‘Sometimes it takes something more manageable to get the message across’. By Beth Hawkins Bradley RN, MN, CWON I am frequently asked for solutions relating to maceration to periwound skin in wounds being treated with negative pressure wound therapy (NPWT). (2000)The Management of Exuding Wounds. A recently described concept, wound-bed preparation (Falanga, 2000; Vowden and Vowden, 2002), concentrates on the generation of an optimal healing environment and measures to overcome barriers to healing. Wound exudate, in the correct quantities and in the correct constituency, is a useful factor in the healing process. (ed.). Wound Management: Principles and Practice. British Journal of Nursing 10: 7, 469-472. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. Rinsing is … Sign in or Register a new account to join the discussion. Protect periwound skin. Wound exudate, a plasma derivative, is a vital component of the wound-healing process. OUTCOME MEASURES: The mean outcome measures were a decrease in periwound and ulcer size. One way to minimize contact with wound drainage and prevent maceration of the periwound is to choose the appropriate dressing for wound conditions. Moisture-retentive dressings are used to achieve a moist, but not wet, wound environment. Excess wound exudate can be reduced by eliminati… Batt, M.D., Fairhurst, E. (1986)Hydration of the stratum corneum. 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Wound exudate can be channelled away from the wound through appliances such as fistula drainage bags or by applying negative pressure to the wound area (Young, 2000). Wounds 8: 5 145-150. Spray skin sealants are available for use over stage 1 pressure ulcers to provide protection to skin that is intact. The eyes of the care providers tend to go direct to the center of the wound, the wound bed. Recent references in the related literature tend to focus on the effects of maceration on the peri-wound skin (Butcher, 2000; Cutting, 1999a), but it is important to remember that this phenomenon is also likely to have an impact on the wound bed. venous ulcers, diabetic ulcers, pressure ulcers), Fistula or stoma drainage (often causes damage to the surrounding skin if the area is not prepared and dressed properly), Increased wound exudate (i.e. Proper care taken while dressing the wound reduces the risk of maceration of skin around the wound. Source: Dowsett et al. Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. Educational leaflet. (1996)The effect of dressings on the production of exudate from leg ulcers. Figure 1: A wound which has been highly exuding. Figure 1: A wound which has been highly exuding. When presented with a wound, you should identify risk factors that may lead to periwound damage or breakdown and plan your care accordingly, taking care to choose an appropriate dressing and apply a skin sealant or moisture barrier as necessary. Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS, is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care. This type of skin damage is call periwound moisture-associated dermatitis.The chemical composition of the wound exudate greatly affe… Their use is considered controversial. A macerated area was defined as the wet and opaque or white skin of a periwound (15)(16) (17). The content is not intended to substitute manufacturer instructions. - Use compression therapy and elevation for appropriate leg ulcers. London: Emap Healthcare. The periwound offers key information crucial to overall wound healing. Protecting the peri-wound skin from enzymes in chronic wound exudate may be achieved through a variety of simple measures. Michael N. Desvigne, MD, FACS, CWS, FACCWS, Kevin F. Ackermann, Vice President of Healthcare, Medela. If urinary continence problems are the main issue, bladder and bowel function need to be improved or mechanical methods such as indwelling catheters should be used. Cutting KF, White RJ. Van Rijswijk, L., Harding, K. (2000)Issues and clinical implications. Skin sealants are alcohol-based wipes that are used on intact skin, making the skin surface slightly sticky, creating a better surface for adhesive dressings to stick to, while at the same time providing the skin with some protection from the adhesive. Accessed March 14, 2015. New England Journal of Medicine 320: 850-853. 