Words on Wounds

A forum to discuss the latest news and ideas in skin and wound care.

Tuesday, January 16, 2018

Cyanoacrylates have been used in medicine for decades to approximate the edges of incisional wounds, skin tears, and simple traumatic lacerations; they are an alternative to sutures, staples, and sterile strips to achieve closure by primary intention. But what are cyanoacrylates?

Cyanoacrylates are a distinct class of acrylate polymer derivatives; the commonly used cyanoacrylate monomers are n-butyl or 2-octyl cyanoacrylate, or a blend of the 2 monomer types. These materials are alkyl esters of cyanoacrylates, with an extra cyano (-CN) group attached to the acrylate portion of the molecule. This cyano chemical group portion of the monomer renders these compounds very sensitive to polymerization initiated by moisture on skin, resulting in the formation of a flexible yet tough film very quickly (within seconds) on the skin. Cyanoacrylates also infiltrate into the tiny openings on porous or fibrous surfaces to form a secure anchor below the surface. Over time, the cyanoacrylate film barrier is then shed naturally from the skin surface as the stratum corneum sloughs off.​

Butyl cyanoacrylates polymerize faster but they are also more rigid and brittle (easy to crack). This problem can be mitigated by adding the stronger and more flexible 2-octyl cyanoacrylate monomers. Together, the cyanoacrylate monomers form covalent (permanent) bonds with the molecules in the skin as opposed to being deposited as a polymer film, and form a more durable and pliable protective layer when compared with traditional hexamethylene disiloxane (a silicone based solvent) or alcohol-based polymer skin protectants. 

Providers often apply cyanoacrylate to edges of negative pressure wound therapy dressings to promote and maintain a secure seal, especially areas with skin colds and movements. For certain types of skin tears, they also use cyanoacrylate to stabilize a skin flap once it is re-approximated.​ Other than the exothermic polymerization reaction that is associated with a mild warm sensation on the skin, there are few common adverse reactions.

Tuesday, August 22, 2017

​Prevention and treatment of pressure injury is a standard benchmark for quality of care, performance, risk reduction, and patient safety. While a plethora of advanced dressings are designed to promote moist wound healing, the relative effectiveness of various wound dressings or topical treatments for pressure injuries is undetermined. 

Foam dressings occupy the largest share of the topical wound therapy market. According to data from a local regional hospital, over 51% of the advanced wound care expenditure was on foam dressings. Foam dressings are recommended for treatment of pressure injuries by the National Pressure Ulcer Advisory Panel (NPUAP) and skin tears by the International Skin Tear Advisory Panel (ISTAP).​Increasing attention has been drawn to the role of soft silicone foam composite dressings. Foam dressings are designed to wick away a large volume of exudate with minimal lateral movement to prevent periwound skin maceration; this renders foam dressings a popular choice for the treatment of chronic wounds with high to moderate amounts of exudate. In addition, multi-layer foam dressings may alleviate pressure and minimize shear as the dressing materials slide against each other. Multi-layer foam dressings also may be more effective in minimizing shear because the dressing materials slide against each other, reducing friction and shear at the interface between the skin and the support surface, thereby protecting the wounded area from further mechanical damage. The other potential advantage is the ability of a breathable foam dressing to minimize heat and moisture accumulation.

Although there are a number of new studies indicating that pressure injury incidence is reduced by the introduction of silicone foam composite dressings in critical care settings, little is known about whether foam dressings are superior than other dressing materials for the treatment of chronic wounds. More evidence is needed to confirm the efficacy of using a dressing to treat pressure injuries and it appears, at least at this point in time, that the evidence may not be directly transferable between products because of variations in design and components. 

Tuesday, July 18, 2017

The term "moisture-associated skin damage" (MASD) delineates a spectrum of skin damages characterized by the inflammation and erosion (or denudation) of the dermis resulting from prolonged exposure to various sources of moisture and potential irritants. Incontinence-associated dermatitis (IAD) is a more specific condition that develops from exposure of skin to urine and/or stool.  Excess moisture from incontinence, sweating, and wound exudation can cause skin maceration, weakening the connections between epidermal cells and collagen fibers. The interruption of normal barrier function increases skin permeability to irritants and pressure damages.  Evidence to date suggests that extremes of skin temperature and/or humidity and skin moisture appear to increase the sensitivity of skin to the damaging effects of pressure, shear stresses, and friction. In addition, the alteration of skin pH and proteolytic activities for activated fecal enzymes can precipitate skin inflammation. Incontinence-associated dermatitis is recognized by skin erosion, edema, scaling, papules, or bullae containing serous exudate with accompanying pruritus, burning, or pain.  

