One of the most common wound care problems is the maceration of the skin around the wound. In most cases, this causes discomfort and irritation, but it may also lead to ulceration and damage of the unaffected tissues.
Epidermal tissue of the skin is the most effective barrier against fluid loss, bacterial attacks, and the effects of external forces. When the tissue is exposed to moisture or corrosive body fluids for a long period of time, it becomes ineffective in protecting the body against the external factors. Acute maceration of the skin is caused by exposure to high levels of moisture. In the presence of high levels of moisture, the outer keratinized layer of skin becomes swollen, leading to the weakening of the bonds between the tissue planes. This makes it more susceptible to the damage caused by friction.
In severe cases, the outer layer of skin is removed, exposing the inner germinative layers. This causes pain and increases the risk of damage and infection by bacteria and fungi. Drying the skin at this juncture may lead to further damage. Wiping the skin causes the stripping of tissues and leads to desiccation. As the germinative layers dry, the damage moves deeper into the tissue layers.
The epidermis cannot withstand enzyme-rich fluids such as small bowel effluent and pancreatic secretions. The enzymes present in the fluids breakdown the cell matrix leading to the removal of epidermal tissue. Small bowel fistulae or persistent and profuse diarrhoea are some of the causes for such superficial skin loss. Incontinence may also cause prolonged exposure to urine and feces. If the soiling is not cleared immediately the urea present in the soiling may be metabolized by the flora of the skin leading to the production of products with high pH. Alkaline environment reduces the defence mechanism of the body. Other skin conditions like dermatitis may also arise due to prolonged contact with exudates and effluents.
Problems in the management of skin maceration
- Pain – Skin macerations are highly inflammatory and sensitive. Products containing alcohol or other irritants may lead to further problems, as they are cytotoxic in nature.
- Excessive moisture – Prolonged exposure to moisture may remove the protective barrier causing more damage.
- Application of products – Dressing of the wound is very hard because of the loss of superficial epidermis and the presence of surface moisture. Moreover, many areas where skin exacerbations are seen, like perianal region and around stoma, are difficult to dress.
- Interaction with other treatments – products which are often used to protect the skin in macerations often interact and interrupt with other products and appliances. For example, ointments and zinc paste preparations may interfere with the adhesive dressings.
With any care provider who is dealing with the problem of skin maceration, the management techniques should comply with a number of issues.
Any treatment for skin maceration should:
- Be easy to apply
- Not cause further difficulties in application or removal
- Not interfere or interact with the dressings or continence products
- Not increase the risk of infections
- Protect the tissues from moisture
- Be non-sensitizing
Management of skin maceration
Any treatment method should focus on the root cause for exposure to the body fluids or excess moisture. If exposure is caused by urinary incontinence, treatment to improve the bowel and bladder function should be used or mechanical methods like catheters should be administered. Using fistula drainage bags or applying negative pressure on the wounds may help to channelize the wound exudates away from the wound area. Treating the infection will also help to reduce the wound exudate. If the cause of moisture is venous and capillary congestion, compression may be applied to reduce the damage.
Prolonged exposure should be prevented if infection is unavoidable. For this highly absorbent dressings and continence pads can be used to take away the moisture from the region. This dressing should be changed frequently to avoid further damage. Alginate, hydrocellular foam and hydropolymer dressings are some of the effective ways to manage wound exudates.
Oil-based creams and zinc paste are effective in preventing over-hydration of the epidermis. Care should be taken, as it may affect the application of adhesive dressings and interfere with the absorptive properties of foams and continence products. Creams may be replaced by liquid film dressings, in which the solvent evaporates leaving the polymer film. These are more reliable than a product with alcohol as the solvent.