Cowdell Fiona, Jadotte Yuri T, Ersser Steven J, Danby Simon, Lawton Sandra, Roberts Amanda, Dyson Judith
Birmingham City University, Faculty of Health, Education and Life Sciences, City South Campus, Westbourne Road, Edgbaston, Birmingham, UK, B15 3TN.
Renaissance School of Medicine at Stony Brook University, Department of Family, Population and Preventive Medicine, Stony Brook, NY, USA, 11794-8434.
Cochrane Database Syst Rev. 2020 Jan 23;1(1):CD011377. doi: 10.1002/14651858.CD011377.pub2.
Ageing has a degenerative effect on the skin, leaving it more vulnerable to damage. Hygiene and emollient interventions may help maintain skin integrity in older people in hospital and residential care settings; however, at present, most care is based on "tried and tested" practice, rather than on evidence.
To assess the effects of hygiene and emollient interventions for maintaining skin integrity in older people in hospital and residential care settings.
We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL, up to January 2019. We also searched five trials registers.
Randomised controlled trials comparing hygiene and emollient interventions versus placebo, no intervention, or standard practices for older people aged ≥ 60 years in hospital or residential care settings.
We used standard methodological procedures as expected by Cochrane. Primary outcomes were frequency of skin damage, for example, complete loss of integrity (tears or ulceration) or partial loss of integrity (fissuring), and side effects. Secondary outcomes included transepidermal water loss (TEWL), stratum corneum hydration (SCH), erythema, and clinical scores of dryness or itch. We used GRADE to assess the quality of evidence.
We included six trials involving 1598 residential care home residents; no included trial had a hospital setting. Most participants had a mean age of 80+ years; when specified, more women were recruited than men. Two studies included only people with diagnosed dry skin. Studies were conducted in Asia, Australasia, Europe, and North America. A range of hygiene and emollient interventions were assessed: a moisturising soap bar; combinations of water soak, oil soak, and lotion; regular application of a commercially available moisturiser; use of two different standardised skin care regimens comprising a body wash and leave-on body lotion; bed bath with "wash gloves" containing numerous ingredients; and application of a hot towel after usual care bed bath. In five studies, treatment duration ranged from five days to six months; only one study had post-treatment follow-up (one to eight days from end of treatment). Outcomes in the hot towel study were measured 15 minutes after the skin was wiped with a dry towel. Three studies each had high risk of attrition, detection, and performance bias. Only one trial (n = 984) assessed frequency of skin damage via average monthly incidence of skin tears during six months of treatment. The emollient group (usual care plus twice-daily application of moisturiser) had 5.76 tears per month per 1000 occupied bed-days compared with 10.57 tears in the usual care only group (ad hoc or no standardised skin-moisturising regimen) (P = 0.004), but this is based on very low-quality evidence, so we are uncertain of this result. Only one trial (n = 133) reported measuring side effects. At 56 ± 4 days from baseline, there were three undesirable effects (itch (mild), redness (mild/moderate), and irritation (severe)) in intervention group 1 (regimen consisting of a moisturising body wash and a moisturising leave-on lotion) and one event (mild skin dryness) in intervention group 2 (regimen consisting of body wash and a water-in-oil emulsion containing emollients and 4% urea). In both groups, the body wash was used daily and the emollient twice daily for eight weeks. There were zero adverse events in the usual care group. This result is based on very low-quality evidence. This same study also measured TEWL at 56 ± 4 days in the mid-volar forearm (n = 106) and the lower leg (n = 105). Compared to usual care, there may be no difference in TEWL between intervention groups, but evidence quality is low. One study, which compared application of a hot towel for 10 seconds after a usual care bed bath versus usual care bed bath only, also measured TEWL at 15 minutes after the skin was wiped with a dry towel for one second. The mean TEWL was 8.6 g/m²/h (standard deviation (SD) 3.2) in the hot towel group compared with 8.9 g/m²/h (SD 4.1) in the usual care group (low-quality evidence; n = 42), showing there may be little or no difference between groups. A lower score is more favourable. Three studies (266 participants) measured SCH, but all evidence is of very low quality; we did not combine these studies due to differences in treatments (different skin care regimens for eight weeks; wash gloves for 12 weeks; and single application of hot towel to the skin) and differences in outcome reporting. All three studies showed no clear difference in SCH at follow-up (ranging from 15 minutes after the intervention to 12 weeks from baseline), when compared with usual care. A clinical score of dryness was measured by three studies (including 245 participants); pooling was not appropriate. The treatment groups (different skin care regimens for eight weeks; a moisturising soap bar used for five days; and combinations of water soak, oil soak, and lotion for 12 days) may reduce dryness compared to standard care or no intervention (results measured at 5, 8, and 56 ± 4 days after treatment was initiated). However, the quality of evidence for this outcome is low. Outcomes of erythema and clinical score of itch were not assessed in any included studies.
AUTHORS' CONCLUSIONS: Current evidence about the effects of hygiene and emollients in maintaining skin integrity in older people in residential and hospital settings is inadequate. We cannot draw conclusions regarding frequency of skin damage or side effects due to very low-quality evidence. Low-quality evidence suggests that in residential care settings for older people, certain types of hygiene and emollient interventions (two different standardised skin care regimens; moisturising soap bar; combinations of water soak, oil soak, and lotion) may be more effective in terms of clinical score of dryness when compared with no intervention or standard care. Studies were small and generally lacked methodological rigour, and information on effect sizes and precision was absent. More clinical trials are needed to guide practice; future studies should use a standard approach to measuring treatment effects and should include patient-reported outcomes, such as comfort and acceptability.
