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OFFICIAL JOURNAL OF THE SOCIETÀ ITALIANA DI DERMATOLOGIA MEDICA,
CHIRURGICA, ESTETICA E DELLE MALATTIE SESSUALMENTE TRASMESSE (SIDeMaST)

VOLUME 150 - No. 6 - DECEMBER 2015


Principles of skin care in the elderly
C. SURBER 1, 3, S. BRANDT 2, A. COZZIO 3, J. KOTTNER 4
With aging, skin undergoes progressive structural and func-
tional degeneration that leaves it prone to a wide variety of
bothersome and even serious conditions and diseases. As skin
conditions and diseases may affect all ages from cradle to
grave, a disproportionate burden will clearly fall on the el-
derly and may significantly impact on quality of life (QoL).
With a reduced ability of the skin to regenerate, the elderly
are at an increased risk of skin breakdowns from even the
simplest insults. It is therefore vital that skin care in the late
adulthood is seen as a priority among both clinicians and
caregivers. The scientific literature on diagnosing and assess-
ing age-related skin conditions and diseases is vast; however,
when it comes to preventive care and treatment, the scientific
data available is less profound, and the recommendations are
often based on personal experience, opinions or at best on
consensus documents rather than on scientific data retrieved
from controlled clinical trials. In addition to the absence of
the scientific data, the imprecise terminology to describe the
topical products, as well as the lack of understanding the es-
sence of the vehicle, contributes to vague and often unhelp-
fully product recommendations. This paper aims to elucidate
some basic principles of skincare, the choice of skincare
products and their regulatory status. The paper discusses
adherence to topical therapies, percutaneous absorption in
the elderly, and skin surface pH and skin care. Lastly, it also
discusses skin care principles in selected age related skin con-
ditions and diseases.
Key words: Skin care - Aging - Administration, topical – Aged.
O ur skin reflects our origin, lifestyle, age and
state of health. Skin color, tone and evenness,
pigmentation, as well as skin surface characteristics
are signs of youth and age. Even in adolescence, the
Corresponding author: C. Surber, Department of Dermatology, Glori-
astrasse 31, CH-8091 Zürich, Switzerland.
E-mail: christian.suber@unibas.ch
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 699
G ITAL DERMATOL VENEREOL 2015;150:699-716
1 Department of Dermatology
University Hospital Basel, Basel, Switzerland
2 Galderma S.A., Egerkingen, Switzerland
3 Departments of Dermatology
University Hospital Zürich, Zürich, Switzerland
4Clinical Research Center for Hair and Skin Science
Department of Dermatology and Allergy
Charité‑Universitätsmedizin Berlin, Berlin, Germany 
potential signs of skin aging – supported by promo-
tional marketing – accompany our daily thoughts
and behavior. The cosmetic and pharmaceutical in-
dustry offers a vast armamentarium of products and
procedures to fight the signs of skin aging and prom-
ise youth and rejuvenation from both the outside and
the inside.
Despite critical voices regarding the effectiveness
of the antioxidants to prevent and repair age-related
damage, they are omnipresent in sophisticated for-
mulations for both systemic and topical applica-
tion.1 It is important to note a comment from the
authors of the systematic Cochrane Review “Anti-
oxidant supplements for prevention of mortality in
healthy participants and patients with various dis-
eases” including 78 randomized studies with almost
300,000 participants - «We found no evidence to sup-
port antioxidant supplements for primary or second-
ary prevention. Beta-carotene and vitamin E seem
to increase mortality, and so may higher doses of
vitamin A. Antioxidant supplements need to be con-
sidered as medicinal products and should undergo
sufficient evaluation before marketing».2 The body
of evidence for the effectiveness of topical antioxi-
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY
dants is equally insufficient. There is a noted paucity
of data, specifically in the form of double-blind, ran-
domized, placebo controlled trials and scientific in-
formation discussing the radical scavenging activity
of antioxidants before, during and after application.
Skin moisturization is another popularized health
ritual to fight the supposed signs of skin aging and
dry skin. In early adulthood the often environmen-
tally and lifestyle induced dry skin conditions with
the commonly accompanied pruritus can – in later
stages of life – become a serious skin health issue
(xerosis).3, 4 So far no comprehensive studies have
revealed the “best” methods of xerosis management,
and much of what we practice is based on empiri-
cal insights. However, it is generally agreed that the
keys to xerosis management in the later adulthood
population must include mild skin cleansing regimes
and normalizing the moisture gradient within the
stratum corneum.5 With age the functional capability
of all organs of the body undergoes a progressive de-
generative decline, including the skin. 6, 7 Moreover,
because the skin is in direct contact with the envi-
ronment, it commonly shows the cumulative signs
of these external insults. Hence, skin aging is com-
monly defined as a process in which both intrinsic
and extrinsic determinants lead progressively to a
loss of structural integrity and physiological func-
tion.8 Intrinsic aging of the skin occurs inevitably as
a natural consequence of physiological changes over
time at variable yet indeterminate genetically vari-
able rates.8 Extrinsic factors may be, to varying de-
grees, controllable and include exposure to sunlight,
air pollution and/or smoking, as well as repetitive
muscle movements like frowning, and lifestyle com-
ponents such as diet and pharmacotherapies.8 How-
ever, both pathways of skin aging are closely as-
sociated and the synergistic effects of intrinsic and
extrinsic aging over the human lifespan produce an
overall deterioration of the cutaneous barrier,9-11 and
significant-associated morbidity.12 Aged skin is sus-
ceptible to pervasive dryness and itching, cutaneous
infection, autoimmune disorders, vascular compli-
cations and increased risk cutaneous malignancy.
In fact, most people over 65 have at least one skin
disorder, and many can have two or more simultane-
ously.13
The demographics worldwide are changing rap-
idly with respect to its elderly population. Accord-
ing to the latest United Nations Revision of World
Population Prospects, the global population will
700 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015
grow to 8.5 billion in 2030. This goes along with sig-
nificant gains in life expectancy. Today, worldwide
901 million people are aged 60 years or over. This
number will increase to 1.4 billion in 2030.14 This
megatrend in the population dynamics will continue
to affect incidence and prevalence of age associated
skin diseases, as well as skin conditions. As skin
diseases may affect all ages from cradle to grave,
a disproportionate burden will clearly fall on the
elderly.12, 15 There is a prevailing perception among
clinicians that due to the prevalence of skin disease
among this demographic, many of the common skin
diseases, e.g. xerosis, or pruritus, may be of little
consequence in the overall health status of the in-
dividual in late adulthood. So, frequently in both
clinical and non-clinical real life situations many of
these skin diseases and conditions are not diagnosed
nor treated, 16 despite evidence that intolerable itch-
ing or moisture-associated skin changes carry severe
sequalae that can indisputably affect patient’s QoL
and self-image. In long-term care settings basic skin
care intervention received by care dependent vulner-
able elderly also vary widely and are not necessarily
evidence-based.17
With a reduced ability of the skin to regenerate
and a less efficient protective immune system, the
elderly are at an increased risk of skin breakdowns
from even the simplest insults. It is therefore vital
that skin care in the late adulthood is seen as a prior-
ity among both clinicians and caregivers.
Against this background, this paper aims to elu-
cidate some basic principles of skincare, the choice
of skincare products and the irregulatory status. We
have discussed adherence to topical therapies, per-
cutaneous absorption in the elderly and skin surface
pH and skin care. Lastly, we will discuss skincare
principles in selected age related skin conditions and
diseases.
Principles of skin care
The concept of skin care is not well defined. It is
a kind of umbrella term covering cleansing, perfum-
ing, changing appearance, changing body odor, pro-
tecting and keeping the skin in a “good condition”.
In the last decades our perception of skin care has
broadened and soothing of skin symptoms/condi-
tions, and improvement and restoration of the skin’s
barrier function and integrity have been added. To-
PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
day, modern basic skin care includes cleansing,
soothing, restoring, reinforcing and protecting. With
increasing age the emphasis on skin care is evolv-
ing.18 The importance of soothing, restoring, rein-
forcing increases and cleansing should be executed
with particular care. The character of skincare shifts
from more cosmetic objectives – smooth, healthy
looking skin – to more therapeutic and preventive
objectives – soothing, restoring, reinforcing and pro-
tecting stressed skin. Even though skin protection
plays an important role throughout lifetime, the inju-
ries and the skin areas in primary need of protection
also change. In younger years environmental inju-
ries (e.g. UV radiation) are of primary importance
whereas in advanced years age-related injuries (e.g.
prolonged exposure to various sources of moisture,
including urine or feces, perspiration, wound exu-
date, and their contents) become more important.
Subsequently the skin areas in need of protection
also change - initially skin areas (e.g. face, arms,
legs) exposed to the environment and later enclosed
skin areas (e.g. skin folds, perianal, perigenital skin,
groin, feet) become the vulnerable zones (hot spots).
Skin diseases (e.g. bacterial/fungal infections), sys-
temic diseases (e.g. diabetes) or pharmacotherapies
(e.g. cancer therapies) also necessitate special skin
care (see section “Selected skin conditions and dis-
eases”).
The character of the injuries, the skin symptoms/
conditions and the skin areas in need of protection
determine care procedure and care product choice.
The information on skin care procedures is rich, but
little scientifically documented, and the number of
products available for cleansing, soothing, restoring,
reinforcing and protecting is of an almost infinite va-
riety.
Nonetheless some basic product functionalities,
such as cleansing, soothing, restoring, reinforcing
and protecting, may be described as:
—— removal of dirt, sebum, microorganisms and
exfoliated corneum cells from the skin;
—— reduction of unpleasant skin symptoms (e.g.
pruritus, burning);
—— restoration of damaged skin (e.g. xerosis, dry
skin);
—— reinforcement of undamaged but vulnerable
skin (e.g. skin surface pH balance, germ reduction);
—— protection of damaged, undamaged and vul-
nerable skin from various injuries, respectively.
The functionality of the skincare products ranges
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 701
from mono-functional, e.g. barrier creams to poly-
functional, e.g. soothing and restoring cleansers.
Care procedures – washing/drying and the appli-
cation of leave-on products – should be as benign as
possible. The unduly removal of natural skin com-
ponent (e.g. lipids), prolonged exposure to moisture
and excessive and/or prolonged occlusion of the skin
should be avoided.
Skincare delivered to improve, e.g. the outcome
of aneczema therapy or to reduce, e.g. the adverse
effects of a cancer therapy are often termed as adju-
vant skincare. Nonetheless, preventive and adjuvant
skincare pursue the similar goals.
How to choose a skincare product
There is an overwhelming range of skin care prod-
ucts on the commercial market with a multitude of
promises and application recommendations. The
later often includes recommendations regarding the
choice of vehicle. However, these recommendations
are unfortunately often founded on faulty science.
One reason is the absence of a clear and persuasive
terminology for vehicles. Current recommendations
rarely differentiate between vehicle effect (moistur-
izers, emollients, occlusives, humectants, etc.) and
vehicle form (ointments, creams, lotions, gels, etc.),
e.g. “a moisturizer is a cream for application on face
and body”. From many recommendations suspicion
may arise that the essence of the vehicle is not fully
understood, e.g. “unlike lotions, which do not main-
tain moisture in the skin, cream moisturizers donate
moisture and aid in retention of moisture on the skin
surface”.19 The terms “moisturizer” and “emollient”
are often used interchangeably, despite the fact that
they describe a different mechanism. A moisturizer
adds moisture to the tissue, while an emollient sof-
tens a tissue and makes it flexible. Moisturizers have
softening effects, conversely emollients do not nec-
essarily moisturize.
Without going into physicochemical details, one
may define a vehicle as a mixture of a series of in-
gredients that forms a three dimensional matrix, e.g.
cream or ointment, etc. The physicochemical charac-
ter of the ingredients chosen and the manufacturing
process determine the final form of the vehicle – the
three dimensional matrix. When two immiscible liq-
uid phases, each may contain several ingredients, are
mixed and stabilized an emulsion results. In phar-
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY

