Wounds International February 3(1)Practice Skin integrity update

Skin integrity update

22/02/12 | Skin integrity

Beating blistering through dressing choice

This short report looks at developments in blister prevention through careful attention to wound management and dressing choice, particularly in postoperative wounds. The importance of choosing a dressing that not only maintains a warm moist healing environment at the wound bed, but also protects the periwound area from possible blister formation should not be underestimated. 

Postoperative periwound blistering is a well-recognised phenomenon in orthopaedic surgery and, to a lesser extent, gynaecological surgery[1], occurring when the epidermis is separated from the dermis due to continued friction to the skin[2]. In orthopaedic surgery, postoperative wound blistering has been reported as being caused by the dressing application itself or the type of tape used to hold the dressing in place[3]. Indeed, Tustanowski[4] agrees that inappropriate dressing choice and excessive tape use can cause wound blistering and includes the following as other potential causes:

  • Movement at the wound site
  • Age
  • Gender
  • Type of incision
  • Medications
  • Co-morbidities.


Sanusi[1] states that the development of wound blistering may increase the risk of surgical site infection, require further dressings and increase discomfort, in addition to increasing costs due to delayed discharge and outpatient appointments.

Dressing selection
When choosing a dressing, attention needs to be paid to protecting the periwound area and ensuring that the dressing does not adhere to surrounding skin, that it is easy to apply and remove, and flexible. Flexibility is essential, especially for orthopaedic wounds that are prone to swelling and have an increased risk of friction between the wound and dressing[5]. Using a more permeable dressing can reduce friction, helping to maintain an optimal moist wound healing environment that will reduce pain at dressing changes[4].

Other studies outline[6] how traditional dressing pads secured with tape and newer 'central' pads with an adhesive border can cause wounds to become macerated, whereas vapour-permeable films transmit excess wound fluid as moisture vapour, thus preventing maceration.

Flexibility is an important component of a dressing as it permits movement at the wound site and periwound area. Waring and Butcher[7] discuss the importance of dressing conformability and state that the dressing should behave like a second skin, while recognising that there are factors that influence how a dressing conforms to a patient:

  • Level of adhesion
  • Isometric elasticity of the dressing
  • Dressing thickness
  • Shape of wound site
  • Quantity of exudate held within the dressing.


Prevention of friction has been discussed extensively by Dillon et al[8] who concluded that hydrocolloids (ie Duoderm®, ConvaTec), films (ie Tegaderm®, 3M Health Care) and films plus fabric (ie Opsite® Post-Op, Smith & Nephew) accommodated skin movement sufficiently to prevent excessive friction and contain postoperative swelling.

Dressings that incorporate soft silicone (eg Safetac® technology, Mölnlycke) have been shown to minimise the risk of trauma and pain associated with the use of adhesive dressings[9]. Soft silicone adhesives are described as micro-adherent, forming a seal between intact skin and the dressing and preventing lateral movement of wound exudate onto the surrounding skin, which helps to prevent maceration of the periwound area[9].

The author suggests that the use of skin barrier creams/lotions can be beneficial if applied to the periwound area before dressing application, helping to prevent potential skin damage from moisture and excess exudate.

Conclusion
Despite the amount of literature available on dressing choice, there does not appear to be international consensus on the prevention and treatment of wound blisters. There needs to be more research in this area to explore dressing and skin protection interventions that can help to reduce the incidence of blisters. Additionally, there needs to be clear education for all clinicians involved in wound care, including any member of the multidisciplinary team involved in the assessment, planning, treatment and evaluation of the wound and periwound area. Sanusi [1] concludes that incorrect application of wound dressings resulting in painful blistering is 100% preventable and should never be permitted to develop on patients.


Karen Ousey is Reader Advancing Clinical Practice, University of Huddersfield, UK.

  1. Sanusi AL. Severe wound traction blisters after inadequate dressing application following laparoscopic cholecystectomy: case report of a preventable complication. Patient Saf Surg 2011; 5(1): 4.
  2. Cuzzell J. Clues: bruised, torn skin. Am J Nurs 1990; 90(3): 16-18.
  3. Gupta SK, Lee S, Moseley LG. Postoperative wound blistering: is there a link with dressing usage? J Wound Care 2002; 11(7): 271-73.
  4. Tustanowski J. Effect of dressing choice on outcomes after hip and knee arthroplasty: a literature review. J Wound Care 2009; 18(1): 449-58.
  5. Ousey K, Gillibrand W, Stephenson J. Understanding and preventing wound blistering. Wounds UK 2011; 7(4): 50-56.
  6. Aindow D, Butcher M. Films or fabrics is it time to re-appraise postoperative dressings? Br J Nurs 2005; 14(19): S15-20.
  7. Waring M, Butcher M. An investigation into the conformability of wound dressings. Wounds UK 2011; 7(3): 14-24.
  8. Dillon JM, Clarke JV, Deakin AH, et al. Correlation of total knee replacement wound dynamic morphology and dressing material properties. J Biomech 2007; 40(Suppl 2): S61.
  9. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005; 4(1): 14-22.

 

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