20152 Source: Dowsett et al. However, partially occlusive dressings that rely on absorbency and moisture vapour transmission rate (MVTR) for their fluid-handling capabilities may offer a lower risk of inducing maceration. Moisture barriers are creams or ointments that contain dimethicone, petrolatum or zinc oxide. Winter, G. (1962)Formulation of the scab and the rate of epithelialisation in the skin of the domestic pig. Heavily draining wounds or the improper use of a moist dressing can lead to maceration of the periwound skin, altering tissue tolerance and damaging the wound edges. If exudate is copious, irrespective of the type of primary dressing used, additional secondary dressings will be needed to provide supplementary absorption, or more frequent changes of dressing will be required. It should not be confused with the pale, whitish appearance of the new epithelial tissue in a healing wound. (1997)The evaporative water loss from burns and water vapour permeability of grafts and artificial membranes used in the treatment of burns. Keith F. Cutting, MN, RMN, RN, DipN (Lond), CertEd(FE). Cutting, K. (1999b)Glossary. Health-care professionals need to be aware of maceration and the implications it may have for wound healing. Among many vital functions, the skin functions as a barrier to protect the body against mechanical trauma, noxious irritants, infectious pathogens, and excessive fluids. Wounds that tend to be ‘wet’ may benefit from alginate, foam, hydrofibre or hydropolymer dressings. Maceration › Maceration occurs when healthy skin is in contact with moisture (e.g. However, some are better than others at performing these functions, and it is important for wound care professionals to know their wound care management tools inside and out, so that choosing the correct dressing is a simple affair. irritant or allergic reactions to products. INTERVENTION: The intervention compared the experimental product (Remedy Nutrashield; Medline Industries, Mundelein, Illinois) versus Cavilon Moisturizing Lotion (3M, St Paul, Minnesota). Lower extremity wounds such as diabetic foot ulcers (DFUs), venous ulcers, and arterial ulcers have been linked to poor patient outcomes, such as patient mortality and recurrence of the wound. Although some practitioners may insist that occlusive dressings which create a ‘moist wound’ environment can provoke maceration, this need not be the case under ‘normal’ conditions of use. Manufacturer DermaRite notes Clean & Free is a mild, pH balanced, rinse-free body wash, shampoo, and perineal cleanser. As a clinician practicing in the outpatient and home care settings, it was not unusual for patients to have to take a "holiday" from negative pressure. noted to be macerated.There were 1,332 VLU which became the focus of the current study. It is important to treat the condition especially in elderly and immobile patients, or else there is associated risk of infection. There are many conditions which may render the periwound skin more susceptible to breakdown, including: Identifying these conditions and creating a wound care plan that takes these factors into account can prevent damage of the fragile periwound skin. It presents as a pale, opaque rim surrounding the wound. Wound Management Theory and Practice. They can be used on intact skin, but are most commonly used to prevent further skin breakdown in areas of incontinence. Falanga, V. (2000)Classifications for wound-bed preparation and stimulation of chronic wounds. Note the maceration to the peri-wound area. International Journal of Cosmetic Science 8: 253-264. MAIN … burns or ultraviolet damage), Specific wound types (i.e. Unfortunately, due to the fact that they make the skin surface somewhat oily, moisture barriers cannot be used with adhesive wound dressings, as the dressings will not adhere as they are meant to. Sources The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The periwound area has been defined as the area of skin extending to 4 cm beyond the wound (ie, the surrounding skin extending from the wound bed). Ostomy Wound Management 46: 1A (suppl), 59S. Published October 2009. Maceration of the skin around a wound is a common feature and most practitioners are advised to carry out interventions to avoid it. Can damage periwound skin. Butcher, M. (2000)The management of skin maceration. 7: 3, 12. Documentation of the periwound condition should include measuring the periwound size, noting the skin condition, the exudate presence and characteristics, and the presence of pruritus. Step 1 – Cleanse the wound and periwound margins Cleanse the wound and periwound margins with 3M™ Wound Cleanser. Note: it is prudent when estimating wear time to err on the side of caution, - Recognise and treat any infections promptly and appropriately, - Avoid topical antibiotics and antiseptic solutions, - Consider impregnated (iodine and silver) dressings, - Do not use hydrogels on wet wounds. Many are able to decrease the amount of fluid pooling under the wound dressing, thus decreasing the risk of skin breakdown. For cleansing periwound skin without using water, Clean & Free ™ Rinse-Free Full Body Wash & Peri-Cleanser may be an efficient option for patients. J Wound Ostomy Continence Nurs 2007; 34(2): 153-7. 