Your Skin
Know about your skin
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How the skin normally works
Your skin is your body’s largest organ.
It serves as a protective barrier against most external agents like infection, dirt and harmful rays from the sun. It permits the senses of touch, pain, heat and cold to travel from the nerve endings in your skin to your brain through the spinal cord and helps regulate your body temperature.
Your skin regulates your body temperature through the dilation and constriction of blood vessels and the process of sweating.
When you’re in cold weather, your skin signals your blood vessels to constrict and keep you as warm as possible.
When you’re in hot and/or humid weather, your skin signals blood vessels to relax and triggers sweat glands under your skin to produce water and salt which in turn increases sweating. This process cools you down as the water evaporates from your skin.
Effects of a spinal cord injury on skin integrity
In people with a spinal cord injury, the nerves that carry messages back and forth between the skin below the level of your injury, spinal cord and brain don’t work the way they should.
The following happens to the skin in people with a spinal cord injury:
- Decreased or absent sensations to register touch, pressure, pain, heat and cold below the level of a spinal cord injury.
- Reduced sweating to help cool body down below the level of the spinal cord injury.
- Excessive sweating may occur above the level of a spinal cord injury.
- Weakness or loss of muscle strength below the level of the spinal cord injury can produce swelling or oedema of the lower limbs due to pooling of the fluids.
- No change to the protective function of your skin below or above the level of a spinal cord injury allowing the skin to protect internal organs against heat, light, injury and infection.
- A pressure injury involves damage to the skin and the tissue underneath the skin due to prolonged or excessive pressure or pressure applied in combination with shear or sliding
and friction.
Pressure is applied for too long or at a very high pressure over a bony prominence
Results in a compromised blood supply reducing
oxygen to the affected area
The end result is skin breakdown or a
pressure injury
Before your spinal cord injury, your body sent signals for you to move, squirm or change positions when you became uncomfortable. After your spinal cord injury, your early warning system doesn’t work as well. You need to actively think about your body and regularly relieve pressure.
Toolbox
Pressure injuries toolbox
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The pressure injuries toolbox
Management of a skin problem can be challenging because many factors play a role. A single strategy, for example, applying a wound dressing, may not be as effective when used in combination with other strategies. Your specialist nurse or doctor may need to try a combination of treatments and this may take some time.
Think about using the pressure injuries toolbox to treat your pressure injury. The toolbox is made up of 8 strategies as seen in the picture below.
Important Note
It is unlikely that using just one strategy will fix a pressure injury. Consult a specialist nurse or doctor to find the best combination of strategies to use.
The eight strategies
1. Assessment
A proper assessment of a pressure injury considers all the possible factors that can impact healing and risk of recurrence.
These factors include:
- Spinal cord injury-specific factors
- Classification of stages of pressure injury
- Diet and nutrition
- Mechanical factors
- Pre-existing medical conditions
- Psychological and lifestyle factors.
- It is recommended to assess and address all of the above factors while monitoring them regularly to maximise pressure injury healing.
Spinal cord injury-specific factors
A variety of characteristics associated with a spinal cord injury affect your risk of getting a pressure injury and the time for healing. Factors include level and extent of injury, ageing, spasms, and bladder and bowel incontinence.
Remember that the greatest pressure is always on the deep tissues and overlying bony prominences.
Locations where pressure injuries commonly develop are shown in the picture below:
Do you know?
90% of pressure injuries are preventable.
Classification of stage of pressure injury
Pressure injury can be divided into 6 types. Duration of healing is directly related to the relevant pressure injury stage and applying the appropriate treatment. The 6 stages are:
Stage 1
Intact skin with a localised area of non-blanching redness with pressing, usually over a bony prominence. If treated early, stage I pressure injury can heal in about 3 days.
Stage 2
Partial thickness loss of dermis presenting as a shallow open wound with a red-pink wound base. Healing from this stage can last anywhere from 3 days to 3 weeks.
Stage 3
Wound extending through epidermis and dermis into the fatty subcutaneous layer. Healing usually needs at least 1 to 4 months.
Stage 4
Full thickness tissue loss extending into underlying tissues, such as muscle and possibly bone. Healing can take anywhere from 3 months to 2 years.
Deep tissue injury
Purple or maroon localised area, an area of discoloured intact skin, or a blood-filled blister.
Unstageable
Full thickness tissue loss in which the base of the pressure injury is covered by unhealthy skin.
Image courtesy of The National Pressure Ulcer Advisory Panel 2016
Diet and nutrition
Unplanned weight loss, nutritional deficiency and insufficient dietary intake are key risk factors for development of a pressure injury and impaired wound healing. Assessment of nutritional status using suitable tools and techniques will help to guide interventions for improving nutritional status and promoting pressure injury healing. Seeking advice from a qualified dietitian is recommended.
