Barrier function of skin

Recommendations

Identify and Treat the Cause
1 Take a careful history and assess each patient’s risk factors for skin barrier disruption. Level of Evidence
Not Assessed


Address Patient-centered Concerns
2 Provide information and advice on prevention and treatment options. Level of Evidence
Not Assessed


Provide Local Care
3 Develop and implement an individualized plan to restore, maintain and/or prevent barrier impairment. Level of Evidence
Not Assessed
4 Ensure use of gentle cleansers and routine skin moisturizing. Level of Evidence
Not Assessed
5 Protect skin from contact with urine or fecal material by using appropriate barriers, protectants and containment devices. Level of Evidence
Not Assessed
6 Maintain wound moisture and bacterial balance and protect periwound skin. Level of Evidence
Not Assessed
7 Reassess skin barrier function regularly and modify the clinical approach as necessary. Level of Evidence
Not Assessed


Provide Organizational Support
8 Facilitate healthcare professionals to gain relevant knowledge and skills to offer appropriate advice and information. Level of Evidence
Not Assessed


Background

Normal intact skin forms a barrier that protects the body against pathogens, ultraviolet light, noxious substances, and fluid and electrolyte loss. The barrier function of the skin resides primarily in the stratum corneum, which is highly impermeable to water. This impermeability is due to the structure of the stratum corneum, which is composed of protein-rich nonviable cells and an intercellular lipid bilayer. Maintenance of barrier function depends on the stratum corneum having a 10% moisture content. Normally, loss or impairment of the skin’s barrier function accelerates homeostatic processes, including lipid synthesis and processing, to repair the barrier. The barrier function also adapts to the environment. Intercellular lipid content increases in a dry environment, reducing transepidermal water losses.

Numerous risk factors, however, can impair the skin’s barrier function, increase susceptibility to infection, and significantly affect health.
• Inflammation alone can disrupt the skin barrier.
• Dermatitis may be the cause or the result of an impaired skin barrier.
• Hypersensitivity may develop when an impaired barrier allows entry of normally excluded chemicals and allergens. The importance of barrier disruption to development of hypersensitivity is unknown.
• Aging, which is associated with decreased skin thickness, barrier function and physiologic activity, predisposes elderly individuals to breaches of skin integrity.
• Incontinence: Loss of skin integrity among institutionalized elderly individuals is frequently due to incontinence-related dermatitis.
• Wounds: Wound exudate can damage normal skin surrounding the wound, and leaky dressings may result in periwound skin maceration.
• Edema, due to lymphedema or venous insufficiency, stretches the dermis and epidermis, disrupting the skin barrier, causing inflammation and further skin damage, which may then result in infection.
• Adhesive products, including tapes and bandages, such as hydrocolloids, films and some foams, and procedures to remove them, may compromise the skin’s barrier function.
• Diabetes mellitus is associated with impaired skin barrier function, possibly due to reduced capillary circulation of the skin and abnormal lipid content of the stratum corneum.
• Contact dermatitis may occur with skin barrier disruption, and decreased skin hydration may increase sensitivity to irritants.
• Xerosis may result from any condition that damages the skin barrier and increases transepidermal water loss. These conditions include dermatoses, frequent hand washing or exposure of skin to detergents or other damaging chemicals, and changes associated with aging.
• Stress: Chronic physiologic and psychological stress can reduce skin lipid production, delay normal barrier repair, and reduce the water content of the skin.

Clinical warning signs of an abnormal skin barrier include lack of skin elasticity, redness, inflammation, itching, scaling, cracking, and fissuring. Restoring and maintaining normal epidermal hydration is the most basic requirement for maintaining adequate skin barrier function. Useful measures include selection of cleansers with a pH as close as possible to normal skin pH (5.4), possibly with added moisturizers, and routine skin moisturization, especially after bathing or contact with water.

The optimal treatment approach to maintain the skin’s barrier is individualized and based on specific risk factors, clinical signs, and underlying causes.

References

Essential Publications
1 Topical skin care Quality Indicator
 Type: Systematic review
Hodgkinson B, Nay R, Wilson J (2007) A systematic review of topical skin care in aged care facilities. Journal of Clinical Nursing 16, 129-136.
This systematic review of systematic reviews, RCTs, and non-randomized controlled studies was conducted to determine the effectiveness of topical skin care interventions for residents of aged care facilities by examining the incidence of adverse skin conditions such as rash, skin irritation, haematoma or tears, and by patient satisfaction. Since the interventions and outcomes measured in the studies varied, the results were not combined but one or more individual studies were reported. Although the results are inconclusive, evidence suggests the use of disposable rather than non-disposable bodyworns, no rinse cleansers rather than soap, and bag bath to maintain skin integrity.
2 Skin Integrity Quality Indicator
 Type: Narrative Review
Sibbald RG, Campbell K, Coutts P, Queen D. Intact Skin – An Integrity not to be lost. Ostomy Wound Continence 2003;49(6):27-41
This comprehensive article outlines the skin integrity issues and suggests products that might be used for prevention and treatment.
3 No-Sting Barrier Film Quality Indicator
 Type: Systematic review
Schuren J, Becker A, Sibbald RG. A liquid film-forming acrylate for peri-wound protection: a systematic review and meta-analysis (3Mâ„¢ Cavilonâ„¢ no-sting barrier film) Int Wound Journal 2 (3) Sept 2005.
This publication is useful because it demonstrates the effectiveness of No-Sting Barrier Film in protecting peri-wound skin. The studies showed that the film protected the integrity of the skin, minimized pain and improved quality of life of patients.
4 No-Sting Barrier Film Quality Indicator
 Type: Narrative Review
Campbell K, Woodbury MG, Whittle H, Labate T, Hoskin A. A clinical evaluation of 3M no sting barrier film. Ostomy Wound Manage. 2000 Jan;46(1):24-30.
This publication is useful because it demonstrates the effectiveness of No-Sting Barrier Film in protecting peri-wound skin. The studies showed that the film protected the integrity of the skin, minimized pain and improved quality of life of patients.


Enablers for practice

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