Saving Your Skin: What You Need to Know
This section includes basic information that is shared with patients of Toronto Rehab’s Spinal Cord Rehabilitation Program at educational sessions. It should be used along with other resources on the topic of how to prevent skin breakdown.
This section includes information on skin care, skin breakdown, early warning signs of skin problems, and prevention. The more information you have, the better you can prevent skin problems from developing. For skin to remain healthy and strong, it requires oxygen and nutrients which it receives from your blood supply.
Statistics on skin breakdown
- 85% of people with a spinal cord injury develop skin breakdown in their lifetime
- 66% develop skin breakdown on the pelvis
- 15% have skin breakdown on the heels
Causes of skin breakdown included, but are not limited to:
- Moisture
- Stubbed toes
- Sitting on foreign objects
- Sports injuries
- Burns
- Scrapes
- Pressure, shearing and friction
The pelvis area is more at risk because it comes into contact with all equipment surfaces including:
Skin on the heels breaks down because of:
- Shoes
- Sandals
- Casters on wheelchair
- Sheering in bed
Skin ulcers
A skin ulcer is an area of skin or underlying tissue that is dead or dying. It is usually caused by resting on a bony prominence for too long. This cuts off the blood supply to the area.
- Pressure sores
- Decubitus ulcers
- Bed sores
- Skin breakdown
These are the common names for skin ulcers. Think about a garden hose with a kink in it—this is what happens to the vessels when pressure is present. There are not enough nutrients and blood flow to the restricted end, which results in damage to that area.
Hot spots
Skin breakdown generally happens on bony prominences such as:
- Elbows
- Hips
- Ankles
- Shoulder blades
- Sit bones
These areas don’t have much between the bone and skin, so they are more likely to have skin breakdown. The areas with ‘meat’ on them are not usually affected. Even the head can have skin breakdown from lying in bed or from the headrest of a wheelchair.
Stages of pressure sores
Staging a skin breakdown gives medical professionals guidelines for how to treat the area. There are common standards for how to treat each stage and what to look for and consider.
A suspected deep tissue injury has a purple area of intact skin or a blood-filled blister due to damage of the underyling tissue. The area may be painful, firm, mushy, warm or cold.
Stage 1
- A red area indicates that the blood flow is interrupted. You need to find the cause before any more damage is done.
- The redness does not go away even after 20 minutes of removing the cause.
- Usually occurs over a bony area
- People with dark skin should look out for skin turning even darker or lighter (pink) colour as compared to surrounding area. This is the first sign of skin trauma.
- When you press on the area with your finger, it does not ‘blanch’ or change colour. This means there is already skin damage.
Stage 2
- Partial thickness loss of dermis (the lower or inner layer of the two main layers of cells that make up the skin)
- Shallow open ulcer with red pink wound bed
- May also look like a blister. Think about what your skin looks like when you get a blister—the top of the skin is broken down but the wound does not go any deeper than this.
Stage 3
- Full thickness tissue loss
- Subcutaneous fat may be visible
- Bone, tendon, muscle are not exposed
- May have undermining/tunneling
In Stage 3, the wound has progressed into the fatty tissues below the skin. There might be tunnels below the surface, away from the wound opening, that you cannot see but a wound care nurse will find.
What is underneath the hole can be much bigger than you think. The nurse will often make the wound hole much bigger so the wound bed can be cleaned. This will help to heal the wound from the foundation up.
Round edges on a wound indicate a pressure. Look at your equipment as a potential cause.
The hole at the skin surface can be small compared to the hold under the skin. It may look like a small sore but can be very large—you just can’t see it.
Stage 4
- Full thickness tissue loss with exposed bone, muscle, tendon
- Often includes undermining/tunneling
The wound is extremely serious at this stage (see previous stage for information on tunneling). The goal of wound healing is to heal from the inside out.
Unstageable
- Full thickness tissue loss
- The base of the wound is covered by slough and/or eschar
The wound is full of dead tissue and infection, and the nurse isn’t sure how deep the actual wound is. Medical attention is a must. The wound needs the attention of a medical doctor or wound care nurse so that the wound bed can be cleaned and healing can begin.
Healing pressure sores
- It takes 2 years for a scar to mature.
- Healed scar tissue is only 80% as strong as the original skin.
- Healing a wound is much like building a house. The wound bed is the foundation, so healing has to start there. Then the walls are built, and finally the roof is built.
What causes pressure sores?
- Pressure
- Friction
- Shearing
- Moisture
To prevent skin problems, 3 forces need to be managed—pressure, friction and shearing. Add moisture to this mix and skin breakdown will happen even faster and more severely.
Transfers and bowel/bladder challenges add to the risks of trying to keep skin healthy and wound-free.
Try to manage the 3 main forces as much as you can when using all equipment and the materials used to construct equipment (mattresses, cushions, commodes, toilet seats, etc.).
What is pressure?
Pressure = Force
Mass
- Between bony prominences and a hard surface
- Sustained pressure prevents blood and oxygen from getting to the tissues.
Think about spreading the pressure on your skin over the largest area possible. Consider contouring in cushions and emersion in mattresses.
What about friction?
Friction is caused by the rubbing of your skin against a surface or object.
- Sliding in bed (or when a person is pulled up and down in bed)
- Spasms (for example, in bed)
- Transfers
What is shearing?
Shearing occurs when the layers of the skin are pulled in opposite directions. For example—shearing happens when bone moves and skin stays or when skin moves and bone stays. You will notice this most when lying in bed and moving the head of your bed up or down.
Shearing is often caused:
- By sliding in bed
- By transfers
- When tissue layers rub against each other
More about moisture
Moist skin can contribute to skin breakdown because the skin is fragile and mascerated (softened by wetting or soaking). For example, think of when you have been in water for a long time—you get ‘puny fingers.’
What causes moisture on the skin?
- Sweating
- Incontinence of bowel or bladder
- Not properly drying skin after bathing
- Wearing clothing that is not breathable
How to prevent skin breakdown
- Pressure relief for 15 seconds every 15 minutes. Lean forward, side to side, push up, or use the tilt system on your power chair if you have one.
- Good skin hygiene. Keep your skin dry, check skin regularly with a long-handled mirror or with assistance from another person. If someone else checks your skin, ask them to hold a mirror for you to see—use a larger mirror or even a camera to see. Try to use the same person and do the skin checks at the same times of day—consistency is important. You are the best person to monitor for changes if possible.
- Check skin morning and night.
- Limit elevation of head of bed. Raising the head of the bed can add to shearing and friction. Try moving your legs up first or put a pillow under your knees first, before head of bed is raised.
- Use turn or life sheet to reposition.
- Protect skin from body fluids.
If you have a Stage I pressure sore
- Do not rub or massage the affected area.
- Stay off the affected area.
- Call your doctor or health care professional.
- Eat well and keep your body well hydrated.
If you have to stay in bed, consider the following:
- What caused the problem in the first place?
- How can I fix the problem?
- How will staying in bed affect your fitness, mood and energy levels?
Protecting your skin
- Avoid clothes or shoes that are too tight.
- Cook safely. Always protect your lap with lap trays, cutting boards, newspaper, etc. Be careful not to burn your arms on the stove top. If you have to reach across a hot pot or element, be very aware of your skin and positioning.
- Avoid temperature extremes.
- Change your position frequently.
Always monitor the surfaces you are sitting on—wheelchair, commode, toilet, cushion, car seat, etc. for signs of wear and tear that could affect your skin. Be careful to monitor your skin when you are vulnerable :when you are sick, hospitalized, stressed, on vacation or have a change in your routine such as starting school or work, or getting new equipment.