I’m always worried about her skin; it gets bruised just like that

Do you know of, or care for, someone who has skin as thin as tissue paper? Even a slight pinch or an accidental bump can result in a skin tear that just bleeds and bleeds. Large brown spots called hemosiderin spots can form on the skin over time (1). That’s when blood gets into the skin but is not completely reabsorbed. Residual iron from the red blood cells results in the brown color. Damage to the skin can also result in irregular white scar tissue that is not elastic and pulls at the skin (2). The scar tissue has no pigment. The superficial “epidermal” level of skin grows back but the deeper layers don’t recover. The result of all this is fragile and wrinkled skin. Do you see all these changes in the picture above?

What causes damaged skin?

Some older patients have beautiful skin. It is healthy and well cared for. It has also been protected from the sun. In contrast, people who have worked outdoors their entire lives have sun damage, especially on their hands, forearms, and face. Hobbies such as gardening, and sports such as fishing, golf, or tennis, also predispose the participants to sun damaged skin.

Myth Buster: Aging causes fragile skin

Aging itself plays only a small role in fragile skin. The proof is on the butt. That skin is just as old as the skin on the rest of the body. “Butt” that skin is protected from the environment and “sheltered” from the sun. It’s usually the nicest skin on the body.


Most skin damage is not due to aging. Exposure to cigarette smoke leads to drying, thinning and discoloration. It also results in sagging tissue with baggy eyelids, visible small blood vessels and prominent wrinkling around the lips (smoker’s lines). Tar from smoking results in yellow discoloration of the fingers and teeth. Chronic diseases such as diabetes, congestive heart failure and renal failure result in tissue edema and loss of structural integrity. Lastly, the skin is a living tissue. Diseases injure the tiny blood vessels (capillaries) in the skin. Blood does not circulate well, and the skin weakens.

Medicines can also cause problems. Long term use of corticosteroids weakens the skin. This is seen in patients with COPD who are prescribed prednisone or steroid inhalers. It is important to emphasize, at this point, that strong (high potency) steroid creams should not be used on the face. Skin on the face is too thin and absorbs too much of the steroid. Aspirin and NSAIDS such as Advil, decrease clotting. Blood thinners such as warfarin, Eliquis, and Xarelto are prescribed for certain heart problems. These medicines can result in prolonged bleeding or extensive bruising in damaged skin.


dermis and mattress comparison

A Skin and Mattress Comparison

One way of thinking about skin is by comparing it to a mattress. The cover of the mattress is like the part of the skin that you can feel and see – this is called the “epidermis”. But the strength of the skin, and of the mattress, is the part that is underneath. 90% of skin is the layer which is under the epidermis - this layer is called the “dermis”. The dermis provides the cushion and elasticity to the skin, just like the springs and fillers in a mattress.

When the protein in the dermis weakens, the skin sags, just like a mattress sags when the springs break. Further damage results in thinning. Thin skin is like a thin mattress. It doesn't provide comfort nor resist pressure.

The damage is done, what can be done to prevent further damage?

Fragile skin must be handled with extra care and attention.

The  key step is to use a moisturizing cream at least twice daily. There are many quality brands, but the crucial point is not the brand. It is the regularity and frequency of use. Moisturizing creams provide a healthy microenvironment and add an extra layer of protection. Creams also make skin slippery so that there is less friction and pulling on the skin. This is important. Healthy skin isn't damaged by a slight pull. But fragile skin shears with minimal friction.

Be sure to use sunscreen outdoors. Protect the face and neck from direct sunlight with a hat. Coverings over the forearms protect the skin against sun, shearing and injury. Long-sleeved clothing and full-length pants protect the skin.

sun protection sleeve

I use sun protection sleeves.

Be gentle with the skin. Just use your hands, mild soap and warm, not hot, water to wash the face and skin. Do not scrub with brushes or towels. (And face cream at night is a treat.)

Be careful in general. The skin naturally protects the body from the environment. But when skin is damaged, it becomes injured easily. Unfortunately, pets frequently cause skin tears, so be on the lookout for that.

Avoid using adhesive bandages. When the skin is weak, it is not well anchored to deeper tissue. The adhesive on the bandage will win the tug of war and the skin will be torn off. I will discuss this in more detail in my next post. Skin tears occur commonly when the skin is weak. How SHOULD they be managed?

Warmest Aloha,

[email protected]

PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.


Posted in Active Aging, Caregiving, Dr. Warren, Geriatrics with Aloha and tagged , , , , , .


  1. Thank you Dr. Wong for this timely article! We are taking care of dad who now needs 24/7 care and his arms look so beat up! We just noticed a tiny skin tear on his bottom due to being up all day in his wheelchair and now needing briefs because he can’t get to the toilet or get the urinal in place in time. Looking forward to your follow up article!

  2. Always great information, Dr. Warren. I am not all that old but have very fragile skin. Mostly likely due to my near-naked youth on the beach and in the hills. Hope all is well.

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