Resources

Call the doctor or nurse immediately or go to the emergency room if any of the following symptoms occur:

• Sudden, severe all over itching
  Itching that occurs all over the body or in many places could be a sign of liver or kidney disease, thyroid disorder, or an allergy.
• Blisters, or a rash on the forehead or temple, accompanied by inflammation or pain in the eye
  This could be a sign that shingles is involving the eye. This is an emergency, and must be treated right away.

Call the doctor or nurse during office hours to discuss the following problems:

• Severe itching on underarms, abdomen, hands, wrists, and groin
  This could be a sign of scabies or mites. These are sometimes picked up during a hospital stay. Scabies is easily treated.
• Moles that (1) have grown in size, larger than one-quarter inch, (2) are discolored (have pearly blue, black, or red color and an irregular shape), or (3) bleed. This could be one kind of skin cancer and should be seen by a doctor.
• The appearance of red areas on the skin, especially over the hips, buttocks, tailbone, elbows, and heels.  This could be a sign of pressure ulcers developing, especially if the older person is bedridden, is dependent on a wheelchair, or wears a brace.
• A skin problem starts or becomes worse just after starting a new medicine, increasing the dose, or finishing the course of a medicine.  The doctor can change the dosage, change the medicine, or treat the reaction. Skin reactions to medicines can include hives, eczema, blisters, swelling, itching, and burning or stinging after being in the sun.
• If a skin ulcer stays longer than two weeks without healing, or grows in size, ask a doctor to look at it; this could be one of several kinds of skin cancer. A biopsy might be needed to give the answer. Fortunately, many forms of skin cancer can be cured.
• You appear to have cellulitis, a common skin infection caused by bacteria.  Skin in the infected area will become red, hot, irritated, and painful.  Any infections should be seen by the doctor; you may need to be prescribed antibiotics. 

Know the answers to the following questions before calling the doctor

• When was the last skin exam? (This should be a part of a physical examination.)
• What medicines is the older person taking? Include non-prescription, herbal, and other remedies as well as prescription medicines.
• If the problem is a mole, what does it look like? Describe the appearance of the mole in detail including size, color, shape, and if it is raised or flat.
• If the problem is a skin ulcer that is not healing, describe how long it has been there, its size, whether it is getting bigger, and whether it ever bleeds.
• Is there a history of previous skin cancer?
• If the problem is itching, where is it affecting the body most?
• If the problem is a rash, where is it? (chest, abdomen, back, arms, or legs?)
• What does it look like?
• Color?
• Size?
• Shape?
• Round
• Raised
• Blister-like
• Wavy
• Sharp edges
• Several spots grouped together
• Straight line

Here is an example of what you might say when calling for help
"Hello this Lois Hanover. I am calling about my father, Mr. John Simpson. I noticed that one of the moles on his back has changed. It has gotten larger and the shape has changed. It used to be a small round mole, now it has grown longer and much darker. We had a routine skin exam last year and everything was fine."

These are several kinds of skin problems that need your help: itchy skin, fungal infections, shingles, and pressure ulcers.

Dry, itchy skin
This happens more often in winter when there is less humidity. Severe itchy skin (pruritus) can be very uncomfortable and can cause sleep loss and other symptoms of skin problems. The following are suggestions to prevent or treat dry, itchy skin:

• Moisturize the skin
  After a shower or bath, gently pat skin with a towel but still leave the skin moist. Then apply a lotion, body oil, or moisturizer that is high in petroleum (AquaphorTM, EucerinTM). Avoid moisturizers with perfume or alcohol since these dry and can irritate the skin.
• Take fewer showers and use good bathing techniques
  Keep baths and showers warm (not hot), and short. Water and heat draw moisture away from the body. Don't scrub roughly. Use a soft cloth or sponge instead of a rough washcloth. Soap should be a glycerin soap or one with moisturizing cream like ToneTM or DoveTM. Make sure you rinse well.
• Use petroleum jelly
  For problem dry spots, apply petroleum jelly to troubled areas after a bath. If you use petroleum jelly, make sure pajamas and/or socks are worn to protect bedding and clothing.
• Change bed sheets and clothing often
  Keep these clean. Wash clothes and sheets in detergents free of perfumes and fabric softeners that could irritate the skin. Make sure you rinse bed linens thoroughly. The older person should wear cotton as much as possible since synthetics and other fabrics can be irritating to skin.
• Fluids
  Drink lots of water and stay away from caffeine and alcohol. (Check with your doctor about how much liquid the older person  should drink if he or she is taking a diuretic medicine.)
• Humidifier
  Keep the air moist. Change the water daily to slow down the growth of bacteria.
• Severe itching
  Try colloidal oatmeal (AveenoTM) baths. Use calamine lotion or cortisone creams on the itchy areas. Let the older person rub in the lotion. Keep the nails trimmed and encourage him or her not to scratch as this will only increase the itchiness. For severe, persistent itching, ask your doctor for advice since there are several types of medicines that can help.

Fungal infections
These affect normal people as well as those with poor circulation, weak immune systems, diabetes, and people who take antibiotics or cortiscosteriod drugs. Fungus tends to grow in warm moist areas of the body like armpits, the mouth, scalp, behind the ears, genitals, under large breasts, folds in the abdomen, and between toes. The skin appears cracked, is very itchy, and can become very inflamed.

• Keep skin clean and dry
• Change socks and shoes once a day
• Wear loose, cotton clothing
• Use antifungal powder or cream, such as clotrimazole (LotriminTM) or miconazole (MicatinTM), both available over-the-counter. It can be effective to apply the antifungal cream to the affected area, then sprinkle the antifungal powder over the cream.  

