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Title: Effects of bed baths with weak wiping pressure using cotton and disposable towels on the skin barrier function of the lower limbs in older patients with heart disease: A quasi-experimental (crossover) studyAuthors: Inaho Shishido and Rika Yano
Affiliation: Faculty of Health Sciences, Hokkaido University
[Adress] Kita 12, Nishi 5, Kita-ku, Sapporo 060–0812, JAPAN
Corresponding author: Inaho Shishido
[Affiliations] Faculty of Health Sciences, Hokkaido University
[Adress] Kita 12, Nishi 5, Kita-ku, Sapporo 060–0812, JAPAN
[Phone number] + 81 11 706 3718
[Email address] inaho_s@hs.hokudai.ac.jp
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Abstract
Background
The skin of older hospitalized patients is affected by disease, treatment, and aging. Bed baths are commonly used to maintain skin hygiene in these patients. However, the effects of bed baths on the skin barrier function of the lower limbs in older patients, who may have particularly fragile skin, remain unclear. This study investigated the effects of bed baths with weak wiping pressure using cotton and disposable towels on the skin barrier function of the lower limbs in older hospitalized patients.
Methods
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Thirty-three older hospitalized patients with heart disease participated in this quasi-experimental (crossover) study. Participants received two randomly ordered wipes (AB or BA): A, bed baths of the lower limbs and forearms using disposable towels; and B, bed baths of the lower limbs and forearms using cotton towels. Weak wiping pressure was used (10–20 mmHg). Skin barrier function was measured before, 15 min after, and the day after the bed bath using transepidermal water loss (TEWL), stratum corneum hydration (SCH), and overall dry skin score (ODS). Mixed-effects models for repeated measures were used to compare the changes over time between the two types of bed baths.Results
SCH and TEWL were lower in the lower limbs than in the forearms, while ODS was higher. An interaction for TEWL was observed in the lower limbs (F [2,25] = 4.0, P = 0.030); however, TEWL did not differ significantly across time points or towel types. No interaction or main effects of the time point or towel type on lower limb SCH and forearm TEWL were noted. Only the main effect of time on SCH of the forearms was observed, which was significantly lower 15 min after the cotton towel bed bath than before (t = 3.2, P = 0.004, MD [95% CI]: 0.8–3.5). ODS at baseline and the following day demonstrated no difference.
Conclusion
Regardless of the material used, bed baths of the lower limbs did not worsen the skin barrier function in older hospitalized patients when weak wiping pressure was applied. However, the lower limbs tend to be drier than the forearms, requiring maintenance of the skin barrier.
Trial registration
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UMIN R000061354 (date of registration: March 3, 2024)Key words
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10 words)
bed baths, hygiene care, lower limbs, older patients, skin care, stratum corneum hydration, transepidermal water loss
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Background
Skin hygiene is essential for maintaining skin integrity and overall health [1]. Patients who are bedridden or have limited self-care abilities due to physical or mental impairments often receive bed baths to maintain skin hygiene [2]. Typically, hot towels are used to wipe the skin during bed baths. Optimal skin care should maintain cleanliness and skin integrity while providing comfort to the patients [3]. Due to the aging of the global population, many hospitalized patients are older adults, who comprise the majority of those receiving bed baths. As older patients tend to have fragile skin due to age-related changes [4–6], it is important to consider the effects of bed baths on their skin barrier function.
Regarding the effects of bed baths on skin barrier function, a literature review identified frictional stimulation and chemical products as the key influencing factors [7]. Frictional stimulation of the skin during bed bathing is influenced by both the wiping pressure and towel material. Konya et al. [8, 9] classified wiping pressure as weak (10–20 mmHg) and ordinary (20–30 mmHg) based on a survey conducted with 101 nurses regarding the wiping pressure. Weak wiping pressure did not impair the skin barrier function of the forearms in older patients [10, 11]. Furthermore, the safety of weak wiping pressure has been verified even in older patients with dry skin conditions that require special skin care, when performed on the forearm [11]. Matsumoto et al. [12] reported that disposable towels were more effective than cotton towels in maintaining stratum corneum hydration (SCH) on the inner forearm and thigh after bed baths in healthy older adults. Schoonhoven et al. [13] found that six weeks of bed baths using disposable towels slightly reduced the number of skin abnormalities on the buttocks, abdomen, and groin compared to cotton towels, although there was no significant difference in the skin lesions. As such, evidence is accumulating regarding the impact of bed baths on the skin barrier function. Notably, many studies selected the flexor side of the forearm as the target site, as it has less body hair and surface irregularities, making the measurement of the skin barrier function easier and reliable. However, dry skin is commonly observed on the extremities, with a higher incidence on the lower limbs than on the forearms [14, 15]. In addition, the lower limbs are more prone to skin tears and edema [16]. Therefore, the skin barrier function in the lower limbs is more prone to deterioration than in other areas, and special care is required when providing bed baths.
