Physical data indicated that although hair color was not associated with reported skin problems, the effect of sun exposure and type of skin did correlate. Those who self-reported a Fitzpatrick type I also reported significantly greater incidence of offensive odor from the liner (p = 0.0480) than others. Subjects with medium or dark skin reported excessive sweating (p = 0.0238) and skin itching (p = 0.0262) significantly more often.
Limb data results indicated that significantly more subjects who shaved their limb complained of excessive sweating than those who did not shave (p = 0.0473). The type of soap used to clean the limb (antibacterial, deodorant, with or without perfumes, or no soap) made no significant difference; however, those who washed their limb more frequently did report red skin significantly more often (p = 0.0496) than others. Those who washed their limb at varying times throughout the day had more complaints of allergic reaction (p = 0.0095), heat rash (p = 0.05), and excessive sweating (p = 0.0247) than others, whereas those who washed their limb in the morning reported less problems with excessive sweating (p = 0.0014) and offensive odor from the liner (p = 0.0117) than others.
Prosthesis data were compared with skin problems. No significant differences were found in reported skin problems based on the frequency of liner cleaning, liner cleanser, brand or thickness, time since fitted with a liner, or whether a pin was used for suspension. Those who used nothing between their skin and the liner reported significantly more problems with offensive odor from the liner than those who used something (p = 0.0012). However, when the use of something is compared with nothing, each group reported the same (p = 1.0000) prevalence of allergic reaction, ingrown hair, open sore, excessive sweating, and red skin. Prosthesis habits, such as sock ply thickness and prosthetic wearing time made no significant difference for reported skin problems, but activity level did. Results indicated that those who have higher activity levels reported significantly greater incidence of ingrown hair (p = 0.0335) and skin itching (p = 0.0425) than those with lower activity levels.
All subjects who received a physical exam with the dermatologist indicated a history of at least one skin problem. The most common skin problems were ulcer or erosion (52.7%), irritant or frictional dermatitis (34.78%), and folliculitis (30.43%). Approximately 22% of subjects presented at the dermatological exam without any skin problems (Table 6). However, the remaining subjects were diagnosed by the dermatologist with the following skin problems: lichenification (30.43%), irritant or friction dermatitis (26.09%), folliculitis (17.39%), ulcer or erosion (8.70%), hyperpigmentation (8.70%), and other (8.70%).
Reliability and validity testing were completed to compare the data self-reported by the subject on the survey and that reported to or assessed by the dermatologist during the exam. No significant difference was found between the survey and exam for the amputation cause (p = 0.5000) or hair color (p = 0.1000), which were each self-reported by the subject on the survey and during the exam. This indicates that the survey is reliable. Validity testing compared the subject’s self-reported data on the survey to the dermatologist-assessed data for the Fitzpatrick skin type and the untanned skin color of the upper inner arm. No significant difference was found between data (p = 0.0894 and p = 0.5318, respectively). Therefore, the data on the survey was considered valid.
Approximately 91% of subjects reported that they had experienced a skin problem while using the roll-on liner with their prosthesis. Excessive sweating, skin itching, and red skin were the most common skin complaints. This is similar to the results of Hachisuka et al.5 who found that 60.2% of the subjects reported itching, 47% reported excessive perspiration, and 43.4% reported an offensive odor from the liner. Although Lyon et al.6 found that only 34% of subjects had skin problems, their study included lower limb, upper limb, and two limb amputees, which may lower the percentage.
Similar to previous studies, race and gender did not have significant affect on reported skin problems.4,5,7 However in this study, it was found that high cholesterol was associated with an increased reporting of heat rash and red skin. The explanation of this is uncertain. All of these subjects wore their prosthesis a minimum of 3 hours per day, with the majority wearing it greater than 12 hours per day. This group has an even distribution of skin type, cause of amputation, and so forth. It is uncertain whether these subjects take a similar medicine whose side-effect may cause this presentation. No significant differences were found for reported skin problems between those with vascular disease and/or diabetes-related amputations. Therefore, these two groups were combined for further comparison. Similar to previous results, the data from this study indicated that the diabetic vascular group had significantly less complaints of excessive sweating than the remaining subjects, which were mostly traumatic.4,5,7 The dysvascular population has a decreased production of sweat due to neuropathy causing a lack of sympathetic release of sweat. Neuropathy also causes decreased sensation, making it more difficult to feel the sweat.
Results from limb data had indicated that those who washed their limb more frequently or shaved had more complaints of specific skin problems. The complaint of excessive sweating with those who shaved their limb is more likely due to the ability to feel the sweat than the amount of sweat produced. Increased frequency of limb washing was associated with red skin. Clinically washing more frequently adds friction and rubbing irritation and dryness to the skin that may lead to the redness observed by subjects. An increase in skin problems was associated with a variance in the time of day that the limb was washed, while it was significantly lower in the group who washed in the morning. Perhaps the frequency or variation in washing is a result of limb problems rather than vice versa.