For more detailed information, refer to the Diet and nutrition section.
Mechanical factors
Various mechanical factors can influence healing of a pressure injury:
- Impaired mobility
- Altered sensory perception
- Reduced tissue tolerance due to:
- Moisture
- Friction
- Shear.
Strategies:
- Avoid weight bearing on the pressure injury area
- Minimise weight bearing over bony prominences by:
- Leaning forward or to side in your wheelchair for 2 minutes for regular pressure relief
- Frequently changing position while in bed.
Pre-existing medical conditions
If your pressure injury is not healing after 4 weeks (it should be improving by at least 25% per month) or getting worse despite intervention, ask your GP to screen for common conditions, such as anaemia, infection, diabetes and nutritional deficiency, which are known to delay healing. Ensure that you receive appropriate treatment if any of these medical conditions are present.
The presence of infection in the pressure injury can be assessed using the below guide:
If 3 or more of the following signs are present, this means you have a high amount of bacteria in a superficial wound
- Your pressure injury is not healing
- Increasing ooze (exudate) from your pressure injury
- Red, friable tissue that tears and bleeds more easily
- Appearance of unhealthy tissue with debris or dead cells
- Your pressure injury is smelly.
If 3 or more of the following signs are present, this means you have a high amount of bacteria in a deep wound and surrounding skin
- Your pressure injury has increased in size
- You have a fever
- Exposed bone can be seen at the base of your pressure injury
- You have developed a new pressure injury in the surrounding area
- Redness and swelling (cellulitis) in the surrounding skin
- Increasing ooze (exudate) from your pressure injury
- Your pressure injury is smelly.
Increasing clinical problems
Contamination (being made impure)
Colonisation (establishing in an area)
Vigilance required
Local infection
Spreading infection
Systemic infection (widespread infection)
Vigilance required
Medical treatment required
Source: Wound Care Made Incredibly Easy! 2nd ed., Lippincott Williams & Wilkins, 2007.
Ask your GP to perform the following tests to rule out certain health conditions:
Full blood count
Inflammatory markers
Iron profile
Biochemical screen
Check for level of haemoglobin (cells carrying oxygen to tissues) and the number of white blood cells (that fight infection).
Full blood count
Check for level of haemoglobin (cells carrying oxygen to tissues) and the number of white blood cells (that fight infection).
Inflammatory markers
C-reactive protein and ESR which are raised with infection.
Iron profile
Check for levels of ferritin, serum iron, percentage saturation, and total iron binding capacity which aids healing.
Biochemical screen
Check for fasting or random blood glucose, as well as markers of adequate nutrition, including protein, prealbumin and albumin levels.
What does research tell you?
It is recommended to use antimicrobial dressings if signs of infection are present.
Psychosocial and lifestyle factors
Psychosocial and lifestyle factors also contribute significantly to skin breakdown and impact on wound healing. Consider the following factors:
- Limited social support or living alone
- Inadequate personal care and/or domestic assistance
- Caregiver fatigue
- Financial concerns including access to quality equipment, repairs and provision of services
- Unsustainable work or family commitments
- Signs of mental health concerns, such as depressed mood, social withdrawal, excess use of drugs or alcohol, or worsening of a pre-existing mental health condition
- Level of motivation
- Lifestyle priorities, competing interests, roles and responsibilities (trade-off between pressure management requirements and living life)
- Reduced ability to self-manage/direct care, problem solve and troubleshoot
- Smoking.
2. Interdisciplinary team approach
An effective way of treating a pressure injury is to have a comprehensive treatment plan developed with the support of an interdisciplinary team that may include doctors, community nurses, wound nurses, therapists, social workers, psychologists, engineers and dietitians.
The plan should address the cause of the pressure injury, other contributing factors, methods for relieving pressure, specific wound care, adjunctive therapies to support healing as necessary, surgery for complex or deep pressure injuries (stage 3 and 4, if indicated), management of complications, and educational and nutritional interventions.
Interdisciplinary team members for pressure injury management
What does research tell you?
Expert opinion recommends a comprehensive assessment by an interdisciplinary team to identify pressure injury risk factors. This assessment includes level and completeness of your spinal cord injury, associated health conditions, level of functioning and mobility, nutritional status, continence, psychological and social factors, care and equipment.
3. Wound care
Good wound care is important and includes:
Cleansing
Cleanse pressure injuries at each dressing change with a generous volume of sterile solution, e.g. saline water.
Consider adding an antiseptic agent if there are signs of infections, e.g. Betadine Solution.
Dressings
The selected dressing should:
- Provide an optimal level of moisture to the wound base of a stage 2 or 3 pressure injury.
- Meet your needs based on the location of the pressure injury or injuries and can be modified depending on your goals and/or change in wound status.
