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DRHow to Use PolyMem
in the Management of Epidermolysis Bullosa
Jackie Denyer, Clinical Nurse specialist, Epidermolysis Bullosa (Paediatric) Great Ormond Street Hospital, London and DEBRA UK Ruthie Winblad, Clinical Development Manager, Ferris MFG. Corp
What is Epidermolysis Bullosa (EB)? Epidermolysis bullosa (EB) is the generic term for a large group of inherited skin fragility disorders. There are four main types of EB • EB simplex • Junctional EB • Dystrophic EB • Kindler syndrome The common factor is a tendency for blistering and stripping of skin and mucous membranes following minimal everyday friction and trauma. EB varies in its effects from relatively minor blistering of the hands and feet (Localised EB Simplex) to increasing disability resulting from internal and external contractural scarring (Severe Generalised Dystrophic EB) and in its most extreme form (Herlitz Junctional) EB leads to death in early infancy from complications including laryngeal blistering and failure to thrive. Those affected with severe forms of EB have a tendency to develop chronic wounds and the later complication of squamous cell carcinoma often lead to death in early adulthood. At present there is no cure or effective treatment for this painful and devastating condition, but research is progressing towards availability of both gene and cell therapies. Treatment is symptomatic with emphasis placed on skin and wound management, pain relief and nutritional and psychological support.
Neonates Babies with severe forms of EB are frequently born with wounds, typically on the limbs and these wounds can be extensive. The wounds result from inter-uterine movements and are compounded by trauma caused by the delivery. For more comprehensive care of newborn with EB please look at the New Baby Guidelines from Great Ormond Street Hospital, London and DEBRA UK. Children and adults When introduced to new products older children and adults often demonstrate a reluctance to try them. This is due to previous bad experiences with dressings causing trauma, pain or being ineffective. Due to its uniqueness and special mode of action it is advisable to initially try PolyMem on a small isolated wound until confidence in the product is gained. In general adults will often choose to use smaller pieces of PolyMem to cover individual wounds rather than wrapping the whole limb. Recommendations for dressing changes are the same as for the neonate.
What is PolyMem? PolyMem is a unique multifunctional dressing specifically designed to reduce a patient’s total wound pain experience, while actively encouraging healing. All PolyMem dressings effectively cleanse, fill, absorb and moisten wounds throughout the healing continuum. Activated by wound fluid… • •
• Superabsorbent starch co-polymer • Mild, non-ionic, non-toxic, tissue-friendly wound cleanser/surfactant (F68)
The PolyMem dressing will expand and gently fill the wound. The mild, non-ionic, non-toxic, tissue-friendly wound cleanser/surfactant F68 and the glycerin incorporated in the dressing will be released to the wound bed, while the starch co-polymer and the polymeric membrane will bind fluid in the dressing. The semi-permeable film cover will control moisture vapor transmission.
PolyMem dressings help reduce wound pain associated with dressing changes. Dressings which stick to the wound bed cause wound pain and trauma when they are removed during dressing changes and are also associated with delayed healing. PolyMem dressings are non-adherent to the wound bed.
Cleansing wounds is known to cause wound pain during dressing changes. PolyMem dressings usually eliminate the need for wound bed cleansing during dressing changes. PolyMem dressings facilitate effective autolytic debridement, reducing the need for more painful debridement options.
PolyMem help reduce spread of inflammatory reaction into surrounding, uninjured areas by altering the actions of certain nerve endings.1 The most common cause of pain in chronic wounds is tissue damage, which is referred to as nociceptive pain or inflammatory pain. Nerve damage is another cause of wound pain and is called neuropathic pain. Neuropathic pain is often experienced after chronic unrelieved nociceptive pain. PolyMem formulation dressings help to inhibit the action of some of the pain-sensing nerve fibers (nociceptors) which carry some of the pain messages after tissue-damaging injuries and inflammation. These nerve endings transmit information that can result in: (A) Incision only
• Allodynia (pain caused by normally non-painful stimuli, such as lightly brushing the skin); • Primary hyperalgesia (increased sensitivity to pain at the site of injury) • Secondary hyperalgesia (pain caused by touching an uninjured area surrounding the injured site). These populous nerve endings, found in the epidermis, dermis, muscle, joints and viscera, are also responsible for spreading the inflammatory reaction into surrounding uninjured tissues.
