Carol McLoughlin, BSc (Hons), RSCN, RGN.
Deputy Editor, Professional Nurse...
Personal hygiene has traditionally been part of basic routine nursing care. As a result, it is a practice that rarely finds itself under scrutiny. However, in the campaign for a return to basics and the emergence of the Essence of Care (DH, 2003), it has been brought into the spotlight and formalised in the benchmark for personal and oral hygiene. While consideration is often given to whether patients can wash themselves or whether they require assistance, less attention is paid to the products and methods used.
In the case of mobile self-caring patients with a healthy diet, it could be argued that they should be free to use the same products as they use at home. However, in the case of more vulnerable, immobile, incontinent and older patients it may be worth paying greater attention to the skin hygiene routine employed and the products used.
The cost of managing patients with pressure ulcers has been estimated at £321 million a year (DH, 1992). While the UK may be some way behind developing a litigation culture similar to that of the USA, there are indications to suggest that this may change. With an increased focus on clinical governance, a stronger patient voice and a more openly accountable culture emerging in the NHS, we may see a decline in tolerance to poor and negligent care, and this may manifest in increasing litigation.
While individualised care may be promoted by the use of personally chosen rather than communally available products, there may be times when a specialised product would be better suited to a patient's needs. Given the altered circumstances (illness, immobility, environmental temperature changes) often associated with hospitals there is scope for additional skincare support and protection.
While patients are generally expected to supply their own toiletries, the benchmark of best practice stipulates that these should be provided until patients can supply their own. Thus, it is necessary to have products available for patient use. These are likely to be standard stock delivered alongside routine supply deliveries.
However for more specialised products, it is necessary to research the market, and assess and evaluate products to ensure that what is purchased is safe and cost-effective.
If you find yourself in a position with a budget to purchase a wash-cream product, you may be surprised to find that how few of those available in the UK have hospital patients in mind. This may be because we do not consider there to be a need for specific products or simply because the subject has not been given much thought.
Ageing and the skin
Ageing leads to many changes in the skin and its appendages (nerves, glands, hair, nails). These are categorised as intrinsic (true) ageing or photoageing. Intrinsic ageing is associated with time alone, whereas photoageing is due to preventable chronic exposure to ultraviolet radiation superimposed on intrinsic aging (Merck, 2004).
As the skin ages, it undergoes structural and functional changes (see box, p46)). The former include skin dryness, roughness, wrinkling and laxity; the latter include a decline in cell replacement and a reduction in barrier function, wound healing, immunologic responsiveness and thermoregulation.
The effects of skin ageing can be further compounded by the chemicals in many soap products, which can be harsh and potentially harmful. Most soaps alter the pH of the skin, which is normally between 4.5 and 5.5. The skin's mild acidity acts as an effective antimicrobial barrier. Sebum, produced by the sebaceous gland in the hair follicle, has natural fungicidal and bactericidal properties. As sebum moves along the follicle to the surface of the skin, it mixes with dead skin cells to form an acid mantle. Soap is a powerful degreaser that emulsifies fats and removes lipids, which bind to water from the skin resulting in skin dryness (Skewes, 1996).
Types of wash creams
There is a range of formulations, including creams (Clinisan, Tenaset), lotions (Esemtan), and foams (Necesse). Some are fortified with moisturisers and surfactants, while others have deodorant or antimicrobial properties. Some products can be used without water and do not require rinsing, while others are also suitable for dissolving in baths (Esemtan wash lotion). Some products require time to penetrate faeces before being wiped off.
As with many cosmetic products, these formulations are likely to be marketed as 'dermatologically tested'. Such statements require that the acute and long-time tolerance of a cosmetic product be confirmed by scientific methods in a reproducible manner (Voss et al, 2004).
There are different dermatological testing methods to test for possible irritation and allergic reactions, the most important being the patch test. This involves application (generally, to the back) of 0.1ml of a substance in an occlusive dressing which is then inspected at 24, 48 and 72-hour intervals. Variations on the standard test patch include the in-use test and the repetitive patch test, which assess sensitisation and long-term tolerance.
Recommendations of good practice and European Union (EU) directives provide guidance to the cosmetics industry in the interest of consumer safety. The European Cosmetics Directive 76/768 stipulates which ingredients can be used in cosmetic manufacturing, as well as addressing the use of animals in testing. The directive specifies lists of ingredients that are forbidden, restricted or that may be used without limitation in cosmetic manufacture.
Since 1998 animal testing on finished products no longer occurs. There have also been moves to prohibit the marketing of cosmetic products containing ingredients tested on animals. In 2001, the European Union committed to a ban on animal testing once alternative methods have been fully developed and validated (Voss, 2004).
Progressive technology has seen the development of sensitive instrumentation such as sebumetry and laserprofilometry that make it possible to test other properties of products and substantiate claims of efficacy. Various physiological effects can be measured using laboratory tests such as:
- Moisturising effect, using a corneometry
- Effects on sebum, using sebumetry
- Skin roughness, using computer-aided laserprofilometry
- Increase in blood circulation, using infra-red thermography
- Increase in skin elasticity, using cutometry.
Cosmetics as a finished product are not subjected to any registration procedures. All safety tests are incumbent on the manufacturer, who must make products according to good manufacturer practices. In cases of doubt, the manufacturer must prove in court that the methods used guarantee a product's safety and that the promises made in the advertising statements are proven by scientific methods (Voss et al, 2004).
The skin is a changing organ that is affected by the season, air humidity, age and temperature. It responds differently under different conditions and will be affected by ill-health and immobility. When choosing a wash-cream solution, it is crucial to consider not only the issue of cleanliness, but also infection control, skin breakdown and wound healing.
Carol McLoughlin, BSc (Hons), RSCN, RGN, is Deputy Editor, Professional Nurse.
Department of Health. (1992)Pressure Sores: A key quality indicator. London: The Stationery Office.
Department of Health. (2003)The Essence of Care: Patient-focused benchmarks for clinical governance. London: DH.
Merck and Co. (2004)The Merck Manual of Geriatrics. Aging and the Skin. Chapter 122. Available at: www.merck.com (accessed on January 6, 2005).
Skewes, S. (1996)Skin care rituals that do more harm than good. American Journal of Nursing 96: 10, 32.
Voss, W., Schlippe, G., Breuer, M. (2004)Test on Cosmetics: Scientific Standards. Available at: www.dermatest.de (accessed on January 6, 2005).
Voss, W. (2004)Dermatological Reports on Cosmetics: Possibilities and pitfalls. Available at: www.dermatest.de (accessed on January 3. 2005).