Palliative Case Discussion: Moisture Associated Skin Damage in Elderly Male

Case Discussion: Moisture Associated Skin Damage In Palliative Care

79 year-old male who presents to the wound center with a ‘pressure injury’ to the bilateral buttocks. He had a recent hospital admission one month before and was sent directly to the home setting for recuperation. The family (daughter and son-in-law) who were looking after him had been to see the primary care physician for recommendations. He had been placed on ciprofloxacillin for a presumed infectious process along with lidocaine gel for the pain to be used as needed. Confusing additional information included a history of shingles on the bilateral buttocks in the past, and a remote history of radiation in the late 1950’s for Hodgkin’s Lymphoma.

The examination revealed moist areas bilaterally with generalized skin destruction. There was no evidence of a cellulitis. The injuries to the skin were multiple and shallow. There was no odor noted.

Initial presentation with multiple open area bilaterally, moist, and tender.

Our working diagnosis was moisture associated skin damage [disorder, dermatitis], also known as MASD. We recommended that he stop the antibiotics, stop using the gel which would have added additional moisture, and utilize frequent applications of a protective barrier cream (there are dozens on the market and we freely given patients and their families their choice). In addition, the patient was admonished to not spend a lot of time on his bottom as any further injury such as pressure would make the healing process that more difficult. For his intermittent incontinence, we recommended that undergarments be changed with more frequency.

After three weeks, the patient was greatly improved and discharged from our service.

Within three weeks, resolution of the open skin areas.

Palliative Discussion

1. Moisture Associated Skin Damage (MASD) is a common clinical finding in the elderly population, especially in those patients with recent transitions between levels of care and in those patients who wear undergarments that hold in moisture.

2. Constant moisture over the skin weakens the structure. The easiest analogy that works to explain the situation to a patient or caregiver is to picture the skin as a brick wall: moisture does not necessarily destroy the bricks but weakens the mortar so that the bricks collapse upon each other.

3. MASD can be quite disabling and result in long healing times in patients that are already at risk of losing function, so the correct diagnosis and treatment are very important.

4. As with this patient, moisture and pressure occur in the same areas (buttocks, coccyx, sacrum) so that often both risk factors must be addressed.

5. The misdiagnosis of moisture associated skin destruction is often confused with many other conditions. Patients are often placed on antibiotics by primary care clinicians adding to the polypharmacy issues common to our elderly and poor antibiotic stewardship. Many of these patients have already been exposed to multiple antibiotics as they are brought through the transition of care. Increasing the risk of Clostridium difficile infection adds further difficulty to a successful recovery for these vulnerable patients.

6. There are many choices for skin protection with actually dozens of choices. Most patients and families already have an appropriate protective cream in their possession but were ill advised on the diagnosis and proper treatment plan. Next to the choice of wound care products (in any setting), the choice of protective creams by wound care professionals is subject to an intense degree of United Nations style negotiations at the least, and World Wars at the worst. Our wound care center motto: frequency is more important than the product!

The general discussion of the patient above is truthful. Identifiable data has been modified in order to make sure that the patient cannot be identified, so modifications of age, gender, and other details were altered that do not affect the overall discussion.

© 2016 Scott Matthew Bolhack MD MBA CMD CWS FACP FAAP

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