08.20.2024

Back to Basics: Skin Conditions & Topical Treatment

The skin is the largest organ in the human body. It functions to protect against microorganisms, dehydration, and mechanical damage. It is the human body’s first physical barrier against the external environment. Internal organ and system dysfunction is common at end of life so it is not surprising that there too are skin-related symptoms that may afflict patients managed by hospice.

In this month’s Palliative Pearls, we review the basics of local skin-related symptoms, with a focus on prevention and topical management of dermatitis caused by incontinence and other moisture irritants, fungal infections, bacterial infections, and pruritus.

Moisture-Associated Skin Damage/Dermatitis (MASD)

Dermatitis is inflammation of the skin caused by an irritant where it becomes red, irritated, swollen, and sore (sometimes with small blisters). It can be precipitated by the irritants urine and feces (i.e., incontinence), typically, when incontinent briefs are worn, on convex skin surfaces that are in direct contact with briefs, including the buttocks, lower abdomen, genitalia, and upper thighs. Other moisture irritants like sweat and exudate can also lead to dermatitis. Excess moisture can decrease the barrier function of the skin and result in skin breakdown, potential ulceration, pain, and/or infection. 1-3

Contributors to MASD include: 2

  • Excessive moisture
  • Friction from absorbent incontinence products (e.g., briefs, pads), clothing, or surfaces (e.g., bed, chair)
  • Skin shearing from repositioning and prolonged immobility
  • Increased skin pH and change in the skin microbiome – colonization of bacteria commonly found on the skin surface and in stool
  • Fecal enzymatic activity – fecal bacteria produces the enzyme urease that, when interacting with urine, raises the skin pH

General non-pharmacological measures:2

  • Increase absorbent incontinence product changing frequency, where applicable
  • Gentle cleansing with warm water and a small amount of mild cleanser (fragrance- and alcohol-free wet wipes may be used however some have preservatives that can exacerbate irritation)
  • Pat or air dry after cleansing
  • Avoid powders like cornstarch and talcum – not recommended as they can be accidently aspirated into the lungs

Outside of the general measures above, preventing dermatitis from absorbent incontinence product use, incontinence, and other moisture irritants does not get more basic than skin protectants and barrier creams. Barrier products form a physical shield between the skin and potential irritants to prevent damage from friction, moisture, or other insults. Dry, clean skin is less likely to break down and lead to skin integrity issues.2

For mild to moderate dermatitis:

  • Zinc oxide products, alone (e.g., Balmex®, Desitin®) or in combination with topical anesthetics like menthol (e.g., Calmoseptine®), are among the most popular barrier creams and ointments. Zinc oxide also serves as an anti-inflammatory and is insoluble in both water and oils, making it an ideal moisture barrier.2,4,5
  • Petroleum jelly, alone (e.g., Vaseline®) or in combination with lanolin (e.g., Vitamin A&D® and Bag Balm® ointments), is an inexpensive option as well. Lanolin alone (e.g., LanaShield®) is not as common in the adult population however may be seen used in infants and children in diapers.6,7

For severe dermatitis, assess for evidence of infection:2

  • If infection is present, consider a topical antifungal or topical antibiotic, as appropriate [See FUNGAL INFECTIONS or BACTERIAL INFECTIONS sections]
  • If infection absent, consider the use of a low-potency topical steroid like hydrocortisone 1%

Topical application guidance: 2

  • Apply a thin layer to affected area(s) as often as necessary to promote comfort and protection. A thick layer will not harm, but it is not necessary and often messy.
  • When prolonged exposure to wetness is expected (e.g., overnight), it is acceptable to apply product liberally, as often as necessary (e.g., with each absorbent incontinence product change)
  • In cases where an additional topical product is necessary, continue the use of a barrier cream or ointment, applying the barrier preparation last, after the antimicrobial or topical steroid

Fungal Infections 8-10

There are two primary types of topical fungal infections: yeast and dermatophyte. Fungi thrive in warm, moist environments, which make areas of the body with little airflow like skin folds and the groin prone to fungal infections. These infections are associated with an itchy, red skin rash, a foul smell, and soreness. Risk factors for fungal skin infections include immobility, obesity, incontinence, poor hygiene, excessive sweat, and immune deficiencies (e.g., diabetes mellitus, HIV).8-10

Non-pharmacological treatment and prevention:8,9

  • [See DERMATITIS General non-pharmacological measures section]
  • Aeration of the area when feasible
  • Utilization of absorbent material to separate skin folds
  • Weight loss, if applicable
  • Management of pre-existing diabetes

Yeast infections (i.e., cutaneous candidiasis) typically present as red, moist, shiny patches of skin with distinct borders and are typically found in skin folds, the groin, under the breasts, and in the absorbent incontinence product area. Rashes can cause itching, burning, and soreness, and in extreme cases, the skin can crack or ooze. Candida albicans is the yeast most associated with these infections.

