Chapter 5: Skin Care

Chapter 5 presents information on the prevention and management of pressure injuries after spinal cord injury.

INTRODUCTION

Spinal cord injury (SCI) creates a risk for pressure injuries^a—localized areas of tissue damage that can occur when the skin, underlying tissues, or both are damaged by pressure or pressure combined with shear.^1,2 Pressure injuries are a significant problem at all time points and in all settings for individuals with spinal cord injuries, beginning at the time of injury and continuing through the remainder of the person's life. They are among the most common complications of spinal cord injury.^3-9 It has been estimated that as many as 85% of people with spinal cord injuries develop at least one pressure injury at some point after injury.^10-12

Pressure injuries can appear as intact skin or open wounds.¹ Most occur over bony prominences. The tissues superficial to the sacrum, coccyx, heels, ischium, and greater trochanters are the most vulnerable areas in individuals with spinal cord injury and dysfunction.^5,9,13-16 Pressure injuries can also occur over nonbony areas; these are caused by pressure from medical devices or other objects¹ such as cell phones or handcuffs.¹⁷

ETIOLOGY OF PRESSURE INJURIES

An understanding of the etiology of pressure injuries is critical for health professionals who work with patients who have spinal cord injuries because it can guide measures taken for both prevention and treatment. Pressure injuries develop when mechanical loads acting on soft tissues cause tissue death. This typically occurs when external forces are applied to the skin for a prolonged time, but can also result from higher magnitude forces that are applied briefly. In both of these cases, tissue death results from complex processes that include the combined effects of direct mechanical trauma to the cells, interrupted circulation, and inflammation.¹ As a pressure injury develops, damage often occurs from the inside out, beginning with the deterioration of muscle tissue, which is more susceptible to damage than skin.¹⁸

A variety of factors are thought to make people with spinal cord injuries particularly vulnerable to the formation of pressure injuries; these factors are illustrated in Figure 5-1. Skin collagen degradation after spinal cord injury makes the skin more fragile.^16,18,19 In addition, spinal cord injury leads to compromised peripheral blood flow, which results in a reduction in oxygen and nutrient supply to the tissues. Furthermore, the skin and subcutaneous tissues are more vulnerable to mechanical loads; the interruption of skin blood flow caused by external stresses is more pronounced in people ...