Practice development in venous leg ulceration[5]


. Some reports


have documented the incidence of allergic contact dermatitis in patients with venous leg ulceration to be as high as 40%[5]


. To minimise


the risk of allergic contact dermatitis, the more ‘greasy’ emollients are preferred — a 50/50 mix of white soft paraffin and liquid paraffin offers a safe option[5]


.


Remove topical treatments and wash the leg All too often topical treatments are left to


Expert Commentary Mieke Flour is a Dermatologist at the Katholieke Universiteit


Hospital, Leuven, Belgium


The following piece is a commentary on the article Preventing skin breakdown in lymphoedema by Mei R Fu that was published in the September issue of Wounds International.


In this article, Mei R Fu summarises the role of inflammation and lymphangiogenesis in the pathogenesis and exacerbation of lymphoedema and lists complications such as infections, inflammation, lymphangitis and cellulitis, which may lead to a worsening of oedema.


Despite the amount of knowledge available about the occurrence of lymphoedema following lymph node removal for the treatment of breast cancer, patients attending oncology clinics all over the world still express a need for information and education on (self-)management.


The author’s team set up a pilot research programme aimed at improving clinical practice through educational and behavioural interventions to ameliorate lymphoedema-related symptoms and to promote early detection of complications. Most of the recommendations in this programme would be endorsed by other groups and guidelines. In general, clinicians need to focus on behavioural measures to prevent skin injuries and provide step-by-step instructions to enhance behavioural competence. Of these measures, daily skin care forms an integral part of lymphoedema risk reduction, because skin integrity reduces the risk of infection and may diminish inflammation.


The main components of this skin care regimen are sound hygiene, use of emollients, inspection for skin lesions, and prevention and early treatment of infection. In particular, deep and moist skin folds or ingrown toenails may challenge even the most meticulous patients. Intact and attached nail cuticles should be left in place unharmed since they act as a barrier and prevent colonisation by bacteria and fungi. As a general rule, and in order to avoid the development of microbial resistance, topical antiseptics may turn out to be a better choice for prevention than topical antibiotics, which are appropriate for limited infections.


Adherence to these recommendations may reduce the risk of complications, but unfortunately other factors play a role in the development of lymphoedema. Clinicians should try to avoid frightening patients out of using the ‘at-risk’ arm, but keep a healthy balance between the ‘dos and don’ts’, as although many recommendations are based on common sense, there is little published scientific evidence to support them. It is my personal experience that breast cancer survivors especially are very cautious about using the affected arm in an ‘ordinary’ way. Often they need encouragement to move normally or to follow a sport or fitness programme because not using the arm at all will affect the musculature and functionality (including lymph flow) of the trunk, shoulder and the arm itself, and in turn the patient’s quality of life and self-esteem.


Figure 6 – The presence of a heaped edge in an enlarging wound should always raise the possibility of cancer.


accumulate on the skin’s surface, perhaps because they appear similar to skin scales as well as the misguided assumption that washing the wound will increase the risk of infection. In fact, the opposite is true — the build up of emollients and skin scales removes the bactericidal barrier on the skin’s surface and permits bacteria to proliferate. Moreover, all chronic wounds are colonised by bacteria, and washing in tepid tap water reduces the number of surface microbes as well as any loosely adherent slough[6]


.


CONCLUSION The skin barrier is a remarkable feat of evolution. It protects the body from potential pathogenic microbes as well as the desiccating effect of the environment. However, as explained above, the barrier function of the periwound skin is at risk of damage and measures for monitoring and protecting it should be an integral part of any wound management strategy.


AUTHOR DETAILS Dr Girish K Patel, MBBS MRCP MD, is a Senior Clinical Research fellow and Honorary Consultant, Department of Dermatology and Wound Healing, Cardiff University, School of Medicine, Cardiff


17 Wounds International Vol 2 | Issue 1 | ©Wounds International 2011


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