Shingles
Shingles is a disease of the nervous system that affects the skin. It is the same virus that causes chicken pox (herpes zoster). Before the small blisters form, the disease causes fatigue, chills, and headaches. Pain can be felt in the area of the body supplied by the affected nerve. When the blisters open and then form crusts, they can be painful. Healing takes two to four weeks, and the skin is very sensitive during this time. As the rash progresses towards healing, itching can be troublesome.

• It is important to keep the affected area of skin clean and dry until it heals. Your doctor or nurse can give you a soothing dressing to apply to the sensitive areas, and recommend treatment if itching is a problem
• TylenolTM and other pain medicines can ease the symptoms. Doctors often prescribe an anti-viral drug, such as acyclovir (ZoviraxTM), valacyclovir (ValtrexTM), or famciclovir (FamvirTM). These are most effective if given early in the disease.  It is important to see a doctor and get these medications within 72 hours of symptoms occurring. 

Pressure ulcers
If the older person is confined to a bed, chair, or a wheelchair, he or she is in danger of getting pressure ulcers. When there is constant pressure on a bony area such as the tailbone, heels, elbows, and back of the head, the blood flow is blocked, and blisters or open sores appear on the skin. Pressure ulcers can also be caused by friction damage, for example, if a bedridden patient is pulled over the sheet rather than carefully lifted. Skin that has become too moist because of sweating or that is bathed in urine due to lack of bladder control can develop cracks or sores. The following are preventive measures you can take:

• Reposition every one to two hours
  Do not turn the person onto the reddened areas. Protect heels and elbows from rubbing on sheets as well as from pressure. Pressure can be reduced in these areas by positioning pillows or pads so that the heel or elbow isn't pressing on the bed. Frequent repositioning is needed to keep blood flowing to the lower back and sides of hips. Pillows wedged behind the back will help keep the older person on his or her side. While lying sideways, a pillow between knees protects the knees from rubbing against each other. Big turns aren't needed during the night; small position changes will help and do not interrupt sleep.
• Keep sheets pulled flat without wrinkles
  This is important because wrinkles can press on the skin, causing pressure ulcers. Avoid dragging the person along the bed sheets when turning or repositioning. Using a lifting sheet will help.
• Movement
  Get the older person to stand or walk around. If he or she is unable to do this, encourage squeezing the toes, moving arms, raising legs, or other movements to keep blood flowing. Encourage him or her to do "push ups" when sitting in a wheelchair. This means pushing down against the wheelchair arms, which raises the body and allows the person to change position.
• Keep skin clean and dry
  Sheets should be changed daily especially if the older person is incontinent or sweaty. Avoid plastic coated materials under the person, since they cause sweating. Cotton or sheepskin pads are best because they allow air to circulate next to the skin.
• Massage
  A gentle massage is great for circulation. Do not massage red areas, since friction may do more damage to the area, but do massage around the reddened area to increase circulation.
• Use pads or protectors
  Heels and elbows can be protected by putting a cotton covered foam pad on the feet or over the arms. These are called "heel protectors" or "elbow protectors" and can be purchased at medical supply stores.
• Make sure the older person eats a good varied diet
  with enough protein every day (such as four to six ounces of meat or fish) and takes a daily multi-vitamin pill containing zinc and magnesium.
• Cover the pressure ulcer with a bandage or dressing
  Providing a clean and protective environment can help a pressure ulcer heal and prevent infections.  The type of dressing will be different depending on the severity of the ulcer.  The doctor or nurse will be able to give you instructions for changing the dressing. 
• Relieve pressure on the ulcer
  Use special mattresses or beds that redistribute the patient’s weight with alternating pressure or padding.  This reduces the amount of time and pressure spent lying on the ulcer, which reduces damage to the area.

Problems You Might Have Carrying Out Your Plan

Problem
"Dry skin is just a problem of old age."

Response
Yes, it is true older skin is less oily and it is thinner than that of a younger person. If untreated, dry skin can turn into severe itchy skin or pressure sores, causing discomfort and disruption of normal daily activities such as sleep. Preventive measures can greatly reduce the chances of severe skin problems happening.

Problem
"It's too difficult to reposition my father every one to two hours, since he is bedridden."

Response
Repositioning is very important and must be done to avoid pressure ulcers. A visiting nurse can provide pointers on how to accomplish the turning more easily, or a home health aide might be needed to help you.

Think of Other Problems You Might Have Carrying Out Your Plan
What other problems could get in the way of doing the things suggested in this section? For example, will the older person cooperate? Will other people help? How will you explain your needs to other people? Do you have the time and energy to carry out this plan?

• Prevention is your first goal. Keeping the skin clean and moisturized are the best preventive methods for dry, itchy rashes, as is frequent repositioning for pressure ulcers. Be alert for the development of new rashes, slow-to-heal skin ulcers, or other skin growths. Never let the older person go outdoors without applying sun block of at least 15 SPF to all exposed skin, even on a cloudy or foggy day. The sun block needs to be reapplied after three to four hours, more often if the person is sweating a lot or is swimming. This is to prevent the development of skin cancers. A shady hat is a good idea, as is avoiding outdoors during the sunniest hours between 10 a.m. and 3 p.m. When a skin problem happens, develop a plan and follow it. It is important to do each step regularly and to persist since skin problems often take time to heal.
• Always be on the lookout for early signs of skin problems. When treating a skin problem, ask the doctor how long it typically takes to return to normal so that you can judge if you are making progress.

If skin problems become worse in spite of what you do, contact the doctor and ask for advice.