Managing Skin Break down

total credit for this article goes to Baylor EDU

The skin is the largest organ of the body and is subject to a variety of problems in advanced disease of any kind. Among the more common skin problems of patients with advanced cancer are decubitus ulcers (bed sores), malignant ulcers (necrotic area caused directly by cancer), fistulas (abnormal opening between body parts or cavities, e.g., between rectum and vagina), fungating tumors (rapidly growing external tumors), itching or pruritus, infections, skin problems resulting from cancer treatment, and paraneoplastic syndromes. There is also a general deterioration of skin condition in patients with advanced cancer and other illnesses, including thinning, loss of elasticity, dehydration, deepening of sores and wrinkles, and pigmentation disorders. Skin problems, especially infections, are common in persons with AIDS.

Because a general deterioration of skin condition is very common, it is important to pay careful attention to (1) preventing problems and (2) identifying problems early in their development. See the discussion below on preventing skin breakdown.

Decubitus Ulcers (Pressure Ulcers or Sores, Bed Sores, Skin Breakdown)

Decubitus ulcers are caused by decreased circulation from pressure at a specific site, especially at or near bony prominences such as the sacrum ("tailbone"), hip, ankles, or sometimes ear. Multiple factors are involved in the development of decubitus ulcers, including:

• Trauma, e.g., friction, shearing, bruises, multiple same-site injections

• Immobility and constant pressure on the same site

• Moisture from any source, but especially urine

• Poor hydration, nutrition, circulatory, or mental status.

Infection, fatigue, anemia, long-term steroid use, and edema increase the risk of skin breakdown. Decubitus ulcers can cause pain, infection, protein loss, multiplication of lesions, cellulitis, sepsis, osteomyelitis, and increased demands on the workload of caregivers. More than 20% of patients in hospice settings may develop pressure sores.

Like so many other problems of terminal illness, it is best to prevent decubitus ulcers. Preventive measures include frequent turning, correct positioning, good hygiene, and adequate hydration and nutrition. Readers will note that almost all these measures require good pain management. Frequent assessment of skin condition is important in identifying skin breakdown at an early stage. Unless development is stopped and reversed, decubitus ulcers generally progress as follows:

Initially when pressure is first relieved, an area of skin, usually over a bony prominence, is lighter in color, then flushes red as circulation is restored. If there is no lasting damage, the redness disappears, usually in one to two hours. If the redness remains, damage has occurred. These changes in coloration are more difficult to see in a dark-skinned person. With or without lasting damage, there may be pain in the area.

The skin remains red, there is superficial tissue damage, and the skin is moist. Skin may appear to be scraped, a thin flap of skin may be torn back, or there may be blister-like areas.

The ulcer develops past the first thin layer of skin and usually becomes larger in size. The margins show skin layers and the inside area is usually pink if there is no infection. Drainage is thin and tinged with blood.

Ulceration extends into muscle or other tissue past the full thickness of skin. Bone may be exposed and a dark hard necrotic area (eschar) may develop. Infection is common and drainage becomes purulent.

Preventing and Managing Decubitus Ulcers

Prevention is the first priority. At the first hint of breakdown, treatment should be instituted as described below.

Prevention includes the following:

The patient should be turned at least every two hours with care taken while turning that the skin does not slide against the sheet and thus create friction and further damage.

A soft bed with sheepskin or egg crate foam helps avoid compression of tissue and skin breakdown. If sheepskin is used, it should be kept clean and brushed daily. An alternating pressure mattress is best for patients with skin problems, especially for those who are exceptionally thin. These beds are usually more comfortable than other types of beds, particularly for patients with pain. Preventive devices, such as pads to place between knees or sheepskin pads shaped to fit over heels, are helpful for very debilitated patients.

At least part of the time patients should lie at an alternating oblique (30 degree) angle on the bed rather than always straight up and down. This prevents the patient's body forming a trough in the middle of the bed.

Mobility, whether out of or in bed should be maintained as long as possible. Good pain management is thus an integral part of skin care.

Skin should be kept clean, dry, and as free as possible from urine, stool, drainage, or perspiration. Frequent washing dries skin, so hypoallergenic moisturizing lotions should be used - but sparingly. Skin powders should not be used, as they tend to accumulate in skin folds to a greater extent that when the patient was healthy. Soaps and detergents used for skin and linens should be mild, non-irritating, and non-scented.

