What is skin turgor?
Skin turgor [from Latin turgor = fullness] refers to skin tension or elasticity, which gives the skin the ability to return to normal shape after being pulled and released 22. A doctor or a nurse usually checks skin turgor during physical examination to assess the level of dehydration in an individual.
What is skin mobility?
Skin mobility refers to how easily can the skin be pulled from its original position 23. The skin that has increased mobility usually, but not always, has decreased turgor and vice versa.
Skin Turgor Assessment
A doctor or a nurse pinches the patient’s skin at a certain site with the thumb and index finger and releases it and then measures the time in which the skin recoils completely. See the skin turgor test on the hand in Picture 1.
Picture 1. Skin turgor assessment on the forehead (at glabella)
(free image use)
Picture 2. Skin turgor assessment on the back of the hand
(free image use)
CHART 1. Sites (Locations) for Skin Turgor Test
|SITE – FROM MOST TO LEAST RELIABLE||COMMENT|
|Glabella — the most prominent part of the forehead between the eyebrows (Picture 1) 6||At these locations, the skin is least affected by age-related skin wrinkling|
|Upper chest: over the sternum or below the clavicle|
|Forearm (outer side; see video below), thigh (inner side) 14 or calf (the back side) 3||Checking at these locations causes least discomfort in a patient|
|Abdomen, near the umbilicus 12||In infants and small children|
|Back of the hand between the thumb and index finger (Picture 2)||The least reliable, affected by wrinkling, but easily accessible for a quick check|
|Neck||Often contains redundant skin 8|
|Face, back, buttocks||Skin turgor decreased only in severe dehydration|
|Finger knuckles||Poor skin turgor despite good hydration|
Video 1: Description of the skin turgor test on the forearm
Explanation of the Results
- When the skin fold recoils immediately, the skin turgor (tension) is said to be good.
- Skin recoil delayed for less than 2 seconds is described as poor skin turgor, which suggests moderate dehydration.
- Skin recoil delayed for more than 2 seconds speaks for severe dehydration.
- Skin fold persisting for several seconds or even minutes is described as tenting.
- References 1,3.
A Measure of Skin Turgor in Medical Documentation Charts
In different hospitals doctors and nurses may use different terms to describe skin turgor “types:”
- Elastic or non-elastic (inelastic)
- WNL — Within Normal Limits (there is no actual “normal range,” so only immediate recoil is normal)
- Good or poor (bad, loose, reduced, decreased)
- Brisk (resilient) or sluggish
- Normal or prolonged (delayed) for 2+, 3+, 4+…seconds
- Tenting, also described as moist/doughy/boggy if prolonged for several seconds
- An example of documented skin turgor test: “Skin recoil 3 seconds at clavicle”
No more detailed classification or rating of skin turgor values exists.
Normal Skin Turgor
Skin turgor is considered normal when the skin after being pinched and released recoils almost instantly (in milliseconds). Note that immediate skin recoil does not always mean good hydration: obese people, those with scleroderma or certain other conditions can have increased skin turgor, but can still be dehydrated (see Chart 3).
Poor Skin Turgor
Skin turgor is considered poor when the skin recoil is delayed for any amount of time, even for a half of a second. Note that decreased skin turgor does not always mean dehydration: older people and others with wrinkled skin have poor skin turgor but can still be well hydrated (see Chart 2). In general, old people are no more dehydrated than younger ones.
Normal skin turgor (fullness and elasticity) is maintained by presence of water in the skin cells and between them and by elastic fibers in the skin. In both overall body dehydration and in “isolated” skin dehydration, such as in elderly, there is less water in the skin, what decreases skin fullness and hence its elasticity.
Chart 2. Causes of Poor Skin Turgor
|CAUSES of GENERALIZED poor skin turgor||COMMENTS|
|Dehydration||Most common cause|
|Wrinkled skin caused by age, smoking 20, premature ageing (progeria)|
|Quick loss of weight 20||Redundant skin|
|Decreased abdominal volume in women after delivery||Poor skin turgor on the abdominal wall|
|Malnutrition: Deficiency of vitamin A, C or E, and selenium 25||Common in chronic alcoholism, prolonged starvation, anorexia nervosa|
|End-stage kidney failure in individuals on hemodialysis or peritoneal dialysis 4||Dry, rough skin or xerosis|
|Cutis laxa with skin hanging in folds; loose joints||Inherited or acquired connective tissue disease|
|CAUSES of LOCALIZED poor skin turgor|
|Anetoderma — 1-2 cm big button-hole like wrinkled depressions or elevations anywhere on the skin: genetic or associated with chickenpox, acne, systemic lupus erythematosus (SLE), Lyme disease, Graves disease, Addison’s disease, HIV/AIDS, syphilis, leprosy|
|Photoageing changes on the sun-exposed skin|
|Onhocerciasis (a form of filariasis): thin, itchy skin with red rash on lower back, buttocks and legs||In tropics; transmitted by a blackfly|
Increased Skin Turgor (Decreased Skin Mobility)
Chart 3. Health Conditions in Which the Skin Can be Hard to Pinch
|CAUSES OF DECREASED SKIN MOBILITY and INCREASED TURGOR||COMMENTS|
|ALL OVER (GENERALIZED)|
|Obesity 21||Thick skin due to increased skin fat|
|Severe kidney failure resulting in generalized edema (anasarca)||Water retention|
|Severe systemic allergic reaction (anaphylaxis)||Escape of fluid from the vessels|
|Systemic sclerosis (scleroderma), Sjögren’s syndrome, Ehlers Danlos syndrome||Overgrowth of the fibrous connective tissue in the skin|
|LOWER LEGS — SYMMETRICALLY|
|Pitting Edema 18||When you press the skin over the shinbone with the thumb it remains depressed for few seconds|
|– Prolonged standing or sitting|
|– Before and during menstruation|
|– Chronic heart failure|
|– Kidney failure|
|– Nephrotic syndrome 11|
|– Liver cirrhosis|
|– Water overdose (intoxication) in marathon runners resulting in hyponatremia||Edema in hands and feet, nausea, headache, weight gain|
|– Hypothyroidism or myxedema||Pretibial edema|
|LOWER LEGS — ASYMMETRICALLY|
|– Varices (chronic venous insufficiency)|
|– Deep vein thrombosis|
|– Obstruction of the lymph flow in elephantiasis, lymphoma, tumors in pelvic cavity|
|– Liver cirrhosis|
|– Heart failure|
|– Protein malnutrition (kwashiorkor)|
|– Hypoproteinemia from other reasons|
|– Bruise (skin or muscle)|
|– Insect sting or snake bite|
|– Hematoma, ganglion cyst or tumor under the skin|
|– Cellulitis (subcutaneous bacterial infection)|
|– Gas gangrene (after Clostridium perfringens infection) 19|
|– Allergic reaction (hives)|
|– Contact dermatitis|
|– Steroids||Swelling of the face and upper body|
Poor skin turgor is a late sign of dehydration and can be observed in moderate dehydration, which means > 3-5% loss of body weight due to water loss 1.
