November 2009 1.0 November 2009 Arne Langøen RN Associate Professor, Stord/Haugesund University College, Norway arne.langoen@hsh.no Sandra Lawton RN, OND, RN Dip (Child), ENB 393, MSc, QN Nurse Consultant Dermatology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, UK sandra.lawton@nuh.nhs.uk vulnerable skin periwound skin venous leg ulcers pressure ulcers diabetic foot ulcers venous eczema contact dermatitis allergens This short paper forms the third in a series of three articles examining care of the skin surrounding wounds. The first two papers examined the pathophysiology of vulnerable skin and the assessment and management required when caring for patients with wounds. The focus of this article is on those dermatological conditions that are directly related to specific wound types. All periwound skin can become vulnerable and requires careful assessment and management. Certain wound types cause dermatological problems in the surrounding skin and require particular care, including venous leg ulcers, pressure ulcers and diabetic foot ulcers. Allergic reactions to substances used in wound management and skin care, such as cosmetics and soaps, may exacerbate periwound skin problems. As discussed in papers one and two of this series, care of the periwound skin, including its protection against mechanical injury (such as tissue trauma caused by the removal of adhesive tapes and dressings) and chemical injury (caused by products used on the skin, bodily fluids and wound exudate), is an essential requirement for those providing wound and dermatological care ref1 ref2. This paper examines dermatological problems associated with specific wound types, including venous leg ulcers, pressure ulcers and diabetic foot ulcers. In some cases, especially in leg ulcer management, vulnerable periwound skin can be the most challenging aspect of care and cause far more problems for the patient and carer than the wound itself. Skin assessment involves obtaining a detailed dermatological history by questioning the patient, observing the skin meticulously and making detailed notes. This may provide clues to diagnosis, management and nursing care of the existing or potential problem ref2 ref3. Periwound skin care is perhaps most challenging in patients with venous leg ulcers. A number of physiological changes in the skin are caused by changes in the venous circulation in such patients. Venous hypertension leads to micro-oedema, where red blood cells and other macromolecules leak into the extravascular space. There is release of iron pigment from haemoglobin, which results in brown staining of the skin (haemosiderin). Patients with chronic venous ulcers often have lipodermatosclerosis, atrophie blanche, hyperpigmentation, dry, scaling and atrophic skin and venous stasis eczema. These conditions are often associated with vulnerable periwound skin that is thin and easily damaged by adhesives, for example. This skin condition can be further complicated by allergic or irritant reactions (see Tables 1 and 2 ref4 ref5). The key to successful management is to treat the chronic venous hypertension, either surgically or with compression therapy. Without this, local treatment will be ineffective. Allergen Possible sources of allergen Rubber Gloves, bandages, hosiery Topical antibiotics Creams, ointments and medicated dressings Emulsifiers Stiffening agent in creams Perfumes Creams and bath additives Preservatives Creams and gels Adhesives Dressings and plasters Common allergens and their sources Potassium dichromate Found in cement, safety matches, tanned leather, paint, printing ink and crayon, glues and detergents. Neomycin sulphate An aminoglycoside antibiotic found in medicaments for external use. Thiuram mix Used in rubber processing, antiseptic sprays, as a preservative in medicaments and as a bacteriostat in soaps. p-phenylenediamine Found in hair dyes and photographic development chemicals. Cobalt chloride Found in metals, cement and pigments in paint. Caine mix III Used to detect allergy to local anaesthetics. Formaldehyde Used in the production of urea, phenolic melamine and acetate resins. Used as an astringent, disinfectant and preservative in cosmetics, shampoos and metal-working fluids. Colophony Found in adhesive tapes, plasters, cosmetics, glues, varnishes and rubbers. Quinoline mix. Antibacterial agents used in topical pharmacaceutical preparations. Balsam of Peru (Myroxylon pereirae) Used in haemorrhoid, burns and scabies treatments, as a fragrance in cosmetics and as an aromatic additive in food and soft drinks. N-Isopropyl-N-phenyl-4-phenylenediamine Found in tyres, gloves, adhesive tapes and squash balls. Lanolin alcohol Found in topical medicaments, cosmetics, printing inks, hand lotions, creams and ointments. Mercapto mix An accelerator in rubber processing. Epoxy resin Widely used in industry; found in glues, paints and dentures. Parabens mix Preservatives found in creams and cosmetics. 