Dr. Jeannine Maguire: Welcome to this presentation, Protecting Fragile Skin in Wound Care: Techniques, Products, and Best Practices. This presentation today is brought to you by Halyard as well as PAWSIC. I'm the president of PAWSIC. My name is Dr. Jeannine Maguire, and PAWSIC is the Post-Acute Wound & Skin Integrity Council. We are an interprofessional team that seeks to create standards and care and guidelines for all wound types under the auspices of patient-centered care, bringing the interprofessional approach alive all through the lens of the nuances in post-acute care. 

I'm so excited to introduce our esteemed presenter, Dr. Wahab. Dr. Wahab is the owner of Wound Care Experts, serving patients today in Las Vegas. Dr. Wahab is a member of many different organizations, including the American Professional Wound Care Association, as well as a member of the Alliance of Wound Care Stakeholders and many more. Without further ado, let's turn this presentation over now to Dr. Wahab. 

Dr. Naz Wahab: Welcome to HealHorizon and PAWSIC. I appreciate everyone showing up. We want to actually talk today about Protecting the Fragile Skin in Wound Care: Techniques, Products, and Best Practices. I'm Dr. Naz Wahab. 

Some of our learning objectives that we will be talking about today is really identifying the unique factors, challenges of fragile skin in wound care, why is that important? We need to discuss the key techniques for protecting fragile skin, evaluate the various skin protection products, and discuss best practices for selecting those appropriate products and helping our patients protect their skin and skin integrity. 

So what exactly is fragile skin? I think we use this terminology quite frequently, but what really is it? It really refers to the skin that has an impaired barrier function and reduced elasticity, making it much more vulnerable to injury, irritation, breakdown. This condition occurs when the structural integrity of the skin is really compromised. The skin is unable to withstand mechanical stress or balance homeostasis, and that would also be part of the definition of fragility in the skin. And also in this state, when the skin is compromised, the skin becomes very vulnerable to external and internal mechanical forces, possibly resulting in tissue breakdown. 

So what are the contributing factors to skin fragility as well? I think we need to take a thought about skin just being an organ like any other organ, like we have the heart, the brain. The skin is our largest organ and it's susceptible and has the same contributing factors to its fragility that any other organ does. So aging, malnutrition, environmental exposure, and medical conditions and medications. 

So aging, I think because the skin is on the outside and we're constantly looking at ourselves, we're noticing this aesthetically that the skin is thinning of the epidermis and dermis. There's reduced sebaceous gland activity and slower cell regeneration. Malnutrition—we talk about this quite often when we're dealing with wound care and regeneration of tissue—but malnutrition, deficiencies in both macronutrients and micronutrients, really play a large role in skin repair and maintenance. Environmental exposures, just as if we have environmental exposures to sunlight, UV radiation, low humidity, too high of humidity, extreme temperatures, this can damage, dry out the skin, make it too moist, and then again, the skin integrity is lost. And then you have the medical conditions such as diabetes, vascular disease, long-term steroid use. Long-term use of any medications can cause some skin integrity issues as well. 

So what are the clinical implications? Why do we even care? Because there's an increased risk of skin tears we see as the aging population and also just with the population of people who are having delayed wound healing. And then we also have a greater susceptibility to infections and complications. We don't think of some of these small abrasions as being something big, but in the end, many of these skin-compromised situations that may be a bit undervalued turn into huge and large problems in the hospital and for wound care in general. 

Factors influencing skin integrity. Again, I think one of the things that we don't think about as much is the patient's hydration. And not just hydration as an external, but intravascular hydration. Where in the body is the fluid? Are we third-spacing that fluid? Are we actually maintaining fluid balance within the skin and the layers of the skin that need it the most? Nutrition, again, very important. Macronutrients, micronutrients. We're going to go into some of these in greater details in the upcoming slides as well. Exposure to toxic substances, medications, and skin tissue perfusion. That's something that we need to be thinking about. Again, as the skin is an organ, just like any organ, we need enough oxygen to that organ and we need enough blood flow to that organ. We need enough cellular signaling to that organ. If we start thinking about the skin as an organ, I think we will have a different approach to how we're utilizing the rest of the patient's bodily vital signs, their labs, etc and how we can utilize it to treat their skin. 