(B) Incision with Gauze
(C) Incision with PolyMem
This series of images shows the width of the spread of the inflammatory cells, in muscle, around an incision. The dark portion of the scale in each image (each segment is 100µm) represents the spread of the zone of the inflammatory reaction around the center line of the incision. In images A and B, there is no difference in the spread of the inflammatory reaction around the center of the injury. In image C, notice how PolyMem reduces the spread of the inflammation into the surrounding tissue. Statistically, PolyMem reduces the spread of the inflammatory reaction into the surrounding undamaged tissue by approximately 25 percent.
General recommendations in how to use PolyMem PolyMem can be used in all forms of EB where there is an open wound. Where skin is vulnerable and wounding likely to occur under a dressing PolyMem or PolyMem MAX can be used for protective padding. PolyMem MAX is a thicker, more absorbent version of PolyMem. Use regular pink PolyMem unless recommended by the clinician to treat infection by using PolyMem Silver. While there is no specific limit to use of PolyMem Silver dressings, International guidelines recommend to limit the use of silver dressings to two weeks. Note the text on the backing film; “THIS SIDE OUT”. Make sure the backing film is away from the wound. With PolyMem WIC it doesn’t matter which side you place on the wound as it doesn’t have a backing film. Due to the composition of PolyMem you will often experience an increase of wound fluid the first week or two so it might be a good idea to start with PolyMem MAX in order to get a longer wear time.
PolyMem and PolyMem MAX with printed backing film
PolyMem roll comes in several sizes.
PolyMem WIC (without backing film, also available in silver)
PolyMem Silver (also available in a MAX version)
Application Always try to use large sizes of PolyMem that can be applied in one piece. PolyMem should be placed around the limb in a sufficiently large piece to be able to overlap itself and be secured with tape dressing and or tape. Cut slits one third of the way into the dressing at each side when the dressing is placed over a joint to allow movement and fold over the effected area. Fixate with a gentle tape and a tubular bandage if needed. If it is necessary to join several PolyMem dressings, overlap the two pieces rather than placing them edge to edge to avoid risk of blistering at the join edges and danger of tape adhering to the wound or fragile skin. When covering isolated wounds make sure to let PolyMem overlap the wound with at least 1-3 cm. Never occlude the dressing with too much tape or bandage (the semi permeable film will not vent moisture and the wound can macerate). When wrapping PolyMem around a limb or digit wrap securely to ensure direct skin contact, but do not wrap too tightly in order to avoid tournique effect.
Place the limb on a large pre-cut PolyMem.
Wrap securely but not too tight.
Always overlap the edges to avoid risk of blistering.
Slit dressing in advance to allow movement over the joints.
Finished result, a firm “boot” protecting the foot and leg.
Fixation A variety of different fixation methods can be used depending on the area of the body and fixation materials avaliable. Some examples are; tubular bandage, silicone tape, retention garments and overlapping and taping PolyMem to itself. When securing PolyMem to itself with tape avoid tapes with aggressive adhesion due to the risk of skin contact in case they become detached from the dressing. Tubular bandage can be applied over PolyMem to further secure the dressing and prevent trauma caused from the child rubbing on the dressing and/or tape. Place the tubular bandage above or below the wound before the dressing is applied so it can be pulled in place quickly before the dressing moves. On areas where it is not possible to apply a tubular bandage a soft stretch gauze wrap can be wrapped around the torso or limbs to keep PolyMem in place.
Do not occlude with too much tape.
Silicone tape fixating PolyMem on the back.
Avoid use of aggressive tapes over PolyMem.
Tubular bandage over elbow.
Stretch gauze wrapped around the torso and arms.
Change frequency Change the dressing when staining of the wound contour is visible on the outside of the dressing. This will initially be daily, or, in some cases when there is copious exudate, twice a day for the first week or two. PolyMem MAX can be used if longer wear time is needed. When you have extremely high levels of fluid PolyMem WIC can be used under PolyMem or PolyMem MAX to achieve longer wear time. The exudate level will normalize as the wound gets cleaner and starts to heal. When using PolyMem there is no need to clean the wound during dressing changes due to the built in wound cleanser.
Oversaturated dressing. Change more frequently or choose PolyMem MAX instead
Staining visible from the outside of the dressing following the contures of the wound indicates that it is time to change the dressing.
Problems and Solutions Odour In order to facilitate healing - PolyMemâ€™s mode of action often create an outflow of wound fluid. This wound fluid can have a distinct odour. Odour is therefore not uncommon when PolyMem is initially used. When this happens the dressing should be changed more frequently, or use PolyMem Max in place of regular PolyMem. Despite the odour the wound should look clean once the dressing is removed. In absence of other clinical signs odour doesnâ€™t indicate infection. If it is not possible to change the PolyMem frequently use in conjunction with a charcoal dressing to reduce the odour.
