Dermatology: The skin and periwound skin disorders and management
The skin and periwound skin disorders and management
a
Woo KY, PhD, RN, ACNP, GNC(C), FAPWCA b Ayello EA, PhD, RN, ACNS-BC, ETN, FAPWCA, FAAN a Sibbald RG, MD, FRCPC(Med)(Derm), MEd, FAPWCA
a
Wound Healing Clinic, Women’s College Hospital, University of Toronto, Toronto, Canada b Excelsior College School of Nursing, Albany, New York, USA
Correspondence to: Dr Elizabeth Ayello, e-mail: [email protected]
Keywords: periwound complications, maceration, moisture-associated skin damage (MASD), skin protectants, skin barriers
Abstract
As the largest visible organ of the body, the skin serves many important functions that are sometimes undervalued. There are many threats
to the skin’s integrity including aging, wounds, skin tears, and moisture-associated skin damage (MASD) with an aetiology of incontinence
associated dermatitis (IAD), or wound exudate leading to periwound maceration. Water and moisture balance are both vital to maintaining
the skin’s normal acid mantle and integrity. Skin that is too wet or too dry is in danger of breakdown and bacterial invasion. Clinicians need
to identify the aetiology of the skin problem and then follow a corrective plan of skin protection. This can include the selection of dressings
that match the level of exudate from the wound as well as changing the dressing at the right frequency, use of physical skin barriers such as
zinc oxide, ointments, creams, film forming liquid barriers, adhesive dressings, and fluid managers, skin cleansers, and moisturisers. After
a brief overview of some of the common periwound skin disorders, this review article provides a succinct review of management options
illustrated with some clinical photos.
Wound Healing Southern Africa 2009;2(2):43-48
The skin as a vital organ
Figure 1). Conditions which affect the anchoring of the epidermis at
the basement membrane such as normal aging or diseases such as
the four types of epidermolysis bullosa underscore the importance of
an adequate junction of these two skin layers.
The skin is the body’s largest visible organ. Even though diseases
in other body organs such as the heart, kidneys and liver result in
symptoms that can be readily identified by changes in the skin,
the importance of the skin is sometimes undervalued. Yet the skin
performs many important functions, including:
• Protects against infectious pathogens, ultraviolet light, harmful
chemicals and other noxious substances
• Prevents fluid/electrolyte loss
• Facilitates vascular thermoregulation
• Provides protective sensation and painful signals indicating
injury
• Participates in the synthesis of Vitamin D in the presence of
sunlight and ultra violet radiation needed for the absorption of
calcium and phosphate1,2
Figure 1: Schematic representation of the epidermis and dermis basement
membrane junction
The right balance of water and moisture is vital to maintaining skin
integrity. Typically, clinicians evaluate the presence of water in the
skin cells by testing the skin turgor. In research, transepidermal
water loss (TWL) is often measured to indicate the movement of
water through the epidermis. Rates of TWL are proportional to the
severity of skin damage caused by chemicals, mechanical insult, or
pathological conditions. However, TWL is also affected by several
factors such as humidity, temperature, time of the year (e.g. in
some parts of the world that are cold in the winter people have skin
dryness or “winter itch”) or the hydration status of the skin. Normally
the stratum corneum has a moisture content of from 10–15%. When
it drops below 10%, the skin becomes dry, cracked or fissured.
This can compromise the skin barrier function and lessen the usual
protection function of the skin.
The skin is composed of several layers, with the most superficial
cellular layer being the epidermis. Although in lay language we hear
the phrase “that someone is thick skinned”, the skin is actually very
thin (about 0.1 mm) in most parts of the body. Only the skin on the
palms of the hand and the soles of the feet are thicker at one to
two mm. This is probably nature’s way of providing protection from
the stresses of walking and using the hands in various activities.
The epidermis is made up of keratinocytes that migrate from the
basal layer through the stratum granulosum to the stratum corneum
where the dead keratinocytes are shed off the skin surface. Clinically,
you might see these as desquamated flakes of skin on the patient’s
bed sheet.
