- 1 - Welcome to the twelfth edition of the Dressings Times which contains an account of a clinical assessment of a new tech- nique for the treatment of skin reactions following radio- therapy and a brief review of the importance of nutrition in wound management. THE MANAGEMENT OF DESQUAMATIVE RADIATION SKIN REACTIONS When radiation therapy was first introduced, severe radia- tion skin reactions were very common. The orthovoltage ma- chines in use at that time produced the maximum radiation dose at the skin surface, damaging the dividing cells in the basal layers of the skin. This produced a temporary halt in cell division and inhibited the production of keratinised epithelial cells. This effect was observed clinically as a painful desquamative reaction with blistering and a slough- ing of the dermis. Fortunately with the use of modern high energy (megavoltage) machines, this phenomenon has become much less common. This is due to the fact that with these machines the maximum deposition of energy occurs several millimetres below the surface, thus producing less effect on the basal layer. However, skin reactions may still be trou- blesome in a number of specific situations. These are; i. Following the use of beams which are tangential to the skin surface (as in the treatment of breast cancer). ii. Associated with the use of bolus to intentionally raise the maximum dose to the skin surface. iii. Following electron beam therapy. iv. When the patient is receiving concomitant chemothera- py which may sensitise the basal cells to radiation. Within our department, moist desquamative reaction were pre- viously managed by the oncology nursing team using conserva- tive methods. Bland cleaning agents were used to remove any discharge, then 0.5% aqueous gentian violet was applied to act as a mild antiseptic. No dressings were used and the pa- tient was encouraged to expose the area whenever possible to encourage drying. This approach, however, is not satisfactory for a number of reasons:- i. Relief of discomfort is only partial and often of short duration. ii. Gentian violet is staining and messy, and it is fre- quently difficult to achieve adequate drying of the area. iii. The healing process may be prolonged, often lasting several days. We therefore decided to evaluate the use of an alternative treatment, Spenco 2nd Skin a hydrogel sheet, that has been used in the past for the treatment of minor burns, pressure sores, and varicose ulcers. The dressing consists of a transparent cross-linked polyethylene oxide hydrogel con- sisting of 96% water. The gel is supported on a polyethylene net and covered on both surfaces with a piece of plastic film. Prior to use, one layer of film is removed and the dressing applied to the skin surface. The film on the outer surface of the dressing may be removed or left in position depending upon the amount of exudate produced by the wound. Study Design A total of 19 patients undergoing radiotherapy as part of the conservative treatment of early breast cancer were en- tered into the study. At the time of admission, all pa- tients had a moist desquamative skin reaction within the ra- diation field that had developed during, or following com- pletion, of radiotherapy. Skin assessments, dressings and data collection were carried out by the nursing staff. Ap- propriate patients were assigned alternately to the standard treatment which consisted of twice daily applications of 0.5% gentian violet solution and maximum air exposure, or to twice daily application of polyethylene oxide gel in the oc- clusive mode. If the 2nd Skin dressing provided continued relief of symptoms after 12 hours it was left in situ for 24 hours. Skin swabs were not taken routinely at the start of treat- ment but were only obtained if there was a clinical sugges- tion of local infection or if healing was prolonged. Only positive cultures were recorded as episodes of skin infec- tion. At the completion of treatment, patients were asked to com- plete a questionnaire about their symptoms and feelings about their individual treatment. Results The opinions of those patients who participated in the trial are summarised below Gentian Violet 2nd Skin Initial (No.) (%) (No.) (%) Symptoms Pain/Burning 9 100 10 100 Skin Irritation 6 66 4 40 Restriction of 4 44 4 40 movement Disturbance of 7 77 8 80 sleep Relief by treatment Complete 3 33 6 60 Partial 4 44 4 40 Minimal 2 23 - - Duration of relief after application 2-3 hours 6 66 6 60 4-6 hours 1 11 2 20 6-8 hours 2 20 2 20 Days to heal 5-22 4-6 Mean 11 4.6 Episodes of 1 2 infection Overall, the response to the use of 2nd Skin by patients and nurses alike was very positive. There was often an immedi- ate relief of symptoms and the dressing also appeared to cause less restriction of arm movements. Sleep patterns and overall morale also improved. Many patients had skin in the axilla region affected, and in this area particularly, fixa- tion and retention of the dressings was sometimes difficult because of the site anatomy and the size of the dressings. Discussion Although severe radiation induced skin