The importance of the skin barrier in managing periwound areas
Figure 4 – The lipid barrier. Lipid layers
INNOVATIONS Over the past few years’ skin biologists have added to the understanding of the skin barrier, identifying novel mechanisms (as described above) that protect us from the environment. Even subtle changes in epidermal differentiation can greatly influence the efficacy of the barrier, for example, many cases of severe atopic eczema are associated with inadequate expression of a single small protein (called filaggrin) in the uppermost layers of the skin[1]
.
Similarly, small antimicrobial peptides which are released onto the surface of the skin destroy pathogenic bacteria. There is also the complex microbial flora that lives on the skin and which actively prevents colonisation by pathogenic organisms. The therapeutic potential of these scientific advances are only now being explored but they certainly hold a lot of promise.
TOP TIPS FOR PRACTICE Observe the surrounding skin Diagnosis is the foundation upon which all treatment should be based. The surrounding intact skin often contains the clues necessary to aid clinical diagnosis, for example chronic venous insufficiency is characterised by the presence of oedema, varicosities, venous flares, hyperpigmentation, atrophie blanche and lipodermatosclerosis. Whenever the clinical signs do not match a proposed diagnosis, clinicians should always question it. Similarly, all post-surgical wounds almost
by definition should have normal surrounding skin. If this is not the case there may be additional complications to consider such as the presence of a violaceous boarder in pyoderma gangrenosum [Fig 5].
Observe for ‘heaped’ edge or the presence of satellite lesions While not always the case, the presence of a heaped edge or satellite lesions in the presence
Figure 5 – Patient’s limb demonstrating the presence of pyoderma gangrenosum.
of an enlarging wound should always alert the clinician to the possibility of cancer [Fig 6].
Skin infections are common Wound bed colonisation predisposes patients to wound infection, but similarly the surrounding skin is also at risk of infections that are often attributable to the treatments used to manage the ulcer. For example, the use of emollients and compression bandages or hosiery both occlude and ‘pull’ the hair follicles, thus increasing the risk of Staphyloccus aureus folliculitis[2]
. Likewise,
heavy exudate from an ulcer may macerate the skin of the foot and lead to athlete’s foot (tinea pedis). Early diagnosis and appropriate treatment of these skin infections can dramatically reduce their impact.
Control maceration Maceration of the surrounding skin due to exudate is a frequent occurrence in wound care. In the case of venous ulcers, the aim should be control of oedema by compression as well as concomitant use of absorbent dressings[3]
. Even when wound exudate is
controlled in this way, emollients are still effective at enhancing the skin barrier. However, it is not always possible to control the periwound skin’s exposure to moisture, especially in the case of peristomal skin. In this context, emollients containing either zinc, titanium or drapolene may be necessary to provide a further barrier[4]
. Whenever an emollient, or any other topical
therapy, is considered it must be remembered that there is a risk that the product may cause or exacerbate pre-existing allergic contact dermatitis[5]
risk of sensitisation as is the surrounding skin
www.woundsinternational.com 16 References
4. Lyon CC, Smith AJ, Griffiths CE, Beck MH. The spectrum of skin disorders in abdominal stoma patients Br J Dermatol 2000; 143: 1248–60.
5. Patel GK, Llewellyn M, Harding KG. Managing gravitational eczema and allergic contact dermatitis. Br J Comm Nurs 2001; 6: 394–406.
6. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2008; Jan 23(1): CD003861.
. Mucosal surfaces are at particular
Page points
1. Diagnosis is the foundation upon which all treatment should be based
2. The presence of a heaped edge or satellite lesions in the presence of an enlarging wound should always alert the clinician to the possibility of cancer
3. Wound bed colonisation predisposes patients to wound infection, but similarly the surrounding skin is also at risk of infections that are often attributable to the treatments used to manage the ulcer
Practice development
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