WOUND BLOG by Matthew Livingston RN

I recently received a note from a reader who is having considerable problems with breakdown of skin underlying the KCI wound VAC drape.  Typically, this is caused by four problems.  First, improper removal of the VAC drape can strip fragile skin. Second,  some individuals are  reactive to wound VAC drape itself.  Third,  individuals with considerable edema (fluid build up) in the surrounding tissues are more susceptible to the striping of fragile skin.  Finally, a fungal component may lead to areas of red, itching, weeping, combined microlesions. The following are my recommendations for adapting your approach to VAC Therapy dressing changes  with each of these situations.

1. Denuded Fragile Skin -

A. Drape Removal – First, use adhesive remover wipes to work under the drape. As you move the wipe under the drape pull the drape away from (not up from) the center of the dressing. Apply light pressure ahead of the elevated aspect of the dressing so you don’t pull to much drape to soon. Applying light pressure in this manner also helps to defer the sensation of discomfort in this area. Continue this technique slowly and take breaks as needed. Note: use these removal techniques for the other three skin conditions.

B. Placement – Placing VAC drape directly over  denuded fragile skin can lead to more skin stripping when attempting to remove the drape (regardless of skin prep). First, make the size of the VAC drape dressing as small as possible. Second, under the drape place a Duoderm thin or other hydrocolloid. Finally only place the VAC drape over the hydrocolloid and foam. According to the KCI VAC Therapy Clinical Guidelines it is appropriate to leave the duoderm intact to the skin for up to seven days (KCI, 2007). Only removing the foam in the interim. When finally removing the Duoderm (hydrocolloid) consider using an adhesive remover.

2. Reactive Skin – For individuals who are reactive  to wound VAC drape (reactive skin is located only under the drape, red, and perhaps a little swollen and itchy). I have found benefit in reducing the size of the footprint of the VAC drape. Placing Duoderm thin or other hydrocolloid as a non-reactive protectant over the reddened areas. Then adhering the VAC drape over the top of the duoderm.  When replacing the VAC foam, during the next dressing change, it will be OK to remove only the foam. Leaving the duoderm intact to the skin for up to seven days (KCI, 2007). When finally removing the Duoderm (hydrocolloid) consider using an adhesive remover. It will take about a week  for the redness to fade. If in this time the red areas have not reduced in intensity, consider the chance that there may be an autoimmune component to the wound. If able to reduce the size of the dressing consider using Topicort ointment  as an anti-inflammatory agent for the  inflamed areas over the undressed skin.

3. Denuded Weeping  Edematous Skin – Placing VAC drape over denuded weeping  edematous skin is one of the most difficult challenges  for a wound care nurse. I have had good luck with placing Stoma Powder (Convatec) over the weeping area. Typically, with up to  moderate weeping, the stoma powder will dry over the open areas allowing  for VAC drape placement. Please note that the stoma powder can sting. For excessive weeping skin conditions (common in individuals with gross pitting edema ) and when it is imperative that VAC therapy be continued; place a layer of wound veil over the weeping denuded area.   Then place the VAC drape over the foam, wound veil, and then attach the VAC drape to the skin that has not eroded. This should allow the skin to be protected while removing any fluid. To prevent continued skin erosion of the healthier tissue consider placing a duoderm (hydrocolloid) down over the healthier skin. Then lay the VAC drape over the top of of the hydrocolloid, Wound Veil, and VAC foam. If the skin continues to degrade consider holding off on the VAC Therapy until the skin condition improves.

4. Fungal Skin Rash -For light to moderate fungal infections consider using the smaller foot print trick listed above. Consider using a process called “crusting” which is a progressive build up of layers of alternating anti-fungal powder with Skin Prep (applied by dabbing lightly so that it moistens the powder but doesn’t remove the lower layer of powder). After about eight or so alternating applications a crust of anti-fungal powder should form with enough stick to allow the wound VAC drape to adhere to its service. For a raging fungal infection consider holding VAC Therapy (until resolved) and providing a systemic anti-fungal (Diflucan).Note an example of anti-fungal powder is Micro Guard Powder AF from Coloplast with Miconazole Nitrate 2%.

KCI, 2007. V.A.C. Therapy Clinical Guidelines retrieved from http://www.kci1.com/Clinical_Guidelines_VAC.pdf