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skin care
The outcomes of barrier protection
in periwound skin and stoma care
Jackie Stephen-Haynes
T
his article offers an overview of the anatomy
and physiology of the skin and acknowledges the
importance of moisture balance, the maintenance
of skin integrity, the importance of protecting
fragile skin and the periwound/peristoma area. These are
discussed and the impact of such damage on quality of life
is considered. The evidence relating to the impact of barrier
films on periwound and peristomal protection is reviewed,
and a conclusion reached that an evidence-based approach
can significantly affect patient outcomes. The extrapolated
results are presented from an evaluation of 95 patients
(n=95) over a 3-month period, exploring the clinical
effectiveness and potential financial benefit of a barrier film
and barrier cream. The study results, following analysis by
clinical indication, includes 54 patients (n=54) presenting
with periwound exudate. A healthy volunteer experimental
evaluation of 20 (n=20) is also presented. The studies
presented confirm the effectiveness of barrier protection in
healthy skin in an experimental evaluation and a 54 patient
study requiring periwound protection.
© 2014 MA Healthcare Ltd
The skin
The skin is the largest organ of the body and comprises
several layers. The outer layer is the epidermis and the
deeper layer the dermis, which contains the blood vessels,
hair follicles and sweat glands. This forms a barrier between
the internal organs and the environment, offers cushioning
to underlying tissues and requires care throughout life. Skin
performs the functions of absorption, excretion, protection,
secretion, thermoregulation, pigment production, sensory
perception and immunity (Hampton and Stephen-Haynes,
2005; Woo et al, 2009). Damage to the skin compromises
the barrier, and can have a range of effects, including
discomfort and increased risk of infection and further skin
breakdown (World Union of Wound Healing Societies
(WUWHS), 2007). While a wide range of factors can
increase the vulnerability of skin to damage, excessive
moisture on the skin surface and dryness of the skin
are among the most common factors (Gray et al, 2011;
White-Chu et al, 2011). These factors are exacerbated by
the structural change that occurs during ageing, including
a decrease in sweat glands, decreased vascular function,
epidermal thinning, reduced elasticity and slower wound
healing (Butcher and White, 2005).
An increase in skin fragility is often associated with the
ageing process, as it becomes thinner, drier, more wrinkled
and more prone to periwound damage (White et al,
2008). The dermis reduces in thickness by 20% as part of
Abstract
This article considers the anatomy and physiology of the skin,wound
healing, excoriation, maceration, peristomal skin and the importance
of periwound protection. The results of a 54-patient study of the
use of barrier film forming skin protection in periwound skin are
presented and a 10-patient healthy volunteer experimental evaluation.
The results confirm the effectiveness of barrier protection in healthy
skin in an experimental evaluation and a 54-patient study requiring
periwound protection.
Key words: Pressure ulcer
■
Stoma
■
Skin care
■
Skin barrier
the ageing process, which leads to a reduction in blood
vessels, nerve endings and collagen, leading to a decrease
in sensation, temperature control, rigidity and moisture
retention (Baranoski and Ayello, 2004).
Exudate production
Exudate is defined as fluid leaking from a wound. It plays
a central role in wound healing and is a normal part of the
inflammatory process (Thomas, 1997). It is mainly water, but
also contains electrolytes, nutrients, proteins, inflammatory
mediators, protein ingesting enzymes, growth factors and
waste products, as well as various types of cells (Romanelli
et al, 2010). The production of wound exudate occurs as a
result of vasodilation during the early inflammatory stage of
healing under the influence of inflammatory mediators, such
as histamine and bradykinin. Its appearance should be serous,
clear to straw-coloured or serousanguinous, clear to pinkcoloured fluid in the wound bed, keeping the wound moist
and promoting healing (White and Cutting, 2006). Until
wound closure, there will be a variable flow of exudate from
the wound. The ideal level of exudate necessary for healthy
uncomplicated healing is not known (Vuolo, 2004).
In the chronic wound, exudate contains proteolytic
enzymes and other components not seen in acute wounds
(Cutting, 2003). This type of exudate has justifiably been
termed ‘a wounding agent in its own right’, because it has
Jackie Stephen-Haynes is Professor, Practice Development Unit,
Birmingham City University and Consultant Nurse, Tissue Viability,
Worcestershire Health and Care Trust
Accepted for publication: February 2014
This article is reprinted from the British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
Moist wound healing
The work of Winter (1962) identified the importance of moist
wound healing nearly 50 years ago. The balance between too
little and excess moisture is not fully understood (Vuolo,
2004). During wound healing, keratinocytes from the wound
edge migrate over the wound, providing epithelialisation.
