Periwound skin management is just as important as wound bed preparation in wound healing. The goal of periwound management is to maintain an optimal moist wound healing environment while preventing skin breakdown and infection. Skin is more vulnerable in patients with certain comorbidities and conditions. Periwound skin breakdown is just one of the culprits that delay wound healing and increase pain. It is important to identify conditions and risk factors early in your wound assessment to help prevent any risk of wound progress declination.

Periwound Assessment

The wound assessment should include the periwound and surrounding skin, extending 4cm from the wound bed.¹ Assessing wound location, shape, color, edges, margins, periwound, and surrounding skin is most significant in a thorough wound evaluation.^1,2 The periwound and wound margins are good indicators for identifying the wound type, infection, and moisture balance and for managing the plan of care.^1,3 A periwound assessment is similar to the wound assessment; however, it is helpful to keep a few more key factors in mind:⁴

• Periwound temperature
• Exudate amount
• Wound location
• Periwound shape
• Periwound color
• Wound depth

Periwound Characteristic Terms

• Abscess: Collection of fluid within tissue that is a result of an acute or chronic localized infection.
• Erosion: Loss of some or all of the epidermis.
• Epibole: Wound edge that is thickened and rolled under.
• Hyperkeratosis: Callous-like tissue formation at wound edges that can extent around wound.
• Induration: Firmness of tissues.
• Crepitus: Air or gas accumulation in tissues.
• Pitting edema: Fluid in tissue that can be indented.
• Non-pitting edema: Fluid in tissue under skin that is taut and shiny and cannot be indented.
• Secondary cutaneous infection: Most often candidiasis.
• Maceration/denuded: Both of these terms mean inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, exudate, ostomy effluent, mucus, and saliva. Otherwise known as moisture-associated skin damage (MASD), this is based on chemical content of moisture, friction, and presence pathogenic organisms.¹

Four Categories of Moisture-Associated Skin Damage

1. Incontinence-associated dermatitis (IAD): Inflammation and skin erosion associated with exposure to urine and/or stool.¹
2. Intertriginous dermatitis: Intertrigo is skin-skin or skin-to-device inflammation related to perspiration, friction, or bacterial and/or fungal bioburden.¹
3. Periwound moisture-associated dermatitis: Wound exudate that has sustained contact with the skin and caused damage. Inflammation and erythema to skin with or without erosion.¹
4. Peristomal moisture-associated dermatitis: Inflammation surrounding a stoma resulting from sustained contact with stool or urine.¹

Periwound Skin Breakdown Prevention and Management

Any break is the skin is at risk for periwound breakdown and/or complications. Prevention, treatment with appropriate dressings, and managing the periwound regularly will ensure that wound healing progress is moving toward the goal of wound closure. Identify and treat abnormal periwound complications as indicated. There is an array of products available to bolster preventive techniques and manage the periwound and surrounding skin of wounds.

Prevention Strategies

1. Use skin sealant dressings (liquid or spray) on the periwound and surrounding skin for protection and to help lessen friction forces.^3,5
2. Utilize larger foam dressings to maximize absorption.^3,6,7
3. Avoid repeated application and removal of adhesive dressings and tapes because this can damage the wound and/or periwound.8 This is known as medical adhesive–related skin injury (MARSI) and is defined as caused by trauma to the skin from medical adhesives.
4. Remove adhesive dressings correctly. This can be done most effectively by pressing down on the skin near the edge of the dressing while lifting up the adhesive.
5. Use barrier creams and/or ointments to prevent and protect the skin from moisture, primarily from incontinence.¹
6. Moisture balance is paramount. For example, use the correct absorptive dressing to maintain a balance in moisture and avoid maceration.¹

Conclusion

A patient’s quality of life is already compromised when a wound develops, and complications such as periwound skin damage can be avoided. As clinicians, we should take into consideration that every patient with a wound is vulnerable to further skin breakdown. We must have a clear understanding of causes, treatment, and prevention strategies for periwound skin damage. Ongoing assessment and monitoring will help in identifying skin changes and plan of care. Take into consideration a patient’s age, prior skin conditions and skin breakdown, skin allergens, and compliance with the plan of care.

References

1. Carver C. Is it moisture-associated skin damage or a pressure ulcer? WoundSource.com. 2015. https://www.woundsource.com/blog/it-moisture-associated-skin-damage-or-…. Accessed December 30, 2018.

2. Morgan N. Measuring wounds. Wound Care Advisor. 2012. http://woundcareadvisor.com/measuring-wounds/. Accessed December 30, 2018.

3. WoundSource Editors. The surrounding area: protecting periwound skin in chronic wounds. WoundSource.com. 2018. https://www.woundsource.com/blog/surrounding-area-protecting-periwound-…. Accessed December 30, 2018.

4. Livingston M, Wolvos T. Scottsdale Wound Management Guide. A Comprehensive Guide for the Wound Care Clinician. 2nd ed. Malvern, PA: HMP Communications ; 2015.

5. Lawton S, Langoen A. Assessing and managing vulnerable periwound skin. World Wide Wounds. 2009.http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-s…. Accessed December 30, 2018.

6. Meyers B. Wound Management: Principles and Practice. 2nd ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2008:56–7.

7. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Elsevier Mosby; 2011:117.

8. Cooper P. Skin care: managing the skin of incontinent patients. Wound Essentials. 2011;6:69–74.