Assessing and managing vulnerable periwound skin October 2009 1.0October 2009SandraLawtonRN, OND, RN Dip (Child), ENB 393, MSc, QNNurse Consultant Dermatology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, UK
sandra.lawton@nuh.nhs.ukArneLangøenRNAssociate Professor, Stord/Haugesund University College, Norway
arne.langoen@hsh.novulnerable skinperiwound skinskin strippingmacerationexudate damageskin assessmentAll patients requiring wound care have vulnerable periwound skin.Clinicians must be aware of the key factors that may exacerbate the vulnerability of the skin surrounding a wound and how to prevent or reduce further damage. Factors that may damage vulnerable periwound skin include tissue maceration, traumatic insult due, for example, to wound-dressing adherence and wound-related dermatological disease. When caring for a patient with a wound, healthcare professionals should take a detailed history of the patient's skin and assess it regularly at dressing changes, planning management according to the risk factors identified.
Abstract This is the second in a series of three articles on vulnerable periwound skin. The first discussed the pathophysiology of vulnerable periwound skin. This article examines the factors that lead to or exacerbate the condition. The assessment, management and prevention of periwound skin problems are also discussed. The third article in this series focuses in more detail on how the underlying pathology of certain wound types can result in dermatological disease and the effect this may have on periwound skin. IntroductionThe skin is the largest organ of the human body and one of the most
important. Throughout a person's lifetime the skin is subjected to a large
number and variety of insults, both internal and external, that may affect
either its structure or function. In healthy individuals skin is strong,
resilient and will repair itself in response to all but the most severe
insults. However, skin may be subject to changes that result in it becoming
vulnerable, impaired and dysfunctional. Some of these changes are
intrinsic, such as the effects of skin conditions, ageing or underlying
illness, and some are extrinsic, such as environmental damage. The skin surrounding a wound is particularly vulnerable and although
it may appear healthy, periwound problems occur frequently. There are many
factors that increase the risk of vulnerable skin, and clinicians caring
for patients with wounds must recognise that they have a key role to play
in preventing periwound skin problems and in identifying patients who may
be at risk of developing them. Periwound skin damage contributes to
protracted healing times, can cause pain and discomfort, and may
adversely affect a patient's quality of life 1.
This paper focuses on the risk factors associated with vulnerable
periwound skin such as wound-specific pathologies, dressing-related
problems and existing dermatological problems. In relation to these points,
the physiological and practical reasons why patients with wounds are at
risk of vulnerable skin and the healthcare professional's role in
assessing, managing and preventing such problems in the periwound area are
discussed.Risk factors associated with vulnerable periwound skinFor the purposes of this paper, vulnerable skin can be defined as
skin that is susceptible to damage as a result of a traumatic incident that
would not normally damage the skin of a healthy individual. This can either
be at a macroscopic level (for example, skin tears caused by traumatic
injury) or at a microscopic level (such as epidermal cell stripping, caused
by the removal of an adhesive dressing). Wound-specific pathologiesAs discussed in the first of this series of three papers on
periwound skin, vulnerable skin may occur as a result of increasing age,
a skin disease (such as eczema), environmental damage (such as
ultraviolet radiation), or a disease related to an underlying pathology
(such as lipodermatosclerosis) or a congenital disorder (such as
epidermolysis bullosa) 2. Major skin changes are one of the many
features that occur with ageing and it is estimated that 70% of elderly
people have skin problems that have a significant impact on all aspects
of daily living 3.In addition to the above, there is a number of factors, related
specifically to the underlying pathology of certain wound types, that
increase the risk of vulnerable skin or cause dermatological problems
that result in vulnerable skin 4. See
Table 1.
Table 1: Examples of wound types that contribute to the risk of vulnerable skinVenous leg ulcersPatients with chronic venous ulcers often have
lipodermatosclerosis, atrophie blanche, hyperpigmentation, dry,
scaling and atrophic skin and venous stasis dermatitis. This results
in vulnerable periwound skin that is thin and easily damaged by
adhesives, for example. The skin condition can be further complicated
by allergic or irritant reactions.Raised intra-capillary pressure
as a result of damage to the venous system leads to oedema, which may
cause maceration. The skin directly below the wound is at greatest
risk of maceration owing to the gravitational effect of wound exudate
drainage.Pressure ulcersSacral ulcers are particularly at risk of maceration because
of the presence of urinary and/or faecal incontinence or the presence
of skin folds in obese patients.Diabetic foot ulcersMost of these wounds produce low amounts of exudate. However,
the predominantly neuropathic nature of plantar ulcers makes
maceration a real risk. Inappropriate dressing selection may also
cause skin maceration in the diabetic foot.