maceutics and cosmetics the emulsion is termed as a
cream or a lotion. Creams are semisolid whereas lo-
tions are more liquid. The difference between these
two forms is primarily viscosity. Depending on the
ingredient (emulsifier) chosen to stabilize the emul-
sions, the emulsion may become an oil in water (o/w)
or a water in oil (w/o) emulsion (Figure 1).
In case of o/w emulsion the lipophilic (inner) phase
Figure 1.—Depending on the ingredients (emulsifier) chosen to
stabilize the emulsions, the emulsion may become an oil in wa-
ter (o/w) or a water in oil (w/o) emulsion. Semisolid emulsions
are termed as creams whereas more liquid emulsions are termed
as lotions. The difference between these two forms is primarily
viscosity. It is also easy to imagine that the sensory character of
the o/w and the w/o emulsions on the skin may be very different.
Due to evaporation the o/w emulsion will convey the immediate
impression of “cooling”.
is dispersed in the hydrophilic (outer) phase. In case
of w/o emulsion the hydrophilic (inner) phase is dis-
persed in the lipophilic (outer) phase. It is easy to
imagine that the sensory character of the emulsion
on the skin may be very different. Due to evaporation
the o/w emulsion will convey the immediate impres-
sion of “cooling”. A considerable number of ingre-
dients that are used to create semisolid formulations
are volatile, e.g. water, alcohol and even propyleng-
lycol. Due to this phenomenon – termed as metamor-
phosis of the vehicle, the three dimensional matrix
(vehicle) may change dramatically after application
to the skin (Figure 2).20 This phenomenon becomes
often recognizable as the visual aspect of the skin
surface is changing. It gives the false impression to
both consumers and professionals that the product is
well absorbed, even though only volatile ingredients
are evaporating. Absorption into or through the skin
of most ingredients demands much more time.
As a consequence one may differentiate between
two types of vehicles: the primary vehicle in the tube,
bottle or jar, and the secondary vehicle that forms
after application on the skin. The latter has lost all
or significant amounts of its volatile ingredients.
Besides, the original three-dimensional matrix may
have completely changed. The primary formulation
is responsible for the application sensation, while the
secondary formulation is responsible of the subse-
quent skin feel and long-term effect. Furthermore the
properties of the ingredients – hydrophil (solubility

