Adequate nutrition and hydration are absolutely fundamental when preventing and treating damage to the skin.1, 2  Why?  The easiest way to explain this is with an analogy. 

Think of the human body like a house, with its own live-in renovation team.  Just like the outside walls of a house protect all of the valuables inside, skin acts like a barrier to protect all of the vital organs and tissues inside the body.  But the walls of a house can be made from many different materials — brick, wood, stucco, etc.  Some of these materials, like brick, are extremely durable and can withstand all sorts of damage (like rain, hail, wind, etc).  Other materials, like wood, are moderately durable and can withstand some damage.  Other materials, like tissue paper, can barely withstand any kind of damage at all.  The food someone eats will ultimately determine how “durable” their skin is and how much damage it can tolerate before breaking down.  

It’s often forgotten that every single food that someone eats is broken down into nutrients (aka “building blocks”), which are then used to make new cells, repair existing ones and allow certain metabolic processes to take place.  A diet comprised of adequate amounts of protein, water, vegetables and fruit is like making a house out of brick.  It makes the skin resilient and able to withstand higher levels of friction and pressure before damage occurs.  A diet high in toast, biscuits, crisps and chocolate, on the other hand, is a bit like making a house out of tissue paper.  It won’t be very durable and it won’t take much wind or rain before it gets damaged.  This is because less nutritious food doesn’t offer many nutritional “building blocks” to the body’s renovation team. 

Nutrition…the missing link

Improving someone’s nutritional intake isn’t generally the first thing that comes to mind when someone is at risk for a pressure injury.  Instead, a high Waterlow score (or equivalent) tends to initiate moisturisers, pressure cushions, repositioning schedules, regular skin checks and SSKIN documentation (Surface, Skin inspection, Keep your patient moving, Incontinence/moisture, Nutrition/Hydration).3, 4  But monitoring fragile skin and trying to prevent it from getting damaged, while incredibly important, is a bit like putting a security guard outside a house made out of tissue paper and thinking that is going to prevent damage from happening.  It might work to a degree, but damage will still occur due to factors which are outside of everyone’s control.  Tissue paper, by its very nature is fragile, and so it shouldn’t be surprising when a house made out of tissue paper begins to tear and get damaged.   

Even when someone already has damage to their skin, nutrition is often overlooked.  The first people that come to mind tend to be the amazing district nurses who are able to offer and implement a variety of different dressings and wound-care strategies.  But the best dressing in the world will have limited impact, if someone’s skin is the equivalent of tissue paper.  The purpose of a dressing is to create the best environment to allow the body to heal itself,5 but the actual “building block” materials need to be there for the repairs to take place. 

Who should be referred to a dietitian to improve skin integrity?

1.  Clients who have difficulty chewing, swallowing or who are vegetarian.

Foods such as meat, legumes, eggs, dairy products, nuts and seeds, provide the body with protein and zinc which are critical when it comes to keeping the skin strong and healthy and repairing damage.  Unfortunately, if someone is experiencing chewing or swallowing problems or if someone is following an unbalanced vegetarian diet, a person’s protein intake tends drop unless their support team is really attentive and offering other palatable and appropriate substitutions.  One possible correction strategy is to “fortify” milk with extra protein by adding skim milk powder to it.  This “fortified milk” can then be used to make smoothies, porridge, soups and other foods the person may find appealing.  It is fast, easy and inexpensive to do, but support workers and families need to know this is an option and when to apply it.  Other times fortified milk won’t be enough and oral nutrition supplements or special supplements containing arginine (an amino acid) will be required for wound repair. 2, 6

2.  Clients who are losing weight (intentionally or not)

If someone is losing weight, it means they are taking in less calories than what their body needs.  Whether or not this is a good thing depends on the person and what other health issues they have going on.  When it comes to skin health, losing weight puts someone at high risk, because the protein that would otherwise be put towards skin health or wound healing is now being burned for energy.2 The body will then start to break down the person’s muscle mass in order to try and heal the wound and this contributes to a reduced immune system and increased risk of infections.7   So even if it looks like the person is eating a sufficient amount of protein, if they are losing weight, they likely aren’t getting enough protein to impact the health of their skin.  If the goal is to heal a pressure sore or other wound, the aim should be to maintain the person’s weight until that wound has healed.  Large wounds dial up the body’s metabolic rate to assist with healing, but this means the person will need to eat more in order to maintain their weight.2, 6

3.  Clients with a poor fluid intake

Skin which is dehydrated is less elastic and more fragile.8  Fluid also helps to circulate nutrients through the blood in order to keep skin healthy and/or repair damage.8  Urine which is darker than the colour of straw is often an indication that someone is not drinking enough.9

4.  Clients with anaemia or diabetes.  

If someone has a wound which is slow to heal, a blood test should be done to make sure they have adequate amounts of iron in their blood and to make sure their blood glucose levels are well controlled.10.

Iron is used to make haemoglobin which is what transports oxygen to the cells and helps heal wounds.  

High blood glucose levels cause nerve damage over time.10  This nerve damage can cause people to lose sensation in their limbs which means wounds may go unnoticed because there is little (if any) accompanying pain.10  High blood glucose levels also slow wound healing and make wounds more prone to infection.10

5.  Clients who dislike (or eat very few) vegetables and fruit

Vegetables and fruit are rich sources of vitamins A & C which are critical for wound healing and preventing damage to the body’s cells.2  Sometimes a short-course of prescription-strength vitamin A can also be used to assist wound healing, particularly in clients on corticosteroids.2   

After almost every type of catastrophic injury, the skin will be damaged to some degree.  Even after someone has been discharged into the community, skin damage can still occur due to pressure sores, elective surgeries and accidental injuries. Wounds heal from the inside out.1  Trying to heal a wound when someone’s nutritional status is compromised is a bit like trying to build a house using tissue paper instead of bricks.  It is going to be pretty difficult to do and even if you somehow manage it, the end result will not be very durable.  Therefore, nutrition really needs to be at the forefront of any strategy aimed at preventing and repairing damage to the skin.

For more information on nutrition and wound healing, contact Specialist Nutrition Rehab at info@specialistnutritionrehab.co.uk or 0121 384 7087.

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