Avoid daily dressing changes if possible, by using a dressing type (absorbent dressing) that manages fluid coming out from the wound bed (also known as exudate) and odour as well as remains in place for as long as possible.
In some instances, wound care may also include wound debridement
Debridement is the removal of dead (necrotic) or infected skin tissue to help a wound heal.
Ensure only a qualified doctor or a nurse debrides devitalised (dead) tissue from a pressure injury, using a method appropriate to the wound status.
Should you need to use any of these strategies you are advised to discuss this with your community nurse or general practitioner before applying.
Deciding on what type of wound care dressing is right for your situation
Selecting the right dressing will depend on:
- The size of your wound
- The amount of moisture in the wound
- The level of infection
- The condition of the surrounding skin.
Dressing moisture scale
Pressure injury is too moist
Management strategy
Absorb moisture by:
Absorb moisture by:
- Promoting debridement and cleaning the dead tissue from the wound, using an alginate dressing.
- Using an absorptive dressing that contains multiple layers of highly absorbent materials suitable for draining wounds.
- Using a hydrocolloid dressing that is adhesive, mouldable, impermeable to oxygen and water, and promotes debridement.
- Filling a deep wound with wound fillers to promote healing.
- Using foams to provide thermal insulation and create a moist wound environment.
Pressure injury neither too moist nor too dry
Management strategy
Maintain existing moisture level by:
Maintain existing moisture level by:
- Using a collagen dressing to promote growth of tissue and blood vessels.
- Using dressings that are made from a woven or perforated material and to be placed directly over the wound then secured by a contact layer dressing.
- Using a transparent film dressing that adheres to the skin and helps maintain a moist wound environment. These types of dressings promote debridement and stimulate formation of granulation tissue.
Pressure injury is too dry
Management strategy
Add moisture by:
Add moisture by:
- Using a hydrogel dressing to promote hydration to the wound and soften dead tissue.
Other types of dressings
Composite
Combines two or more types of dressings into one depending on the stage of the wound.
Anti-microbial
Contains ingredients such as silver and iodine to protect your wound from bacteria.
What does research tell you?
Expert opinion recommends using a dressing that maintains an optimal level of moisture at the base of the pressure injury.
4. Offloading pressure
Strategies for managing pressure depend on:
- The location of your pressure injury
- Your circumstances and available resources.
Strategies to aid the healing process include:
- Full-time (24-hour) bed rest
- Limited time sitting with close monitoring
- A graduated sitting protocol for a healed pressure injury (see below for more details)
- Monitoring of equipment condition
- A positioning aid such as a heel wedge.
Graduated sitting protocol for pressure injury management
Perform a skin check prior to – and after – sitting at all times.
Day 1 | Sit up for 15 minutes twice a day | |
If skin condition does not deteriorate after the 1st day, increase sitting time as described on Day 2. | If skin condition does deteriorate after the 1st day of sitting, return to bed rest until re-evaluated by medical staff. | |
Day 2 | Sit up for 30 minutes twice a day | |
If skin condition does not deteriorate after the 2nd day, increase sitting time as described on Day 3. | If skin condition does deteriorate after the 2nd day of sitting, return to 15 minutes of sitting only. | |
Day 3 | Sit up for 1 hour twice a day | |
If skin condition does not deteriorate after the 3rd day, increase sitting time as described on Day 4. | If skin condition does deteriorate after 3rd day of sitting, return to 30 minutes of sitting only. | |
Day 4 | Sit up for 2 hours twice a day | |
If skin condition does not deteriorate after the 4th day, increase sitting time as described below this section. | If skin condition does deteriorate after 4th day of sitting, return to 1 hour of sitting only. |
Day 1 | Sit up for 15 minutes twice a day |
If skin condition does not deteriorate after the 1st day, increase sitting time as described on Day 2. If skin condition does deteriorate after the 1st day of sitting, return to bed rest until re-evaluated by medical staff. | |
Day 2 | Sit up for 30 minutes twice a day |
If skin condition does not deteriorate after the 2nd day, increase sitting time as described on Day 3. If skin condition does deteriorate after the 2nd day of sitting, return to 15 minutes of sitting only. | |
Day 3 | Sit up for 1 hour twice a day |
If skin condition does not deteriorate after the 3rd day, increase sitting time as described on Day 4. If skin condition does deteriorate after 3rd day of sitting, return to 30 minutes of sitting only. | |
Day 4 | Sit up for 2 hours twice a day |
If skin condition does not deteriorate after the 4th day, increase sitting time as described below this section. If skin condition does deteriorate after 4th day of sitting, return to 1 hour of sitting only. |
Sitting times can progress by doubling the overall length of time from the day before as long as skin checks demonstrate no new pressure-related problems.
