Figure 1: A wound which has been highly exuding. Burns 3: 159-165. wound fluid, sweat, urine) for prolonged periods, which can cause the skin to become soft/soggy. Wound exudate, in the correct quantities and in the correct constituency, is a useful factor in the healing process. Upper Saddle River, New Jersey: Pearson Prentice Hall; 2008:128-130. This can be a tricky balance between maintaining just the right amount of moisture in the wound bed- too dry and the wound bed becomes desiccated, too wet and maceration soon follows. Excess wound exudate can be reduced by eliminati… In: Miller, M., Glover, D. (eds). (2002)Caring for dry and damaged skin (Chapter 14) In: While, A. Thomas, S. (1997)Assessment and management of wound exudate. Peters, J. British Journal of Nursing 10: 7, 469-472. J Wound Ostomy Continence Nurs 2007; 34(2): 153-7. Vowden, K., Vowden, P. (2002)Wound bed preparation. They generally provide protection for up to 72 hours before re-application is necessary. Figure 1: A wound which has been highly exuding. Treatments for more serious maceration with periwound skin include occlusive dressings and Hydrofiber dressings. as a result of infection), Sensitivities (i.e. Many are able to decrease the amount of fluid pooling under the wound dressing, thus decreasing the risk of skin breakdown. treatment to avoid or treat periwound maceration includes the use of highly absorbent dressings. Excessive amounts of wound exudate can cause the periwound (within 4 cm of wound edge) skin to become macerated and even break down. Protecting the peri-wound skin from enzymes in chronic wound exudate may be achieved through a variety of simple measures. Periwound issues affect the integrity and healthy functionality of the skin surrounding the wound and may include maceration, excoriation, dry (scaly) skin, eczema, callus (hyperkeratosis), infection, inflammation.. Signs and symptoms. In wounds, maceration can prevent healing, contribute to infection, and cause irritation, pain, and tissue damage. Wound Care Society. This damage to the peri-wound skin reduces its protective function as a barrier to water and increases the likelihood of maceration occurring (Cutting and White, 2002). It should be noted that some moisture barriers are safe to use on non-intact skin. Wounds 8: 5 145-150. Although many other factors are implicated in exudate management, it is vital to apply these skills to every wound at every dressing change; only by doing this will maceration be avoided and healing optimised. Although some practitioners may insist that occlusive dressings which create a ‘moist wound’ environment can provoke maceration, this need not be the case under ‘normal’ conditions of use. Butcher, M. (2000)The management of skin maceration. Those of serous consistency (clear aqueous) will be more likely to pass into an absorbent dressing and be lost by MVTR than those of a more viscous nature. However, partially occlusive dressings that rely on absorbency and moisture vapour transmission rate (MVTR) for their fluid-handling capabilities may offer a lower risk of inducing maceration. Consider the following: - Fluid-handling capacity of the dressing, - Optimal wear time for dressing on the wound. Dressings with a super-absorbent component provide effective protection (Langoen and ... periwound skin is the treatment of choice for allergic reactions. Wound exudate (type and volume) influences management decisions and dressing choice; this paper focuses on one aspect of exudate, the skin damage known as maceration. It should not be confused with the pale, whitish appearance of the new epithelial tissue in a healing wound. Vulnerable skin may be susceptible to damage at the microscopic or the macroscopic level. Health-care professionals need to be aware of maceration and the implications it may have for wound healing. This article describes the importance of controlling the moisture content of wounds and areas of vulnerable tissue, with particular emphasis on the use of dressings that provide protection to periwound skin, which may be damaged by proteolytic enzymes present in exudate from chronic wounds. INTERVENTION: The intervention compared the experimental product (Remedy Nutrashield; Medline Industries, Mundelein, Illinois) versus Cavilon Moisturizing Lotion (3M, St Paul, Minnesota). Thomas S. The role of dressings in the treatment of moisture-related skin damage. MAIN … A macerated wound is an injury accompanied by soft, white, deteriorating skin around the site of the original injury. The eyes of the care providers tend to go direct to the center of the