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Diagnosis And Treatment Of Periwound Dermatitis

The integrity of periwound skin is an important consideration in wound care. The disruption in the continuity of periwound skin can negatively impact wound healing outcomes. Moreover, periwound complications can adversely impact the patient's quality of life and increase the risk of wound infections. Periwound dermatitis is a common problem encountered in patients with chronic wounds. It is important for wound care specialists and podiatrists to readily identify and treat this periwound complication for better patient outcomes.

What Is Periwound Dermatitis?

Periwound skin refers to the area of the skin within 4 cm of the wound edge. A healthy periwound skin is essential for optimal wound healing. The integrity of the periwound skin can be compromised especially in patients with chronic wounds. One common complication often encountered in patients with chronic wounds is "periwound dermatitis". 

Periwound dermatitis is an inflammatory disorder that presents with erythematous, pruritic skin. The type of dermatitis which is present in patients with chronic wounds is "contact dermatitis". Further subclassifications of contact dermatitis include “allergic contact dermatitis” and “irritant contact dermatitis”. Allergic contact dermatitis might result from an allergic reaction to a material in the wound dressing material. However, the majority of cases are "irritant contact dermatitis" resulting from exposure to irritants in wound exudate. 

Periwound dermatitis is often classified as a subtype of moisture-associated skin damage (MASD). Compared to acute wounds, the chronic wound exudate contains a higher level of proteolytic enzymes that damage the skin barrier. The aggressive removal of wound dressings during dressing changes can also result in periwound damage by stripping away the upper layers of the skin. 

Management of Periwound Dermatitis: Diagnosis And Treatment

The diagnosis of periwound dermatitis requires a comprehensive evaluation and assessment of the periwound skin by the wound care specialist. Since the presence of periwound dermatitis can lead to a significant decline in the quality of life, healthcare professionals should be able to readily identify patients at an increased risk of periwound complications. Early identification and management of periwound complications can have a significant positive impact on patient satisfaction and quality of life. 

Clinical Assessment

An accurate diagnosis of periwound dermatitis depends on a thorough history and periwound skin assessment. Regular assessment of the periwound skin should be done at every dressing change. This also includes a visual assessment of skin integrity, color changes, texture, and appearance. Patients should be asked about any symptoms of itchiness, soreness, or pain at the periwound site. Any recent skin changes, lesions, and excoriations should be noted. 

Some signs that might be indicative of dermatitis include red, itchy skin, increased skin temperature, and a burning sensation. An important thing to keep in mind when assessing periwound skin is that erythema and skin changes might appear differently on darker skin. For instance, redness of the skin might not be readily visible on darker skin. 

Patient factors should also be taken into consideration that can contribute to vulnerable periwound skin. Some of these include aging, the presence of comorbidities, nutritional factors, and a history of skin disorders. Venous insufficiency might also exacerbate periwound dermatitis and maceration. Clinicians know wound care and management best, for better wound damage prevention, always consult your practicing clinician.

Removal of Causative Agent

As contact dermatitis is triggered by an irritant, removal of the offending agent is a necessary part of management. Since wound exudate is the most common cause of periwound dermatitis, skin barriers such as zinc paste, petrolatum, or other skin protectants should be used. If the wound dressing material is identified as a potential trigger, an alternative wound dressing material should be selected. Some patients might develop periwound dermatitis due to the use of wound cleansers. Therefore, the use of wound cleansers should be avoided in these patients, and instead normal saline should be used. In short, periwound skin should be protected from the offending trigger agents by the use of skin barriers and regular cleansing.

Wound Exudate Management

The common cause of periwound dermatitis is moisture-associated skin damage resulting from excessive wound exudate. Therefore, the selection of appropriate wound dressing for the management of wound exudate is essential for the treatment of periwound dermatitis. For wounds with heavy exudate, absorbent wound dressings such as hydrofiber or hydrogels might be suitable. Wound dressings with occlusive properties should be avoided as they have the potential to aggravate periwound maceration. 

Compression Therapy

Patients with venous ulcers are at an increased risk of developing “stasis dermatitis” due to venous insufficiency. The periwound skin often appears hyperpigmented due to the deposition of hemosiderin which is the breakdown product of hemoglobin obtained from red blood cells. Compression therapy is often indicated in patients with venous ulcers as it helps to alleviate local edema that contributes to periwound dermatitis. An adequate blood supply to the lower limbs should be ascertained using the ankle-brachial pressure (ABI) index before the initiation of compression therapy.

Drug Treatment

The pharmacological treatment for periwound dermatitis can include topical corticosteroids, oral antihistamines, and moisturizers. During the selection of skin moisturizers, it should be ensured that the formula is hypoallergenic and fragrance-free. Topical barriers such as skin ointments, powders, and pastes can also be used to protect fragile periwood skin. Some notable options include petrolatum-based barrier ointments, zinc oxide based barriers, and silicon-based barrier products.

Promotion of Skin Health

The integrity and health of periwound skin are important for optimal wound healing. Dry skin is more prone to breakage, irritation, and inflammation. In normal healthy skin, natural moisturizing factors are usually present. However, periwound skin is more prone to dryness. Therefore in addition to educating patients about the importance of skin moisturizers, patients should also be informed about best practices for optimal skin health. Products containing ceramides, essential fatty acids, and vitamins can help promote healthy skin.

Contact dermatitis is a common problem encountered in patients with chronic wounds. While it may not be feasible to achieve an absolute cure, the symptoms of dermatitis can be effectively managed using the best practices described above. Regular assessment of periwound skin along with patient education can help to improve wound healing outcomes through early detection and management of periwound dermatitis.