00Singer_prelims-F 7/8/10 7:52 PM Page i Skin and Soft Tissue Injuries and Infections: A Practical Evidence Based Guide 00Singer_prelims-F 7/8/10 7:52 PM Page ii 00Singer_prelims-F 8/31/10 7:05 PM Page iii Skin and Soft Tissue Injuries and Infections: A Practical Evidence Based Guide Adam J Singer, MD Professor and Vice Chairman for Research Department of Emergency Medicine Stony Brook University and Medical Center Stony Brook, NY Judd E Hollander, MD Professor and Clinical Research Director Department of Emergency Medicine University of Pennsylvania Philadelphia, PA Robert M Blumm, MA, PA-C, DFAAPA Course Instructor, Surgery and Emergency Medicine Hofstra University Hempstead, NY Chairman, PA Advisory Board, clinician1.com 2011 PEOPLE’S MEDICAL PUBLISHING HOUSE—USA SHELTON, CONNECTICUT 00Singer_prelims-F 7/8/10 7:52 PM Page iv People’s Medical Publishing House–USA Enterprise Drive, Suite 509 Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: info@pmph-usa.com © 2011 PMPH-USA, Ltd All rights reserved Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher 09 10 11 12 13/PMPH/9 ISBN-13: 978-1-60795-029-5 ISBN-10: 1-60795-029-4 Printed in China by People’s Medical Publishing House of China Copyeditor/Typesetter: Spearhead Global, Inc Cover Design: Mary Mckeon Library of Congress Cataloging-in-Publication Data Skin and soft tissue injuries, and infections : a practical evidence based guide / [edited by] Adam J Singer, Judd E Hollander, Robert M Blumm p ; cm Includes bibliographical references and index ISBN-13: 978-1-60795-029-5 ISBN-10: 1-60795-029-4 Skin—Wounds and injuries Soft tissue injuries Surgical emergencies Evidence-based medicine I Singer, Adam J II Hollander, Judd E., 1960- III Blumm, Robert M [DNLM: Soft Tissue Injuries—therapy Evidence-Based Medicine Skin—injuries Soft Tissue Infections—therapy Wound Healing WO 700 S628 2010] RD93.S58 2010 617.4′77044—dc22 2010025068 Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications This is particularly important with new or infrequently used drugs Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated The reader is cautioned that the purpose of this book is to inform and enlighten; the information 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Acknowledgments This book is dedicated to my wife Ayellet, and my three children Daniel, Lee, and Karen, without whose support this book never would have been written AJS This book is dedicated to Jeanne, Greg, and David, who allowed me the time to write this book JEH My gratitude to my wife Celia for editing my contributions to this book as well as to Dr Singer for impressing upon me that three creative sentences, joined together, is no longer considered evidence based medicine RMB 00Singer_prelims-F 7/8/10 7:52 PM Page viii 00Singer_prelims-F 7/8/10 7:52 PM Page ix Foreword Skin and soft tissues injuries and infections are among the most common ailments affecting mankind While most heal uneventfully, skin and soft tissue injuries and infections may result in significant morbidity and mortality Early and proper evaluation and management of these injuries and infections will help optimize care and minimize the risk of serious complications Skin and soft tissue injuries and infections are managed by a large number of health care practitioners including nurses, nurse practitioners, physician assistants, and physicians In addition, a wide variety of medical specialties are involved in their care including primary care practitioners, emergency practitioners, and surgeons Over the last two decades a large body of evidence has accumulated allowing many of our practices to be based on sound preclinical and clinical studies Wherever possible, the recommendations of this book are based on such high-quality evidence In the absence of such evidence, the recommendations are based on expert opinion and consensus It is our hope that this book will be helpful for both junior practitioners, including students and residents, as well as for more experienced practitioners Adam J Singer Judd E Hollander Robert M Blumm 22Singer _CH22-F 192 7/5/10 CHAPTER 8:33 PM Page 192 22 / Evaluating and Treating Skin Ulcers COMPLEMENTARY AND ALTERNATIVE MEDICINE Patients or their families may be interested in or utilizing therapies unfamiliar to allopathic clinicians Open communication allows those in clinical practice to identify those treatments that may be harmful or not helpful while monitoring progress or deterioration of wound management The onus of identifying complementary and alternative medicine and beliefs of the patients and their families must also be taken into consideration for these patients Unripe papaya is used as skin ulcer therapy, and has been reported to enhance desloughing, granulation, and healing, and to diminish odor.37 Additionally, it is available and cost-effective and regarded to be as effective as other therapies in skin ulcer treatment A more recent study utilizing honey on burns and leg ulcers revealed enhanced healing of thermal injuries, yet no appreciable difference for chronic leg ulcers.38 Of interest, patients with diabetes were not mentioned in this study Draconian and originating from ancient medical interventions, maggot therapy on leg ulcers was found to be both effective in débridement and to promote healing The actual time to heal after larval therapy was not improved compared with hydrogel dressings and patients treated with maggots experienced more associated pain.39 PATIENT DISPOSITION Hospitalization may be required for those severely ill patients with skin ulcers These include septic or febrile, infected, and severely debilitated cases that cannot be managed on an outpatient basis, or have not progressed despite intensive nonhospital-directed therapies Associated primary diagnoses of sepsis, urinary tract infections, and pneumonia will also more likely require