The epidermis has no blood vessels so it gets its nutrients from the
layer below it called the dermis. The point at which the epidermis
is attached to the dermis is called the basement membrane (see
Wound Healing Southern Africa
A breach of the skin’s integrity can result from a variety of insults
and cause a range of consequences, some of which can be life-
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Dermatology: The skin and periwound skin disorders and management
threatening.3 Skin breakdown is very debilitating,4 with the elderly
having a lower threshold for compromise. Aging affects the skin by:
• thinning the epidermis, dermis, and subcutaneous layers
• reducing epidermal turnover, increasing time to healing,
decreasing the injury response
• compromising barrier function as the rete pegs lose their
depth resulting in a loosening of the normal anchoring of the
epidermis to the dermis through the basement membrane
• delaying chemical clearance rate and reduced sensory
perception
• decreasing immune function, vascular responsiveness,
thermoregulation, and the production of sweat, sebum, and
vitamin D1,5,6
Excreted body fluids (faecal or urinary incontinence) are responsible
for the most common breaches of skin integrity in institutionalised
elderly.10 Wound exudate that is not contained may also macerate
and lead to skin erosions and ulceration.11 The body’s waste effluents
can be particularly caustic to the skin. For example, faecal material
contains more than 500 different organisms many of which produce
contact irritants in their secretions.12
Moisture associated skin damage (MASD)
Several articles13–16 have attempted to bring clarity to the language
and understanding of causes of moisture damage to the skin. These
authors have proposed the term Moisture Associated Skin Damage
(MASD). This global term of MASD encompasses the various
etiologies of moisture that can cause skin problems. This moisture
damage may include:
Clinically, the skin appears paler, more fragile, thinner and drier
in the elderly population. The body feels cold as the skin’s ability
to regulate surface temperature is diminished. Areas of vascular
permeability to red blood cells lead to elderly skin discolouration
called senile purpura that is most common on the sun damaged skin
on the forearms (see Figure 2). Skin tears are an acute traumatic skin
injury often seen over areas of senile purpura (see Figure 2). Careful
handling of the skin to prevent such problems from shear or friction
can help avoid such skin injuries. A good review of prevention and
management of skin tears can be found elsewhere in the literature
by LeBlanc and Baranoski.7
• wound exudate leading to periwound maceration
• incontinence from urine, stool or both leading to incontinence
associated dermatitis (IAD)
• effluent from a stoma or fistula
• perspiration including for example excessive moisture in skin
folds
In the following sections, the first two will be discussed in more
detail.
Wound exudate leading to periwound maceration
Wounds are often excellent providers of local moisture, but when
present in excess and allowed to sit in contact with the periwound
skin, moisture leads to damaging maceration.17 Macerating aqueous
wound exudate is associated with additional damage from corrosive
cellular debris and enzymes.18 In addition, dressings may facilitate
periwound damage with lateral leakage or upper surface strike
through and they are often changed only after leakage has occurred.
As a result, the surrounding skin is continuously exposed to potentially
damaging wound exudate.17,19 Moisture and maceration will increase
the skin’s permeability to irritating substances, compromising
the barrier function and increase the likelihood for superficial
critical microbial colonisation.3 This can lead to delayed healing,
increased risk of deep tissue infection, and wound enlargement.
Furthermore, less friction is then required to damage skin when it
is overhydrated.19
Areas of senile
purpura without
skin tears
Note skin tear
over circled area
of senile purpura
Photo copyright 2009 from Jane Fore used with permission
Figure 2: Senile purpura
The patient/caregiver team is primarily responsible for the
maintenance of healthy skin. Many skin care practices and products
may help maintain integrity. The following review emphasises the
role of skin health on the general health of the patient and suggests
a toolkit of strategies to maintain skin integrity especially for the
periwound skin.
Most infected wounds, burns, fungating wounds, lymphoedema
and venous leg ulcers are typical wounds that have a large amount
of exudate. Periwound skin for these patients is best managed by
protecting the periwound skin with appropriate products (see Table I ).
Over hydration of the periwound skin from under contained wound
exudate needs to be recognised as part of routine wound assessment
and a more absorptive dressing chosen for moisture balance or
the dressing needs to be changed more frequently. Maceration
of the periwound skin typically presents as white, wrinkled soggy
tissue at the wound edge as seen in Figure 3. Selecting the right
dressing and size to absorb the exudate from the wound and the
appropriate frequency of dressing change as not to exceed the
manufacturers recommended “wear time” are crucial to minimise
periwound maceration. A variety of skin barriers can protect against
the damaging effects of moisture (see Table I).
