Skin Care and SCI/D

By Tom Scott

Skin damage is a common secondary condition that many individuals with spinal cord injuries and disorders (SCI/D) encounter. This damage is usually caused by pressure sores, also referred to as pressure ulcers, ischemic ulcers, decubitis ulcers, or bed sores. Pressure sores occur when an excessive amount of pressure is placed on an area of skin for long periods of time (i.e, sitting or lying down) resulting in the loss of blood flow and the eventual death of the skin and underlying tissue. They can also occur from friction or shearing, meaning your skin moves one way and the bone underneath moves in the opposite direction (i.e., poor sitting posture). Pressure sores can form in as little as two hours, usually over bony areas of the body, such as the hips, tailbone, ankles, and heels. They have also been medically documented throughout human history. Scientists have even found evidence of them in unearthed mummies.

Stages

There are four widely-accepted stages of pressure sore damage within the medical community, which include:

Stage I-Skin becomes red or discolored, but not broken. The change in skin color does not go away 30 minutes after pressure is removed. This may be the first sign of tissue destruction.

Stage II-Pressure continues to be applied to this area of skin starving it of blood and causing its outer layer to die. You will notice the red/discolored area has now turned into a blister or superficial ulceration. You may also begin to notice a foul odor from this area.

Stage III-If left untreated, the infection penetrates through deeper and deeper layers of skin forming a crater.

Stage IV-All layers of skin are now lost, exposing muscle and bone in the infected area.

Note: Not all pressure sores follow standard stages of progression or regression. Consult a physician for proper diagnosis.

Risk Factors

If you have dealt with a stubborn pressure sore in the past, you’re not alone. Researchers estimate that approximately 80% of individuals with SCI/D will have at least one pressure sore during their lifetime, and 30% will have more than one. Why does SCI/D increase your risk of developing them? SCI/D slows blood circulation through your body and affects its ability to heal. Reduced sensation to some parts of the body due to SCI/D can also cause skin damage and its associated pain to go unnoticed allowing a sore to persist.

It’s often difficult to treat pressure sores once they form. Even with proper medical intervention and treatment, they can take many months to heal, and in some cases, may still cause severe complications such as blood infections. The death of actor Christopher Reeve, founder of the Christopher Reeve Foundation and co-founder of the Reeve-Irvine Research Center was allegedly linked to an infected pressure sore that caused bacteria to enter his blood stream.

A Focus on Prevention

The treatment of pressure sores costs billions of dollars annually, yet there is no universally accepted practice of prevention. Although, most health care professionals will agree that the key to avoiding pressure sores is to avoid the pressure associated with them. That’s why pressure sore prevention is big business. There are over 75 companies that sell pressure-reduction devices

(i.e. foam devices, air-filled devices, low-airloss beds, and air-fluidized beds) with annual industry revenues in excess of $8 billion. Visit United Spinal’s USA TechGuide Web site (www.usatechguide.org) for detailed information and reviews on different types of pressure-reduction devices.

Here are some simple preventative steps you or your caregiver can take to limit your risk of getting a pressure sore:

• Frequently change position when sitting or lying down• Live actively and exercise regularly

• Inspect skin daily and keep pressure off any red or discolored areas

• Use pressure-reducing bed and wheelchair aids (i.e., use special mattresses and seat cushions made with sheepskin, foam, gel or air)

• Clean and dry skin that becomes wet—excessive moisture can lead to skin break down and cause sores to develop

• Massage skin in areas susceptible to pressure sores two to three times daily to increase blood circulation

• Drink plenty of water daily

Treatment Options

After a pressure sore develops a multi-disciplinary approach may be needed depending on the extent of damage to the skin and underlying tissue. Treatment focuses on 1) pressure relief, 2) infection control, 3) nutrition, and 4) surgical intervention.

The initial goal in pressure sore management is to relieve the pressure associated with the infection in order to ensure effective treatment and the prevention of future sores. The next step in treatment is to control skin damage and enable healing and recovery, which is achieved by thoroughly cleaning the area with a sterile solution and forming a protective barrier against bacterial contamination by dressing the wound. Wound drainage and absorption is also vital in the healing process.