discharge to a skilled nursing facility or other long-term domiciliary care Hospitalizations for skin ulcers have increased 80% in the past decade, resulting in increased levels of patient care, worsening disease, and death More than half of patients admitted to hospitals for a primary ulcer in 2006 were aged older than 65 years Three out of four hospitalizations reported in 2006 for secondary pressure ulcers in 2006 were, similarly, in patients aged older than 65 years Those same hospitalizations of patients diagnosed with pressure ulcers required payments of $11 billion in the same time period In younger patients, the primary diagnosis shifts to paralysis and spinal cord injury as the primary justification Fluid and electrolyte imbalance in both groups is more likely associated with inadequate nutrition with two primary variables: patients’ inability to feed themselves and caretaker abilities or resources REFERENCES Trent JT, Falabella A, Eaglstein WH, Kirsner RS Venous ulcers: pathophysiology and treatment options Ostomy Wound Manage 2005;51(5):38–54 Reiber GE The epidemiology of diabetic foot problems Diabet Med 1996;13(suppl 1):S6–S11 Consensus Development Conference on Diabetic Foot Wound Care:7-8 April 1999, Boston, Massachusetts American Diabetes Association Diabetes Care 1999;22(8):1354–1360 Hirshberg J, Coleman J, Marchant B, Rees RS TGF-beta3 in the treatment of pressure ulcers: a preliminary report Adv Skin Wound Care 2001;14(2): 91–95 Chen WY, Rogers AA Recent insights into the causes of chronic leg ulceration in venous diseases and implications on other types of chronic wounds Wound Repair Regen 2007;15(4):434–449 O’Meara S, Cullum NA, Nelson EA Compression for venous leg ulcers Cochrane Database Syst Rev 2009;(1):CD000265 Robson MC, Cooper DM, Aslam R, et al Guidelines for the treatment of venous ulcers Wound Repair Regen 2006;14(6):649–662 Fletcher A, Cullum N, Sheldon TA A systematic review of compression treatment for venous leg ulcers BMJ 1997;315(7108):576–580 Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA Dressings for healing venous leg ulcers Cochrane Database Syst Rev 2006;(3):CD001103 10 Palfreyman S, Nelson EA, Michaels JA Dressings for venous leg ulcers: systematic review and metaanalysis BMJ 2007;335(7613):244 11 Jull A, Waters J, Arroll B Pentoxifylline for treating venous leg ulcers Cochrane Database Syst Rev 2002;(1):CD001733 12 Robson MC, Cooper DM, Aslam R, et al Guidelines for the prevention of venous ulcers Wound Repair Regen 2008;16(2):147–150 13 Mayfield JA, Sugarman JR The use of the SemmesWeinstein monofilament and other threshold test for preventing foot ulceration and amputation in persons with diabetes J Fam Pract 2000;49(11 suppl): S17–S29 14 O’Neal LW, Wagner FW The Diabetic Foot St Louis, MO: Mosby; 1983:274 15 Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ Evidence-based protocol for diabetic foot ulcers Plast Reconstr Surg 2006;117(7 suppl): 193S–209S 16 Edwards J Debridement of diabetic foot ulcers Cochrane Database Syst Rev 2002(4): CD003556 17 Steed DL, Attinger C, Colaizzi T, et al Guidelines for the treatment of diabetic ulcers Wound Repair Regen 2006;14(6):680–692 22Singer _CH22-F 7/5/10 8:33 PM Page 193 CHAPTER 18 Bergin SM, Wraight P Silver based wound dressings and topical agents for treating diabetic foot ulcers Cochrane Database Syst Rev 2006;(1):CD005082 19 Robson MC, Payne WG, Garner WL, et al Integrating the results of Phase IV (postmarketing) clinical trial with four previous trials reinforces the position that Regranex (becaplemin) gel 0.01% is an effective adjunct to the treatment of diabetic ulcers J Appl Res 2005;5:35–45 20 Eginton MT, Brown KR, Seabrook GR, Towne JB, Cambria RA A prospective randomized evaluation of negative-pressure wound dressings for diabetic foot wounds Ann Vasc Surg 2003;17(6):645–649 21 Hinchliffe RJ, Valk GD, Apelqvist J, et al A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes Diabetes Metab Res Rev 2008;24(suppl 1):S119–S144 22 Steed DL, Attinger C, Brem H, et al Guidelines for the prevention of diabetic ulcers Wound Repair Regen 2008;16(2);169–174 23 Spencer S Pressure relieving interventions for preventing and treating diabetic foot ulcers Cochrane Database Syst Rev 2000;(3):CD002302 24 Self-management to prevent ulcers in veterans with SCI (spinal cord injury) [clinical trial] Available at: http://clinicaltrials.gov/ct2/show/results/NCT 00763282 25 Stasis dermatitis information for adults [Skinsite Web page] Available at: http://www.visualdxhealth com/adult/stasisDermatitis-selfCare.htm 26 Armstrong DG, Holtz-Neiderer K, Wendel C, Mohler MJ, Kimbriel HR, Lavery LA Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients Am J Med 2007; 120(12):1042–1046 27 Anczak JD, Nogler RA II Tobacco cessation in primary care: maximizing intervention strategies Clin Med Res 2003;1(3):201–206 28 Surgical treatment options [Cleveland Clinic Web page] Available at: http://my.clevelandclinic.org/ 22 / Evaluating and Treating Skin Ulcers 29 30 31 32 33 34 35 36 37 38 39 193 disorders/atherosclerosis/vs_surgical_treatment_ options.aspx Bansal C, Scott R, Stewart D, Cockerell CJ Decubitus ulcers: a review of the literature Int J Dermatol 2005;44(10):805–810 National Pressure Ulcer Advisory Panel for Pressure Ulcers Ulcer classification [Web page] Available at: http://www.woundcare.org/newsvol2n1/ ulcer1.htm Community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) [Centers for Disease Control and Prevention Web page] Available at: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca html Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA Treatment of pressure ulcers: a systematic review JAMA 2008;300(22):2647–2662 Whitney J, Phillips L, Aslam R, et al Guidelines for the treatment of pressure ulcers Wound Repair Regen 2006;14(6):663–679 Siedliecki SL, Good M Effect of music on