Oct-Dec 2001: Wound Care

LymphLink Question Corner - Archived from Oct-Dec 2001
Caroline E. Fife, MD

Q:  I have lymphedema of the leg and also have a small wound. Swimming is helpful for my edema, but what type of dressing I can put on my wound that will be waterproof?

A:  Even under the best of circumstances, it can be difficult to make a reliable waterproof dressing. For that reason, you must first make sure that if your dressing leaks and water does come in contact with the wound, it will not be a major problem. One of the reasons we worry about swimming pool water is an unusual type of pathogen called mycobacterium. It can exist even in chlorinated water (as can a number of bacteria, depending on the chlorine level and degree of water contamination). The problem in the lymphedematous limb is that the immune system does not function normally, so a wound may be at greater risk of infection from contamination than "normal" wounds. (Remember, by definition, any chronic, non-healing wound is abnormal!).

So, with that caveat, the dressing most likely to be really waterproof is an occlusive film. Examples of this include Tegaderm and Opsite. However, it is important to remember that film dressings have no absorptive capability at all. If the wound drains a lot, or if there is a lot of perspiration in the area, the film will keep that moisture on the skin and this can cause maceration of the surrounding tissues (wet, white skin). It is possible to place other dressing UNDER the film (a hydrocolloid pad, or even simple gauze or telfa pads). This can provide the advantage of an absorptive or protective layer, as well as the waterproof properties of the film. Many over the counter (OTC) "waterproof" dressings are combination products. I looked at these recently when one of my children needed to swim with a wound.

The OTC products listed as "waterproof" probably perform just as well as products available from medical supply houses. However, whether they are really waterproof depends in part on the area you attach them to. Very thin or dry skin, or skin with moisturizer on it, will limit adhesion of the film and allow water to leak into the wound. Also, if the surface is very irregular (like the palm of the hand) or is hairy, adherence will be negatively affected. One thing you can do to help with adhesion is to use a skin preparation like "Cavilon" (3M).

A warning is in order, which is that adhesive films have pretty good adhesion and can tear fragile skin when they are taken off. Once you put on an adhesive film, it is best to leave it on for two or three days, unless water does leak into the dressing, or if there is so much drainage that the dressing needs to be changed. This will lessen the chance of trauma from dressing removal. Also, rarely, there can be problems with yeast (Candida) under an occlusive film if it is worn for many days.

Q:  If you injure an area with lymphedema, what is the best thing to clean the wound with, and what can you put on it to decrease the chances of infection?

A:  We need to make a distinction between what we might put on an "acute" (just happened) open wound, and what we put on chronic wounds. In chronic wounds with healing problems, I subscribe to Claude Burton's philosophy (from Duke University) that "you should not put anything in a chronic wound that you wouldn't put in your eye." This is because peroxide, betadine and other caustic cleansers can kill new skin cells. However, when a wound has just happened, there is nothing wrong with cleaning it with peroxide or OTC wound cleaners. As for prevention of infection, no topical product can be guaranteed to prevent problems. Dermatologists favor using Bactroban antibiotic ointment, but it is available only by prescription. The OTC antibacterial products (Polysporin or Neosporin) are probably fine, but some people are allergic to topical antibacterials and they can cause a nasty skin eruption. Silvadine cream (sliver sulfadiazine) has been used for many years by burn doctors. It is a prescription product and has the disadvantage of having to be wiped off in order to allow the wound to be inspected.

A number of interesting new types of products designed to decrease bacterial counts are available for more long-term wound management. Products containing silver ions (Acticoat, Arglaes) are toxic to bacteria but not to growing skin. They are expensive but may stay on the wound for several days at a time without requiring changing. Also, there is cadexomer iodine (in a cream and a pad: Iodoflex and Iodosorb), a derivative of betadine, which is not toxic to granulation tissue, but does inhibit bacteria. These products would normally be reserved for a significant wound that is cared for in a wound center, rather than for home use as a prophylactic measure.

For most "household" minor trauma, the topical antibiotic ointments are acceptable if you are not allergic to them. Probably, the best way to limit the risk of infection in a limb with lymphedema is to have good edema control.

Caroline E. Fife, MD is Associate Professor of Anesthesiology at the University of Texas Health Science Center, Director of the Memorial Hermann Center for Wound Healing and Lymphedema Management in Houston, TX, and a member of the NLN Medical Advisory Committee.

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