Assignment week 4 _ Lab Assignment: Differential Diagnosis for Skin Conditions
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Clinical review
A review of the effects of ageing on skin integrity and wound healing
Abstract
It is well known that advancing age is a factor that affects the normal course of wound healing. The population over the age of 65 years is increasing globally, and this may be accompanied by an increase in the number of individuals experiencing delayed wound healing. There is a breadth of research to show that age-related changes in the epidermis and dermis change the skin’s ability to resist damage and injury. In particular, the dermo- epidermal junction becomes flattened, which
predisposes the tissue to shear and friction forces. Within the dermis, alterations in the amount and structure of collagen also mean that the tissue is much more rigid. Prompt assessment of the skin to identify existing conditions as well as preventive measures is therefore essential. This article discusses the anatomy of the skin and the effects of ageing on the tissues. It also offers some guidance on skin assessment and the basics of skin care.
■ Ageing ■ Skin integrity ■ Wound healing ■ Skin tears ■ Fragility
Hilary Bonifant Senior Diabetes Podiatrist, Tū Ora Compass Health, Wellington, New Zealand
Year 2 Student, Masters in Wound Healing and Tissue Repair, Cardiff University School of Medicine, College of Biomedical and Life Sciences
Samantha Holloway Reader, Centre for Medical Education Programme Director, MSc in Wound Healing and Tissue Repair
Cardiff University School of Medicine, College of Biomedical and Life Sciences
Accepted for publication: January 2019
Wound healing is a complex, highly orchestrated process requiring a well-coordinated series of cellular activities and the action of mediators which, under normal conditions, occurs over a number of overlapping events and collectively leads to repair of the injured tissue (Ashcroft et al, 2002). Many factors affect and interfere with normal wound healing, such as infection, medication, complex comorbidities, age, obesity, smoking and nutrition (Guo and DiPietro, 2010; Gould and Fulton, 2016).
Morbidity associated with delayed wound healing imposes an enormous social and financial burden on the healthcare system
(Ashcroft et al, 1995; Guest et al, 2017). The world population is rapidly increasing, and older adults comprise the fastest growing age group worldwide: the proportion of the world’s population over 60 years of age is expected to double between the years 2000 and 2050, from 11% to 22% (World Health Organization, 2013). It is estimated that there are 11.8 million people in the UK who are over the age of 65 years, making up 18% of the population (Office for National Statistics, 2018). By 2030, one in five people in England will be over 65 years old. The NHS managed an estimated 2.2 million patients with a wound during 2012/2013, with the annual cost estimated to be between £4.5 and £5.1 billion (Guest et al, 2015).
With advancing age, medical conditions and other factors that adversely affect wound healing become more prevalent (Gosain and DiPietro, 2004). Comorbidities such as diabetes, peripheral arterial disease and venous insufficiency complicate wound healing and impair or delay healing of chronic wounds (Thomas, 2001; Wicke et al, 2009).
As the average life expectancy is increasing, the ageing skin and its influence on wound healing are of particular importance (Montagna and Carlisle, 1990). This review discusses the existing research, including studies from 1960 onwards to provide a chronological perspective with regard to the proposed influence that ageing has on wound healing.
Anatomy of the skin
The skin is the largest organ in the body and consists of two tissue compartments, namely, the epidermis and dermis. The outermost layer of the skin, the epidermis, is a stratified layer
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consisting of epithelial cells that serves as a protective barrier against invading micro-organisms and the harmful effects of the environment (Haschek et al, 2013). The epidermis is in constant interaction with the environment, and its thickness varies depending on the anatomical site (Holloway and Jones, 2005). The epidermal layer of the skin interfaces via the dermal-epidermal junction (DEJ) with the underlying dermis (Langton et al, 2016). Structurally, the dermis contains an extracellular matrix (ECM), which includes collagen, elastin and glycosaminoglycans (GAGs) (Gosain and DiPietro, 2004) (Figure 1).