4-tert-Butylphenol formaldehyde resin A resin used in adhesives, especially in shoes. Fragrance mix I Found in perfumed goods. Quaternium 15 Preservatives in medicaments and cosmetics Nickel sulphate An alloying ingredient in many metals. Kathon CG (CI+ME-isothiazolinone) A preservative in cosmetics and toiletries. Mercaptobenzothiazole An accelerator in rubber. Primin Found in plants of the primula family. Sesquiterpene lactone mix Used in the detection of a contact allergy against composite flowers. Chlorocresol (p-chloro-m-cresol) A fungicide in creams, topical antiseptics, pharmaceutical products, protein shampoos, baby cosmetics and cooling fluids. Bronopol (2-Bromo-2-nitropropane-1,3-diol) Preservative used in cooling fluids, hand and face creams, shampoo and mascaras. Cetearyl alcohol An emulsifier and emollient in cosmetics and pharmaceutical preparations. Sodium fusidate (fusidic acid) A topical antibiotic. Tixocortol-21-pivalate A topical corticosteroid belonging to the group A (hydrocortisone) type of steroids. Budesonide A non-halogenated corticosteroid for use in topical preparations and for treatments of rhinitis and asthma. Imidazolidinyl urea (Germall 115) Preservative in lotions, creams, hair conditioners, shampoos and deodorants. Compositae mix Found in ragweed, arnica, feverfew, chamomile, yarrow. Diazolidinyl urea (Germal 11) Preservative used in cosmetic creams, lotions, shampoos and hair gels. Methyldibromoglutaronitrile Preservative used in cosmetic hair products of both leave-on and rinse-off types. Ethylenediamine dihydrochloride Stabiliser used in steroid creams and rubber latex. Inhibitor in antifreeze and cooling fluids. 4-Chloro-3,5-xylenol (PCMX) A preservative in cooling fluids, creams, topical antiseptics. Also used in pharmaceutical products, hair conditioners, toiletries, deodorants and soaps. Carba mix Used in rubber processing. Adapted from Bourke J, Coulson I, English J. Guidelines for the management of contact dermatitis: an update. Br J Dermatology 2009; 18: 946-54, with kind permission of the publishers, Wiley-Blackwell. Venous eczema can benefit from treatment with topical corticosteroids, although these must be used with caution as they can damage the thin and vulnerable skin if used incorrectly and may even exacerbate the condition. If the eczema is wet a topical corticosteroid cream is preferable; if the eczema is dry an ointment should be used. In severe cases, problems can be dealt with using potassium permanganate 0.01-0.03%, applied once or twice a week for two weeks or so, preferably in conjunction with corticosteroid therapy ref6. This will reduce the number of bacteria and reduce the secretion from both the wound and the eczema. Topical corticosteroids are generally used once or twice daily over short periods of one to two weeks and then stopped. However, in the case of gravitational eczema or allergic contact dermatitis surrounding a leg ulcer, the ulcer will usually be undergoing treatment by compression therapy and dressing changes will not allow this frequency of application. Occlusion enhances the potency of topical corticosteroids by aiding absorption and this should be considered when choosing a preparation ref7. Side-effects from the use of topical corticosteroids can include topical effects (thinning of the skin, irreversible loss of elasticity, striae, worsening of skin infections or acne) and systemic effects (pituitary and adrenal suppression, and Cushing's syndrome) and are related to potency, While it is important to use the least potent topical corticosteroid whenever possible, the treatment does need to be effective and using a more potent preparation initially may result in less topical corticosteroid being used in the long term ref7. When using topical corticosteroids their use and therapeutic effect should be monitored and evaluated. If there is a poor response to treatment the skin should be reassessed and differential diagnoses considered such as an infection (bacterial or fungal), or allergic contact dermatitis (possibly caused by a product used on the wound or skin, see Table 1). A recent study showed that 82.5% of patients with chronic leg ulcers had at least one positive patch test reaction ref8. Patients with venous leg ulcers are at risk of bacterial infections in the skin surrounding the wound, a condition often called cellulitis. It can be difficult to distinguish between cellulitis and venous eczema, since both conditions leads to oedema and erythema. They can also occur simultaneously ref9. Cellulitis is often associated with well-demarcated erythema, warmth, pain and tenderness to the touch, while dermatitis has more diffuse edges and more dry and scaling skin. To reduce the risk of allergic reactions, Romanelli and Romanelli (2007) suggest the prophylactic use of an ointment comprising 50% soft white paraffin and 50% liquid paraffin ref10. It is important to recognise that the use of ointments can lead to folliculitis caused by blockage of the hair follicles, and therefore all emollient preparations should be applied smoothly in the direction of hair growth ref11. A film containing acrylate can be used as protection against wound fluid and fluid from eczema ref11 ref12. The film protects for 72 hours, and should not be used in combination with local corticosteroid treatment, as the film will inhibit its effect. Zinc oxide can be used to protect the periwound skin; however, the salts in zinc inhibit the action