I think one of the things that we need to talk about is total caloric intake. We should be getting about 30 to 35 kilocalories per kilogram of ideal body weight. And the name of the game is to really avoid catabolism. What is catabolism? Catabolism is where the human body is actually breaking down its own proteins, and that's muscle. So if we're not actually giving the body enough caloric intake, then the body will actually start breaking down our own muscles in order to maintain those calories to utilize for our organs. So it's important not to have any kind of calorie restriction, particularly when patients are very sick in the hospital. 

It's also important to look at the macronutrients as a whole—proteins, fats, carbohydrates. We tend to really focus on proteins. We need about 1.2 to 1.5 grams per kilogram of ideal body weight, but the fats and the carbohydrates are just as important. And if we are eating too much protein, not enough fats, not enough carbs, there will be an imbalance in this as well and leads to a skin integrity issue. So it's very important to make sure our macronutrients are balanced.  

Micronutrients, those are the vitamins. So vitamins A, C, D, E, zinc, but micronutrients are very important. Are we absorbing those micronutrients and are we getting enough of them? So just because we're eating enough and we're getting the caloric intake and we may be getting enough protein, are we also getting enough fruits and vegetables that can deliver the correct micronutrients to us as well? So these are things that we should be working together with the dietary program in the hospitals and in the outpatient to help our patients get better nutritional value for skin integrity. 

Adequate hydration, this is something, again, I think we underestimate. We don't think about these things particularly in the hospital. The average water intake needed to maintain a healthy skin is about 3.7 liters for adult men and about 2.7 liters for adult women. But this applies to really healthy, sedentary people in moderate climates. 

Maintenance of the skin turgor and skin compliance really has to do with also salt and potassium intake. If we have a reduced consumption of salt coupled with an increased consumption of potassium intake, this can actually blunt the age-related rise in blood pressure. But what that ends up doing is also causing some skin integrity issues. And so we really need to be having a more balanced diet in which we don't overdo sodium, but we don't also use sodium substitutes, which tend to be potassium, to overdo that as well. Fruits and vegetables are both low in sodium and high in potassium, and it's a natural way to absorb and keep absorption and hydration in the skin. And of course, having a plethora of different types of foods such as spinach, cantaloupe, almonds, other types of vegetables and fruits, particularly water-filled fresh vegetables and fruits. 

I take a long time counseling my patients, particularly the elderly patients. We tend to live in a very hot and dry environment. Because of the medications they're on and just simply as the aging process, they tend to be very dehydrated. And also because patients don't want to walk to the bathroom, don't want to continue taking some of their diuretics or they're over-diuresed, these play a huge impact in skin integrity, and it slows down the wound-healing process. I take time to tell them that they should be eating water-filled fruits and vegetables and also seeds. These things help to create intravascular hydration versus just taking a lot of water in. 

Chronic kidney disease, we should just be pretty, understand that the only, is recommended is 4.7 grams per day of potassium. Again, that's because of the kidney and the decreased excretion, but also understand which layers of the skin are most needed to maintain some of this hydration. And that's really the outer layers of the epidermis, which retain a lot of water and maintain the hydration and health. So also external types of lotions and creams that can maintain that integrity is important.  

So the nutrition for the skin layers, again, the epidermis is the thinnest layer of the skin, and the dermis is the thickest layer, but both require that hydration. The dermal layer contains the collagen and elastin, which provides that thickness and support of the overall structure. The dermis and the hypodermis contain the connective tissues which have the nerve endings, sweat glands, oil glands, and hair follicles. When we have excessive moisture loss, then we have the lack of collagen. We have poor blood supply, poor nerve innervation, and this leads to a decrease in cell resistance and finally, loss of skin integrity. 

So as you can see, it's really important. We just take for granted that perhaps patients are neuropathic. We take for granted that patients may not be sweating as much or over-sweating or have an autonomic dysfunction. These are all leading to hydration issues and skin integrity issues in that skin. And we should be addressing that more aggressively as clinicians. 