Figure 2.—A) In clinical situations, most topical vehicles (structural

matrix and ingredients) undergo considerable changes after they are
removed from the primary container and are applied onto the skin.
This process is termed as “metamorphosis of the vehicle”. B) Due
to evaporation of volatile ingredients (hydrophil phase), the initial
structural matrix of the primary vehicle will most likely change dur-
ing and after application of the product. Compounds originally dis-
solved in volatile vehicle ingredients may precipitate after vehicle
evaporation. The secondary vehicle determines the after appliocation
of skin feel and the delivery of “actives”.

702 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015

PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER

in water) or lipophil (solubility in oil) – chosen to
formulate the vehicle, determine its final character.
This means, theoretically and practically, that for
most of the vehicles (e.g. lotions, gels) a hydrophilic
and a lipophilic form exists, e.g. hydro- vs. lipolo-
tion or hydrogel vs. oleogel. From a practical point
of view, it is important to note, that lipophil formula-
tions are often less effectively removed from the skin
than hydrophil formulations. In the case of stressed
skin topical formulation must be easily removable
and an appropriate cleansing product/procedure has
to be chosen.
As a consequence for the future one may expand
previous criteria of vehicle choice (cream, lotion,
ointment, gel) and also use polarity (hydrophil vs.
lipophil) and viscosity (low vs. high). Hydrophilic
vehicles are more suitable for moist and lipophilc
vehicle are more suitable for dry skin conditions.
Low viscosity vehicles are more suitable for larger
whereas high viscosity vehicles are more suitable for
smaller skin areas (Figure 3).
A vehicle is something that carries, delivers,
transports etc. A vehicle for topical application may
carry, transport or deliver pharmaceutical or cos-
metic actives. While often expected, the effect of
most skincare products cannot be assigned to one
single “active” ingredient. The following exam-
ple may illustrate this fact. A skincare lotion may
contain glycerin, dimethicon and/or paraffin. They
are concurrently integral part of the vehicle and ac-
tive ingredient. Glycerin (hydrophilic ingredient)
termed as humectant attracts water from the envi-
ronment and from within the skin once penetrated
into the stratum corneum. Dimethicone and/or par-
affin (lipophilic ingredients), considered as occlu-
sive, keep the moist within the skin by decreasing
trans epidermal water loss of the skin through oc-
clusion. These ingredients formulated in emulsions
serve as moisturizing creams or lotions. Again the
combination of ingredients is responsible for the
moisturizing effect and not the three-dimensional
form – the cream or lotion.
For daily practice, healthcare professionals, pa-
tients and consumers may put more emphasis on
polarity and viscosity of the vehicle rather than
the vehicle form. As these features are rarely men-
tioned on the product labeling or in the accompa-
nying information only own previous experience or
recommendations from thirds parties may help to
choose the adequate product of preference. Another
option is to rely on the functionalities claimed on
the product.

Figure 3.—From a theoretically and practical point of view, polarity (hydrophil vs. lipophil, x-axis) and viscosity (low vs. high, y-axis)
are relevant vehicle features to consider when choosing a product. Hydrophilic vehicles are more suitable for wet/moist and lipophilc
vehicle are more suitable for dry skin conditions (x-axis, top). Low viscosity vehicles are more suitable for larger skin areas whereas
high viscosity vehicles are more suitable for smaller skin areas. Typical vehicles are: (y-axis, right) aqueous solution; (y-axis, right)
o/w- orhydrolotion; (y-axis, right) o/w-cream; hydrogel, hydrophilic ointment; (y-axis, right) cross-linked hyaluronic acid gel (cubed
water); (y-axis, right) lip stick; (y-axis, right) lipogel, lipophilic ointment; (y-axis, right) w/o-cream; (y-axis, right) w/o- or lipolotion;
(y-axis, right) oil.

Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 703

SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY
Cleansing products
Cleansing includes washing, showering and bath-
ing. It removes dirt, sebum, microorganisms and
exfoliated stratum corneum cells from the skin.
Cleansers are products that are used as such, added
to the washing water or are part of wipes to remove
debris from the skin in an emulsified form. The key
cleansing ingredients are the “surfactants” – a term
derived from the words “surface” and “active” – that
lower the surface tension on the skin and hence re-
move the debris. Syndet is another portmanteau word
created by combining the words “synthetic” and “de-
tergent”. Soaps were the first surfactants people used
for cleansing. They are made by reacting fatty ac-
ids with a base (e.g. sodium hydroxide) – a process
that is called saponification. All the terms are often
used as linguistic synonyms even though the physi-
cochemical difference between the classic soap and
syndets/detergents is distinctive. Soaps have a pH of
9 to 10, whereas syndets/detergents show a pH of 5
to 6. The latter pH is preferable for the skin. Depend-
ing on the emulsifying capability of the surfactants,
they may disturb or disrupt the skin barrier and hence
aggravate an unfavorable skin condition.21-23 Cleans-
ers may contain antimicrobials (e.g. benzalkonium
chloride or iodine) or humectants (e.g. glycerin) or
occlusives (e.g. paraffin) to compensate cleansing-
induced damage. Because cleansers are rinse-off
products, the effectiveness of antimicrobial addi-
tives have been questioned.24 The effect of other ad-
ditives may also be questioned because significant
amounts are lost during cleansing. Acidic cleansers
with “mild” surfactants (non-ionic/silicone-based
surfactants) – minimal disturbance/disruption and
yet high rinsibility – are generally recommended to
cleanse vulnerable skin of the elderly.
Soothing, restoring, reinforcing products
Even though there are linguistic differences be-
tween the terms soothing, restoring, reinforcing it
is difficult to subcategorize products accordingly.
The soothing character of a product can rarely be
awarded to a single substance in the product. Prod-
ucts restoring the skin (e.g. moisturization) will most
likely soothe the skin (e.g. pruritus). Reinforcing
products will create or support natural and healthy
skin conditions (e.g. acidic skin pH, limit bacterial/
704 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015
fungal growth). Xerosis, skin surface pH and skin
infections are discussed separately in this text.
Protecting products
“Barrier cream” is the colloquial term for topical
products that are placed as physical barriers between
the skin and contaminants that may harm the skin.
“Barrier creams” may also be intended as products
that may restore a damaged skin. In this sense, any
moisturizing or emollient product can be considered
a potential skin barrier improver.25 Unfortunately,
this term is used vaguely – both in guidelines and
scientific papers. Furthermore, “cream” is just one
possible form of such products: other forms such
as ointments, pastes or foams also exist. To avoid
linguistic misunderstandings one may differenti-
ate between “barrier products” and “barrier repair
products” (see also “Restoring products” section).
The first is defined as a product that provides a real
barrier against noxious agents, the latter is defined
as a product with the clear intention to restore and
reinforce the skin. A barrier product does not si-
multaneously provide a barrier against all noxious
agents. The general rule is that more lipophilic for-
mulations are effective against hydrophilic solutions
of irritants, and hydrophilic formulations are more
effective against lipophilic materials. Even though
studies have shown effects of barrier products in age-
associated skin conditions (prevention of superficial
pressure ulcers and incontinence-associated dermati-
tis) their general benefits are still debated.5
Shortly, it seems that functionality is an adequate
mean to describe a product and alleviate the product
choice. However, the industry is prone to exagger-
ated embellishments of the product functionality and
reliable choices are often difficult.
Skin care products and regulatory issues
Skin care products can be assigned to three differ-
ent regulatory classes: medicinal products, medical
device and cosmetics. For medicinal products and
medical devices a health promise is allowed, where-
as for cosmetics a health promise is prohibited. The
health promise refers to the preventive and/or thera-
peutic purpose of the medicinal product or the medi-
cal device. They achieve their principal intended ac-
PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
tion in or on the human body by pharmacological,
immunological or metabolic means or by non-phar-
macological, non-immunological or non-metabolic
means, respectively. Cosmetics are meant to clean,
to perfume, to change appearance, to correct body
odor, to protect and to keep in good condition.26 Cur-
rently the majority of skincare products are cosmet-
ics. For medicinal products and medical devices the
indication are clearly labeled, e.g. xerosis cutis or
pruritus. In cosmetic, products claims often describe
their functionalities and may be as simple as “soothe
signs of dry skin” but may also be more fanciful like
“Multi-Ingredient Anti-Aging Moisturizer Designed
to Improve the Appearance of Facial Skin”.27 It is im-
portant to note, that while the boundaries of the three
regulatory classes seem well defined, there are many
examples to demonstrate that these boundaries are
not as well defined as one may assume. Occasional-
ly, you will find that regulatory bodies will question
promotional claims and require commercial suppli-
ers to provide additional substantiation or change
the products’ claim. To increase professional cred-
ibility and reputation some commercial organiza-
tions promote their products as cosmeceuticals and
more recently they started to conduct clinical trials
with their cosmetic products. Both, however, do not
change anything regarding the regulatory status of
the product and the permitted claims. It is obvious
that the label “clinical proven” has a promoting and
valorizing effect even though the clinical relevance
may be insignificant. Whereas for medicinal prod-
ucts and to a certain degree for medical devices any
change of the product is subject to a formal regula-
tory announcement and process, there are few rules
for cosmetics. The latter facilitates the introduction
of new “active” cosmetic ingredients to create new
unique selling proposition and to satisfy the consum-
er’s desire. A well-known example ingredient is Aloe
vera incorporated in many topical formulations. The
authors of a recent Cochrane Review on the effect
of Aloe vera topical agents or Aloe vera dressings as
treatments for acute and chronic wounds came to the
conclusion that there is currently insufficient clinical
trial evidence available.28 This was primarily due to
the lack of high quality trials with adequate method-
ology. Currently, this judgment also applies to many
of the “active” cosmetic ingredients and their sup-
posed effects.
This regulatory situation is unknown to most of the
consumers and healthcare professionals and it rarely
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 705
influences a procurement decision. So far a difference
in product performance between products of differ-
ent regulatory classes (cosmetics and medical device)
could not be shown and it was postulated that the cos-
metic products were more cost-effective.29, 30 Con-
sumers and healthcare professionals have to trust the
current regulations on cosmetic products and quality
standards used by the manufacturer.
Skin care related issues
Adherence to topical therapies and age
Poor adherence can hinder the successful treat-
ment of chronic conditions. Research during the
past several decades showed that, depending upon
the condition and severity as well as the complex-
ity of the prescribed regimen, 40% of patients do
not adhere to the agreed treatment recommenda-
tions.31 In its 2003 report, the WHO recognized that
‘‘increasing the effectiveness of adherence interven-
tions may have a far greater impact on the health
of the population than any improvement in specific
medical treatments’’.32 Low medication adherence
leads to an inefficient use of health care resources
and therefore creates a considerable financial loss
to society. Furthermore, low adherence can result
in a misleading clinical picture in a patient’s treat-
ment.33 Even though there is no data available on
adherence to topical therapy in the elderly one may
assume that it will decrease with age and concurrent
loss of cognitive skills and may only become better
when the elderly has caregiver support in place for
daily living. Finlayson et al. showed in patients with
chronic venous insufficiency that depression, self-
efficacy and disease state knowledge were found to
be significantly related to adherence to compression
therapy as a primary strategy to prevent recurrence
of venous leg ulcers.34 For some indications topical
formulations have been developed to ease therapy
adherence. A popular concept is to simplify prod-
uct application e.g. using a spray 35 to avoid rubbing
(Figure 4), an application stick to avoid product-fin-
ger contact (urea stick) or to reduce the application
frequencies from daily to weekly applications.36
It should therefore be a primary goal of any com-
mercial organization (developer, healthcare supplier
and healthcare consumer) to develop and to use care
products that favor adherence.
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY

Figure 4.—Spray applications are welcome in situations where rubbing or product-finger contact should be avoided. The presented fast
breaking foam spray demonstrates additional advantages. The white foam appearance alleviates the accurate dosing of diseased skin
areas but “disappears” within less than 30 seconds and leaves no residues. The fast breaking foam spray is also a distinctive example
for the metamorphosis of the vehicle (see section How to Choose a Skin care Product). This phenomenon tempts both consumers and
professionals to believe that the product is well absorbed, even though only volatile ingredients are evaporating. Penetration into and
permeation through skin (absorption) of most ingredient demands more than 30 seconds.