Source: Adapted from Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians.
Talk with your community nurse or GP before starting a graduated sitting protocol.
5. Support surfaces and positioning
Ensure proper bed positioning by using devices and techniques that are suitable
for the type of support surface and your health status.
- Use pillows, cushions and positioning aids to:
- Bridge contacting tissues, including bony prominences
- Unload bony prominences
- Protect pressure injuries and other vulnerable areas of skin.
- Do not use closed cut outs in mattresses or donut type cushions, and avoid being positioned directly on your pressure injury.
Do you know?
Positioning in bed with the head of the bed elevated more than 30 degrees can cause destructive friction and shearing forces, especially over lower back/sacral region. Use the knee break to prevent sliding down the bed.
Education is essential so you and your caregivers know how to:
- Carry out repositioning manoeuvres safely, including correct positioning of pillows and wedges, and aids to reduce friction such as slide sheets.
- Avoid pinching of catheter tubing and wrinkling of your clothing under weight-bearing parts of the body.
Important Note
Do not place incontinence sheets over the top of your support surface as it negates the redistribution and relief of pressure.
Talk with your community nurse or GP before using any of the above-mentioned methods.
What does research tell you?
Expert opinion recommends the reassessment of the pressure-relieving performance of sitting support surfaces at least every 2 years, or sooner, if there is:
- A change in your health status, including weight or functioning level
- Wear and tear of equipment
- Development of a pressure injury
- A change in your living circumstances, care and support needs.
Support surfaces are broadly classified in 2 categories: reactive or active types.
Reactive or Static
A reactive support surface is a powered or non-powered support surface with the capability to change its load distribution in response to the applied load.
Type | Performance characteristic | Application |
|---|---|---|
Foam |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
High-specification foam |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
Static flotation air, gel or water |
| Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation |
Foam | |
|---|---|
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
High-specification foam | |
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
Static flotation air, gel or water | |
Performance characteristic
| |
Application Pressure injury prevention or treatment of uncomplicated pressure injury for high-specification foam or static flotation | |
Active or Dynamic
An active support surface is a powered support surface with the capability to change its load distribution properties, with or without the applied load.
Type | Performance characteristic | Application |
|---|---|---|
Alternating air pressure |
| Pressure injury prevention or treatment:
|
Alternating air pressure |
|---|
Performance characteristic
|
Application Pressure injury prevention or treatment:
|
Source: Modified from Houghton PE, Campbell KE and CPG Panel (2013). Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for Clinicians.
Do you know?
The optimal period for a change in position is still unknown. However, changing position every 2 hours is widely recognised as an effective and clinically useful strategy.
Talk to your community nurse or GP before deciding on a suitable support surface.
6. Diet and nutrition
One size does not fit all
Consult a registered Dietitian for a comprehensive assessment to develop a personalised nutrition and diet plan, in consultation with your GP.
Your diet plan will tell you:
- How many calories to consume each day
- How much protein to include daily
- Which minerals and multivitamins you need to promote healing of your pressure injury
- Which supplements to take or avoid.
Important Notes
- Inadequate food intake, poor nutritional status, excessive nutrient and fluid losses, and unplanned weight loss impair wound healing.
- Low protein (albumin and prealbumin) values in your blood reflect the severity of illness or injury and the potential for the development or worsening of malnutrition, regardless of nutrition status.
- Inadequate fluid intake may result in dehydration, which plays a role in delayed wound healing.
- Effectively managing your bowel and bladder to avoid incontinence can also impact on the healing of your pressure injury.
Do you smoke? The most important thing you can do is quit.
What does research tell you?
Expert opinion recommends having an early assessment by a dietitian to provide optimal nutritional support for all people with a spinal cord injury who have a severe pressure injury, a pressure injury that is not healing at the expected rate, unintentionally lost weight or are at risk of malnutrition.
7. Adjunctive therapy
The two most common methods used to promote healing of a pressure injury are:
Electrical Stimulation
A small battery-like device sends an electrical current via two small rubber pads attached to the skin or surrounding a pressure injury.
This method is used for stage 2, 3 and 4 of pressure injuries.
Negative Pressure Wound Therapy
A suction is attached to a wound dressing that covers the pressure injury, which exerts carefully controlled suction or negative pressure. This action removes wound
and tissue fluid from the treated area
by draining it into a canister.
This drainage method is used for stage 3 and 4 pressure injuries.
The following interventions are less widely used for promoting healing of a pressure injury, and also have less evidence-based research:
- Maggot Therapy
- Electromagnetic Energy
- Ultraviolet Light
- Topical Oxygen
- Laser
- Hyperbaric Oxygen.
Talk to your community nurse or GP before using any of the above-mentioned methods.
What does research tell you?