Several factors can affect this, including inflammation in the
underlying tissue, which causes degradation of the surface
keratin (Zillmer at al, 2006), thus compromising the barrier
function of the periwound skin. This impaired barrier
function also increases susceptibility to exudate, hinders
healing and creates an environment that is conducive to
bacterial proliferation and may lead to the development of
biofilm ( Wolcott et al, 2010).
Several factors lead to an increase in exudates in the
periwound area, including periwound inflammation,
bacterial infections and uncontrolled oedema. While a moist
environment supports the migration of epidermal cells, the
management of exuding wounds warrants barrier protection.
Excoriation
Excoriation is inflammation of the skin surrounding the
wound (periwound skin), caused by an irritant. The irritant
may be bacteria or destructive components in the patient’s
own exudate, or more specifically, proteolytic enzymes in
the wound exudate. A group of proteolytic enzymes called
matrix metalloproteinases (MMPs), which are released from
white blood cells, play a vital role in the autolysis of necrotic
tissue, damaged collagen and elastin, therefore debriding
and cleansing devitalised tissue. MMP activity is controlled
by tissue inhibitor of matrix metalloproteinases (TIMPs)
(Hampton and Stephen Haynes, 2005).
In an acute wound, such as a surgical wound or a new
trauma wound, these two components are balanced in such
a way that only devitalised tissue is degraded. However, in a
chronic wound, MMPs become more prolific and TIMPs less
available. This imbalance results in a destructive exudate that
causes damage to any skin tissue it comes into contact with
(Hampton and Stephen Haynes, 2005).
can result in further skin breakdown that may enlarge the
wound (Cameron et al, 2005; Guest et al, 2011).
When dressings are repeatedly applied and removed, care
must be taken to protect the skin. The effect of the repeated
action is exacerbated by the structural change that occurs
during ageing, including a decrease in sweat glands, decreased
vascular function, epidermal thinning, reduced elasticity and
slower wound healing (Butcher and White, 2005).
Skin stripping and integrity
Adhesives spread over the skin surface into crevices and
surface detail. The effectiveness of the adhesive is dependent
on the adhesive chemistry, the risk of irritation from the
adhesive, allergic reaction to the materials, minor inclusions in
the adhesive system, which can cause contact dermatitis, and
the restriction of transpiration of moisture by the adhesive
product (Berry et al, 2007). The removal of adhesive products
will remove loosely bound epidermal cells and, with repeated
use of adhesive products, can strip away varying amounts of
the stratum corneum (superficial epidermis) layer (Dykes et al,
2001; Zillmer et al, 2006). This increases the trans-epidermal
water loss, leading to a burst of mitosis in the basal epidermal
cells. The ensuing inflammatory skin reaction leads to skin
breakdown, which changes the skin’s barrier function.
Dressing and tape damage can present as skin discolouration
on intact skin, contact dermatitis or broken, stripped skin. It
tends to represent the shape of the dressing or tape, but this is
not always the case, due to the uneven distribution of adhesive
(Zillmer et al, 2006).
Further complications can result from the effects of
ageing on the skin, where there is a loss of dermal thickness
and a reduction in skin elasticity. Indeed, most damage
is created when dressing or tape is removed from fragile,
incontinence/exudate damaged or circulatory-comprised
skin. Skin stripping is seen in a number of particular groups—
elderly, fragile, paediatrics, epidermolysis bullosa (EB) and
those with a stoma. Therefore, care must be taken to protect
the skin when medical adhesive devices are repeatedly applied
and removed.
Maceration
Maceration is an indication of excessive exudate, which
has the potential to lead to further wound breakdown. It is
caused by over-hydration of the wound and the periwound
skin, which becomes saturated, white and friable. If not
corrected by effective management, the macerated skin will
break down, leading to wound extension (Fletcher, 2002;
Stephen-Haynes, 2008). A protective agent can be applied
to reduce risk of maceration and excoriation (Cameron,
2004). Macerated skin is weaker than non-macerated skin, as
it is damaged by physical trauma and eroded by proteolytic
enzymes in the exudates (Young, 2000; Fletcher, 2002).
