Preventative practices

Skin washing and drying practices
The earlier section on washing the skin highlights the importance of several factors in maintaining the skin barrier; avoiding excessive use of soap and where possible using soap substitutes or cleansers, not using water that is too hot and minimising rough drying technique.

For those with chronic skin conditions such as psoriasis and eczema, emollients may be used as soap substitutes (see Emollients). For routine skin care for those requiring regular washing, such as the incontinent patients, skin cleansers may provide an alternative means to maintain skin hygiene. They may reduce some of the adverse effects of soap, due to their chemical composition, and help to maintain a pH level that minimises barrier disruption. Several studies have compared the use and effect of skin cleansers with soap and water use, but design weaknesses are common, such as small sample size, and hence conclusions are often unclear. For example, Whittingham (1998) compared the relative effectiveness of one of two cleansers (Triple Care, Smith & Nephew and Clinisan, Vernacare) with that of using soap and water on skin condition among a sample of highly dependent elderly patients with some degree of incontinence. Other studies have compared the combined use of cleansers with a barrier cream with the effectiveness of soap and water, although again design weaknesses are common (e.g. Byers et al., 1995; Dealey, 1995) compared to skin washing and cleansing regimens and their effect on skin integrity using a ‘multi-baseline crossover design’, with soap and water as the baseline control. Although a small study, repeated observations revealed statistically significant differences between the regimens, and there was no clinically observable evidence of skin breakdown. Based on the transepidermal water loss (TEWL) and erythema measurements, the soap and water regimen was the least efficient in promoting skin health. There were statistically significant differences on TEWL measures between the soap and water control and the use of cleanser alone (p = 0.02), soap and barrier cream (p = 0.01) and cleanser plus barrier cream (p = 0.03). Soap also produced a more alkaline skin (pH 7.5), but barrier function improved with the use of a barrier cream and was even greater with the cleanser and cream regimen. As such, for use with vulnerable skin, the use of carefully selected cleansers and emollients should be considered (see Emollients).

The capillary action of the towel wicks water away from the surface and various authors have suggested drying the skin gently, patting it rather than rubbing to reduce frictional damage (Fiers, 1996). Unpublished preliminary observations from the authors’ group would support the fact that a minimal rubbing drying technique, such as patting, may reduce frictional damage. Measurements of skin barrier function (including TEWL) were significantly increased following a single wash with towel drying by rubbing, the mean pre-wash TEWL (±SEM) being 8 ± 0.12 g/hm² increasing to 12.6 ± 0.52 g/hm² after a single wash, representing a significant disruption to skin barrier function (p < 0.01) (Ersser et al., 2005).