Discolouration Do not be alarmed if the dressing is discoloured, this is just an indication that the dressing is doing its job cleaning up the wound. In most cases the wound surface is clean and healthy without any indications of infection despite of the colour of the dressing. If you continue to change the dressing frequently according to exudate level the colour of the exudate will soon normalise.
Bleeding Nothing to be alarmed over as long as the bleeding is not caused by the dressing sticking to the wound surface. Apply greasy emollient or spray bleeding points with emollient spray. You can also use a syringe and drip saline onto PolyMem to correspond to bleeding points to reduce the capillary effect of PolyMem.
No signs of infection despite malodour.
When the dressing is malodourus and discoloured but the wound is clean it does not indicate a wound infection.
Bleeding area on the hand after dressing removal (not due to adherence)
PolyMem is sticking to the wound This is unusual and may mean the dressing needs to be changed more frequently. If the dressing has become adherent use Silicone Medical Adhesive Remover (SMAR) or a greasy emmolient in ointment or spray form to release it without trauma. If PolyMem continues to stick place a layer of lipocolloid wound contact layer (Urgotul) beneath the PolyMem.
The wound is dry and crusted Where there is dried exudate around the wound, or if the healed edges are dry, apply a greasy emollient to the dry areas to prevent adherence. If PolyMem Max is being used change to regular PolyMem. You can also try moistening the skin with saline prior to application of PolyMem Stop using PolyMem if the wound is healed and does not need protection. (Note, if there is no problem with dry crusted skin you can continue to use PolyMem as a protective padding).
Signs of a wound infection 1. Take a wound swab. 2. Apply Flaminal Alginogel to the infected area and cover with PolyMem. 3. Start appropriate oral antibiotic if streptococcal infection shown on culture or patient showing signs of systemic infection. 4. PolyMem Silver can be used if the child is over 1 year. Silver dressings should not be used for more than 2 weeks (Age recommendations according to guidelines from GOSH, some countries might allow the use of silver dressings at an earlier age.).
Urgotul under PolyMem to prevent adherence
Dry crusted skin after prolonged use of PolyMem MAX on intact skin.
PolyMem Silver used on an infected knee.
Neonates Minimal handling restrictions may be imposed on sick neonates inhibiting frequent dressing changes. If changes more than twice daily are required consider using PolyMem Max or make some cuts on the outer film of the PolyMem and place an absorbent dressing over the top â€“ the outer dressing can then be changed when wet and the PolyMem left in place decreasing the change frequency to daily. Where raw surfaces of digits are adjacent there is a risk of fusion of fingers and toes. A hydrofiber and/or a thin wound contact layer should be placed in strips around and between the digits to discourage fusion. Change the hydrofiber at each change of PolyMem. If the edges of the dressing rub and cause blisters, place a strip of hydrofiber beneath the edges of PolyMem to protect the skin. It is also possible to cut/phase down the edges of PolyMem with sharp scissors prior to application. Do not leave neonates and infants in wet, over-saturated dressings as these can become cold and reduce the babyâ€™s core temperature.
Soft silicone wound contact layer and hydrofiber between the fingers.
Hydrofiber between the toes to prevent fusion..
Bathing not recommended for neonates with open wounds.
Blistering caused by edges of the dressing.
Hypothermic foot caused by oversaturated dressing.
Bathing Regular bathing in a mild antiseptic solution is recommended. Table salt can be added to reduce pain and some advocate bathing in diluted bleach solution. We do not recommend bathing neonates who have extensive skin loss until prenatal and birth damage are healed. This is to avoid pain and further trauma from attempting to handle the infant without dressings. Many older children and adults choose not to bathe due to difficulties in getting in and out of the bath, pain and a dislike of having all their wounds exposed at the same time. In general showering is too painful for those with severe EB.
Bathing with dressing on.
Blisters Contrary to what is taught in regards to normal skin, in EB it is important to pop blisters as the pressure of the fluid in the blister lifts the nearby skin, making the blister larger. Popping blisters helps to keep them from spreading. It is important to leave the blister cap on the wound, as it serves as natural protection or a covering for the area. These must be lanced with a sterile needle or snipped open with very sharp clean scissors. Where the roof remains on the blister there is no need for a dressing, if the blister roof is missing cover with PolyMem.
Gently press the blister to encourage complete emptying.