As the human skin begins to age, its structure undergoes a range of significant changes (Desai, 1997). A combination of extrinsic and intrinsic factors leads to a loss of the structural integrity and physiological function of the skin (Thomason and Hardman, 2009). The former include long-standing exposure to ultraviolet radiation from sunlight or environmental damage (Farage et al, 2008), while the latter include changes in cellular function, proteins and growth factors, which result in epidermal and dermal changes (Gosain and DiPietro, 2004). Skin ageing is associated with increased susceptibility to a wide range of age-related conditions including chronic wounds and pressure ulcers (Farage et al, 2008; Chang et al, 2013).
Effects of ageing on the epidermis
Epidermal ageing involves the flattening of its inferior surface at the DEJ, giving the appearance of atrophy (Kurban and Bhawan, 1990). The epidermal cells are less evenly aligned on the basement membrane and are also less regular in size and shape (Montagna and Carlisle, 1990) (Figure 2).
Guo and DiPietro (2010) discussed that the rate of epithelisation declines with age, something that has been observed in both in vivo and in vitro studies. For example, Holt et al (1992) examined the rate of re-epithelialisation in 2 x 2 cm split-thickness thigh wounds in two groups of volunteers: healthy young subjects (age, 18–55 years) and older subjects (age, 65 years and over). They found a 1.9-day delay in re-epithelialisation in the older group.
Keratinocytes, a major cellular component of the epidermis, are responsible for the restoration of tissue through epithelialisation (Raja et al, 2007). In an early experimental study, Gilchrest (1983) examined the proliferation of keratinocytes from neonatal foreskin and tissue from the trunk of older human donors and found the neonatal keratinocytes grew faster than the adult keratinocytes.
Langerhans cells (LCs), which function as antigen- presenting cells within the epidermis, play an important role in acute wound healing (Streilein and Bergstresser, 1984). The number of LCs has been found to decrease greatly in older adults, even in sun-protected sites (Ashcroft et al, 1995; Tobin, 2017). A decline in the number and function of LCs is likely to have a significant effect on the skin health of older individuals and their susceptibility to infection and skin morbidity (Pilkington et al, 2017).
Age-related changes in the DEJ of the epidermis are also significant as they contribute substantially to the increased fragility of the skin and are known to cause trauma and shear-type injuries (Hatje et al, 2015). Flattening of the DEJ due to the retraction of the epidermal papillae reduces the proliferative capacity of the epidermal cells and results in fragility (Kurban and Bhawan, 1990; Desai, 1997), with an increased risk of skin tears (LeBlanc et al, 2018) and pressure ulcers (LeBlanc et al, 2016).
Effects of ageing on the dermis
Fibroblast proliferation and function According to Sgonc and Gruber (2013), the dermis of older skin has fewer fibroblasts, mast cells and macrophages, as well as decreased amounts of ECM components such as collagen and GAGs. Fibroblasts are responsible for producing collagen, which is essential for granulation tissue formation, while mast cells and macrophages are key inflammatory cells (Holloway et al, 2016). Low numbers of these cells thus result in delayed wound healing (Broughton et al, 2006).
Schroeder et al (1984) conducted biopsy examinations of the leg skin from individuals of varying ages (<35 and >44 years [range, 28–55]; n=6). Each biopsy sample was divided into 20–24 pieces for subsequent testing. The authors observed age-related changes such as changes in the lipid composition of the fibroblasts and their mitochondrial membranes, which hampered the functioning of these cells. However, a limitation of this study was that there were no participants above the age of 55 years, which limits the wider generalisability of the findings to older persons. Pienta and Coffey (1990) studied human fibroblast cells obtained from male donors using time-lapse video-microscopy and demonstrated a global decline in all types of fibroblast motility with increasing donor age. Similarly, Kondo et al (1988) found that serum from older adults did not inhibit fibroblast proliferation when compared to that from younger donors. The production of cytokines and hormones may also be affected by fibroblast ageing (Karlsson and Paulsson, 1994). More recently, Gunin et al (2011) investigated age-related changes in the size and proliferation of fibroblasts and found
Figure 1. Structure of the skin
Stratum corneum
Capillary (artery/vena cava)
Basal layer
Fibroblasts
Sebaceous gland
Substrate (hyaluronic acid)
Collagen
Elastin
Sebum
Hair
Sweat gland
Fascia
Epidermis
Dermis
Blood vessel
Subcutaneous fat
Muscle
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that the number of fibroblasts in the human dermis reduces with age, partly because of a reduction in their proliferative activity. Ageing has also been shown to affect other cytokines and hormones such as insulin and epidermal growth factor receptors (Phillips et al, 1984; Shiraha et al, 2000).
