The Skinny on Protecting your Skin

Skin, our largest organ spanning a surface area of 1.5 to 2.0 square meters, serves a vital role for our bodies.¹ The integumentary system makes up our body’s outer layer comprised of our skin, hair, nails, glands, blood vessels and nerves.²  It serves to protect internal structures, maintain homeostasis through body temperature regulation & other functions, promote immunity and perceive sensations.² These sensory receptors enable us to respond to temperature, levels of touch, vibration and pain thereby allowing us to explore the world and help protect us from injury.²

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Integumentary Integrity

While this amazing organ has the ability to heal itself should harm befall us, best practice is to avoid injury.² Damage to skin can lead to replacement with scar tissue which provides 20-30% less elasticity and ultimately less tensile strength than its predecessor.² Aging of the skin and medical conditions such as diabetes negatively affect the body’s ability to heal.² Chronological age is only one facet. Skin aging is greatly impacted by external factors including but not limited to exposure to UV radiation, malnutrition, poor hygiene and lack of medical care.²

CCO 1.0

Checking and maintaining the integrity of the integumentary system is vital to a healthy lifestyle. Impaired immune function, delayed healing and decreased vascular supply increase the individual’s risk of infection, cancer and limb loss.²  Daily skin checks, routine hygiene and a balanced diet are just a few ways of ensuring skin remains viable and protected. Use of a long-handled mirror helps provide access to viewing difficult to reach, pressure-prone areas.

Under Pressure

Contact between your skin and your orthosis or prosthesis will provide some amount of pressure. These interventions are custom fit or molded to you by your Certified Prosthetist Orthotist (CPO) and are engineered with force systems designed to offload pressure sensitive areas and load pressure tolerant areas.^3,4 Some redness of your skin may occur, but knowing how much is acceptable is key. Blanchable erythema is a term used to describe when skin is red but changes to original skin tone after lightly pressing on it.³ This is okay. Non-blanchable erythema is not; i.e., red and stays red with light touch. This indicates injury. If this occurs, contact your CPO to assess the fit of your O&P device. Continued exposure to this excessive pressure could lead to skin breakdown and the inability to wear your orthosis or prosthesis.  

Discovered redness on your foot following use of your orthosis? Consider the following:^3,4

• Are you wearing socks? An interface between your skin and an orthosis is important to reducing friction.
• Did you recently change your shoes? Watch out for seams at the forefoot of the shoe and crowded toe boxes. Ensure the laces or Velcro are secured so your foot and AFO are not sliding within the shoe.
• Are your legs swollen? Have you changed your diet or medications? Have you recently gained weight?  A change in the shape of your lower extremity can alter the fit of the orthosis.
• Is your ankle tight? Have you been stretching? Can you get your foot all the way into your AFO? If your foot cannot lay flat on the footplate and your heel cannot make contact with the AFO in standing, the fit needs to be adjusted. Are you taking medications for tone management? This may need to be addressed with your MD.

Discovered redness on your residual limb following use of your prosthesis? Take into account these considerations:^3,5

• Are you consistently wearing your shrinker sock or prosthetic liner when your prosthetic socket is doffed? Volume changes occur throughout the day. Maintaining limb volume is essential to proper fit.
• Are you wearing sufficient sock ply with your prosthesis? Keep extras with you to accommodate your fit due to altered volume.
• Do you hear noise coming from your prosthesis when walking? Pistoning up and down within the socket can lead to friction, pressure areas and fluctuations in limb volume. Recheck your fit to help reduce this from occurring and consult with your Prosthetist as needed.
• Is your residual limb not sitting properly within your vacuum suspension prosthesis? A void in the system may occur causing excessive pressure as your soft tissue gets pulled. This, too, can create pressure areas and volume changes.
• Have you changed your diet or medications? Have you recently gained weight?  Are you retaining fluids? Any of these can impact the size/shape of your residual limb and the fit within the prosthetic socket.

A common misconception is to just add padding when areas of redness are noted. Padding means increased pressure between your skin and the orthosis or prosthesis. As noted, this places you at risk of skin breakdown. Consult your CPO. They are experts in O&P design and can strategically place padding, modify the shell to redistribute forces and offload affected areas or make other necessary adjustments.⁴ For example, do you experience discomfort or increased pressure on your limb in sitting? Provided it supports the integrity and function of your O&P device, material changes can be made to the posterior thigh panel of a KAFO or prosthetic socket (e.g., exchanging plastic for sail-like fabric). Discuss with your CPO which adjustment is right for you.

Inspect to Protect

Monitor your skin daily with use of your orthosis or prosthesis. If you are unsure of the fit of your device, schedule an appointment with your Orthotist/Prosthetist or check with your PT at your next treatment session.

“An ounce of prevention is worth a pound of cure.” -Benjamin Franklin

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References

1. Institute for Quality and Efficiency in Health Care. “How does skin work?” Informed Health, 2019 April 11, https://www.ncbi.nlm.nih.gov/books/NBK279255/.
2. Park, Ji-Whan, et al. Integumentary Physical Therapy E-Book. Germany, Springer Berlin Heidelberg, 2016.
3. Jorge, Milagros, et al. Orthotics and Prosthetics in Rehabilitation E-Book. Saunders, 2019.
4. Webster, Joseph B., Douglas Murphy, and Elsevier. Atlas of Orthoses and Assistive Devices. Elsevier, Philadelphia, PA, 2019; 2018.
5. May, Bella J., et al. Prosthetics & Orthotics in Clinical Practice. McGraw Hill, 2011.