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Words on Wounds
A forum to discuss the latest news and ideas in skin and wound care.
Wednesday, January 22, 2014
Blisters are common across all ages. In general, blisters are formed in areas where friction is a problem, such as tight footwear rubbing against the feet. A Stage II pressure ulcer can present itself as a blister. Blistering is also a predominant clinical sign for certain autoimmune skin diseases, such as pemphigoid and pemphigus. There is no consensus for the management of blisters. We conducted a recent quick poll on our website asking you whether blisters should be deroofed or removed. The majority of respondents voted in favor of leaving the blisters intact. I think the answer to whether to pop the blister or not will depend on a few factors: 1. Location: For areas such as the ankle, wrist, and elbow, where the blister may impair mobility or range of motion, it may be wise to drain the blister and use an atraumatic dressing to cover the area. 2. Stability of the blister: If the blister is large and protected by very fragile skin, it may be beneficial to manually drain the blister in a clean and controlled environment to minimize contamination of underlying tissue if the blister were deroofed accidentally. 3. Content of the blister: We usually recommend not to remove blisters that are clear and filled with serous fluid. However, pus and blood can be irritating to underlying tissue and may warrant prompt evacuation. 4. Pain: Blisters that are painful may also benefit from manual evacuation. To evacuate a blister, you can use a sterile needle or lancet to puncture the epidermis without damaging the dermal layer. Manual expression may be required to drain the fluid. Keep the skin flap to cover the dermis and consider an atraumatic dressing for protection.

Monday, October 21, 2013

It has been demonstrated that when bacterial growth reaches a critical threshold of 105 bacteria per gram of tissue, bacterial toxins can cause tissue damage in the superficial wound compartment, delaying healing. This phenomenon is referred in the literature as critical colonization, increased bacterial burden, covert infection, or localized infection. It is estimated that half of chronic wounds exhibit signs that are consistent with local infection, which is often caused by biofilm that is defined as a community of microorganisms living in an extra cellular polysaccharide matrix and attached to a substrate or surface. The prevailing opinion supports the notion that biofilm may be one of the primary causes for wounds that do not progress to complete healing. There are ways to remove biofilms. Sharp debridement is effective in physically removing and disrupting the biofilm structure rendering bacteria more susceptible to antimicrobial treatment. It has been demonstrated that biofilm and bacterial count can be significantly reduced after wound debridement. The recent Quick Poll questioned on this website asked readers’ opinion whether biofilm would reform in 24 hours. Indeed, there is evidence that if the wound is left without any treatment of topical antimicrobial agents after debridement, the biofilm can be reformed within 24-48 hours. The questions are:

• Does early use of antimicrobial agents could prevent biofilm from forming?

• If biofilm is ubiquitous in wounds, how often should antimicrobial dressings be used to promote healing?

• What kind of antimicrobial dressings should be used to treat biofilm infection?

Further research is needed to provide answers to the questions. Feel free to share your thoughts and practice with your colleagues. We’d love to hear your feedback!


Wednesday, June 19, 2013

Wound cleansing has been part of routine wound care to remove surface debris, dried up exudate, and other proteinaceous materials that could trigger a pro-inflammatory response, promote bacteria growth, and impair normal wound healing. The need and technique for wound cleansing, however, has recently been challenged. Moore and Cowman1 reviewed randomized controlled trials that evaluated wound cleansing for pressure ulcers. Of all the randomized controlled trials reviewed, the authors did not find evidence to support the use of any particular wound cleansing solution or technique that promotes healing of pressure ulcers. Furthermore, there is evidence to dispute the notion that using nonsterile tap water could increase wound infection.2

 

Nonetheless, evidence should always be appraised critically and interpreted with caution considering the context in which evidence was developed. Before we adopt the use tap water for cleansing, we should question about the source of tap water, hygienic practice of the person with wounds, and other co-existing factors that put the person at risk for wound infection. Unless the underlying factors of pressure ulcers, including moisture, shear, friction, and nutrition, have been adequately addressed, routine cleansing of the wound is not likely to yield significant improvement in the healing. Based on results of the recent poll posted on this website, 90% of you believe that cleansing is needed, particularly for wounds that have deep sinus and undermining. However, irrigation of wounds with tunnels should be done with caution. It is important to ensure that the irrigation solution is retrieved by gently expressed the areas with undermining. Otherwise, excess residual fluid left in wound may spill over to the periwound skin causing maceration and potentially promote bacteria growth.

 

References

1. Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev 2013;3:CD004983.

2. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev 2012 Feb 15;2:CD003861.


Monday, May 13, 2013
Share your skin and wound care questions or challenges with ASWC. Give us your comments and we’ll respond! 

Thursday, February 21, 2013

Pressure ulcers (PrUs) are a significant problem across the continuum of healthcare settings. In 2009, the overall prevalence was 12.3% (N = 92,408) in the United States, according to a national survey. The burden of PrUs is significant; the average cost associated with the treatment of deep PrUs and related complications is $129,248 in acute care. In a number of reviews, support surfaces (eg, medical-grade sheepskin, high-specification foam mattresses) have been recognized as reducing the incidence of PrUs. The majority of specialty surfaces are expensive and evidence to support PrU prevention is scarce.

     Increasing attention has been drawn to the role of using silicone foam dressings to prevent PrUs. It is hypothesized that the multilayer material inside the foam dressing will help minimize shear as the dressing materials slide against each other, reduce friction at the interface between the skin and the support surface, and protect the skin from mechanical damage. The other potential advantage is the ability of breathable foam dressings to minimize heat and moisture accumulation that tends to render the skin more vulnerable to pressure damage. So, can foam dressings prevent PrUs? In the current Quick Poll found on this website, 40% of the respondents to date answered “yes.” A number of new studies indicate that the incidence of PrUs is reduced by the introduction of silicone foam dressings in critical care settings. However, more evidence is needed to confirm the efficacy of using a dressing to prevent PrUs.

     It is important to remember that the extent and severity of tissue injury is dependent on a number of intrinsic factors that predispose individuals to the development of PrUs. Some of these key factors are poor nutritional intake, low body mass index (<18.5), hypoproteinemia, low systolic blood pressure, anemia, contractures and prominent bony prominences, vascular disease, neuropathy, and uncontrolled diabetes. Selection of support surfaces, dressings, or any interventions should be individualized, taking into consideration the risk of tissue tolerance to injury. Clinicians must not forget the primacy of frequent repositioning and meticulous nursing care.

About the Author

Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA
Kevin Y. Woo, PhD, RN, ACNP, GNC(C), FAPWCA, is Director of Nursing/Wound Care Specialist, Villa Colombo, Homes for the Aged, Inc, Toronto, Ontario, Canada; Wound Care Consultant, West Park Healthcare Centre, Toronto; Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; and Associate Director, Interprofessional International Wound Care Course, MScCH program, University of Toronto.