power, pain, depression and disability J Adv Nurs 2006; 54(5)553–562 Maratos AS, Gold C, Wang X, Crawford MJ Music therapy for depression Cochrane Database Syst Rev 2008;23(1):CD004517 McInnes E, Bell-Syer SEM, Dumville JC, Legood R, Cullum NA Support surfaces for pressure ulcer prevention Cochrane Database Syst Rev 2008;(4): CD001735 Hewitt H, Whittle S, Lopez S, Bailey E, Weaver S Topical use of papaya in chronic skin ulcer therapy in Jamaica West Indian Med J 2000;49(1): 32–33 Jull AB, Rodgers A, Walker N Honey as a topical treatment for wounds Cochrane Database Syst Rev 2008;(4):CD005083 Dumville JC, Worthy G, Bland JM, et al Larval therapy for leg ulcers (VenUS II): randomized controlled trial BMJ 2009;338:b773 22Singer _CH22-F 7/5/10 8:33 PM Page 194 7/5/10 8:33 PM Page 195 CHAPTER 23Singer _CH23-F 23 Postoperative Care of Wounds Judd E Hollander, MD Postoperative wound care should optimize healing It must be tailored to both the type of wound and method of wound closure Sutured or stapled lacerations should be covered with a protective, nonadherent dressing for 24 to 48 hours Maintaining a warm, moist environment increases the rate of reepithelialization Hinman and Maibach1 studied experimental split thickness wounds in human volunteers who served as their own controls They found that occluded wounds healed faster than those exposed to air, although after week both groups were similar On the other hand, leaving lacerations exposed to air does not affect the infection rate Howells and Young2 showed that lack of postoperative dressings in 105 patients did not result in an increased infection rate Therefore, maintenance of a moist wound environment with a dressing may improve healing but it does not decrease the infection rate Details of the various dressing options are addressed in Chapter 8, Wound Dressings Topical antibiotics can be used to maintain a moist environment in sutured or stapled lacerations but not in lacerations repaired with tissue adhesive Topical antibiotic ointments may help reduce infection rates and prevent scab formation Dire and coworkers3 compared topical antibiotics to petrolatum gel in 465 patients They found that the infection rates with postoperative topical triple antibiotic or bacitracin were one third the infection rate of patients treated with petrolatum alone Therefore, maintenance of a moist environment in sutured or stapled lacerations might be best accomplished by using topical antibiotics However, patients whose lacerations are closed with tissue adhesives should not use topical ointments because they will loosen the adhesive and may result in dehiscence Additionally, tissue adhesives serve as their own antimicrobial barrier Semipermeable films are manufactured from transparent polyurethane or similar synthetic films, coated on one surface with a water-resistant hypoallergenic adhesive They are highly elastic, conform easily to body parts, and are generally resistant to shear and tear They are permeable to moisture vapor and oxygen but impermeable to water and bacteria These films are sometimes used to cover sutured or stapled wounds without any topical antibiotics The disadvantages of many of these materials are that they cannot absorb large amounts of fluid and exudate and they not adhere well in very moist states They are generally more appropriate for covering elective surgical incisions and not traumatic lacerations When possible, the site of injury should be elevated above the patient’s heart to limit the accumulation of fluid in the wound interstitial spaces Wounds with little edema heal more rapidly than those with marked edema Pressure dressings can be used to minimize the accumulation of intercellular fluid in the dead space 23Singer _CH23-F 196 7/5/10 CHAPTER 8:33 PM Page 196 23 / Postoperative Care of Wounds ANTIBIOTICS Prophylactic oral antibiotics should not be used except for specific indications Several studies and a metaanalysis have all found no benefit to prophylactic antibiotics for routine laceration repair.4 Use of antibiotics should be individualized based upon the degree of bacterial contamination, the presence of infectionpotentiating factors (e.g., soil), the mechanism of injury, and the presence or absence of host predisposition to infection.5 In general, decontamination is far more important than antibiotics Antibiotics should be used for most bites by humans, dogs, or cats; intraoral lacerations; open fractures; and exposed joints or tendons.5 Additionally, patients with dirty soft-tissue lacerations who are prone to the development of infective endocarditis, patients with prosthetic joints and other permanent “hardware,” and patients with lymphedema should receive antimicrobial therapy Patients at high risk for systemic complications such as endocarditis can be given intravenous antibiotics before wound care PREVENTION OF TETANUS Tetanus status should be assessed prior to discharge Two thirds of the recent tetanus cases in the United States have followed lacerations, puncture wounds, and crush injuries For every wounded patient, information about the mechanism of injury, the characteristics of the wound and its age, previous active immunization status, history of a neurologic or severe TABLE 23–1 hypersensitivity reaction after a previous immunization treatment, and plans for follow-up should be recorded in a permanent medical record Proper immunization plays the most important role in tetanus prophylaxis Recommendations on tetanus prophylaxis are based on the condition of the wound and the patient’s immunization history.6 A summary guide to tetanus prophylaxis of the wounded patient is outlined in Table 23-1 Passive immunization with tetanus immune globulin (TIG) must be considered for each patient Contraindications to tetanus and diphtheria toxoid (Td) and the reduced diphtheria toxoid and acellular pertussis (Tdap) is a