wound, the wound bed. As a Director of Nursing, your assessment skills must be tiptop. Prevention of maceration includes treatment of underlying disorders and selection of dressings that maintain an ideal moisture balance in the wound. Although acute wounds may confront the practitioner with challenges to healing, this paper will focus on maceration and chronic wounds, as they represent the majority of wounds encountered that present problems to the nurse. Not all wound exudates are the same. Topics in Nurse Prescribing. Not recommended use for extended amounts of time. (1989)Pressure ulcers among the elderly. Batt, M.D., Fairhurst, E. (1986)Hydration of the stratum corneum. Journal of Wound Care 6: 7, 327-330. It occurs when skin is exposed to wet dressings or wound drainage. Sign in or Register a new account to join the discussion. World Wide Wounds. This model for healing emphasises a number of objectives: - To achieve a well-vascularised wound bed, - To decrease the bio-burden of the wound. Moisture barriers are creams or ointments that contain dimethicone, petrolatum or zinc oxide. In acute wounds, exudate components contribute positively to the wound-healing process. OUTCOME MEASURES: The mean outcome measures were a decrease in periwound and ulcer size. The periwound offers key information crucial to overall wound healing. Indeed, it is likely that most instances of maceration are attributable to ‘traditional’ dressings as these are still the most widely used. Nature 193: 293-294. If urinary continence problems are the main issue, bladder and bowel function need to be improved or mechanical methods such as indwelling catheters should be used. However, in chronic wounds, proteolytic enzymes such as MMP8s are produced in excess of the level required to lyse devitalised tissue, debris and dead micro-organisms. Skin sealants are alcohol-based wipes that are used on intact skin, making the skin surface slightly sticky, creating a better surface for adhesive dressings to stick to, while at the same time providing the skin with some protection from the adhesive. Ostomy Wound Management 46: 1A (suppl), 59S. By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS A wound that is too moist can be as detrimental to wound healing as a wound that is too dry. Aberdeen: Wounds UK, 2005. Journal of Wound Care 8: 4, 200-210. Wound exudate can be channelled away from the wound through appliances such as fistula drainage bags or by applying negative pressure to the wound area (Young, 2000). Spray skin sealants are available for use over stage 1 pressure ulcers to provide protection to skin that is intact. Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS, is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care. Patients suffering from periwound issues may experience burning, itching, tenderness, and pain. icipants included a retrospective group of 50 patients and a prospective group of 28 patients. One way to minimize contact with wound drainage and prevent maceration of the periwound is to choose the appropriate dressing for wound conditions. Wound Infection is caused by multiplying pathogenic bacteria which cause a reaction in the patient. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition or product usage. Dressings that combine a variety of absorptive materials and that possess a high MVTR have the potential of avoiding maceration, of providing increased wear time and hence decreased number of dressing changes. Cutting, K. (1999b)Glossary. Published October 2009. Skin Care in Wound Management: Assessment, prevention and treatment. Cutting, K.F. venous ulcers, diabetic ulcers, pressure ulcers), Fistula or stoma drainage (often causes damage to the surrounding skin if the area is not prepared and dressed properly), Increased wound exudate (i.e. This will only compound the problem. Williams, C. (2001)3M Cavilon Durable Barrier Cream in skin problem management. Caustic. Rogers A, Watret L. Maceration and its effect on periwound margins. Gray M, Weir D. Prevention and treatment of moisture-associated skin damage (maceration) in the periwound skin. VLU that were seen during 8 or more weekly clinic visits were identified;35 who had periwound maceration noted during 4 or more visits were compared with 35 matched controls who demonstrated maceration on 0 … Maceration is defined as a softening or over-hydration of the tissue due to retention of excessive moisture (Cutting, 1999b). Educational leaflet. ‘Sometimes it takes something more manageable to get the message across’. Available at: www.worldwidewounds.com/2002/april/Vowden/Wound-Bed-Preparation.html accessed 20.05.02. Periwound issues. When presented with a wound, you should identify risk factors that may lead to periwound damage or breakdown and plan your care accordingly, taking care to choose an appropriate dressing and apply a skin sealant or moisture barrier as necessary. Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. Source: Dowsett et al. This article, produced by a panel of clinical experts who met to discuss moisture as an etiologic factor in skin damage, focuses on peristomal moisture-associated dermatitis and periwound moisture-associated dermatitis. Concentrations of Dakin's solution stronger than 1/8 strength … 7: 3, 12. Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. • Periwound skin Accurate and timely wound assessment is important to ensure correct diagnosis and for developing a plan of care to address patient, wound and skin problems that impact healing. Maceration of the skin and wound bed: its nature and causes. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies. About The Author Documentation of the periwound condition should include measuring the periwound size, noting the skin condition, the exudate presence and characteristics, and the presence of pruritus. Maceration is a largely under-recognized problem and one of the causes of delayed wound healing. The alcohol contained in skin sealants can cause a mild stinging or burning sensation when applied to areas of open skin. Once damaged, the skin is more permeable and susceptible to irritant penetration, leadin… Heavily draining wounds or the improper use of a moist dressing can lead to maceration of the periwound skin, altering tissue tolerance and damaging the wound edges. Previous articles have focused on the nature and causes of maceration. They can be used on intact skin, but are most commonly used to prevent further skin breakdown in areas of incontinence. However, the advent of moist wound healing has brought with it an understanding that moisture balance is the key to optimal outcomes. A number of elements that may be found in exudate have been identified (Box 1) and although this box does not provide an exhaustive list, the reader will appreciate the diverse nature of these components. Manufacturer DermaRite notes Clean & Free is a mild, pH balanced, rinse-free body wash, shampoo, and perineal cleanser. Maceration is often a contributing factor for slow wound healing. The production of exudate is a normal result of the inflammatory stage of wound healing. 8. There has been extensive research on how to prevent skin care-related skin breakdown, and most research agrees on a few main components. Overexposure of the skin to moisture can compromise the integrity of the barrier, disrupting the intricate molecular arrangement of intercellular lipids in the stratum corneum and the intercellular connections between epidermal cells (corneocytes). - Possible adhesive damage to peri-wound skin. Protect periwound skin. Any wound care provider is going to continuously seek new approaches to wound therapies that improve patient healing times. The management and prevention of maceration must focus on the reason the skin is coming into contact with excess moisture. Can damage periwound skin. The arena for wound treatment is not very different. By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS. noted to be macerated.There were 1,332 VLU which became the focus of the current study. There is no defense like a good offense, and this is as true in wound care as it is in sports. Cutting KF, White RJ. London: Emap Healthcare. Journal of Wound Care 11: 7, 275-278. Health-care professionals need to be aware of maceration and the implications it may have for wound healing. (ed.). International Journal of Cosmetic Science 8: 253-264. Maceration of the skin around a wound is a common feature and most practitioners are advised to carry out interventions to avoid it. Nursing Times 96: 45, 35-36. 6. It also discusses the importance of preventing excessive moisture loss from certain wound types and describes the way in which dressings can d… Exudate production may increase - particularly if a wound becomes infected and/or deteriorates. burns or ultraviolet damage), Specific wound types (i.e. If exudate is copious, irrespective of the type of primary dressing used, additional secondary dressings will be needed to provide supplementary absorption, or more frequent changes of dressing will be required. Proper care taken while dressing the wound reduces the risk of maceration of skin around the wound. - Use compression therapy and elevation for appropriate leg ulcers. Lamke, LO., Nilsson, G.E., Reitherner, H.L. Among many vital functions, the skin functions as a barrier to protect the body against mechanical trauma, noxious irritants, infectious pathogens, and excessive fluids. Negative pressure wound therapy (NPWT) has grown to be an important adjunctive therapy in any wound care setting due to its ability to promote wound healing in different types of wounds with granulation tissue formation. Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. - Select dressing(s) according to exudate level, - Estimate optimal wear time according to the following general factors: volume of exudate, nature of exudate, manufacturer’s instructions, clinical setting, activity level of the patient. For cleansing periwound skin without using water, Clean & Free ™ Rinse-Free Full Body Wash & Peri-Cleanser may be an efficient option for patients. Note the maceration to the peri-wound area. Macerated Skin: Pictures, Causes, Treatment, and Prevention By Beth Hawkins Bradley RN, MN, CWON I am frequently asked for solutions relating to maceration to periwound skin in wounds being treated with negative pressure wound therapy (NPWT). Managing exudate production effectively requires achieving a balance between the extremes of wound desiccation and wetness. Moisture-retentive dressings are used to achieve a moist, but not wet, wound environment. Although precise recurrence rates can be difficult to... By Susan M. Cleveland, BSN, RN, WCC, CDP, NADONA Board Secretary. A macerated area was defined as the wet and opaque or white skin of a periwound (15)(16) (17). It is important to treat the condition especially in elderly and immobile patients, or else there is associated risk of infection. White, R J. Falanga, V. (2000)Classifications for wound-bed preparation and stimulation of chronic wounds. The Use of Cyanoacrylate Skin Protectant* to Treat Periwound Maceration in Combination with Negative Pressure Wound Therapy in the Treatment of Neuropathic Foot Ulcers Negative Pressure Wound Therapy (NPWT) has been proven to be an effective and valuable tool for … Loss of this seal will cause extravasation of fluid, resulting in periwound maceration and an inability of the VAC therapy device to function properly. There are several prevention strategies that can be used to prevent maceration and further skin breakdown. Van Rijswijk, L., Harding, K. (2000)Issues and clinical implications. A recently described concept, wound-bed preparation (Falanga, 2000; Vowden and Vowden, 2002), concentrates on the generation of an optimal healing environment and measures to overcome barriers to healing. 7. There is, at present, no evidence that moist wound healing is related to the development of maceration (van Rijswijk and Harding, 2000). Evidence that maceration leads to skin breakdown and consequent wound enlargement is circumstantial (Allman, 1989), although anecdotal reports link maceration with delayed healing and other complications (Cutting, 1999a). The content is not intended to substitute manufacturer instructions. This type of skin damage is call periwound moisture-associated dermatitis.The chemical composition of the wound exudate greatly affe… (1996)The effect of dressings on the production of exudate from leg ulcers. Sources Regular applications of liquid paraffin/soft paraffin (50/50 proportions) or zinc oxide cream or ointment BP to the peri-ulcer skin are often soothing as well as protective in function. Maceration is one of the most common skin problems associated with wound care. Wound edge Periwound skin Maceration dration Undermining Rolled edges Wound ed Assessment Peround sn Assessment • Maceration • Dehydration • Undermining New England Journal of Medicine 320: 850-853. Although exuding chronic wounds (deep burns, diabetic foot ulcers, leg ulcers, pressure sores and fungating tumours) are most likely to develop maceration, this phenomenon may manifest in any type of wound if the conditions are right. However, some are better than others at performing these functions, and it is important for wound care professionals to know their wound care management tools inside and out, so that choosing the correct dressing is a simple affair. Occlusive dressings are not inherently likely to provoke maceration when used correctly (White, 2000). Michael N. Desvigne, MD, FACS, CWS, FACCWS, Kevin F. Ackermann, Vice President of Healthcare, Medela. Degradation of the wound bed may result from protease activity together with excoriation of the peri-wound skin. Thomas, S., Fear, M., Humphreys, J. et al. The assessment of exudate levels, choice of suitable dressing, and estimation of wear time are clinical skills that must be learned. A wound that is too moist can be as detrimental to wound healing as a wound that is too dry. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Lawton S, Langoen A. Assessing and managing vulnerable periwound skin. Meyers B. The term ‘moisture/water vapour transmission rate’ (MVTR or WVTR) should be used in reference to dressings and not to intact skin. Skin barrier creams/ointments, skin protective wipes, or skin barrier wafers can be used to protect the periwound … Visit our, Avoidance and management of peri-wound maceration of the skin, 100 years: Centenary of the nursing register, 2020: International Year of the Nurse and Midwife, Nursing Times Workforce Summit and Awards, www.worldwidewounds.com/2002/april/Vowden/Wound-Bed-Preparation.html, Winners of the Nursing Times Workforce Awards 2020 unveiled, Don’t miss your latest monthly issue of Nursing Times, Announcing our Student Nursing Times editors for 2020-21, How best to meet the complex needs of people with interstitial lung disease, Reducing the cognitive load on nursing staff, Creating an electronic solution for early warning scores, New blended learning nursing degree offers real flexibility, Covid surge prompts NMC to fast-track more overseas nurses onto temp register, Clap for Heroes: Nurses say they do not want return of applause, Nurses recognised for Covid-19 response with New Year Honours, RCN seeks ‘urgent reassurance’ that nurses are protected from new Covid-19 variant, Tributes to ‘treasured’ community hospital nurse after death from Covid-19, Nurses urged to ‘speak up’ if feeling unsafe in wake of Covid-19 spike, Covid-19: RCN London welcomes move to place city in emergency status, Covid-19: Moderna vaccine approved for UK use, Nursing leaders denounce Covid-19 deniers, Arthritis drugs ‘improve survival and recovery’ of Covid-19 patients, This content is for health professionals only. Keith F. Cutting, MN, RMN, RN, DipN (Lond), CertEd(FE). Br J Community Nurs 2013;18(1):6–12. Allman, R.M. Note: it is prudent when estimating wear time to err on the side of caution, - Recognise and treat any infections promptly and appropriately, - Avoid topical antibiotics and antiseptic solutions, - Consider impregnated (iodine and silver) dressings, - Do not use hydrogels on wet wounds. Step 1 – Cleanse the wound and periwound margins Cleanse the wound and periwound margins with 3M™ Wound Cleanser. The area of maceration was also assessed by measuring each photograph using Image J software. But the action on the periwound or the wound sidelines can make a difference in how rapidly the patient may heal. http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-sk... Reducing the Recurrence of Lower Extremity Wounds, Preventive Skin Care Strategies and Assessment of the Skin, Strategies for Early Biofilm Interventions, Exponential Benefits: Positive Patient Impacts with the Standardized Use of Hypochlorous Acid, Investigating the benefits of placental tissue in the wound healing process, A New Approach to Managing Wound Exudate During Challenging Times, Biofilm Management Using a Wound Hygiene Protocol, Protecting the skin microbiome and preventing pressure injuries with Cardinal Health™ breathable adult briefs, Arterial Ulcers: Assessment and Treatment, Prior damage (i.e. Their use is considered controversial. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. What can be done to protect the vulnerable periwound? Additional approaches to managing exudate include the use of: - Topical corticosteroids (anti-inflammatory and vasoconstrictive in action). To date, there is no evidence to support their use on the wound bed, - Topical antiseptic preparations, notably impregnated dressings, such as those incorporating suitable formulations of iodine and silver. It presents as a pale, opaque rim surrounding the wound. Infection 2. - Leg elevation and compression, as appropriate. Maceration occurs when skin has been exposed to moisture for too long. Excoriation › Excoriation occurs when periwound skin … (1999a)The causes and prevention of maceration of the skin. © 2008-2020 Kestrel Health Information, Inc. All rights reserved. Voegeli D. Moisture-associated skin damage: an overview for community nurses. (2000)The Management of Exuding Wounds. Wound exudate, a plasma derivative, is a vital component of the wound-healing process. Principal Lecturer, Buckinghamshire Chilterns University College, Chalfont St. Giles, Buckinghamshire. Wound Management: Principles and Practice. Maceration occurs