Percutaneous absorption Skin surface pH and basic skin care

It is reasonable to speculate that increased skin
dryness, decreased sebaceous gland activity and
thinning of the epidermis – typical signs in the skin
of the elderly – will impact percutaneous absorp-
tion.37, 38 Despite the paucity of in vivo data avail-
able on percutaneous absorption of lipophilic and
hydrophilic compounds in humans over the age of
65, there is a definite dose-dependent relationship
in humans over the age of 65 that demonstrates a
pronounced decrease in cutaneous absorption of hy-
drophilic compounds and a lesser decrease in cuta-
neous absorption of lipophilic compounds in older
adults.39 However it remains unclear whether these
observations noted in intact skin have clinical rele-
vance. There is reliable data that skin barrier function
impairment can dramatically increase percutaneous
absorption.40 Depending on skin barrier impairment
and local ambient skin conditions percutaneous ab-
sorption can be significantly impacted. It is therefore
advisable to avoid topical products with unneces-
sary additives such as perfumes etc. With transder-
mal drug delivery systems - e.g. matrix patch with
rivastigmine (Exelon®) - the permeability of the skin
is of minor relevance since the “rate-limiting” step
of drug delivery is controlled by the delivery system
(e.g. patch).
The skin surface pH is normally acidic, ranging
in pH values of 4-6, while the body’s internal en-
vironment maintains a near-neutral pH.41 The physi-
ologic role of an acidic skin surface, termed the acid
mantle, has been historically thought to be a defense
mechanism against invading organisms.42 More re-
cently, it has been shown that several key enzymes
involved in the synthesis and maintenance of a com-
petent skin barrier are influenced by pH. A number
of factors, including both endogenous (e.g. age,
anatomic site, skin moisture, sweat) and exogenous
(e.g. detergents, cosmetics, soaps, occlusive dress-
ings, topical antibiotics) factors can have a signifi-
cant influence skin pH.43, 44 Immediately after birth
the skin surface pH drops gradually from approxi-
mately 7 to 5 during the first month of life.45 In older
adults there is an increase in skin pH, as well as a
reduced buffer capacity.46, 47 Ceramide deficiencies,
commonly present in aged skin can have significant
implications on cutaneous barrier function and may
be explained by elevated activity levels of enzymes
that have alkaline optima.48 Alkaline ceramidase,
which has a pH optimum of 9 and is involved in bar-
rier lipid degradation, has a higher activity in aged
human skin.41 The pH is higher in the interdigital
spaces and intertriginous areas - axillae, groin and

706 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015

PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
inframammary zone and can promote colonization
by bacteria and yeast.44, 49 Several dermatoses char-
acterized by disruption of the permeability barrier
have reported an altered skin pH. Higher pH in dia-
betic intertriginous skin was interpreted as a possi-
ble factor promoting host susceptibility to candida
infection. Significant correlation between severity
of diaper dermatitis and elevated skin pH in the dia-
per area has also been demonstrated.50 Exposure of
urine and feces generates ammonia and produces
an alkaline environment. Alkaline pH activates fe-
cal proteases and lipases which breakdown the skin
barrier. Adult diapers using acidic cellulose material
in order to maintain a pH of 4.5-5.5 in the diaper
area supported the resolution of pre-existing irri-
tant skin lesions and cleansing wipes with increased
pH buffering capacity to maintain physiologic skin
pH have also been developed.51, 52 It seems obvious
that exposure to exogenous agents such as cleans-
ers, moisturizers, emollients, protectants, and topi-
cal drugs have an effect on skin surface pH and can
further exacerbate underlying skin condition or dis-
ease. Selection of topical products that preserve an
acidic environment seems relevant.44, 53 Surprisingly
still many commercial and widely available topical
products are not skin pH adapted or give no specific
instructions for use.54
Epidemiology: what needs to be taken care of?
One of the first published epidemiological figures
about skin conditions and diseases in the aged can be
traced back to the late 1940’s. Based on chart reviews
of 2000 patients in the USA, Lane et al. reported
that actinic keratosis (14.4%), skin cancer (14.3%),
seborrheic keratosis (8.8%), eczema (8.8%), con-
tact dermatitis (6.5%), and pruritus (4.9%) were
the most common diagnoses found during a der-
matological examination in older persons (60+
years).55 Since then other reports followed covering
home and community,56-58 ambulatory,59, 60 long-term
care,61, 62 and hospital settings in various geographic
regions.63, 64 There is a large heterogeneity in terms
of epidemiological study designs and sampling (e.g.
random vs. convenient), ways of data collection
(e.g. self-reported vs. diagnosed), applied diagnos-
tic categories (e.g. ICD-9 vs ICD-10) and results
reporting. Subsequently, the comparability between
prevalence and incidence figures is limited. Besides
these diverse single prevalence and incidence studies
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 707
reviews have been published 65, 66 and a systematic
review is underway.67 Despite the limited compara-
bility and possible methodological limitations of the
available epidemiological figures there seems to ap-
pear similar patterns regarding skin conditions and
disease frequencies in the aged. Interestingly, these
frequency patterns today seem to be similar to the
aforementioned figures reported more than seventy
years ago.
On one hand there is a clear association with in-
creasing chronological age and various benign signs
of intrinsic and extrinsic skin aging like Cutis laxa
senilis (L57.4), dyspigmentation (e.g. lentigenes,
L81.4), and increased wrinkling.63, 57, 68 Although an
aged appearance is not life threatening it can have
significant negative influences on self-esteem and
social relations.69 On the other hand there are vari-
ous clinically relevant skin conditions that need to
be considered in the evaluation of late adulthood
skin disease. The available evidence suggests that
dry skin (xerosis cutis L85.3) is one of the most
frequent skin conditions in the elderly. In ambula-
tory and outpatient settings prevalence of xerosis
can range from 6% to 77%.60, 70, 71 The proportions
of care receivers in long-term care with dry skin are
higher ranging between 30% and 85%.57, 61, 72 There
is a clear association between dry conditions and
pruritus, which is one of the most distressing and
burdensome skin symptoms in the aged.12 In com-
munity and outpatient care settings the prevalence of
pruritus ranges from 1% to 36%.63, 64 In long-term
care the prevalence of pruritus was reported to be
10% and 70%.57, 73, 74 Elderly people are often affect-
ed by skin infections, especially fungal infections.
Approximately one half of long-term care receivers
are affected by Tinea unguium (B35.1).73, 74 Tinea
pedis (B35.3) prevalence ranges from 18% in home
care to 34% in nursing homes.57, 62 Another group of
prevalent skin problems in the elderly are skin and
underlying soft tissue injuries and wounds. Due to
anatomic and physiologic changes in skin and sub-
cutaneous tissue in combination with immobility and
other functional impairments the elderly are espe-
cially prone to develop pressure ulcers. In aged care
settings prevalence of pressure ulcers varies between
4% and 15%.75, 76 Additionally, the increase in preva-
lence of pressure ulcers in the aged is also associated
with a substantial decrease in life longevity, as well
as an increase in disability as the burden of this skin/
tissue condition becomes more significant.12 More
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY

importantly, there are many more superficial skin in-

juries in geriatric care such as incontinence associat-
ed dermatitis or skin tears. Empirical research about
these clinical phenomena in aged patients is sparse.
However, there is data that shows the prevalence of
incontinence associated dermatitis in long term care
facilities can range between 3% and 23%,77, 78 the in-
cidence of skin tear in a cohort of 65+ years Japanese
elderly receiving hospital care was 3.8% 79 and the
prevalence of skin tears in long-term care facilities
was reported to be 4% and 22%.80, 81
The epidemiological figures presented here are
only a small selection out of many more age-asso-
ciated skin conditions and dermatoses. According to
the latest Global Burden of Skin Disease study, there
is not only an increase of certain dermatologic diag-
noses, e.g. pruritus, pressure ulcers, or non-melano-
ma skin cancer, but there is an overall of increase of
years lost due to disability due to skin conditions in
general in elderly populations.12

Selected skin conditions and diseases

In the following section we have provided some

insights into skin care of selected age related skin
conditions and diseases such as A) dry skin (xerosis);
B) pruritus; C) skin infections; D) pressure ulcers; E)
moisture-related skin damage; and F) skin tears.