Periwound healing protection
Quality of life and skin care
Periwound skin damage can occur around chronic wounds
as a result of excessive moisture, due to wound exudate and
damage from inflammatory enzymes in the exudate (Williams,
2010; WUWHS, 2007). The resulting degradation of keratin
compromises the barrier function of the periwound skin and
A literature review by Moore and Cowman (2009) identified
several issues which occur frequently in patients with
pressure ulcers, affecting their quality of life. These include
pain and several wound-related issues, including maceration,
excoriation, skin stripping and management of exudates.
This article is reprinted from the British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
© 2014 MA Healthcare Ltd
the capacity to degrade growth factors and periwound skin
and is predisposed to inflammation.
The control of moisture is a key function of the skin,
contributing to the maintenance of skin integrity, and when
intact, offers a protective barrier. In order to develop an
effective management approach, the clinician must be able
to accurately assess and understand the implications of the
composition and quantity of exudate present in the wound
(White and Cutting, 2006). Failure to understand and manage
the role of exudate can lead to exudate saturation and leakage
onto the surrounding skin with the potential to damage and
prolong wound healing (Rich and McLachlan, 2003).
skin care
Peristomal skin
102 000 people have a stoma in the UK and a large
proportion of those will have experienced some sort of
stomal complication or peristomal skin problem (Black,
2009). Stomal complications, such as leakage, maceration
and skin-stripping on removal, are common and occur
frequently after the stoma has been fitted (Lynch et al, 2008).
The integral adhesive wafer of stoma appliance is made of
hydrocolloid, which aims to protect the skin from faeces and
urine. The tissue surrounding a newly created stoma may
become inflamed or oedematous shortly after surgery, and
the fit of the flange may need adjustment as the surrounding
tissue returns to normal. Problems with skin creasing around
the stoma may also cause leakage (Burch, 2013).
Poor technique, repeated applications and pre-existing skin
conditions can lead to peristomal skin problems. As Lyon and
Smith (2010) note, patients who physically pull their stoma
appliance off to remove it, rather than easing it from the skin,
are more likely to suffer from peristomal skin breakdown.
Berry et al (2007) observe that appliance removal will
inevitably lead to the removal of loosely bound epidermal
cell layers and that more cells will be removed as the process
continues. Williams et al (2010), in an 80-ostomate study,
reported that 68% of patients had peristomal skin problems
with repeated application and removal of stoma appliances,
which affected peristomal skin.
Therefore, an important objective of stoma care is to
maintain good peristomal skin. Skin around the stoma should
be clean, dry and intact, with the objective of there being no
difference between peristomal skin and the remainder of the
healthy abdominal skin. Appropriate assessment can help the
clinician to consider the potential effect of exudates on the
periwound and peristomal area.
Dowsett (2011) suggests this should include:
■■ A full and detailed assessment of the patient
■■ The impact of wound exudate on the patient’s quality of
life
■■ Assessment of the wound
■■ Assessment of the periwound skin
■■ Assessment of the type and amount of exudate
■■ Assessment of the current dressing regimen and its
effectiveness at managing exudate.
This offers a comprehensive framework for a holistic
approach to care and its implementation would contribute to
protecting the periwound and peristomal area.
© 2014 MA Healthcare Ltd
Results from the Sorbaderm
evaluation on the periwound
A study (n=95) investigating the efficacy of Sorbaderm barrier
film and barrier cream (Stephen-Haynes and Stephens, 2012)
included 54 subjects recruited for periwound protection
or management in the barrier film segment of data stream
(the remaining 41 subjects were recruited as part of a wider
evaluation of Sorbaderm, including pressure ulcers and stoma).
Patient consent was obtained following fulfilment of the
inclusion criteria. Patients who were under 18 years of age,
not willing to participate, affected by incapacity to consent
or unable to follow product instructions were excluded from
this evaluation. The evaluators could also exclude any patients
(in their opinion) deemed to be unsuitable to undertake this
evaluation for any other reasons. Participants were invited to
take part in the study, consent was obtained and participants
were able to leave the study at any time.
Evaluators were instructed to seek indications where
barrier films or creams are routinely used. Indications
included periwound protection, incontinence and
pressure ulcers.
The clinical indications explored were:
■■ Prevention of skin breakdown
■■ Maintenance of skin condition
■■ Periwound maceration
■■ Excoriation and incontinence-related skin protection
■■ Adhesive skin stripping.
Inclusion criteria
■■ Patient
is >18 years of age
is willing to participate and has capacity to consent
■■ Patient has an indication suitable for treatment with a
barrier product
■■ Patient will be seen regularly by the evaluator.