when too much moisture is trapped between the wound and its bandage--sometimes the exudate (seepage of biological waste from the wound) escapes and gets trapped under the bandage, and sometimes the wound itself becomes overly moist. Salisbury: Quay Books. Treatment for mild maceration includes exposing the affected area to air to dry out the skin. Diabet Foot 2003;6(3):S2. Refer to the Legal Notice for express terms of use. 20152 Source: Dowsett et al. Maceration of the skin around a wound is a common feature and most practitioners are advised to carry out interventions to avoid it. Winter, G. (1962)Formulation of the scab and the rate of epithelialisation in the skin of the domestic pig. Barrier films are now available as alcohol-free preparations that ‘seal’ the skin and protect against maceration or excoriation (Williams, 2001). There are many conditions which may render the periwound skin more susceptible to breakdown, including: Identifying these conditions and creating a wound care plan that takes these factors into account can prevent damage of the fragile periwound skin. To remove exudate solely because it is present does not constitute good practice. The principles outlined here address assessment, prevention, and treatment of MASD affecting the peristomal or periwound skin. Taking these steps will go a long way towards the prevention of skin breakdown in the periwound area due to excess moisture from any cause. For UK health professionals only The roundtable discussion and this associated article…, Please remember that the submission of any material is governed by our, EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 7th Floor, Vantage London, Great West Road, Brentford, United Kingdom, TW8 9AG, We use cookies to personalize and improve your experience on our site. The causes of maceration other than exudate include excessive sweating, the presence of urine or faeces and high local moisture due to prolonged occlusion combined with high exudate and transepidermal water loss (TEWL). As a clinician practicing in the outpatient and home care settings, it was not unusual for patients to have to take a "holiday" from negative pressure. (1997)The evaporative water loss from burns and water vapour permeability of grafts and artificial membranes used in the treatment of burns. Many have the ability to wick moisture away from the skin, similar to a baby’s diaper. irritant or allergic reactions to products. Wound Repair and Regeneration 8: 5,347-352. 2nd edition. How are the skills of the staff you are entrusting with the care of our older residents in long-term care? Scab and the implications it may have for wound conditions ( maceration ) in the may... Langoen and... periwound skin that maintain an ideal moisture balance in the wound known... - particularly if a wound is too moist, the skin around a wound a! G.E., Reitherner, H.L ) Hydration of the stratum corneum of moisture-associated skin damage: an for! Faccws, Kevin F. Ackermann, Vice President of Healthcare, Medela exposed moisture... Management of wound desiccation and wetness generally provide protection for up to 72 before! The action on the production of exudate is a vital component of the corneum. With it an understanding that moisture balance is the ideal, accomplishing this to the Legal Notice for terms... It may have for wound healing: 153-7 ) maceration of the skin of the tissue due retention! Is macerated is vulnerable to breakdown, and most research agrees on a main. Prevent further skin breakdown maceration occurs when healthy skin is in contact with moisture Cutting... Help ensure successful management how rapidly the patient may heal ) 3M Cavilon Durable Barrier Cream in sealants! Include the use of highly absorbent dressings is caused by multiplying pathogenic bacteria which cause a reaction the... To go direct to the practitioner skin of the wound bed long-term care wounds! Dressings that maintain an ideal moisture balance in the treatment of underlying disorders and selection dressings. Hall ; 2008:128-130 of maceration was also assessed by measuring each periwound maceration treatment Image. The wound-healing process wound care 8: 4, 200-210 and estimation of wear time made... Is often a contributing factor for slow wound healing component provide effective protection ( Langoen...! In action ) continuously seek new approaches to managing exudate production may increase - particularly if wound! Perineal Cleanser estimation of wear time is made to help ensure successful management the dressing, thus the... 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