Electrical stimulation has been shown to increase the proportion of healed pressure injuries when compared with no stimulation. However, the research evidence to date supporting the positive effects of electrical stimulation is insufficient to support its widespread use.
Research evidence supporting the positive effects of negative pressure wound therapy is minimal. In comparison, a standard dressing has better outcomes and lower intervention costs.
8. Surgical treatment
Surgery can play an important part in the management of pressure injuries that are non-responsive to other strategies, e.g., in stage 3 or 4 pressure injuries.
There are a range of surgical interventions:
- Surgical debridement or removing dead tissue
- Direct wound closure
- Skin grafting
- Skin-muscle flap repairs.
Important Note
Consulting a Specialist Spinal Plastics or Skin Care Service for a comprehensive interdisciplinary evaluation is essential before deciding to undergo surgical intervention.
Advantages of surgical intervention:
- Definitive wound debridement with skin and soft tissue coverage
- Improved blood supply
- Improved healing with removal of underlying bony infection called osteomyelitis
- Improved function and independence.
Important Note
Surgery is a huge commitment requiring total bed rest in the prone position for months in hospital prior to and after surgery. There is also a risk of further skin breakdown after the surgery.
Quiz
Quick quiz
You may wish to see how much your knowledge has grown by taking this quick quiz.
Manage problems
Management of skin problems
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Manage a problem ‘just-in-time’
Serious complications can arise if pressure injuries are not managed in a timely way.
In the long term, these issues can lead to:
Worsening of the pressure injury:
The pressure injury may get larger and deeper, and result in tunneling which is a formation of track between layers
of muscle, fat or bone that may be hard to heal.
Infection:
In a deep pressure injury, the bone can become infected, known as osteomyelitis. The infection can spread into your bloodstream making you extremely sick, in some cases leading to death.
Scarring:
Most superficial injuries heal by forming scar tissue. Scar tissue has poor blood supply, is less elastic and more susceptible to breakdown than normal skin, making reoccurrence of a pressure injury more likely. If you have scar tissue on a weight-bearing area, limit your time in that position to prevent recurrent breakdown.
‘Just-in-time, or the right care at the right place at the right time, will reduce risk and prevent complications. As a result, you will maintain your quality of life, independence, health and wellbeing.
Be proactive and take responsibility for managing your own health risks
This involves:
- Education to know how your spinal cord injury affects your skin and what the research tells us.
- Becoming a partner in decision-making with your doctor and health professionals.
- Developing an individual health management plan.
- Engaging in ongoing health and wellness activities for healthy skin by:
- Relieving pressure regularly
- Knowing how to identify a pressure problem
- Maintaining a healthy diet and drinking plenty of water
- Scheduling an annual check-up to rule out other causes of skin breakdown.
What does research tell you?
One third
of people with spinal cord injury had one or more current pressure injuries
One quarter
of individuals reported having other skin-related problems, such as skin rashes and dermatitis, venous/arterial ulcers, infection (osteomyelitis and cellulitis), sinus and ingrown toenails
Two thirds
of pressure injuries were located over the ischial tuberosities (sitting bones), sacrum and greater trochanters (bone at side of hip)
Pressure injuries are most common between
21-30 years post-injury
2015 Rural Spinal Cord Injury Project survey of 681 people living with spinal cord injury in rural NSW
Pressure injuries
A pressure injury (also known as bedsore, pressure ulcer, pressure sore or decubitus ulcer) is an injury to your skin and/or underlying tissue over a bony prominence.
Pressure injury occurs as a result of pressure, shear and/or friction. there are four stages that describe the severity of the pressure injury (for more details refer to the toolkit).
Symptoms of pressure injury
- Skin swelling
- Pain or tenderness
- Changes in skin color (non-blanchable redness in lighter skin tones and non-blanchable blue/purple skin in darker skin tones)
- Skin that feels cooler or warmer to the touch than other areas
- Skin loss, exposing deeper layers of skin
- Pus-like drainage from an open area of skin for severe grade.
How to treat pressure injuries
Treatments for pressure ulcers (sores) include:
- Regularly changing your position
- Using special mattresses to reduce or relieve pressure
- Use dressings to help heal the ulcer
- Surgery may sometimes be needed.
For details prevention and management strategies, please refer to the pressure injuries toolbox
Skin rashes and dermatitis
A skin rash describes an area of irritated or swollen skin, which may be dry, itchy, red, painful, rough, smooth, cracked, moist or blistered in appearance.
A rash can affect only a small part of the body or cover a large area. Possible causes of rashes include dermatitis, infections, allergic reactions to taking a medication and certain diseases.
Dermatitis is a general term that describes a common skin irritation, with 3 common types: atopic dermatitis (eczema), seborrheic dermatitis (e.g., scalp dandruff) and contact dermatitis from exposure to an irritant. Applying a moisturising cream regularly helps control the symptoms of dermatitis. Treatment may also include medicated ointments, creams and shampoos.
