Basic Skin Care

Posted by Nurse Linda in Life After Paralysis on June 30, 2021 # Health

Skin is the largest organ of the body. It is the major organ system that has direct contact with the outside world while it is also the front-line barrier to protecting the inner body. The skin has a high rate of cellular turnover, which makes healing quick compared to other internal organs. One of the main characteristics of skin is that it is elastic. This elasticity gives skin the ability to have a certain amount of ‘give’ when stretched over joints, allowing movement of the body without disruption of the protective outer organ. For instance, as you bend an elbow, the skin will stretch over the joint and contract back when the elbow is relaxed.

women in wheelchair in a gym studioBasic care for skin includes a healthy diet and fluid intake. Nutrients obtained from food provide the energy for skin cells to remain healthy as well as to make new skin cells. Nutrients will assist in healing if there is a disruption in the skin. Fluid hydrates the cells. If you look at healthy skin under a microscope, you will see that skin cells sort of ‘float’ on top of each other. Hydration keeps the skin moist, which creates the protective barrier of skin cells. Water is the best fluid to hydrate skin.

Other care issues for the skin include cleaning with mild soap and water. This rids the skin of dirt and debris that collects on the outer surface. As you wash skin, you are removing substances, including bacteria that can invade the body. This includes the prompt removal of mouth secretions such as drool and food, urine and feces, which can be caustic to the skin. The washing and drying process also helps the skin slough off dead skin cells replaced with new skin cells from within the body.

Skin heals itself quite rapidly. If you get an injury to the skin, the immune system is activated, blood cells are sent to cushion the area and to fight infection. This results in some swelling, redness and heat, or warmth in the area due to the extra metabolism. This is a normal body process. A large amount of swelling, redness, and heat, especially with pus, are signs of an infection.

Individuals move their bodies thousands of times a day and night. Some are big positional movements such as getting up to stand or walk. Others are small moves like twitches or minor adjustments. These movements are directed by the autonomic nervous system when sensory nerves indicate too much pressure is being applied to an area of the body. In response, the motor nerves cause us to move. Often these smaller movements are not even noticed by an individual. When paralysis occurs, this ability is affected either in part or fully.

Children’s skin is resilient but can be affected by paralysis. It would seem that young skin is so resilient that nothing can harm it. Small children that have open heart surgery will not even have a scar years later. However, after paralysis, injury to the skin can be a huge issue. A pressure injury is a danger to areas of the body affected by paralysis because it forms within the body. By the time an area of skin shows a change in pigmentation, the damage has already occurred deep within the body.

Pressure injury starts within the body and works its way to the surface. The bones of the body are hard. Some have rounded or even pointy bumps on the ends. These are called boney prominences. Skin is soft and has an extensive complex of blood vessels that travel through it. Some of the blood vessels are extremely small in diameter, which compresses when pressure is applied. When the skin is against a solid surface, boney prominences will press against the inside of the skin due to body weight, even in small children. The pressure is too much for the small blood vessels to remain open, not allowing blood to pass through them. If blood is not flowing, even for short periods, the blood vessel collapses, which denies the nutrients cells need to survive. This is the start of a pressure injury. More tissue has been affected internally by the time you see the pigment change on the surface of the body.

There are actions to be taken to avoid pressure injuries.