To our knowledge, only one study [17] has evaluated the effect of bed baths on the skin barrier function of the lower limbs. In that study [17], bed baths of the lower limbs with disposable or cotton towels were performed for 12 weeks, and changes in SCH before and after the bed baths were compared. However, trans epidermal water loss (TEWL) was not measured, which is an important parameter for measuring the skin barrier function [18]. The primary skin barrier is located in the stratum corneum [19]. TEWL is defined as the flux density of water diffusing from the dermis and epidermis through the stratum corneum to the skin surface [20] and is directly correlated with skin barrier dysfunction [21]. The SCH reflects the water content of the stratum corneum. Therefore, the effects of bed baths on the skin barrier function of the lower limbs have not been fully investigated yet.
The purpose of this study was to examine the effects of bed baths with weak wiping pressure using cotton and disposable towels on the skin barrier function of the lower limbs in older hospitalized patients. This study will test the following hypotheses:
Hypothesis 1
Bed baths with weak wiping pressure using disposable and cotton towels in older patients negatively affect the skin barrier function of the lower limbs (TEWL increases and SCH decreases after bed baths compared to the values before the intervention).
Hypothesis 2
The skin barrier function of the lower limbs after bed baths with weak wiping pressure using cotton towels is worse than that after bed baths using disposable towels in older patients (TEWL of the lower limbs after bed baths using cotton towels is higher than that after bed baths using disposable towels, while the SCH is lower after bed baths using cotton towels).
Methods
Study design and setting
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A quasi-experimental crossover study was conducted between March and May, 2024 (spring). To investigate the effect of towel materials on the skin barrier function, we used cotton and disposable towels, which are commonly used in clinical practice. Patients with heart disease received bed baths with disposable or cotton towels on either side of their forearms and lower limbs, and cotton or disposable towels on the opposite side. The order, as well as the left and right sides of the intervention were randomly assigned. If a peripheral intravenous catheter or shunt for hemodialysis was present in the forearms or lower limbs, bed bath was performed on the same side, with a minimum bed bathing interval of 48 h. The study was registered in the University Hospital Medical Information Network (registration no: UMINR 000061354) and was performed according to the Transparent Reporting of Evaluations with Non-randomized Designs guidelines (TREND guidelines, Additional file 1) [22].Participants
This study included 33 hospitalized patients with heart disease at a hospital in northern Japan. Older patients with heart disease often receive bed baths to maintain skin cleanliness due to their unstable circulation and difficulty in showering or bathing. In addition to age-related changes in the skin, older patients with heart disease often take diuretics and statins and have chronic renal failure and diabetes, which are known risk factors for skin dryness [23–25]. Therefore, as pointed out in a previous study [26], older patients with heart disease are the target population who need appropriate skin care after careful consideration of their skin condition.
The inclusion criteria were as follows: (1) patients aged 65 years or older and (2) those with heart disease. The exclusion criteria were: (1) patients with difficulty in communication (e.g., dementia, delirium, or severe conditions) and (2) those who had been diagnosed with a skin disease or prescribed ointments or creams. Nursing managers in each unit identified eligible patients, and the researchers provided both verbal and written explanations of the study.
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Only those who gave written informed consent were included. Sample size calculations for the main analysis interaction were performed using the G Power software ver. 3.1.9 [27], assuming a median effect size of η2 = 0.07 [11], α = 0.05, and 1-β = 0.80. The calculated minimum sample size was 28, and after accounting for a 20% dropout rate, 33 patients were included.Intervention and measurement areas
The target areas were both lower limbs, which are the most common sites of dry skin and edema [14, 15], and both forearms, which were the intervention sites in previous studies [10, 11].
Intervention
Cotton towels
A washcloth (32 cm × 32 cm, 33 g) was wrung out to a total weight of 88 ± 2 g, including water [28], and heated in a towel warmer (TW-7F, Daishin Shoji Ltd., Chiba, Japan) for 30 min to a surface temperature of approximately 43°C. The weight of each towel was measured using a digital scale (KW-001; Tanita Ltd., Tokyo, Japan).