See your doctor if your skin becomes painful, if you are experiencing discomfort that distracts you during everyday life or interferes with your sleep, if you think that your skin is infected, and/or you have tried self-care steps, but the signs/symptoms persist.
Ingrown toenails
- If the area around the nail is red and you see pus when you press on the edge of the nail, your nail may be cutting into the skin.
- Soak your foot in soapy water, wash it well, rinse and gently dry.
- Place a small piece of cotton under the nail to keep the edge of the nail away from the skin. Change the cotton daily.
- If it does not begin to heal in 2 or 3 days, see your doctor or healthcare provider.
- Make sure your socks and shoes leave plenty of room for your toes.
- Keep your feet clean and dry.
- Keep your toenails trimmed.
Heat and cold injuries
Heat injuries
Loss of skin sensation puts you at risk for a burn injury.
How to treat heat injuries
Apply cool water and administer first aid immediately. Do not use ice or an ice pack on a burn. Seek medical attention as soon as possible.
Cold injuries
Loss of skin sensation increases your chances of getting a cold injury, also known as frostbite.
How to treat cold injuries
Since skin may be numb, people with frostbite can harm themselves further unintentionally. Seek medical attention as soon as possible.
Did you know?
Chilblains are patches of discoloured (red, blue, white) skin, along with swelling and blistering on your hands and feet. Chilblains are thought to be caused by a combination of cold weather and poor circulation. The toes are particularly vulnerable and tight shoes can contribute by further reducing circulation to the toes. Most chilblains don’t cause any permanent damage to tissue, although sometimes they can cause skin ulceration.
Moist skin
Sweating, urine incontinence or diarrhoea make your skin wet increasing your chances of a skin infection.
Healthy tips
- Keep your skin clean and dry.
- Pay special attention to cleanliness in sweating areas.
- Clean and dry well under skinfolds.
Sunburn
Sunburn is a form of radiation burn affecting living tissue, e.g., skin, as a result of overexposure to ultraviolet or UV radiation, usually from the sun.
Healthy tips
- Check weather conditions on your weather app or check online and make sure you apply sunscreen with a recommended sun protection factor.
- Wear a hat and a long-sleeved shirt when you are out in the sun.
- Certain medications, such as antibiotics and local skin ointments, can make your skin more sensitive to sunburn. Check with your pharmacist.
More fragile skin over scar tissue
Scarred skin can be thinner and susceptible to re-injury than healthy skin. An old scar may also be more prone to breakdown if overlying bone. With ageing, the skin may become more fragile and prone to tearing due to skin atrophy.
Signs and symptoms of fragile skin
- Skin that appears thin, dry, or transparent
- Skin that tears or bleeds easily
- Thinning (atrophy) of the top layers of the skin
- Frequent skin bruising.
How to treat scarred skin
- Stay hydrated: good skin needs proper moisture and hydration, and one of the best ways you can achieve this is by staying hydrated and drink a total of 6-8 glasses per day. The more water you consume, the better you can flush out all the toxins and pollutants in your body. Staying hydrated also removes any dry patches on your skin too
- Improve Your Diet: your diet nourishes your body and can make a huge difference on your skin as well.
Cellulitis, an infection of the skin
Cellulitis is a serious infection of the skin, where bacteria enter the skin through a crack or break. The infection can further spread to other part of the body and may sometimes lead to blood poisoning (sepsis). This needs urgent treatment with antibiotics.
Signs and symptoms of cellulitis
- The skin appears swollen, red and warm to the touch
- Cellulitis usually affects the lower legs, but it can occur on the face, arms and other areas of the body.
How to treat cellulitis
- Finish full course of your antibiotics (typically 7-10 days) even if you start to feel better.
- An important strategy for prevention is to
- maintain good skin hygiene,
- ensure feet and between toes are dried, and
- avoid cracking of the skin.
Osteomyelitis, an infection of the bone under the skin, fat and muscle layers
Osteomyelitis is inflammation or swelling that occurs in the bone. It can result from an infection that can reach bones through the bloodstream or spreading from nearby tissue. Testing for osteomyelitis may involve a bone biopsy, as well as x-rays, CT or MRI scans.
Signs and symptoms of Osteomyelitis
Pain, fever, failure of healing or recurrent wound breakdown.
How to treat osteomyelitis
Treatment is usually surgery, to remove the sections of bone that are infected or dead. This is followed by intravenous antibiotics in hospital and a prolonged course of oral antibiotics for 3-6 months.
Check if you have a problem
Check if you have a problem
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Quick Health Check
If you are experiencing a health issue, to support you to identify the problem, check the seriousness of the problem and understand what action to take to manage it, we have provided easy-to-use tools to help you.