So who are the populations most at risk? The elderly and usually the neonates. Elderly tend to have a very thinner skin, loss of collagen, decreased hydration, increased susceptibility to tears and wounds. And then the neonates and the newborns on the other side, their skin is very immature and it's much thinner than adults’. Their underdeveloped barrier function really make it more permeable and delicate. 

So moisture, balance, and temperature, why is this important? We tend to talk about, patients go into the hospital. They have lots of blankets on. They like to stay very warm. Because there's a nutritional issue, there's a loss of hydration through their skin also. So there's a lot of temperature regulation issues happening when people are sick. And this is something we should be looking at, particularly in ICUs and even in the rest of the hospitals and post-acute facilities. But the optimal skin temperature for maintaining skin integrity is roughly about 33 to 37 degrees Celsius. The range allows the skin to function properly, including maintaining moisture and regulating blood flow, which is really crucial to healthy skin. 

There's some newer things that we've seen, which has been very interesting on the market. There's a transepidermal water loss evaluation system. And what it's really doing is looking at the ability to see how much water is in the stratum corneum and looking at that hydration scale. And so these devices sometimes on the market can give us an idea if the skin is compromised. And if it's compromised, then are they more susceptible to getting a wound? 

And there's some studies out there. The one in particular that I'm referring to here is Mifsud. And in 2022 in Advances in Skin and Wound Care, you can see that they did a systematic review of 11 studies, and they wanted to see whether the increase in skin temperature led to a decrease in skin structure and function. And what they did was they actually had a prolonged loading time, so pressure of 45 minutes, and at increased pressure, there was an increase in temperature, about 1.7 to 3.1 degrees Celsius in the sacral area and about 1.9 degrees Celsius in the heel. And did that have an impact on the transepidermal water loss or the stratum corneum hydration scale? And yes, it did. 

And so what that really showed us is that there was a loss in skin integrity with an increase in temperature and an increase in pressure. And so when we take that back to our clinical evaluation, when patients are being left in the bed for long periods of time in the same place, not being moved, under a lot of blankets, the temperature in the room is very warm, and their temperature, body temperature, is increasing. That's really leading to skin integrity issues as well. So something we should be thinking about as clinicians. 

Exposures to toxic substances. We think of UV light or other chemical burns, but in reality, exposure to bodily fluids is like the same thing as a chemical burn. So we should be really maintaining the removal of all of these toxic substances, because what these things can do is change the pH and create an increased inflammatory response in the skin, which leads to increased temperature, loss of moisture, and finally, loss of skin integrity. We need to avoid the external moisture such as urine, feces, sweat, third spacing when patients are just leaking through the skin. This is all altering the temperature, the moisture, and the pH of the skin, which again, as clinicians, and we can monitor this and we can do something about it. Instead of just adding a cream or a lotion on top of the skin, we really need to be combating this and recognizing this from the inside as well. 

pH for optimal skin integrity. What is the optimal pH? It usually falls between the levels of 4.7 to 5.75. This is slightly acidic. Those of us that have been doing wound care for a long time understand that when we slightly acidify the wound bed, we actually, it's moving towards wound healing. So I think it's because we're moving it towards the natural skin pH as well. What's so important about this natural skin pH? Well, we notice that when we have too much of an acidic environment, when we move the pH to about 4 to 4.5, that actually creates an overgrowth of the natural flora, which then become more pathogenic. And then also if we have too alkaline, that also leads to the inability for some of these bacteria to leave the skin or to use it as true natural skin flora. So we have to have skin pH in that 4.7 to 5.75 is really our goal. 

Avoiding the external moistures, like we talked about, is very important. Using lotions and creams are important. As emollients, that could help with the skin barrier. But again, if we're not removing the toxic substances, it doesn't matter what we do externally. We really have to remove those toxic substances and change that pH. But looking for topical products, such as creams, lotions, emollients, that are natural to our natural pH, that are not too alkaline and not too acidic, are also very important as product choices. And of course, avoiding dryness, dehydration, topical cleansers that should be pH balanced is very important when we're choosing our products. 