Disposable towels
A disposable towel (20 cm × 32 cm, 22 g, Mitsubishi paper mills Ltd., Tokyo, Japan) was heated in a towel warmer (TW-7F, Daishin Shoji Ltd., Chiba, Japan) for 15 min to a surface temperature of approximately 43°C. The towels were made of water, propylene glycol, phenoxyethanol, benzalkonium chloride, and propynyl iodide butyl carbamate.
Bed baths
The interventions were performed on days without major invasive catheterization, treatment, surgery, bathing, or showering. In addition, an interval of at least 24 h was ensured from the previous hygiene care intervention.
The lower limb (or forearm) on either side was wiped with either a disposable towel or cotton towel thrice from the ankle to the knee joint on the front of the lower limb (or the forearm flexor, from the wrist to the elbow joint) [11, 28]. The moisture on the skin surface was wiped off with a dry towel (dry wiping). The contralateral side was similarly wiped with either a cotton or disposable towel, followed by dry wiping. The same researcher wiped each patient’s skin.
Wiping pressure during bed baths was set at 10–20 mmHg, based on a previous study [9] that showed this low pressure effectively removes dirt without impairing the skin barrier function in older adults. To control frictional stimulation during wiping, patients were required to remain in a supine position. For lower limb wiping, the patients’ knee joint was extended, and the lower limb was externally rotated. For forearm wiping, patients were asked to abduct the forearm so that the dorsal side was in contact with the bed surface. If the participants experienced respiratory distress on lying down, they were placed in the fueler or sitting position, and the posture was standardized among the participants. To optimize the wiping pressure, we gave bed baths to five healthy adults in the laboratory. The intraclass correlation coefficient (ICC) for intra-rater reliability of the wiping pressure on the forearm was 0.85. As the ICC was above 0.61, the reliability was considered adequate [29].
Data collection (Fig. 1)
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Please place Fig. 1 here.A
Figure 1. Study protocolNotes
Black circles; measurements.
Participant characteristics
Patient information was collected from the nursing and electronic medical records, including demographic characteristics (age, sex, body mass index [BMI, kg/m2]), hospitalization days, degree of independence (J, independent; A, house-bound; B, chair-bound; C, bed-bound), medication history (disease, medical history, and medical treatments [steroids, anticoagulants, diuretics, anticancer therapy, radiotherapy, and hemodialysis]), nutritional status, smoking history, and sun exposure. These items were selected based on a literature review that identified the factors associated with worsening skin barrier function in older patients [30]. Nutritional status was assessed using the controlling nutritional status (CONUT) score, which was automatically calculated from the serum albumin, total cholesterol, and total lymphocyte count [31]. In general, the nutritional status was assessed based on the BMI and dietary intake. However, participants in this study were prone to weight gain due to fluid retention as a result of heart and kidney failure, making it difficult to use only the BMI to assess the nutritional status. In addition, prehospitalization skin care habits, subjective skin symptoms, dryness, and edema status were assessed prior to the intervention. Edema of both the lower limbs and forearms was evaluated based on the presence and degree of indentation after pressure was applied to each site while the participant was lying on the bed (0, none; 1, slight indentation [2 mm] and normal contours; 2, deeper pit after pressing [4 mm] and fairly normal contour; 3, deep pit [6 mm] that persists for several seconds after pressing; 4, deep pit [8 mm] that persists for a prolonged time, possibly minutes, after pressing) [32].
Skin barrier function
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The skin barrier function was evaluated on the anterior surface of the lower limbs and inner forearms before the bed bath (baseline), 15 min after the bed bath (15 min after), and the day after the bed bath (next day). The participants were asked to rest for 15 min before the skin barrier function was measured. To avoid measurement errors, it was ensured that uniform pressure was generated when the device touched the measurement site. The participants were asked to lie down to ensure stable probe contact with the skin. When measuring the skin barrier function of the lower limbs, the patients’ knee joint was extended, and the lower limb was externally rotated. The skin barrier function on the lower limbs was measured at the knee joint, medial to the tibia, and at the center of the ankle joint (Fig. 2a). The measurement sites in the flexed forearm were the elbow joint and the center of the wrist joint (Fig. 2b). Furthermore, the body hair and bone were avoided during measurements. If the participants experienced respiratory distress on lying down, they were placed in the fueler or sitting position, and the posture was standardized among the participants.1) Trans epidermal water loss (TEWL)
TEWL is the amount of water that passively evaporates through the skin to the external environment due to the water vapor pressure gradient on both sides of the skin barrier and is used to characterize the skin barrier function [33]. The higher the TEWL value, the greater the water loss and lower the skin barrier function [21]. TEWL was measured using a VapoMeter (SWL-5001; Delfin Technologies Ltd., Kuopio, Finland). The average of the 30 s values measured at each time point according to the guidelines [18] was used for further analysis.