Avoid "mechanical" factors that can injure or irritate skin. Among such factors are wrinkled sheets, crumbs, tape (especially adhesive tape), jewelry, long fingernails (patient or caregivers), vigorous drying with towels, rough sheets, heat, and any other factors that can contribute to skin breakdown.

Protein deficiency and dehydration are linked to skin breakdown, hence hydration and nutrition should be maintained as long as the patient is able and willing to eat and drink. See discussion of nutrition under anorexia in the chapter on gastrointestinal problems.

Patients at risk for skin breakdown should be regularly checked for signs of developing problems. While giving baths and massages, caregivers should carefully check the skin, especially the back, hips, heels, ankles, and any other bony areas or sites of likely or previous breakdown.

Treatment of pressure ulcers

Open wounds that do not show signs of infection (purulent drainage, odor, darkened areas) can be cleaned with a sterile normal saline solution. The area around the wound should also be cleaned with mild soap. When infection is present, the wound can be cleaned with hydrogen peroxide or an enzymatic agent - though ongoing use of hydrogen peroxide retards healing and should be avoided. In some cases, infected tissue is removed surgically in a hospital.

After the wound is cleaned, allow it to dry. Depending on the condition of the wound and direction from hospice staff or physician, the wound may simply be covered with a dressing (see below); or Maalox, Duoderm granules, or other preparation may be put into the wound.

The dressings should be a semi-permeable membrane such as Op-site or a polyurethane film. In some cases, a wet (Ringer's solution) dressing or gauze pad may be put over the wound and covered by a dry dressing. Dry dressings should not be used; and occlusive dressings, such as stomahesive, Duoderm, and others should not be used on immuno-suppressed patients such as those with AIDS.

In general, the wound should be kept moist, while surrounding tissue should be kept dry.

Infection is best treated with systemic antibiotics, typically prescribed according to microorganism, most commonly enterobacteria, staphylococci and streptococci. Treatment might thus be with a fluoroquinolone or trimethoprim and sulfamethoxazole (TMP/SMX). Pharmacotherapy is not always successful. If there is infection, wound care is usually given three times each day and include use of a topical antibiotic.

Malignant Ulcers, Fistulas, and Fungating Tumors

Malignant ulcers, fistulas, and fungating tumors usually are associated with advanced or rapidly advancing disease. They are most common in patients with breast cancer (>60%), sarcomas, recurrent gynecologic tumors and squamous cell tumors of the head and neck in the last six months of life. Associated problems include bleeding, odor (from secondary infection), drainage, pain, and appearance.

Managing Malignant Ulcers, Fistulas, and Fungating Tumors

Bleeding may progress from slight to profuse. Small amounts of bleeding can be managed by frequent cleaning and dressing changes (pressure bandages). Bleeding is managed medically by radiation, cryosurgery, or embolization. Patients with major, irreversible hemorrhage can be sedated and dark towels used to minimize the visual impact of bleeding.

Foul odor is due to anaerobic microorganisms. The infected area should be cleaned at least three times daily with hydrogen peroxide or povidone iodine. Systemic antibiotics are most effective in treating infection; and a topical antibiotic may be used as an adjunct, but not for primary treatment. Dressings may include charcoal packing or other compounds to absorb odor. Good air circulation is important and ionizers are helpful to some extent. Room "deodorizers" are helpful to some patients, but others find the smell of the deodorant worse than that of the wound. Oral medications that help reduce odor from wounds include metronidazole (Flagyl) and clindamycin, but neither is effective for long-term use.

Drainage from infection is treated as above. Drainage from fistulas (e.g., of gastric fluids or waste) to adjacent areas can result in infection, excoriation, and odor. Fistulas that open with one or two sites onto the skin can be managed similarly to an ostomy, both with respect to discharge (using an ostomy bag) and protection of surrounding skin (with stomahesive). Rectovaginal and rectoperineal fistulas require frequent cleaning and creative management, using tampons, sanitary pads, as well as more traditional dressings. All patients with fistulas should be referred to an interstomal specialist (a registered nurse who specializes in ostomy and related care). If the hospice or other involved program does not have an interstomal specialist on staff, they should (and are ethically bound to) arrange for a series of visits from a specialist from another agency.

Large malignant ulcers may be painful with or without infection. Pain is managed with analgesics and by treating the infection.

Biologic agents, e.g., blood-derived macrophages are probably the most effective treatment for ulcerating wounds. They are, however, expensive.

Problems of odor and appearance are psychologically and socially very difficult for most patients. Every effort should be made to control odor and keep air fresh. Visible tumors and wounds should be kept covered, especially when visitors are present. Some people wear a veil or swathe of cloth to cover large facial or neck tumors. Support and diversion are essential.