  • Azole antifungals are the most utilized, however benzylamines and allylamines are also effective. Two to four weeks of therapy is usually sufficient.8,9 [See Table: Topical Antifungal Medication]
  • While nystatin is also an option for candidal infections, it is not preferred because other antifungals have broader coverage and anti-inflammatory properties 9
  • Topical corticosteroid therapy is reserved for concomitant pruritis not managed by an antifungal alone and for short-term use. Use a low-potency topical steroid like hydrocortisone. [See PRURITUS for recommended regimen].9
  • Combination steroid-antifungal creams (e.g., betamethasone-clotrimazole (Lotrisone®) and nystatin-triamcinolone (Mycolog II®)) are not recommended. Betamethasone and triamcinolone are overly potent for this indication and have a higher risk for side effects.7

Dermatophyte infections often present as circular, ring-shaped lesions, with a red border, and clearer skin in the middle. These infections are prevalent in warm, moist areas around the groin (tinea cruris), feet (tinea pedis), scalp (tinea capitis), nails (tinea unguium or onychomychosis), and body (tinea corporis). Symptoms include itching, redness, scaling, and sometimes blistering or oozing of the affected area.

  • Most infections are limited to the epidermis and can be managed with topical antifungal therapy. Effective medication classes include azoles, allylamines, butenafine, ciclopirox, and tolnaftate.10
  • If lesions are highly inflammatory and itchy, the addition of low-potency topical steroids can be considered after an antifungal is trialed
  • Allylamines and ciclopirox antifungals have anti-inflammatory properties10

Topical Antifungal Medications7,10

Bacterial Infections 2,11-23

Cellulitis, erysipelas, and abscess may come to mind when you think of bacterial skin and skin structure infections. These infections penetrate too many layers of the skin and/or structure for topical treatments to be effective; systemic therapy with oral or parenteral antibiotics is warranted. Signs and symptoms that systemic treatment may be indicated include fever, skin redness, pain, tenderness, warmth, and swelling. Consider the patient and family’s goals of care, patient prognosis, and time to antimicrobial effect in these cases before starting systemic antibiotics.12

Over-the-counter (OTC) antibiotic topical products, containing bacitracin, neomycin, and polymyxin B alone, or in combination, have a limited role outside of prevention in superficial bacterial conditions like minor cuts, abrasions, and burns. 18-22

  • OTC products have come under scrutiny in recent years due to the increased risk of contact dermatitis shown from bacitracin and neomycin and polymyxin B combined with bacitracin. In addition, studies show that petrolatum (i.e., petroleum jelly) alone has comparable wound healing properties.19-21
  • Common products include Bacitracin® (bacitracin), Polysporin® (bacitracin-polymyxin B), and Neosporin® (neomycin-bacitracin-polymyxin B)(i.e., triple antibiotic ointment)
  • For the prevention of skin and skin structure infections, including wound management of skin abrasion and minor burn wound infection: Apply a thin film (amount equal to the surface area of the fingertip) to the affected area 1 to 3 times daily for up to 7 days.7

Mupirocin (Bactroban®) is a prescription antibiotic product that has several FDA-approved indications. It should be noted that severe and extensive cases of the following indications require use of oral or parenteral antibiotics.

  • Impetigo – a highly contagious bacterial skin infection forming pustules and yellow crusty sores 11
    (Organisms: A Streptococcus and Staphylococcus aureus)

    • Therapy with topical cream/ointment is indicated only when a limited number of lesions are present. Apply a thin layer to the affected area(s) 3 times daily for 1 to 2 weeks. The area(s) may be covered with a sterile gauze dressing.
  • Methicillin-resistant Staphylococcus aureus (MRSA) decolonization – an infection control strategy to mitigate MRSA infections for those at elevated risk 13-15
    • Nasal ointment: Apply a small amount in each nostril twice daily for 5 days. Consider using in combination with daily chlorhexidine baths.
  • Staphylococcal folliculitis – a common skin condition usually caused by an infected hair follicle 16,17
    • Mild folliculitis (few pustules) may resolve spontaneously. Treatment with an antimicrobial cleanser, such as benzoyl peroxide, may be sufficient.
    • For extensive disease (numerous papules or involvement of more than one body area) or persistent disease that does not resolve spontaneously within several weeks
      • Topical ointment: Apply to affected area(s) 3 times daily for 5 to 7 days
  • Diaper dermatitis – an inflammatory reaction of the skin of the diaper area primarily caused by increased moisture, prolonged contact with urine or feces, and other irritants 2
    • Infections are the second most common cause. Candida albicans is the leading fungal organism followed by bacterial infection with Staphylococcus aureus or Streptococcus pyogenes.
    • Diaper dermatitis is often mild and self-limiting, requiring minimal intervention
      • Topical ointment: Apply to the affected area(s) twice daily for 5 to 7 days

