Skin & Wound Management Under the Wraps Providing effective treatment and protection beneath compression bandaging is necessary to promote healing.

Matthew Livingston, BSN, RN, CWS, ACHRN

ound management for patients pustules around hair follicles, occurs and a drier skin surface dressing, such as living with venous insuffi- due to any type of trauma to the fol- cotton batting, will reduce the fungal ciency often involves multiple licle, such as pressure or friction, chemi- outbreak. Be aware that most rashes in W 1 complexities. These variations require cal irritation, or bacterial colonization. venous disease are from stasis dermatitis, providers to consider a spectrum of Milder forms of this skin condition are not candidiasis. strategies. Some require an advanced referred to as superficial folliculitis. This In its milder form, a latex allergy knowledge of skin conditions and dif- is considered self-limiting as long as the caused by compression wraps appears as ferential diagnosis while others are de- source of the injury is reduced. Painful, an itchy rash or hives over the major- pendent on “tricks of the trade” for deep folliculitis warrants a culture to ity of the lower extremity, or just above dressing changes and the understanding isolate the type of bacteria involved, and the knee (with possible systemic effects of different dressing modalities. treatment with systemic antibiotics.1 including puffy face and full-body rash). Fungal infections including candidia- The elastic component of the multilayer The ‘Skinny’ on Skin sis present as groups of small, red open compression dressing can be replaced Several dermatological conditions re- or closed pustules around the moist with a latex-free brand. Depending on sult from certain types of compression. edge or macerated wound. This is of- the severity of the rash, the provider may These include folliculitis, fungal infec- ten exacerbated by the use of moist or choose to prescribe antihistamines or tions, and contact allergies. occlusive dressings.DUPLICATE In this case, an anti- corticosteroids (such as methylpredniso- Folliculitis, which appears as inflamed fungal ointment or powder over the area lone) to mediate the latex reaction. If changing to a non-latex brand of com- An Approach to Addressing Slippage pression is ineffective in mediating the skin reaction, patch testing may be or- 1. Start by creating a tacky area (on healthy skin only) by using a thick barrier paste at the dered to rule out other causative agents. anterior aspect just below the knee. This step will greatly improve the chance of securing the dressing. Use caution when putting creams and ointments on these patients as Skin conditions related to chronic sensitivity reactions are common. venous insufficiency are also a concern. Stasis dermatitis presents as a rash with 2. Bolster the wicking and elastic layer of the multilayer compression wrap with tape running in an upward spiral to secure each of the horizontal wrap layers together. flaking skin and complaints of itching. Be careful not to form ridges that can lead to skin irritation. Skin may become thickened over time, a condition known as hyperkeratosis. This 3. Insure the dressing is hingedNOT around the posturer aspect of the upper calf (in the area that contours back into the break of the knee). Take care not to cause increased occurs due to the chronic inflammation compression here (LaPlace’s law). caused from venous insufficiency when white blood cells become trapped in the 4. Build several layers of rolled cotton (ie, web roll) around the lower third of the lower extremity to help limit slippage by reducing its lower inward angle. However, maintain larger sluggish flow through capillaries, be- circumference at the calf to maintain pressure gradient. come activated, and release pro-inflam- matory cytokines, which leads to chron- 5. Use a tacky foam, such as Rosidal Soft, which is used in lymphedema care. This can be ic inflammation and hypersensitivity to placed on the entire anterior tibia, ankle, and foot to pad, protect, and prevent slippage. DO products.2 This should be managed with 6. Apply 1 layer of paste bandage in a spiral fashion up the foot and leg. This will grip the medium potency corticosteroid oint- leg and prevent slippage, but will increase the cost of wrapping the patient. ments. Choose ointments that do not

