, and the term “skin turgor” itself is used with no general regard to a specific method.

If skin turgor assessment is to be used clinically, there is a need for further research in the field to ascertain the most reliable sites as well as methodology for pinching and interpretation of results. Currently, there is evidence emerging that supports the use of other assessment methods, such as suction-based measurement devices. The future goal would be to provide a more objective measurement with little variation among clinicians. With the current evidence that is available, this systematic review suggests that skin turgor may not be an appropriate measure for use in some clinical settings or for some applications.

Meri T. Goehring, PhD¹; Joni Farran, DPT¹; Courtney Ingles-Laughlin, DPT¹; Sarah Benedista-Seelman, DPT¹;
and Betsy Williams, MSLIS¹

¹College of Health Professions, Grand Valley State University, Grand Rapids, MI.

Address all correspondence to: Meri T. Goehring, PhD, Health Campus, 301 Michigan St. NE, Suite 200, Grand Rapids MI, 49503; email: goehrinm@gvsu.edu.