Threats to skin integrity
The skin needs the right balance of moisture because problems
occur both if it is too wet or too dry. Common clinical situations that
can result in damage to the skin include itching (pruritus) leading
to damage from the inflammatory insult and the patient scratching
their skin. Other sources of physical damage occur from the fluid
of a draining wound or fistula, urinary or faecal incontinence,
perspiration, and the skin stripping and other damage from the use
of skin adhesives.8,9
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Dermatology: The skin and periwound skin disorders and management
These preparations can also be messy to use and often difficult
to remove.20 Film forming liquid acrylates have also been used to
protect the skin. Since they form a transparent film on the periwound
that dries, they don’t interfere with adhesion of the wound dressing.
A recent article rated these products with level one evidence. 21
Incontinence-associated (related) dermatitis (IAD)
Waste excretion fluid is constantly being emitted from the body.
Persistent skin from urine, stool or both results in diaper dermatitis in
the young or incontinence-associated dermatitis (IAD) in the elderly;
both are forms of contact irritant dermatitis.15,16 Statistics from
chronic care facilities identified the urinary incontinence prevalence
to be between 50% and 70%.22,23 Therefore, knowledge of the skin’s
function, strategies to maintain integrity and the treatment from
incontinence-related contact irritant dermatitis is crucial for every
caregiver.
Note the white, soggy macerated
wound margin of this pressure ulcer
© Ayello, 2004, used with permission
Figure 3: Wound maceration at wound margin
The excess moisture and maceration provides an excellent
environment for the growth of bacteria,24–26 resulting in the production
of ammonia.27 The ammonia increases the pH of the skin,25 reducing
the acid mantle’s protective capacity as a bacterial barrier,25,26
subsequently facilitating bacterial proliferation and lowering the
threshold for skin breakdown from chemical irritation by urine,
faeces, and other sources of excess moisture.
Traditionally, both zinc oxide and petrolatum ointments have been
used to protect the periwound area.20 Although they are effective
barriers, this approach can interfere with dressing absorption and
adhesion. The ointment vehicle melts and the oleaginous component
can creep into the wound base interfering with the ionisation of
certain aqueous agents such as silver, rendering them less effective.
Table I: LOWE® Skin Barriers for Wound Margins:
LETTER TYPE
ADVANTAGES
DISADVANTAGES
L
Liquid film forming acrylates e.g. no sting,
skin prep
• Transparent surface that resists removal
• Low incidence of reactions
• Don’t interfere with adhesion of dressing
• Some skin sealants may evaporate and dry out • Lack of availability on some institutional
formularies
O
Ointments
• Petrolatum
• Zinc oxide
• Relatively cheap and easy to apply
• Petrolatum liquefies with heat
• Zinc oxide ointment does not allow visualisation
of underlying wound margin
• Ointment vehicle may interfere with the action of
ionised silver
• Can interfere with adhesion of dressing
W
Windowed dressing framing of wound margin
with protective adhesive (hydrocolloid, film,
acrylates, silicone etc)
• Provides a good seal around the wound edge
• Some products facilitate visibility of the wound
margins
• Reactions to the adhesive can occur
• If seal is compromised moisture may accumulate
under the dressing
E
External collection devices
• External pouching may help in locations
where an external seal is difficult (e.g. perirectal
area)
• Devices need to monitored for external seal
• These devices do not replace a search for the
cause of the excessive exudate and the need to
correct the cause
Wound exudate can be classified in two ways
• Type (colour and consistency)
- Serous or clear colour that represents serum or transudate
- Sanguineous for blood
- Purulent for pus made up of inflammatory cells and tissue debris that can result from infection or an inflammatory process
These exudates may exist as a single form or in combinations (e.g. serosanguineous)
• Amount
- None
- Small: there is just a detectable discharge when the dressing is removed, less than 33%
- Moderate: Discharge is covering less than 67% of dressing surface
- Large: Discharge is covering more than 67% of the surface.
