Tissue Viability – wound prevention and healing

Referral

All referrals into Tissue Viability will be triaged by a Tissue Viability Nurse and the referrer contacted within one working day.  Please note that we work Monday to Friday and do not cover bank holidays.

Any referrals deemed to be urgent will be offered an appointment within two working days of triage.

Assessment/appointment

Patients who are invited to attend one of our leg ulcer clinics will be sent a letter prior to their appointment which will provide information about what to expect.

All of our clinics are in hight demand, so we ask that you inform us as soon as possible if you are unable to attend your appointment.  Please use the contact number listed above.

After your appointment

If our Tissue Viability Team feel that your healing will best be supported by some self-care, you or your carer/family member will be given advice leaflets appropriate to your ongoing care at your appointment – this information is also in our self-care section below. You will also be supported until you or your carers are confident in your treatment.

Our team will review you at least every four weeks until you are healed. This could be to apply a dressing or compression hosiery/wraps. You will be provided will contact details for support outside of Tissue Viability working hours if needed.

What is the Well Leg Service?

The Well Leg Service helps you keep your legs healthy after a leg ulcer has healed. You will be referred to the service by your district nurse or our Tissue Viability team.

The Well Leg Service offers checks, advice, and support to help prevent ulcers coming back. You may be seen in a Well Leg clinic or at home if you are housebound, depending on your needs.

At your appointment we:

• check your legs and skin
• make sure your compression stockings or garments fit properly and that you are happy with them
• talk to you about looking after your legs at home
• give advice on skin care, movement and exercise
• answer any questions or concerns you may have

Our aim is to help you stay comfortable, independent, and confident. Occasionally we call you back for a new assessment of your legs including a vascular assessment, to ensure compression therapy is still the best treatment for you.

If needed, we can refer you to other services such as:
• Lymphoedema services
• Vascular services
• Dermatology (skin) services

How many appointments will I have?

Most people need 2–3 appointments, depending on their needs.
Your care will be personalised and reviewed by our nurses. Most importantly it you gives you direct contact with a professional who can best support you should any concerns arise.

Why is the Well Leg Service important?

Regular checks, good skin care and the right compression can greatly reduce the chance of a leg ulcer returning. The Well Leg Service helps you stay independent, comfortable, and confident in looking after your legs.

Patients, carers and family members can find useful information about pressure ulcers – what they are and how to prevent them on our dedicated pressure ulcers – guide for patients and carers page.

Care homes and other professionals seeking information and support for patients, residents or clients with pressure ulcers, should please see our ‘for professionals‘ tab.

Patients, carers and family members can find useful information about leg ulcers – what they are, symptoms and treatment on our leg ulcers – guide for patients and carers page.

Care homes and other professionals seeking information and support for patients, residents or clients with leg ulcers, should please see our ‘for professionals‘ tab.

Patients, carers and family members can find useful information about wounds and wound care on our Looking after your wound page.

Care homes and other professionals seeking information and support for patients, residents or clients with wounds, should please see our ‘for professionals‘ tab.

Emollients are moisturising treatments applied directly to the skin to soothe and hydrate it. They cover the skin with a protective film to trap in moisture.

Emollients are often used to help manage dry, itchy or scaly skin conditions such as eczema, psoriasis, Varicose eczema  – NHS and ichthyosis.

They help prevent patches of inflammation and flare-ups of these conditions.

Types of emollients

Lotions – good for hairy or damaged areas of skin (such as weeping eczema – where pus is seeping out of damaged areas of skin). This is because lotions are thin and spread easily, but they’re not very moisturising.

Sprays – good for hard-to-reach areas and sore or infected skin that should not be touched and are absorbed quickly.

Creams – good for daytime use as they’re not very greasy and are absorbed quickly.

Ointments – good for very dry, thickened skin and night-time use as they’re greasy, thick and very moisturising. Ointments are usually free of preservatives so are suitable for sensitive skin but should not be used on weeping eczema.

Leave-on products – there are lots of different types of leave-on emollient that can be put directly on the skin. Some create a protective barrier over the skin to lock in moisture. Some have added ingredients to reduce itching or prevent infection. Your healthcare professional will talk to you about which type of emollient will work best for your skin condition. You may have to try a few different emollients to find the best one for you or your child’s skin.Many of these leave-on products can also be used to wash with.

