Use of dermatological and wound-management products that incorporate adhesives to help keep them secure and in place has grown in line with the increasingly ageing population and changing demographics throughout the UK (Office for National Statistics, 2018). Coupled with the increased recognition of a number of genetic conditions that affect the skin (such as epidermolysis bullosa (EB) (Denyer, 2011)), there is growing need for health professionals to consider not only what dressing, tape, drape, device or electrode to use, but also how to remove the same without causing any unnecessary damage to the skin (Zillmer et al, 2006). This is a current and ongoing healthcare objective, given that it was predicted that an average clinical commissioning group or health board with a catchment adult population 250 000 would be managing 19 800 wounds in 2017/18 and 25 800 wounds in 2019/20 at a cost of £45 million and £54.5 million respectively. This represents a prevalence and cost increase of 5% and 11% compared with 2012/13 (Guest et al, 2017).
The assessment of a patient's skin, and in particular the skin surrounding any wound, is an important aspect of care for health professionals (Shultz et al, 2003). As a person ages, their risk of skin stripping increases, and this is a particular issue for patients who require wound dressings that need to be attached to the skin using adhesive tape (Cutting, 2008). As a consequence of polypharmacy (the use of a number of medications to manage a number of clinical conditions that one patient is being treated for at the same time), general skin condition and healing potential may be compromised (Levine, 2017). For example, in the author's experience, an increasing number of patients have multiple comorbidities that need to be addressed at the same time as any skin condition they may have. This makes any wound or skin assessment/management more complex (Collier and Radley, 2005; Chamanga, 2016).
Patients are more frequently reporting skin abrasions or tears as a result of minor trauma (Lloyd-Jones, 2017). In fact, research has previously indicated that the prevalence of skin tears—a number of which are caused by the inappropriate removal or technique used to remove an adhesive tape or dressing—was higher than that of pressure ulceration; the prevention and management of which is high on the current NHS agenda (NHS Improvement, 2018). Skin tears are often under-reported and the consequences of this are widely underestimated (LeBlanc and Baronski, 2011; LeBlanc et al, 2016).
Medical adhesive related skin injuries
When adhesive tapes or dressings are removed from unprotected skin, varying amounts of superficial stratum corneum are removed along with them and this may be further exacerbated by the repeated application and removal of adhesive tapes and wound dressings from the same skin site. This is known as exogenous damage (skin stripping) or medical-adhesive-related skin injuries (MARSIs). Repeated MARSIs may then result in inflammatory skin reactions, local oedema and soreness; all of which can have a further adverse effect on the skin's barrier function (Dykes et al, 2001; Cutting, 2008; McNichol and Bianchi, 2016).
If the barrier function of the skin is compromised in any way, the patient is more at risk of bacterial contamination which, if not recognised and managed appropriately, can delay any anticipated wound healing; compromise the patient's wellbeing and lead to infection (Collier, 2004; Dryden et al, 2015; Reevell et al, 2016). The appropriate use of evidence-based sterile skin protectants or adhesive removers can minimise these potentially negative effects.
Pain
In the author's experience, a more often-reported and important consequence of repeated tape and/or dressing removal is that of pain—especially during or immediately after tape or wound dressing changes. This unwanted patient experience has previously been identified in the literature by Hollingworth and Collier (2000) and subsequently reported to be considered the most painful aspect of wound management (European Wound Management Association, 2002; Upton, 2014). Nonetheless, it has been previously reported that all too often nurses fail to acknowledge or manage pain effectively when changing dressings (Hollingworth and Collier, 2000; White and Hollingworth, 2006). White and Hollingworth have further suggested that wound-related pain has become a ‘professional and humanitarian’ concern and that the only way this can be minimised is if all health professionals:
‘Understand the patient's experiences and the impact that pain has on their lives’.
This pain has been reported to delay wound healing (Becherta and Abraham, 2009) and so should be avoided in all clinical circumstances, through the use of evidence-based skin protectants or adhesive removers.