Exudate may indicate that the cause of the wound has not been treated (e.g.o edema due to venous insufficiency), Congestive heart failure is present (look for bilateral
involvement and extension above the knee), low albumen (malnutrition, kidney or liver disease), or infection (check for symptoms or signs).
Periwound skin needs protection from exudate by using absorbent dressings over the wound and protecting the periwound skin. There are four ways to protect external
skin of a wound. So remember: LOWE
©2006, Ayello & Sibbald, used with permission
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are special sheets of material that can wick moisture away from
the skin and can be placed between the skin folds to absorb the
moisture.
Faecal incontinence should alert clinicians to the potential for skin
breakdown.28 As faeces pass through the gastrointestinal tract,
digestive enzymes are deactivated. When faeces mix with urine on
the skin, the urine converts to ammonia, and the resultant alkaline
pH reactivates the digestive enzymes, further increasing the risk of
skin breakdown and local bacterial damage24, 25
Skin adhesives
Adhesive products that strip the skin may also compromise the
skin’s barrier properties. These products include tapes and adhesive
bandages such as hydrocolloids, films, and some foams. Skin tack
(ability to stay in place on the skin surface) varies among adhesive
products. High-tack products have a bonding pressure that will
cause skin tears if inappropriately removed. Acrylic adhesives,
primarily found on film dressings, are best removed by pulling
laterally to decrease the skin bond before lifting upwards and off the
skin.29 Careful technique requires more caregiver time to minimise
skin damage.
Clinically, IAD can be identified by redness (erythema), or rash on the
skin (see Figure 4). Typically IAD skin injury is shallow and diffuse.
The patient may complain of burning pain and itching. All of these
characteristics are helpful in differentiating IAD from pressure ulcers
in the sacral area.15,16 A summary of instruments for evaluating IAD
has been published elsewhere.15,16 Periwound petrolatum or zincbased barriers must be removed and reapplied following each
incontinent episode. This, in turn, can cause more skin damage due
to the friction required to remove these products. If contamination has
not occurred however, a tongue depressor can be used to decrease
frictional resistance and facilitate the application of barriers to just
fill in the spaces.
Physical skin barriers and protectants
Physical barriers
Don’t forget that skin folds in bariatric patients can also be damaged
from excessive moisture. Some new products are available; these
For the purpose of this review, a physical barrier is defined as a
permanent interface between two surfaces to protect skin integrity.
Skin barrier products have been developed for this protective
need.30–32 A summary of the pros and cons of a number of these
products is presented in Table I.
Figure 4: Moisture-associated skin damage (MASD) aetiology from urinary
incontinence dermatitis (IAD)
Zinc oxide preparations
Zinc oxide barriers, probably the most widely used barrier preparations ,have been readily available for a number of years, and
zinc oxide and petrolatum ointments have been routinely used to
protect the periwound skin.33 When the diaper region is red, an active
anti-inflammatory or anti-yeast product sometimes in combination
(e.g. 1% hydrocortisone powder in clotrimazole or other imidazole
cream) can be applied first and then the barrier applied with the use
of a tongue depressor on top to give a uniform thicker layer similar
to icing on a cake. For example, the most commonly used diaper
rash treatments for babies are zinc oxide and petrolatum-based
skin barrier products. In persons with sensitive skin, such as babies
and the elderly, zinc preparations are helpful. Such preparations
are often robust, easily accessible and inexpensive, making them
conducive for general use. Although generally effective, significant
product variability exists between preparations with regard to
potential allergens (especially added perfumes or lanolin derivatives)
and consistency. A soft or runny zinc oxide preparation can be made
stiffer on the skin surface by applying talc with a cotton ball. This, in
turn, provides greater barrier function protection.33 Zinc products are
also labour-intensive, and bacterial contamination in situ is possible.
Due to their robustness and permanency, they can clog containment
devices and interfere with absorbency, adhesion, and antimicrobial
properties of topical treatments. Most importantly, caregivers are
unable to visualise the underlying skin.
Photo copyright 2009 J. Fores, used with permission
Figure 4a-Skin damage from an older adult incontinence protective device
(diaper) and some urine leaking from around her urinary catheter (Foley).