Adapted from Hampton S, Stephen-Haynes J. Skin maceration: assessment, prevention and treatment. In: White R, editor. Skin Care in Wound Management: Assessment, prevention and treatment. Aberdeen: Wounds UK, 2005, with kind permission of the publishers.Poor management of vulnerable skin in the immediate periwound
region or in the surrounding area can cause multiple problems for both
the patient and the healthcare professional. For example, tissue
maceration arising as a result of poor wound exudate management and
traumatic insult due to aggressive wound dressing adherence will
exacerbate the problems in already vulnerable periwound skin. Hampton and
Stephen-Haynes (2005) have identified a number of wound-related factors
that can compromise periwound skin 5. These include:
Drainage from fistulaeDrainage from a stomaExcessive perspirationIncreased wound exudateRemoval of adhesive productsSensitivities (allergic or irritant reactions).
Maceration, excessive wound exudate and skin stripping are discussed below.
MacerationMaceration refers to the skin changes seen when moisture is
trapped against the skin for a prolonged period. The skin will turn
white or grey and will soften and wrinkle. This is a process that is
purely moisture dependent and occurs as a result of over-hydration
(constant wetness) 67. This altered state may lead to the
breakdown of the periwound area, thus enlarging the wound 68.
Maceration of the skin around wounds is not only caused by exudate; it
can also occur where skin has been exposed to urine or excessive
perspiration. Macerated skin is more permeable to micro-organisms and
prone to damage from friction and irritants than intact skin.
Wound exudateDamage to the periwound skin can arise from inadequate wound
exudate management. This may occur with the use of dressings that are
unable to cope with the level of exudate produced. It may also occur
when dressings are not changed frequently enough and exudate levels are
allowed to build up and leak. The presence of proteases in wound
exudate may accelerate the development of maceration by impairing the
skin's barrier function and is one of the most common causes of
problems in the skin surrounding a wound. Furthermore, chronic wound
exudate is characterised by greatly increased amounts of
pro-inflammatory cytokines, free oxygen radicals and proteases such as
matrix metalloproteinases (MMPs) and elastase 9. The enzymatic
activity of proteases, for example, can damage healthy epidermis,
resulting in a red, weeping surface, or may cause skin breakdown if the
wound fluid leaks on to the surrounding skin and is left in contact
with it 5710. In addition, there is increasing evidence that
the presence of bacteria can lead to elevated levels of MMPs in the
wound surface and in the wound fluid, thus damaging both the
extracellular matrix (ECM) in the wound and the periwound skin 1112.
Skin strippingRegardless of any underlying condition or illness, all patients
with wounds are prone to the effects of skin stripping of the periwound
region. This is caused by the repeated application and removal of
adhesive tapes and dressings from the skin. This process inflicts
variable levels of damage to the layers of the stratum corneum, and may
cause inflammatory skin damage, oedematous changes, skin soreness and a
detrimental effect on skin barrier function 1314. The quantity and
depth of corneocyte removal has a direct relationship to the degree of
skin irritancy, with repeated applications enhancing these detrimental
effects 1415. Overcoming clinical challenges associated with vulnerable periwound skinPeriwound skin management should start with protection against the
mechanical and chemical injuries discussed above. A thorough skin assessment is required and will include obtaining a
detailed dermatological history (Table 2)
involving meticulous observation of the skin. This may provide clues to
diagnosis, management and nursing care of any existing or potential
problems 16. Making both a general and a periwound skin assessment should
be seen as part of an holistic approach to wound care. The periwound area
must be assessed at every dressing change. It is important to establish the
degree of pain, itching and soreness present, as well as any periwound skin
changes. Prevention should be the ultimate goal. Where clinicians recognise
that the periwound skin is vulnerable and at an increased risk of damage,
it is important that they take precautions by minimising periwound skin
contact with exudate, protecting the area with an appropriate barrier and
using atraumatic dressings where possible to avoid skin stripping. Any
underlying pathology must always be treated in order to manage the
associated dermatological condition.It is important to recognise that skin lesions and inflammation will
look different in different shades of skin. Lesions that appear red or
brown in white skin, may appear black or purple in black or brown skin.
Mild degrees of redness (erythema) may be masked completely in dark skin.
At sites of inflammation all shades of skin may show areas of
post-inflammatory hypopigmentation or hyperpigmentation 16.
Table 2: Taking a history of a patient's skin conditionDoes the patient have intrinsic risk factors for
vulnerable skin, such as old age, diabetes, atopy or thin
skin? Does the patient have wound-related risk factors
such as venous eczema, infection or high exudate levels?
