Skin Care & Stump Hygiene
The skin on a residual limb sustains many stresses, making good skin care essential. The skin and tissue of the stump was not designed for weight-bearing nor the uneven pressures and friction against the skin, especially near the brim of the prosthetic socket. These stresses on the skin of the stump create issues in skin care that must be addressed.
Proper stump hygiene is essential. An amputee has a smaller surface area of skin, making the body's natural cooling mechanism less efficient. Prosthetic sockets trap sweat against the skin of the stump, and prevent air from circulating around it to dry it. Small disorders quickly get out of hand in the warm, moist environment of the socket and, if not properly treated, could lead to a more serious condition preventing the amputee from wearing the artificial limb until the condition heals.
Over time the skin and tissue on the residual limb starts to show the effects of years of trauma from wearing artificial limbs - so the longer you have been an amputee the more important these issues become.
As the saying goes an ounce of prevention is worth a pound of cure!
How The Skin Works
The body's skin is a resilient, elastic covering, which is able to repair itself after injury, and shore up weaker areas that endure additional wear. It will thicken, or form callouses in response to repeated stress - amputees notice this at areas where the socket of the artificial limb causes pressure.
The skin helps regulate body temperature by producing sweat, which evaporates and cools the body. Amputees deal with several issues when it comes to how the body regulates temperature. Amputees have a reduced skin surface due to the missing limb(s) making the body's natural cooling system less efficient. The residual limb may get wet with perspiration because it is enclosed within the socket and air does not reach it - this perspiration cannot naturally evaporate from the skin surface. As well, the amputee uses more energy to get around than than those without amputations which naturally will increase the body's temperature, and thus, perspiration. These issues are dealt with in depth in other sections.
Main Causes of Skin Disorders
No matter how hard you try to prevent them, sores and abrasions can occur for numerous reasons: the pressure of the socket against the stump causes trauma to the skin and tissue; perspiration builds up in the socket causing friction which leads to abrasions; sockets may be made of materials that are irritants to the body (i.e. cause allergic reactions); and the warm, moist environment of the socket is the perfect breeding ground for bacteria that can cause skin problems.
As amputees we must deal with these issues or we will end up uncomfortable. Skin problems could even prevent us from being able to wear our artificial limbs at all, until the condition has healed.
Heat and Perspiration
Let's look at why the human body perspires. Perspiration is the means through which the body controls its temperature. When the weather is hot or as we carry out activities extra heat is generated by the body.
Our perspiration contains solids which accumulate in the socket of an artificial limb and on the residual limb. These solids, combined with the warm, moist environment within the socket, make an ideal breeding ground for bacteria. A strict daily hygiene routine is necessary to prevent the numerous skin complaints that can arise as a result of the environment within the prosthetic socket. As perspiration builds up within a socket it can also lead to the stump "pistoning" or moving around within the socket, which in turn can chafe the skin and cause abrasions.
Do amputees really perspire more than individuals who are not amputees? Yes they do and the reasons are varied.
There is no way to totally eliminate the issues with perspiration, but some practical ideas might help control it so that it does not become a real problem.
Bacteria and tiny organisms are everywhere, including on the skin. Some of these are harmless, while others can cause infection in the proper circumstances. Normal skin expels bacteria through drying by evaporation, and also by releasing special fatty acids from glands on its surface. However drying can't occur in the moist environment of an enclosed socket. Also normal skin has a negative charge which repels bacteria, but an amputee's skin, when bathed in salty solutions (such as perspiration) for long periods, can develop a positive charge which can attract more bacteria than would otherwise be present. Hygiene becomes doubly important in these circumstances where the number of potentially infection-causing germs has increased beyond the skin's normal capacity.
Skin Disorders Affecting Amputees
Skin, as the first point of contact with the socket of an artificial limb, needs to be healthy to enable amputees to be as active as possible without experiencing pain or discomfort - so prevention of skin disorders is a very important consideration.
The following are some problems that may result from these factors:
Rashes and Abrasions - these are the most common skin disorder which may occur intermittently or even frequently thoughout the amputee's life time.
Edema - characterized by skin swelling, drying and roughening at the end of the stump, and a red-brown pigmentation, this can usually be prevented by gradual compression using an elastic bandage. Although this may seem like a minor affliction at first, it can develop into a serious complication - a doctor should always be consulted.
Contact Dermatitis - this is caused by an irritant, whether in the materials of the socket, or from an outside source, such as a cleaning agent, powder, lubricant or ointment used in amputee care. Once the cause is discovered and treated, the problem usually disappears.
Cysts - this usually occurs after a limb has been worn for months or even years. They commonly plague above-knee amputees, occurring on the inside of the leg along the upper edge of the artificial limb, but below-knee amputees can experience them as well. They start as small bumps, or nodules which vanish when the artificial limb is temporarily removed, but the constant rubbing of the artificial limb can make the problem worse as cysts become larger and more numerous. Cysts should always be treated by a doctor, as they can become infected and cause further damage.
Folliculitis - a bacterial infection of the hair follicle which produces small, itching, solid areas. If left untreated, these may later develop into boils in which deep-red, painful nodules rise to the surface of the skin. Anti-bacterial soaps may cut down on the bacteria which cause these conditions. Experienced amputees recommend not shaving the residual limb.