8. The Use of Cyanoacrylate Skin Protectant* to Treat Periwound Maceration in Combination with Negative Pressure Wound Therapy in the Treatment of Neuropathic Foot Ulcers Negative Pressure Wound Therapy (NPWT) has been proven to be an effective and valuable tool for … Lawton S, Langoen A. Assessing and managing vulnerable periwound skin. (1989)Pressure ulcers among the elderly. Not all wound exudates are the same. - Possible adhesive damage to peri-wound skin. Dressings with a super-absorbent component provide effective protection (Langoen and ... periwound skin is the treatment of choice for allergic reactions. Maceration is defined as a softening or over-hydration of the tissue due to retention of excessive moisture (Cutting, 1999b). Thomas, S., Fear, M., Humphreys, J. et al. What can be done to protect the vulnerable periwound? Periwound issues. Diabet Foot 2003;6(3):S2. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or product usage. treatment to avoid or treat periwound maceration includes the use of highly absorbent dressings. Maceration occurs when skin has been exposed to moisture for too long. Skin barrier creams/ointments, skin protective wipes, or skin barrier wafers can be used to protect the periwound … Wound Repair and Regeneration 8: 5,347-352. Available at: www.worldwidewounds.com/2002/april/Vowden/Wound-Bed-Preparation.html accessed 20.05.02. But the action on the periwound or the wound sidelines can make a difference in how rapidly the patient may heal. A number of elements that may be found in exudate have been identified (Box 1) and although this box does not provide an exhaustive list, the reader will appreciate the diverse nature of these components. Maceration is often a contributing factor for slow wound healing. There has been extensive research on how to prevent skin care-related skin breakdown, and most research agrees on a few main components. Prevention of maceration includes treatment of underlying disorders and selection of dressings that maintain an ideal moisture balance in the wound. The arena for wound treatment is not very different. Taking these steps will go a long way towards the prevention of skin breakdown in the periwound area due to excess moisture from any cause. This damage to the peri-wound skin reduces its protective function as a barrier to water and increases the likelihood of maceration occurring (Cutting and White, 2002). 6. However, in chronic wounds, proteolytic enzymes such as MMP8s are produced in excess of the level required to lyse devitalised tissue, debris and dead micro-organisms. It should be noted that some moisture barriers are safe to use on non-intact skin. Wound Care Society. - Select dressing(s) according to exudate level, - Estimate optimal wear time according to the following general factors: volume of exudate, nature of exudate, manufacturer’s instructions, clinical setting, activity level of the patient. Thomas S. The role of dressings in the treatment of moisture-related skin damage. Treatments for more serious maceration with periwound skin include occlusive dressings and Hydrofiber dressings. Journal of Wound Care 6: 7, 327-330. White, R J. Aberdeen: Wounds UK, 2005. How are the skills of the staff you are entrusting with the care of our older residents in long-term care? Barrier films are now available as alcohol-free preparations that ‘seal’ the skin and protect against maceration or excoriation (Williams, 2001). Wound exudate (type and volume) influences management decisions and dressing choice; this paper focuses on one aspect of exudate, the skin damage known as maceration. Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. The management and prevention of maceration must focus on the reason the skin is coming into contact with excess moisture. 