Wound Care and Dressings

Brittney Schultz, MD

Conditions like pemphigus and pemphigoid (P/P) lead to blisters and wounds on the skin and mucosal surfaces, such as the mouth. These are frequently painful and have significant impacts on the ability to perform normal activities of daily living. It can be challenging and time-intensive to care for these lesions. We hope to review some tips for managing these lesions below. Please remember that all advice should be discussed with your doctor to determine if these recommendations are appropriate for your or your loved one’s case.

Dressing Basics

There are several types of dressings, including gauze, hydrocolloid, foams, alginate, films, and nonadherent (or nonstick) dressings. Within each type of dressing, there are many brand names. Each type of dressing has different benefits and is better suited for certain wounds. Several frequently used dressings are reviewed in further detail below. Please note this is not an all-inclusive list.

Gauze

• Examples: petrolatum (Vaseline ® ) gauze, Adaptic®, Xeroform®

• Advantages: used to keep wound base moist

• Not occlusive, needs to have an additional dressing on top of the gauze to keep it secured

Hydrocolloid

• Example: Duoderm®

• Advantages: keeps wound base moist, absorbs some drainage, can be cut to fit wound, can leave in place for a few days

• Not good for wounds with significant drainage

• Hydrogels such as Restore® have similar benefits

Foams

• Example: Mepilex®

• Advantages: keeps wound base moist, absorbs more drainage, may need to be changed frequently if wound has significant drainage

• Better for wounds with more drainage

• Alginates such as Algisite® have similar benefits

Nonadherent dressings

• Examples: Telfa®, ABD (abdominal) pads

• Advantages: do not stick to surrounding skin so it’s easier to remove without pulling skin, good for heavy drainage

• Need to be secured in place (Kerlix ® , clothing, Hidrawear®)

Films

• Example: Tegaderm®

• Advantages: keeps wound base moist, flexible (good for difficult to cover areas, such as joints), transparent (makes it easier to monitor the wound), can leave in place for a few days

• Not good for draining wounds

Wound Care Tips

Tip #1: Moist is better than dry and crusty. Cover your wounds.

Moist, covered wounds heal better than dry, crusty wounds. For this reason, we recommend covering wounds (if a patient can) with some form of dressing (we will get creative below). We also recommend applying some form of lubricating ointment or gauze beneath this dressing as this helps the wound heal and makes it easier to remove the dressing. This can be difficult to do depending on the location or extent of your wounds, so this advice should be adapted to your situation. For example, it would be impractical to cover wounds in the mouth but moisturization can still be utilized on the lips. There are additional specifics to achieve these tips below.

• For open areas on the skin, a common regimen might entail topical steroid ointment applied to the wound, followed by petrolatum (Vaseline ®) gauze, then a nonstick dressing such as Telfa®, followed by Kerlix® to secure it in place.

• If wounds cover a large surface area, other ideas to hold the dressings in place instead of Kerlix® could include a tight-fitting T-shirt, camisole, or leggings. For extremities like arms or legs, tubular bandages such as Tubigrip® can help secure dressings as well. Hidrawear® is a clothing brand originally designed for patients with a different skin condition that also leads to draining wounds on the skin and can be used to hold dressings in place. This clothing is more expensive, but insurance coverage is sometimes possible.

• If wounds are over a joint such as an elbow or knee, films such as Tegaderm® can keep the wound protected, as a film dressing is more flexible.

• In general, we try to avoid popping blisters. If a blister must be popped (or pops on its own), we recommend leaving the blister skin on top of the sore as a natural bandage. You can discuss this with your doctor if it would be reasonable for your case to use a small sterile needle to pop certain blisters when they are very large/tense.

Tip #2: Topical steroids come in all shapes and sizes (or rather, potencies and formulations). Find the one that works for you!

Topical steroids are frequently used in the treatment of P/P. It can sound like alphabet soup to remember all their different names. A few key things to know are that topical steroids come in different potencies or strengths. Different strengths are better for different body locations (in general, we use weaker steroids on thinner skin such as face, groin, armpits, and stronger steroids for thicker skin such as hands and feet). Additionally, topical steroids come in different formulations, such as gels, creams, ointments, lotions, oils, and solutions. Different formulations are better for different body locations. Some general recommendations for use of topical steroids are below, but please note that it is very common for different patients to have different preferences. The most important thing is finding what works for you.

