Exploring the Critical Role Skin Health Plays in Wound Care: A Conversation With Heather Hettrick

The skin is the largest organ in the body and the first line of defense. Like any other organ, it can fail if it is not properly maintained, especially as it ages. Vincent Falanga, MD, FACP, has said, “We are outliving our skin,” and as the population lives longer, the ability to ensure skin health is maintained and managed — regardless of condition or diagnosis — becomes increasingly important to health care providers.

Heather Hettrick, PT, PhD, CWS, CLT-LANA, CLWT, Associate Professor, Physical Therapy, Nova Southeastern University, Fort Lauderdale, FL, shared her perspective of skin, why the skin needs to be a top care priority, and how skin failure can provide clues to larger concerns.

The Importance of Skin Health

Why is skin health so critical to a patient’s overall health? Health care providers need to remember the skin plays a vital role in a person’s overall health and is an essential component in care. The skin often is taken for granted, even though as clinicians we interact with the skin daily using all our senses. When we transfer patients, we touch the skin. When we provide medication and assess other body systems and organs, these actions often occur through the skin. For other body systems to work properly, the skin needs to be viable and healthy. 

What can you share about the concept of skin failure? Skin, like every other organ, has the potential to fail. It has a finite life span. Skin failure can be the first visible manifestation of multiorgan system failure or multisystem trauma. This is what happens when patients present with Kennedy Terminal Ulcers. The blood has shunted to vital organs (eg, the heart and brain) causing the skin to lose perfusion and the ability to sustain key functions. 

People are living longer, often with medical conditions. When the skin fails, it is important to understand it isn’t always because of negligent care. It can be an overt sign of the body shutting down. 

Why is skin care important? Unfortunately, a disconnect exists between skin and health. Clinicians deal with the skin 24/7 — personally and with patients — but only when something goes awry or there is a visual issue (eg, ulceration, rash, pressure injury) do we recognize skin’s importance. We need to be more proactive with prevention and not reactive after the fact.

Skin care and implementing skin protection strategies are vitally important to maintaining proper pH and in aiding the skin’s function as a living biochemical organ. Consider this: we exercise for cardiopulmonary health, we sleep for mental health, and we try to eat well for gastrointestinal health and immunity. We need to take on similar habits to protect the skin for its health: hygiene, moisturization, sun protection, offloading, and so on. The ultimate goal is to keep the skin intact and healthy so it can function properly. 

We must remember that some of the issues that occur with skin are preventable. We need to ask questions about how we are handling skin, how are we protecting it, and how we can mitigate stress on the skin. Skin is the one organ we can physically interact with and we need to do everything we can to not inadvertently cause harm. 

Clinician Advocacy for Skin

Often when we talk about skin concerns, they relate to the reduction of pressure injuries. What other skin-related concerns should clinicians address? Many other skin impairments need our attention and focus on prevention as well. These issues include moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), skin tears, and lymphedema. Awareness is the first step in prevention; with this knowledge and focus on maintaining skin health, we can drive positive patient outcomes and satisfaction. 

The skin is a mirror into a patient’s overall health. We need to think about the overall condition of the skin and ask questions such as:

• Is the skin too wet, leading to MASD? 
• Is it too dry, which could lead to cracking/fissuring and an entrance for bacteria? 
• Does your patient have allergies and skin sensitivities that could lead to issues with MARSI? 
• Are you aware of age-related skin changes?
• How are the nails and hair presenting? Are they brittle, dry, dystrophic? Is fungus present?   

Interestingly, we segment parts of the patient when in actuality everything is interconnected. We need to stop the siloed approach to care. Any issue (disease, trauma, ailment) can impact other aspects of the body. Congestive heart failure can lead to edema and additional skin issues. Incontinence-associated dermatitis has been recognized as a risk factor for pressure injuries. Dysfunction in 1 area can lead to dysfunction in another. 

How should skin health be viewed by different care settings? Health care is a team effort. Everyone needs to be accountable to the patients under their care. It doesn’t mean just the diagnosis or symptom. It means looking at the entire patient in context and exploring what we can do to best manage that person through the initial issue without potentially creating additional complications. 

We should not dismiss the importance of the skin. A little bit of attention can go a long way in helping correct or maintain skin health. Take time to do a comprehensive assessment, document, talk to the patient, ask questions about their skin and, if you see something, say something!

Never underestimate the importance of the patient experience. Extreme pain may not allow a patient to focus on care. Skin health is strongly correlated to the quality of a person’s life. Think about how devastating it can be for teens when they have severe acne. Consider how challenging it is for a patient with a chronic wound that may drain, smell, or cause pain. 

Awareness is the first step of prevention. We need to continue to make people aware of the importance of the skin and how it is linked to everything we do. We need to educate providers and patients on the importance of correcting or maintaining skin health. 

Educating the Next Generation 

As a professor, you are educating up-and-coming wound care providers. How has your curriculum and approach changed over the years? In physical therapy, our curricular focus centers around the 4 body systems: cardiopulmonary, musculoskeletal, neuromuscular, and integumentary. My goal is to educate students on the importance of the skin, its link to the other body systems, and its biological vitality. I want students to appreciate the skin’s daily impact on us and our patients. From there, we can explore skin impairment and dysfunction and appreciate how we can intervene from a physical therapy perspective.

What makes you most excited about your students and the next generation of clinicians? I am very passionate about the skin, and my goal is to instill that passion in others. Even if students do not elect to focus on a career in wound management, burns, or lymphedema, knowing they have the interest and basic knowledge necessary to help others in need is tremendously gratifying. 

You utilize innovative, hands-on ways of teaching students about wound care. How do you develop these approaches? My teaching philosophy reflects my belief that learning should be active, fun, and engaging. I love to use analogies and experiences people can relate to in everyday life. Knowledge transfer is improved through a multimodal approach that supports all aspects of adult learning. Interactive, experiential, immersive environments enhance the learning experience. My goal is to provide unique learning opportunities and formats for students to embrace in content areas they may not have considered important or relevant, such as the skin. 

To hear more from Dr. Hettrick, visit the archived webinar program at www.o-wm.com/3mskinhealth.

Practical Perspectives is made possible through the support of 3M, St. Paul, MN. The opinions and statements of the clinicians providing Practical Perspectives are specific to the respective authors and are not necessarily those of 3M, Ostomy Wound Management, or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.