history of neurologic or severe hypersensitivity reaction after a previous dose Local side effects not preclude repeated use Local reactions, generally erythema and induration with or without tenderness, are common after the administration of vaccines containing diphtheria, tetanus, and pertussis antigens These reactions are usually selflimited and require no therapy If a systemic reaction is suspected to represent allergic hypersensitivity, immunization should be postponed until appropriate skin testing is undertaken If the use of a tetanus toxoid is contraindicated, passive immunization against tetanus should be considered in a tetanus-prone wound POSTOPERATIVE WOUND CLEANING Sutured or stapled wounds can be gently cleansed within 12 hours Goldberg and colleagues7 demon- Recommendations for Tetanus Prophylaxis History of Tetanus Immunization < or uncertain doses ≥ doses Most recent dose within yrs Most recent dose within to 10 yrs Most recent dose > 10 yrs ago Clean Minor Wounds All Other Woundsa Administer Td or Tdapb Administer TIG Administer Td or Tdapb Administer TIG Yes No Yes Yes No No Yes No No No No Yes Yes No No No Notes Td = tetanus–diphtheria toxoid; Tdap = reduced diphtheria toxoid and acellular pertussis; TIG = tetanus immune globulin aFor example, contaminated wounds, puncture wounds, avulsions, burns, crush injuries bAdolescents and adults who require a tetanus toxoid–containing vaccine as part of wound management should receive Tdap instead of Td if they have not previously received Tdap If Tdap is not available or was administered previously, Td should be administered Tdap is not licensed for use among adults aged 65 years and older, as it has not been studied in this population.6 23Singer _CH23-F 7/5/10 8:33 PM Page 197 CHAPTER strated that the use of soap and water to cleanse lacerations was not associated with an increased infection rate Heal et al randomized 857 patients to keeping the wound dry for 48 hours compared with wetting the wound within 12 hours and found no difference in infection rate.8 When the wound is wet, gentle blotting should be used to dry the area Wiping could result in dehiscence Daily cleansing ensures that the patient examines the laceration for early signs of infection Patients should be instructed to observe the wound for redness, warmth, swelling and drainage, as these findings may indicate infection Use of standardized wound care instructions improves patient compliance and understanding.9 Reapplication of topical antibiotics will continue to decrease scab formation, improving the likelihood of continued wound-edge apposition Patients with tissue adhesives may shower but they should avoid bathing and swimming because prolonged moisture will loosen the adhesive bond FOLLOW-UP Patients should be told when and with whom to follow-up for suture removal or wound examinations Sutures or staples in most locations should be removed after approximately days (Table 23-2) Facial sutures should be removed within to days to avoid formation of unsightly sinus tracts and hatch marks.10 Sutures subject to high tensions (on the joints or hands, for instance) should be left in place for 10 to 14 days When one is removing sutures, care should be FIGURE 23-1 Method of removing sutures 23 / Postoperative Care of Wounds TABLE 23–2 197 Time From Wound Closure Until Removal of Sutures or Staples Location Number of Days Face Scalp Chest Back Forearm Fingers Hand Lower extremity Foot 3–5 days days 8–10 days 10–14 days 10–14 days 8–10 days 8–10 days 8–12 days 10–12 days taken to avoid applying tension in a direction that would tend to cause dehiscence The suture should be cut on one side of the knot and then pulled out through the skin in the same direction (Figure 23-1) One should not attempt to remove the suture by passing the knot through the wound, as this may result in wound dehiscence Use of a specialized curved stitch cutter and fine forceps helps ease removal of fine sutures Any scab or crusting over the sutures may be débrided prior to suture removal by gently applying hydrogen peroxide with gauze To remove staples, the double-sided jaw of the staple remover is inserted beneath the exposed 23Singer _CH23-F 198 7/5/10 CHAPTER 8:33 PM Page 198 23 / Postoperative Care of Wounds cross-limb of the staple, and the upper jaw is closed over the staple, elevating the ends of the staple and removing the staple from the skin (see Figure 11-3) Tissue adhesives will slough off on their own within to 10 days of application They not require removal by a health care practitioner When a topical skin adhesive is used, the patient should be careful to avoid picking at it or scrubbing the area or exposing it to water for more than brief periods until healing has occurred When tissue adhesives remain on the skin for prolonged periods, antibiotic ointment, petrolatum or bathing can accelerate removal, although delayed sloughing is not necessarily a disadvantage Acetone can be used when more rapid removal is required Healing lacerations and abrasions should not be exposed to the sun; exposure can result in permanent hyperpigmentation.11 Abraded skin should be protected with a sun-blocking agent for at least to 12 months after injury REFERENCES Hinman CD, Maibach H Effect of air exposure and occlusion on experimental human skin wounds Nature 1963;200:377–378 Howells CH, Young HB A study of completely undressed surgical wounds Br J Surg 1966;53(5): 436–439 Dire DJ, Coppola M, Dwyer DA, Lorette JJ, Karr JL Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue 10 11 wounds repaired in the ED Acad Emerg Med 1995; 2(1):4–10 Cummings P, Del Beccaro MA Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies Am J Emerg Med 1995;13(4): 396–400 Singer AJ, Hollander JE, Quinn JV Evaluation and management of traumatic lacerations New Engl J Med 1997;337(16):1142–1148 Kretsinger K, Broder