Groin ulcers occurred where diaper was too tight (arrow)
Ointments/creams
Ointment preparations are petrolatum-based with a continuous oil
phase and suspended water with a cream being the opposite having
a continuous water phase with suspended oil. Recently creams have
been given a greater lubricant or ointment-like property with the
introduction of silicone-based cream preparations. Not all creams
are alike and it is important to know the specific type of cream that
Photo copyright 2009 J. Fores, used with permission
Figure 4 b- Extensive skin damage with bright red erythema from incontinence
associated dermatitis typically seen in IAD.
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is being used on a particular patient. For example some barrier
creams are transparent and others are not while some interfere with
dressing adhesion and other does not.
approach has the benefit of providing a constant non-resorbable
barrier that does not require frequent changing while allowing
visualisation of the underlying skin through the dressing.
The petrolatum-based products are similar to the zinc-based products
discussed above except that they have a greater fluid creep into
the surrounding skin or wound tissue. They are readily accessible,
relatively inexpensive, and widely used as skin barriers for other, less
medically intense, situations (e.g. as lip balms). Petrolatum-based
products are also variable (35 grades of petrolatum are available)
with potential added allergens (e.g. perfumes, lanolin) and varying
consistency. They tend to melt and wash off easily and, like zincbased products, have the tendency to clog containment devices or
interfere with the absorbency of dressings.34
Although this approach has some advantages, some less beneficial
considerations must be addressed. These disadvantages include
dressing edge roll, lifting, and undersurface trapping of exudate
or bacterial proliferation. Adhesive dressing allergies are also a
possibility. The typical meltdown and odour associated with some
hydrocolloid dressings may be problematic.38 Experience is needed
to appropriately size and create the drainage port. Some of the newer
dressings have the advantage of locking the wound exudate away
from the wound surface and thus preventing maceration.
Silicone-based products are more expensive but they are far less
variable, easier to apply, have lower frictional resistance, and
are more resistant to wash off. They are transparent, allowing
visualisation of the underlying skin. An important disadvantage of
ointments and cream-based products is the user application amount
variance and techniques and the need to reapply the product.
For this review, the reader should distinguish protectants from
barriers. A protectant (fluid managers, skin cleansers, moisturisers)
is defined as an indirect temporary technique or application to
maintain the integrity of high risk skin. A number of skin protectants
have been developed and marketed, each with its own advantages
and disadvantages (see Table I).
Film forming liquid barriers
Fluid managers
Liquid forming barriers are like “putting a clear breathable rain slicker
on the skin” to repel moisture. They come in a variety of application
forms such as pads, sticks, and sprays. Liquid-forming barriers are
relatively new and provide important user benefits:
Fluid managers are absorbent devices that remove fluid/effluent
from the skin surface (e.g. dressings, diapers and fluid containment
devices). Dressings may serve as barriers on intact skin, as well
as protectants when applied over an open wound. These products
are designed to remove or collect fluid and nothing else. Although
absorbent, some dressings or diapers do not wick fluid away from
the skin; rather, they form a dynamic equilibrium. As a result, the
fluid can be more damaging to the skin interface, causing dressing
strike-through and leakage.
Protectants
• They are flexible and conformable
• Easy to use
• Allow uniform application/distribution
• Resist wash off
• Do not trap contaminants and
It may be difficult to choose from among multiple devices with
differences in absorptive capacity and wear time, even within the
same product category. In general, foams provide a fluid exchange
in contrast to fluid lock properties of the non-bioresobable hydrofiber
and the resorbable calcium alginates.
• Provide visualisation of the underlying skin
• Allow for adhesion of a dressing
These products have a low allergic sensitisation rate compared with
traditional barrier preparations.35,36 Unlike their zinc and petrolatum
counterparts, some of these products work well under adhesive
dressings and do not interfere with containment devices.
Skin cleansing
Adhesive dressings
What the skin is washed with is also important. The pH of the skin
is normally about 5.5 giving rise to the phrase “the acid-mantle of
the skin”. Soaps can be classified as antibacterial, super fatted or
neutral. Many soap products are alkaline, thus raising the pH of the
skin surface to a more alkaline environment that facilitates bacteria
growth decreasing local resistance to irritants and potential invasion
into the body. In some countries, basin washing patients with soap
and water has been replaced with soapless, no-rinse products
decreasing skin injuries such as skin tears and pressure ulcers. The
appropriate time to apply moisture is after washing while the skin is
still damp and not completely dry. This will help to “trap” the right
amount of moisture on the skin surface.