The Tools
The Quick Health Check is an automated version of the five following tools. These tools work together to help you with skin problems.
- Checklist
Answer a few simple questions to help you to quickly identify a problem - Warning Signs
Check whether you have a serious problem that needs immediate attention by a healthcare professional - Severity Scale
Quickly assess how severe the problem is - Interference Scale
Select one number to determine how much the problem interferes with your daily life - Action to Take
The severity and interference scale ratings combine to provide you with the recommended action you need to take to manage the problem.
You can use the 5 manual tools below if you prefer this approach to using the automated Quick Health Check in the top right-hand corner of the page.
1. Checklist
Check if you have a problem
If you answer ‘yes’ to any of the questions below, refer to the Severity scale to see whether your problem is mild, moderate or severe, and then the interferance scale and action to take table, to understand whether you can self-manage or whether you need to manage with the support of a healthcare professional.
- Do you have any signs of a red spot, area of firmness, or discolouration to skin over a bony point?
- If your skin is currently broken, is there any sign of infection (e.g., increasing discharge from wound, redness or swelling, unhealthy looking tissue or smelliness)?
- Do you monitor your skin for pressure injuries twice a day, or have someone else do this for you?
- Old scar tissue can makes your skin more fragile and at risk of breakdown.
- Any change in your pattern of spasms, neuropathic pain or autonomic dysreflexia may indicate underlying skin damage.
- Area of skin that is to moist due to bladder or bowel leakage or excessive sweating?
- Change in your, equipment, (e.g., cushion/sitting position) and/or, activities or ability to transfer.
2. Warning Signs
If you experience any of the following warning signs, you need to seek medical attention:
- Purple or discoloured skin or a blood-filled blister indicating a deep pressure injury that develops from the inside out
- Fevers, sweats, the shakes or you have been feeling unwell because of a pressure injury
- Your pressure injury is discharging a lot of pus and/or the surrounding skin is red
- Your pressure injury has not been improving, has increased in size and depth or has unhealthy tissue at its base
- Having more than one current pressure injury
- Any major change in your weight (increase or decrease)
Have you ever required surgery for a severe (stage 3 or 4) pressure injury?
You may need to restrict your activity and use special dressings that help protect the area while it heals. In severe cases, surgery, hospitalisation, medication, and skin grafts may be needed.
If you experience any of these issues there may be a serious problem requiring further investigation – see medical advice immediately
3. Severity scale
To check how severe your problem is, use the Severity Scale to assess the intensity, duration and frequency of your signs and symptoms.
Problems | Mild | Moderate | Severe |
|---|---|---|---|
Pressure injury | Stage 1 or 2 pressure injury, which heals rapidly | Stage 2 pressure injury (≥ 4 weeks), AND/OR infection (superficial) present Recurrent or multiple Stage 1 or 2 pressure injuries | Stage 3-4 pressure injury, deep tissue injury, prolonged healing (≥ 3 months) AND/OR infection (deep) present Recurrent pressure injuries/previous flap repair (Stage 3-4) Deteriorating or pressure injuries over multiple areas |
Burn | Superficial burn (first-degree). Skin is red, painful, dry, without blisters. Mild sunburn | Partial thickness (second-degree) burn. Skin is red, blistered, and may be swollen and painful. | Full thickness (third-degree) burn. Skin looks white or blackened and charred. |
Cellulitis | – | Red, swollen, tender, warm area of skin Occurs infrequently (once every 12 months or less often) | Red, swollen, tender, warm area of skin Occurs frequently (twice or more per year) AND/OR spreads to involve lymph nodes and/or enters bloodstream |
Pressure injury |
|---|
Mild Moderate Recurrent or multiple Stage 1 or 2 pressure injuries Severe Recurrent pressure injuries/previous flap repair (Stage 3-4) Deteriorating or pressure injuries over multiple areas |
Burn |
Mild Moderate Severe |
Cellulitis |
Mild Moderate Occurs infrequently (once every 12 months or less often) Severe Occurs frequently (twice or more per year) AND/OR spreads to involve lymph nodes and/or enters bloodstream Any skin-related symptoms of any severity associated with autonomic dysreflexia are considered SEVERE and require URGENT MEDICAL ATTENTION. |
Any skin-related symptoms of any severity associated with autonomic dysreflexia are considered SEVERE and require URGENT MEDICAL ATTENTION.
4. Interference scale
To determine to what extent your problem interferes with participating in everyday activities, use the scale below:
5. Action to take
This table provides a way to combine your severity and interference ratings from above scales to help you decide what level of support you may need to most effectively manage your problem.