Structural changes in the ECM and collagen According to Kenedi et al (1966), the straightening of collagen fibres could be a factor that contributes to the increased tensile strength of aged skin. The structure of the ECM becomes impaired with age, and this affects the production of collagen by fibroblasts. Lavker et al (1987) reported that collagen fibre bundles increase in density in ageing skin and exist in aggregates of loosely woven, straight fibres in comparison to the rope-like bundles of tightly packed fibres in young human dermis. Additionally, elastin fibres also appear denser in ageing skin because of the increased production of elastin. Lovell et al (1987) reported that the proportion of type III collagen in the dermis increases from age 65 years onwards as part of the ageing process, and this changes the nature of the dermis in older people.
Shuster et al (1975) assessed dermal thickness and density in biopsy specimens from the midpoint of the dorsal forearm of 90 males and 107 females aged 12–93 years. The results showed gradual thinning of the dermis with age in males. However, in females, the dermis was consistently thin until 50 years of age, after which it further decreased, most likely because of menopause. Shuster et al (1975) concluded that photo-exposed areas thicken with age, whereas protected
areas become thinner. Using pulsed ultrasound to measure skin thickness on the forearm, Tan et al (1982) found that this parameter decreased linearly after 20 years of age. Interestingly, a study by Gniadecka et al (1994) suggested that age-related changes in skin depend on the location on the extremities rather than to sun exposure.
Assessment and management of integrity in ageing skin
Much information can be gained about a person’s general health from simple visual observation combined with physical examination of the skin (Table 1) (Morison et al, 1997; Newton and Cameron, 2004; Holloway and Jones, 2005; Baranoski et al, 2016). Skin assessment is acknowledged to be an important aspect of care in terms of pressure ulcer prevention (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan-Pacific Pressure Injury Alliance, 2014), and NICE guidelines concerning pressure ulcer prevention (2014) suggest that skin assessment and care should be part of a training and education programme for healthcare professionals.
A number of practical considerations in maintaining skin integrity have been suggested by Thomas-Hess (2000), all of which are still applicable in clinical practice (Table 2). Integration of procedures that address the ‘basics’ of skin care are fundamental in the management of older individuals, whose tissue is at a high risk of damage (LeBlanc et al, 2018).
It is important that the information gathered from the inspection of the patient’s skin be documented and that aspects of management be clearly recorded for reference.
Figure 2. Differences between young and ageing skin
Sweat gland
Smoothening of epidermal/dermal junction
Disorganisation and loss of collagen fibres
Fat cells
Vascular tissue
Reduced vascular tissue
Organised collagen fibres
Hair Hair
Epidermis
Dermis
Hypodermis
Young skin Ageing skin
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Conclusion
It is generally accepted that wound healing becomes impaired or delayed as individuals age. Evidence has demonstrated the effects of older age on the epidermis and dermis, the main one being the changes in the DEJ that lead to changes in skin integrity and increase the susceptibility of the epidermis to injury. When an injury does occur, epithelialisation is slower because of the reduced capacity of keratinocytes to proliferate
and migrate. At the same time, age-related changes in the dermis mean that the type of collagen produced is denser, reducing the integrity of the tissue. In order to improve the skin’s resilience as individuals age, it is important to undertake a comprehensive skin assessment to identify any issues that need addressing. In addition, maintenance of skin integrity through the use of moisturisers to hydrate the skin on at least a daily basis is vital, as is paying attention to preventative measures to reduce the risk of skin damage in older adults. CWC
Conflicts of interest: none
Ashcroft GS, Horan MA, Ferguson MW. The effects of ageing on cutaneous wound healing in mammals. J Anat. 1995; 187:1–26
Ashcroft GS, Mills SJ, Ashworth JJ. Ageing and wound healing. Biogerontology. 2002; 3(6):337–345. https://doi.org/10.1023/A:1021399228395
Baranoski S, Ayelloe EA, Levine JM, LeBlanc K, Tomic-Canic M. Skin: an essential organ (chapter 4). In: Baranoski S and Ayello EA (eds). Wound care essentials: practice principles. 4th edn. Philadelphia (PA): Lippincott Williams & Wilkins; 2016:52–81
Broughton G 2nd, Janis JE, Attinger CE. The basic science of wound healing. Plast Reconstr Surg. 2006; 117(7S):12–34. https://doi.org/10.1097/01. prs.0000225430.42531.c2
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Table 1. Aspects of skin assessment
Assess Consider
Colour Is the colour normal for the patient?
