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Skin Care of the Residual Limb

By James Baird, CPO, Director of Education, Hanger Clinic

Skin that comes in contact with the prosthesis must be cared for meticulously to prevent skin damage such as irritation, skin breakdown, and infection. Skin breakdown is the process of skin being worn away, possibly resulting in sores.

Usually, the disorders that put people at risk of amputation (such as blood vessel disorders or diabetes, which decrease circulation to the limbs) also increase the risk of skin breakdown and infection after amputation. Some of these disorders (such as diabetes) and others (such as neurologic disorders) impair the ability to feel pain and other sensations. People with such disorders may not feel discomfort or pain when skin breaks down or infection develops and thus do not notice these problems. These people should remove their prosthesis several times a day to check the skin for redness and other signs of breakdown or infection. Other people should check for these signs at least once daily.

Skin problems can be serious and should be evaluated and treated as necessary by a health care practitioner in consultation with a prosthetist, an expert who designs, fits, builds, and adjusts prostheses and provides advice about how to use them. As people become familiar with recurrent problems, they may be able to identify which problems are minor and manage them on their own. However, anything unusual, persistent, painful, or worrisome should be evaluated by a health care practitioner.

Preventing skin breakdown

The skin next to the prosthesis tends to break down because the prosthesis puts pressure on and rubs against it and because moisture collects in the space between the residual limb and prosthetic socket. The first sign of skin breakdown is redness, which may be followed by cuts, blisters, and sores. When skin breaks down, the prosthesis is often painful or impossible to wear for long periods of time, and infection can develop. Infection can lead to serious problems, including the need for a second operation (called revision surgery).

Several measures can help prevent or delay skin breakdown:

  • Having an interface that fits well is important. But even with a good fit, problems can occur. The residual limb changes in shape and size throughout the day, depending on activity level, diet, and the weather. Thus, there are times when the interface fits well and times when it fits less well. In response, people can improve the fit by changing to a thicker or thinner liner or sock, by using a liner and a sock, or by adding or removing thin-ply socks. But even so, the change in the residual limb’s size may vary too much and too often, making skin breakdown inevitable. Then, people should see a prosthetist to have the interface adjusted without delay. Skin breakdown is often the first sign that the prosthesis needs adjustment.

  • Maintaining a stable body weight is the best way to make sure the prosthesis continues to fit. Even small changes in weight can affect the fit.

  • Eating a healthy diet and drinking lots of water help control body weight and maintain healthy skin.

  • For people with diabetes, monitoring and controlling their blood sugar level as instructed by their doctor helps maintain blood flow to the skin and thus keep it healthy.

  • For people with a lower-limb prosthesis, avoiding changes in the way they hold their body (body alignment) can help. Such changes can cause skin breakdown because pressure is placed in different areas. Wearing different shoes can change alignment. For example, the heels may be a different height or have a different composition (hard rather than soft). When the prosthesis is fitted, people can help minimize potential changes in body alignment by wearing shoes that are similar to ones they usually wear.

When people see signs of skin breakdown, they should promptly see a health care practitioner to be evaluated and a prosthetist to have the prosthesis adjusted. People should avoid wearing the prosthesis when possible until it can be adjusted.

Preventing infections

The socket of the prosthesis creates an airtight, warm, damp, contained space where the person’s natural body oils and sweat collect—an environment that encourages the growth of bacteria and development of infection. Damp skin tends to break down, giving bacteria easy entry into the body. As a result, infections may spread.

Signs of infection include reddened skin, sores, a discharge of pus, tender spots, blisters, and other skin abnormalities or rashes. A bad odor may indicate infection or poor hygiene. Bacterial infections may begin as a pimple or painful red area. However, they can form a pocket of pus (an abscess, similar to a boil) or lead to a spreading infection (such as cellulitis) or to impetigo (an itchy, scabby rash). Bacterial infections may cause fever and a general feeling of illness (malaise).

Any sign of infection should be evaluated promptly by a health care practitioner. The following symptoms require immediate evaluation to prevent infection from becoming life threatening:

  • The residual limb feels cold (indicating decreased circulation).

  • The affected area is red and tender.

  • The affected area gives off a bad odor.

  • Lymph nodes in the groin or armpits swell.

  • Pus or a thick discharge is present.

  • The skin becomes gray and soft or black (either may indicate gangrene).

If people who wear a prosthesis think that they have a bacterial infection, they should see a health care practitioner immediately. Treatment often requires drugs, applied topically or taken by mouth.

To help prevent infections, people who wear a prosthesis should wash the residual limb with antibacterial soap at least once a day. The soap should be unscented and uncolored. People who sweat a lot or who are prone to rashes or infections should wash more frequently. An antiperspirant spray can be used, but it should have no scent or other additives. Sprays with less than 15% aluminum chloride can be obtained over the counter. Stronger antiperspirant sprays can be obtained with a prescription. Alcohol-based lotions should not be used because they dry the skin, increasing the risk of skin breakdown. The prosthetist will recommend a lubricant or lotion that can be used with the socket interface material. Some modern materials used in socket interface design can be damaged by long-term application of skin lotions, so it is best to follow the prosthetist's or material manufacturer's recommendation.

Any part of the interface that touches the skin—the socket, prosthetic sock, or liner—should also be washed thoroughly every day with hot water and antibacterial soap.

Liners and prosthetic socks should also be dried thoroughly before putting them on. Soap left in the socket or liner can cause rashes, so people should make sure that the socket and liners are completely free of soap after washing. An itchy rash usually indicates irritation or an allergic reaction, not infection. A doctor can prescribe a cream or ointment to treat rashes.

Fungal infections should be treated with an over-the-counter antifungal cream. If the diagnosis of a fungal infection is not clear or if fungal infections persist, a doctor should be consulted.

Preventing other skin problems

Ingrown hairs and infection of the hair follicle (folliculitis), although not dangerous, can cause substantial pain and discomfort. Sometimes, if recommended by a physician or prosthetist, over-the-counter ointments can help decrease localized swelling and redness. Not shaving the hair on the residual limb can also help prevent these problems.

The appearance of rough, warty bumps, usually at the far end of the residual limb, can result from an ill-fitting interface. (This condition rarely occurs nowadays because prostheses and fitting techniques are much better than they used to be.) If untreated, this disorder, called verrucous hyperplasia, can lead to a serious infection. If bumps resembling warts appear, people should immediately consult the prosthetist to check the fit and adjust the interface as needed. Then they should see their doctor so that verrucous hyperplasia can be treated.

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