  1. Release pressure continuously. This means turning while in bed and doing pressure releases when up. Sometimes people think smaller children will not get pressure injuries because they are so small and light. However, their internal structures are small as well, which makes them just as susceptible to pressure injury. Follow turning schedules and pressure releases when upright, as indicated by your child’s healthcare provider.
  2. Utilize pressure dispersing equipment. This must be medical grade pressure mattresses, overlays, seat cushions and other supports for the body. The equipment you use must disperse or spread pressure away from the boney prominences of the body. Often mistakenly used are pillows and couch types of cushions, both of which, when compressed, become hard areas that add pressure to the skin.
  3. Provide adequate hydration to keep the skin moist. Skin is affected from the inside, so blood and fluid traveling through the blood vessels to the skin cells protects them at the deepest level. Know your child’s fluid limits for age, size, and bladder program restrictions. Work within these parameters. Gain an understanding of how to advance them as they grow and what to do for temporary illnesses such as a fever, diarrhea, vomiting, or other issues that change their fluid needs.
  4. Provide a healthy diet. Breast milk is preferred for infants. Requests a nutritional consultation to understand calorie needs when well or if the child becomes ill. Starting at an early age will establish good eating habits for a lifetime. The dietitian can also help you advance your child’s diet as they grow.
  5. Look at your child’s skin whenever you move them or if new equipment is provided. If pigment changes do appear, record them on your personal camera with a measurement for reference. This can assist you with the following progress.
  6. Involve your child in the process regardless of their age. Tell the infant that you are looking at their skin for changes. Young children will not have the mental status to understand but understand before they can verbalize, so this develops a habit. At toddler age, let the child look with you using a mirror. Toddlers love to seek and find games. In this instance, see if they can find a change in their skin first. Older children can join in with you in looking at their skin. This builds confidence that they are in charge of their own body. Teens need to be in control of their healthcare. Some will do skin checks thoroughly; others will need assistance with reminders. Always check with your child to ensure nothing is missed.
  7. Do not rub or massage over boney prominences as this is adding pressure to the area, creating pressure injury. If lotion is used on the skin, be sure it is an emollient type and apply very lightly.

Two other forms of pressure injury occur for individuals with movement and sensory issues. These are shearing and friction. Shearing occurs when the top layer of skin separates from an underlayer of skin. It occurs when an individual is slid when changing positions instead of picking up their body. The top layer of skin stays in place, but the under a layer of skin moves. It separates the two layers. Friction injury is a removal of the top layer of skin. It is like a rug burn with discoloration of the skin on the surface and removed from the topmost layer of skin. This comes from dragging the skin across a surface.

Children are prone to shearing and friction injuries, just like adults. However, children have some increased risk if they play on the floor. Playing outside of their wheelchair offers more mobility and opportunity. It is a wonderful way for a child to explore the world. Just be sure their skin is protected, so they do not drag their skin, creating one of these types of injury. Also, teaching the child to pick up their body part while moving can help avoid shearing.

Much of our skin is shed by moving our bodies. Skin is in contact with clothes. When we move in clothing, socks and shoes, old skin cells are removed. If an individual is not moving, skin tends to shed in sheets, much like the peeling of a sunburn but without the burn. Remove this skin by using a washcloth and drying with a towel. Peeling the skin will leave small openings in the skin where it is torn off, allowing bacteria to enter. The washcloth and towel will remove the skin only where it is ready to come off, not damaging the living skin. Keep the area moist with emollient lotion.

One other issue that can develop is calluses where the skin is thick such as on the feet and hands but can develop anywhere. Adaptive devices applied to the body can rub, leading to calluses. On the hands, calluses typically develop from pushing a wheelchair or the use of walkers and crutches. On feet, calluses build up from lack of movement in the shoe. This is a normal body response. However, calluses are dry, dead skin cells that can crack because they do not have that elastic property of skin. A cracked callus is painful. The body will react to the pain even if the pain message is not felt. The opening of the callus is an entryway for bacteria. If necessary, the callus can be reduced by soaking the area in warm water and buffing it with a wet washcloth. The skin under the callus will be thin and fragile. Do not remove the callus all at once but do so over time, allowing the skin under it to strengthen as the callus becomes thinner.

There is more information about skincare in general in the booklet about skin produced by the Christopher & Dana Reeve Paralysis Foundation. It has pictures of the boney prominences that need to be observed for pressure injury. Consult with your healthcare professional for treatment of any pressure injury. If a pressure injury appears, treating it early leads to better healing and success. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.