2) Stratum corneum hydration (SCH)
SCH reflects the water content of the stratum corneum [18] and was measured using MoistureMeter (SC Compact, Delfin Technologies Ltd., Kuopio, Finland). Three measurements were performed at each point, and the average value was used for analysis. To minimize the influence on the TEWL measurement, SCH measurements were performed after the TEWL measurement [34].
In order to control the measurements, we measured TEWL and SCH in five healthy adults in the laboratory. In the forearm, the ICCs for TEWL and SCH were 91.5 and 85.3, respectively. In the lower limbs, the ICCs for TEWL and SCH were 98.2 and 83.4, respectively. The ICCs were greater than 0.61, indicating adequate reliability [29].
3) Dry skin
Dry skin on the lower limbs and forearms was assessed using the Japanese version of the overall dry skin score (ODS) [35]. This scale is a typical skin assessment index that evaluates the absence and severity of skin dryness using a five-point scale (0, no skin dryness; 4, severe skin irritation, scale, inflammation, and cracking). The validity of this scoring system has been demonstrated [36].
Please place Fig. 2 here.
Figure 2. Measurement site of skin barrier function
Notes
a, measurements of skin barrier function; b, the lower limbs; c, the inner forearms. Squares, measurement site of transepidermal water loss; circles, stratum corneum hydration.
Subjective evaluation
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After each intervention, the participants were asked to freely express their opinions on the bed baths. A
To accurately record the participants’ response, an integrated circuit (IC) recorder was used to record the participants’ voices from the beginning to the end of each intervention.Experimental procedure
Considering the burden placed on the participants, data collection was conducted in a hospital room. The room temperature and humidity were measured at all measurement points. To standardize the experimental conditions, measurements were performed in a room with controlled temperature (22–25° C) and humidity (45–55%). The actual room temperature (mean ± standard deviation) was 25.9 ± 1.2°C before the intervention, 26.3 ± 1.2°C after 15 min, and 25.0 ± 1.4°C on the next day. The humidity (mean ± standard deviation) was 30.6 ± 6.7% before the intervention, 30.2 ± 6.7% after 15 min, and 31.4 ± 6.5% on the next day.
Statistical analysis
For the participant characteristics, the mean and standard deviation or frequency were calculated and summarized. The skin barrier function was analyzed using the MMRM, where time and towels were defined as the fixed factors, whereas participants were defined as random factors. The factors in this MMRM were “time” (baseline, 15 min after, and next day) and “towels” (disposable and cotton). For the interaction, “time and towels” was set up. If at least one of the factors or interactions was significant, a post hoc test was performed on the means to compare the data between the two intervention types. In addition, changes in the skin barrier function over time were compared using the MMRM only in patients with dry skin and chronic kidney disease (CKD), which are risk factors for skin barrier disorders. The significance level was set at 5%. In this study, the Bonferroni method was used for the post-hoc test to confirm the differences between the time points within each condition and between the conditions at each time point (total of nine conditions); the P-value was determined to be significant at 0.05/9 = 0.0056. Analyses were conducted using JMP® Student Edition 18.2.1 (SAS Institute Inc., Cary, NC, USA). For the qualitative data analysis, the voice recordings captured on an IC recorder were transcribed verbatim, and the content was organized for thematic interpretation.