Prevention, first-line approach, we need to minimize friction, shearing forces, and maintain moisture. I think that's very important. That should be our first-line approach. Second, what we're doing is we have to reposition the patient. Any kind of pressure, like we talked about, is going to cause an increase in temperature, is going to cause also skin integrity issues. And we do need to obviously have healthy hygiene practices where we're removing toxic substances and we're replacing the skin with pH-balanced cleansers and lotions and emollients to maintain that skin integrity and hydration. 

Skin protection products, what are the categories that we're looking at? We look at barriers, so moisture barriers. So if obviously the patient is incontinent, we can't get to them all the time. We need to look for, one, materials close to their skin that are wicking away, but also things that we're using on their skin should be helping avoid the moisture getting in, the toxins and the over-moisture getting into their skin. So they're actually liquid skin protectants and barriers. Silicone-based adhesives, they're helpful because they're kinder to the skin, especially when removing. And also to help sliding if there's friction forces, the silicone-based creams and adhesives tend to be easier on the skin for shearing forces; but again, not all patients can tolerate them. 

And then we also should be looking at wear time, ease of use, and compatibility. If we're constantly removing an adhesive off the skin every, 2, 3 times a day, this is going to impact the skin integrity. If we're unable to get it off because the adhesive is too strong, that's going to impact skin integrity, and it really needs to be compatible with the patient and the patient's skin and their clinical scenario. 

So what are the best practices for product selection? Again, we should be looking at that skin integrity. We should be looking for comfort, patient comfort, and cost-effectiveness. Some of these products can be extremely expensive, and if you're having to use them constantly or they're not cost-effective, then they're really not going to be able to be continued and used all the time. And so cost-effectiveness is something we need to be looking at. 

And one of the greatest things is ensuring staff training and consistent application. I tend to really want to involve our, not just nursing staff, but our CNA staff and all staff who are looking, who are coming to the patient, who are cleaning, and also caretakers. Caretakers are doing this. If we don't train them appropriately on how to use some of these barriers—some of these creams, adhesives—that can also cause skin integrity loss just because of lack of knowledge. 

So we need to also talk about moisture-associated skin damage. That is MASD for short. And what is this? It's usually the skin is repeatedly exposed to moisture—leading to inflammation and tissue erosion—such as urine, feces, sweat, third spacing from the body. It was interesting that there was this Norwegian study from Johansen in 2020, which revealed... It was a Norwegian multi-center, one-day prevalence study to look for MASD in ICUs. And the interesting part is that someone actually looked at this. We assume and we take it for granted that yes, when we're exposed to these toxic substances, there's more MASD, but they actually quantified it and were able to find that actually feces, particularly liquid and semi-liquid types of feces, were more toxic than even urine and caused more MASD and likely in the pelvic area. 

It was interesting also, countries with the fewest MASD incidences though were associated with greater urinary catheter use, higher nursing skill level, and usually a one-to-one nurse-to-patient care. I think those are obvious things too, but to actually quantify it and look at it and say that we should be using this in our hospital systems or our post-acute systems is very important. 

Then there's medical adhesive-related skin injury. This is MARSI. Skin injuries caused by adhesives used in the medical settings. We're using a lot of adhesives now to keep down ET tubes, to keep down IV tubing, whatever. Even our Foley catheters, we're using a lot of adhesives on the skin. These can be very injuring to the skin, especially if, we've already talked about that fragile skin. It was interesting also, another study that in 2023, this was a part of two Brazilian hospitals looked at MARSI, and they saw that there was an incidence of about 42% of medical adhesive-related skin injury, which again, if we think about it, but did we ever quantify it? And I appreciate that someone has taken the time to try to quantify these things, because it's important. 

And then what are the risk factors? Because now what we have to do is actually restratify these patients. Should we be using a medical adhesive on them or not? And so they notice that patients with advanced age, prolonged hospital stay, dry skin, repetitive adhesive removal, a low Braden score, hypoalbuminemia, were all really associated with a higher incidence of the MARSI. Again, there was nasoenteral catheters seem to be the highest incidence in this particular study. We also have noticed that in the places where I practice. A higher incidence in catheters fixed with adhesives using natural rubber as well. And then there were the types of MARSI that were more predominant was really a mechanical or skin stripping. And then less common was more of a tension injury or blister. And this again, is just one study, but interesting for us to see that there is data out there over some of these things that we've been talking about, but we haven't been able to quantify in the past. 