Adhesive dressings, such as films or thin hydrocolloids, are also
used as skin barriers. They are applied using a picture window
framing technique, where a hole is cut in the dressings to allow for
the movement of effluent into a management device (e.g. overlying
absorbent dressing) while protecting the wound margin. Framing
the surrounding skin prevents effluent from attacking healthy skin
by forming a solid interface between the skin and exudate. This
Skin cleansers or cleansing regimens are designed for the skin and
should not be applied on the surface of open wounds where they
can have a potential detrimental effect on healing. These products
are essentially designed to remove debris from the skin surface. In
general, they are surfactant-based (surface active agents) and are
superior to water or saline for debris removal because they have
been specifically developed for this purpose.
Although reported to be cost-effective, the unit purchase price of
liquid-forming barriers is relatively high.36 Most, but not all, of these
preparations contain carrier agents such as acetone or alcohol which
can cause burning and stinging on application. There is a learning
curve to correctly apply these preparations and must be considered
when educating staff or lay-caregivers. Some of the newer products
provide a flexible, durable, moisture-repellent film on the skin, and
an alcohol-free liquid form with a variety of pain free application
options (e.g. No sting, Cavilon 3M Minneapolis, Minnesota).37 This
product can be used on sensitive infant and aged skin.35,36
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References
However, using these products presents some potential disadvantages. They may contain known sensitisers (e.g. perfumes).
As part of their cleansing action, they change skin pH or remove its
acid mantle, resulting in skin surface drying and stratum corneum
stripping. Healthcare providers are often confused by products in this
category, sterile and non-sterile, ionic and nonionic, and some have
higher tissue toxicity than others. There is confusion with overuse
and misuse of products in this protectant class often causing more
harm than good.39
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Conclusion
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Skin is an important organ which requires the right moisture balance
to maintain its important functions with the periwound skin especially
susceptible to damage. The skin barrier is constantly challenged with
a range of irritant and allergic substances, even in healthy individuals.
When health is compromised, the skin is more vulnerable to injury.
The clinical challenges and consequences of assessment, treatment,
and healthy skin maintenance are factors, not only in skin care, but
also in overall well being. A number of products have been developed
and marketed for the protection of the periwound skin.
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31.Coutts P, Sibbald RG, Queen D. Peri-Wound Skin Protection: A Comparison of a New Skin Barrier vs.
Traditional Therapies in Wound Management. Poster at CAWC Meeting, London, Ontario. November
2001.
32.Campbell KE, Keast DH, Woodbury GM, Houghton PE, Lemesurier A. The Use of a Liquid Barrier Film
to Treat Severe Incontinent Dermatitis-Case Reports. Poster at CAWC Meeting, London, Ontario.
November 2001.
33.Sibbald G, Cameron J. Dermatological aspects of wound care. In: Krasner D, Rodeheaver G, Sibbald
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34.Grove GT, Lutz JB, Burton SA and Tucker JA. Assessment of diaper clogging potential of petrolatum
based skin barriers. Poster at the 2nd National Multi-Specialty Nursing Conference on Urinary
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Economically, prevention is better than the treatment of peri-skin
maceration, erosion, secondary increased bacterial burden and
infection. The basic premise here is to remember to treat the whole
patient rather than the exudate without looking at the “hole” and its
origin.
35.Campbell K, Woodbury MG, Whittle H, Labate T, Hoskin A. A clinical evaluation of 3M No Sting barrier
film. Ostomy/Wound Management. 2000;46(1):24–30.
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37.Kennedy KL, Leighton B. Cost-Effectiveness Evaluation of a New Alcohol Free Film-Forming
Incontinence Skin Protectant. White Paper – 3M Healthcare, USA. 1999.
38.Thomas S, Loveless P. A comparative study of the properties of twelve hydrocolloid dressings. World
Wide Wounds. 1997;July. Available at: www.worldwidewounds.com. Accessed March 15, 2002.
Clinicians should not jeopardise their integrity by failing to protect
the integrity of the periwound skin.
Wound Healing Southern Africa
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