What colours can you see—red, purple, brown, etc.? Is there bruising present?
Temperature Does the skin feel warm to touch?
If it feels hot, is it because the patient has a fever or is there infection present?
If the skin feels cold, is this because of poor vascularisation?
Texture Does the skin feel dry or moist?
Is it papery, or very thin?
Is the moisture due to sweat, urine or leakage from a wound?
Is the skin becoming macerated, that is, soggy and white?
Is there any oedema?
Integrity Are there any broken areas?
Is there presence of skin tears or epidermal stripping?
Source: adapted from Morison et al, 1997; Newton and Cameron, 2003
Table 2. Skin care basics
■ The skin should be assessed at least daily
■ The skin should be cleansed at frequent intervals, to include the use of a pH-balanced cleansing agent and application of moisturisers and a barrier cream
■ The force being applied when washing the skin should be kept in mind, and massaging areas which could be easily damaged should be avoided
■ Prompt attention is required when incontinent episodes occur, and the skin should be protected with barriers
■ Avoid drying of the skin through temperature extremes
■ Ensure that patients are positioned, transferred and turned properly to avoid friction and shear forces
Source: Thomas-Hess, 2000
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CPD REFLECTIVE QUESTIONS • Thinking about the effects of ageing on the skin, name two main changes that occur in both the epidermis and
dermis of the skin in older persons?
• What are the four aspects of a visual skin inspection that need to be assessed?
• What can you do to ensure that the skin care basics are implemented into your own clinical practice?
Helping nurses treat common skin conditions
Order your copies by visiting www.quaybooks.co.uk
or call +44 (0)1722 716935
Jean Watkins
Dermatology Differential Diagnosis
About the book Skin problems are one of the most common reasons for people to seek help from a nurse or GP in general practice. This handy reference guide is the essential collection of common dermatological cases encountered in everyday practice with concise content on the aetiology, diagnosis, management and prevention so that healthcare practitioners can effectively treat their patients. Importantly, this book also examines other issues that impact patient care, with consideration for how social and psychological factors impact patients and treatment of skin conditions.
This book comprises updated articles from a long running and highly popular series published in the Practice Nursing journal on the differential diagnosis of dermatological conditions. It has been highly illustrated with colour pictures provided throughout to aid diagnosis. The chapters have been presented in a user-friendly format making this a highly practical text for nurses and GPs.
About the author Dr Jean Watkins is a retired GP and remains an active member of the Practice Nursing Editorial Board and, in April 2004, was awarded a Fellowship of the Royal College of General Practitioners.
9 7 8 1 8 5 6 4 2 4 0 1 1
ISBN 1-85642-401-4
www.quaybooks.co.uk
D erm
ato lo
g y D
ifferential D iagnosis
Jean W
atkins
QB DermaDiffs cover.indd 1
05/08/2010 12:12
This practical and user-friendly book is made up of articles from a popular series in Practice Nursing and covers:
• The aetiology, diagnosis, management and prevention of most common dermatological cases
• Social and psychological factors and their impact on patients and treatment of skin conditions
It has been highly illustrated with colour pictures provided throughout to aid diagnosis. The chapters have been presented in a user-friendly format making this a highly practical text for nurses and GPs.
ISBN-13: 978-1-85642-401-1; 297 x 210 mm; paperback; 200 pages; publication 2010; £29.99
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