reactions are now relatively uncommon, they remain a source of much discomfort for some patients, resulting in a general lowering of morale. This adds to the stress already experienced by a pa- tient who is worried about the diagnosis of cancer and who has often had to undergo a prolonged course of radiotherapy. Any procedures that can help to alleviate a patient's symp- toms will markedly increase their quality of life. Tradi- tional methods of dealing with moist desquamative reactions have been divided between the wet and the dry approach. The former requires minimal applications to the skin surface but encourages maximum drying of the exudate by free or even forced circulation of air. This promotes the formation of a `crust' which although usually more comfortable, is itself restricting and often irritating. The converse approach has relied upon the application of creams and ointments to the skin surface, often combined with a dry and semi occlusive dressing. The various applications are difficult to apply to the wet skin surface, and dry dressings often remove healing dermis when they are removed. There has been a further con- cern about encouraging local skin infections by occlusive dressings. In the 1960s, Winter demonstrated that primary wounds kept moist healed 50% faster than dry ones but unfortunately ini- tial work with occlusive polythene dressings confirmed fears about increased wound infection. Subsequent studies with semipermeable substances such as Opsite and hydrocolloid dressings such as Granuflex, did not show the same increased infection rate. Information on the use of modern dressings in the management of radiation injuries is limited although one previous study involving the use of a semipermeable polyurethane film, did suggest an improvement in the healing time of this condition.1 The results of the current study indicate that the use of Spenco 2nd Skin dressing reduces discomfort and decreases healing time although this effect does not reach statistical significance because of the small sample size. The dress- ing is also non-adherent and thus causes little trauma on removal from sore and healing areas. Dr D.G. Pickering, MB., BS., MRCP., FRCR. Consultant Radio- therapist and Oncologist. Mrs S Warland, SRN. Staff Nurse, Radiotherapy Dept, Pembury Hospital, Tunbridge Wells, Kent. References 1. Shell JA, Stanutz F, and Grimm J, Comparison of moisture vapour permeable (MVP) dressings to conventional dressings for management of radiation skin reactions, Onc. Nurs. Fo- rum, 1986, 13, 11-16. NUTRITION AND WOUND HEALING The provision of an adequate diet is an important factor than can influence the healing rate of wounds of all types. In surgical patients, clinical studies have revealed a link between malnutrition and the incidence of major complica- tions in wound healing, including a reduction in strength and the formation of infection. Strong links have similarly been established between malnutrition and the development of pressure sores. It has been suggested that protein-calorie malnutrition is common in acute and chronically sick adults and ranges from 30-50%. In a wound healing context there- fore, nutritional support should be considered for individu- als who are already malnourished or are likely to become so. Particular attention should be paid to the elderly, and those with large pressure sores, burns, trauma or sepsis or to patients in the peri-operative period. In order to identify the need for nutritional support, it is necessary to perform a patient assessment. This may take the form of a dietary history or survey, or a physical or bio- chemical examination taking account of factors such as serum albumin levels, skin test antigen response and various an- thropomorphic indices such as skin fold thicknesses, and limb muscle circumferences etc. (Although serum albumin levels can provide a useful warning of post-operative mor- bidity or pressure sore formation, such measurements cannot provide an indication of nutritional status in acutely-ill catabolic patients.) An accurate determination of a patient's nutritional status and dietary requirements can be a complex process that re- quires the involvement of an experienced dietician, but it is intended that this simple summary, should provide some basic information on the role of the major nutrients on the healing process. Glucose Glucose provides a vital source of energy for leucocytes and macrophages which in turn are responsible for the production of factors which stimulate the growth of fibroblasts and the synthesis of collagen. Assessments of the amount of energy required are often difficult and may be imprecise but it is suggested that about 2000 - 2500kcal/day will be adequate for most patients, although burns patients will require more, up to 3500-4500 kcal/day. In severely injured pa- tients the equivalent of 150 grams of glucose may be re- quired and this cannot be replaced by fat. It is believed that during healing, glucose is metabolised aerobically by fibroblasts and macrophages as they invade the wound area, a process that requires a good blood