Skin Turgor Test

What is skin turgor?

Skin turgor [from Latin turgor = the normal state of fullness] refers to skin tension or elasticity, because of which the skin recoils after you pinch and release it [22]. A doctor or a nurse uses the skin turgor test during a physical examination to check for eventual dehydration.

What is skin mobility?

Skin mobility is the ability of the skin to be pulled from its original position. 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 a patient’s skin with the thumb and index finger and releases it and then measures the time needed for the skin to recoil completely.

Picture 1. Skin turgor assessment on the forehead (at glabella)

Picture 2. Skin turgor assessment on the back of the hand

CHART 1. 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] The least affected by age-related skin wrinkling Upper chest: over the sternum or below the clavicle Forearm (outer side; see Video 1 below), thigh (inner side) [14] or calf (the back side) [3] 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) Less reliable, affected by age-related wrinkling, but convenient for a self-test UNRELIABLE SITES Neck Often, redundant, saggy 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

The skin that, after being pinched and released, recoils immediately suggests good hydration.

suggests A skin fold persisting for <2 seconds suggests mild de hydration.

suggests A skin fold persisting for 2-10 seconds speaks for moderate dehydration.

speaks for A skin fold persisting for several seconds or even minutes speaks for severe dehydration.

or even speaks for References: 1,3

A Measure of the Skin Turgor in Medical Documentation Charts

In different hospitals, doctors and nurses may use different terms to describe skin turgor “types:”

WNL — Within Normal Limits (there is no actual “normal range,” so only immediate recoil is normal)

Normal vs. prolonged (delayed)

Good vs. poor (reduced, decreased)

Elastic vs. non-elastic

Brisk (resilient) vs. sluggish

Tenting (doughy), if prolonged for several seconds or minutes

An example of a 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 less than 0.5 seconds). Note, that immediate skin recoil does not always mean good hydration: obese people, those with a condition with a thick skin called scleroderma or other conditions can have normal skin turgor but can 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 if only 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 be well hydrated (see Chart 2).

Mechanism

Normal skin turgor (fullness and elasticity) is maintained by the presence of water and elastic fibers in the skin. Skin elasticity can decrease either due to whole body dehydration or due to “isolated” skin dehydration (without whole body dehydration), commonly observed in elderly.

Chart 2. Causes of POOR (DECREASED, PROLONGED) Skin Turgor CAUSES COMMENTS Dehydration Most common cause Wrinkled skin caused by age or smoking [20] Quick loss of weight [20] or decreased abdominal volume in women after delivery Redundant skin on the abdominal wall Malnutrition: deficiency of vitamin A, C or E, or selenium [4] Common in chronic alcoholism, prolonged starvation, anorexia nervosa End-stage kidney failure in individuals on hemodialysis or peritoneal dialysis Dry, rough skin or xerosis Cutis laxa with skin hanging in folds; loose joints Inherited or acquired connective tissue disease

Chart 3. Causes of INCREASED Skin Turgor (Decreased Skin Mobility) 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 Septic shock Systemic sclerosis (scleroderma), Sjögren’s syndrome, Ehlers-Danlos syndrome Overgrowth of the fibrous connective tissue in the skin FACE and UPPER BODY Treatment with steroids LOWER LEGS — SYMMETRICALLY Pitting edema due to prolonged standing or sitting, pregnancy, menstruation, chronic heart failure, kidney failure, nephrotic syndrome, water intoxication with hyponatremia [11,18] When you press the skin over the shinbone with the thumb it remains depressed for few seconds Nonpitting edema due to 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 ABDOMEN (ASCITES) in liver cirrhosis Abdominal distension

Dehydration and Skin Turgor

Poor skin turgor is a relatively late sign of dehydration and can be observed in moderate and severe dehydration, that is after a loss of more than 3% of body weight [1].

A doctor can make a diagnosis of dehydration from a combination of known or suspected causes, symptoms, signs and skin turgor test:

Causes: insufficient drinking, excessive sweating, hyperventilation, diarrhea, vomiting, excessive urination or polyuria, for example, in diabetes mellitus

insufficient drinking, excessive sweating, hyperventilation, diarrhea, vomiting, excessive urination or polyuria, for example, in diabetes mellitus Symptoms: thirst, less urination, dark urine, fatigue, loss of body weight

thirst, less urination, dark urine, fatigue, loss of body weight Signs: dry mouth, poor skin turgor, sudden loss of body weight

Metabolic Disorders and Skin Turgor

Metabolic disorders by themselves do not affect skin turgor, but certain metabolic disorders are associated with dehydration and hence with poor turgor:

Hypernatremia [13,14]

Hyperkalemia with hyponatremia in adrenal insufficiency (hypoaldosteronism) [7]

in adrenal insufficiency (hypoaldosteronism) Hyperglycemia in untreated diabetes mellitus

Chart 4. Differential Diagnosis of Skin Turgor CONDITION WITH POOR SKIN TURGOR SKIN SIGNS 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) Hot weather, insufficient drinking Heat stroke Flushed, warm, dry skin Body temperature > 104 °F (40 °C), severe headache Hot weather, insufficient drinking Hypovolemic shock Pale, cool, moist skin Low blood pressure (late sign) Severe bleeding

Skin Turgor in Infants and Toddlers

Usually checked on the abdomen [2,16]

A common 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 a nail [1,2]

Skin Turgor in Elderly