How is IAD evaluated? A group of researchers led by Dr Dimitir Beeckman from Belgium and Dr Jan Kottner from Germany had developed a Ghent Global IAD Categorization tool (GLOBIAD). The tool is very simple to use.  First, the damaged skin is assessed to determine whether persistent redness or skin loss is present.  Next, clinical infection or intertrigo are evaluated based on a cluster of signs and symptoms.  As such, the IAD will be classified into 4 categories: persistent redness without clinical signs of infection, persistent redness with clinical signs of infection, skin loss without clinical signs of infection, persistent redness with clinical signs of infection. You can visit their website (www.SKITGhent.com) to obtain the actual tool and all IAD and pressure injury-related reports/publications.  I am sure that the project team would love to hear about your stories about IAD.

 Why do we need tools like GLOBIAD to describe IAD?

In order to prevent and manage IAD, there is a need to use the same language to communicate assessment findings among clinicians.  Incontinence-associated dermatitis tools will help raise awareness and standardize documentation for clinical coding.  Finally, researchers will benefit from validated tools to design studies that evaluate interventions to prevent or mitigate IAD.

Wednesday, April 12, 2017

The most recent National Pressure Ulcer Advisory Panel (NPUAP) update in 2016 introduced the term pressure injury to replace pressure ulcer.   According to the NPUAP, "a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities and condition of the soft tissue." (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages)

Since its inception, the new terminology has sparked impassioned discussion within the practice communities.  In our recent Quick Poll on this journal's website, we asked whether readers had espoused the term pressure injury in practice and only half of the respondents indicated in the affirmative.

There are polarized but not irreconcilable perspectives on whether the term "injury" should or should not be used.  According to the Merriam-Webster Dictionary, injury is defined as:  (1) an act that damages or hurts; or (2) violation of another's rights for which the law allows an action to recover damages.  Injury can be sustained either by accident or intention; obvious characteristics that will vary include permanence or transience; potential for grievous harm or not.  Even if the injury was caused by negligence or breach of duty, the responsible party is liable for payment of damages for the harm caused.

In keeping with the definition, pressure injury connotes damage to tissue due to pressure, but whether the injury is a direct result of an action or lack thereof is debatable.  Skin failure and changes at life's end may not be amendable to actions that are normally considered effective for the prevention of skin injuries due to significant physiological changes that accompany multisystem failure and circulation collapse.

The NPUAP points out that injury is a common term used to refer to several health conditions and medical diagnoses, such as acute brain injury, and it does not connote or assign blame.  Proponents for the use of pressure injury also highlight the added clarity and precision that the new terminology offers to the description of a Stage 1 pressure injury, which refers to intact skin with nonblanchable redness of a localized area usually over a bony prominence.  Calling this type of skin injury as ulcer is misleading. Besides, deep tissue injury is a term that is already well accepted and recognized.  Perhaps we should use injury for skin damages associated with moisture, venous insufficiency, arterial disease, and diabetes foot complications.

Thursday, February 2, 2017

Peripheral artery disease (PAD) is a common and disabling health condition affecting 20% of people over age 75. This disease is primarily caused by atherosclerotic changes in the arteries limiting normal blood flow to the lower extremities. As the disease progresses, insufficient oxygen and nutrients to the tissue can result in complications such as chronic leg pain, skin ulceration, gangrene, and eventually amputation. One of the most common and earliest manifestations of PAD is intermittent claudication; described as pain in a lower extremity muscle group (such as the buttock, thigh, and calf) that is elicited by exertion and relieved within a few minutes of rest.  Over time, pain may be elicited by minor exertion and become more frequent even at rest. There is evidence that two-thirds of people with mixed venous arterial leg ulcers experience moderate to severe pain daily.  As such, people with PAD are more likely to experience a loss of autonomy, disability, work impairment, emotional distress, and poor quality of life compared with individuals without PAD.

Ischemic pain is complex and caused by a multitude of mechanisms, including the lack of oxygen, accumulation of metabolic waste, reperfusion injuries, inflammation, nerve damage, vasospasm, trauma, and anxiety.  However, ischemic PAD is underrecognized, underdiagnosed, and therefore, undertreated.  Routine use of opiates could cause many adverse effects (such as drowsiness and confusion), but do not always provide adequate pain relieve. Although we recognize a need for a holistic approach to address ischemic pain, none of the existing guidelines addresses best practice for ischemic pain. This is an area that will benefit from interprofessional collaboration involving specialists in pain management, psychology, rehabilitation science, vascular medicine, and palliative care.