For the past two decades, I've had a deep interest in wound care, but my son's wound care experience in 2020 shifted my attention to a largely overlooked population. As a mother, as I prepare to face his third incarceration, I am an even stronger advocate for transforming families and the lives...
by Cathy L. Wogamon-Harmon, DNP, MSN, FNP-BC, CWON, CFCN
The periwound is generally defined as the area from the wound edge to 4 cm beyond circumferentially. Breakdown of the periwound can adversely affect wound healing even if the wound itself is doing well.
After the initial assessment of the wound bed and edges, one should direct their assessment to the periwound.1 Generally speaking, there are three major conditions (other than intact) in which you may find the periwound: damaged from trauma, too moist, or in an inflammatory state. The periwound can become damaged from adhesive removal from dressings. Therefore, it is always very important to choose a dressing that will adhere but will not cause trauma, especially in already fragile skin, such as in older adult patients. Wound exudate can cause the periwound to become too moist, resulting in loss of the protective mechanisms of the skin and leaving the periwound open to breakdown and microorganism invasion.2 Irritation from an adhesive, allergic reactions, or inflammation from the wound itself can cause the periwound to become inflamed. This can also cause breakdown of the periwound skin or even a new open area as a result of the irritation.
Basically, gentle cleansing of the periwound at each dressing change with wound cleanser or normal saline is sufficient. If using a stronger cleanser for the wound such as hypochlorous acid, acetic acid, etc., you will want to continue the gentler cleansers as stated previously for the periwound. The wound should always be cleansed first and then the periwound (from the inside to the outside), even if using the same cleanser. Allow the area to dry thoroughly before applying skin protectant of any type.
There are thousands of choices of products for periwound protection. You will need to choose a product that coincides with the primary or secondary dressing you are choosing, the condition of the periwound skin, and the amount of exudate.3 Here is a look at the basic categories of periwound protectants:
Petroleum-based ointments provide a water-repellent cover for the periwound, thus preventing moisture from damaging the skin. These ointments are simple to apply; however, they can melt at normal body temperature and can be greasy, preventing the secondary dressing from adhering. These ointments will need reapplying at each dressing change.3
Zinc oxide ointments coat and shield without adding moisture. Because they are adherent to skin, they do not require daily application. It is not necessary to remove all of the ointment at each dressing change; however, the periwound care be cleansed gently and more ointment can be applied over the previous ointment. Zinc ointments can be difficult to remove and can cause some adherence issues for the secondary dressing.3
Dimethicone provides protection as well as moisturizes, which can be helpful for an overly dry periwound but can be ineffective for a moist periwound or a heavily exudating wound.3 It is simple to apply and should be reapplied at each dressing change. As with the other ointments, dimethicone can cause adherence issues for secondary dressings.
Liquid skin protectants or sealants provide a transparent coating over the periwound. They are available in a wide variety of forms, which can be beneficial.3 They are simple to apply and require complete drying of the product to be effective. These work very effectively if crusting is needed, such as in a Candida infection, by sealing the medication directly onto the affected area. Generally, all formulations are available sting-free. Some are reapplied at each dressing change, and some require less frequent reapplication.
Hydrocolloids come in the form of pastes, sheets, and powder. These can be useful for heavily exudating wounds.3 They are not usually removed for several days, and this can pose a problem for careful monitoring of the periwound skin. As the name implies (hydro-), hydrocolloids need to be monitored closely because they can cause or contribute to maceration.
Transparent films are semiocclusive and are also transparent, as the name indicates, which provides easy viewing of the periwound skin. As with hydrocolloids, they are not easily removed and can be traumatic to fragile skin.3
Problems: Skin Break-Down and MASD
As stated previously, there can be three major problems related to the periwound. The initial intervention is to ascertain the cause of the condition. This will help provide the pathway to the solution.
Damage or trauma: Provide teaching of caregivers in proper dressing removal. Utilize atraumatic dressings. Remove dressings parallel to the skin. Avoid traumatic taping. In the older adult patient, it is best to avoid tapes and adherent adhesives directly on the skin because these can actually result in tearing of the skin on removal.
Excess moisture: Utilize a dressing appropriate for exudate management. Apply a skin protectant or barrier appropriate for the wound, exudate, and state of the periwound. Adjust dressing changes more frequently as needed.4
Inflammation: First, determine whether the irritation is an acute contact dermatitis, which is usually caused by the dressing. If the periwound irritation is in the pattern of the secondary dressing, it is most likely a contact dermatitis, which is usually relieved by removal of the dressing. The periwound can often develop a Candida infection resulting from excessive moisture. This rash is identified by the yeast buds on the periwound and can be treated with topical miconazole crusted onto the periwound with a liquid skin protectant or sealant. If the wound and the periwound are inflamed, the cause could be a local infection of the wound or cellulitis, which should be treated with antibiotics or antimicrobials as indicated.
- Dowsett C, Protz K, Drouard M. Triangle of wound assessment made easy. Wound International. 2015. Accessed January 24, 2022. www.woundsinternational.com/resources/details/triangle-of-wound-assessme...
- LeBlanc K, Beeckman D, Campbell K et al. Best practice recommendations for prevention and management of periwound skin complications. 2021. Wounds International. Accessed January 24, 2022. www.woundsinternational.com/resources/details/best-practice-recommendati...
- Thayer, D, Rozenboom, B, LeBlanc, K. Prevention and management of moisture-associated skin damage, medical adhesive-related skin injury and skin tears. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2022:328-344.
- Woo KY, Beeckman D, Chakravarthy D. Management of moisture-associated skin damage: a scoping review. Adv Skin Wound Care. 2017;30(11):494-501. doi:10.1097/01.ASW.0000525627.54569.da
- Accessed January 24, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657465/pdf/swc-30-494.pdf.
About the Author
Dr. Cathy Wogamon-Harmon, DNP, MSN, FNP-BC, CWON, CFCN is a Nurse Practitioner at the VA Medical Center in Lake City, Florida. She is the Wound Care Provider in the Out-Patient Clinic serving the Veteran Population of North Florida and South Georgia. Cathy is certified in wound, ostomy and foot care. In addition to her wound care experience, she also has experience in acute care, pediatrics, home health, long-term care and has served as a Professor of Nursing. Cathy’s passion for wound care began while she was working in the long-term care setting as an RN. She serves the veteran population as a memorial to her dad, a combat wounded WWII Veteran.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.
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