Causes, Symptoms and Signs of Dehydration
The diagnosis of dehydration should not be made from the poor skin turgor alone, but from a combination of other signs, symptoms and suspected causes of dehydration:
- Causes: insufficient drinking, excessive sweating, diarrhea, vomiting, excessive urination or polyuria, for example in diabetes mellitus. Check for more causes.
- Symptoms: thirst, less urination, dark urine, fatigue, headache
- Signs: dry mouth, poor skin turgor, sudden loss of body weight. Check for more symptoms and signs.
- Hypernatremia is usually associated with severe dehydration and hence poor skin turgor 13,14.
- Hyperkalemia with hyponatremia and dehydration with poor skin turgor can be present in adrenal insufficiency (hypoaldosteronism) 7.
- Hyperglycemia in untreated diabetes mellitus can result in excessive urination (polyuria), dehydration and poor skin turgor.
Chart 4. Poor skin turgor in combination with skin color and other signs
|CONDITION WITH POOR SKIN TURGOR||OTHER SKIN SIGNS||OTHER SYMPTOMS and SIGNS||CIRCUMSTANCES|
|Severe dehydration||Pale, cool, dry skin||Excessive sweating, diarrhea, vomiting|
|Heat exhaustion||Pale, cool, moist skin||Body temperature 98.6-104 °F (37-40 °C)||Heat wave, dehydration|
|Heat stroke||Flushed, warm, dry skin||Body temperature > 104 °F (40 °C), severe headache||Heat wave, dehydration|
|Hypovolemia (hypovolemic shock)||Pale, cool, moist skin||Low blood pressure (late sign)||Severe bleeding|
Infants and Toddlers
- Usually checked on the abdomen 2,16
- The main cause of poor skin turgor in small children is dehydration caused by diarrhea.
- Other signs of severe dehydration in infants: dry mouth mucosa, sunken fontanels and eyes, decreased body weight, prolonged or minimal capillary refill after pressing upon the nails 1,2
- Many older adults have permanently wrinkled skin due to reduced skin turgor because of skin dehydration, which is NOT the same as overall body dehydration. An older person with reduced skin turgor can be well hydrated, dehydrated or even overhydrated, so the skin turgor test in elderly may not be a reliable test for dehydration.
- In elderly, skin turgor can be optimally assessed at sites that are least affected by skin wrinkling: over the sternum, below clavicle, in the forehead between the eyebrows 9 or on the inner thighs 14. Hands and arms are not a good site to check skin turgor in elderly 15.
- Poor skin turgor is a risk factor for developing pressure ulcers in bedridden elderly individuals 10.
- Emedicine (Physical examination findings in pediatric dehydration)
- Jamanetwork.com (Skin turgor in infants)
- Nejm.org (Severe dehydration)
- Parkhurstexchange.com (Skin manifestations of kidney disease)
- Clevelandclinic.org (Skin related complications of diabetes)
- Askdefine.com (Glabella)
- Oxfordjournals (Hypoaldosteronism, hyponatremia, hyperkalemia and dehydration)
- Passeidireto.com (Evaluation)
- Nursinghome.org (Geriatric patients)
- Docs.google.com (Pressure ulcers)
- Emedicine (Pediatric nephrotic syndrome)
- Fluid and Electrolyte Balance, y.2012 (Skin turgor in children)
- Emedicine (Hypernatremia)
- PubMed (Hypernatremia in elderly)
- Nursing Diagnosis Handbook, An Evidence-Based Guide to Planning Care, 10th edition, y. 2013, p.364 (Geriatric skin turgor assessment)
- Pediatric Nursing: Caring for Children and Their Families, 3rd edition, y. 2012, p.448 (The procedure in children)
- Portable Signs and Symptoms, by Lippincott Williams & Wilkins, y. 2008 (Systemic sclerosis)
- Adult-Gerontology and Family Nurse Practitioner Certification Examination, p. 203 (Edema)
- MedlinePlus (Gas gangrene)
- WebMD (Causes of wrinkled skin)
- Patient.info (Obesity)
- Adam.com (Definition)
- Smu.edu.cn (Skin hair and nail assessment)
- Dermnetnz.org (Anetoderma)
- Nyu.edu (Antioxidants–vitamin A, C, E,selenium–and wrinkled skin)