Spinal Cord Injury Skin Management

What is the skin?

Your skin is much more than an outer surface for the world to see. It protects you from bacteria, dirt and other foreign objects and the ultraviolet rays of the sun, and contains the nerve endings that let you know if something is hot or cold, soft or hard, sharp or dull. Your skin also plays an important role in regulating your body’s fluids and temperature.

Below the smooth, hairy outer skin, or epidermis, that we see every day is a thick, strong and elastic layer of tissue known as the dermis. The dermis is richly supplied with blood vessels, sweat and oil glands, and nerve endings.

How to take care of your skin

NUTRITION:
To keep your skin healthy, eat a well-balanced diet that includes plenty of protein foods, fresh fruits and vegetables and liquids. If you are having a skin problem, such as a Pressure Sore or a healing surgical incision, you should increase your intake of protein (lean meats, dairy foods and legumes), carbohydrates (breads, cereals), vitamins A, B6, C, E, and zinc. Extra iron may be needed if you are anemic.

CIRCULATION:
With a lack of air circulation, feeling and movement daily skin care is very important in order to avoid infections, sores, and irritations.  The skin is served by a large number of blood vessels, and adequate circulation is needed to maintain skin health. You can help ensure a healthy blood supply by considering the following suggestions:

• Smoking — DON’T! Nicotine in cigarettes causes blood vessels to get small (constrict) and prevents blood, oxygen and nutrients from flowing to the body tissues.
• Edema, or swelling caused by fluid collecting in the tissues, usually occurs in a part of the body that is not moved frequently and is below the level of the heart (i.e., the feet, legs and hands). Skin over areas of edema becomes thin and pale and injures easily because of poor circulation. Edema can be prevented by elevating your legs and hands frequently, performing regular Range of Motion (ROM) exercises and wearing compressive stockings.  A massage technique similar to squeezing a tube of toothpaste can be used to work the fluids out of the fingers and feet.  After a couple of minutes massage the swelling should begin to subside.
• Anemia (a decrease in red blood cells). Oxygen is essential for skin health, and is carried by red blood cells. A decrease in their number means less oxygen gets to the skin, which means that skin cells may become unhealthy or even die. Anemia should be evaluated and treated by your health care provider.
• Vascular Disease, or a narrowing of the blood vessels, can be caused by diabetes, smoking, high blood pressure or elevated cholesterol. The result is decreased blood flow to the skin. Work closely with your health care provider to manage conditions that can lead to vascular disease and cause skin problems.
• Diabetes
  Diabetes damages the blood vessels and nerves.  Wounds and sores can become infected easier and heal at a much slower rate.  If you have been diagnosed with diabetes follow your insulin routine carefully.  You will also want to perform the skin inspections more closely, paying special attention to any reddening of the skin as they can become dangerous faster than those who do not have diabetes.

Tips for maintaining good skin care

• Avoid using soaps labeled “antibacterial” or “antimicrobial.” These tend to reduce the skin’s acidity, which acts as a protection from infection.
• Keep the skin clean and dry. Wash with soap and water daily, then rinse and dry thoroughly.
• Skin folds or creases (as in the groin area and underarms) need washing more frequently — twice a day, morning and bedtime. Rashes can easily form in these areas because of increased moisture and warmth. Increasing the air circulation to these areas to help prevent rashes can be accomplished by positioning the arms and legs so the skin surfaces are separated. For example, use the “frog” position to air the groin area. Air these areas two times a day.
• Rashes can be caused by tapes, soaps, fabrics or other irritants. Total body rashes may result from food or drug allergies. Consult your health care provider for treatment of any rashes you may have.
• Avoid using items that may dry the skin — for example, harsh soaps or alcohol based products such as lotions. (A good non-drying lotion to use is Alpha Keri.)
• Lubricate dry skin with moisturizing creams or ointments (such as Eucerin or Aquaphor). Use care in applying creams over bony areas, since they may soften the skin and promote Skin Breakdown.
• Soiled skin can break down easily. Urine and stool have irritants in them and should be cleaned up immediately to prevent weakening and breakdown of the skin surface.
• Avoid using talc powders, as they may support yeast growth. They can also “cake up” and keep moisture in, causing skin breakdown.
• Calluses may form on your feet and hands. These can be removed by soaking frequently in warm water and toweling briskly to remove dead skin. You can use moisturizing creams to help soften calluses.
• Finger and toe nails require special care. Soak them and rub gently with a towel to remove dead skin and decrease the chance of hangnails forming. Nails are easier to cut after soaking; be sure to cut them straight across to avoid ingrown nails, and keep them short for safety.