Results
Participant characteristics
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Twenty-seven patients were included in the analysis (Fig. 3). Of these patients, 16 (59.3%) were female and the mean age (standard deviation) was 83.1 (8.0) years (Table 1). Twenty-five patients had dry skin (ODS ≥ 1) on the lower limbs and 23 had dry skin on the forearms. The mean ODS of the lower limbs (1.7 [0.7]) was significantly higher than that of the forearms (1.2 [0.7]) (P = 0.001, t = 3.5, mean difference [MD], 95% confidence interval [CI]: 0.2, 0.8). The mean TEWL (P = 0.021, t = − 2.4, MD [95% CI]: −2.4, − 0.2) and SCH (P < 0.001, t = − 5.1, MD [95% CI]: −7.9, − 3.3) of the lower limbs were significantly lower than those of the forearms.Variables | Values, Range | ||
|---|---|---|---|
Sex [female] | n (%) | 16 (59.3) | |
Age | years | 83.1 (8.0) | , 67–99 |
Body mass index | kg/m2 | 20.8 (4.1) | , 14.2–28.7 |
Disease | |||
Myocardial Ischemia | n (%) | 11 (40.7) | |
Heart Valve Diseases | n (%) | 4 (14.8) | |
Chagas Cardiomyopathy | n (%) | 5 (18.5) | |
Arrhythmias, Cardiac | n (%) | 18 (66.7) | |
Heart Failure | n (%) | 19 (70.4) | |
Kidney Failure | n (%) | 9 (33.3) | |
Hypertension | n (%) | 14 (51.9) | |
Diabetes Mellitus | n (%) | 10 (37.0) | |
Treatment | |||
Renal dialysis | n (%) | 1 (3.7) | |
Use of diuretics | n (%) | 21 (77.8) | |
Use of antithrombic drug | n (%) | 20 (74.1) | |
Use of statin | n (%) | 9 (33.3) | |
Use of steroid | n (%) | 1 (3.7) | |
Undernutrition Degree | |||
Normal (0–1) | n (%) | 4 (14.8) | |
Light (2–4) | n (%) | 5 (18.5) | |
Moderate (5–8) | n (%) | 15 (55.6) | |
Severe (9–12) | n (%) | 3 (11.1) | |
Smoking | n (%) | 11 (40.7) | |
Sunlight exposure | n (%) | 4 (14.8) | |
Degree of independence | |||
J, Independence | n (%) | 12 (44.4) | |
A, Requires assistance to leave home | n (%) | 7 (25.9) | |
B, Nearly bedridden | n (%) | 3 (11.1) | |
C, Bedridden | n (%) | 5 (18.5) | |
Hospitalization days | days | 12.7 (12.2) | , 2–51 |
Overall dry skin score (ODS) | |||
Forearm ODS = 0 ODS = 1 ODS = 2 ODS = 3 | n (%) | 4 (14.8) 14 (51.9) 9 (33.3) 0 (0.0) | |
Lower limb ODS = 0 ODS = 1 ODS = 2 ODS = 3 | n (%) | 2 (7.4) 7 (25.9) 16 (59.3) 2 (7.4) | |
Transepidermal water loss (TEWL) | |||
Forearm | g/m2h | 8.4 (2.4) | , 4.5–13.3 |
Lower limb | g/m2h | 7.1 (1.7) | , 3.0-9.5 |
Stratum corneum hydration (SCH) | |||
Forearm | A.U. | 17.8 (5.0) | , 10.1–27.6 |
Lower limb | A.U. | 12.2 (4.8) | , 5.7–26.4 |
Subjective skin symptoms | |||
Feeling of itchy skin | n (%) | 7 (25.9) | |
Feeling of dry skin all the time | n (%) | 12 (44.4) | |
Feeling of dry skin in winter | n (%) | 7 (25.9) | |
Feeling of dry skin after taking a bath | n (%) | 1 (3.7) | |
Edema (Scale ≥ 1) | |||
Forearm | n (%) | 12 (44.4) | |
Lower limb | n (%) | 13 (48.1) | |
Skin care habit | |||
Taking a bath | times/week | 2.3 (1.9) | , 0–7 |
Taking a shower | times/week | 0.4 (0.9) | , 0–3 |
Others | times/week | 0.1 (0.7) | , 0-3.5 |
Scrubbing when washing | n (%) | 10 (37.0) | |
Use a lot of soap | n (%) | 3 (11.1) | |
Lathering soap | n (%) | 12 (44.4) | |
Soaking in hot water | n (%) | 6 (22.2) | |
Wiping hard with a towel | n (%) | 5 (18.5) | |
Applying moisturizer | n (%) | 2 (7.4) | |
Please place Table 1 here.
Please place Fig. 3 here.
Figure 3. Diagram of the flow
Change in the skin barrier function
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Although the main effects of time (F [2,25] = 0.5, P = 0.617) and towel type (F [1,26] = 0.3, P = 0.592) on TEWL of the lower limbs were not significant, the interaction between time and towel type was significant (F [2,25] = 4.0, P = 0.030). However, no differences were observed in the TEWL values of the lower limbs across the time points or towel types (Fig. 4a). The main effects of time (F [2,25] = 0.8, P = 0.443) and towel type (F [2,25] = 2.3, P = 0.120) on SCH of the lower limbs and the interaction (F [1,26] = 0.6, P = 0.451) for SCH of the lower limbs were not significant (Fig. 4b). Although not statistically significant, the MD for SCH in lower limbs from baseline to the following day was − 1.2 A.U. (95% CI = -2.8, 0.3) under the cotton towel condition and − 1.3 A.U. (95% CI = -2.5, 0.0) under the disposable towel condition (Additional file 2).There was no significant interaction (F [2,25] = 0.2, P = 0.806) and main effects of time (F [2,25] = 1.4, P = 0.271) and towel type (F [1,26] = 1.4, P = 0.255) on TEWL of the forearms (Fig. 4c). The interaction (F [2,25] = 1.1, P = 0.339) and main effect of towel type (F [1,26] = 0.0, P = 0.837) on SCH of the forearms were not significant, but the main effect of time was significant (F [2,25] = 8.8, P = 0.001). For bed baths with cotton towel, SCH at 15 min after the intervention was significantly lower than the SCH at baseline (t = 3.2, P = 0.004, MD [95% CI]: 0.8, 3.5) (Fig. 4d).