Severity rating | Interference rating | Management strategies |
|---|---|---|
Mild problem | (0) Not at all | Self-manage without support |
Mild problem | (1) A little of the time | Self-manage without support |
Mild problem | (2) Some of the time | Self-manage with support from your GP or other healthcare professional |
Mild problem | (3) A lot of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (0) Not at all | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (1) A little of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (2) Some of the time | Self-manage with support from your GP or other healthcare professional |
Moderate problem | (3) A lot of the time | Manage with specialist support |
Severe problem | (0) Not at all | Manage with specialist support |
Severe problem | (1) A little of the time | Manage with specialist support |
Severe problem | (2) Some of the time | Manage with specialist support |
Severe problem | (3) A lot of the time | Manage with specialist support |
Note: If you are self-managing without support and your problem has not been resolved, you should seek help from your GP, other healthcare professional or involve a spinal cord injury specialist in your management plan.
Prevent problems
Prevention
How to prevent pressure injuries
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Self-management tips
Relieve pressure regularly
Check skin twice a day
Use appropriate pressure-relieving devices
Use the right cushion and look after it
Know how to identify skin breakdown
Maintain good skin hygiene
Wear loose fitting clothes
Maintain a healthy lifestyle
Do not use too many powders and creams
Know your medications
Action: Reposition yourself and/or lean forwards or from side-to-side in your wheelchair. Try to lean for 2 minutes, at least once every hour.
Relieve pressure regularly
Action: Reposition yourself and/or lean forwards or from side-to-side in your wheelchair. Try to lean for 2 minutes, at least once every hour.
Check skin twice a day
Action: Use a mirror and/or touch to see or feel your skin, or instruct others to check your skin if you cannot check it yourself.
Use appropriate pressure-relieving devices
Ensure you have a mattress that meets your needs.
Action: If you are using an air mattress, ask your therapist for instructions and then teach others how to use the equipment properly.
Use the right cushion and look after it
Learn how to look after and maintain your cushion, and always have a repair kit handy. Seating should be reviewed when replacing cushions, chairs or if problems develop. Avoid over-inflating your cushion, if you have the cushion shown in the picture.
Action: If unsure, see a seating specialist.
Know how to identify skin breakdown
Knowing how to identify skin damage can help you decide on the right course of action and recognise improvement or further breakdown.
Action: Understand the different stages of skin breakdown.
Early detection reduces time to healing, improves outcomes and decreases cost.
Image courtesy of The National Pressure Ulcer Advisory Panel 2016
Maintain good skin hygiene
Action: Keep your skin clean and dry, especially after showering or swimming. Pay attention to the groin, between the buttocks and in between your toes.
Wear loose fitting clothes
Tight-fitting clothes and shoes can damage skin.
Action: Wear clothes that are appropriate for the weather. Wear properly fitting shoes to avoid too much pressure which can cause an ingrown toenail.
Maintain a healthy lifestyle
A healthy lifestyle will assist in keeping your skin healthy.
Do not use too many powders and creams
Powders can turn into tiny hard balls when moist, causing damage to the skin. Creams can make your skin ‘soggy’, making it more susceptible to breakdown.
Action: Avoid using powders and ensure creams are gently applied and completely absorbed.
Know your medications
Action: Understand the side effects of certain medications, such as sensitivity to sun if taking Baclofen (Lioresal) for spasms.
How to prevent heat injuries
When bathing
- Check yourself or ask someone to check the water temperature by dipping the hand (with normal sensation) into the water for 5 seconds. If you feel comfortable, then the water temperature is safe.
- Do not set your hot water system higher than 48 degrees Celsius.
Use of heat packs
- Avoid them, especially on body parts with little to no sensation.
Household amenities
- Do not sit too close to heat inside your house such as fireplaces, hot stove burners and radiators. When outdoors, don’t sit too close to campfires.
- Do not use electric blankets.
- Do not carry hot fluids or foods in your lap without a tray. Have a cup holder and do not overfill the cup.
How to prevent cold injuries
Outside in cold weather
- Cover your head, nose, ears, chin and hands.
- Wear warm socks and sturdy shoes.
- Remove any wet clothing.
Please note: If you feel cold and tingling on your ears, then most likely your feet are cold too so move indoors.
Ice packs
- Always wrap them in a towel.
- Do not use them for more than 10 minutes.
Please note: Be careful with carrying frozen food on your lap in the supermarket.
Using a wheelchair
- Wear gloves to push your manual wheelchair.
Please note: Wheelchair parts and gel cushion can get cold and may cause your skin to dry out, causing cracks, splits and cold injuries that are hard to heal.
Take home messages
EAT
a balanced diet
MAINTAIN
good hygiene with special attention to your groin and washing/drying between your toes
KNOW
how to identify signs of a pressure injury and skin breakdown
TREAT
your pressure injury at an early stage
RELIEVE PRESSURE
regularly