Itching (Pruritus)

Itching is common in patients with primary polycythemia, Hodgkin's disease, lymphoma, leukemia, and pancreatic cancer, as well as other tumor types. Itching also develops as a result of systemic processes such as uremia and cholestasis especially when there is obstructive jaundice. Infections such as candida or eczema also cause itching. Itching is sometimes due to anxiety and beginning opioid use.

Managing Itching

The cause is treated whenever possible. Comfort measures include:

Some relief may be gained from cooling baths with sodium bicarbonate, moisturizing lotions for dry skin, medicated lotions (2% phenol, menthol), anesthetic gel (0.5-2.0% lidocaine) every two hours, and calamine lotion.

Other measures include keeping the patient's nails trimmed to avoid excoriation from scratching, treating insomnia (itching is often worse at night), avoiding coffee and alcohol, and providing distraction.

Detergents used for bed linens and clothing should be mild.

People who scratch in their sleep may need to wear gloves at night.

For severe itching, systemic and topical therapies should be combined. Atarax is commonly prescribed. Although antihistamines and over-the-counter medications such as diphenhydramine (Benadryl) may be effective for itching from allergic reactions and (to a lesser extent) from other causes, complications may arise from their use, so professional consultation is necessary before using them. Antihistamines are ineffective for itch due to cholestasis (related to interruption in bile production). Aspirin may be helpful to patients with Hodgkin's disease and polycythemia vera; and cimetidine is effective in some patients with polycythemia vera.

Infection

Skin infections in patients with terminal cancer are most often bacterial, but also viral, fungal, or mixed. Infections are frequently complicated by or due to a combination of immuno-suppressive medications (e.g., steroids), neutropenia (decrease in the number of neutrophilic leukocytes and thus a tendency to develop infections), general debility, lymphedema, and other factors.

Managing Skin Infections

Some infections are prevented through effective hygiene, prevention of skin breakdown, early identification of skin changes, good wound care, and maintenance of other aspects of health status. Once present, skin infections are treated on the basis of the causative microorganism and symptoms such as pain or odor are managed as in any other circumstance.

One of the most common skin infections of patients with cancer is herpes zoster ("shingles") which is painful. Antiinflammatory and opioid drugs may be required. Since the pain is classed as neuropathic, anticonvulsants such as Tegretol or antidepressants such as Elavil are used to good effect. Early use of Elavil (and perhaps other such drugs targeting neuropathic pain) help decrease later pain, i.e., post-herpatic neuralgia.

Skin Reactions to Treatment

Both radiation and chemotherapy can cause skin problems. Because of advances in radiation therapy, radiation injuries are less common than in years past. Radiation can cause reddened, inflamed (sometimes with blisters), moist skin followed by superficial loss of tissue. Skin may also become dry and hair loss may occur. This problem usually resolves with only slight changes in pigmentation remaining. Late reactions to radiation may be irreversible and include thickening or atrophy of skin and malfunction of dermal glands.

Skin problems from chemotherapy in terminal illness include necrosis from intravenous drug extravasation (leaking into tissue at the injection site), hair loss, allergic or hypersensitive reactions, and changes in pigmentation. The primary use of chemotherapy in terminal illness is to palliate symptoms, and the amounts given and subsequent toxicity is not usually great.

Managing Skin Reactions to Treatment

People who receive radiation should avoid irritants such as harsh or heavily perfumed soaps, tight clothing, and trauma such as scrapes or bruises to the irradiated area. Skin should be cleansed gently with warm water and mild soap, and not a washcloth. Mild skin lotions should be used, but sparingly. Treatment of ulcers and infections is as discussed elsewhere. Once a reaction to radiation begins, there is nothing to reverse the process and it usually simply runs its course.

Extravasation may occur with intravenous chemotherapy, and results most often in local irritation which is treated with ice packs for 24 hours after occurrence and wound care if necessary.

Paraneoplastic Syndromes

Paraneoplastic syndromes (or distant and indirect effects of cancer) of the skin include acanthosis nigricans, dermatomyositis, acquired ichthyosis, erythema gyratum repens, and others. Paraneoplastic syndromes of the skin may be painful, cause severe itching, result in necrotic areas, or cause other problems. Rash, thickening, increased pigmentation, and other skin and/or hair changes are typical. Treatment is generally limited to resolution of the tumor and/or palliation with corticosteroids.

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