Skin & Wound Management Under the Wraps

  Wound management for patients living with venous insufficiency often involves multiple complexities. These variations require providers to consider a spectrum of strategies. Some require an advanced knowledge of skin conditions and differential diagnosis while others are dependent on “tricks of the trade” for dressing changes and the understanding of different dressing modalities.

The ‘Skinny’ on Skin

  Several dermatological conditions result from certain types of compression. These include folliculitis, fungal infections, and contact allergies.   Folliculitis, which appears as inflamed pustules around hair follicles, occurs due to any type of trauma to the follicle, such as pressure or friction, chemical irritation, or bacterial colonization.¹ Milder forms of this skin condition are referred to as superficial folliculitis. This is considered self-limiting as long as the source of the injury is reduced. Painful, deep folliculitis warrants a culture to isolate the type of bacteria involved, and treatment with systemic antibiotics.¹   Fungal infections including candidiasis present as groups of small, red open or closed pustules around the moist edge or macerated wound. This is often exacerbated by the use of moist or occlusive dressings. In this case, an anti-fungal ointment or powder over the area and a drier skin surface dressing, such as cotton batting, will reduce the fungal outbreak. Be aware that most rashes in venous disease are from stasis dermatitis, not candidiasis.   In its milder form, a latex allergy caused by compression wraps appears as an itchy rash or hives over the majority of the lower extremity, or just above the knee (with possible systemic effects including puffy face and full-body rash). The elastic component of the multilayer compression dressing can be replaced with a latex-free brand. Depending on the severity of the rash, the provider may choose to prescribe antihistamines or corticosteroids (such as methylprednisolone) to mediate the latex reaction. If changing to a non-latex brand of compression is ineffective in mediating the skin reaction, patch testing may be ordered to rule out other causative agents.   Skin conditions related to chronic venous insufficiency are also a concern. Stasis dermatitis presents as a rash with flaking skin and complaints of itching. Skin may become thickened over time, a condition known as hyperkeratosis. This occurs due to the chronic inflammation caused from venous insufficiency when white blood cells become trapped in the sluggish flow through capillaries, become activated, and release pro-inflammatory cytokines, which leads to chronic inflammation and hypersensitivity to products.² This should be managed with medium potency corticosteroid ointments. Choose ointments that do not have preservatives in them (eg, fluocinolone ointment 0.025%) to minimize risk of sensitivity reactions. Once skin is cleared up, discontinue the corticosteroid. No creams or ointments are used at this point to avoid new hypersensitivity reactions. If skin is exceptionally dry, use of hypoallergenic dimethicone-based lotions without fragrance may be tried.

Going The Distance

  Compression wraps, which may remain intact for up to 7 days, pose another problem as this length in time can increase the risk for maceration, odor, or dressing slippage. The best solution for this is to change the wrap more often (every 3-5 days). Some patients may be unable to come into the clinic for more frequent dressing changes or may have maceration or odor even with more frequent wrap changes. These scenarios require the use of various dressing management strategies:     • There is not conclusive evidence that the type of dressing used on venous ulcers affects wound healing.³ Therefore, practical aspects such as exudate management and avoidance of peri-wound skin irritation should guide dressing choices. Because venous ulcers, especially early in treatment as edema is reducing, may have substantial exudate, use of absorbent dressings is essential. Foams are ideal dressings in this case as they are absorptive and also provide local compression over the ulcer. For high exudate, use foams that do not have film backing so that drainage can wick out into the wrap. Trapping exudate in the dressing can lead to further maceration of surrounding skin. Calcium alginates or starch copolymer-based dressings can be cut to fit the wound under the foam for extra absorption. A new category of quick-wicking products (eg, Drawtex,® SteadMed,TM Fort Worth, TX; or Active Fluid Management,® Milliken, Spartanburg, SC) may help prevent maceration by moving exudate quickly into the dressing away from the skin. Sometimes, a contact layer and gauze 4 x 4 are enough to keep the wound moist and absorb exudate. Avoid putting too much bulk under compression wraps; this will decrease sub-bandage pressure by increasing limb size, thus leading to increased exudate due to poor edema control. It is rare that venous ulcers require moisture-donating products such as hydrogels. Avoid adhesive dressings due to high risk of contact sensitivity in these patients.     • Odor related to long dressing wear (not infection) can be treated with a thorough washing of the skin and wound along with the use of an antimicrobial wound cleanser. If odor remains, apply metronidazole gel with each wrap change.     • Skin cleansing should occur with each compression wrap change. Use a gentle soap, such as Cetaphil,® and, occasionally, for odor and ongoing folliculitis, temporary use of Hibiclens® is useful.   Maintaining the integrity of multi-layer compression dressings for patients with a large calf and small ankle circumference (also referred to as an inverted champagne bottle appearance) provides a challenge for many clinicians. For strategies to deal with this, consider the steps noted in the table on page 25. Matthew Livingston may be reached at m_livingston@hotmail.com.

References

1. Habif T. Clinical Dermatology: A Color Guide to Diagnosis and Treatment. 4th ed. Philadelphia: Mosby; 2004. 2. Bergan JJ, et al. Chronic venous disease. N Engl J Med. 2006;355:488-498. 3. Palfreyman S, Nelson EA, Michaels JA. Dressings for venous leg ulcers: a systematic review and meta-analysis. BMJ. 2007;335:244-255. Erratum in BMJ. 2007;335:0.