Wound Practice and Research

Comprehensively understanding the structure, physiology and function of the skin can help us identify skin conditions, comprehend wound healing mechanisms and explore new prevention and treatment strategies for skin disroders. This short review describes the structure, composition and different cell types that make up the skin, and discusses the functions of the skin and the impact of ageing on skin structure.

The integumentary system is the largest and most visible body organ and is composed of the skin, hair, nails, sebaceous glands, eccrine and apocrine sweat glands. Integumentary assessment, prevention of its injury and management of the injury or other defect, should it occur, is a paramount goal for all clinicians across all health domains. Furthermore, it is a fundamental requirement for ensuring quality care outcomes. However, in order to conduct a comprehensive and informative assessment the clinician needs to recognise and consider the normal skin characteristics that present across the lifespan in order to identify any pathological  presentations. The major lifespan periods that influence the integumentary system changes are: neonatal, childhood, adolescence, pregnancy, adulthood and elderly time periods.

Chronic wounds can lead to amputations and significant decreases in quality of life. Many commonly used medications are known to cause ulcers or perpetuate chronic wounds. A variety of medication classes can impair wound healing through affecting cells within the skin, metabolism, immune cell function, angiogenesis and coagulation. This review aims to highlight the main types of drugs which negatively impact wound healing. Cancer treatments, non-steroidal anti-inflammatory drugs (NSAIDs), anticoagulants, immunosuppressants, and some antibiotics are all risk factors for cutaneous adverse effects. Identifying drug-induced impaired wound healing is important to counsel patients and their medical practitioners on weighing up the benefits and risks of these medications.

Aim To synthesise evidence regarding skin care to maintain skin integrity and prevent wounds.

Methods An electronic search of key terms (skin care or skin integrity) was undertaken of articles published between 1 January 2018 until 30 September 2023. A narrative integrative review synthesised results.

Results In all 73 articles met the inclusion criteria. The topics included cleansers, moisturisers, and/or barrier products (n=33), health service interventions related to skin care (n=15), and the impact of dressings on skin integrity (n=12). Eight encompassed multiple interventions, three examined self-management and two foot skin care.

Conclusion Strong evidence on skin management to prevent wounds is limited. Moderate evidence supported the use of mild, non-alkaline cleansers and low pH moisturisers with humectants to improve skin integrity and prevent skin tears; in addition to prompt cleansing, use of topical barrier leave-on products and absorbent products to prevent incontinence-associated dermatitis. The choice of prophylactic dressing is not a one-size-fits-all decision but rather a nuanced clinical decision that must consider the specific needs and circumstances of each patient. Use of person-centred care, evidence-based interventions by healthcare providers, and involvement of the interprofessional teams emerged as central themes of skin care for prevention of wounds.

‘Skin integrity’ refers to intact, unbroken, and healthy skin. Disruption of skin integrity can be caused by intrinsic and extrinsic factors including altered nutritional status, vascular disease, diabetes, and tissue injury, and this is often associated with development of localised clinical infection. Skin health and hygiene is important for preventing wounds and development of localised clinical infection or sepsis. Clinical wound infection is an increasing problem in healthcare, with the potential for increasing the burden of antimicrobial resistance (AMR), if antimicrobials are overused to treat wound infection.

In this review we discuss skin integrity and wound infection prevention and outline the guiding principles of antimicrobial resistance and antimicrobial stewardship for infection control. Additionally, we provide a critical review of current best practice, highlighting the pathway to guide management of patients at risk of infection development, and discuss the latest research progress on antimicrobial resistance and skin integrity.