Questions from practice: caring for sore skin around a wound
Q. I’ve had an operation and was told to change the dressing every couple of days but now the skin around the cut is getting sore. Have you got something to put on it?
A. Surgical incisions are usually dressed with island dressings (absorbent pads with a self-adhesive border). Damage to skin around a wound can be caused by stripping of the skin cells, shearing forces between the dressing and the skin, or maceration, and this should be first explored before recommending a product.
Removing an adhesive dressing will remove some surface skin cells. Repeated stripping of cells from the same area erodes the skin surface. Dressings are coated with different types of adhesive in an attempt to minimise damage, including water-based ones (eg, polyacrylate in Mepore) to reduce residue remaining on the skin, which would have to be removed. For fragile skin (eg, in old people or skin damaged by exudate), a soft polymer dressing might be preferred — soft silicone polymer (eg, Mepilex) has been shown to reduce cell stripping. It does not adhere to a moist wound surface but adheres to the dry surrounding healthy skin without the need for additional adhesive, and with minimal removal of skin cells at dressing change.
• Stripping of the skin cells, shearing forces and maceration can damage skin around a wound.
• If skin is damaged, dressing suitability, the site of the wound, and the frequency of dressing change should be checked.
• Barrier creams and polymer films can be used to protect the skin around a wound but they can interfere with dressings so should be recommended as a last resort.
Blistering at dressing edges suggests friction or tension between the dressing and the skin causing the epidermis to separate from the dermis. The site of a wound may be important — blistering is common around dressings applied over a joint. Movement of the joint causes tension in the dressing, which creates a force between the edges of the dressing and the skin. Applying the dressing so that the least amount of tension is created in movement, while ensuring that there is no creasing or wrinkling at the edges that might allow bacteria to enter, can be difficult. A non-adhesive dressing (eg, Melolin) fixed with tape is an option. Blistering might be reduced by placing the tape longitudinally to the joint only (this may mean several pieces of tape at the top and bottom ends of the dressing, as close as possible to ensure covering of all edges), or use of a retention bandage instead of tape.
Blistering at a site not involving a joint indicates that the dressing is being stretched during application, creating continuous tension between the dressing and the skin. Similar tension can occur if there is inflammation under the dressing but this would be most likely shortly after surgery, because initial inflammation often occurs in wounds as part of the healing process. Longer lasting inflammation or oedema occurring several days later is a sign of possible infection and wound management would need reassessment. The importance of not stretching dressings, along with checking the site for any sign of infection, should be emphasised.
Maceration occurs when there is excess fluid under a dressing. Causes include using a dressing with a low absorptive capacity leading to leakage of exudate and a build-up under the dressing. Dressings commonly used for surgical wounds include perforated dressings (eg, Opsite Plus) and vapour-permeable membranes and films (eg, Mepore).
A dressing that incorporates an absorbent pad should be used if there is any exudate. It is important to check that the pad is large enough to cover the wound and eliminate leakage but, even if it is, fluid accumulation and leakage can occur if the rate of water vapour loss is slower than the rate at which exudate is generated. Unless infected, surgical wounds usually produce low to moderate levels of exudate. Increasing exudate can be a sign of infection.
If the wound is not exuding maceration can still occur due to insufficient water vapour loss where perspiration under the dressing is an issue. Again, this may depend on the site of the dressing. Obesity is a factor because tissue folds will be deeper. Dressing type may also be a factor — vapour-permeable film dressings appear to have a higher rate of water vapour loss than perforated dressings.
It is important to check dressing suitability, the site of the wound, and the frequency of dressing change before suggesting other options. Barrier creams and polymer films (eg, Cavilon) can be applied to the surrounding skin to protect it but they can interfere with dressings (eg, breathability) so should only be recommended as a last resort.
Lynda Steer, is a locum pharmacist and freelance writer, Cheshire.
Unless stated otherwise, Learning &?development material is commissioned by The Journal and is not peer-reviewed
Citation: The Pharmaceutical Journal URI: 11078117
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