Please place Fig. 4 here.
Figure 4. Changes over time in skin barrier function in forearms and lower limbs by towel material (n = 27)
Notes
a, TEWL in the lower limbs; b, SCH in the lower limbs; c, TEWL in the inner forearms; d, SCH in the inner forearms. Circles and squares, the least square means as estimated by the mixed model; error bar, 95% confidence interval. *P < 0.0056. SCH, stratum corneum hydration; TEWL, trans epidermal water loss.
Changes over time in the skin barrier function of the lower limbs and forearms by towel material in patients with dry skin
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In patients with dry skin (ODS ≥ 1) on the lower limbs (n = 25), the main effect of time (F [2,23] = 0.8, P = 0.477) and towel type (F [1,24] = 0.4, P = 0.528) on TEWL of the lower limbs were not significant, although the interaction between time and towel type was significant (F [2,23] = 4.6, P = 0.021). However, there were no differences in the TEWL values of the lower limbs across the time points or towel types (Fig. 5a). The main effects of time (F [2,23] = 0.9, P = 0.439) and towel type (F [2,23] = 2.1, P = 0.141) on SCH of the lower limbs and the interaction (F [1,24] = 0.5, P = 0.508) for SCH were not significant (Fig. 5b).In contrast, in patients with skin dryness on the forearms (n = 23), there was no significant interaction (F [2,21] = 0.1, P = 0.910) and main effects between time (F [2,21] = 1.7, P = 0.215) and towel type (F [1,22] = 3.1, P = 0.093) on TEWL of the forearms (Fig. 5c). The interaction (F [2,21] = 0.7, P = 0.495) and main effect of towel type (F [1,22] = 0.3, P = 0.618) on SCH of the forearms were not significant, but the main effect of time was significant (F [2,21] = 5.3, P = 0.013). However, there were no significant differences in the SCH measurements of the forearms across the time points (Fig. 5d).
Please place Fig. 5 here.
Figure 5. Change over time in skin barrier function in forearms and lower limbs by towel material in patients with dry skin (lower limbs: n = 25; inner forearms: n = 23)
Notes
a, TEWL in the lower limbs; b, SCH in the lower limbs; c, TEWL in the inner forearms; d, SCH in the inner forearms. Circles and squares, the least square means as estimated by the mixed model; error bar, 95% confidence interval. *P < 0.0056. SCH, stratum corneum hydration; TEWL, trans epidermal water loss.
Changes over time in the skin barrier function of the lower limbs and forearms by towel material in patients with CKD (n = 9)
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No interaction (F [2,7] = 0.9, P = 0.444) or main effect (time, F [2,7] = 0.3, P = 0.750; towel, F [1,8] = 0.1, P = 0.750) were observed for TEWL of the lower limbs of patients with CKD (Fig. 6a). Furthermore, no interaction (F [2,7] = 1.0, P = 0.429) or main effects (time, F [2,7] = 2.7, P = 0.131; towel, F [1,8] = 1.2, P = 0.313) on SCH of the lower limbs were observed (Fig. 6b). Similarly, no interaction or main effects on TEWL (interaction, F [2,7] = 1.1, P = 0.399; main effect of time, F [2,7] = 0.3, P = 0.731; main effect of towel, F [1,8] < 0.0 P = 0.885) and SCH (interaction, F[2,7] < 0.0, P = 0.966; main effect of time, F[2,7] = 2.8, P = 0.130; main effect of towel, F[1,8] < 0.0, P = 0.945) were observed in the forearms (Fig. 6c, 6d).Please place Fig. 6 here.
Figure 6. Changes over time in skin barrier function in forearms and lower limbs by towel material in patients with CKD (n = 9)
Notes
a, TEWL in the lower limbs; b, SCH in the lower limbs; c, TEWL in the inner forearms; d, SCH in the inner forearms. Circles and squares, the least square means as estimated by the mixed model; error bar, 95% confidence interval. *P < 0.0056. SCH, stratum corneum hydration; TEWL, trans epidermal water loss.