Pruritus

Pruritus (itch) is the unpleasant sensation that provokes an urge to scratch. Pruritus can have several origins including allergens (e.g., urticaria, contact dermatitis, drug reactions), dermatological state (e.g., dryness, wetness, irritation, psoriasis), metabolic function (e.g., hepatic failure, renal failure, hypothyroidism), infections (e.g., scabies, lice, fungus, bacteria) and psychogenic profile (i.e., psychiatric disorders).23

In addition to physical effects (e.g., skin injury, secondary infections, scarring, sleep deprivation), pruritus can contribute to emotional disturbances, such as anxiety and depression. In severe cases, pruritus can be incapacitating.24 There are varied sources of itching; we will focus on ones most applicable to the hospice population.

Localized pruritus is a symptom that affects a limited area of skin. There are three main etiologies: 25

  • Inflammatory skin disorders (e.g., atopic dermatitis (i.e., eczema) which may be treated with topical anti-inflammatory medications
  • Histamine-mediated itch (e.g., insect bites) which are treated with topical antihistamines
  • Neuropathic itch which may be treated with topical anesthetics

Nonpharmacological Management 24,27

  • Regularly lubricate with nonfragrant topical emollients (especially post bathing)
  • Wear nonirritating and loose-fitting clothing
  • Maintain a cool, humidified environment; application of cool compresses may be helpful
  • Avoid irritants like perfumes
  • Utilize moisturizers. Moisturizers are classified based on the amount of oil and water they contain. The more oil the better for significantly dry skin. Ointments have the highest oil content (e.g., petroleum jelly), followed by creams, then lotions and skin barrier repair creams.
  • Oatmeal baths may also help (e.g., Aveeno®)

Pharmacological Management

  • Cooling agents (e.g., aloe, calamine, camphor, menthol) are mildly antipruritic, the cooling sensation produced can help provide a sense of relief. Products may contain various ingredients alone or in combination with other symptom-relieving ingredients. 24,25
    • Sarna® Calm/Cool Anti-Itch Lotion (pramoxine hydrochloride, menthol, witch hazel extract, aloe) is best for itch and pain associated with insect bites, sunburn, and poison ivy 26
    • Calamine lotion (calamine, zinc oxide) is indicated for minor skin irritations like contact dermatitis from poison ivy or sumac 27
    • Original Sarna® (camphor, menthol) is indicated for the relief of minor burns, cuts, scrapes, insect bites and other skin irritations and rashes due to poison ivy, poison oak, or poison sumac 26
  • Topical corticosteroids are useful for pruritus secondary to skin inflammation (e.g., atopic dermatitis, contact dermatitis, psoriasis). Steroid selection should focus on formulation and potency. For instance, use any formulation of a low potency steroid, like hydrocortisone, to manage mild conditions; for more severe cases, consider ointments of higher potency steroids, like betamethasone dipropionate.24, 25, 27-29
    • Seek ointment rather than cream formulations to better alleviate concomitant dryness
    • Apply a thin layer topically to the affected skin area(s) 2 to 4 times daily for up to 2 weeks
    • Examples of products by potency and formulation (not an all-inclusive list): 30

