An original fitting, whether for an upper or lower extremity prosthesis, is an emotional moment for a new amputee. Questions run through a patient’s mind as they begin a new phase in their life. Will my life ever be normal again? Can I still maintain an active lifestyle? Am I ready for this challenge? A question regarding the type of moisturizer one should use during the winter season is understandably not a patient’s main concern.
While it may not be considered a top priority at that moment, an amputee’s skin is at great risk without proper protection between the residual limb and socket. Abrasions, blisters or staph infections may form without suitable precautions. Proper hygiene, an intimate fit and even seasonal changes should be under consideration when preparing to care for the skin of the residual limb.
“I basically talk to patients about number one, keeping their skin clean and washing with soap and water,” Bill Beiswenger, CPO, FAAOP, Abilities Unlimited Inc. said. “I normally just propose they use the same soap they were using before.”
Patients can choose from numerous moisturizers, soaps and anti-bacterial creams, but in most cases, they should simply wash their residual limb thoroughly with soap and water. Like Beiswenger, Bill Jeracki, CP, Orthotic Prosthetic Solutions, takes the simple yet specific approach when advising his new patients. He recommends products with as little chemical composition as possible for their skin or materials touching their skin. When considering soaps, Jeracki recommended a liquid hand soap because bar soaps tend to leave a scummy film, especially if the patient has hard water in their home. The film could be pushed into the skin causing a reaction.
When choosing moisturizers, patients should consider those with little to no fragrances in them. Fragrances are likely to cause a reaction on the skin, according to Jeracki. He explained that many skin problems are blamed on allergic reactions to materials on the skin. In his view, most reactions are caused by some form of chemical that is in the product used to moisturize or clean the skin.
Patients must also remember to wash their liners and materials. Washing a leg thoroughly is useless if the materials touching the skin are not sanitary. For the active amputee, sock and liner management is crucial to their quality of life. Inevitably, an amputee will sweat. The perspiration forms bacteria on the skin. Left unwashed, this bacteria could eventually cause an infection if not carefully monitored.
According to Jeracki, an amputee can develop a staph infection rather easily if there is a high bacterial count on the residual limb due to improper hygiene or unwashed liners. Scratching an itch too strongly on a bacteria infested residual limb will disturb the skin and may lead to infection.
Beiswenger and Jeracki suggest a cycle of washing the limb and the liner at night and then allowing your skin to dry. It is not recommended to don a prosthesis with wet skin.
“What we’re trying to do is clean the leg and clean the material over the leg,” Jeracki told O&P Business News. “We try to keep the leg free of dirt and reduce the bacterial count as much as we can.”
The weather factor
Cleaning the residual limb with soap and water will reduce the risk of bacteria on the skin, but lotions and moisturizers become particularly important as the seasons change. During the summer months, liner wearers may feel understandably uncomfortable.
“In the hotter days, amputees may not be as active because they are trapped in these closed cell plastics that retain heat,” Beiswenger said. “The liners retain heat, so keeping their skin as dry as possible in the summer is very advantageous for the amputee.”
When a new amputee wears liners, they still have their old sweat habits. New amputees tend to sweat profusely while donning their new prosthesis. Sweat unlocks the coupling between the skin and the liner. This may cause shear between the liner and the socket due to the perspiration. In this case, wearing compression socks would be the most helpful for the patient. Compression socks are better suited to absorb perspiration.
“We see a lot less liner problems in the fall, winter and spring because we don’t have this sweating,” Jeracki explained. “If I worked in a place that was 90·F all the time, I probably wouldn’t use as many liners as I do.”
As the summer heat gives way to drier, colder air, skin management is still the key to a higher quality of life. Without moisturizer, skin in the winter can become dried and cracked. Dry skin in combination with an ill-fitting prosthesis could lead to blisters, abrasions or calluses on the residual limb.
In the winter, the reverse occurs. The cold air becomes trapped in the socket and gets transferred into the limb. Beiswenger and Jeracki recommend patients use moisturizer with minimal fragrances at the end of the day before bed so the lotion has the entire night to soak in. Too much lotion will cause the silicone liner to slide, which may lead to additional shear force.
“In the fall you stop having the heat problem and more people are comfortable with the overall fit,” Jeracki said. “But in the summer and winter the air is always dry, so moisturizer is something I always push for with patients as a rule of thumb and I think that is pretty consistent throughout the nation.”
The creation and subsequent technological advancements of soft liners have had drastic effects on amputee skin care. Liners act as an interface between the limb and the socket. This provides additional protection for the residual limb by maintaining the proper amount of shear force and reducing the risk of skin problems.
“I do think liner technology has reduced the types of abrasions that I have seen and had come to my attention early in my career,” Jeracki said.
A liner will be successful for the patient as long as it worn properly. A liner or sock donned improperly has the potential to form blisters on the distal end of the residual limb, according to Beiswenger. Diabetic patients should be especially careful when donning liner materials and their prosthesis. Diabetic patients who have lost some of their sensation, may not feel a blister form on their residual limb. That blister could potentially turn to a damaging sore, become highly painful and harm the patient’s quality of life. Beiswenger has treated patients with sores so painful they decide to no longer wear their prosthesis.
“I think a good deal of what we say is related to overall fit and not having an optimal fit,” Jeracki said.
An intimate fit between the limb and a prosthetic socket is ideal when caring for the skin. Jeracki described an intimate fit as one between the limb and the socket that is tight enough to keep the limb stable and avoid shear, without causing discomfort. A loose fit will increase shear and has the potential to cause pain.
“Good education on proper fit and how their limbs should fit into the socket, along with sock and liner management, is all part of what a prosthetist needs to do to help solve a particular problem or prevent any of these issues,” Beiswenger said.
Patients, in Jeracki’s view, tend to glaze over when discussing specific materials and products they do not necessarily need at that moment with their prosthetists.
“We always advise our patients if they have any issues that caused a problem on the skin and if they can’t figure out why, they should come in and see a prosthetist,” Beiswenger recommended. “Have us help troubleshoot and see if they may have done something inadvertently or if the socket is ill-fitting, which could cause long-term sores and problems if left untreated.”
Anthony Calabro is a staff reporter for O&P Business News.