Skin inspection
Inspecting the skin daily is extremely important as pressure sores and infections could occur very quickly.  Skin should be inspected at least once a day.  Look for reddened areas, scrapes, cuts, bruises or any kind of discoloration out of the norm.  Areas that need special attention are the groin area, behind knees, the areas around the ankles and elbows, and your Posterior (hips and tailbone areas should be checked carefully).

The only way to know if your skin is healthy and intact is to look at it regularly. In areas where sensation (feeling) is decreased, skin inspection is essential and should become a habit. Plan it as a part of your regular routine, during a time when you are undressed anyway — like after a shower, before dressing in the morning or after undressing in the evening.

If you are unable to see some parts of your body, use a mirror or teach another person to check your skin for you. Long handled mirrors and other specially designed mirrors are available. Check all of your bony prominences, or areas where the bones protrude slightly below the skin (see illustrations below for the locations and names of these areas).

What to Look for
Look for any reddened areas, rashes, cuts, bruises, scrapes, or indentations from seams or elastic binding. Check also for blisters, bumps, insect bites, dry flaky skin or pimples. Check toenails for any redness or pus formation around the end of the nail.

Whenever you notice a problem, try to figure out its cause and make any changes necessary to prevent further problems. The first step in curing any skin problem is to eliminate the cause.

Preventing skin injuries

• PRESSURE RELEASES
  In both bed and wheelchair, change your position according to your skin tolerance. Pressure releases in a wheelchair can be done by pushing straight up, leaning side to side, bending forward over your knees, reclining the seat of your electric wheelchair or having someone tilt you back in your manual chair. Always use your wheelchair cushion. In bed, body parts can be padded with pillows to keep bony prominences free of pressure. Get into the habit of checking your body position for correct alignment and pressure-free positioning of bony prominences.
• EQUIPMENT
  Are you using the best equipment? Does it fit you properly? Here are some concerns:
  • Wheelchair — Does it support your back? Are your footrests the right height? Are you using the best wheelchair cushion?
  • Bed — Are you using a good mattress?
  • External catheters — Is the correct size being used? Is it being changed frequently enough?
  • Leg bags — Are the straps too tight?
  • Splints/Braces — Do they fit properly? Do you do skin checks after wearing them?
• TEMPERATURE
  Extremes of temperature call for extra caution in protecting your skin:
  • Heat — Avoid sunburn by covering up or using sun-block. Don’t put plates of hot food on your lap without protecting your skin. When riding in a car, keep your feet away from the heat outlet and check vinyl seats before you sit on them to make sure they aren’t too hot. Any exposed pipes in your kitchen or bathroom sink should be wrapped to protect your legs from burns. When you go camping, protect your feet by sitting a safe distance from the campfire.  Also avoid heating pads or electric blankets and close proximity to fireplaces or heaters .
  • Cold — Be sure to dress warmly to prevent frostbite if you are out in cold weather for long periods of time. Dressing in layers of clothing will provide extra warmth. Avoid putting frozen foods on your lap.
  • Fever — Your skin tolerances can change due to the increased body temperature that occurs with a fever. You may find that you cannot lie in one position as long.
• BODY WEIGHT
  • Too much — Being overweight can cause increased pressure on bony prominences. Delayed healing may occur because there are fewer blood vessels in fat tissue.
  • Too little — Excess pressure over bony prominences may occur because there is less padding (muscle and fat) over these surfaces. In addition, underweight persons may lack the proper nutrition to maintain healthy skin.
• CLOTHING
  Proper fit is important. Avoid sitting on seams and back pockets, and always check your skin carefully after wearing new shoes or clothing.
  • Too loose — Loose clothing can form wrinkles that put pressure on your skin.
  • Too tight — Overly tight clothing can hinder circulation.
• ALCOHOL
  Over-indulgence in alcohol — or any other drug — may interfere with attention to your personal care needs. For example, while under the influence you might forget to turn yourself, or be too weak to transfer yourself properly.
• STRESS & Depression
  Stress and depression can have a similar effect by causing you to lose interest in your personal care and pay less attention to your skin and general health.
• Spasticity
  Spasticity may cause your arms and/or legs to bump against an object, or to fall off your armrest or footrest, and be injured. Spasms may cause your skin to rub against something (for example, the sheets on your bed), which could produce an open sore.