Periwound Management: What Clinicians Should Know
The wound is a disruption in the continuity of the epithelium which affects the protective barrier function of the skin. Periwound skin refers to the surrounding area of the wound edge. In literature, it is defined as the area within 4 cm of the wound edge. However, it should be kept in mind that it is not possible to quantify and demarcate the exact boundaries of the periwound area. Periwound management is an important part of wound care. This is because the integrity of periwound skin has a direct impact on wound healing. Wound care specialists and podiatrists need to carefully assess and manage periwound complications for the best wound healing outcomes.
Importance of Periwound Management
Even though it might appear healthy, the periwound skin is vulnerable and its complications can directly impact wound healing. Therefore special attention should be given by wound care specialists and podiatrists to periwound skin management. Wound-related factors and the underlying pathophysiology can cause damage to the integrity of the skin. Some of the wound-related factors that can cause damage to the periwound skin include wound exudate, bacterial infections, and dressing-related allergic reactions. The damage to periwound skin is associated with delayed wound healing, increased size of the wound, and reduced quality of life of the patient. In addition, it is also linked with increased patient discomfort and pain.
One of the mechanisms through which periwound complication can impede wound healing include an increased risk of wound infection. Bacterial infection results in increased inflammation at the wound site, which if not controlled, leads to poor healing outcomes. Periwound skin problems are a common challenge encountered in wound care and should be timely addressed.
Periwound Skin Problems
Periwound problems are a common occurrence in wound care practice. Some of the issues encountered in periwound management include:
- Wound maceration: Chronic wounds produce excessive amounts of wound exudate. Wound exudate is not an inert fluid. It contains enzymes like matrix metalloproteinases and growth factors that play a role in wound healing. However, excessive wound exudate can cause damage to the surrounding skin and lead to maceration. The macerated periwound skin is whitish and soggy in appearance. Macerated skin is associated with an increased risk of contact dermatitis.
- Dry skin: Dry, flaky, itchy skin is a common problem encountered in periwound skin. Cracks and fissures in the dry skin allow easy entry of bacteria into the periwound skin.
- Allergic reactions: The components present in the dressing or adhesive materials can lead to the development of allergic reactions. Patients with venous insufficiency are more susceptible to allergic reactions.
- Adherence of wound dressing: Dressing material can adhere to the fragile periwound skin which causes damage and discomfort to the patient on removal.
- Eczema: Eczema appears as red, itchy inflamed skin around the wound. If it occurs in association with venous ulcers, it is called venous or 'gravitational eczema'.
Principles of Periwound Management
The protection of periwound skin from external trauma and chemical injury is the most important step of periwound management. The periwound area should be carefully assessed and evaluated. Some of the basic principles of periwound management include:
- Treatment of the underlying pathophysiology
- Implementation of a skincare regime
- Selection of appropriate wound dressing
Some other important considerations in periwound management are described below.
Skin maceration is a leading complication of excessive wound exudate. Excessive amounts of wound exudate production can occur because of the underlying presence of wound infection. Therefore, a careful assessment of the characteristics of wound exudate should be done. Antimicrobial therapy should be started to lessen the burden of bacterial infection. Clinical signs and symptoms of infection include pain, erythema, and swelling.
Patients with chronic venous insufficiency can also have production of excessive exudate. These patients can benefit from compression therapy as it helps to reduce local edema. To protect the periwound skin from maceration, absorbent dressings should be used.
Allergic reactions to the dressing and adhesive materials can be misdiagnosed as an infection. It is important to remove the potential agent from the wound site. A thorough history and examination should be carried out. If suspecting an allergic skin reaction, topical corticosteroids can be applied to the periwound skin. The opinion of a dermatologist should be sought for further investigation of the underlying cause.
Periwound skin is fragile and vulnerable especially in the elderly. Frequent application and removal of the wound dressing can result in 'skin stripping'. Therefore, it is important to recognize at-risk individuals. Dressing changes should be minimized. In addition, silicon-based products have been developed that can be used as a protectant for the fragile periwound. Non-adhesive wound dressings are also a viable option. Dry skin is prone to breakdown and can result in an increased risk of periwound infection. Emollients and moisturizers can help restore the barrier function of the skin.
Periwound management is an essential component of wound care. Periwound breakdown is linked with increased pain, patient discomfort, and delayed wound healing. Therefore, special attention should be given to periwound management to reduce the healthcare costs associated with periwound complications and improve the patient's quality of life.