If wound contamination does occur, a tissue biopsy is often taken to find out what type of bacteria is present and what type of antibiotic should be administered, if any. Nutritional supplements, such as protein, zinc and Vitamin C may also be administered.

Most Stage I pressure sores do not require a wound dressing, but it’s still important to have a physician supervise treatment of the wound. If confined to the epidermis or dermis (layers of skin), treatment of Stage II sores may include use of a hydrocolloid occlusive dressing (DuoDerm®), which helps maintain a moist environment so tissue can restore itself; foam dressings that absorb drainage, such as Restonâ„¢ and BIOPATCHâ„¢; collagen dressings, such as BGC Matrix® or FIBRACOL®, to stop bleeding and aid healing; absorptive dressings, such as Mediporeâ„¢ and Iodoflexâ„¢; and hydrogel dressings, used to keep the wound wet and to absorb drainage, including Tegagel and NU-GEL. A large variety of treatment options are available for advanced pressure sores (Stage III and IV), including wet-to-dry dressings, incorporating isotonic sodium chloride solution or dilute Dakins solution (sodium hypochlorite), Silvadene®, Sulfamylon®, hydrogels (Carrington Dermal Wound Gelâ„¢), xerogels (Sorbsanâ„¢), and vacuum-assisted closure (VAC) sponges. Daily whirlpool use also may serve to irrigate and mechanically debride (clean) the wound.

With proper medical treatment a majority of pressure sores at Stage I and II will heal on their own, however Stage III and IV may also require surgery. In such cases, healthy skin is removed from other parts of the body and transplanted, or grafted, over the sore.

There is also an ongoing study into whether anabolic steroids could effectively heal recurring pressure sores in persons with SCI, co-chaired by Dr. William A. Bauman and Dr. Ann M. Spungen of the James J. Peters VAMC in the Bronx. It is the first

study to combine the resources of the VA’s Cooperative Studies Program with the Rehabilitation Research & Development Service, as well as the first cooperative study to involve the VA’s SCI Services.

The proper treatment and management of recurring pressure sores is a lifetime battle for some people with SCI/D. Education is an important aspect of prevention, as is maintaining a healthy, active lifestyle, taking the proper precautions to avoid subjecting your skin to excess pressure, and visiting your physician regularly.

Pressure Sore Facts-University of Florida College of Medicine

• Two-thirds of pressure sores occur in patients aged > 70 years.• Eighty-three percent of hospitalized patients with pressure sores developed them in the first 5 days of hospitalization. The largest number occurred on the day of operation.

• The prevalence rate in nursing homes is estimated to be 17-28%.

• Among neurologically impaired patients pressure sores occur at an annual rate of 5-8%, with lifetime risk estimated to be 25-85%.

• Pressure sores are listed as the direct cause of death in 7-8% of paraplegics.

• Hospitalized patients have a 3-17% incidence rate, while hospitalized surgical patients have a 12-66% incidence rate.

• Immobilized patients in long-term care facilities have a 33% incidence rate. Some estimates suggest that 60,000 people die from pressure sores or their sequelae per year.

• Recurrence rates for pressure sores maybe as high as 90%.

References

Bansal, C., Scott, R., Stewart, D., & Cockerell, C. (2005). Decubitus ulcers: A review of the literature. International Journal of Dermatology, 44, 805-810.

Revis, D. (2005). Decubitis ulcers. E Medicine from WebMD. www.emedicine.com/med/topic2709.htm.

The Merck Manual of Health and Aging, Section 3, Chapter 35. Pressure Sores. www.merck.com/ pubs/mmanual_ha/sec3/ch35/ch35g.html.

SCI-Info-Pages. Spinal Cord Injury—Skin and Pressure Sores. www.sci-info-pages.com/skin_pres.html.

Sisk, B. (2002). NurseScribe Pressure Sore Update. www.enursescribe.com/pressuresores.htm

Tom Scott is staff editor.