Skin Problems and Irritations

Skin problems can be caused by a number of reasons after an amputation as the residual limb (stump) sustains many stresses. The skin and tissues of the residual limb were not created to bear weight or to have uneven pressures and friction. These additional pressures on the residual limb create skin problems which need to be carefully managed to avoid more serious problems developing. The symptoms can range from mild irritations to severe problems. We hope that this section will help you to know what to look for and where possible how to avoid such issues. It is important that you consult your rehabilitation doctor for appropriate treatment.

The skin we are in

Skin is (dictionary definition) a resilient, elastic living surface, which is self healing. What is remarkable is that weaker areas prone to injury are strengthened through thickening. The tougher skin on the elbows and knees are examples of this. The skin will thicken or form calluses in response to additional stresses and strains. You may notice this hardening of the skin in areas where the artificial limb causes pressure and friction.

The skin also forms part of the mechanism which regulates temperature by producing perspiration, which evaporates into the air to help keep the body cool.

We face two main issues with regards to perspiration. Firstly an individual without one or both lower limbs uses more energy to carry out daily activities. This ranges from the lowest -  a single below knee amputee and considerably higher for a double above knee amputee. This increased energy exertion results in an increase in the body’s temperature and logically more perspiration to cool the body down. The surface area of the residual limb is smaller and therefore the bodies cooling mechanism is less efficient. The residual limb can get wet with perspiration in the summer or through activity, but because it is encased in a socket the air can not reach it to dry the perspiration, which would normally evaporate on the surface of the skin.

Stump and socket hygiene

It is important to clean the residual limb (stump), the sleeve (liner) and stump socks on a daily basis and or after activity. The residual limb is more prone to skin problems because is has a smaller surface area, making the bodies natural cooling mechanism less efficient. Prosthetic sockets, liners, sleeves and socks trap the perspiration against the skin of the stump due to a lack of ventilation, preventing the air from circulating and drying the perspiration. This warm moist environment is an excellent breeding ground for infection and therefore poor hygiene may result in bacterial and fungal infections, eczema and cysts. If not treated properly minor irritations and infections can lead to more serious problems, which will prevent you from being able to wear your artificial limb until the condition has heeled, which can be extremely frustrating.

It is worth noting that after years of wearing an artificial limb the skin and tissue on the residual limb may start to show the effects, it is therefore important to take care of your residual limb.

What causes skin disorders?

The causes of skin problems on the residual limb are numerous. Prevention is always better than cure, but sometimes, no matter how hard you try to prevent sores and abrasions, the pressure of the socket against the residual limb causes trauma to the skin and tissue. Friction of the socket or liner against the skin leads to abrasions and the socket materials can lead to allergic reactions.

Excessive perspiration

Perspiration is the mechanism through which the body controls temperature. When the weather is hot or we exercise heat is generated. Due to the increased energy required to carry out daily activities we are more prone to excessive perspiration. This is a common problem among artificial limb wearers, particularly in the summer and individuals who are active.

Prosthetic sockets, liners, sleeves and socks trap the perspiration against the skin of the stump due to a lack of ventilation, preventing the air from circulating and drying the perspiration. This warm moist environment is an excellent breeding ground for infection

As perspiration builds up it can lead to a separation of the liner (sleeve) or socket from the skin which can result in the residual limb moving around in the socket, also called “pistoning”. This pistoning can result in chaffing and skin abrasions.

Aerating the socket is of benefit, but doesn’t always solve the problem. Antiperspirants such as Driclor and Secret Platinum can offer some relief. If you do suffer from excessive sweating you might want to avoid a suction socket, which requires a vacuum to keep it secure. In a few cases patients have been given Botox injections to help relieve the sweating. Another option is to clean the liner (sleeve) and socket, not the skin with antibacterial wipes or liquid, but you must ensure the socket or sleeve is dry before donning it.

Bacteria

Bacteria are minute organisms which are all around us, including on the surface of the skin. Some bacteria can cause infection given the right breeding environment. Normally the skin will prevent these bacteria causing infection as perspiration would be evaporated by the air circulating around us and through the release of fatty acids from the glands on the surface of the skin. In the enclosed socket environment this evaporation is prevented. The skin on the residual limb when wet is encased in a salty solution for long periods of time, which can develop a positive charge attracting more bacteria than it would otherwise. Good hygiene becomes even more important in these circumstances because the risk of infection is increased.

Common Skin Problems

Skin problems can result from a collection of fluids inside the stump which can cause congestion. This could have a medical cause and it is advisable for you to seek medical help from your rehabilitation consultant to control and, where possible, treat the problem.

You may also develop contact dermatitis from the socket material, which can cause intense itching or burning of the skin when using a prosthesis. The socket can sometimes contain materials which may cause an allergic reaction, such as nickel, chromates and adhesives. The cause of this type of irritation can be identified by patch testing. The material that your socket is made from can then be altered accordingly.

Abrasions

Abrasions are the most common problem which can occur intermittently or frequently depending on your other medical conditions and your level of activity.

Oedema

The symptoms of oedema are swollen skin, drying and roughening at the end (base) of the stump and or a red-brown pigmentation. This can often be prevented through compression using a special sock or elastic bandage. Oedema can develop into more serious problems if not addressed; a doctor must always be consulted if you think you might be suffering from this.

Contact Dermatitis

This is caused by an irritant which could either be related to the socket or liner materials or from external causes, such as soap, a cleaning agent, washing powder, lubricants or ointments used on the skin. You can normally isolate the cause by changing the products you use. Once the cause is discovered the dermatitis will normally be resolved. Do speak to your Prosthetists and Rehab consultant because they can change the materials used in socket or liner, if they are made aware of the problem.

Epidermoid Cysts

Cysts can result from the continuous friction from the socket and will often appear in the groin area for above knee (transfermoral) amputees and at the back of the knee for below knee (transtibial) amputees. They can occur after months or years of wearing an artificial limb.

They normally start as small bumps or nodules which disappear when the artificial limb is removed. The constant friction and rubbing of the artificial limb can make them worse with cysts becoming larger and more numerous. Cysts should always be treated by a doctor, as with immediate attention, infections which can result in abscesses can be avoided. This friction can be reduced through adjusting the socket and or using a softer liner (sleeve).

Folliculitis

This is a bacterial infection of a hair follicle which results in small itchy areas. If not treated, these can develop into boils where red, painful nodules rise to the surface of the skin. Anti-bacterial soaps may cut down the bacteria which causes folliculitis. It is possible that shaving the residual limb can increase the risk of folliculitis.

Fungal infections

Also caused by the moist, wet conditions inside the socket. Specific creams and powders will be required to clear up the infection.

Eczema

Dry, scaly skin which becomes moist. The cause needs to be identified or the condition will recur.

Adherent scars

This is where scar tissue becomes attached to the underlying layer of skin. It is possible to prevent this happening by manipulation of the scar through massage. Surgical revision to free the scar is an option. Do consult your rehabilitation consultant to discuss options if this is causing you discomfort.

Boils, Chronis Ulcers, Hair follicle infections

These can result from poor hygiene, bacterial infections, fungal infections or from circulation problems. They can be aggravated by poor circulation, diabetes, ill fitting sockets etc. They can become chronic if not treated immediately.