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Avoidance and management of peri-wound maceration of the skin

Keith F. Cutting, MN, RMN, RN, DipN (Lond), CertEd(FE).

Principal Lecturer, Buckinghamshire Chilterns University College, Chalfont St. Giles, Buckinghamshire

Health-care professionals need to be aware of maceration and the implications it may have for wound healing. Maceration of the skin around a wound is a common feature and most practitioners are advised to carry out interventions to avoid it.

Health-care professionals need to be aware of maceration and the implications it may have for wound healing. Maceration of the skin around a wound is a common feature and most practitioners are advised to carry out interventions to avoid it.

Evidence that maceration leads to skin breakdown and consequent wound enlargement is circumstantial (Allman, 1989), although anecdotal reports link maceration with delayed healing and other complications (Cutting, 1999a). A recently described concept, wound-bed preparation (Falanga, 2000; Vowden and Vowden, 2002), concentrates on the generation of an optimal healing environment and measures to overcome barriers to healing. This model for healing emphasises a number of objectives:

- To achieve a well-vascularised wound bed

- To decrease the bio-burden of the wound

- To optimise exudate levels.

Wound exudate (type and volume) influences management decisions and dressing choice; this paper focuses on one aspect of exudate, the skin damage known as maceration.

Maceration is defined as a softening or over-hydration of the tissue due to retention of excessive moisture (Cutting, 1999b). It should not be confused with the pale, whitish appearance of the new epithelial tissue in a healing wound.

Recent references in the related literature tend to focus on the effects of maceration on the peri-wound skin (Butcher, 2000; Cutting, 1999a), but it is important to remember that this phenomenon is also likely to have an impact on the wound bed.

Despite a literature search a definitive description of this occurrence does not appear to be available. Although acute wounds may confront the practitioner with challenges to healing, this paper will focus on maceration and chronic wounds, as they represent the majority of wounds encountered that present problems to the nurse.

Causes of maceration
There is, at present, no evidence that moist wound healing is related to the development of maceration (van Rijswijk and Harding, 2000). Although some practitioners may insist that occlusive dressings which create a 'moist wound' environment can provoke maceration, this need not be the case under 'normal' conditions of use.

Occlusive dressings are not inherently likely to provoke maceration when used correctly (White, 2000). Indeed, it is likely that most instances of maceration are attributable to 'traditional' dressings as these are still the most widely used. However, partially occlusive dressings that rely on absorbency and moisture vapour transmission rate (MVTR) for their fluid-handling capabilities may offer a lower risk of inducing maceration.

Not all wound exudates are the same. Those of serous consistency (clear aqueous) will be more likely to pass into an absorbent dressing and be lost by MVTR than those of a more viscous nature.

The causes of maceration other than exudate include excessive sweating, the presence of urine or faeces and high local moisture due to prolonged occlusion combined with high exudate and transepidermal water loss (TEWL). The term 'moisture/water vapour transmission rate' (MVTR or WVTR) should be used in reference to dressings and not to intact skin.

Effect of maceration on wound progress
Wound exudate, a plasma derivative, is a vital component of the wound-healing process. A number of elements that may be found in exudate have been identified (Box 1) and although this box does not provide an exhaustive list, the reader will appreciate the diverse nature of these components.

In acute wounds, exudate components contribute positively to the wound-healing process. However, in chronic wounds, proteolytic enzymes such as MMP8s are produced in excess of the level required to lyse devitalised tissue, debris and dead micro-organisms. Degradation of the wound bed may result from protease activity together with excoriation of the peri-wound skin. This damage to the peri-wound skin reduces its protective function as a barrier to water and increases the likelihood of maceration occurring (Cutting and White, 2002).

How to avoid and reduce maceration
Managing exudate production effectively requires achieving a balance between the extremes of wound desiccation and wetness. Although a 'moist' environment is the ideal, accomplishing this to the correct degree consistently provides a challenge to the practitioner.

Although exuding chronic wounds (deep burns, diabetic foot ulcers, leg ulcers, pressure sores and fungating tumours) are most likely to develop maceration, this phenomenon may manifest in any type of wound if the conditions are right.

Exudate production may increase - particularly if a wound becomes infected and/or deteriorates. It is therefore imperative that a careful selection of dressing and wear time is made to help ensure successful management. Consider the following:

- Level and nature of wound exudate

- Fluid-handling capacity of the dressing

- Site and condition of the wound

- Optimal wear time for dressing on the wound

- Specific needs of the patient

- Environmental factors

- Possible adhesive damage to peri-wound skin.

Wounds that tend to be 'wet' may benefit from alginate, foam, hydrofibre or hydropolymer dressings. If exudate is copious, irrespective of the type of primary dressing used, additional secondary dressings will be needed to provide supplementary absorption, or more frequent changes of dressing will be required.

Dressings that combine a variety of absorptive materials and that possess a high MVTR have the potential of avoiding maceration, of providing increased wear time and hence decreased number of dressing changes.

Protecting the peri-wound skin from enzymes in chronic wound exudate may be achieved through a variety of simple measures. Regular applications of liquid paraffin/soft paraffin (50/50 proportions) or zinc oxide cream or ointment BP to the peri-ulcer skin are often soothing as well as protective in function. Barrier films are now available as alcohol-free preparations that 'seal' the skin and protect against maceration or excoriation (Williams, 2001). They generally provide protection for up to 72 hours before re-application is necessary.

Additional approaches to managing exudate include the use of:

- Topical corticosteroids (anti-inflammatory and vasoconstrictive in action). Their use is considered controversial. When managing leg ulcers they appear chiefly to be of benefit on the peri-ulcer skin when wet eczema is present (Peters, 2002). To date, there is no evidence to support their use on the wound bed

- Topical antiseptic preparations, notably impregnated dressings, such as those incorporating suitable formulations of iodine and silver

- Systemic antibiotics

- Leg elevation and compression, as appropriate.

Practical advice
- Select dressing(s) according to exudate level

- Estimate optimal wear time according to the following general factors: volume of exudate, nature of exudate, manufacturer's instructions, clinical setting, activity level of the patient. Note: it is prudent when estimating wear time to err on the side of caution

- Recognise and treat any infections promptly and appropriately

- Avoid topical antibiotics and antiseptic solutions

- Consider impregnated (iodine and silver) dressings

- Do not use hydrogels on wet wounds. This will only compound the problem

- Use compression therapy and elevation for appropriate leg ulcers.

Conclusion
Wound exudate, in the correct quantities and in the correct constituency, is a useful factor in the healing process. To remove exudate solely because it is present does not constitute good practice. The assessment of exudate levels, choice of suitable dressing, and estimation of wear time are clinical skills that must be learned.

Although many other factors are implicated in exudate management, it is vital to apply these skills to every wound at every dressing change; only by doing this will maceration be avoided and healing optimised.

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