Periwound Skin Management in Chronic Wounds
Besides the wound site where the primary injury has occurred, the area of skin immediately surrounding it is also at risk of developing tissue injury. This area referred to as the periwound, is exposed to various harmful stimuli from the wound area. To prevent tissue deterioration in this area, wound care experts must implement protective measures throughout the healing process.
Defining the Periwound area
Although there is controversy among wound care experts about the definition of the periwound area, many wound care providers consider it to extend 4cm in all directions from the primary wound edge. Depending on the etiology of the wound, the tissue perfusion rate, and other factors affecting wound repair, the periwound area might actually be less than 4cm or significantly more extensive. Expected, the smaller the periwound area, the easier and more effective preventive or therapeutic interventions will be.
Etiology of Periwound Damage
There are various causes of periwound damage which are both intrinsic (originating from the wound) and extrinsic (exposure to a harmful external stimulus) in origin. The key determinants of damage to the skin area surrounding a chronic lesion include:
- Moisture-associated skin damage (MASD)
- Injuries sustained from sound dressing
- Medical adhesive-related skin injury (MARSI)
Other factors that contribute to periwound damage are wound site infection, foreign body contamination, and repeat physical trauma.
Moisture-associated skin damage (MASD)
Patients can develop periwound inflammation following exposure to various wound exudates and body secretions. Wound fluid, urine, saliva, sweat, mucus, and stool can damage the skin immediately surrounding a wound if not diverted into proper drainage channels. Periwound MASD will present as redness, pain, itching, pale, friable skin (maceration), and worsening skin erosion.
Wound dressing related injuries
Wound dressings done too frequently can cause the skin around a wound to weaken especially in the young and elderly populations. These groups of patients either have underdeveloped dermal layers or age-associated skin thinning. Consequently, too frequent dressing changes will disturb the fragile skin around the wound leading to periwound inflammation.
Medical Adhesive-Related Skin Injury (MARSI)
The application of various medical adhesives to secure dressings, tubes, and other medical devices in place can have a profound effect on the skin surrounding the wound site. The traumatic events in MARSI occur when the adhesive is being removed. Shear and frictional forces will peel off part of the epidermis leading to an inflammatory reaction. MARSI might cause a transient reaction or worsen with the onset of a superimposed bacterial infection within and around the wound site.
Risk Factors for Periwound Injury
Listed below are the risk factors for developing periwound injuries in a patient with chronic wounds:
- Advanced age
- The presence of a draining fistula or stomas
- Copious wound exudate
- Exposure to corrosive body fluids
- Previous trauma (burns, shear injury, etc.)
- Underlying skin diseases (eczema, psoriasis, irritant dermatitis, etc.)
- Ulcers associated with chronic medical diseases
Signs and Symptoms of Periwound Damage
Patients with periwound inflammation will present with the following clinical features:
- Pain and tenderness in periwound area
- Redness and rashes
- Changes in skin appearance and strength with pale, weak skin (maceration)
Assessing the Periwound Area
When assessing the periwound area for abnormalities, wound care experts must consider five main parameters:
- Depth of the primary wound
- Volume of exudate
The shape and location of the periwound inflammation can give wound care experts an idea of the underlying etiology. For example, wounds occurring in the lower extremities are more often seen in patients with chronic medical diseases like diabetes mellitus, and peripheral arterial disease. The temperature of the periwound area can be compared to unaffected skin to determine the presence of inflammation. Similarly, increased redness can indicate an inflammatory process affecting the skin surrounding a wound.
The appearance of the periwound helps determine the depth of a primary wound. In patients with burns, periwound depth assessment can be used to classify burn wounds into partial or full-thickness injuries. Proper categorization will aid the implementation of appropriate treatments and improve wound healing rates. Lastly, the volume of exudate produced by a wound is a crucial factor to be considered when assessing the periwound. Copious amounts of wound exudate will increase the chances of developing periwound MASD and cause more extensive damage to the skin around the primary lesion.
Management Strategies in Periwound Injury
The emphasis in the management of periwound inflammation/injury is on prevention rather than cure. With the implementation of protective strategies, wound care providers can reduce the chances of periwound complications drastically.
Key preventive interventions in periwound care include:
- The application of skin sealant sprays or liquids around wound margins
- Using more absorptive wound dressing materials to control exudates in patients with weepy wounds
- Careful application of medical adhesives with double layer approaches (non-adhesive layer over skin, followed by an adhesive one)
- The use of adhesive removers to limit frictional and shear forces that might damage periwound
- Avoidance of prolonged use of medical adhesive devices
- Application of protective ointments and barrier creams
In cases where periwound damage has already occurred, wound care experts should implement local wound care strategies (wound cleansing, dressing), manage infections and pain, and treat the underlying etiology.