KR, Cortese MM, et al Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel MMWR Recomm Rep 2006;55(RR-17):1–37 Goldberg HM, Rosenthal SA, Nemetz JC Effect of washing closed head and neck wounds on wound healing and infection Am J Surg 1981;141(3):358–359 Heal C, Buettner R, Raasch B, et al Can sutures get wet? Prospective randomized controlled trial of wound management in general practice BMJ 2006;332(7549):1053–1056 Austin PE, Matlack R II, Dunn KA, Kesler C, Brown CK Discharge instructions: illustrations help our patients understand them? Ann Emerg Med 1995; 25(3):317–320 Crikelair GF Skin suture marks Am J Surg 1958; 96(5):631–639 Ship AG, Weiss PR Pigmentation after dermabrasion: an avoidable complication Plast Reconstr Surg 1985;75(4):528–532 24Singer _Index-F 7/5/10 8:34 PM Page 199 Index Information in figures and tables is indicated by f and t A abscesses anatomical distribution of, 147–148 antibiotic penetration into, 61 antibiotics for, 64t, 149–151, 151t Bartholin’s gland, 153–154 breast, 153 cutaneous and subcutaneous, 3–4 diagnosis of, 148–149 differential diagnosis of, 152–155 drainage of, 151–152 epidemiology of, 147 in immunocompromised patients, 152–153 microbiology of, 148 needle aspiration of, 151 in paronychia, 166 pathogenesis of, 148 pilonidal cyst, 153 risk factors for, 147 special considerations in, 152–155 surgical management of, 151–152 treatment of, 149–152 absorbable sutures, 92t–93t, 96–97 absorptive dressings, 56t acute wounds, dressing of, 54, 55t–56t adhesives see tissue adhesives adverse reactions, to antibiotics, 62 Aeromonas hydrophilia, 63 alfentanil, 42–43, 42t, 43t alginates, 56t, 57, 58t, 59 allergy, anesthetic, 25 amides, 25 amoxicillin-clavulanate, 63, 64t, 67, 119t ampicillin, 63, 64t, 65 amputations, digit, 162–163 anaphylaxis, 25 anatomic location, 14, 14t, 66 anesthesia see also nerve block; procedural sedation and analgesia allergic reactions to, 25 alternatives to commonly used, 25–26 dosages, 24–25, 24t general, 36t injection pain and, 23 local, without injection, 23–24 regional vs local, 26–27 topical, 23–24 animal bites, 2–3, 3t antibiotics for, 64t, 67, 119–120, 119t bacteriology of, 117–118 clinical presentation of, 118 complications of, 121–122 evaluation of, 118–119 rabies and, 120–121, 121t reporting of, 122 tetanus and, 120–121 treatment of, 118–119 from wild animals, 121 ankle nerve blocks, 29–30, 29f, 30f antibiotics for abscesses, 149–151, 151t abscess penetration by, 61 adverse reactions to, 62 effectiveness of, 61, 64t empiric therapy for wound infections with, 62–63 foreign bodies and, 138 Gram-positive organisms and, 62 intravenous, 63 for necrotizing infections, 63–65 in postoperative care, 196 practical issues with, 62 principles of use, 61–62 prophylaxis, 65–67 antimicrobial-impreganted dressings, 59 antistaphylococcal penicillins, 62 anxiolysis, 36t arterial ulcers, 184t, 188–189 arthritis, septic, in hand, 169, 170t 24Singer _Index-F 200 7/5/10 8:34 PM Page 200 Index aspiration, of abscess, 151 assessment medical history in, 13–14 B bacitracin, 55t barnyard injuries, 64t Bartholin’s gland abscesses, 153–154 benzyl alcohol, 25–26 bleeding control, 13 breast abscesses, 153 bupivacaine, 24t buried deep dermal sutures, 113–114 burns, 4, 4f burn center transfers for, 172 chemical, 181–182 in children, 173–174, 174f deep partial-thickness, 179–180 depth determination, 174–175 dermal, 179–180 dressings, 179 early changes in, 172 edema in, 172–173 electrical, 181 escharotomy in, 180–181, 180f extent of, 173–174, 173f, 174f, 177f first-degree, 178 fluid therapy for, 176 full-thickness, 180–181 general principles of care in, 171–172 immediate evaluation of, 171–172 inhalation injury in, 176–178 local care of wound, 178–181 patient age and, 172 physiologic alterations with, 172–173 precautionary measures with, 171 second-degree, 178–179 superficial partial-thickness, 178–179 third-degree, 180–181 butylcyanoacrylates, 50, 84, 85 see also tissue adhesives C cadexomer iodine, 58t Capnocytophaga canimorsus, 118 capnography, 39 carbuncles, 153 cat bites, 118 see also animal bites cefazolin, 63 cefotetan, 64t cefoxitin, 64t ceftaroline, 63 ceftazidime, 63, 64t ceftobiprole, 63 cefuroxime axetil, 119t cellulitis, 64t, 150f cephalexin, 62 cephalosporins, 62, 64t chemical burns, 181–182 children animal bites in, 117 burn surface area in, 174f, 177f hand infections in, 165–166 procedural sedation and analgesia in, 35 chromic gut sutures, 93t, 96 chronic wounds, dressing of, 54, 57 ciprofloxacin, 63, 64t clindamycin, 62, 63, 64t, 65, 119t, 151t clostridial myonecrosis, 65 Clostridium perfringens, 63 Clostridium tetani, 63 closure see also sutures adhesive tapes for, 48t, 49–50 flap, 113 history of, 47, 71 methods, 48–50, 48t needle choice in, 102–103 needle holder in, 101–102 principles, 99–101 selection of method for, 48t staples for, 48t, 49 sutures for, 48t, 49 techniques compared, 48t timing of, 47–48 tissue adhesives for, 48t, 50 tissue handling in, 100–101, 100f community-associated methicillin-resistant S aureus, 62, 63, 67 complementary and alternative medicine, for ulcers, 192 computed tomography, foreign bodies on, 127t, 130–131, 131f conscious sedation, 36, 36t conscious sedation agents, 42t, 43t contamination, 66 continuous dermal sutures, 103t, 109–111 continuous percutaneous suture, 103t, 109 corner stitches, 113 cosmetic outcome, predicting, 15, 15f Crohn’s disease, 154 cutaneous abscesses, 3–4 see also abscesses cyanoacrylates see tissue adhesives D daptomycin, 63 debridement, 19 debriding agents, 58t deep abscess extension, 155 deep peroneal nerve block, 30, 30f deep sedation, 36–37, 36t deep sedation agents, 42t, 43t, 44 deep space infections, 168–169, 168f, 170t delayed primary closure, 20 depth, of burns, 174–175 dermis, diabetic ulcers, 187–188, 187f, 188t dicloxacillin, 62, 67 digital nerve block, 27, 27f diphenhydramine, 25 