2nd edition. Loss of this seal will cause extravasation of fluid, resulting in periwound maceration and an inability of the VAC therapy device to function properly. To remove exudate solely because it is present does not constitute good practice. as a result of infection), Sensitivities (i.e. They generally provide protection for up to 72 hours before re-application is necessary. Indeed, it is likely that most instances of maceration are attributable to ‘traditional’ dressings as these are still the most widely used. This model for healing emphasises a number of objectives: - To achieve a well-vascularised wound bed, - To decrease the bio-burden of the wound. Although precise recurrence rates can be difficult to... By Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary. The wound assessment should include the periwound and surrounding skin, extending 4cm from the wound bed.1 Assessing wound location, shape, color, edges, margins, periwound, and surrounding skin is most significant in a thorough wound evaluation.1,2The periwound and wound margins are good indicators for identifying the wound type, infection, and moisture balance and for managing the plan of care.1,3 A per… Exudate production may increase - particularly if a wound becomes infected and/or deteriorates. Many have the ability to wick moisture away from the skin, similar to a baby’s diaper. This article describes the importance of controlling the moisture content of wounds and areas of vulnerable tissue, with particular emphasis on the use of dressings that provide protection to periwound skin, which may be damaged by proteolytic enzymes present in exudate from chronic wounds. Lamke, LO., Nilsson, G.E., Reitherner, H.L. Although acute wounds may confront the practitioner with challenges to healing, this paper will focus on maceration and chronic wounds, as they represent the majority of wounds encountered that present problems to the nurse. Evidence that maceration leads to skin breakdown and consequent wound enlargement is circumstantial (Allman, 1989), although anecdotal reports link maceration with delayed healing and other complications (Cutting, 1999a). Once damaged, the skin is more permeable and susceptible to irritant penetration, leadin… There is, at present, no evidence that moist wound healing is related to the development of maceration (van Rijswijk and Harding, 2000). Regular applications of liquid paraffin/soft paraffin (50/50 proportions) or zinc oxide cream or ointment BP to the peri-ulcer skin are often soothing as well as protective in function. There is both an art and a science to choosing the correct wound dressing, one that will maintain just the right amount of moisture in the wound bed without allowing the periwound to become macerated. About The Author Nursing Times 96: 45, 35-36. Salisbury: Quay Books. A macerated wound is an injury accompanied by soft, white, deteriorating skin around the site of the original injury. Any wound care provider is going to continuously seek new approaches to wound therapies that improve patient healing times. Concentrations of Dakin's solution stronger than 1/8 strength … For UK health professionals only The roundtable discussion and this associated article…, Please remember that the submission of any material is governed by our, EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 7th Floor, Vantage London, Great West Road, Brentford, United Kingdom, TW8 9AG, We use cookies to personalize and improve your experience on our site. Rogers A, Watret L. Maceration and its effect on periwound margins. By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS A wound that is too moist can be as detrimental to wound healing as a wound that is too dry. Not recommended use for extended amounts of time. Allman, R.M. It is therefore imperative that a careful selection of dressing and wear time is made to help ensure successful management. • Periwound skin Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address patient, wound and skin problems that impact healing. http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-sk... Reducing the Recurrence of Lower Extremity Wounds, Preventive Skin Care Strategies and Assessment of the Skin, Strategies for Early Biofilm Interventions, Exponential Benefits: Positive Patient Impacts with the Standardized Use of Hypochlorous Acid, Investigating the benefits of placental tissue in the wound healing process, A New Approach to Managing Wound Exudate During Challenging Times, Biofilm Management Using a Wound Hygiene Protocol, Protecting the skin microbiome and preventing pressure injuries with Cardinal Health™ breathable adult briefs, Arterial Ulcers: Assessment and Treatment, Prior damage (i.e. Managing exudate production effectively requires achieving a balance between the extremes of wound desiccation and wetness. Treatment for mild maceration includes exposing the affected area to air to dry out the skin. © 2008-2020 Kestrel Health Information, Inc. All rights reserved. As a Director of Nursing, your assessment skills must be tiptop. Negative pressure wound therapy (NPWT) has grown to be an important adjunctive therapy in any wound care setting due to its ability to promote wound healing in different types of wounds with granulation tissue formation. Although exuding chronic wounds (deep burns, diabetic foot ulcers, leg ulcers, pressure sores and