Healthy Living

The burden that problem wounds place on our society in terms of debilitation and costs is staggering. Obviously the best way to avoid this burden is to never develop a problem wound to begin with.

At the Backus Hospital Wound Care and Hyperbaric Oxygen Therapy Center more than 90% of the wounds we see are related to pressure, lower extremity venous disease, or a complication of diabetes.

Pressure or decubitus ulcers often develop in people who are relatively immobile for one reason or another. These ulcers develop because of prolonged pressure on the skin, which results in compromised circulation and resultant skin breakdown.

These people often have issues with nutrition, which further exacerbates the problem of skin integrity. Understanding the cause of these wounds has led to a three-phase approach to caring for, but most importantly, preventing pressure ulcers.

The three phase approach is:

• mobility
• nutrition
• skin health.

Frequent repositioning to avoid prolonged pressure on one area, as well as the use of support surfaces that redistribute pressure, is essential. Repositioning should be done at least every four, and preferably every two hours.

These patients also will benefit from a nutritional assessment and supplements as needed. The use of skin moisturizers, especially to the sacral area, to avoid dry skin has also been shown to be beneficial.

Lower extremity venous disease results from the inability of the valves of the veins to keep the blood from backing up into the legs. This results in fluid retention in the legs and can manifest as a leg ulcer called a venous stasis ulcer. The skin of the legs in this situation is also very susceptible to injury from minor trauma.

Once again, understanding why these ulcers develop is the key to preventing them. Support stockings are available that act as a kind of replacement valve system to keep the blood from backing up. These can be fitted for proper compression. They should be worn during the day and put on before getting out of bed before swelling occurs.

It is important to avoid any trauma to the susceptible skin including sun exposure. Leg shaving should be done with an electric razor to minimize nicks from shaving. Skin moisturizers should be routinely used to prevent skin breakdown, which can lead to ulcers. Washing of the legs should be done with a mild soap and warm water and dried thoroughly by patting the skin dry and avoiding excess skin friction by rubbing with the towel.

Patients with diabetes have several mechanisms at work making them susceptible to ulcer formation. Diabetics have decreased sensation in their legs, or neuropathy, and hence are unaware of repetitive trauma to the same area of the foot. They also often have decreased blood flow, or arterial insufficiency, which further makes them susceptible to skin breakdown. The glucose imbalance of diabetes also makes even minor injury more susceptible to infection.

Understanding these issues can help with effective preventive measures in diabetic patients, including:

• Meticulous attention to foot care and daily foot inspection by the patient are the cornerstone of proper foot care.

• Gentle cleansing with soap and water with gentle drying of the skin followed by topical moisturizers helps maintain healthy skin that can better resist breakdown and injury.

• Thorough nail care and properly fitting shoes are very important in the diabetic patient.

• Because diabetics have decreased sensation, they should exercise great care with exposure to extremes of temperature.

Any of the above patients should have a thorough skin evaluation at the time of healthcare provider visits to evaluate skin integrity and promote good skin care.

These visits, along with patient vigilance, will go a long way to preventing skin breakdown and the resulting patient morbidity and costs associated with these wounds.

Mark Tramontozzi, MD, is board-certified by the American College of Certified Wound Care Specialists and Medical Director of the Backus Wound Care and Hyperbaric Oxygen Therapy Center, which is located in the Backus Outpatient Care Center on Salem Turnpike in Norwich. If you want to comment on this column or others, visit the Healthy Living blog at www.backushospital.org/backus-blogs or e-mail Dr. Tramontozzi or any of the Healthy Living columnists at healthyliving@wwbh.org