The prosthesis and liner directly interface with the amputee’s limb, so it is reasonable to assume that the use, fit, and care of such an item may directly affect the skin. Although a majority of the subjects cleaned their liner once per day, as recommended by their prosthetist and the manufacturer, there was no significant difference in incidence of skin problems based on the frequency of cleaning the liner or the type of soap used. More interestingly, the results indicated that those subjects utilizing nothing between their skin and the liner had more complaints of an offensive odor versus those who used something. Similarly, Lake and Supan4 found an incidence of contact dermatitis as follows: 10% with use of a sheath, 18% with use of nothing, and 50% with use of powder. There was also found to be no difference between those who used something versus nothing with regards to the incidence of ingrown hair, open sore, excessive sweating, and red skin. This is interesting because manufacturers recommend that nothing should be used between the skin and liner. In our clinical experience, a sheath or liner for a liner (Knit Rite, Kansas City, Kansas) can resolve problems of red skin, contact dermatitis, or excessive sweating when used underneath the liner. Although no significant difference (p = 0.0630) was found for skin problems based on sock ply thickness, there is a trend toward those with less sock ply reporting less skin problems. This is reasonable since sock ply indicates the goodness of fit of the prosthesis and possibly the liner. Similarly, no difference was found among liner brands, type of suspension, or liner thickness. It seems that the fit of the prosthesis may be more important than the type of liner.
As expected, the reporting of higher activity levels corresponded to a greater prevalence of ingrown hair and itching skin. It is logical that an increase in activity may cause an increase in body temperature and subsequent mineral or sweat production. This sweat, when held against the skin within the occlusive environment of the liner, may lead to itching skin. Hachisuka et al.5 also found an increase in itching with an increase in activity level and an increase in perspiration with an increased wearing time. However, they also found that these problems decreased after time; a similar trend was not found in this study.
Skin type significantly affected reported skin problems in this study. It was found that those with the most sensitive skin, Fitzpatrick Type I, complained more often about an offensive odor from the liner. The cause of this is unclear. Perhaps these subjects were also utilizing other products, such as lotions, to care for their limb, which may react to the liner. Results also indicated that those with medium or dark skin reported excessive sweating and skin itching more often than those with fair skin. This may be due the medium or dark skin having more oil on it, which when held in the occlusive liner environment leads to excessive sweat and itching.
Although no statistical comparisons were possible for the dermatological exam data, due to the small number of participants, it was determined that irritant or frictional dermatitis, lichenification, and hyperpigmentation were the most commonly diagnosed problems. It is interesting, that unlike previous studies, no epidermal inclusion cysts were observed.1,2,7 This may be due to the use of a rounded posterior aspect of the total surface bearing socket design versus the posterior “wall” concept of the patellar tendon bearing socket design. Subjects commonly presented in clinic with either irritant or frictional dermatitis (Figure 1) or folliculitis (Figure 2) of the entire limb that was contained under the liner. There is a clear demarcation on the skin, corresponding to the proximal edge of the liner where the skin switches from occlusion within the liner to exposure outside of the liner. Many subjects also presented with lichenification (Figure 3) of the distal end. Lichenification is a thickening of the skin resulting in a callous-like formation.
The authors acknowledge and accept that this study may have limits in its direct clinical application. The accuracy of the subject’s self-diagnosis on the survey is uncertain, as is the temporal timeline for reported skin problems. This makes it impossible to conclude a direct cause-effect relationship between demographic or habit data and skin problems, and thereby limits the clinical applicability of this information. Similarly, the small sample size of the dermatological exam made statistical analysis impossible. It is likely that this small sample size was due to great distances that had to be traveled by participants during a time with high gasoline prices and a lack of reimbursement for this participation. Therefore, a future study that prospectively exams the habits and resultant dermatological problems of new amputees on a regular basis for several years is recommended.
This study used a questionnaire and a skin exam with a dermatologist to examine types of skin problems reported and possible causes in transtibial amputee subjects who use a roll-on liner. Prevalence of various dermatological problems was determined and conclusions of possible problems drawn. Data compared between the questionnaire and dermatological examination were determined to be valid and reliable. It is apparent that a greater number of transtibial amputees who use a roll-on liner have dermatological problems than previously suspected or reported.
The authors’ clinical impression is that liners are not perfect. People do have skin problems, no matter the cause of amputation. We would like to challenge the manufacturers, practitioners, and researchers to further evaluate liner problems and make appropriate changes to allow us to better understand what is happening and why, and to make patients’ lives better.
1. Levy SW. Skin problems of the leg amputee. Prosthet Orthot Int
2. Dudek NL, Marks MB, Marshall SC. Dermatologic conditions associated with use of a lower-extremity porsthesis. Arch Phys Med Rehabil
3. Cluitman J, Geboers M, Decker J, et al. Experiences with respect to the ICEROSS system for trans-tibial prostheses. Prosthet Orthot Int
4. Lake C, Supan TJ. The incidence of dermatological problems
in silicone suspension sleeve users. J Prosth Orthot
5. Hachisuka K, Nakamura T, Ohmine S, et al. Hygiene problems of residual limb and silicone liners in transtibial amputees wearing the total surface bearing socket. Arch Phys Med Rehabil
6. Lyon CC, Kulkarni J, Zimerson E, et al. Clinical review: skin disorders in amputees. J Am Acad Dermatol
7. Dudek NL, Marks MB, Marshal SC. Skin problems in an amputee clinic. Am J Phys Med Rehabil
Keywords:© 2008 American Academy of Orthotists & Prosthetists
transtibial amputee; roll-on liner; dermatological problems