Moisture Leisons & Skin Care

1. Moisture Leisons & Skin Care Tissue Viability Team

2. Referral CriteriaTissue Viability Detailed assessment or management advice is required. A wound that falls outside the field of knowledge or experience of the practitioner. The wound fails to progress or infection, exudate, pain, odour or necrotic tissue is a management problem. Pressure ulcers Grade 3 & 4 or a deteriorating pressure ulcer, as well as difficult to manage patients. Patient’s receiving or require advanced therapy (e.g. Topical Negative Pressure or Larvae therapy) Options in managing malignant fungating wounds

3. Referral CriteriaLeg Ulcer Service Detailed assessment or management advice is required. A wound that falls outside the field of knowledge or experience of the practitioner A below the knee wound - no improvement/static after 4 weeks Difficult to control symptoms such as venous eczema, pain or exudate Acute Cellulitis Leg ulcer recurrence Concordance issues affect care If there are problems with investigations such as Doppler Ankle Brachial Pressure Index (ABPI)

5. The Skin • How many layers make up the skin? • Name the individual layers of the skin? • What is the PH of the skin? • Functions of the skin? • The skin varies in thickness from 0.5-0.4mm depending on which part of the body? • Name the part of the body where the skin is the thinnest and thickest? • Name some effects of ageing on the skin?

6. Discuss the cause?

7. How moisture damages skin • Urinary incontinence changes the normal acid mantle to alkaline pH • Skin becomes vulnerable to friction and shear forces that tear the skin • A combination of faecal and urinary incontinence makes the skin much more vulnerable than urinary incontinence alone • Faecal enzymes cause severe skin irritation that can quickly result in incontinence dermatitis with skin breakdown • What else could damage the skin?

8. Discuss the Cause?

9. Causes of Dry skin adapted from Ayer, 2010 – Best Practice statement 2012, Care of the Older Person’s skin

10. Effective Management • Effective promotion of continence or management of incontinence is vital. • Act promptly – Minimise the length of time skin in contact with urine, faeces or sweat • Barrier products such as Cavilon™, which is compatible with many continence aids, may be applied. This is not a substitute for good hygiene. • Zinc oxide cream (Sudocrem™), zinc and caster oil and Metanium should generally be avoided.

11. Causes of Dry skin adapted from Ayer, 2010 – Best Practice statement 2012, Care of the Older Person’s skin

12. Barrier Creams & Emollients • Conotrane Cream - barrier • Medihoney Barrier Cream • Pro Sheild Wash & Barrier Cream • Aqueous Cream – for washing only • Diprobase Cream – for washing • Double Base Gel – for washing • Epaderm Cream – for washing N.B Effective drying of the skin is just as important, especially in skin folds/creases!!

13. Cavilon Cream – “purple” prevention • 3M™ Cavilon™ Durable barrier cream protects intact skin from bodily fluids and helps to prevent breakdown, whilst moisturising the skin. • It is immediately absorbed by the skin, and therefore will not clog incontinence pads • Every 3 washes or daily

14. Cavilon Film – Blue for broken skin • Alternatively, if the skin is already broken and sore, apply 3M™ Cavilon™ No Sting Barrier Film, which will protect the skin against bodily fluids for up to 72 hours, and promote skin-healing.

15. Best Practice skin cleansing • Soap and water should be avoided as made up with a mixture of alkalis and fatty acid that dry the skin out • Emollients from the Dermatology guide in Mimms or BNF • Intrasite Gel is effective for sloughy, wet moisture leisons, once skin has broken.

16. Barrier Creams & Emollients • Conotrane Cream • Medihoney Barrier Cream • Pro Sheild Wash & Barrier Cream • Aqueous Cream • Diprobase Cream • Double Base Gel • Epaderm Cream N.B Effective drying of the skin is just as important!

18. Moisture Leisons/Kissing Ulcers Moisture lesions are as a result of exposure to excessive moisture on the skin usually caused by urinary incontinence, diarrhoea or sweat) Moisture must be present and therefore the skin may appear shiny/glistening, sometimes with a thin layer of slough on the broken areas – Intrasite Gel can be effective with regular pad changes

20. Moisture Leisons/Kissing Ulcers • A moisture lesion may occur over a bony prominence. However, pressure and shear should be excluded as causes, and moisture should always be present. • Intrasite Gel is an effective treatment for moisture leisons in conjunction with regular skin care.

22. Moisture Leisons are usually irregular in shape with a sloughy surface • Ill defined edges ‘wandering’ edges and often occur over the fatty tissue of the buttock cheeks, the perineum, inner thighs, scrotum and vulva (Guy, 2012) • Best practice statement: Care of the older person’s skin 2012

24. Moisture Leisons • Diffuse, different superficial spots are more likely to be moisture lesions. In a kissing ulcer (mirroring lesion) at least one of the wounds is most likely caused by moisture (urine, faeces, transpiration or wound exudate).

25. Best Practice • Regular skin assessment & risk assessment • Document skin changes thoroughly • Good hygiene – use of emollients, dry skin well • Use of barrier films e.g. Cavilon, Medihoney Barrier cream • Well balanced diet • Adequate fluid intake • Continence Assessment/continence products

26. Clinicians should develop good assessment skills of the skin & document any changes • Implement good management strategies to reduce the incidence of moisture lesions. • Seek help/advice from other clinicians or Tissue Viability if a mixed leison is suspected e.g including pressure

27. Moisture lesions are superficial (partial thickness skin loss). In cases where the moisture lesion gets infected, the depth and extent of the lesion can be enlarged/ deepened extensively – not usually over a bony prominence but can be a mixed aetiology!

28. Advances in Skin Protection • Containment Devices – disposable products such as pads • Urinary Sheaths – penile sheaths • Urinary Catheters & Supra pubic catheters • Faecal Management Systems • Skin Cleansers • Skin Protectors/Barrier Creams (Wounds Uk 2012)

29. Pressure Ulcers Immobility Circular & symmetrical in shape Butterfly wing shape if spans out from sacrum Over a bony prominence Necrotic/thick sloughy tissue Grade ulcer according to NPUAP 2010 Moisture Leisons History of faecel/urinary incontinence May be associated with sweating skin folds/natal cleft Leisons will be over fatty part of buttocks/thighs Leisons may extend to perineal area No necrotic tissue/thick slough Do not grade Moisture Lesions V Pressure Ulcers

30. Category 4 Pressure Ulcer