Gastrostomy and Tracheostomy sites One of the complications of gastrostomy feeding is leakage of stomach contents onto the fragile surrounding skin. Despite the advantages in enteral feeding, cutaneous complications following the intractable leakage of acidic stomach contents onto the skin of the abdomen lead to skin loss and chronic wounds. With tracheostomies the main problem for the skin is protection from the tightly fastened securing tapes. The stoma site requires protection from the phalange of the tube and the tapes can cut into the back of the neck particularly in young infants where the neck is short. PolyMem Tube is a pre-cut dressing designed to fit different dimensions of tubes. It comes in two sizes, 7 x 7 cm and 9 x 9 cm. PolyMem Tube applied around a stoma or tube will offer protection from trauma and reduce the risks of infection and overgranulation. PolyMem Tube can be secured using Silicone Tape or tubular bandage. In cases with extreme leakage (mainly gastrostomies) PolyMem Tube might not be sufficient, choose a superabsorbent dressing together with a thin gentle wound contact layer instead.
Example of excoriated skin around gastrostomy site.
PolyMem Tube dressing comes in two sizes, 7x7cm and 9x9cm
PolyMem Tube around a gastrostomy site.
Hints and Tips Many EB specialists prefer to pre-cut all the dressings and store in clean container to avoid delay and subsequent distress during dressing changes. This includes pieces of silicone tape, tubular bandages etc Round off edges of PolyMem to avoid potential blistering. If using adhesive versions of PolyMem cut and round off the adhesive borders. (When using adhesive products silicon medical adhesive remover must be used prior to removal) When applying PolyMem to a wound on a vertical surface secure it with a silicone tape such as Mepitac or Siltac. Cutting through the tape prior to dressing removal eliminates potential risk of skin friction.
Always cut through the tape before removal.
Overlap PolyMem and secure to itself.
Pre/cut dressings in the back. Urgotul used at the edges.
Silicone tape fixating PolyMem on the back.
When wrapping around a limb make sure to wrap securely to avoid the bandage from slipping and causing friction. Make sure to overlap PolyMem rather than placing it edge to edge to itself, as this will reduce the risk of blistering. If the overlap join causes blisters protect the skin by using a non- adherent primary dressing beneath the join (for example a hydrofiber). Ensure the edge of the dressing is placed on intact skin and is not in contact with the wound surface. If using a wrap-around bandage do not allow the bandage to extend beyond the PolyMem (blisters may occur where the bandage rubs on the skin). Do not use honey products in combination with PolyMem as they can cause the dressing to stick to wound bed and surrounding area.
Blistering where bandage was joined edge to edge instead of overlapping.
Honey products causing adherence and leaving residue on the skin.
Blister caused by bandage extending beyong PolyMem.
Blister on elbow caused by too small dressing that has not been wrapped securely enough.
Cutting slits in the dressing over the joint areas allows for better movement of the limbs. Use PolyMem MAX in areas that need extra padding, such as elbows and knees. Try ro avoid the use of aggressive tapes, even on top of PolyMem to avoid the risk of the tape becoming dislodged and sticking to the skin or wound. Silicone Medical Adhesive Removers are very useful when tapes, dressings or clothes are stuck to the skin or wounds. There is a new range of retention garments called “Skinnies” that are very usefull at keeping dressings in place (add website?)
Cuttng slits in PolyMem allows for good movement of the joint.
Tape dislodged and adhered to the skin. Use SMAR to remove.
Use PolyMem Max for extra padding on elbows and knees
PolyMem kept in place with retention garment called Skinnies.
Examples of templates
Template of a boot using PolyMem 20 x 60 cm.
Simple heel template.
Template for the hand.
Example shows one of many different solutions of how to create a “boot” to cover a wound on the foot. Photos courtesy of Anna Ritchie who also wrote “thanks for making this dressing, you may well be a single cause for enabling my daughter’s heels to heal and hopefully wear shoes one day!”
O I S ER
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DR References 1.
Beitz AJ, Newman A, Kahn AR, Ruggles T, Eikmejer L. A Polymeric Membrane Dressing With Antinociceptive Properties: Analysis With a Rodent Model of Stab Wound Secondary Hyperalgesia; The Journal of Pain, February, 2004;5(1):38-47.
Ferris Mfg. Corp. 5133 Northeast Parkway, Fort Worth, TX 76106-1822 U.S.A. Toll Free U.S.A.: 800-POLYMEM (765-9636) International: +1 (817) 900 1301 www.polymem.com or www.polymem.eu
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