Fungal Infections - another product of the moist, warm conditions in the socket of an artificial limb, these require special creams or powders, which can eventually clear up the condition.
Eczema - this is found in dry, scaly skin which becomes moist for no discernable reason. A cause needs to be established or the condition will recur. Allergies, or secondary conditions following edema can contribute to the condition.
Adherent scars - when there has been repeated infection or ulceration damage to the skin, scar formation may be so intense that scar tissue may become attached to the underlying layers of skin. Surgical revision to free the scar is often necessary.
Ulcers - these sores come from bacterial infections, or from circulation problems. They may become chronic if not diagnosed and treated immediately.
Keeping the Residual Limb Clean & Healthy
Cleansing the residual limb should be done at night. Morning washes are not advised unless a stump sock is worn because the damp skin can swell and stick to the inside of the socket.
Wet the skin thoroughly with warm water.
Use mild fragrance-free soap or an antiseptic cleaner.
Work up a foamy lather. Use more water for more suds.
Rinse with clean water, making sure all traces of soap are gone. A soapy film left on the skin may be an irritant.
Dry skin thoroughly.
The socket should be cleaned often - every day in warm weather, to cut down on the accumulation of dried perspiration on the inner surface.
Wash with warm water (not hot!) and mild soap.
Wipe out with a cloth dampened in clean water.
Dry thoroughly before putting on.
Wearing a sock can help wick perspiration away from the skin. Wearing a light sock may have a cooling effect, as well as providing additional padding for the stump. Also some amputees report that using strong anti-perspirants - like the new Secret Platinum which is pH balanced - can help reduce the amount of perspiration produced within the socket.
The stump sock needs to be changed every day (and sometimes more often in hot weather), and should be washed as soon as it has been taken off so perspiration doesn't dry in it. Use mild soap and warm (never hot!) water.
A rubber ball of a similar size can be put inside to help retain its shape.
Products For Stump Care
Serious or persistent stump problems should be assessed by a doctor. For minor skin irritations, however, there are many products to help, and we highlight just a few of them here.
Many amputees find regular use of moisturizing lotions or creams condition the skin which helps it hold up better against abrasions. Vitamin-based creams and lotions are often used, such as EDAP (containing vitamins A and D), which is available through your prosthetist. Other amputees have had recommendations from their prosthetist and/or local pharmacist for off-the-shelf lotions. One suggestion has been Uremol for dry, itchy skin (containing Urea in an emollient cream base).
If you apply a layer of protection on the stump before the socket is donned, particularly in areas that are most stressed, it can lessen the likelihood of sores or abrasions developing. Some amputees use lotions like ALPS Skin lotion (silicone based) or Derma Prevent (Otto Bock; more information below), a film like OpSite (Smith & Nephew) or a silicone gel sheet like Cica Care (Smith & Nephew; for scar care).
Once an abrasion occurs, it is time to consider a medicated lotion. Some amputees use triple antibiotic ointment, available at drugstores, that has zinc oxide as its healing agent. Antibiotic ointments are often used to treat and prevent infections in minor cuts and abrasions. The products simply differ in their active healing ingredients -- some examples include Bactroban (mupirocin), Polysporin (polymixin), and Ozonol (bacitracin, lidocaine hydrochloride). Some conditions may require the attention of a doctor who might prescribe Betamethafone (0.1%).
Second Skin products promote healing and protect the skin through a combination of medicated gel and adhesive bandage. The parent of a CHAMP member who uses Second Skin shares a great tip -- normally it is painful to pull off the adhesive bandage that covers the gel, but soaking in the bathtub loosens the adhesive, making it painless to remove.
Some prosthetists provide Natural Liquid Body Powder to their clients. Based on the age-old healing properties of potatoes, it is applied as a creamy lotion but dries to a powder to control chafing and odours while soothing areas of friction. A member of CHAMP found it worked well in her myoelectric prosthesis as she was unable to shake other kinds of powder into the socket for fear it would damage electrode function.
Controlling perspiration is a large part of preventing abrasions and reducing odour. Dehydral is an anti-perspirant/anti-bacterial cream. Many amputees also find anti-perspirant roll-ons help control perspiration build-up in sockets. Secret Platinum is a new product being recommended. Another product available is the Pure & Natural Crystal Deodorant Stone, which is consumer friendly as it contains no aluminum.
Some amputees use anti-bacterial cleansers on their stumps to limit bacteria that cause skin problems. Products like pHisoderm are available at drugstores.
Otto Bock has introduced its Derma Skin Care products Derma clean (anti-bacterial cleaner for the stump and socket), Derma prevent (protective coating lotion to cover and protect the skin), and Derma repair (anti-bacterial lotion that relieves and repairs irritated skin while moisturizing it). The products come as a set that is available through your prosthetist.
If you are considering products at your drugstore, bear in mind a lightly medicated powder or lotion (such as zinc oxide as mentioned above) can help treat minor skin irritations; an antihistamine cream can help treat a pink rash over the stump (a rash that is not from weight bearing) and an antibiotic cream can help treat actual abrasions.