So what are the risk factors again for MARSI? Patients over 50 are at higher risk, dry skin to edematous skin, a history of a previous MARSI are also risk factors. Any types of skin allergies, external fixation devices, transparent dressings can increase the risk, and then surgical procedures. Patients undergoing especially spinal surgery tended to have a higher incidence of MARSI. 

Evidence-based use of products. Again, we need to address the fact of who are the patients that are getting the MASD? Who are the patients that are getting MARSIs? What are the risk factors? Address them. How do we prevent it? Do we use barriers? Do we just not use adhesives? Do we limit the amount of adhesives? Do we risk stratify the patient to understand who we can use the adhesive on? I think these are all things that we should be thinking about and doing in our own practice settings. And then we have to match that product to the clinical scenario. It's very difficult to give any one product. You really have to individualize this to the patient, their risk level, and what the clinical scenario really is. 

Medications, we always knew that medications causes cutaneous complications. We always told our young ones who perhaps were on some type of acne-type medications, “Don't go in the sun without sun protection,” because we know that that will irritate the skin. So why wouldn't all different types of oral medications or topical medications not also cause some of these skin integrity issues? They absolutely do. Antibacterials, antihypertensive, analgesics, tricyclic depressants, antidepressants, antineoplastic drugs, diuretics, oral diabetic agents, NSAIDs, and steroids, those are just some of them, but as we know, we just have to be cognizant and limit polypharmacy as much as possible for the skin integrity. 

Skin tissue perfusion, this is extremely important. This should, in my opinion, be a lecture all in its own. We need to start thinking about the skin as an organ. This is macro. We need to look at what is the skin blood flow macrovascularly and microvascularly. Are we getting enough blood flow to the organ, which is the skin? Are we getting an adequate hemoglobin-oxygen carrying capacity, again, to the organ, which is the skin? In this case, if you're anemic, which so many patients are in these hospitals, they don't have the adequate hemoglobin-oxygen carrying capacity. And so fixing the anemia is really important. 

Do they have an adequate cardiopulmonary oxygenation? Again, thinking back into a patient in the ICU, if they have ARDS, if they're respiratory compromised, they're intubated, or they haven't... perhaps a low ejection fraction. These are things that are really important in understanding that the skin is an organ and if you don't get the nutrients to it, it too will die or be compromised. Again, adequate cardiopulmonary perfusion pressures. If you have a low ejection fraction, if you have right heart failure, these things are very important. And looking at the pressures, especially if you're in an ICU setting, and maximizing that will help not only with organ perfusion to the brain and the heart but we need to start thinking of organ perfusion to the skin, or excuse me, blood perfusion to the skin as an organ. 

External pressure should also be limited to about 12 to 15 millimeters of mercury if the patient is not moving. So in the ICUs or in the hospitals or when the patient is immobile, we need to be looking at the surfaces, the external surfaces that they're sitting on, they're laying on, and constantly be moving them so that they don't accumulate pressures greater than 12 to 15 millimeters of mercury, because that will also lead to poor skin integrity in multiple ways and will also lead to poor skin tissue perfusion. So again, food for thought and something we should be really managing as clinicians more aggressively. 

So the summary and takeaways, really we need to start with nutrition, moisture balance, hydration, what's optimal pH, removing any toxic substances. Let's look at polypharmacy. What are their medications? Can we remove some of them? Are some of them actually inhibiting skin integrity? And what is the skin tissue perfusion? Are they getting enough blood flow? Are they getting enough oxygenation to the skin? We need to be mindful of the product selection. We need to risk stratify the patient, look at the specific clinical scenario, and then choose the right topical product or product selection for that particular problem and patient. And then also, as with any other organ of the body, the skin requires a multidisciplinary approach. We need both prevention and we need treatment, and we need to keep both of those in mind when we're really looking at treating the patient holistically. 

So I appreciate everyone. Thank you for watching HealHorizon and talking about skin fragility.