Cathecholamines (neurotransmitters produced in the adrenal glands and released in response to stress or pain) decrease the activity of white blood cells, thereby minimising the anticipated effects of the normal inflammatory response (Collier, 2003; Brem and Tomic-Canic, 2007). Any skin stripping or pain, especially if repeated, will induce an inflammatory response and patients who have already experienced skin stripping or pain at the time of medical device/dressing removal are more likely to be anxious and/or stressed immediately before removal.
Furthermore, unresolved pain can have a negative effect on a patient's quality of life (Dueñas et al, 2016). Maintaining or improving a patient's health-related quality of life (HRQoL) is now recognised as one of the most important aspects of health care—especially when wound healing may not be an attainable objective for a variety of reasons—a subject that has been written about widely by a number of authors (Franks et al, 2002; Price, 2006; Verdon, 2015). WUWHS (2004) recommended that assessing and documenting pain during and after dressing changes was essential to ensure that appropriate action could be taken to stop unnecessary pain being experienced by patients.
It is important to remember that small care actions, such as the use of appropriate products/removal techniques, can make a significant difference to a patient's perceived quality of life and therefore all health professionals should be aware of the potential of adhesive tape/dressing related wound pain and assess, plan, manage and most importantly prevent all ‘avoidable’ pain whenever possible. Practitioners should also be aware of and take account of any published protocols or recommendations to prevent other forms of skin damage, such as those of Cutting (2008) (skin stripping) and Lloyd-Jones (2017) (skin tears).
Appeel® Sterile medical adhesive remover: what is it and how should it be used?
Appeel adhesive remover was first launched in 2002 and Appeel Sterile was launched to the wound care market in 2010. The manufacturer describes it as a ‘no sting’ medical adhesive remover containing certified health-grade silicone ingredients. One of the main ingredients included in all variants is siloxane. This is a long chain or cyclical polymer composed of alternating silicon and oxygen atoms with an organic molecule attached to the silicon atoms (Lansdown and Williams, 2007). The siloxane incorporated within Appeel Sterile possesses a ‘searching mode’, meaning it is has a very low surface energy, so that when it comes into contact with the surface of the skin it temporarily changes the chemistry of the skin and disrupts the adhesive link between the adhesive (tape or dressing) and the skin's surface (Cutting, 2006). The size of the polymer and the resulting compound's chemical properties enable the production of siloxanes in a range of forms, such as liquids, gels and resins.
Regardless of which variation of the product is used (sachet, spray, applicator or wipe), a small amount of the solution should be placed on the edge of the tape or dressing. The tape or dressing can then be gently peeled back—this process can be repeated along the entire surface of the tape or dressing until it has been completely removed. Once the dressing has been removed, the silicone on the skin evaporates without leaving any sticky residue. The patient's skin can then be reassessed and managed appropriately. This method of removal also prevents any residue of the adhesive being left on the skin, meaning that the most clinically appropriate tape or dressing can be reapplied as soon as is practical (Cooper, 2010) and the chosen product's adhesive properties are not adversely affected.
Contraindication and precautions
Appeel Sterile should not be used where there is any known sensitivity to any of the ingredients (as listed by the manufacturer). If in doubt, patch test a small area before use. Do not use if the packaging is damaged. Some of the product's ingredients are flammable and therefore Appeel Sterile should be used in a well-ventilated area. Avoid using around flames and sources of ignition (Cowan, 2019).
Clinical indications
Appeel Sterile is a single-use sterile silicone medical adhesive remover (SMAR) that is indicated for use on both intact and broken skin. The applicator allows the product to be used safely on a patient's face (avoid contact with the eyes) and on infants. The care objectives are to prevent or minimise pain, minimise the risk of infection and MARSIs to a patient's skin at the time of adhesive or dressing removal.
