Here are pathways for treating and protecting skin and wounds under multilayer compression bandaging (Profore or dynaflex) for patients with venous hypertension: Please add to this list as you wish. This was last revised 06/25/2010.
Dry Skin
Dry flakey skin – Moisturizer or thicker moisturizer.
Dry denuded skin – Xeroform.
Dry lightly reddened skin – A moderate strength steroid (Topicort), change underlying padding to pure cotton cast padding.
Dry itching burning skin – Viscopaste wrap as first layer.
Moist Skin
Moist denuded skin – wound veil (Smith and nephew) covered with alginate. I recommend the wound veil cover because it will prevent the alginate from binding with the denuded tissue.
Draining wound – alginate or a beveled foam dressing. Note that foams have a tendency to dig into the skin around the edges, so it is important cut and taper around the foam edges.
What antimicrobials can I place on the wound that will last seven days?
Moderate or High draining wounds – Consider Iodosorb or Acticoat 7 flex. Remember to put lots of protective cream (EPC) around the peri-wound. Consider changing the compression wrap twice a week.
The dressing has a foul smell after a few days
Consider a carbon dressing over the primary antimicrobial, debride, treat infection if present, change the dressing more often.
Still Edematous
Swollen moist red skin with new breakdown (even with 30-40mmHg compression) – Typical with fluid over load patients including renal disease. Treat the etiology.
Swollen extremity with reddened skin and new onset calf pain – Rule out DVT.
Edematous knee to thigh after compression – Rule out Lymphedema and consider Edema Wear or Tubigrip from the bottom of the knee (just below the top of the initial compression device) to the top of the thigh. Consider placing a strip of foam dressing just under and over the top of the multilayer compression device if the top of the compression dressing is cutting into the skin (because of the edema).
Swollen Forefoot after Compression – Typically this is a result of the compression dressing being pushed up by mechanical means (related to poor fitting shoes or human intervention). Recommend the patient wear shoes with larger toe space such as Crocs or a surgical shoe. Consider placing an extra turn of the wrap or a 4×4 of plain foam over the swollen area. Also place a thick barrier cream such as EPC cream over the forefoot to provide some tact in the area.
Swollen Toes after Compression – Consider gently wrapping the toes by first separating each toe with a foam dressing to prevent toe to toe pressure. Then place extra padding over the toes before you finish wrapping the toes with Coban. The elastic layer shouldn’t be placed over the toes along with the Coban, as this my apply to much pressure.
Infection
Swollen red skin with open wound and new onset fever or pus – Rule out infection, culture wound, antibiotics.
Inflammation
Bright reddened skin (Inflammatory with no signs of infection) – Topicort topical, medrol dose pack, Could also be related to allergy such as sulfa, bacitracin, or latex. Note that redness from a topical sulfa allergy can clear up in a matter of minutes once removed.
Recurrent reddened skin with an open non-healing wound – Consider differential diagnosis including autoimmune or another micro-occlusive disorder. Micro-occlusive disorders are covered in the Scottsdale Wound Management Guide (which can be purchased at swmghandbook.com). – Topicort to the wound bed and Prednisone oral weening over 6 weeks.
Dermatology
Reddened vessels around hair follicles – Rule out folliculitus
Smaller reddened vessels (in groups or singular) – Consider treatment as fungal infection. Anti-fungal ointment for small area fungal breakouts.
Itchy rash over the majority of lower extremity below and maybe just above the knee to the thigh (If using latex compression wraps) , also possible systemic effects including puffy face, etc… – Rule out latex allergy, Consider Medrol dose pack, Benadryl, and Profore LF (Latex Free)
Shriveled skin – This is a common situation which happens during the first few weeks of compression therapy. The skin typically tightens on its own.
Adherent dry or dead tissue build up – Lotions (without alcohol) and /or mist therapy to loosen. Once loose use a pick-up to remove.
Pain
Vague recurrent pain with application of compression dressing – To much tension, consider less compression to the extremity. Including placing Tubigrip instead of Coban on the final layer. Insure that ABI indicates no arterial component.
Recurrent pain over bone with the application of compression dressing – Assess the skin for areas of bruising or open skin. Cover the area with a hydrocolloid.
Recurrent pain over small protruding bone with the application of compression dressing – Cut out foam around the prominence with the idea of offloading the small protruding bones from the pressure of the wrap.
Recurrent pain over prominent shin bone with the application of compression dressing – Build up an offloading layer of cast padding to the shins sides, then place extra cast padding over the shin down to the anterior ankle .
Pain related to wrap cutting in to skin of fluted lower extremity. Note that fluted refers to a thick upper calf and a narrow distal third of the lower extremity – Assess for rolled undulating skin with straight indentations or openings into the skin that match up with the wrap. Place extra cotton layers around the lower third of the dressing to build the area up. This protects the skin and helps prevent the wrap from sliding down.
Swollen extremity with reddened skin and new onset calf pain – Rule out DVT
Pain with removal of dressing – Consider using Xeroform, Adaptic, Mepetel or Comfort 2 Wound Veil. Saturate the dressing with saline to facilitate removal of dry drainage from viable tissue.
No Improvement in Wound Size:
Consider a vascular consultation starting with a Venous Doppler R/O incompetent perforators.
Consider if wound stalling is related to chronicity or infection. Treat with collagen and /or with seven day anti-microbal dressing.
Consider secondary etiologies such as lymphedema, hypercoagulable states, autoimmune disorders, malignancy, etc…
Unable to convert patient to stockings (without increased swelling and or reopening of wounds)
Consider a vascular consultation starting with a Venous Doppler R/O incompetent perforators.
Try different compression stocking companies including more expensive brands that may have true and appropriate compression(yes there is a difference in quality between brands).
Poor health precludes vascular intervention – Palliative care (keep the patient in multilayer compression).
Revised 12/02/2010 ml
Matthew Livingston R.N. C.W.S.
