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How to prevent skin breakdown: Why you need a holistic approach

5 key ways to help maintain skin integrity for at-risk patients.

According to data from the Urban Institute, by 2040, the number of adults ages 65 and older will reach 80 million, more than double the number in 2020.¹ Because older skin is often susceptible to damage, you face a growing challenge—and opportunity—to help prevent skin breakdown for your at-risk patients.

80 million

Number of adults ages 65 and older by 2040.1

In addition to older age, the National Pressure Injury Advisory Panel (NPIAP) lists other risk factors for skin alterations:2

  • Acute illness
  • Fractured hip
  • Spinal cord injuries
  • Diabetes mellitus
  • Chronic neurological conditions
  • Long-term or community care residents
  • Trauma and/or prolonged surgery

Some of these risk factors are fixed, such as age and residency in a long-term care facility, but others can be modified to reduce risk. It’s important to take all risk factors into account when the goal is to prevent skin alterations.

For instance, a person with diabetic neuropathy may not feel pain from pressure on their foot and end up developing a diabetic foot ulcer; or a patient recovering from surgery might have difficulty getting to the bathroom and, therefore, be at higher risk of incontinence.

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A prevention-first strategy focuses on caring for the whole patient, from their support surfaces to everyday skin care to clinical nutrition. As the NPIAP Guideline says, “The outcome for an at-risk individual can often be altered by carefully selecting and consistently implementing risk-based prevention strategies.”2

Case study for a holistic prevention strategy

Following a hip fracture, a woman in her late 70s moved in with her daughter, where a home health nurse supported her. The woman’s hip was healing well, and her Braden Scale score was 18, indicating only a mild risk of pressure injury/pressure ulcer. She was doing all right. But the nurse was convinced she needed more attention than her Braden score implied.

“If you looked at her on paper, she was low risk and independent,” says Joanne Labiak, MSN, CRNP, CWOCN, CWS, DAPWCA, owner of Certified Wound Care Specialists, LLC, a direct care nurse practitioner, and a Medline consultant. The problem was, the woman had early dementia and depression, and the home health nurse was worried that when her daughter left for work, the woman wouldn’t move all day, increasing her risk of skin breakdown.

Labiak realized that the nurse had hit on something important. Using the Braden Scale as the only assessment tool perhaps doesn’t give the entire picture. It may be a little shortsighted and not inclusive of potential future risk. To address the potential risk, “We put her on a low-air mattress, we started her on twice-a-day nutritional supplementation, and we had her moisturize twice a day. All the things you would do for someone who was at high risk,” Labiak says.

During that time, the woman’s daughter tested positive for COVID-19 and was required to self-isolate, leaving the woman even more alone than before. But, Labiak recalls, “because the nurse was astute and proactive in her care plan approach, we had started her on this routine, she kept doing it, and her skin remained healthy.”

The above scenario reveals 3 key tips to help prevent pressure injuries:

  • View your patient holistically, which includes both physical and emotional health.
  • Trust your bedside nurses to help prevent skin breakdown. Frontline staff interacts with patients on a regular basis and may have insights on a person’s physical or emotional condition that others don’t.
  • Educate caregivers to know what to assess; educate patients to help maintain skin integrity and increase compliance.

Here, we outline 5 important ways to help you achieve your long-term prevention goals and improve patient outcomes

1 |    Start with a proper skin assessment

The NPIAP Guideline recommends conducting a head-to-toe skin assessment “as soon as possible” upon admission to a healthcare facility.2 After that, skin assessments should be ongoing and should be accompanied by documentation, which can help catch skin alterations before they get worse.

Learn how to do a comprehensive skin assessment.

2 |   The right support surfaces can have a positive impact

No matter what the care setting, most patients come into contact with mattresses and cushions. Most pressure injuries happen when a person is lying or sitting in the same position for an extended period of time. The length of time it might take for a pressure injury to develop varies, but it can be as little as four hours.3

The right support surface can help prevent pressure injuries by reducing tissue deformation and improving tissue perfusion. They do this through specially designed features including air, gel, water and foam.

What’s the right support surface for your patient population?


Of stage 4 pressure injuries occur at the heels2

Important things to remember about support surfaces

  • Unprotected heels can lead to skin breakdown. In fact, studies show that as many as 38.5% of stage 4 pressure injuries occur at the heels.2 Offload the heels to help improve outcomes.
  • Mattresses need updating to be effective. Medline collected data that showed that 58% of mattresses evaluated needed immediate replacement.

Find out if your mattresses need replacing.

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3 |    Best-in-class skin care helps protect and soothe skin

Are your skin care products in line with current science? Just as consumer skin care products continually evolve, so do the products you choose for your clinical settings. Some ingredients may be beneficial for fragile skin, while others such as parabens and sulfates might cause irritation.4,5 As we age, the natural barrier of our skin gets weaker, which can make it more prone to pressure injuries and skin tears. When it comes to caring for older patients, it’s important to choose gentle, botanical-rich skin care to cleanse, moisturize, soothe and help protect your patients’ skin.

Patients may also be susceptible to moisture-associated skin damage (MASD), such as incontinence-associated dermatitis and intertriginous dermatitis. Routinely monitor areas of the skin where there’s moisture and warmth, and shield patients against the effects of moisture with the right targeted skin protectants.

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Expert tips to help shield fragile skin from breakdown

Joanne Labiak, MSN, CRNP, CWOCN, CWS, DAPWCA, owner of Certified Wound Care Specialists, LLC, and a Medline consultant offers some practical tips on helping your staff care for patients.

