Wounds and Skin issues Flashcards
Wounds in palliative care - most common site
- High prevalence of wounds in advanced illness
- Most commonly pressure ulcers in the sacral coccygeal area
- Other wounds include malignant wounds, ostomies, traumatic wounds, and venous leg ulcers
Location:
- Cancer patients: Abdomen or chest/breast
- Non cancer patients: Extremities (upper and lower)
Costs related to wounds
Physical symptoms
- Pain
- Exudate
- Odour
- Pruritis
- Bleeding
- Disfigurement
- Psychosocial burden
- Disability
- Reduced survival
Family and caregiver burden
Healthcare costs
Components of wound management
- Wound healing
- Not always feasible in palliative care due to incurable systemic/comorbid/iatrogenic factors
- Life expectancy may not be long enough to permit healing - Wound maintenance
- Prevention of wound-related complications ( sinuses, fistulae, osteomyelitis) - Wound palliation
- Wound prevention
- All patients with wounds are at greater risk of developing additional wounds
Pathophysiology of pressure ulcers
- Ischemic necrosis of skin and underlying tissues
- Occurs due to arterial, venous, and lymphatic stasis
Mechanical factors
- Prolonged, unrelieved pressure
- Repetitive shearing and friction forces may also contribute
- Bony prominences most susceptible
Risk factors for pressure ulcers
- Advanced age
- Comorbid disease burden
- Cachexia
- Neuropathy
- Paralysis
- PVD
Risk assessment tools for pressure ulcers
- Braden scale most widely accepted (most sensitive and specific with high inter-rater reliability)
- Braden often correlates to PPS
Classification of pressure ulcers
Stage I:
- Erythema, no open wound
- Often blanchable
Stage II:
- Skin is broken, shallow ulcer formation
- Wound bed is red-pink
Stage III:
- Sore becomes a crater
- Subcutaneous fat may be visible, but not bone, tendon or muscle
Stage IV:
- Deep sore with extensive damage eroding to muscle, bone, or tendon (visible or palpable)
Unstageable ulcers
- Depth of ulcer is completely obscured by slough or eschar (stage III or IV)
Model for wound healing
‘DIME’ acronym
Debridement and downloading
- Debridement of necrotic and non-viable tissue
- May be done at the bedside, or surgically if the wound is large or analgesia/hemostasis is not avhievable at the bedside
- May also be done with specific wound products that can promote autolytic debridement
- Pressure redistribution to treat and prevent ulcers
Infection and Inflammation
- Acute wounds typically colonized or contaminated with Gram positives
- Chronic wounds typically grow gran negatives and anaerobes
- Wounds may be in a state of ‘bacteria balance’ (contaminated/colonised) or ‘bacteria imbalance’ (replicating organisms are overwhelming host resistance
- Compartment infection and systemic infection can occur, leading to tissue destruction
- Infection may also lead to abscess formation, sinuses, fistulae, or osteomyelitis
- Hyperinflammatory state common in response to wound, including production of matrix metalloproteinases
- MMPs are toxic to dermal cells and epithelial cells - some dressings can bind and inactivate MMPs
- Control by debriding and/or using an antimicrobial dressing
Moisture Balance
- Wound exudates can be harmful (rich in bacterial toxins, pro-inflammatory mediators, products of tissue necrosis, MMPs)
- Can promote maceration of the wound bed and peri-wound tissues and promote an ideal growth medium for fungi, bacteria, and yeast
- Absorptive dressings can ensure moisture balance
- Some wounds that are non healable (e.g. malignant wounds or gangrene) should not be treated with a moist environment
Edge effects
- If the dermis/epithelium does not ‘edge inwards”, other therapies (e.g. hyperbaric oxygen therapy, growth factor therapy, skin grafting, or negative pressure wound therapy) is appropriate
- Negative pressure wound therapy and hyperbaric oxygen therapy are contraindicated in malignant wounds
Wound management: Debridement and downloading
Debridement and downloading
- Debridement of necrotic and non-viable tissue
- May be done at the bedside, or surgically if the wound is large or analgesia/hemostasis is not avhievable at the bedside
- May also be done with specific wound products that can promote autolytic debridement
- Pressure redistribution to treat and prevent ulcers
Wound management: Infection and inflammation
Infection and Inflammation
- Acute wounds typically colonized or contaminated with Gram positives
- Chronic wounds typically grow gran negatives and anaerobes
- Wounds may be in a state of ‘bacteria balance’ (contaminated/colonised) or ‘bacteria imbalance’ (replicating organisms are overwhelming host resistance
- Compartment infection and systemic infection can occur, leading to tissue destruction
- Infection may also lead to abscess formation, sinuses, fistulae, or osteomyelitis
- Hyperinflammatory state common in response to wound, including production of matrix metalloproteinases
- MMPs are toxic to dermal cells and epithelial cells - some dressings can bind and inactivate MMPs
- Control by debriding and/or using an antimicrobial dressing
Wound therapy: Moisture balance
Moisture Balance
- Wound exudates can be harmful (rich in bacterial toxins, pro-inflammatory mediators, products of tissue necrosis, MMPs)
