by Michel H.E. Hermans, MD
by Beth Hawkins Bradley RN, MN, CWON
I am frequently asked for solutions relating to maceration to periwound skin in wounds being treated with negative pressure wound therapy (NPWT). As a clinician practicing in the outpatient and home care settings, it was not unusual for patients to have to take a "holiday" from negative pressure. Treatment was often put on hold for several days to allow skin to recover. Putting negative pressure on hold not only caused a potential delay in forward progress in the wound, but it also created the need for increased dressing change visits for the home care patient. While maceration is reported in wounds located anywhere on the body, it seems to be most prevalent on skin of the lower extremity.
Recalling the impact of diabetes on the skin of the lower extremity may help clinicians understand why maceration associated with negative pressure is common. Neuropathic changes may include inappropriate sebaceous secretions, making the skin dry and unprotected against moisture. Inappropriate sweating is also common. The increased skin moisture underneath the semi-permeable drape prevents evaporation and can contribute to moisture being retained on the skin. Diabetic skin has compromised ability to recover as maceration occurs, leading to the need for putting negative pressure on hold.
There are implications in dressing applications as well as pressure/mode selections that can create or prevent maceration. As we examine these, you may find tips that can help you solve some of your clinical challenges.
Skin Protectant Products to Prevent Periwound Maceration
I encourage clinicians to provide skin protection that best meets the needs of the individual patient. A protective barrier film wipe or spray is a good first step towards preventing maceration. These products apply a breathable layer of protection that allows the drape adhesive to stick to it. There are many brands of these products, each with unique characteristics. Get familiar with the characteristics of the product available to you on hand to make sure that it meets your needs. When applying any barrier film, begin applying at the edge of the wound and work outward to include all skin that will be covered by the drape. Allow the barrier film to dry before proceeding. Two coats may be helpful in fragile skin. In addition to applying skin barrier film, it may be necessary to apply a drape border around the wound edges. This may be done by overlapping 1" strips to frame the wound. Another option is to cut an opening in a piece of drape that is the exact shape of the wound before laying it onto the skin. Either way, drape may prevent maceration that results from moisture from the wound, but will likely not prevent maceration from inappropriate sweating.
Adjust the Target Pressure Setting
Target pressure setting: When maceration occurs, many clinicians assume that it relates to wound fluid coming into contact with the periwound skin. They respond by increasing NPWT device pressures. Additionally, many clinicians use higher pressures in lower extremity wounds to begin with. In some cases, increasing pressures may actually increase maceration. Black foam is hydrophobic, its job is to convey moisture through it. However, high pressures can cause compression and collapse of the foam cells, preventing moisture from being removed from the wound. If there seems to be excessive moisture in the wound and maceration to the surrounding skin, consider other strategies than increasing device pressures.
Adjust the Device's Pressure Mode
Most clinicians use NPWT in the default mode, which is continuous. The intermittent mode may be useful in preventing maceration in wounds that are small, or where higher pressures are used. The intermittent mode is different from manufacturer to manufacturer, but target pressure is held for a period of several minutes, alternated with a shorter period of time spent at atmospheric pressure. This cycle of pressure variation will allow the foam to relax, passing fluid through it and away from the wound.
Alternative Dressing Techniques for Small, Deep Wounds
It was mentioned earlier that lower extremity wounds frequently have maceration to the surrounding skin. Many of these wounds are small with depth. Consider the foam over collapse concept associated with high pressure. Foam can also over collapse when it has low surface area. Therefore, a wound with a small circumference but depth of even 1-2cm can over collapse and cause maceration. To prevent this, consider the "mushroom" or "button" dressing technique. Drape the periwound skin, fill the wound as usual, apply a full-thickness larger piece of foam over the wound, and finish the dressing as usual. This technique gives the foam larger surface area, preventing over collapse.
Although maceration may not always be able to prevented, implementing these strategies may help to reduce its impact. Always assess your patient carefully prior to beginning NPWT, and consider how the skin should be protected, as well as which device settings will be most beneficial.
About the Author
Beth Hawkins Bradley, RN, MN, CWON is the director of Clinical Operations at Cardinal Health. She has been certified in the specialty of Wound, Ostomy, Continence nursing since 1990.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.