  • Topical antihistamines manage histamine-mediated pruritus (local reactions to insect bites or stings, allergic contact dermatitis, or dermatitis due to poison ivy, oak, or sumac).
    • Avoid topical antihistamines in the geriatric population due to concern for systemic absorption
    • Topical application is also discouraged due to questionable efficacy and possibility of sensitivity reactions, especially from prolonged or repeated use31
    • Despite the reservations above, topical antihistamines may improve pruritus from origins (i.e., non-histamine-mediated) like atopic dermatitis 24,27
  • Doxepin 5% cream (Prudoxin®, Zonalon®) 24,27
    • Avoid use in children
    • For the treatment of atopic dermatitis: apply to the affected area topically 4 times daily, allowing at least 3 to 4 hours between applications, for up to 8 days
    • Possible side effects include drowsiness, contact dermatitis, anticholinergic effects, stinging or burning at the application site. Reducing the frequency and surface area of application may manage drowsiness.
  • Diphenhydramine (Benadryl®) 1% & 2% creams 24
    • Data are insufficient to confirm efficacy of topical antihistamines other than doxepin 27
    • For the treatment of local histamine-mediated pruritus: apply to the affected area up to 3 to 4 times per day
    • Potential side effects include photosensitivity, rash, and urticaria
  • Topical anesthetics may be helpful for localized itches, especially neuropathic (e.g., postherpetic itch due to shingles). They are better utilized when there is no associated inflammation at the affected site. While topical anesthetics are more readily associated with their topical nerve pain-related indications, they are also helpful for pruritis.7,32,33
    • Capsaicin is an external analgesic derived from hot chili peppers and other botanicals. It is available in low-concentration transdermal patches, creams, ointments, and lotions.7
      • Do not apply to open wounds, infections, or irritated skin
      • Do not apply external heat or occlusive dressings
      • Avoid contact with eyes and mucous membranes
      • Avoid heat, flame, and smoking during and immediately after application (some dosage forms (0.025% and 0.05% DermacinRx®) are flammable)
      • Wearing gloves, apply sparingly, rubbing into the affected areas until fully absorbed
      • Localized burning and skin irritation can occur with application but should lessen with continued use
      • Pain with administration may be exacerbated by warm water or hot weather
      • Dosing for postherpetic itch is ill-defined but may be extrapolated from other indications:
        • For the treatment of postherpetic neuralgia: 7,35
          • 075%, 0.025% creams: apply 2 to 4 times daily to affected areas
        • For the treatment of diabetic neuropathy: 7
          • 075% topical products: apply topically to painful areas 4 times daily
      • Lidocaine is an amide-type local anesthetic available in multiple dosage forms including topical ointments, jellies, patches, and sprays. The prescription patch dosage forms (Lidoderm®, ZTlido®) are clinically indicated for treatment of postherpetic neuralgia and off label for diabetic neuropathy. The creams and sprays are indicated for general local, topical anesthesia. 27, 34-36
        • Common instructions for lidocaine OTC creams, gels, and solutions includes application to affected areas 3 to 4 times daily as needed; however, directions may vary by product and formulation; refer to package-specific instructions.
        • Avoid excessive quantities and application to raw or blistered areas of the skin
        • The safety or efficacy of topical lidocaine products applied directly to open wounds has not been determined
        • For further review of lidocaine patch dosage forms please see Enclara Pharmacia’s Palliative Pearl Comparing Prescription and Over the Counter Lidocaine Patches
      • Pramoxine (Prax®) is a topical anesthetic used for pain and itching associated with rashes due to poison ivy, poison oak, poison sumac, insect bites, and minor burns.27
        • For the temporary relief of mild pain and pruritus, apply to the affected areas twice daily

Generalized Pruritus

Generalized pruritus is not limited to a specific region of the body and is typically unsuccessfully managed using topical therapies. It can occur secondary to drugs and several disease states including renal disease requiring maintenance dialysis, biliary cholangitis, malignancy, and HIV/AIDS. Generalized pruritus may also occur in the absence of an identifiable etiology.25

  • Drug-induced pruritis is primarily managed by discontinuing the offending agent. Possible etiologies include vasodilation, phototoxicity and resulting dry skin, cholestatic injury, and secondary skin lesions. Medication classes associated with pruritus include: 7, 37-39

  • Opioid related pruritus is observed in 2 to 10 percent of patients receiving chronic opioid therapy. The etiology is not fully understood; however, it is thought that mast cell degranulation with histamine release and central mediation through mu-opioid receptors are contributing factors. The itching is not necessarily a sign of allergic reaction but can mimic an immune response. True anaphylactoid reactions (trouble breathing, swelling of lips and tongue, widespread skin rash and hives) to opioids are rare. General treatment principles involve opioid rotation and systemic antihistamines or steroids. 40,41
  • Systemic (oral, parenteral) therapies are incorporated when topical therapy is insufficient or impractical. Oral sedating antihistamines are common initial therapies for pruritus that interferes with sleep. Gabapentin and pregabalin are common systemic therapies for neuropathic itch. Other systemic therapies used for generalized pruritus may also be beneficial for refractory, localized pruritus. The risks and benefits of systemic therapy needs to be weighed carefully.

Minor Burns 42,43

A comprehensive overview of burn presentation and management is beyond the scope of a basic review. We’ll touch however on a common product for uncomplicated burns. Topical antimicrobials [See BACTERIAL INFECTION section] and silver-based products may be utilized for infection control and prophylaxis.

Silver sulfadiazine (Silvadene®, SSD®) cream is commonly used in the treatment of burn wounds. It can soothe as well as decrease bacterial colonization, however, it may slow wound healing, increasing the need for dressing changes which may result in increased pain.43

  • Apply topically to affected area once or twice daily
  • Avoid use infants less than 2 months of age
  • Avoid use in patients with sulfonamide sensitivity

Wound Care

Wound care and pressure ulcers and the related pain are prominent skin conditions managed in hospice care, however the scope of treatment is beyond the basics. Fortunately, there are several resources available for a more in-depth review:

Enclara Palliative Pearls

PCNOW Fast Facts

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