- Can promote maceration of the wound bed and peri-wound tissues and promote an ideal growth medium for fungi, bacteria, and yeast
- Absorptive dressings can ensure moisture balance
- Some wounds that are non healable (e.g. malignant wounds or gangrene) should not be treated with a moist environment
Wound therapy: Edge effects
Edge effects
- If the dermis/epithelium does not ‘edge inwards”, other therapies (e.g. hyperbaric oxygen therapy, growth factor therapy, skin grafting, or negative pressure wound therapy) is appropriate
- Negative pressure wound therapy and hyperbaric oxygen therapy are contraindicated in malignant wounds
Examples of absorbant wound management products
Foam
- Topical analgesic
Hydrofibre (aquacel)
- Topical antimicrobial
Alginate
- Topical hemostatic
Alginate with ethylene-methyl-acrylate contact layer
- Topical antimicrobial and non-adherent
Cellulose pulp with polyprobylene contact layer
- Non-adherent and protects clothing
Textile with silver complex
- Skinfold management to treat and prevent moisture lesions
Examples of hydrating agents for wound management
Hydrocolloid
- Autolytic debridement
Hydrogel
- Autolytic debridement
Examples of protease modulators for wound management
Oxidised regenerated cellulose/collagen dressings (Promogran)
- Topical hemostatic
Oxidised regenerated cellulose/collagen dressings (Prisma)
- Topical hemostatic
- Topical antimicrobial
Examples of topical antimicrobial for wound management
Nanocrystalline silver (Acticoat) - Absorbent
Ionic silver and hydrogel (Silvasorb)
- Hydrating agent and topical antimicrobial
Examples of anti-odour wound management products
Metronidazole
- Antimicrobial
Charcoal (Actisorb silver)
- Absorbant
Hierarchy of absorptive dressings - how to management wounds with significant exudate
Foam > Hydrofibres > Alginates > Hydrocolloids
May use absorptive pads as primary or secondary dressings where exudate is high
Negative pressure wound therapy may be used in extreme cases (but inappropriate for gangrene or malignant wounds that will not heal)
Components of pressure redistribution for wound management
- Increased contact area (reduces pressure in all areas)
- Patient repositioning to increase contact area of entire body
- Reactive support surfaces:
* Immersion devices (sink into - foam, air, gel, fluid)
* Envelpment devices (conform around - foam, air, gel fluid)
* Combined immersion and envelopment (air fluidized) - Pressure relief (removes pressure from vulnerable/affected areas
- Patient repositioning to minimise pressure from a particular location
- Active support surfaces (alternating pressure, mechanical tilting beds, etc.)
- Lifting body part clear (heel boots, pillows)
Diagnosis of deep compartment infection in wounds
STONES
- four or more sensitive and specific for deep compartment infection
- increased pain is a bad sign regardless of signs below
Size of wound (increased)
Temperature (increased - used infrared technology)
Os (palpable exposed bone)
New areas of breakdown
Exudate (increased), erythema, and edema
Smell (increased)
Diagnosis of superficial compartment infections in wounds
NERDS
- 3 or more sensitive and specific for superficial compartment infection
- increased pain is a bad sign regardless of signs below
Non-healing or deterioration
Exudate (increased)
Red wound bed (hypergranulation)
Debris in wound
Smell (increased)
Risk factors for malignant wounds
- Primary skin neoplasms or local recurrence
- Metastatic deposits from remote primary site
Associated cancers:
- Breast
- Head and neck
- Primary skin
- Primary lung
Presentation of malignant wounds
- Fungating
- Exophytic morphology
Tools to assess malignant wounds
Wound and Symptoms self assessment chart
- Evaluate wound, symptom burden, QOL
Malignant wound assessment tool
- Evaluate wound, symptom burden, QOL
Most effect ways to treat malignant wounds
Systemic Tx
- Chemo therapy
- Hormonal therapy
Local therapy
- Radiation
- Photodynamic therapy
Patients with malignant wounds should be referred to rad onc and med onc
Surgical excision may be considered
Use of Topical 6% miltefosine (cytoxic agent) can reduce progression of fungating wounds
Interprofessional team involved in management of wounds
- Social workers, psychologists, and spiritual care for psychosocial/spiritual needs
- OT
- Review of environment
- Assistive devices and clothing options - PT
- Prevention and treatment of complications (edema, lymphedema, reflex sympathetic dystrophy)
- Ultrasound, laser, and electromagnetic therapy
Treatment of wound management in developing countries
- Fewer available advanced wound dressing materials
- Less access to a interdisciplinary team
Other agents:
- gauze
- sodium hypochlorite (bleach)
- Hydrogen peroxide
- Cetrimide solution
- Chlorhexidine
- Polysaccharides (honey)
Management of wound-related pain
- Rule out infection as a cause of escalation pain
- Analgesia
- Typically both inflammatory and neuropathic pain
- Combinations of systemic opioids and adjuvants can be considered
- No high quality evidence for topical opioids
- Topical agents (EMLA - topical local anesthetic) and use of foam dressings with slow release ibuprofen may be used in chronic leg ulcers
- Pre-medication with rapid-acting opioids prior to wound dressing changes, debridement, cleansing, etc.
