Alexandra Freitas

      In the diabetic foot, loss of autonomic nerve supply can alter the vascular perfusion and nerve supply of the skin. This affects the integrity of the skin and its resistance to mechanical and chemical trauma from pressure and wound exudate (Faber et al, 1993). Maceration is a common problem, particularly in the management of chronic wounds (Thomas, 1997). Moreover, diabetic foot ulceration continues to be synonymous with delayed healing, higher infection rates and an increased risk of lower-extremity amputation (Frykberg, 1998). Several factors can affect the local wound environment in diabetic foot ulceration, such as hyperglycaemia, macrovascular and microvascular disease, polyneuropathy, and impaired host immunological defence (Kamal et al, 1996). Maceration of the wound bed and surrounding skin in diabetic foot ulceration may be one of the least well-recognised factors contributing to impaired healing (Cullum et al, 2000). The impact of maceration on skin integrity, and its traditionally poor management and frequency, make it an obvious contender for inclusion as a risk factor in wound care (Cutting and White, 2002b). However, there is little research on the possible implications of maceration in diabetic foot ulceration (Bale et al, 2001). The aims of wound management are to address patient concerns, correct intrinsic and extrinsic factors where possible, and optimise the healing environment. It is also essential to include the periwound margins as an integral part of wound assessment (Cutting and White, 2002a).

Citation: Freitas A (2022) Periwound maceration skin management strategies using a skin barrier film on diabetic foot ulcers. The Diabetic Foot Journal 25(3): 34–41

Key words: - Barrier Film - Diabetic foot ulcer - Maceration - Periwound protection - Skin management

This article is sponsored by Medicareplus International

Authors

Alexandra Freitas, Clinical Nurse Advisor, Medicareplus International, London

This article explores medical-device related pressure ulcers (MDRPU) in an intensive care unit (ICU) at the Royal United Hospitals Bath NHS Foundation Trust (RUH). The data presented outlines a reduction in PU of 66% over a 6-year period and a reduction in MDRPU of 50% over the same period. MDRPU were particularly challenging to prevent in ICU during the COVID-19 pandemic, where there were additional numbers of patients in the ICU with medical devices in place. Additionally, during the COVID-19 pandemic, an increased number of patients in the ICU were nursed prone (face down), adding additional pressure on the facial structure, a range of measures were put in place to avoid those avoidable MDRPU in the ICU at the RUH. Measures focused on skin checking, offloading and rotation of devices, including endotracheal tubes, non-invasive ventilation, nasogastric (NG) and nasojejunal (NJ) tubes and catheters. A specific comfort and pressure care record was developed for ICU to record the assessments of these at risk areas.

KEY WORDS Pressure ulcer  Device-related  pressure ulcer  DRPU Medical-device related pressure ulcers

NICOLA HEYWOOD Tissue Viability Nurse Specialist, Royal United Hospitals Bath NHS Foundation Trust.

STEPHANIE WORTHINGTON Tissue Viability Nurse and Critical Care Sister, Royal United Hospitals Bath NHS Foundation Trust.

MICHAELA ARROWSMITH  Lead Tissue Viability Nurse,Royal United Hospitals Bath NHS Foundation Trust. 

MARGI JENKINS Matron, Critical Care Services, Royal United Hospitals Bath NHS Foundation Trust.

LAURA HERRING  Tissue Viability Nursing Assistant, Royal United Hospitals NHS Foundation

      Pressure ulcers (PU) are caused when persistent pressure and/or friction/shear force is applied to an area of skin, generally over bony prominences, e.g., heel, trochanter, and sacrum, sufficient to impair the blood supply (National Health Service (NHS) Improvement, 2018; European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), and Pan Pacific Pressure Injury Alliance (PPPIA), 2019). PUs are characterised on a severity scale that ranges from discoloured skin to open wounds with exposed underlying muscle and bone (NPUAP, 2017). Those at risk for the development of a PU are people that are unable to move regularly, especially the critically ill, the elderly, or anyone with a lack of sensory perception, e.g., spinal cord injury or neurological impairment. In addition, the condition of the soft tissue and its microclimate, as well as the nutrition status and comorbidities of the patient, can influence PU formation (NPUAP, 2017). Once a PU has developed, especially if it proves hard-to-heal, it can significantly impact on the quality of life of the patient. Patients report that their emotional, mental, physical, and social wellbeing is affected, especially when an PU proves hard to manage and fails to heal (Gorecki et al, 2012). Therefore, it is imperative that patients are provided with a comprehensive PU treatment plan that ensures the best possible healing outcome for the patient, with the best economic outcome for the healthcare provider.

KEY WORDS Chronic wounds Granulox Haemoglobin Hard-to-heal wounds Pressure ulcer

KATIE JEFFREY Development Community Tissue Viability Nurse, HCRG Care Group, North Kent, Sittingbourne Community Hospital, Sittingbourne, UK

Abstract: This case series investigates the recovery of chronic wounds treated with hyaluronic acid-collagenase (Hyalo4® Start), which facilitates enzymatic debridement, helping prepare the wound bed for healing and closure on top of first-line therapy. We recruited 15 patients with different underlying comorbidities who consented to participate in the case study. Selection criteria include patients with chronic wounds classified as Class 2 and Class 3 according to Harikrishna Periwound Skin Classification (HPSC). Treatment duration varied. The study observed a minimal to 100% reduction in wound size, notably diminished exudate excretion, healthy wound edge, and lower pain score as Hyalo4® Start was applied as part of standard care.

Key words:

■ Chronic wounds ■ Collagenase ■ Hard-to-heal wounds ■ Harikrishna Periwound Skin Classification ■ Hyaluronic acid

Harikrishna K. R. Nair, MD FRCPI FRCPE FCWCS Wound Care Unit, Dept of Internal Medicine, Hospital Kuala Lumpur, Malaysia;

Puteri Nur Athirah, MD, Wound Care Unit, Dept of Internal Medicine, Hospital Kuala Lumpur, Malaysia