  1. Limit jewelry, as well as long or artificial nails on caregivers. “I have seen patients incur some significant excoriations from the effects of long nails or rings of caregivers applying compression stockings.”
  2. Moisturize immediately before applying a compression stocking to make application easier.
  3. Make moisturizing part of bathing protocols.
  4. For residents with dementia, you can add soft shin guards on their legs. “Oftentimes people with dementia don’t have good depth perception or safety self-awareness. Bumping into table legs or wheelchairs can be the cause of many lower extremity skin tears and wounds.”
  5. Try timed toileting. “Even for patients with a diagnosis of dementia, the use of timed toileting schedules can often reduce the frequency of incontinence episodes.”
  6. Consider a 3-in-1 cleanser, moisturizer and barrier product with patients who are wearing disposable undergarments. “If you can increase that frequency of cleansing, you’re reducing the risk of urinary tract infections.
  7. Promote the utilization of dimethicone products for frontline staff to apply to help protect against moisture-associated skin damage, instead of zinc, which is considered a drug.
  8. Look at the cognitive ability and emotional status of the patient. We see a lot of elderly folks with depression. What does depression to many of us? It makes us want to sleep. It makes us want to curl up in a ball. We need to look at that.”
  9. Use your data. Look at your trends to be able to see when you have a problem before it escalates.
  10. Treat patients with a history of pressure injuries like someone who has a pressure injury.
  11. Make skin breakdown prevention multidisciplinary. Every person who goes into the room can play a role in watching for risk factors, such as a resident not eating.

4 |    Proper nutrition is important for wound healing 

Malnourished patients are 4x more likely to develop a pressure injury.6 When patients aren’t malnourished—either under or over, it could be due to a number of factors, including depression. “Depression breeds malnutrition.”

“From the pressure injury perspective, malnutrition is huge,” Labiak says. “And sometimes you don’t know it until the monthly weight is taken. But by then, the patient or resident could have suffered significant weight loss.”

During isolation due to COVID-19, Labiak says, “I’ve seen people losing 20 or 30 pounds over the year.” Maybe staff had to limit their time in residents’ rooms and weren’t able to monitor what they were eating. “Someone may bring a tray into a room, but if the resident doesn’t know how to cut up their own food, or they’re confused as to what it is or they just don’t feel like eating, someone will come back a half hour later and take the tray out, whether that person has eaten or not,” Labiak explains.

“From the pressure injury perspective, malnutrition is huge.”

—Joanne Labiak, MSN, CRNP, CWOCN, CWS, DAPWCA, owner of Certified Wound Care Specialists, LLC, and a Medline consultant

Another issue Labiak has noticed: “We’ve underestimated the impact of family coming in with treats or just encouraging loved ones to eat a little more.”

While a registered dietitian may be called in for consultation on dietary requirements, be aware of changes in a patient’s attitude toward eating, so you can consider specially formulated supplements to help provide missing nutrition.

5 |  Empower staff to do the right thing

Like the home health care nurse who alerted Labiak to her patient’s hidden risk of skin breakdown, frontline nurses are valuable assets in your goal of prevention. “I think the one thing we want to do is to acknowledge the people who are at the bedside,” Labiak stresses. “A lot of times, they’re the worker bees and no one stops to say what do you think?”

While nurses at the bedside make good decisions all the time, it’s important to give them the tools and resources they need. One great way to do that: Create a Skin Champion team. Not only does this give more staff skin health knowhow, but it also emphasizes prevention for every patient in every unit.

A Skin Champion team also helps you standardize best practices. “If you have guidelines that meet the needs at the bedside, you’re meeting the needs of the patient, and you’re meeting the needs of the organization all at once,” Labiak comments.

Another tool for frontline staff? Checklists that cover NPIAP and your facility’s prevention guidelines. “It’s great to have guidance so everybody is doing what’s best,” Labiak says. “That’s the philosophy of evidence-based best practice.” Download this pressure injury prevention checklist.

When it comes to protecting your patients from skin breakdown, take a holistic view of every individual’s risk factors, and determine if you need to strengthen any of your tools and resources to help improve outcomes.

Key takeaway

As Benjamin Franklin famously said, “An ounce of prevention is worth a pound of cure.” This is true of many things, including preventing skin breakdown. It’s especially true when it comes to your patients and residents who have fragile skin. There are many ways to help keep them safe. It starts with conducting a comprehensive skin assessment, and also includes the right support surfaces and offloading resources, gentle skin care, proper nutrition, and education.

Learn more about preventing skin breakdown:
Discover the role nutrition plays in patient health
Pressure injury prevention: Together, we can reduce the impact
Obesity and skinfolds: 4 proven ways to help shield patients from moisture-associated skin damage
How can you help prevent skin tears in elderly patients?
Pressure injuries: how the right patient skin care products can reduce skin breakdown


  1. The US Population Is Aging. (2015, April 3). Urban Institute. Available at
  2. National Pressure Injury Advisory Panel, Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline 2019, page 38, page 67, page 73, pages 145-154
  3. Gefen, A. (2008). How Much Time Does it Take to Get a Pressure Ulcer? Integrated Evidence from Human, Animal, and In Vitro Studies. Wound Management & Prevention, 54(10), 26–35. Available at
  4. Stoiber, PhD, T. (2019, April 19). What Are Parabens, and Why Don’t They Belong in Cosmetics? Environmental Working Group. Available at
  5. Ginta, D. (2019, August 12). Should You Be Going Sulfate-Free? Healthline.Com. Available at