Subjective evaluation
There were no complaints of pain or desire to not use either of the towels, and 11 patients (40.7%) described the wiping as pleasant during and after the bed bath. For bed bath of the lower limbs, 14 patients (51.9%) responded that either option was acceptable, nine (33.3%) preferred disposable towels, and four (14.8%) preferred cotton towels. For bed bath of the forearms, 15 (55.6%) responded that either option was acceptable, seven (25.9%) preferred disposable towels, and five (18.5%) preferred cotton towels. The impressions of bed bath with disposable towel were “feels soft (n = 5),” “feels smooth (n = 3),” and "feels fresh (n = 1).” For cotton towels, respondents commented that “cotton towels are rougher (n = 2),” “feel more familiar (n = 1),” and "thicker and more comfortable on the skin (n = 1).”
Discussion
Skin condition of older patients
The prevalence of dry skin among the patients in this study was approximately 90%, higher than that in previous studies (Konya et al., 2021[10], 64.3% [inner forearms]; 79.5–88.6% [lower limbs]; Yao et al., 2023[6], 53% [95% CI: 36–69%]). The first reason for the tendency toward dry skin among the study participants may be that many of them had CKD [30] or were taking diuretics [24], which are associated with skin barrier dysfunction and dryness. Heart disease and kidney failure affect the systemic blood supply and lead to atrophy of the sweat and sebaceous glands. Therefore, despite the small number of bedridden patients included in this study, many participants had dry skin. Secondly, only 44% of the participants were aware of their dry skin, and appropriate self-care was not routinely practiced. Furthermore, the participants were not aware of the harmful effects of practices such as scrubbing the skin too vigorously or not applying moisturizers. Previous studies [37] have reported that daily skin care habits are associated with dry skin. Thus, poor skin care habits may have contributed to the high prevalence of dry skin symptoms. Thirdly, seasonal factors may have played a role. To avoid the influence of perspiration on skin barrier function measurements, this study was conducted between March and May (spring), when humidity was low, around 30%. Previous research [38] has shown that the skin tends to be drier in winter than in summer. Therefore, it is likely that seasonal conditions also contributed to the high prevalence of dry skin observed in this study.
In addition, TEWL and SCH at baseline were lower in the lower limbs than in the forearms, while the ODS was higher in the lower limbs than in the forearms. Generally, impaired skin barrier function is reflected by increased TEWL and decreased SCH. However, in this study, both TEWL and SCH were found to be low in the lower limbs. The skin turnover time gets prolonged with aging in older individuals, leading to skin thickening [39]. Furthermore, since TEWL measures the amount of water evaporating from the stratum corneum, it is reasonable to assume that less water evaporates when the skin is dry. Therefore, TEWL on the lower limbs was lower than that on the forearms. Based on TEWL and SCH measurements and ODS results, it was confirmed that the lower limbs were drier than the forearms. This trend in the older population was consistent with that reported in previous studies [15, 40, 41]. These findings confirm that the skin on the lower limbs in the study population requires particular attention with regard to the skin barrier function.
Effects of bed baths with weak wiping pressure on the skin barrier function of the lower limbs in older hospitalized patients
TEWL and SCH did not change significantly after bed baths of the lower limbs, along with the ODS. Moreover, these results were similar in participants with dry skin and CKD, which are risk factors for skin barrier dysfunction in older patients [30]. There were no significant differences in TEWL and SCH between bed baths using disposable and cotton towels 15 min after the bed bath and the next day. These results reject Hypotheses 1 and 2 and suggest that bed baths with weak wiping pressure on the lower limbs do not worsen the skin barrier function regardless of the towel material. There were no negative opinions in the subjective evaluations, and the majority of respondents indicated that both towel materials were acceptable for both the lower limbs and forearms. These results confirmed the safety of bed bathing with weak wiping pressure on the lower limbs. Therefore, selecting the towel materials according to the patient's preference is considered appropriate for ensuring patient-centered care.