24 November/December 2012 Today’s Wound Clinic® www.todayswoundclinic.com compressiontherapy

When Edema Remains Beyond Compression or starch copolymer-based dressings can There are times when, regardless of conservative compression techniques, the patient be cut to fit the wound under the foam still presents with unresolved edema. If the extremity as a whole remains swollen (with ad- for extra absorption. A new category of ditional redness, breakdown, or pain while using higher amounts of compression), rule out quick-wicking products (eg, Drawtex,® other causative etiologies such as fluid overload, deep vein thrombosis, or lymphedema. The TM compression dressing, moreover, may not meet the full needs of the patient, which could SteadMed, Fort Worth, TX; or Active include swelling of the toes, forefoot, and/or knees and require specific dressing suggestions: Fluid Management,® Milliken, Spar- tanburg, SC) may help prevent macera- • A certain population (usually related to lymphedema) presents with edematous knees and tion by moving exudate quickly into thighs above the compression wrap. In this case, the clinician may consider an elasticated TM the dressing away from the skin. Some- tubular bandage (Tubigrip, Mölnlycke Healthcare, Norcross, GA; or Medigrip, Medline, times, a contact layer and gauze 4 x 4 Mundelein, IL) or longitudinal yarn compression (EdemaWear,® Compression Dynamics LLC, Omaha, NE) from just below the top of the compression dressing to the top of the are enough to keep the wound moist thigh. To prevent a crossover of compression pressure between the 2 dressings, place a and absorb exudate. Avoid putting too strip of foam dressing under the top of the multilayer compression dressing. much bulk under compression wraps; this will decrease sub-bandage pressure • An edematous forefoot is typically the result of a compression dressing that has been by increasing limb size, thus leading to pushed up by mechanical means (often related to poor-fitting shoes or human interven- tion). Recommend that the patient wear shoes with larger toe space. Minimize use of increased exudate due to poor edema post-operative shoes as they negatively affect ankle mobility and the calf muscle pump. control. It is rare that venous ulcers re- If edema persists with an intact dressing, consider placing an extra turn of the compress- quire moisture-donating products such ing wrap along with a plain foam dressing over the top of the swollen foot area. as hydrogels. Avoid adhesive dressings due to high risk of contact sensitivity • Swollen toes may be controlled by inserting rolled cotton between each of the toes ac- companied by padding over and around the toes before wrapping the toes with a layer of in these patients. non-adhesive elastic. Lymphedema therapists have an excellent technique for wrapping • Odor related to long dressing wear toes. Collaborate with them to learn this method of toe compression. Caution must be (not infection) can be treated with used, however, because pressure ulcers can occur on the plantar surfaces of the toes a thorough washing of the skin and from the wraps, especially in patients with hammer or claw toe deformities. wound along with the use of an an- • The inferior medial and lateral malleolus often presents with wounds (in venous insuf- timicrobial wound cleanser. If odor ficiency patients) along with an area of uncontrolled edema. The low-set contour of remains, apply metronidazole gel with this area along with the protruding aspect of the medial malleolus often leads to the each wrap change. problem of being unable to adequately compress the area. To better control this problem • Skin cleansing should occur with each under compression, the clinician may build up 2 layers of a foam dressing cut to fit the compression wrap change. Use a gentle contoured area. soap, such as Cetaphil,® and, occasion- — Matthew Livingston, BSN, RN, CWS, ACHRN ally, for odor and ongoing folliculitis, DUPLICATEtemporary use of Hibiclens® is useful. have preservatives in them (eg, fluocin- frequent wrap changes. These scenarios olone ointment 0.025%) to minimize require the use of various dressing man- Maintaining the integrity of multi- risk of sensitivity reactions. Once skin agement strategies: layer compression dressings for patients is cleared up, discontinue the corticoste- • There is not conclusive evidence that with a large calf and small ankle circum- roid. No creams or ointments are used at the type of dressing used on venous ul- ference (also referred to as an inverted this point to avoid new hypersensitivity cers affects wound healing.3 Therefore, champagne bottle appearance) provides reactions. If skin is exceptionally dry, use practical aspects such as exudate man- a challenge for many clinicians. For of hypoallergenic dimethicone-based lo- agement and avoidance of peri-wound strategies to deal with this, consider the tions without fragrance may be tried. skin irritation should guide dressing steps noted in the table on page 25. n choices. Because venous ulcers, espe- Going The Distance NOTcially early in treatment as edema is Matthew Livingston may be reached at Compression wraps, which may re- reducing, may have substantial exudate, [email protected]. main intact for up to 7 days, pose an- use of absorbent dressings is essential. other problem as this length in time can Foams are ideal dressings in this case as REFERENCES increase the risk for maceration, odor, or they are absorptive and also provide lo- 1. Habif T. Clinical Dermatology: A Color Guide to Diagnosis and Treatment. 4th ed. Philadelphia: dressing slippage. The best solution for cal compression over the ulcer. For high Mosby; 2004. this is to change the wrap more often exudate, use foams that do not have film 2. Bergan JJ, et al. Chronic venous disease. N (every 3-5 days). Some patients may be backing so that drainage can wick out Engl J Med. 2006;355:488-498. unable to come into the clinic for more into the wrap. Trapping exudate in the 3. Palfreyman S, Nelson EA, Michaels JA. Dress- DO ings for venous leg ulcers: a systematic review frequent dressing changes or may have dressing can lead to further maceration and meta-analysis. BMJ. 2007;335:244-255. maceration or odor even with more of surrounding skin. Calcium alginates Erratum in BMJ. 2007;335:0.

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