of silver in the wound and thus zinc oxide should not be used in combination with silver dressings ref11. Showering or bathing should be encouraged where possible, and can be beneficial for both the wound and periwound skin problems. Using conventional soap products containing surfacants can have a drying effect on the skin, causing immediate after-wash tightness, dryness, redness, irritation and itch, and may damage the skin barrier ref13 ref14. Emollient wash products should therefore be used. When choosing a bandage or dressing for a patient with venous eczema, several factors should be taken into account, including the risk of allergic and toxic reactions, the severity of eczema, and the amount of fluid produced by both the wound and the eczema. A dressing with high absorbing capacity, no adhesive border and an inner layer with a low risk of producing toxic and allergic reactions should be preferred, such as those with an inner layer of soft silicone ref15. In many cases of superficial pressure damage such as stage 1 and 2 pressure ulcers, the damage has occurred because the peripheral circulation has been compromised. When the pressure on the area is relieved, the area is reperfused. The combination of obstruction or reduction of the circulation followed by reperfusion, leads to increased amounts of reactive oxygen species, which cause inflammation in the tissue ref16 ref17. The inflammation, together with reduced circulation, makes the periwound skin more vulnerable. In stage 1 and 2 pressure ulcers, in addition to mandatory measures such as pressure relief, the skin may be protected with an ointment containing 50% soft white paraffin and 50% liquid paraffin or an acrylate-containing film to reduce the risk of skin breakdown. These wounds are often located in areas where contamination with urine and faeces is likely, which can cause a contact dermatitis rash (see Figure 1) ref18 and therefore a barrier cream or ointment can help to protect the skin. Stage 3 and 4 pressure ulcer damage involves deeper layers of the skin and structures under the skin. In some cases there are undermined areas with deep cavities and fistulae. Therefore the periwound area is at risk from excoriation from wound exudate or discharge from the fistulae. When applied carefully to the affected area, barrier ointments can protect periwound skin from the effects of humidity, sweat, protease and lipase production from the wound, urine and faeces and friction from bed linen ref19. In cases where the skin is at greater risk, a good alternative is to protect the periwound skin with either a hydrocolloid or a polyurethane film. However, frequent removal of the hydrocolloid paste or polyurethane film dressings can lead to damage of the periwound skin, owing to a stripping effect. Selecting an appropriate dressing that allows effective exudate management will help to protect the surrounding skin from damage. It is important that these measures are taken alongside the removal of causative factors and the instigation of effective pressure relief.

Diabetic neuropathy causes both dry and scaling skin and an increased production of callus in the periwound area. Diabetic patients can also have ischaemia because of microangiopathy, resulting in dry, atrophic, cold skin on which hair fails to grow ref20. The dry skin of the diabetic foot should be treated with emollient products. Emollients are an important group of agents that play an integral part in the treatment and maintenance therapy of all dry, scaling skin disorders. Emollients come in a variety of formulations and are used for washing, bathing and moisturising. To treat hyperkeratosis, areas of callus should be removed regularly by a podiatrist. Healthcare professionals should strongly encourage patients to prioritise this treatment. Both adhesive and non-adhesive dressings can be used in patients with hyperkeratosis, but it is commonly accepted that dressings with limited absorbing capacity, such as hydrocolloids, should be avoided. This paper describes the common dermatological problems associated with the periwound skin of specific wound types. The key to good management in all cases is gaining an accurate diagnosis and understanding of the cause of the problem and knowing when to refer to a specialist. It is important for clinicians to acknowledge the impact that dermatological disease will have on the patient's quality of life and the wound healing rate. It is easy to misdiagnose even common skin conditions and inappropriate treatment is often the cause of an exacerbation of the condition and great distress to the patient. This article was sponsored by an unrestricted educational grant from Mölnlycke Health Care. 2009 Flour M http://www.worldwidewounds.com/2009/September/Flour/vulnerable-skin-1.htm 2009 Lawton S Langøen A http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-skin-2.html 30 5 43-8 2005 Lawton S 19302065 160 5 2009 Br. J. Dermatol. 946-54 Bourke J J Coulson I I English J J 2009 Bell H K HK Eedy D J DJ Mitchell D M DM Bull R H RH Tidman M J MJ Fuller L C LC Yesudian P D PD Joseph D D Wagle S S 19480192 23 34 40-6 Lawton S S Gill M M 2005

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