Is there a skin condition present, related or
unrelated to the wound? For example, is there anything
unusual, such as a rash or dryness, or is the skin sore or
itchy? How long has the condition been present?
How often does it occur? Are there any seasonal variations?Is there a family history of skin disease? What are the patient's occupation and hobbies?
Some activities may impact on a patient's skin condition,
such as work that involves repeated handwashing or exposure
to chemicalsWhat medication is the patient taking? This
includes both prescribed and over-the-counter products.
Medication may be contributing to an allergic reaction or
exudate production 17Are there any known allergies? What treatments have been used and how effective
have they been?Are there any treatments, actions or behavioural
changes which influence the condition?
Preventing exudate damage and macerationThe principles of treating maceration are essentially about
reducing excessive moisture and must focus on treating the factors
contributing to over-hydration. To avoid maceration and optimise healing,
the exudate and moisture levels should be assessed regularly and
appropriate dressings chosen, with realistic wear times estimated for
each wound at each dressing change 5. There are several ways of
preventing exudate-related damage to the ECM and the periwound skin.The easiest and most economical way of avoiding damage to the skin
is to prevent wound fluid from coming into contact with it. This can be
achieved by using dressings that are capable of managing or containing
the fluid. Modern dressings with enhanced fluid-handling capabilities
offer substantial advantages over products used in the past and have done
much to alleviate the problem of maceration. The evolution of less
aggressive adhesive systems, such as soft silicone technology, allows
dressing changes to be undertaken without causing the skin the trauma and
pain that were associated with traditional adhesive systems 7.
Dressings containing a superabsorbent component give good protection. It
is also possible to actively remove fluid from the wound using topical
negative pressure therapy. The World Union of Wound Healing Societies (WUWHS) has recommended
that dressing choice should be determined by ensuring a number of
practical features are present 17, including the following. The
dressing should:
Stay intact and remain in place throughout wear time Achieve the desired moisture levelPrevent leakage between dressing changesNot cause maceration, allergy or sensitivityBe comfortable, conformable and not impede physical activityBe suitable for leaving in place for a long timeBe easy to remove (should not cause trauma to the surrounding skin or wound bed). The WUWHS also states that appropriate dressings should be selected
that minimise wound-related pain based on wear time, moisture balance,
healing potential and periwound maceration 18. It is also possible to protect the skin using pastes containing
zinc oxide or a spray containing acrylate, which provides a protective
film 11. Both these approaches are thought to be equally successful,
although barrier films are easier to apply and do not require removal. It
is also easier to apply a dressing over an area covered with barrier film
8. If the periwound skin is vulnerable or damaged, it can also be
protected by using a hydrocolloid dressing to cover the periwound area,
but not the wound 7. This method has long been used to protect the skin
around stomas. However, repeated treatment with hydrocolloid-based
adhesive dressings has been shown to induce functional alterations of the
stratum corneum, with hypergranulation tissue developing under the
hydrocolloid 19.It is possible to reduce the amount of MMPs in the wound fluid by
using a protease modulator or by lowering the pH level in the wound with
a pH buffer 20. Adjusting the pH level in the wound from 8 to 4 reduces
the protease activity by 80% 21. However, at a pH level of 4, protease
activity will stop, which is not desirable either. A pH level of between
4.5 and 6 will keep the protease activity in the wound fluid at an
acceptable level 21. There is increasing evidence that bacteria may create biofilms
(complex aggregations of micro-organisms) on the wound surface, which
have a negative influence on healing. When polymorph nuclear granulocytes
(PNGs) attack the biofilm, toxins from the biofilm destroy the PNGs and
MMPs are released. This leads to an elevated level of MMPs in the wound
surface and in the wound fluid, damaging both the ECM in the wound and
the periwound skin 1122. The best way to remove biofilms from the
wound is with a combination of debridement and antibacterial treatment of
the wound surface 22.Preventing dressing-related traumaSkin stripping associated with the removal of dressings leads to
inflammatory skin reactions, oedema and soreness, all of which can have
an adverse effect on skin barrier function 13. This can also cause
extreme discomfort and pain and can affect patients' quality of life.