- Use of non-adherent dressings (gauze tends to be more painful) - e.g. polypropylene, polyethylene
Pattern of wound-related pain
- Continuous background pain with transitory flares (breakthrough), incident pain may also occur
Pathophys of wound-related exudate
- High capillary permeability within wound tissue due to secretion of vascular permeability factor by cancer cells
- Increased hydrostatic pressure from venous or lymphatic obstruction
- Use of hydrating agents can increase exudate (e.g. hydrogels or hydrocolloids)
Management of wound-related exudate
- No class of absorbent dressings is superior to another, as per cochrane review
- Consider choice of dressing based on patient concerns, availability, convenience, and cost
- Consider collateral benefits (e.g. hemostatic properties, analgesic properties, or antimicrobials properties)
Management of extreme wound-related exudate
- If a secondary dressing with super absorbant pads are unsuccessful, consolt with enterostomal nurse specialist
- Ostomy pouches may be helpful
- Ensure production of the peri-wound skin (exudates may cause maceration)
- Watch for skin toxicity from chemo drugs present within wound exudate (apply a hydrocolloid or a barrier product like Cavilon)
Pathophys of wound-related odour
- Decomposing necrotic tissue
- Gram negative infection resulting in release of volatile fatty acids
Management of wound-related odour
- Systemic metronidazole 250-500mg PO BID (no RCTs)
- Less expensive than topica
- Side effects include metallic taste, disulfiram like reaction if used with alcohol - Topical metronidazole (slightly better evidence than odour absorbent dressings)
- Odour-absorbent dressings
- Contain layer of activated charcoal
- Charcoal layer must be kept dry, outermost dressing must be air tight - Others:
- Wound cleansing
- Painting with antiseptics
- Debridement as indicated
- Environmental control (aromatherapy oils, baking soda, pet litter)
Management of bleeding in malignant wounds
- Due to dressing changes or may happen spntaneously
- Minor bleeding
- Local measures - calcium alginates, oxidised regenerated cellulose/collagen dressings, topical thromboplastin, silver nitrate cautery - Severe bleeding
- Ligation of local vessels
- Electrocautery
- Cryotherapy
- Arterial embolization
- Tranexamic acid 500mg PO BID
- Zinc chloride paste (applied topically to fungating breast wounds)
* Ensure any tx is in line with goals of care
Prognostic implications of malignant wounds
- Presence of malignant wounds not associated with reduced survival
- Should not be used as part of decision making process re: ongoing cancer therapy
Indications for compression therapy
- Venous leg ulcers (robust evidence)
- Compression tx is either elastic (lower compression) or inelastic (higher compression)
- Elastic is more effective than inelastic, but requires assessment of arterial supply to ensure limb ischemia is not exacerbated
- Do not use inelastic if ABI < 0.8
- Use only mild compression if ABI 0.6 - 0.8
- No compression if ABI < 0.6
Management of venous leg ulcers
Limb elevation, compression, exercise
DIME -
- Debridement/Downloading
- Infection/Inflammation management
- Moisture balance
- Edge effects
May also consider pentoxifylline 400mg PO TID with compression therapy - may cause GI side effects
Prevention of venous leg ulcers
- Most reasonable in patients with greatly reduced limb movement (e.g. fractures, contractures) due to reduced muscle pump function
- Proactive compression therapy using graded stockings to prevent
Prognostic implications of pressure ulcers
- Markers of limited survival, but not typically a direct cause of death
- Presence of a pressure ulcer increases likelihood of death more than twofold
Components of good skin care
- Skin cleansing
- Soap can strip the skin of natural oils and reduce protective function against colonization by harmful bacteria
- Skin cleansers are available with formulations that minimize alterations to skin pH and maximize protective function of the skin - Moisturizing and hydrating
- Designed to maintain or increase hydration by trapping moisture under the barrier (emollients)
- Lotions designed to be absorbed and improve moisture that way - Protection
- Barrier products to form a thin layer on the skin surface to protecting the skin from excoriating bodily fluids
Prevention of skin damage from moisture
- Skin damage may occur due to contact with bodily fluids (urine, feces, sweat) rather than pressure alone
- Moisture damage can compound damage due to pressure
- Disposable pads and close fitting underwear or adult diapers
- Comprise a fluid handling system (super absorbent and gelling material with hydrophobic skin contact layer) to wick away urine and contain it within the pad
- Fecal matter will remain on the skin side of the pad
- Must be changed when soiled rapidly to maintain dignity and skin integrity - Urinary catheters
- May be used intermittently (in and out or self-cath) or indwelling
- Some patients find this preferable to pads
- Increased risk of UTIs - Anal or stoma bags
- Practicality of bags is dependent on position of anus, stoma, or fistula, amount and consistency of the effluent, and ability to get a good seal.