Dry skin (xerosis cutis) and pruritus

Dry skin, or xerosis, is a common problem that
most people experience to varying degrees at some
stage in life (Figure 5).82, 83
In some instances, the underlying cause may be
a simple case of altered environmental factors (e.g.
seasons, climate, excessive bathing, use of harsh
skin cleansers), while in others, endogenous fac-
tors such as deficiencies in the skin’s natural mois-
turizing factor (NMF) or barrier lipid content may
be involved.84 Because age is an important variable
for consideration in the manifestation of xerosis, its
incidence increases in the aging populations of de-
veloped countries.83 Dry skin conditions typically re-
flect the disruption of the normal functioning of the
epidermal skinbarrier. Once the skin becomes dry, it
is more vulnerable to splitting and cracking, expos-
ing it to increased water loss and more susceptible
to bacterial, fungal and viral invasion, increasing the
Figure 5.—Typical example of xerotic skin (trunk) in an elderly
that needs moisturization.
risk to secondary infections. Dry skin is also associ-
ated with other skin diseases (e.g. eczema, psoriasis,
ichthyosis) as well as systemic illness (e.g. hypothy-
roidism, liver/kidney disease, malnutrition). Mois-
turizers are an important component in promoting
skin health in the elderly and are typically referred
to as the first-line treatment for all dry scaling disor-
ders, regardless of age group. Due to the increasing
prevalence of dry skin conditions affecting a wide
range of people, there has been a rapid increase in the
number of commercial products available to treat this
common and prevalent skin condition. These com-
mercial products contain a wide range of functional