dissociative sedation agents, 42t dog bites, 118 see also animal bites dog ear, 114f dosage, anesthesia, 24–25, 24t doxycycline, 62, 63, 151t drainage, abscess, 151–152 24Singer _Index-F 7/5/10 8:34 PM Page 201 Index dressings absorptive, 56t for acute wounds, 54, 55t–56t advanced products for, 54 antibiotic ointments in, 53 antimicrobial-impregnated, 59 burn, 179 categories of, 57–59 for chronic wounds, 54, 57 history of, 53 ideal, 54 modern, 54 moisture in, 53 moisture-retentive, 54 negative pressure wound therapy, 54, 58t nonabsorptive, 56t petrolatum, 53 selection of, 58t, 59 topical antimicrobial agents in, 55t E edema burns and, 172–173 sutures and, 95 Eikenella corrodens, 118, 119t, 120 electrical burns, 181 enzymatic debriding agents, 58t epidermis, epinephrine, 24t, 25–26 ertapenem, 64t, 65 Erysipelothrix rhusiopathiae, 63 eschar, 180 escharotomy, 180–181, 180f esters, 25 etomidate, 42t, 43t, 44 examination, wound, 14–15 exploration, wound, 14–15 extensor tendon injuries, 159–160 F facial laceration, closure of, 48t facial nerve blocks, 30–32, 31f, 32f fasting, procedural sedation and analgesia and, 38 felons, 154, 166–167, 167f, 169t fentanyl, 41–42, 42t, 43t field block, 26t films, as dressings, 57 fingertip amputations, 162–163 flap closure, 113 flesh-eating bacteria, 65 flexor tendon injuries, 158–159 flexor tenosynovitis, suppurative, 168, 168f, 169t flumazenil, 41 fluoroquinolone, 64t fluoroscopy, foreign bodies on, 127t, 130, 130f foams, as dressings, 57, 58t folliculitis, 153 foot diabetic ulcers in, 187–188, 187f, 188t puncture wounds of, 3, 64t, 142 foot laceration, closure of, 48t 201 foreign bodies, 18 antibiotics and, 138 clinical evaluation with, 123–125, 124t complications with, 123 on computed tomography, 127t, 130–131, 131f decision making on, 134–136 detection of, 123–134 documentation of, 138 features mitigating for removal of, 136t on fluoroscopy, 127t, 130, 130f history in, 124t imaging of, 125–134, 127t on magnetic resonance imaging, 127t, 134 management of, 136–138 on radiography, 18, 126f, 127–130, 127t, 128f, 129f, 131f retained, 135t risks and benefits of removal of, 136t special situations in, 138 on ultrasound, 18, 127t, 130f, 131–134, 131f, 132f, 133f, 134f wound exploration in, 136–138 formation of tissue, in wound healing, 10–11 fracture, open, 64t freshwater exposure, 64t furuncles, 153 furuncular myiasis, 155 G gas gangrene, 65 gauzes, 57, 58t general anesthesia, 36t glycomer 631 sutures, 94t Gram-positive organisms, 62 granulomata, 154 group A streptococcus, 65 H hair removal, 18 half-buried, horizontal mattress sutures, 104t hand amputations in, 162–163 bleeding control in, 157 complexity of, 157 extensor tendon injuries, 159–160 flexor tendon injuries in, 158–159 high-pressure injection injuries to, 163 nail bed injuries in, 161 nerve examination in, 157 nerve injuries in, 161–162 subungual hematomas in, 161 tendon avulsion injuries in, 160–161 hand infections in children, 165–166 deep space, 168–169, 168f, 170t MRSA in, 165 predilection for, 165 hand laceration, closure of, 48t handling, in closure, 100–101, 100f hand nerve block, 27–29, 28f, 29f healing, pathophysiology of, 8–11, 9f, 9t, 11f hemodynamic monitoring, 39 24Singer _Index-F 202 7/5/10 8:34 PM Page 202 Index hemostasis skin in, wound preparation and, 18–19 herpetic whitlow, 154, 167–168, 167f, 169t hidradenitis suppurativa, 153 high-pressure injection injuries, to hand, 163 history in assessment, 13–14 with foreign bodies, 124t in procedural sedation, 37 in ulcers, 183 holder, needle, 101–102 honey, 192 horizontal mattress sutures, 104t, 111–112 human bites, 67, 118 see also animal bites hydrocolloids, 56t, 57, 58t hydrofiber, 58t hydrogels, 56t, 57, 58t hydrogen peroxide, 19 hypertonic saline gauze, 58t hypertonic saline gel, 58t I imipenem, 63 immunodeficiency abscesses and, 152–153 antibiotics in, 64t, 66 impregnated nonadherent dressings, 56t infection risk anatomic location and, 14t, 66 closure timing and, 47 contamination and, 66 delayed presentation and, 66–67 in immunocompromised patients, 66 mechanism of injury and, 66 with sutures, 91, 95 inflammation, 8–10, 9t infraorbital nerve block, 31, 31f inhalation injury, in burn patients, 176–178 injection pain, minimizing, 23 interactive monitoring, 39 interrupted dermal sutures, 103t, 107–109 interrupted percutaneous suture, 103–107, 103t intravenous antibiotics, 63 irrigation, 18f, 19–20 K ketamine, 42t, 43t, 44 L lacerations, 1, 2f see also closure lactated Ringer’s solution, 176 lactomer glycolide/lactide sutures, 96–97 larval therapy, 192 lidocaine, 24t linezolid, 62, 63 local anesthesia alternatives to commonly used, 25–26 injection pain from, 23 regional vs, 26–27, 26t without injection, 23–24 location, anatomic, 14, 14t, 66 long linear laceration, closure of, 48t lymphogranulatoma venereum, 154 M mafenide acetate, 55t maggots, 192 magnetic resonance imaging, foreign bodies on, 127t, 134 mandatory reporting, of animal bites, 122 mattress sutures, 104t, 111–112 mechanical monitoring, 39 mechanism of injury, 14, 66 median nerve block, 28, 28f mediators, wound, 9t medical history, 13–14 mental nerve block, 32, 32f meropenem, 63 metacarpophalangeal blocks, 27, 27f methicillin-resistant S aureus, 62, 63, 67, 148t, 165 methohexital, 42t, 43t, 44 metronidazole, 64t midazolam, 41, 42t, 43t minimal sedation, 36, 36t minimal sedation agents, 41–44, 42t, 43t minimal tension, lines of, 15, 15f minocycline, 151t moderate sedation, 36, 36t moderate sedation agents, 42t, 43t, 44 moisture-retentive dressings, 54 monitoring frequency, 39 hemodynamic, 39 interactive, 39 mechanical, 39 oxygenation, 39 in procedural sedation and analgesia, 39 ventilation, 39 MRSA, 62, 63, 67, 148t, 165 mupirocin, 55t Mycobacterium marinum, 63 N nafcillin, 63 nail bed injuries, 161 naloxone, 43 natural absorbable sutures, 96 necrotizing fasciitis, 64t