Be Watchful for Irritating Skin Conditions

ATLANTA — Serious skin conditions that affect amputees can start
with infections; fever and chills are telltale sign of serious infection. Do
not hesitate to send a febrile patient to a physician or the emergency room for
treatment, according to James T. Highsmith MD, MS, of the department of
dermatology at New York Metropolitan Hospital Center.

He and his brother, M. Jason Highsmith PT, DPT, CP, FAAOP, spoke
about skin conditions in amputees at the American Academy of Orthotists and
Prosthetists Annual Meeting.

  James T. Highsmith MD, MS
  James T.

James Highsmith pointed to recent studies that suggest that petrolatum
has antibacterial properties that make it a preferable anti-infective, topical
treatment for wounds compared with antibacterial ointments or creams.

Although the infection rates may be similar between both treatments,
“if you’re using petrolatum, and it’s s a common bug like staph
or strep, they’re easy to treat,” he said. Use of antibacterial
creams can lead to more severe infections, he said, that become harder to
treat. “I’d encourage you to continue to use the petrolatum,” he

M. Jason Highsmith, assistant professor in the school of physical
therapy and rehabilitation sciences at the University of South Florida, pointed
out that in his practice he makes treatment decisions based on the
patient’s best interest. As the primary point of access into the health
care system, “I have an obligation to do what I think is right. You need
to embrace that role. You’re not going to make a decision for them, but
you will probably help them with it to make sure they get the appropriate
care,” he said.

Bacterial and fungal infections

Bacterial infections colonize damaged skin, and generally cause
inflammation, pain and purulence. The most common bacterial infections are
caused by Staphylococci, which may appear on the skin in a shape similar
to a bunch of grapes, or Streptococci, which more often resembles a
string of pearls. Staph infection is more common.

  M. Jason Highsmith PT, DPT, CP, FAAOP
  M. Jason

Over-the-counter treatments for abrasions or cuts prior to infection
include benzoyl peroxide, a double or triple antibiotic ointment and betadine.
Once an infection sets in, cultures and oral antibiotics are typically

Methicillin-resistant Staphylococcus aureus is a severe infection
that needs immediate treatment.

“It is important to replace soft goods and immediately and
thoroughly clean liners, or risk repeated infections,” M. Jason Highsmith
said. When cleaning the liner, practitioners should weigh the
manufacturer’s recommendations vs. what is best for the patient’s
skin. He recommended cleaning the liners with whatever the patient uses to
clean the skin to avoid further irritation; that may consist of a simple
antibacterial bath soap.

It is acceptable from time to time to take a brief break from using soap
to clean, and just use hot water instead.

Some practitioners may use a bleach solution to clean the liner
periodically, but Highsmith advised caution. Rubber or other constrictive
materials in the liner may react with bleach to form a hapten, a partial
antigen that acts as a skin irritant that will last for the life of the

Fungal infections can be caused by dermatophytes, resulting in a well
demarcated, red scaly patch that is classically annular with central clearing.
Ringworm is a dermatophyte infection, for example. Candidiasis is an
opportunistic yeast infection that elicits an inflammatory response resulting
in a beefy red appearance with satellite lesions. Fungal infections may be
treated with miconazole for candidiasis or terbinafine for dermatophytes.

Infectious follliculitis may have bacterial, fungal or viral causes.
Chronic friction from clothing or prosthetic components, including the sleeve,
sock and liner, chemicals, sweat and water can result in clusters of small red
or pustulant bumps around the hair follicles, as well as red and inflamed skin
accompanied by itchiness.

“We can treat them topically. You might want to use a benzoyl
peroxide 2% to 5%…any more than that and you can get more irritation,”
James Highsmith said. A referral to a primary care physician or dermatologist
may be in order to attain a culture that would determine an appropriate

Volume change

Changes in distal limb volume can result in verrucous hyperplasia, a
warty-appearing condition that can be a relatively asymptomatic absent other
complications. Edema, muscle atrophy, weight gain and a poorly fitted
prosthesis are predisposing factors. Complications may include ulcerations,
squamous cell carcinoma and bacterial or viral infection resulting in further
proximal amputation.

Proper prosthetic fit is essential to effective treatment to reduce
proximal pressure and restore distal contact. Compression bandages or a
shrinker may be used. The patient may need to lose weight and decrease salt
intake to alleviate some of the volume change. Infections can be treated with
antimicrobials, and a culture should be obtained to rule out malignancy.

Negative pressure hyperemia increases the blood flow to the distal end
of the limb and may produce a “hickey” effect. Proper prosthetic fit
should restore distal contact and may require a new interface. Volume
management of the limb may include elevation of the extremity. During the acute
phase of this condition, the patient should minimize prosthetic use.
Prescription diuretics and diet may help reduce fluid volume. The patient
should attempt to improve their nutrition and attempt to quit smoking, if

“You want to restore that distal contact. Encourage them in their
personal lives to maintain smoking cessation; that’s an awesome
thing,” M. Jason Highsmith said.

Decubitus ulcers

Also known as hot spots, pressure sores or bed sores, these sores are
caused by mechanical pressure, usually over a bony protuberance, that leads to
decreased circulation and skin breakdown. According to James Highsmith,
patients with amputations have focal pressure and shearing forces of the
prosthesis, so hot spots may appear in non-traditional areas, particularly the
tibial tubercule, and the distal end of transected long bones.

Stage III decubitus ulcers involve full skin loss involving subcutaneous
tissue; stage IV ulcers involve subcutaneous tissue and the fascia as well, and
may involve muscle or bone.

Practitioners can use topical antibiotics, surgical debridement, and
should change dressings frequently.

Keeping the area clean and dry, promoting wound drainage, and
alleviating pressure on these areas is critical to treatment. Practitioners
should seek to restore proper interface fit and device function. If socks and
adjusting fit and alignment don’t help, practitioners may need to consider
fitting a new prosthesis. If dermatological issues in the amputee become
refractory to usual prosthetic management, it is highly recommended to consult
with a primary care physician or dermatologist to gain the team approach and
reach symptom resolution as soon as possible. — by Carey Cowles

For more information:

Highsmith J, Highsmith MJ. Skin issues in O&P. Presented at the
American Academy of Orthotists and Prosthetists Annual Meeting and Scientific
Symposium. March 21-24. Atlanta.

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