708 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015

PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
ingredients, including occlusives (e.g. petrolatum,
mineral oil, dimethicone) or humectants (e.g. NMFs,
glycerin, sorbitol). Other ingredients such as cera-
mides, ceramide precusors and other barrier lipids
are meant to supplement stratum corneum structural
barrier components or stimulate the endogenous pro-
duction of essential barrier components. The range
of ingredients has become more diverse as consum-
ers are in constant search for newer and more effec-
tive ingredients. It is practical to distinguish between
occlusive based and humectant based moisturizers.
Occlusive-based moisturizers provide a permeabil-
ity barrier support that reduces trans-epidermal wa-
ter loss and protects irritated inflamed skin from
external irritants to promote moisture retention and
allow barrier repair. Humectant-based moisturizers
provide hydrating effects to the skin via humectants
that attract and bind water from the epidermis and
environment to impart hydrating benefits. Replacing
or replenishing the supply of NMF (natural humect-
ants) in the skin through the external application of
NMF-containing moisturizers has been reported to
successfully treat xerotic skin.85 Several NMF com-
ponents have been used for decades, e.g. urea and
lactate have been used in moisturizing products
since the 1940s.86 In general, the currently available
commercial moisturizers include both occlusive and
humectant ingredients. Moisturizers predominantly
made of occlusive ingredients have been described
as “heavy” and tend to report a “greasy” sensorial
affect, whereas moisturizers predominantly made of
humectant ingredients are commonly described as
“light” and report a well-absorbed sensorial affect.
Interestingly, there are currently a number of com-
mercially available products formulated with lipid
and molecular components found in the stratum cor-
neum. However, it is still not clear whether the cuta-
neous effects reported can be uniquely assigned to
the ingredients or the formulation that includes both
occlusive and humectant ingredients.
It is also essential to prescribe adequate quantities.
The joint British Association of Dermatology (BAD)
and Primary Care Dermatology Society (PCDS)
guidelines recommend 600 g of moisturizer per
week for adults (British Association of Dermatolo-
gists/Primary Care Dermatology Society Guidelines,
2006). This should be applied at least twice daily,
preferably after bathing.87, 88
Pruritus is the most common skin complaint in
patients over the age of 65 years and can best be de-
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 709
fined as an unpleasant sensation that leads to a de-
sire to scratch.89 This often-neglected symptom can
have a profound impact on the quality of life in the
elderly, especially impacting sleep cycles and result-
ing sleep deprivation. Given the multitude of vari-
ables that come with advanced age, the management
of pruritus in the elderly poses a particular clinical
challenge, especially when an underlying etiology
cannot be identified.4, 90 The causes of pruritus can
be multifactorial. Pruritus is often a common symp-
tom reported in many skin diseases, such as allergic
contact dermatitis, and is also associated with some
medications (both topical and systemic, e.g. opioids,
aspirin) as well as other exogenous causes, such as
scabies and exposure to environmental agents (e.g.
irritants such as soaps). A number of common sys-
temic disease states frequently encountered in the
elderly may predispose to the development of pru-
ritus, the more common of which includes diabetes,
chronic kidney disease, cholestasis, thyroid dysfunc-
tion and iron deficiency anemia.89 Investigations are
often necessary to establish the cause of pruritus.
However, due to the still limited understanding of
the pathophysiology of pruritus, the development of
effective treatment modalities has proven to be dif-
ficult. At present, there is no universally accepted
therapy for itch. Instead, management of pruritus
takes an individualistically tailored approach. Topi-
cal products (moisturizer, emollients and barrier
products) that improve the barrier function of the
skin are considered the cornerstone of antipuritic
treatment.91 Due to the study design it remains most
often unclear whether an active and/or other ingre-
dients of the topical formulation were responsible
for an observed effect. In addition topical therapies
with products lowering the skin pH may be useful
in optimizing the skin barrier function through their
maintenance of the normal acidic pH of the skin sur-
face.92 Topical corticosteroids, immunomodulators,
antihistamines, menthol, capsaicin, local anesthetics
and cannabinoids have reported antipruritic effects,
however the number of studies are limited and most
of the data available is based on case series or small-
scale studies.89, 93, 94
Skin infections
Due to age-related anatomical, physiological and
environmental factors, elderly individuals can have
an increased susceptibility to skin infections.95, 96 The
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY
types of organisms that cause primary skin and soft
tissue infections are diverse, and include bacterial,
viral and fungal pathogens as well as parasites. In the
elderly, these infections and infestations may present
with atypical signs and symptoms or may complicate
underlying chronic skin disorders. The pharmaco
therapeutic armamentarium for treating infections
of the skin, skin organs and soft tissue is broad and
effective, however some infections, e.g. fungal nail
infections, may require prolonged treatment that de-
mand a very high patient adherence to therapy. Skin
hygiene including germ reduction and skin acidifica-
tion is considered a key preventive mean to maintain
skin integrity. Secondary skin infections may result
from shared patient care items or from persistent
pruritus associated with increasing dryness of the
aging skin.97 Emollients and topical antihistamines
can be useful measures.98
Pressure ulcers
A pressure ulcer is localized injury to the skin
and/or underlying tissue, usually over a bony promi-
nence, as a result of pressure, or pressure in combina-
tion with shear.99 Prolonged deformation of soft tis-
sues leads to ischemia, reperfusion injury, impaired
lymphatic function and direct deformation damage.
Therefore, most effective preventive strategies are
off-loading and pressure redistribution. This could
be accomplished by using special support surfaces,
mobilization and repositioning.99 Skin care in eld-
erly patients at pressure ulcer risk is important, but
it does not have direct preventive action. The mode
of action is indirectly addressing skin surface and
skin microclimate properties. For instance increased
skin surface roughness and moisture may increase
the coefficient of friction between the skin and the
support surface contact.100 Increased coefficients
of friction may increase the strain in deeper tissues
thus increasing pressure ulcer risk. However, tissue
responses depend on the individual morphology,
diseases, the tissue tolerance and various anatomi-
cal characteristics. For instance there are differences
in heel and sacral skin responses during prolonged
loading.101, 102 Therefore, accompanying skin care in-
terventions within pressure ulcer prevention include
activities to keep the skin clean and dry and to avoid
irritation (e.g. due to incontinence) as much as pos-
sible. 99
In a Cochrane Review, Moore et al. reviewed stud-
ies that compared topical agents or dressings with
other methods for preventing pressure ulcers.103 The
710 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015
authors concluded that due to a lack of quality in
clinical trials, as well as potential biases from manu-
facturer sponsorship, the evidence concerning the
use of topical agents or dressings for preventing
pressure ulcers was insufficient to support or refute
the use of topical agents for this purpose.
Moisture-related skin damage
Moisture-associated skin damage (MASD) is
commonly caused by prolonged exposure to various
sources of moisture, including urine or stool, perspi-
ration, wound exudate, mucus, saliva, and their con-
tents. MASD is characterized by a maceration and
inflammation of the skin, occurring with or without
erosion or secondary cutaneous infection. Multiple
conditions may result in MASD; the most common
forms are incontinence-associated dermatitis, inter-
triginous dermatitis, as well as periwound moisture-
associated dermatitis, and periostomal moisture-
associated dermatitis. Although evidence is lacking,
clinical experience suggests that MASD requires
more than moisture alone. The skin damage is usu-
ally associated with to multiple factors, including
chemical irritants within the moisture source, skin
pH, mechanical factors such as friction, and associ-
ated microorganisms.104-106 To prevent MASD, the
caregiver team needs to be vigilant both in maintain-
ing optimal skin conditions, as well as, have a ba-
sic understanding of diagnosing and treating minor
cases of MASD prior to progression and skin break-
down.
While there is a vast amount of data to support
the diagnoses and assessment of MASD the data
discussing the prevention and treatment of MASD
is sparse. Frequently the recommendations for treat-
ment are often based on empirical evidence and and
consenus documents rather than rigorously random-
ly controlled trials. Reported home remedies such as
wet tea bags, Burow’s solution or Domeboro soaks
(aluminum acetate), or diluted vinegar are discussed
in research findings, even though these remedies
have not been tested in controlled studies and offer
no evidence regarding safety and efficacy.107, 108 Ad-
ditionally, there is a body of data available support-
ing empirical findings and clinical opinions that are
contradictory, e.g. McMahon et al. who interviewed
nurses about submammary skin treatment, found that
16.5% recommended talcum powder, while 15.7%
recommended to avoid it.109
PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
Skin tears
Skin tears are wounds caused by shear, friction,
and/or blunt force, resulting in separation of skin
layers. A skin tear may represent as separation of
the epidermis from the dermis or as separation of
both the epidermis and dermis from the underlying
structures.110 Skin tears are common acute wounds
in older adults; however, infants and children can
also be at risk.111, 112 Besides those individuals in late
adulthood additional populations may also be at risk
for skin tears such as those, critically or chronically
ill. Those individuals impacted by skin tears on their