necrotizing infections, antibiotics for, 63–65 needle aspiration, of abscess, 151 needle choice, 102–103 needle holder, 101–102 needle holder positioning, 102 needles, surgical, 97–98 negative pressure wound therapy, 54, 58t neoplastic extension, 155 nerve block see also anesthesia advantages and disadvantages of, 26t ankle, 29–30, 29f, 30f digital, 27, 27f facial, 30–32, 31f, 32f 24Singer _Index-F 7/5/10 8:34 PM Page 203 Index hand, 27–29, 28f, 29f infraorbital, 31, 31f median, 28, 28f mental, 32, 32f radial, 29, 29f supraorbital, 31, 31f supratrochlear, 31, 31f sural, 30, 30f tibial, 29–30, 30f ulnar, 27–28, 28f nerve injuries, in hand, 161–162 neuropathic ulcers, 184t nitrous oxide, 42t, 43t, 44 nonabsorbable sutures, 92t, 96 nonabsorptive dressings, 56t nylon sutures, 92t, 96 O octylcyanoacrylate, 84–85 see also tissue adhesives open fracture, 64t opioids, 41–43 oxacillin, 63 oxygen, supplemental, in procedural sedation and analgesia, 40 oxygenation monitoring, 39 P pain, minimizing injection, 23 papaya, 192 paronychia, 154, 166, 166f, 169t Pasteurella multocida, 118, 119t, 120 Pasteurella species, 117 penicillins, 62, 63, 65 peroneal nerve block, 30, 30f physical status classification, anesthesia and, 37t pilonidal cyst abscesses, 153 piperacillin-tazobactam, 63 plantar nerve block, 29–30, 30f plantar puncture, 64t, 142 poliglecaprone suture, 93t polybutester sutures, 92t, 96 polydioxanone sutures, 94t, 97 polyester sutures, 92t, 96 polyglactin 910 sutures, 93t, 94t, 96–97 polyglycolic acid sutures, 93t, 96–97 polyglyconate sutures, 94t polypropylene sutures, 92t, 96 polyurethane film, 56t postoperative care antibiotics in, 196 follow-up in, 197–198 tetanus and, 196 wound cleaning in, 196–197 Pott’s puffy tumor, 154 preparation debridement in, 19 delayed primary closure in, 20 foreign bodies in, 18 hair removal in, 18 hemostasis and, 18–19 203 irrigation in, 18f, 19–20 scrubbing in, 19 sterile technique in, 17–18, 18f pressure ulcers, 184t, 189–191, 189f, 190f, 190t primary closure, delayed, 20 procaine, 24t procedural sedation and analgesia see also anesthesia adverse events in, 45 in children, 35 comorbidity in, 37 discharge from, 45 equipment for, 38 fasting state and, 38 follow-up for, 45 history in, 37 indications for, 36–37 of intoxicated patients, 38 monitoring in, 39 patient instructions after, 45 personnel in, 38 physical status classification and, 37t precautions in, 38 pre-procedure pain management and, 40 risks in, 38 sedation management in, 40–41 sedation technique in, 39–40 selection of, 35–36 supplemental oxygen during, 40 urgency in, 37–38, 41t use of, 35 workflow, 41t prophylaxis antibiotic, 65–67 tetanus, 196t propofol, 42t, 43t, 44 prosthetic heart valve, 64t Pseudomonas aeruginosa, 63 puncture wounds decision making, 144 epidemiology of, 141 evaluation of, 142–143 follow-up, 144 of foot, 3, 64t, 142 infected, 144 management of, 143–144 microbes in, 63, 142 outcomes in, 142–143 pathophysiology of, 141–142 uninfected, 143–144 R rabies, 120–121, 121t radial nerve block, 29, 29f radiography, foreign objects on, 18, 126f, 127–130, 127t, 128f, 129f, 131f regional anesthesia, local vs, 26–27, 26t remodeling, wound, 11 reporting, of animal bites, 122 rifampin, 62 round needles, 103 rule of nines, 173–174, 173f 24Singer _Index-F 204 7/5/10 8:34 PM Page 204 Index S salt water exposure, 64t saphenous nerve block, 30, 30f scalpels, 101, 101f scalp laceration, closure of, 48t, 79, 81f scrubbing, 19 sedation agents deep, 42t minimal, 41–44, 42t sedation levels, 35–36, 36–37, 36t sedation technique, 39–40 septic arthritis, in hand, 169, 170t silicone dressing, 56t silk sutures, 92t silver sulfadiazine, 55t skin function of, 7, 8t structure of, 7, 8f tears, 1–2 staples, 48t, 49 advantages of, 80 clinical evidence for, 79–80 contraindications for, 80 device choice for, 80 disadvantages of, 80 indications for, 80 methods, 80–81, 81f postoperative care for, 81–82 removal timeframe, 197t sterile technique, 17–18, 18f Steri-Strip S Surgical Skin Closure, 74–75 straight needles, 103 subcutaneous abscesses, 3–4 see also abscesses subcutaneous layer, subungual hematomas, 161 sulbactam, 64t superficial peroneal nerve block, 30, 30f suppurative flexor tenosynovitis, 168, 168f, 169t supraorbital nerve block, 31, 31f supratrochlear nerve block, 31, 31f sural nerve block, 30, 30f surgical debridement, 19 surgical gut sutures, 93t, 96 surgical tapes, 48t, 49–50 adjunct innovations, 74–75 advantages of, 71–72, 72–73, 76t adverse effects in, 72 application of, 75–76 complications of, 72 cost of, 75 disadvantages of, 72–73, 76t indications for, 72 removal of, 76–77 suture vs, 73–74 sutures, 48t, 49, 71 see also closure absorbable, 92t–93t basic techniques, 101–111 buried deep dermal, 113–114 chromic gut, 93t, 96 continuous dermal, 103t, 109–111 continuous percutaneous, 103t, 109 cost of, 75 edema and, 95 glycomer 641, 94t half-buried, horizontal mattress, 104t horizontal mattress, 104t, 111–112 infection and, 91, 95 interrupted dermal, 103t, 107–109 interrupted percutaneous, 103–107, 103t lactomer glycolide/lactide, 96–97 materials, 95–97 mattress, 111–112 natural absorbable, 96 needles in, 97–98 nonabsorbable, 92t, 96 nylon, 92t, 96 placement and removal ease of, 95 poliglecaprone, 93t polybutester, 92t, 96 polydioxanone, 94t, 97 polyester, 92t, 96 polyglactin 910, 93t, 94t, 96–97 polyglycolic acid, 93t, 96–97 polyglyconate, 94t polypropylene, 92t, 96 properties of, 92t–94t removal of, 197f removal timeframe, 197t selection of, 91, 95 silk, 92t surgical gut, 93t, 96 tape vs, 73–74 undermining in, 115 in uneven surface wounds, 113 vertical mattress, 104t, 111–112 in wounds with edges of uneven length, 112–113 systemic antibiotic prophylaxis, 65–67, 66t T tape, 48t, 49–50 adhesives vs, 73 adjunct innovations, 74–75 advantages of, 71–72, 72–73, 76t adverse effects in, 72 application of, 75–76 complications