Benefits to at-risk groups
With the anticipated increase in the ageing population and the associated increase of patients with multiple comorbidities and fragile skin (Guest et al, 2017), the use of catheters inserted into patients and the use of other medical devices that require securement to the skin for any clinical reason is increasing (Stephen-Haynes and Evans, 2015; Oliver and Jones, 2016). It is therefore essential that all health professionals act to minimise any damage to their patient's skin to avoid MARSIs such as unintended trauma, skin stripping, pain and also to minimise the risk of secondary infection (Reevell et al, 2016).
The older person
The blood supply to the skin is reduced with age, which together with the cumulative effects of ultraviolet radiation from sun exposure over time results in detrimental changes. The rate of wound healing falls with age in line with the delayed formation/replacement of collagen; flattening of the dermal–epidermal ridge, through flattening of the dermal papillae, loss of dermal thickness and loss of subcutaneous fat; glandular changes, which include a decrease in the number and function of sweat glands leading to sebaceous gland hyperplasia with decreased sebum production (Kaminer and Gilchrist, 1994).
Skin fragility is evident in the elderly population (Xu et al, 2009) as there is decreased resilience to trauma and in particular to skin tears, which in this age group may lead to the formation of a leg ulcer. If a leg ulcer develops, it is important to maintain the integrity of the surrounding skin to prevent the extension of the wound and to minimise pain during dressing changes. SMARs offer many benefits to older patients and should be considered as and when appropriate.
Patients with diabetes
Patients of any age group who have diabetes are known to be more at risk of infection if their skin barrier function is compromised in any way, due to the effects of the medical condition on their immune system (Wounds UK, 2013; Dryden et al, 2015), and so sterile SMARs are well placed to protect the patient as much as possible from MARSIs. Skin integrity is therefore paramount and so if any skin damage or wounds are present, care must be taken to ensure the peri-wound skin is not damaged by uncontained exudate or by the traumatic removal of dressings (McIntosh and Newton, 2005).
Patients with a stoma and/or urinary sheaths
Patients requiring continence and/or stoma care are at constant risk of skin damage and SMARs should always be an option to protect their skin. Many experience leakage and excoriation, which greatly impacts of their quality of life (Tickle, 2013). Stoma bags and urinary sheaths require secure fixation to the skin to avoid any leakage. Constant removal of these appliances may lead to unintended skin damage unless a preventative approach to removal is undertaken by all health professionals involved with the patient's care.
Clinical evidence
The Nursing and Midwifery (NMC) Code (2019) demands that health professionals:
‘Always practise in line with the best available evidence’
It is vital that companies produce evidence to support any products they wish to be released into the varied healthcare settings. Below is a sample of the currently available evidence to support the clinical use of Appeel Sterile*.
Case studies
Provided by Jan Hitchcock, Vascular Access Lead Nurse, Infection Prevention & Control, Imperial College Healthcare NHS Trust
The use of peripherally inserted catheters (PICCs) has increased in all NHS trusts throughout the UK, for the facilitation of a wide range of intravenous therapies over the last 15 years (Simcock, 2008; Hitchcock, 2016; Oliver and Jones, 2016) and particularly in the case study author's organisation. It is now the vascular access device of choice in most clinical settings within the organisation. Ensuring the patient's PICC remains in situ for the duration of therapy with no complications is one of our main care goals. In order to achieve this, the organisation has a guideline that includes protecting the patient's skin to prevent MARSIs (Box 1).
A new addition to the toolbox for preventing MARSIs that could be considered is that of a sterile SMAR, which traditionally has not been used routinely for the removal of the semi-permeable dressing and securement device that is used to stabilise the PICC once in the correct position. The case studies presented here demonstrate the use of Appeel Sterile in intravenous therapy patients.
Case study 1
A 56-year-old female (‘Jennifer’) was admitted after being found collapsed at home. On admission Jennifer reported recent weight loss, but no other symptoms to explain her collapse. A CT scan was performed and the results showed a large, necrotic primary transverse colonic tumour, with local transmural invasion and fistulous communication with the terminal ileum. There was no evidence of colonic obstruction at this time, however, features of extramural venous invasion and borderline enlarged lymph nodes were noted. No definitive distant metastasis was identified. She weighed 34.8 kg with a body mass index of 13.6 kg/m2.