• You can apply topical steroids to open wounds.

• Ointments are generally preferred for the skin as they work better and do not contain alcohol, so they are less irritating to the skin. If the greasiness of the ointment is not ideal for you, creams are also a good option but sometimes burn when applied.

• For lesions in the scalp, solutions, or oils are often easier to use.

• For lesions in the mouth, gels or swish/spit solutions are often easier to use.

• If you have disease involvement of the gums, consider using a dental tray to apply your medicated gel. This needs to be a dental tray that will reach the gums (not a teeth-whitening tray).

• If you have more localized lesions in the mouth, you can pat the mucosal surface dry with a piece of gauze, apply the medicated gel, and then hold a piece of non-stick dressing such as Telfa® or hold a cotton swab on top of the medicated gel for a few minutes so it can absorb better.

• Consider saline nasal spray for sores in the nose and saline eye drops for irritation in the eyes.

Tip #3: Modify your personal products and practice to fit your needs. Conditions such as P/P can have a dramatic effect on your activities of daily life. It can be helpful to modify some of these activities if possible, to reduce the pain associated with your lesions.

• Baths may be better tolerated than showers.

• Consider toddler toothbrushes and toddler toothpaste as these are gentler. Sodium lauryl sulfate (SLS)-free toothpaste can also be less irritating.

• Flossing tape can be less painful than floss.

• Consider using a peri-bottle (examples: Frida Mom® , Lansinoh®; used by women postpartum) or a small watering can with a long spout when urinating if genital sores are present.

• Certain foods or beverages can be very irritating if you have sores in the mouth. The exact triggers are different for each patient, but foods that can often be irritating include spicy, citrus, and crunchy foods (like chips). More information can be found on the IPPF website at pemphigus.org/nutrition.

Tip #4: Consider antimicrobial soaks. It is normal to have some bacteria on the skin, but the presence or overgrowth of bacteria can make it harder for wounds to heal. Wounds can also become colonized. Antimicrobial soaks, such as dilute bleach or dilute vinegar soaks, can be effective in many skin conditions due to their anti-inflammatory and antimicrobial effects. We frequently use dilute bleach baths in children with eczema. It is like going in a swimming pool with chlorine. If you are experiencing wounds with drainage, please ask your doctor about using these options.

• Dilute bleach baths.

◊ Add ¼ to ½ cup bleach to a tub of warm water (approximately 40 gallons), soak for 5-10 minutes, rinse off completely with warm water.

◊ Alternatively, you can add ½ to 1 teaspoon of bleach into a large bowl (~4 gallons), soak the washcloth in the bowl, apply the washcloth to areas of concern for 5-10 minutes, and rinse off completely with warm water.

◊ You may add a few teaspoons of salt for less irritation or to reduce bleach quantity.

◊ Please use regular or “unconcentrated” household bleach.

• Dilute vinegar soaks.

◊ Add 1 tablespoon of vinegar with 8 ounces of water, soak the washcloth in the bowl, apply the washcloth to areas of concern for 5-10 minutes, and rinse off completely with warm water.

Tip #5: You are not alone. Ask for help. This is the most important tip. Caring for your skin and mucosal surfaces can be a full-time job. You should not have to do it alone.

• Depending on the location of your lesions, it is often helpful to have a specialist dedicated to monitoring and treating that location. For example, your team may include your dermatologist, but also an ophthalmologist, dentist/periodontist, and urologist/gynecologist. We are all wanting and willing to work together to care for you.

• Your primary care doctor is vital to the success of your care team.

• Insurance will sometimes cover home health services for wound dressing changes.

• Additional mental health support is often needed during this difficult time.

• Find a specialist through the IPPF or talk to a peer coach.

Brittney Schultz, MD, is an Assistant Professor of Dermatology and Director of the Autoimmune Blistering Disease Clinic at the University of Minnesota. She is also a Staff Dermatologist at the Minneapolis Department of Veterans Affairs Medical Center.