of, 72 cost of, 75 disadvantages of, 72–73, 76t indications for, 72 removal of, 76–77 suture vs, 73–74 tapered needles, 103 tears, skin, 1–2 tendon avulsion injuries, in hand, 160–161 tenosynovitis, suppurative flexor, 168, 168f, 169t tension, lines of minimal, 15, 15f tetanus, 120–121, 196 tetanus prophylaxis, 196t tibial nerve block, 29–30, 30f ticarcillin-clavulanate, 63 24Singer _Index-F 7/5/10 8:34 PM Page 205 Index timing, of wound closure, 47–48 tissue adhesives, 48t, 50 advantages of, 85 aftercare in, 88 butylcyanoacrylate vs octylcyanoacrylate, 85 chemistry of, 83–84, 84f clinical studies supporting, 84–85 contraindications for, 86t cost of, 75 definition of, 83 disadvantages of, 85 indications for, 86t optimizing use of, 85–87 pitfalls with, 86t tape vs, 73 tissue formation, in wound healing, 10–11 tissue handling, in closure, 100–101, 100f tissue undermining, 115 topical anesthesia, 23–24 topical antibiotic prophylaxis, 65 topical antimicrobial agents, 55t topical skin adhesives see tissue adhesives trimethoprim-sulfamethoxazole, 62, 64t, 151t U ulcers arterial, 184t, 188–189 205 complementary and alternative medicine for, 192 diabetic, 187f, 188t diagnosis of, 183 examination of, 183 history in, 183 neuropathic, 184t patient disposition and, 192 pressure, 184t, 189–191, 189f, 190f, 190t types of, 184t venous, 184t, 185–187 wound care in, 183 ulnar nerve block, 27–28, 28f ultrasound, foreign objects in, 18, 127t, 130f, 131–134, 131f, 132f, 133f, 134f undermining, tissue, 115 V vancomycin, 63, 64t, 65, 151t venous ulcers, 184t, 185–187 ventilation monitoring, 39 vertical mattress sutures, 104t, 111–112 Vibrio species, 63, 155 W whitlow, 167–168, 167f, 169t wild animals, 121 see also animal bites 24Singer _Index-F 7/5/10 8:34 PM Page 206 [...]... MD, and Steven Sandoval, MD CHAPTER 22 CHAPTER 18 Cutaneous and Subcutaneous Abscesses 147 Subhasish Bose, MD, MRCP, and Charles V Pollack, Jr, MD, MA, FACEP, FAAEM, FAHA CHAPTER 19 Soft Tissue Injuries of the Hand 157 Breena R Taira, MD, MPH, Mark Gelfand, MD, and Alexander B Dagum, MD, FRCS(C), FACS CHAPTER 20 Soft Tissue Infections of the Hand 165 Breena R Taira, MD, MPH, Guy Cassara, RPAC, and. .. FACEP CHAPTER 12 Topical Skin Adhesives 83 Adam J Singer, MD CHAPTER 5 Wound Anesthesia 23 CHAPTER 13 Joel M Bartfield, MD, FACEP Selecting Sutures and Needles for Wound Closure 91 CHAPTER 6 Judd E Hollander, MD, and Adam J Singer, MD Procedural Sedation and Analgesia 35 CHAPTER 14 James Miner, MD Basic Suturing and Tissue Handling Techniques 99 CHAPTER 7 Adam J Singer, MD, and Lior Rosenberg, MD Wound... children and older adults Surgery 2006;140(4):705–717 01Singer _CH01-F 7/5/10 8:19 PM Page 6 7/5/10 8:20 PM Page 7 CHAPTER 02Singer _CH02-F 2 The Biology of Wound Healing Adam J Singer, MD, and Richard A.F Clark, MD THE FUNCTION AND STRUCTURE OF THE SKIN The skin is the largest organ in the body and is composed of three layers: the epidermis, dermis, and hypodermis (Figure 2-1) The thickness of the skin. .. papillary dermis and the reticular dermis The dermis contains mostly fibroblasts, which are responsible for secreting collagen, elastin, and ground substance that give support and elasticity to the skin The dermis also contains blood vessels that supply the epidermis and help regulate body temperature, as well as epithelial appendages including hair follicles, sebaceous glands, and apocrine glands Immune... Devitalized tissue needs to be removed from wounds prior to closure This includes crushed and devascularized or grossly contaminated tissue This is particularly true at the wound margins where healing will be impaired by the presence of nonviable tissue. 26 Small islands or pedicles of tissue are frequently devascularized and should be removed Inorganic material left in the dermis or superficial subcutaneous tissue. .. the skin s integrity also requires complex interactions between the epithelial and mesenchymal elements of the skin. 29 REFERENCES 1 Ebrahimian TG, Pouzoulet F, Squiban C, et al Cell therapy based on adipose tissue- derived stromal cells promote physiological and pathological wound healing Arterioscler Thromb Vasc Biol 2009;29(4): 503–510 2 Gurtner GC, Werner S, Barrandon Y, Longaker MT Wound repair and. .. mechanical (e.g., abrasions and lacerations), thermal, chemical, electrical, ischemic, and irradiationinduced With all types of wounds, the original insult results in the activation of multiple cellular and molecular processes intended to restore the integrity of the skin. 2,3 Except for with very superficial wounds and in early fetal life,4 the regenerative capacity of the skin is limited and most wounds are... superficial subcutaneous tissue can result in tattooing and should be removed whenever possible.27 Delayed healing and/ or the presence of contaminated tissue increases the risk of developing wound infections Sharp excision with a scalpel resulting in clean edges of healthy tissue results in better healing and cosmesis Irregular wound margins with devitalized tissue can be debrided in an elliptical shape to... MSN, APRN, BC Gregory J Moran, MD, and Hans R House, MD CHAPTER 2 CHAPTER 10 The Biology of Wound Healing 7 Adhesive Tapes for Closure of Acute Wounds and Surgical Incisions 71 Adam J Singer, MD, and Richard A.F Clark, MD Robert M Blumm, MA, PA-C, DFAAPA CHAPTER 3 Patient and Wound Assessment 13 Judd E Hollander, MD CHAPTER 11 Surgical Staples 79 Adam J Singer, MD, and Mary Jo McBride, PA CHAPTER 4... based on location and age Although the skin has many functions (Table 2-1), its primary function is to serve as a barrier between the organism and the external environment This function reduces the risk of infection and evaporative fluid losses The barrier function is mainly attributed to the outermost epidermal layer, and in particular to the stratum corneum The importance of the skin is demonstrated