Although there was no statistically significant difference, MD in SCH of the lower limbs between baseline and the day after bed bathing was 1.2–1.3, which is a greater change than the smallest detectable change (0.31 A.U.) reported in a previous study [11]. In contrast, SCH in the forearms decreased once after bed bathing and recovered the following day, regardless of the presence of skin dryness or CKD. The same trend was observed in a previous study involving weak–pressure wiping on the forearms of older individuals [11]. Similarly, Gillis et al. [17] reported that unlike the time-course changes in SCH of the forearms after bed bathing, SCH of the lower limbs showed a slight downward trend post-bed bathing, consistent with the findings of the present study. The changes in SCH after bed bathing between the forearms and lower limbs differ because of differences in the skin barrier function depending on the body site. Compared to areas such as the face, both the forearms and lower limbs have lower sebum levels and are more prone to dryness [42]. In particular, the lower limbs tend to be drier than the forearms, which was also observed in the present study. When the skin becomes dry, its natural barrier function deteriorates [43]. Therefore, the more vulnerable condition of the skin on the lower limbs may explain the MD of 1.2–1.3 in SCH between the day after bed bathing and baseline. The results of this study indicate that regardless of towel material, weak wiping pressure does not impair the skin barrier function. However, this conclusion is based on a single intervention, as our study did not address how the skin condition of the lower limbs may change with repeated daily bed bathing. Considering that bed bathing constitutes a routine aspect of daily care, future studies should rigorously assess the impact of continuous interventions on the skin condition of the lower limbs.
Limitations
This study has several limitations. First, the room temperature at the measurement site was relatively high. Because the intervention and evaluation of skin barrier function were conducted in hospital rooms, rather than in controlled laboratory settings, the room temperature may have influenced the measured values. Future studies should consider supplementing instrumental measurements with visual skin assessments, such as the ODS. Second, the sample size was small and limited to patients with heart diseases. Given that skin integrity may be variably affected by different diseases and treatments, future studies should include more diverse patient populations, such as those with cancer. Third, temporal SCH changes after bed bath appeared to differ between the lower limbs and forearms; however, the mechanism underlying this difference remains unclear. Fourth, the lower limb is not the recommended site for measuring the skin barrier function [44]. Compared to the forearm, the lower limb has body hair and an uneven surface. However, we fully acknowledged this limitation and implemented appropriate measures to ensure accurate assessment of the skin barrier function, and confirmed the reliability of the measurements using the ICC. Finally, as only one type of disposable towel was used in this study, future research should assess whether similar outcomes can be achieved using other types of disposable towels.
Conclusion
This study examined the effect of bed baths with weak wiping pressure using cotton and disposable towels on the skin barrier function of the lower limbs of older hospitalized patients. Changes in TEWL and SCH over time revealed that bed baths of the lower limbs did not worsen the skin barrier function in older hospitalized patients, regardless of the towel material, provided weak wiping pressure was applied. The ODS, an indicator of skin dryness, did not change between the day before and day after a bed bath. The same trend was observed over time for the skin barrier function of the lower limbs after bed bath in patients with CKD and dry skin who had heart disease, who were at higher risk of skin barrier dysfunction. However, the skin on the lower limbs tended to be drier than that on the forearms, and further research is needed to examine the changes in the skin barrier function when interventions are applied continuously.
List of abbreviations
BMI, body mass index
CKD, chronic kidney disease
CONUT, controlling nutritional status
ICC, intraclass correlation coefficient
MMRM, mixed-effects models for repeated measures
ODS, overall dry skin score
SCH, stratum corneum hydration
TEWL, trans epidermal water loss
Declarations
Ethical approval and consent to participate
A
A
This study was approved by the Ethical Review Board of the first author’s affiliated university (approval no.23–102, Date: 08.03.2024) and performed in accordance with the Declaration of Helsinki. Patients referred by the nurse manager received written and verbal explanations from the researchers pertaining to (1) the purpose of the study, (2) methods of the study, (3) right to drop out at any time, (4) they would not suffer any disadvantages if they did not participate or stopped participating, (5) the study will be conducted in careful and safe conditions, (6) they can terminate the study immediately and cool down in case of excessive heat or pain, and (7) the data will be strictly anonymous. A
All participants provided informed consent.Consent for publication
A
Written informed consent for participation and publication was obtained from all participants after oral and written explanation of the study.Competing interests
The authors declare that they have no competing interests.
A
Funding
This study was supported by JSPS KAKENHI (grant number: JP 21K21157).
A
Author Contribution
IS designed and coordinated this study; carried out data collection, analysis, and interpretation; drafted and revised the manuscript. RY contributed to the design of this study, interpretation of the study findings, and critically reviewed the manuscript. All authors have approved the final version of the manuscript.
A
Data Availability
The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.
A
Acknowledgement
We would like to express our sincere gratitude to all participants for their cooperation in this study.
Supplementary Information
Additional file 1.
TREND statement checklist.
Additional file 2.
Details of statistical information in Fig. 4.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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