Identifying and Managing Skin Issues with Lower-Limb Prosthetic Use

Identifying and Managing Skin Issues With Lower-Limb Prosthetic Use

by M. Jason Highsmith, DPT, CP, FAAOP, sive tension, friction or heat. James T. Highsmith, MD, and Jason T. Additionally, the skin reacts Kahle, CPO to increased temperature with perspiration, which is unable Fitting a prosthesis is complicated to evaporate because of the because parts of the human body are closed prosthetic environ- used for tasks for which they are not ment. This results in more designed. The skin/prosthesis interface heat and moisture softening is at fault for many complications. Here, the skin, thereby disrupting a synthetic material, such as silicone or normal integrity (maceration). plastic, is in constant contact with the Figure 2. Allergic contact dermatitis skin. Skin is not well-suited for this type Pressure is another mechanical issue introduced in a prosthetic users. Either of these can occur when the socket. Certain parts of the skin is exposed to a material that creates human anatomy are well- a skin aggravation. If a known irritant suited to disperse pressure, or allergic component exists in the such as the fat pad of the patient’s prosthesis, it should be switched heel. With amputation, the to another material. Furthermore, both normal pressure-distributing conditions can be treated with topical anatomy is missing or steroids or a barrier cream. Several altered. Therefore your pros- over-the-counter (OTC) topical prepara- thetist must use anatomic tions are available for these conditions, areas not well-suited for such as hydrocortisone and zinc oxide. weight-bearing pressures. Figure 1. Bony prominences with decubiti Untreated, dermatitis can lead to chronic (pressure sores) Improper socket fit can inflammation, cellular damage and carci- increase pressure and accel- nogenesis (cancer). Therefore, we urge all of material contact. Skin problems are erate skin breakdown. Pressure sores one of the most common conditions can often be corrected with affecting lower-limb prosthetic users minor prosthetic adjust- today. Skin problems are experienced by ments. However, sometimes approximately 75 percent of amputees pressure areas can be more using a lower-limb prosthesis. In fact, significant and require amputees experience nearly 65 percent recovery time out of the more dermatological complaints than the prosthesis and/or a complete general population. new socket fit.

Abnormal mechanical and thermal Irritant contact dermatitis conditions are introduced in a prosthesis, and allergic contact derma- Figure 3. Irritant contact dermatitis with exco- such as socket contact against the skin. titis are two more common riation (excessive scratching which breaks the This can traumatize tissue by exces- problems affecting prosthetic surface of the skin – circled)

Contact the Amputee Coalition at 888/267-5669 or amputee-coalition.org 41 prosthetic users to see a physician when specialist (see ﬂow diagram). breakdown can lead to more severe prob- they have failed conservative therapy lems, such as infection, cancer, osteo- or have a lesion that won’t heal. It is Skin issues are very common among myelitis (bone infection), and ultimately imperative that these lesions are evalu- amputees. Because amputees require an revision surgery. Start with your prosthe- ated so that various forms of cancer can unusually high demand from their skin, tist to determine, and hopefully resolve, be ruled out. and because not wearing a prostheses the problem. If your prosthetist cannot is often not an option, they sometimes ﬁnd a solution, you may need to consult Avoiding skin complications begins with dismiss the importance of hygiene and a specialist, such as a dermatologist. good hygiene and daily skin inspections. monitoring of their skin. Skin issues Photos provided by James Highsmith, Jason Clean all parts of your prosthesis daily need to be taken seriously. A simple skin Highsmith and Jason Kahle that contact your skin. The reverse is also true: Inspect and clean all parts of your skin daily that contact your prosthesis. Don’t rely on feeling a problem as your primary means of detecting skin problems. Many patients are desensitized and can’t feel damage to the skin. The best inspections make use of a mirror or a spouse who can view all aspects of your limb. Every amputee’s needs are unique, so discuss your inspection needs with your provider.

If you encounter a skin problem that you are unable to resolve or that will not heal, then the ﬁrst step is to see your prosthetist. The prosthetist can then determine if the problem can be resolved pros- thetically or through other conservative means. If not, the prosthetist may refer you to your primary care physician or a Photo Diagnosis History [Signs/Symptoms] Physical Exam Findings Acute Management Long-Term Management (Name) Figure 1 Pressure sores Pain and/or redness over bony prominences Erythema (redness) or ulceration over x Stop using prosthesis x Prosthetic adjustment (Decubitus ulcers) bony prominences x Antibiotic ointment (e.g., Polysporin*) x New socket Figure 2 Allergic Contact x First exposure causes no reaction (type IV x Acutely, may have well-demarcated x Moisturizer Allergen avoidance Dermatitis delayed hypersensitivity reaction) erythema, weeping or blisters x Topical steroids (e.g., hydrocortisone) (substitute allergen for x Itching and redness appears 1-5 days after x Subacutely, erythema, less well-demar- materials that do not aggravate second exposure and affects everywhere the cated, maybe scaly skin symptoms) allergen contacts the skin x Chronically, erythema and dry, thick, x May extend beyond allergen contact areas scaly skin if severe Figure 3 Irritant Contact x Itching and redness typically appear immedi- Same as allergic contact dermatitis x Barrier cream [zinc oxide] Avoid or minimize irritant Dermatitis ately after contact (even with first exposure) x Moisturizer exposure (e.g., perspiration from x Severity related to duration & amount of x Topical steroids heat or friction) exposure x Never extends beyond contact area Figure 4 Negative Pressure x Negative pressure socket, pain and erythema Well-demarcated erythema that is exqui- x Stop using prosthesis x Correct underlying problems: Hyperemia under prosthesis in a well-circumscribed sitely tender to palpation x Moisturizer x Curb weight gain (diet/ pattern exercise) x Usually a history of limb volume change (i.e., x Treat edema weight gain/loss, edema) x New socket? Figure 5 Folliculitis Itching, possibly pain, “pimple” (properly termed x Direct visualization of folliculocentric x Decrease heat and friction (remove Avoid shaving area (increases pustule) pustule prosthesis if possible) incidence) x Typically with erythema x Topical or systemic antibiotics Figure 6 Abscess Inflammation with erythema and severe pain Visualization of erythematous nodule that Incision and drainage absolutely x Keep area clean is exquisitely painful necessary by physician, may also need x Avoid shaving affected area systemic antibiotics Figure 7 Xerosis Dry skin, may have erythema and/or itching Dry scaly or flaky skin, may have excoria- Moisturizers (over-the-counter) x Keep area clean tions or erythema x Maintain hydration (systemi- cally and locally) * Polysporin® is recommended over Neosporin® due to a high incidence of allergic contact dermatitis. Consult your dermatologist for more information.

42 inMotion Volume 21, Issue 1 January/February 2011 Figure 4. Negative pressure hyperemia in an above-knee limb

Figure 5. Folliculitis

Figure 6. Infected abscess on a below-knee residual limb

Figure 7. Xerosis

Contact the Amputee Coalition at 888/267-5669 or amputee-coalition.org 43