Care for Skin
People living with Duchenne or Becker, especially wheelchair users, may experience issues with skin integrity. This includes problems such as pressure wounds (also known as pressure ulcers or pressure sores), skin infections, and other issues such as dryness or thickening that can cause discomfort.
If you or your child are experiencing discomfort or pain from skin issues or wounds, please consult your neuromuscular team. They may refer you to a wound care specialist, who is often a nurse or other healthcare professional who has special training in managing complex skin problems. A Physical Medicine & Rehabilitation physician and/or Physical Therapist may also be able to discuss solutions for positionings so these problems can be addressed and avoided in the future.
COMMON SKIN ISSUES IN DUCHENNE
Because many individuals with Duchenne or Becker use medical equipment, skin breakdown can occur at those points of contact. Additionally, individuals with mobility challenges can have trouble repositioning themselves. Some medical devices/equipment that can cause skin breakdown and pressure ulcers include:
- Wheelchairs, scooters, or other mobility devices
- BiPAP masks
- G-Tubes
- Device tubing- such as urinary catheters, IV tubing, or tracheostomy tubes
It’s important to monitor these points of contact frequently and treat any signs of skin breakdown as soon as possible.
Swelling in the lower legs and feet (called edema) is also something many individuals with Duchenne or Becker experience. This can happen simply from sitting or lying with legs hanging down (called dependent edema), or it can be related to the heart, when it isn’t pumping as effectively and fluid builds up in the body.
To help manage swelling, try keeping legs elevated when possible and consider using compression socks or stockings. Before starting anything new, including compression or medications, be sure to talk with your or your child’s cardiologist. In some cases, the doctor may recommend a medication called a diuretic to help the body get rid of extra fluid.
PRESSURE POINTS
Pressure injuries are localized damage to the skin that can present as intact discoloration or an open ulcer. These injuries are typically caused by prolonged pressure over
bony prominences or by medical devices or equipment. Below is a diagram of common pressure points to consider in caring for our boys with DMD:
Additionally, skin breakdown can happen in individuals who have more severe foot and or ankle contractures. As the side of the foot ends up resting on the wheelchair footplate or even in the bed, a pressure ulcer can develop.
PRESSURE INJURY CLASSIFICATIONS
- Stage I: Skin remains intact, but localized, nonblanchable redness. Nonblanchable redness does not fade or turn white when pressed. In a person with dark skin pigmentation, a stage I ulcer may appear as a persistent red, blue, or purple discoloration.
- Stage II: Partial-thickness loss of tissue; shallow ulcer with red-pink wound bed
- Stage III: Full-thickness loss of tissue; bone, tendon, or muscle NOT exposed; may have some dead tissue in the woundbed
- Stage IV: Full-thickness loss of tissue; bone, tendon, or muscle IS exposed; may have dead tissue that separates from healthy tissue
- Unstageable: Full-thickness tissue loss with the entire wound base covered with dead tissue
- Deep tissue injury: purple or maroon localized area of discolored, intact skin or blood-filled blister; may be painful, firm, soft, boggy, different temperature compared to intact skin.
SIGNS AND SYMPTOMS OF INFECTION
Pressure injuries which progress to stage II or greater (open wounds) are at highest risk for becoming infected. Signs of infection can include worsening redness around the wound, swelling, warmth, drainage from the wound bed, increased pain, and can progress to fever and chills. Notify your healthcare provider immediately if you are concerned that your or your child’s wound is infected. Your provider may pursue further work up and initiate treatment with antibiotics if infection is a concern. Steroids can limit the body’s ability to fight the infection sufficiently, which can lead to quicker progression of the infection, thus it is important to treat infection as soon as possible.
COMMON PRODUCTS USED
There are a wide variety of wound care products on the market making it difficult for one to know exactly what they need on their own. The type of wound, injury to deeper structures, and the amount and quality of drainage must be considered when choosing the right wound care regimen. Below are some common products used for wound healing:
Be sure to always check with your physician before starting any medications or topical treatments. This includes over the counter topical creams and ointments.
Topicals:
- Antibiotic ointments prescribed by physician: Bactroban (mupirocin), Silvadene (silver sulfadiazine) , gentamicin
- Enzymatic debriding prescribed by physician: Santyl (collagenase)
- Antifungals prescribed by physician: clobetasol and nystatin
- Barrier cream with zinc: recommended for application to wound edges on wounds with drainage. This will reduce the risk of further skin breakdown.
Alginates: used for wounds with moderate to heavy drainage
Hydrocolloids: retain moisture, promote autolytic debridement; self-adherent and molds well to skin; light to moderate drainage
Absorbent dressings: gauze, ABD pads, Drawtex, extra-absorbent pads (diapers or incontinence pads)
Negative pressure therapy: helps seal the wound with a specialized gauze or foam dressing, must be under care of a physician, typically requires home health. Sometimes referred to as vacuum-assisted closure (VAC) or wound VAC.
Moisture wicking: InterDry for areas of moisture
HELPFUL RESOURCES
Page Contributer: Danielle Dwiggins, BSN, RN
