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By Liza G. Ovington, PhD, CWS
Ovington & Associates
Ft. Lauderdale, FL
Prevention is better than cure. - Desiderius Erasmus
Physical forces contributing to pressure ulcer formation include unrelieved pressure, friction, and shear. Dry skin is thought to contribute to frictional forces, and consequently to the development of pressure ulcers. Skin lubrication is one method of reducing frictional forces recommended by the 1992 Agency for Health Care Policy and Research (AHCPR) Pressure Ulcer Prevention Guidelines. Maintaining skin with adequate hydration and elasticity is vital to preventing loss of skin integrity.
Essential fatty acids (EFAs), specifically linoleic and linolenic acids, have been shown to play an important role in maintaining the moisture barrier function of the skin (e.g., preventing water loss and skin dehydration). Studies of cutaneous biology have shown that a diet deficient in EFAs can lead to characteristic scaly skin disorders. It has been observed that in patients receiving parenteral nutrition, there is a concomitant depletion of stores of essential fatty acids. It is further known that such a depletion of EFAs leads to skin conditions such as scaling and dermatitis. Patients receiving parenteral nutrition may be at high risk for pressure ulcer formation, not only from the direct effects of inadequate nutrition, but from secondary effects on their skin condition.
EFAs can be found in a variety of plant and seed oils such as safflower oil, sunflower oil, and evening primrose oil. The body uses these fatty acids to maintain healthy cell membranes and also as starting materials for building other fatty acids.
Research in both human and animal models has shown that oral administration of EFAs can reverse dietary depletion and results in a transient increase in skin cell proliferative activity and amelioration of scaling (even in the absence of depletion). A similar increase in proliferative activity was later achieved in animal models by a topical application of the EFA in a cream base. Topical application allows the EFA to penetrate the epidermal layers down to the basal layer, where it enhances proliferation in specific areas, such as those at risk for breakdown.
The use of topical EFAs as a skin lubricant in at-risk patients recently has been shown to be effective in preventing pressure ulcer formation. A randomized controlled blinded study in 86 patients compared the effects of lubrication of the skin every eight hours with two different topical solutions. One topical solution contained EFAs combined with vitamins A and E (to prevent oxidation of the oils). The other topical solution contained mineral oil combined with vitamins A and E. All of the patients were rated high-risk (using the Norton Scale for risk assessment) and most were severely malnourished and receiving parenteral nutrition. All patients received preventive interventions as described by guidelines from the AHCPR in addition to skin lubrication with the test solutions.
Evaluation of skin integrity after 21 days of treatment revealed that of the 43 patients treated with the EFA solution, two developed Stage I pressure ulcers and none developed Stage II ulcers. Of the 43 patients treated with the mineral oil solution, 12 (27%) developed Stage II pressure ulcers.
Subjective ratings of skin hydration and elasticity differed for the two treatment groups as well. Of the 43 patients treated with the EFA solution, 42 maintained skin hydration and 32 maintained skin elasticity. Of the 43 patients treated with the mineral oil solution, only nine maintained skin hydration while 34 showed evidence of deep dehydration and scaly skin. Ten of the mineral oil patients maintained skin elasticity and 33 exhibited a loss of skin elasticity.
Based on this research, the use of topical EFAs to promote skin integrity and prevent ulcer formation looks promising. One product that takes advantage of the lubricating and proliferative effects of topical EFAs and further boosts their efficacy in pressure ulcer prevention is an oxygenated oil called Decubitene (Ferndale Laboratories,  548-0900). Decubitene consists of a glycerol molecule esterified with three fatty acids (two of which are EFAs). The three fatty acids are further oxygenated using a patented process. It has been suggested that hyperoxygenation of the fatty acid esters contained in the product provides the benefit of increasing local blood flow in the area of application as measured by transcutaneous oximetry. Because pressure ulceration results from local ischemia, an increase in local blood flow could be a preventive benefit.
In a study done in France, 28 high-risk patients were treated with the hyperoxygenated oil. Transcutaneous oxygen measurements (TcPO2) were taken in the treated area during pressure exertion both before and after application of the oil. It was found that the sites treated with the hyperoxygenated oil experienced less than half the loss of TcPO2 during pressure exertion than did the sites treated with control oil. These results suggest that the hyperoxygenated oil had a positive impact on blood flow. In addition, the positive effects of the EFAs on skin hydration, elasticity, and proliferation complement Decubitene's oxygenation effects in maintaining skin integrity.
Based on the various studies on the effects of topical EFAs on skin (and perhaps on microcirculation in the case of the hyperoxygenated versions), they may provide a valuable and multifunctional tool in pressure ulcer prevention.
1. Declair V. The usefulness of topical application of essential fatty acids (EFA) to prevent pressure ulcers. Ostomy Wound Mgmt 1997; 43:48-52, 54.
2. Colin D, Chomard D, Bois C, et al. An evaluation of hyper-oxygenated fatty acid esters in pressure sore management. J Wound Care 1998; 7:71-72.
3. Jeppesen PB, Hoy CE, Mortensen PB. Essential fatty acid deficiency in patients receiving home parenteral nutrition. Am J Clin Nutr 1998; 68:126-133.
4. Morris GM, Hopewell JW, Harold M, et al. Modulation of the cell kinetics of pig skin by the topical application of evening primrose oil or Lioxasol. Cell Prolif 1997; 30:311-323.
5. Ziboh VA. The significance of polyunsaturated fatty acids in cutaneous biology. Lipids 1996; 31:S249-S253.
6. Abushufa R, Reed P, Weinkove C, et al. Essential fatty acid status in patients on long-term home parenteral nutrition. J Parenter Enteral Nutr 1995; 19:286-290.