As Jennifer is at risk of obstruction due to a large fistulating colonic tumour, oral/enteral nutrition is not suitable for providing the required nutrition support. It was therefore agreed by the multidisciplinary team (MDT) to restrict oral intake to sips of free fluids for comfort and to provide parenteral nutrition for 14 days to improve the patient's nutritional status before surgery. A PICC was inserted to facilitate this. The PICC was secured with a securement device that has no adhesive associated with it and a semi-permeable dressing.
Due to her frailty, Jennifer's skin was assessed as being in a suboptimal condition at this time and at the time of dressing changes associated with her PICC the standard Trust guideline was followed. A sterile medical adhesive remover was used to help facilitate the atraumatic removal of the dressing. Appeel Sterile liquid sachet was the product variant selected. The liquid was applied according to the manufacturer's instructions and the dressing was removed with no discomfort to Jennifer; it was noted that there was no residual liquid on the skin after removal of the dressing and most importantly there were no signs of MARSI and the insertion site of the PICC was clean and dry. Jennifer had four dressing changes associated with her PICC and each time the liquid medical adhesive remover was used successfully with the same observations being noted.
Case study 2
A 36-year-old female (‘Aysha’) presented with a number of complex clinical issues further to gastric bypass surgery in Venezuela in 2003 with small bowel obstruction, which ultimately resulted in her having a small bowel resection. In the past 2 years she has had multiple admissions as a result of a number of electrolyte imbalances, including hypoalbuminaemia and anasarca with two distinct episodes of acute abdominal pain and hyperamylasaemia with evolving pancreatic changes on imaging and anastomotic ulcers seen endoscopically. Her ongoing care was particularly challenging when she was admitted as she has very poor vasculature and has had multiple vascular access devices over the past 2 years including midline catheters, central venous catheters and PICCs. Her current vascular access on her most recent admission was a quad lumen central venous catheter, which was inserted on admission, as she was not able to be cannulated peripherally by multiple members of the nursing and medical teams. A PICC was inserted on day 13 of her admission for ongoing intravenous therapy.
The PICC was managed according to Trust guidelines at the time and she was discharged after 37 days as an inpatient. Changing her dressing during her admission was often painful for Aysha, despite removing the dressing according to manufacturer's instructions.
As Aysha was to have weekly blood tests it was decided that her PICC should remain in situ and be reviewed regularly in the vascular access clinic. After 2 weeks at home there were clear signs of MARSI associated with the dressing change being noted. A decision was therefore made to use a sterile SMAR at the time of all future dressing changes—in this case the Appeel Sterile foam applicator. The Appeel Sterile foam applicator was gently applied to the outside of the dressing, including the edges and allowed to dry before removing the dressing as per local protocol. After this amendment to the patient's care plan, she reported there was now no pain associated with the removal of the dressing—which it was observed came off easily. However, it was also noted that the adhesive of the securement device was not affected by the adhesive removal, so an additional Appeel Sterile foam applicator was required for this.
Since adding the sterile SMAR to Aysha's dressing regime her skin condition has improved; moreover, with the enhanced management of her skin, signs of MARSI have also improved. Aysha has since required readmission; however, at the time of writing there are no signs of MARSI associated with a PICC that has been in situ for 11 weeks.
Conclusion
The skin is the largest and one of the most important organs of the body and as such it is essential that skin integrity is maintained to preserve normal body functions as much as possible at all times. Health professionals must endeavour to minimise any pain and trauma likely to be encountered by their patients through the use of a variety of medical products and devices that are designed to adhere to the skin.
The case studies presented here demonstrated to those using Appeel Sterile that it is an important addition to the SMAR product range. The product is clinically indicated for a range of patients whose skin is at risk of being easily compromised for a variety of reasons, as the skin is one of the body's major barriers to bacteria and secondary infection. It can be used on both intact and broken skin; on infants in incubators; around central lines and for the safe removal of a range of other medical devices and connections to a patient's skin.