衰老对皮肤有退行性影响，使其更容易受到损伤。卫生和润肤干预措施可能有助于维持住院及接受机构护理的老年人的皮肤完整性；然而，目前大多数护理是基于“经验证的”做法，而非基于证据。
评估卫生和润肤干预措施对维持住院及接受机构护理的老年人皮肤完整性的效果。
我们检索了截至2019年1月的Cochrane皮肤专科注册库、CENTRAL、MEDLINE、Embase和CINAHL。我们还检索了五个试验注册库。
比较卫生和润肤干预措施与安慰剂、无干预措施或标准做法，针对年龄≥60岁的住院或接受机构护理的老年人的随机对照试验。
我们采用了Cochrane预期的标准方法程序。主要结局是皮肤损伤的频率，例如，完整性完全丧失（撕裂或溃疡）或部分丧失（皲裂），以及副作用。次要结局包括经表皮水分流失（TEWL）、角质层水合作用（SCH）、红斑以及干燥或瘙痒的临床评分。我们使用GRADE评估证据质量。
我们纳入了六项试验，涉及1598名机构护理院居民；纳入的试验均未涉及医院环境。大多数参与者的平均年龄在80岁以上；具体而言，招募的女性多于男性。两项研究仅纳入了诊断为干性皮肤的人群。研究在亚洲、澳大拉西亚、欧洲和北美进行。评估了一系列卫生和润肤干预措施：一块保湿肥皂；水浸、油浸和乳液的组合；定期使用市售保湿剂；使用两种不同的标准化皮肤护理方案，包括沐浴露和免洗身体乳；使用含有多种成分的“洗手套”进行床上擦浴；以及在常规护理床上擦浴后使用热毛巾。在五项研究中，治疗持续时间从五天到六个月不等；只有一项研究有治疗后随访（治疗结束后一至八天）。热毛巾研究的结局是在皮肤用干毛巾擦拭15分钟后测量的。三项研究各自存在高失访风险、检测风险和实施偏倚风险。只有一项试验（n = 984）通过治疗六个月期间皮肤撕裂的平均月发生率评估了皮肤损伤频率。润肤剂组（常规护理加每日两次使用保湿剂）每1000占用床日每月有5.76次撕裂，而仅常规护理组（临时或无标准化皮肤保湿方案）为10.57次撕裂（P = 0.004），但这基于极低质量的证据，因此我们对该结果不确定。只有一项试验（n = 133）报告了副作用测量情况。在距基线56 ± 4天时，干预组1（由保湿沐浴露和保湿免洗乳液组成的方案）有三种不良效应（轻度瘙痒、轻度/中度发红和重度刺激），干预组2（由沐浴露和含有润肤剂及4%尿素的油包水乳液组成的方案）有一项不良事件（轻度皮肤干燥）。两组中，沐浴露每日使用，润肤剂每日两次，持续八周。常规护理组无不良事件。该结果基于极低质量的证据。同一项研究还在56 ± 4天时测量了中前臂掌侧（n = 106）和小腿（n = 105）的TEWL。与常规护理相比，干预组之间的TEWL可能无差异，但证据质量较低。一项研究比较了在常规护理床上擦浴后使用热毛巾10秒与仅常规护理床上擦浴的情况，还在皮肤用干毛巾擦拭一秒后15分钟测量了TEWL。热毛巾组的平均TEWL为8.6 g/m²/h（标准差（SD）3.2），常规护理组为8.9 g/m²/h（SD 4.1）（低质量证据；n = 42），表明两组之间可能几乎没有差异。分数越低越有利。三项研究（266名参与者）测量了SCH，但所有证据质量都非常低；由于治疗方法不同（八周不同的皮肤护理方案；12周使用洗手套；以及单次对皮肤使用热毛巾）和结局报告不同，我们未合并这些研究。与常规护理相比，所有三项研究在随访时（从干预后15分钟到距基线12周）的SCH均无明显差异。三项研究（包括245名参与者）测量了干燥的临床评分；合并分析不合适。与标准护理或无干预相比，治疗组（八周不同的皮肤护理方案；使用保湿肥皂五天；以及水浸、油浸和乳液组合12天）可能会降低干燥程度（在开始治疗后5、8和56 ± 4天测量结果）。然而，该结局的证据质量较低。纳入的任何研究均未评估红斑和瘙痒临床评分的结局。
目前关于卫生和润肤剂在维持住院及机构护理环境中老年人皮肤完整性方面效果的证据不足。由于证据质量极低，我们无法就皮肤损伤频率或副作用得出结论。低质量证据表明，在老年人机构护理环境中，某些类型的卫生和润肤干预措施（两种不同的标准化皮肤护理方案；保湿肥皂；水浸、油浸和乳液的组合）与无干预或标准护理相比，在干燥临床评分方面可能更有效。研究规模较小，总体缺乏方法学严谨性，且缺乏效应量和精确性方面的信息。需要更多临床试验来指导实践；未来的研究应采用标准方法测量治疗效果，并应纳入患者报告的结局，如舒适度和可接受性。
