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Heading
Assessing and managing vulnerable periwound skin
Authors
Sandra Lawton, RN, OND, RN Dip (Child), ENB 393, MSc, QN,
Nurse Consultant Dermatology, Queen's Medical Centre, Nottingham University
Hospitals NHS Trust, UK
Email: [email protected]
Arne Langøen, RN, Associate Professor, Stord/Haugesund University College,
Norway
Email: [email protected]
Keywords: vulnerable skin, periwound skin, skin stripping, maceration, exudate
damage, skin assessment.
Key Points
1. All patients requiring wound care have vulnerable periwound skin.
2. 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.
3. Factors that may damage vulnerable periwound skin include tissue maceration,
traumatic insult due, for example, to wound-dressing adherence and wound-related
dermatological disease.
4. 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.
Heading A
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.
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Heading A
Introduction
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.
Heading A
Risk factors associated with vulnerable periwound skin
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
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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).
Heading B
Wound-specific pathologies
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 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.
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 fistulae

Drainage from a stoma

Excessive perspiration

Increased wound exudate

Removal of adhesive products

Sensitivities (allergic or irritant reactions).
Maceration, excessive wound exudate and skin stripping are discussed below.
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Heading C (like a B heading but in italics)
Maceration
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.
Heading C
Wound exudate
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].
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Heading C
Skin stripping
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].
Heading A
Overcoming clinical challenges associated with vulnerable periwound skin
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.
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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].
Heading B
Preventing exudate damage and maceration
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, including the following [17]. The dressing should:

Stay intact and remain in place throughout wear time

Achieve the desired moisture level

Prevent leakage between dressing changes
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
Not cause maceration, allergy or sensitivity

Be comfortable, conformable and not impede physical activity

Be suitable for leaving in place for a long time

Be 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
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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].
Heading B
Preventing dressing-related trauma
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].
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
Heading A
Vulnerable skin and dermatological problems
The following dermatological problems may impact on vulnerable periwound skin.
Heading B
Fungal infections
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.
Heading B
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.
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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 acrylatecontaining 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.
Heading A
Quality of life and cost implications of periwound skin damage
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. It is reported as the prime
cause of 2.8% of consultations in general practice [29]. Romanelli et al [2008) state
that the key to managing quality-of-life issues in patients with chronic wounds lies in
identifying problems early [30]. 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
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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.
Heading A
Conclusion
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.
In box as style – linked to Molnlycke and blue background tint.
Acknowledgement
This article was sponsored by an unrestricted educational grant from Mölnlycke
Health Care.
Table 1: Examples of wound types that contribute to risk of vulnerable skin* [5]
Venous
Patients with chronic venous ulcers often have lipodermatosclerosis,
leg ulcers
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.
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Pressure
Sacral ulcers are particularly at risk of maceration because of the
ulcers
presence of urinary and/or faecal incontinence or the presence of skin
folds in obese patients.
Diabetic
Most of these wounds produce low amounts of exudate. However, the
foot ulcers
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.
Table 2: Taking a history of a patient’s skin condition
•
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
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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?
Heading A
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