extremities report a significant impact on their daily
activities, sometimes requiring special transporta-
tion and repositioning and special procedures for
dressing, patch, and bandage removal. Additionally,
those affected by skin tears are at high risk for de-
veloping secondary wound infections.113, 114 Patients
suffering from skin tears frequently complain of pain
associated with their skin tears as well as a decreased
quality of life. By recognizing which patients are at
risk for skin tears, caregivers can save patients undue
pain and suffering.115 The International Skin Tear
Advisory Panel (ISTAP) has created a comprehen-
sive tool kit for the prevention, identification, and
treatment of skin tears.116 Prevention of skin tears
seems to be simple by avoiding consistently any me-
chanical stress to skin. Fingernails should be kept
short to avoid skin tears from scratching and rubbing
of the skin after a bath or after cleansing should be
blandly. Even though no controlled studies with skin
care products in individuals prone to skin tears have
been completed, the use of pH-balanced cleansers
and moisturizers to keep the skin clean and moist is
considered an important cornerstone of skin care for
the elderly prone to skin tears.
Care of skin conditions in diabetics and patients
undergoing chemotherapy or targeted therapies
Diabetes mellitus
It is estimated that currently an average 8.3% of
the world population are suffering from diabetes
and this number is estimated to increase in the next
decades. Interestingly, a significant majority 80% of
those diagnosed with diabetes live in low and mid-
dle income countries.117 The hyperglycemicstate of
Vol. 150 - No. 6 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA 711
diabetes mellitus leads to changes in practically all
cell types and organs of the human body and skin
changes are considered common manifestations of
diabetes mellitus. Diabetes mellitus can give rise to
several skin conditions, including bacterial (Staphy-
lococcus aureus), fungal infections such as Candidi-
asis, as well as dry and itchy skin. Tinea pedis occur-
ring between the toes and sometimes the fingers is
most frequently caused by Trichophyton mentagro-
phytes and Trichophyton rubrum. Candida albicans
is another common fungus that causes skin infections
and it most commonly affects the vaginal and groin
areas. Foot ulcers (open sores) are also common in
people with diabetes, especially those with problems
with peripheraly neuropathy and vascular insuffi-
ciencies, and unfortunately many times amputation
cannot be avoided in these patients.118, 119 It is impor-
tant to note that foot ulcers not only lead to physical
disability and loss of quality of life, but also to a sig-
nificant economic burden. In 2014 worldwide one in
nine healthcare dollars was spent on diabetes.117 The
focus should therefore remain on prevention of skin
disease sequelae associated with diabetes including
skin infections and foot ulcers.
Prevention measures focusing on basics such as
footwear, and meticulous nail and skin care is consid-
ered a cornerstone of preventing skin impairments.
Patients are urged to examine their feet on a daily
basis and to wash them in a lukewarm bath at least
once a day including special attention to drying be-
tween the interdigital spaces and toes. The avoidance
of chemical substances and chemical pads or plasters
to treat calluses on the feet is also important.120 In
diabetics the dryness of the plantar surfaces of the
feet and heels is common. Minor traumas combined
with the dry skin create cracks, which facilitate the
entrance of microorganisms into the skin and con-
sequently foot infections are often inevitable. It is
recommended to apply emollients containing urea,
lactates or salicylates with the ability to penetrate
into the dry and hyperkeratosis skin to increase skin
hydration and tissue flexibility and to foster desq-
uamation. However, the use of these emollients in
the interdigital spaces is highly discouraged.120 Pa-
tients unable to care and treat their feet should en-
trust themselves to a professional care team.121 Skin
acidification is considered a key preventive mean to
limit bacterial, fungal load of the skin and to main-
tain skin integrity (see section “Skin surface pH and
basic skin care”).
SURBER PRINCIPLES OF SKIN CARE IN THE ELDERLY
Often, particular importance is attached to patient
education and prevention in those suffering from
diabetes. Dorresteijn et al. report in their Cochrane
review that in some trials, foot-care knowledge and
self-reported patient behavior seem to be positively
influenced by education in the short term. However,
based on the only two sufficiently powered studies
reporting the effect of patient education on primary
end points, they conclude that there is insufficient
scientific evidence to support that patient educa-
tion in isolation is effective in achieving clinically
relevant reductions in ulcer and amputation inci-
dence.122 Thus, these findings underline the impor-
tance and relevance of multidisciplinary care teams
in supportive treatment of those suffering from dia-
betes.123
Pharmacotherapeutic interventions: skin care in
cancer patients
Various pharmacotherapeutic interventions are
known to provoke unfavorable skin conditions that
need care attention.124 The medical progress of the
last decades has also brought a number of new thera-
peutic options to treat various solid and hematologic
tumors.125, 126 Patients of all ages are now surviving
longer and are generally reporting an enhancement
in QoL while undergoing cancer treatment. How-
ever, skin reactions due to cancer related therapies
can be a significant problem for many cancer pa-
tients.127-129 While effective for treating cancer, can-
cer related therapies can disturb the cutaneous bar-
rier function, causing reactions sometimes soon after
initiation of treatment that can have a significant im-
pact on patient wellbeing. Additionally, once treat-
ments are completed, patients can often be left with
significant cutaneous sequelae from their treatment,
which can be unwanted reminders of their previous
diagnosis. Therefore preventing and managing these
cutaneous reactions in cancer related treatments are
becoming increasingly important to the overall suc-
cess of anti-cancer therapy.130
The most common skin conditions found in these
patients include skin irritation (inflammation), acnei-
form eruptions, nail changes, hand-foot syndrome
and xerosis.131 Cutaneous eruptions are associated
with pain and decreased QoL. While other common
conditions such as, hand-foot syndrome are less vis-
ible they can still be extremely painful and have a
significant impact on QoL. Additionally, severely
712 GIORNALE ITALIANO DI DERMATOLOGIA E VENEREOLOGIA December 2015
dry skins often associated with significant pruritus
and can be more susceptible to secondary skin infec-
tions. More frequently, there are reports that these
skin conditions are frequently associated with de-
pression and anxiety due to their psychosocial im-
pact.132
Efforts to support directed skin care before the start
of the anticancer treatment could offer a simple solu-
tion to many patients and also have a direct impact
on QoL during anticancer therapies. The use of gen-
tle cleansers without fragrances, efforts to take short
showers/baths with lukewarm water, and the skin
moisturizers after each shower/bath that have proven
effectiveness and tolerability may be helpful in pre-
venting the unwanted skin dryness and cutaneous
side effects. Additionally, it is important to note that
many chemotherapies can cause photosensitivity,
and an increased sensitivity or susceptibility to sun-
burns. Sun protection – protective hats and clothing,
sunglasses, and the use of sun screens are strongly
recommended to avoid any UV radiation associated
adverse skin reaction.133, 134As anticancer therapy-re-
lated cutaneous adverse events are commonly linked
to skin barrier dysfunction, the maintenance of skin
barrier function is often the key to control the sever-
ity of these symptoms. Patients should be carefully
guided by HCP when choosing skin care products, as
patients tend to experiment with inappropriate self-
care products that potentially aggravate the skin con-
dition and irritate their vulnerable skin. Despite the
fact that experts present plausible recommendations,
larger controlled studies on effectiveness and toler-
ability of skin care products and skin care regimens
in anticancer therapies are currently missing and rec-
ommendations are still based on experience that are
unanimously accepted.135-137 The recommendations
remain somehow vague and lack precise terminol-
ogy regarding skin care product forms.
Conclusions
Aged skin undergoes progressive structural and
functional degeneration that leaves it prone to a wide
variety of bothersome and even serious conditions
and diseases. These may significantly impact qual-
ity of life in the older patient. Many of these skin
conditions and diseases are perceived as common,
but have received moderate attention. The scientific
literature on diagnosing and assessing age-related
PRINCIPLES OF SKIN CARE IN THE ELDERLY SURBER
skin conditions and diseases is vast, however when it  
comes to preventive care and treatment the scientific  
data available is less profound and the recommenda-
tions are often based on personal experience, opin-
ions or at best on consensus documents rather than  
on scientific data retrieved from controlled clinical
trials. Many of the products used and recommend-
 
ed for the preventive care of age-related skin con-
ditions and diseases are based on products that are
under cosmetic regulations. This does not guarantee
 
the same product quality as the one for medicinal
products and medical devices. Changes of product
ingredients or production procedure may generate
 
unwelcome effects. Furthermore skincare in nursing
homes and institutions are often under cost pressure
and product quality and documentation is of minor
 
concern. Hence, economic rather than quality rea-
sons shape the purchase decision.
In addition to the absence of data retrieved from  
controlled clinical trials, the imprecise terminology
to describe the topical products as well as the lack of  
understanding the essence of the vehicle contribute
to vague and often unhelpfully product recommen-  
dations.
Future efforts should include the clarification of  
the terminology and the essence of topical products.
 
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Conflicts of interest.—The authors certify that there is no conflict of
interest with any financial organization regarding the material discussed
in the manuscript.
Epub ahead of print on September 8, 2015.