supply and adequate tis- sue perfusion. Fatty acids Essential polyunsaturated fatty acids (PUFAs) have numerous important and complex functions. They are an important com- ponent of the structure of cell membranes and are also in- volved in the formation of secondary agents concerned with vascular and inflammatory responses. The precise function of the PUFAs once incorporated into the cell membrane of a macrophage appears to depend upon the dietary source. Metabolism of those PUFAs derived from dietary fish results in prostaglandin E3 which has vaso-dilatory and anti- inflammatory properties whilst those from vegetable oils re- sult in metabolites that include prostaglandins E2 and I2 which mediate the inflammatory response, platelet aggrega- tion and vaso-constriction. The relative proportions of the two types of PUFAs in the diet may therefore have important implications for wound healing and wound infection. Proteins Inadequate protein levels will result in prolongation of the healing cycle associated with decreased collagen synthesis and angiogenesis and hypoalbuminaemia. It has been shown in animal studies how pre-operative protein depletion can ad- versely affect the healing of colonic anastomoses resulting in decreased bursting strength. Amino acids, the so-called `building blocks' of proteins are metabolised within the wound area to form structural proteins such as collagen and keratin in addition to cellular or intra-cellular struc- tures. All essential amino acids are required for optimal wound healing as well as some non-essential amino acids. Zinc Zinc is an essential co-factor for the activity of many en- zymes involved in protein and nucleic acid synthesis and protein and lipid metabolism, and a deficiency will result in delayed or impaired healing. It has been shown that the administration of oral or topical zinc preparations may have beneficial effects, but these are only likely to occur in patients whose original serum zinc levels are low. Zinc al- so has mild antibacterial action against Gram positive or- ganisms, probably due to inactivation of enzyme systems. Vitamin C Vitamin C is an essential co-factor for the production of collagen. It is also an important anti-oxidant, that helps to `mop-up' oxygen free-radicals that can lead to the damage of cells and enzyme systems. The value of vitamin C supplements in wound healing remains a matter of some debate but it is likely that these may be useful in deficiency states or where such states are antici- pated as a result of serious injury. Other vitamins that have a role in the healing process include vitamins A, B and E. The information contained in this article has been abstract- ed from a comprehensive review written by Susan Mclaren that was first published in the proceedings of the 1st European Conference on Advances in Wound Management, held in Cardiff in September 1991. This article will appear in full in the Journal of Wound Care, Volume 1 Number 3. SMTL PUBLICATIONS The SMTL has recently published three books that may be of interest to the readership of the Dressing Times. These are; 1. Current Practices in the Management of Fungating Le- sions and Radiation Damaged Skin. (5 inc. P & P) This 32 page booklet combines the results of a litera- ture review with the findings of a survey of the prod- ucts and techniques employed in the management of both types of wounds by radiotherapy centres and oncology departments around the United Kingdom. The book is in- tended to provide medical and nursing staff who care for these unfortunate patients on an infrequent basis with some broad guidelines on treatment derived from the collective wisdom of others who may be more expe- rienced in the field. 2. Graduated External Compression and the Prevention of Deep Vein Thrombosis. (NHS price, 10 inc. P & P.) This 57 page book contains a comprehensive literature review on the role of external compression in the pre- vention of DVTs and describes in detail the results of a laboratory-based study that was undertaken to mea- sure the compression profiles of 10 brands of antiem- bolism stockings available in the United Kingdom. 3. A Handbook of Surgical Dressings (7.50 inc. P & P) This handbook contains nearly one hundred `information cards' on surgical dressings each of which provides practical guidance and advice on the indications and method of use of the products concerned together with data on contra-indications and warnings and precau- tions. The handbook, which will now be produced annu- ally, replaces the highly popular Surgical Dressings Information Cards produced by SMTL in 1988. We consider that this publication is an essential pocket reference guide for all those involved in wound management. Requests for any of these publications should be sent to the address shown below together with a cheque made payable to Mid Glamorgan Health Authority. Discounts may be avail- able for bulk orders. The Dressings Times is produced by the Surgical Materials Testing Laboratory, (SMTL) Bridgend General Hospital, Quarella Road, Bridgend, Mid Glamorgan. Telephone No.(0656) 752820.