■■ Patient
Exclusion criteria
■■ Patient
is <18 years of age
does not wish to participate or have
capacity to consent
■■ Patient not suitable for barrier product treatment
■■ Instructions for the product use cannot be followed
■■ Any other reason the evaluator feels the patient
should be excluded.
To ensure competency, consistency and reduce data
variability, evaluators were selected who had completed
their tissue viability/continence care qualifications and
competency, with all staff having completed an accredited
course (a degree-level accreditation in tissue viability).
Additionally, a study initiation visit was undertaken at each
centre, during which the protocol was explained to each
evaluator by the same evaluation monitor and evaluators
training on the appropriate application technique for each
Sorbaderm product.
Indications treated included surgical sites (n=4),
extravation injury (n=1), peripressure ulcer (n=6), stoma
(n=1), percutaneous endoscopic gastrostomy (PEG) (n=1),
adhesive skin stripping (n=11), active maceration (n=19) and
prevention of maceration or adhesive skin stripping (n=11).
Of the 19 subjects recruited into the study with active
periwound maceration, 9 subjects were completely reversed
during a 72-hour period with a daily treatment application
of barrier film. The remainder (n=10) were reported to have
a dramatically improved periwound skin condition. Subjects
with a peripressure ulcer (n=6), with exudate levels reported
to be moderate or high, were all prevented from developing
signs of maceration throughout the study.
Periwound adhesive skin stripping from dressings and
devices was prevented in surgical sites (n=4), peripressure
ulcer (n=6), stoma (n=1), PEG (n=1). Where active adhesive
skin stripping (n=11) was present on recruitment into the
study, a dramatic improvement was reported within a 72-hour
period. Barrier film application was predominantly every
■■ Patient
This article is reprinted from the British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
Healthy volunteer experimental evaluation
To gain an objective view, the authors conducted a healthy
volunteer experimental evaluation comparing the two barrier
films (n=10) and creams (n=10). The study barrier and the
previous treatment gold standard barrier were used.
Healthy volunteers were recruited as per inclusion criteria
within study protocol. Recruitment baseline visual skin
assessment and photographs were obtained. Application of
barrier film or cream to a 10 x 10 cm area marked with
surgical ink was made, 5 cm product ‘S’ and 5 cm product
‘C’. The experimental area was covered with water-saturated
foam dressing and double layered with an outer film dressing
to maintain moisture and humidity at the experiment site.
At 72 hours, maceration skin assessment was conducted and
photographic evidence of the experimental area obtained.
After 72 hours, the water-logged dressings were removed to
reveal zero maceration at either half of the barrier site. These
findings reinforce the previous subjective feedback that the
evaluated barrier performed the same as or better than the
gold standard.
Discussion
A number of patients have the potential for epidermal stripping,
including the young, elderly, those with frail skin, ostomates
and those with specific skin conditions, such as haemangiomas
and EB. Both low and high levels of exudate can lead to
significant clinical challenges, with a low level of exudate
resulting in drying of the wound, which can inhibit the healing
process. A poorly-managed high level of exudate can cause
periwound damage. Failure to protect the periulcer skin or
stoma from wound exudate may delay healing and result in
patient discomfort. The ease of use of skin barrier protectors
and the visibility of the skin can assist the clinician in
maintaining intact skin. The use of a barrier film or barrier
cream is an effective treatment, management or preventative
Key points
nThe appropriate assessment and management of exudate and effective
periwound protection can prevent the breakdown of the periwound area
nThe frequent application and removal of adhesives can damage skin
by stripping away the epidermis and therefore the periwound skin
requires protection
nPeristomal skin is at significant risk of break-down
nOlder people, neonates, stomates and those with epidermolysis bullosa
(EB), haemangiomas and fragile skin are particularly at risk of periwound
breakdown
nThere is increased emphasis on effective care that does the patient no-harm,
and barrier skin protection contributes to this
strategy for periwound skin damage. The studies presented
confirm the effectiveness of barrier protection in healthy skin
in an experimental evaluation and a 54-patient study requiring
BJN
periwound protection. Conflict of interest: the Sorbaderm product was supplied by
Aspen Medical. No other support was provided
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This article is reprinted from the British Journal of Nursing, 2014 (Stoma Supplement), Vol 23, No 5
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24 hours, due to daily dressing or device change. Periwound
condition in the stoma and PEG (n=2) was reported to be
healthy, indicating effective protection from corrosive stomal
fluid and chronically exuding PEG.
The authors accepted subjectivity as being a limitation of
the original study due to reflective comparison to previous
treatment regimen, rather than any form of direct comparator.