Basic care with hydrophilic and lipophilic ingredients

In many countries, xerosis cutis is the most common dermatological problem in the geriatric population. Especially when xerosis cutis is associated with pruritus, this leads to a considerable reduction in quality of life. The structural and functional changes in senescent skin require prophylactic and, if necessary, therapeutic barrier-protective skin care.

The appearance of xerosis cutis is listed as a separate diagnosis in ICD-10 (coding L85.3) and is associated with the intrinsic ageing process [1,2]. The incidence increases in an age-correlated manner, although the relevant information in the specialist literature varies depending on the study and the population examined [2]:

In a study conducted in Germany in 2019-2021 among 314 nursing home residents from 17 facilities, the prevalence of xerosis cutis was 95.9%, with the average age of this study population being 85.4 years (SD 7.1) [3].
In a study conducted in 2015/2016 on 1662 nursing home residents (average age: 81 years) and 1486 hospitalized patients (average age: 70.2 years), the prevalence was 41.2% and 55.2% respectively [4].
And in a multi-center study of patients over 65 years of age in primary care (n=756), xerosis cutis was documented in 55.6% [5]. Among those without other skin diseases in this study, quality of life (SF-12 questionnaire**) was more impaired in older patients than in younger patients.

** Short version of the SF-36 questionnaire (The 36-Item Short Form Health Survey) [15]

The “Overall Dry Skin Score” (ODS) is widely used to assess the severity of skin dryness [6].

It is important that basic care is applied at least twice a day and that certain behavioral measures are observed. Showering or bathing for too long or too hot should be avoided [10]. Synthetic detergents should be preferred to soaps and the room air should not be too dry.
Sufficient fluid intake is also recommended, as the feeling of thirst is usually reduced in old age and drug therapies (e.g. diuretics) can lead to additional fluid loss [10].

Skin dryness and age-associated pruritus

Xerosis in older adults is multifactorial: intrinsic changes in keratinization and lipid content, the use of diuretics and other medications, systemic diseases and heating/air conditioning may contribute [7,8]. Xerosis cutis is associated with reduced hydration of the stratum corneum, increased pH and reduced elasticity [2].

Itching associated with dry skin can have a particularly negative impact on quality of life [9]. Scratching can lead to painful wounds and scratch excoriations are an entry point for infectious agents [2,10]. The prevalence of age-associated pruritus reported in the literature varies greatly [10]. Renal and hepatic functional impairments are considered to be augmentation factors and the use of diuretics can reduce the availability of a biocompatible water phase in the stratum corneum [11,12].

In older skin, the renewal rate of keratinocytes slows down and their number can decrease as a result and due to increased apoptosis [16]. As the stratum corneum formed by keratinocytes is an essential element of the skin barrier function, its weakening not only leads to a reduced protective function but also to increased water loss [8]. This effect is also intensified by the decrease in the number and function of the sebaceous glands, so that a weakening of the lipid layer, another key element of the barrier and the waterproof layer, must be expected [16]. These factors lead to dehydration of the skin and thus to increased susceptibility and severe itching [8]. With the gradual degeneration of the skin’s innervation and the reduction in the number of sweat glands, the heat balance and cold tolerance deteriorate. The dry skin further increases susceptibility, and the subsequent scratching due to eczema and itching can lead to the formation of secondary lesions, i.e. excoriations and erosions [17].

Compensate for functional deficits in the physicochemical barrier

Membrane-forming lipids (ceramides or phospholipids), water and hygroscopic molecules are the decisive substituents for the formation of membrane structures in the intercorneocyte matrix [10]. And for effective rehydration, the choice of an acidic pH value (≤5.5), a high buffering capacity and inert and effective humectants (e.g. glycerol or urea) are important factors [13]. The particularities of aged skin have certain implications for the application of topical preparations: it should be remembered that the absorption of active ingredients is reduced due to the atrophy of the stratum corneum (reservoir function), but at the same time the epithelial permeation rate may be increased compared to adult skin [14]. In addition, a change in the diffusion conditions caused by the reduced microcirculation in the corial tissue can be assumed [14]. It is therefore recommended to apply basic skin care products several times a day and to observe certain accompanying measures (box).

Literature:

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