Recommendations for preventing or minimising skin damage on dressing
removal are described below 11723. A number of factors will indicate if dressings are causing damage, including the following:
Is there pain on dressing removal? Such pain may be
associated with trauma and skin stripping. Assessing pain using a
systematic and documented approach before, during and after dressing
changes is recommended by the WUWHS 18. Are there signs of damage? It is important to assess
the periwound skin for signs of damage by observing for skin tears or
breaks, erythema, oedema, heat, purulence or odour. A systematic and
documented approach is required in order to plan management. Are the wound margins deteriorating? Assess the wound
margins for an expansion of the area of breakdown. How vulnerable is the healing tissue? Assessing the
vulnerability of healing tissue is important. As epithelialisation
begins and there is re-establishment of an intact epithelium, the new
areas of skin cover are particularly delicate and sensitive to damage.
It is important at this stage of healing to take appropriate
precautions to prevent damage to the newly restored skin
tissue. Are appropriate dressings being used? It is important
to recognise the vulnerability of healing tissue and vulnerable skin
and to select dressings that are known to be atraumatic on removal,
such as soft silicones 18.Vulnerable skin and dermatological problems The following dermatological problems may impact on vulnerable periwound skin.Fungal infectionsWound fluid has a pH of between 5.5 and 9 and alkaline wound fluid
will promote the growth of both bacteria and fungal infections or
mycoses, such as Tinea infections and Candida albicans21. The
increased humidity associated with closed bandages can contribute to
fungal growth 24. Superficial fungal infections or mycoses, and
superficial Candida infections, are the most common of all mucocutaneous
infections and are often caused by overgrowth of transient or resident
flora associated with a change in the microenvironment of the skin. A
number of local factors increase a person's susceptibility to fungal
infections. These include damaged skin that is either excessively moist
or dry, and changes in the temperature and normal acid balance (pH) of
the skin 24. A common reason for treatment failure is misdiagnosis. Maceration
and fungal infection can be difficult to distinguish, but it must be
recognised that these are separate conditions, requiring different
treatments. Fungal infections can also be mistaken for eczema.
Inappropriate treatment with topical corticosteroids will exacerbate the
infection and lead to a condition described as 'Tinea incognito' 24.
Where a fungal infection is suspected, skin samples, scrapings, nail
clippings and hair debris, as appropriate, should be collected for
laboratory examination, according to local protocols. Contact dermatitis Also called contact eczema, contact dermatitis is a generic term
applied to acute or chronic inflammatory reactions to substances that
come into contact with the skin. Irritant contact dermatitis is caused by
a chemical irritant, while allergic contact dermatitis is caused by an
allergen 25. Cumulative skin irritation, inflamed skin and a damaged
skin barrier provide enhanced conditions for sensitisation and allergic
contact dermatitis 26. Allergic contact dermatitis is a type IV
(cell-mediated or delayed) hypersensitivity. Clinically, irritant contact
dermatitis is indistinguishable from allergic contact dermatitis. To
differentiate between the two, a comprehensive history, involving
physical examination and patch testing is necessary to determine a
definitive diagnosis 27. The key to the successful treatment of allergic reactions is to
identify and remove the cause. It is quite common for clinicians to
mistakenly diagnose an allergic reaction in periwound tissue as an
infection or protease damage. When an allergic response is the right
diagnosis, it is possible to treat with corticosteroids. The use of an
acrylate-containing film will also reduce both the allergic reaction and
the irritant reaction, but should not be used if there are plans to treat
the skin with a topical treatment such as corticosteroids, because the
film will prevent penetration of the skincare treatment for up to 72
hours after application. The choice of dressing should be one that has
been shown to have a low risk of contact reaction and a good absorbing
capacity. Dressings with adhesive borders should be avoided.Quality of life and cost implications of periwound skin damageThe impact of dermatological problems on a patient's quality of life
is well researched 28. Itching (pruritus), for example, is the principal
symptom of dermatological disease and can be an extremely distressing
complaint. The key to
managing quality-of-life issues in patients with chronic wounds lies in
identifying problems early 29. The emphasis must be on good symptom
control, with the elimination of pain a priority for all patients.Although data on the economic implications of periwound skin damage
is not currently available, it is likely that an additional financial
burden results from extended problems with wound management 30. Damage to
the skin from inappropriate dressing selection can in many cases be avoided
or reduced by using modern dressings. This means that in the future this
may become a potential area for litigation, a point that healthcare
professionals can emphasise when requesting access to appropriate dressings
and resources.ConclusionPatients with wounds, irrespective of their aetiology, have the
propensity for developing vulnerable periwound skin that may be
associated with disease processes or their treatment regimen. Periwound
skin damage can exacerbate pain, increase wound size and delay healing,
thereby increasing healthcare costs and reducing patients' quality of
life 1. This should be recognised by the healthcare professional and
appropriate sympathetic or active treatment provided accordingly.AcknowledgementThis article was sponsored by an unrestricted educational grant from
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