When attempting to manage a pressure ulcer it is easy to focus attention on the wound while overlooking the periwound area. However, although managing vulnerable periwound skin presents the clinician with a set of unique challenges, effective treatment can prevent unnecessary skin breakdown. This article examines management techniques, including pressure relief, the use of barrier creams and exudate control.

INTRODUCTION
Pressure ulcers can result in extensive damage to tissues, cause pain and negatively affect a patient's quality of life. Clinicians must recognise that the skin surrounding a pressure ulcer is also vulnerable and needs careful assessment and management [1].


PRESSURE ULCERS AND SKIN BREAKDOWN
Pressure, shear and friction can all result in occlusion of the arterial circulation in the dermis. When pressure is relieved and the area is reperfused, the circulatory system can overcompensate for the recent lack of oxygen and the area of skin affected can become hyperaemic. The cycle of obstructed circulation and reperfusion results in an increase in reactive oxygen species in the tissues, causing inflammation (the skin becomes red).

Where the damage is permanent, the area will remain red even with the application of pressure – this is known as non-blanchable erythema and indicates that there is a persistent inflammation in the skin resulting in the development of a Stage 1 pressure ulcer.  This inflammation, coupled with reduced circulation, can also make the periwound tissue more vulnerable.

A recent innovation in relation to pressure ulcer pathophysiology and skin integrity is new clarity in the understanding of role of microclimate in the context of pressure ulcers. This has been explored in an international consensus document, which states that 'excessive skin moisture and high relative humidity weaken skin and increase the likelihood of damage from pressure, shear and friction'. The document asserts that efforts should be made to control extreme temperature or skin moisture and provides a number of practical suggestions [2].


PRESSURE ULCERS AND MOISTURE LESIONS
It is sometimes difficult to distinguish the difference between a superficial pressure ulcer and other forms of skin damage. This includes skin damage caused by skin conditions such as incontinence-associated dermatitis. Incontinence-associated dermatitis is one of a number of causes of moisture lesions [2].
 
It is important to identify whether a lesion is a pressure ulcer or a moisture lesion in order to provide the correct treatment. If the lesion has been caused by moisture it is important to control urinary and faecal incontinence; if the lesion has primarily been caused by pressure offloading is key; and if the lesion is a result of damage from wound exudate then dressing procedures targeted at effective exudate management are an important priority. In all cases, the protection of the skin with emollients, zinc paste and protectors are essential (see below). Table 1 details the main differences between pressure ulcers and moisture lesions [3].

Table 1 – The differences between a pressure ulcer and a moisture lesion [3]