- Leakage may cause skin damage - Fecal management systems
- Rectal tubes with feces drained into collection bags
- Not commonly used, except for in settings where there is high fecal output and risk of cross infection (eg Norovirus or C Diff)
Methods of debridement
- Autolytic
- Hydrogel dressings - Biological
- Larval therapy - Mechanical debridement
- Ultrasound and water irrigation - Surgical/sharp debridement
- Scalpel, scissors, forceps by trained RN or surgeon - Chemical debridement
- Active dressings
- Medical grade honey - Enzymatic depridement
- Collagenase agents
Necrotic tissue management where life expectancy is short, there are head and neck wounds, or multiple wounds over the body
- Consider promoting and maintaining dry scab rather than debriding
- Apply astringent antiseptics (permanganate) - can dry broken skin that is oozing fluid (note that it can stain the skin)
How to protect fragile granulation or epithelializing tissue
Granulation tissue
- semi-occlusive, non-gauze based dressings
- Foam dressings with low adherent wound contact layer
Epithelial tissue
- Low-adherent moisture conserving primary dressings
Management of fistula
- Prevent skin excoriation with barrier products
- Collect effluent in closed stoma devices or wound manager devices
- Manage odour with a closed device
- Nutrition and fluids to maintain hydration/nutrition that may be lost through the fistula
- Supportive care to protect autonomy, ability to socialise, and sense of self
Cutaneous metastases
- Occurs in 10% of patients with metastatic cancer
- Most commonly appears as discrete nodules, but can also form a diffuse pattern like edema or cause aspread to the skinn inflammatory plaque
- Ulceration is common due to disruption of blooed vessels
- Breast, lung, melanoma, and colon ca commonly
Melanosis
- Generalised darkening of the skin
- May be accompanied by dark urine
- Occurs due to a ‘shower’ of melanoma cell disemmination that may occur with melanin-producting metastatic melanoma
Hyperpigmentation
- May occur with adrenal insufficiency
- May be a side effect of chemotherapy (bleomycin, capcitabine, hydroxyurea)
Xerosis
- General skin dryness, which is common in cancer and in elderly patients
- Often brought on by chemo, decreased food intake, or hypoproteinemia
Erythroderma
- General redness of the skin
- End stage of skin diseases, including Sezary syndrome (variant of cutaneous T cell lymphoma), leukemia, lymphoma, and less commonly solid tumours
- Pathophys unknown
- Sometimes managed with emollients and systemic steroids
Paraneoplastic syndromes: Dermatomyositis
Dermatomyositis
- Associated with almost every solid tumour, but especially common in melanoma and lymphomas
Presentation:
- Heliotrope rash
- Gottron’s papules (violaceous paupes and plaques over finger joints, also elbows, knees, and feet)
- Proximal muscle weakness
- Slight scale
- Poikiloderma - Erythematous eruptions in a photosensitive distribution (often upper chest)
Treatment:
- Steroids
- In resistant causes, immunsuppressive agents can be used (MTX, azathioprine, etc.)
Tinea corporis and cruris
Presentation:
- Large, confluent polycyclic or psoariaform plaques over the buttocks, lower back, inguinal region, inner aspectsof the thigh, public region, genital, and perianal skin
Cause:
- Tichophyton rubrum (dermatophyte)
Diagnosis:
- KOH skin scraping (showing hyphae)
Treatment:
- Topical agents (imidazole, ciclopirox)
- If resistant, fluconazole PO
Diaper dermatitis
- Urinary incontinence can lead to prolonged periods of wetness and soaking of the skin
- Maceration of the skin and barrier damage enhances the irritant effect of urine and feces
- Inflamed patches may result in a burning sensation
Treatment:
- Zinc oxide treatments to restore barrier and protect skin
- Topical steroid combined with barrier agents if significant dermatitis has occurs