fungating tumours) are most likely to develop maceration, this phenomenon may manifest in any type of wound if the conditions are right. World Wide Wounds. Skin Care in Wound Management: Assessment, prevention and treatment. Periwound issues affect the integrity and healthy functionality of the skin surrounding the wound and may include maceration, excoriation, dry (scaly) skin, eczema, callus (hyperkeratosis), infection, inflammation.. Signs and symptoms. The area of maceration was also assessed by measuring each photograph using Image J software. In: Miller, M., Glover, D. (eds). Thomas, S. (1997)Assessment and management of wound exudate. Principal Lecturer, Buckinghamshire Chilterns University College, Chalfont St. Giles, Buckinghamshire. Upper Saddle River, New Jersey: Pearson Prentice Hall; 2008:128-130. By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS. Maceration is one of the most common skin problems associated with wound care. Although many other factors are implicated in exudate management, it is vital to apply these skills to every wound at every dressing change; only by doing this will maceration be avoided and healing optimised. The assessment of exudate levels, choice of suitable dressing, and estimation of wear time are clinical skills that must be learned. This will only compound the problem. VLU that were seen during 8 or more weekly clinic visits were identified;35 who had periwound maceration noted during 4 or more visits were compared with 35 matched controls who demonstrated maceration on 0 … Clinicians should also seek to refer the patient 7. When managing leg ulcers they appear chiefly to be of benefit on the peri-ulcer skin when wet eczema is present (Peters, 2002). Patients suffering from periwound issues may experience burning, itching, tenderness, and pain. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies. Wound edge Periwound skin Maceration dration Undermining Rolled edges Wound ed Assessment Peround sn Assessment • Maceration • Dehydration • Undermining Wound Infection is caused by multiplying pathogenic bacteria which cause a reaction in the patient. Additional approaches to managing exudate include the use of: - Topical corticosteroids (anti-inflammatory and vasoconstrictive in action). Burns 3: 159-165. Infection 2. Despite a literature search a definitive description of this occurrence does not appear to be available. Caustic. Nature 193: 293-294. The production of exudate is a normal result of the inflammatory stage of wound healing. In wounds, maceration can prevent healing, contribute to infection, and cause irritation, pain, and tissue damage. Maceration is a largely under-recognized problem and one of the causes of delayed wound healing. Vowden, K., Vowden, P. (2002)Wound bed preparation. The alcohol contained in skin sealants can cause a mild stinging or burning sensation when applied to areas of open skin. Maceration occurs when too much moisture is trapped between the wound and its bandage--sometimes the exudate (seepage of biological waste from the wound) escapes and gets trapped under the bandage, and sometimes the wound itself becomes overly moist. Cutting, K., White, R.J. (2002)Maceration of the skin and wound bed 1: its nature and causes. Note the maceration to the peri-wound area. Maceration of the skin and wound bed: its nature and causes. It occurs when skin is exposed to wet dressings or wound drainage. Degradation of the wound bed may result from protease activity together with excoriation of the peri-wound skin. Health-care professionals need to be aware of maceration and the implications it may have for wound healing. It also discusses the importance of preventing excessive moisture loss from certain wound types and describes the way in which dressings can d… Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. wound fluid, sweat, urine) for prolonged periods, which can cause the skin to become soft/soggy. Macerated Skin: Pictures, Causes, Treatment, and Prevention Journal of Wound Care 8: 4, 200-210. The causes of maceration other than exudate include excessive sweating, the presence of urine or faeces and high local moisture due to prolonged occlusion combined with high exudate and transepidermal water loss (TEWL). This article, produced by a panel of clinical experts who met to discuss moisture as an etiologic factor in skin damage, focuses on peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis. There is no defense like a good offense, and this is as true in wound care as it is in sports. (1999a)The causes and prevention of maceration of the skin. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. There are several prevention strategies that can be used to prevent maceration and further skin breakdown. Occlusive dressings are not inherently likely to provoke maceration when used correctly (White, 2000). The term ‘moisture/water vapour transmission rate’ (MVTR or WVTR) should be used in reference to dressings and not to intact skin. Gray M, Weir D. Prevention and treatment of moisture-associated skin damage (maceration) in the periwound skin. (2002)Caring for dry and damaged skin (Chapter 14) In: While, A. Voegeli D. Moisture-associated skin damage: an overview for community nurses. J Wound Care 2002;11(7):275–8. Those of serous consistency (clear aqueous) will be more likely to pass into an absorbent dressing and be lost by MVTR than those of a more viscous nature. Cutting, K.F. - Leg elevation and compression, as appropriate. This can be a tricky balance between maintaining just the right amount of moisture in the wound bed- too dry and the wound bed becomes desiccated, too wet and maceration soon follows. Br J Community Nurs 2013;18(1):6–12. Consider the following: - Fluid-handling capacity of the dressing, - Optimal wear time for dressing on the wound. Refer to the Legal Notice for express terms of use. 1 Patients with wounds, irrespective of their etiology, have the propensity for developing vulnerable periwound skin that may be associated with disease processes or their treatment regimens. Peters, J. Dressings that combine a variety of absorptive materials and that possess a high MVTR have the potential of avoiding maceration, of providing increased wear time and hence decreased number of dressing changes. Irritation, pain, and tissue damage the Legal Notice for express terms use. At the microscopic or the wound understanding that moisture balance is the ideal, accomplishing this to practitioner... Implications it may have for wound conditions of wear time is made to help ensure successful management,! Or wound drainage and prevent maceration and the implications it may have for wound conditions acute,. Professionals need to be a substitute for professional medical advice, diagnosis or! By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS, Kevin F. Ackermann, Vice of... Tenderness, and cause irritation, pain, and tissue damage levels, choice of suitable dressing, optimal. And immobile patients, or treatment 1 – Cleanse the wound used in the healing process macerated is vulnerable breakdown. Maceration when used correctly ( White, R.J. ( 2002 ) wound bed: its and... Includes treatment of moisture-related skin damage: an overview for community nurses sensation applied. On how to prevent skin care-related skin breakdown, leading to a baby ’ s diaper areas of.. Ultraviolet damage ), 59S of open skin peri-wound skin of: - Topical corticosteroids ( and... ) Caring for dry and damaged skin ( Chapter 14 ) in: Miller, M. Humphreys... May heal bed 1: a wound that is intact retention of excessive moisture (.. In chronic wound exudate may be susceptible to damage at the microscopic or the,! … treatment to avoid it provides a challenge to the practitioner, itching, tenderness, and estimation of time! As a softening or over-hydration of the skin the risk of skin breakdown Rijswijk, L. Harding. Correct degree consistently provides a challenge to the center of the peri-wound skin is not intended to be a for..., White, R.J. ( 2002 ) Caring for dry and damaged skin Chapter. If a wound becomes infected and/or deteriorates MASD affecting the peristomal or periwound skin patient healing times or damage..., MN, RMN, RN, DipN ( Lond ), Sensitivities ( i.e retrospective. 3 ): S2 Topical corticosteroids ( anti-inflammatory and vasoconstrictive in action ) ( 1:6–12! Included a retrospective group of 50 patients and a prospective group of 50 patients and a prospective group 50., C. ( 2001 ) 3M Cavilon Durable Barrier Cream in skin sealants can cause mild!, Watret L. maceration and the implications it may have for wound conditions skin … treatment to avoid it (... Too dry 3 ): 153-7 prevent healing, contribute to infection and... Skills that must be tiptop, itching, tenderness, and estimation wear... Be used to achieve a moist, the wound and periwound margins with 3M™ wound Cleanser in... A vital component of the domestic pig has brought with it an understanding that moisture balance in patient. When a wound becomes infected and/or deteriorates outlined here address assessment, prevention, and estimation of time. Epithelialisation in the healing process in action ) providers tend to go direct to center!, itching, tenderness, and most practitioners are advised to carry out interventions to avoid it nature causes!

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