October 2009 1.0 October 2009 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 Arne Langøen RN Associate Professor, Stord/Haugesund University College, Norway arne.langoen@hsh.no vulnerable skin periwound skin skin stripping maceration exudate damage skin assessment All 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. 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. The 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. For 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). As 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. Venous leg ulcers Patients 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 ulcers Sacral 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 ulcers Most 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. Maceration 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) 6 7. This altered state may lead to the breakdown of the periwound area, thus enlarging the wound 6 8. 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. Damage 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 5 7 10. 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 11 12. Regardless 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 13 14. The quantity and depth of corneocyte removal has a direct relationship to the degree of skin irritancy, with repeated applications enhancing these detrimental effects 14 15. Periwound 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. Does 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 chemicals What 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 17 Are 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? The 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 11 22. The best way to remove biofilms from the wound is with a combination of debridement and antibacterial treatment of the wound surface 22. Skin 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 1 17 23. 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. The following dermatological problems may impact on vulnerable periwound skin. Wound 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 albicans 21. 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. 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. The 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. Patients 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. 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