Soap substitutes – everyday soaps, shampoos and shower gels usually dry out the skin and can make skin conditions like eczema worse. It’s recommended to use leave-on emollients as a soap substitute if you have dry or itchy skin. Emollient soap substitutes that are used instead of normal soap in the bath or shower are not usually available on the NHS.

How to get emollients

You can buy emollients from a pharmacy without a prescription. If the skin condition is severe, talk to a GP, nurse or health visitor, as you may need a stronger treatment.

If you or your children need to use an emollient regularly, it’s a good idea to keep some in small pots or tubes at home, school or work.

How to use emollient lotions, sprays, creams and ointments

Emollient lotions, sprays, creams and ointments should be applied directly to the skin.They should be smoothed, not rubbed, into the skin gently in the same direction that your hair grows. This helps prevent hair follicles getting blocked.

They can be used to replace lost moisture whenever your skin feels dry or tight. They’re very safe and you cannot overuse them.

You may need to experiment with different emollients or try a combination. For example, you may decide to use a cream during the day and an ointment at night.

How to wash with emollients

Mix a small amount (around teaspoonful) of leave-on emollient or soap substitute in the palm of your hand with a little warm water and spread it over damp or dry skin.

Rinse and pat the skin dry, being careful not to rub it.

You can use leave-on emollients or soap substitutes for handwashing, showering or in the bath. They do not foam like normal soap but are just as effective at cleaning the skin.

If your skin stings after using an emollient wash product and does not settle after rinsing, ask a pharmacist to recommend a different product.

Using emollients with other skin treatments

If you’re using a steroid cream or another treatment for your skin condition, wait 20 to 30 minutes between using an emollient and using the other treatment. Ask a doctor which one to use first.

This avoids diluting the effect of the treatment and spreading it to areas of skin that do not need it.

When to apply emollients

Emollients can be applied as often as you like to keep the skin well moisturised and in good condition. Ideally, this should be done at least 3 or 4 times a day.

It’s especially important to regularly apply an emollient to your hands and face, as they’re exposed to the elements more than any other part of your body.

Certain activities, such as gardening, can irritate the skin. It may help to apply an emollient before doing these.

It may help to apply an emollient before and after swimming. Leave enough time for it to be absorbed into your skin before you swim.

It’s a good idea to protect babies’ hands and cheeks with an emollient before mealtimes to stop them getting sore from food and drink.

Emollients are best applied after washing your hands, taking a bath or showering because this is when the skin most needs moisture.

The emollient should be applied as soon as you have patted your skin dry to make sure it’s properly absorbed.

Skin reactions

Emollients can sometimes cause a skin reaction, such as:

• an overheating, burning sensation or stinging that does not settle after a few days of treatment – usually caused by a reaction to a certain ingredient in the emollient
• blocked or inflamed hair follicles (folliculitis) that may cause boils
• rashes on the face that can aggravate acne

If you experience any of these symptoms, talk to a GP, nurse or pharmacist.

Safety advice when using emollients

Always keep emollients away from fire, flames and cigarettes when using all types of emollients (both paraffin-based and paraffin-free). Dressings, clothing and bedding that have been in contact with an emollient can easily catch fire. Washing fabrics at high temperatures may reduce the build-up of an emollient but does not remove it completely. Please read this fire safety leaflet:

Emollient-Fire-Hazard-Leaflet-09.23-FINAL.pdf

Risk of infections

Use a clean spoon or spatula to remove emollients from a pot or tub. This reduces the risk of infections from contaminated pots.

Risk of slipping

Be careful not to slip when using emollients in a bath or shower, or on a tiled floor. Protect the floor with a non-slip mat, towel or sheet. Wear protective gloves, wash your bath or shower afterwards with hot water and washing-up liquid, then dry with a kitchen towel.

Skin irritation from aqueous cream

Aqueous cream is no longer recommended as an emollient. It contains an ingredient called sodium lauryl sulphate (SLS) which can cause skin irritation such as burning, stinging, itching and redness. Some people still find it helpful as a soap substitute.

Topical Steroids

What are topical steroids?

‘Topical’ means applied directly to the skin. ‘Steroids’ are synthetically made hormones. Topical steroids are used in the treatment of many skin conditions.

How do topical steroids work?

Topical steroids help to reduce inflammation, speed up the healing of the skin, and help to make your skin less red, hot, itchy, and sore.

Topical steroids are not a cure for your skin condition but should help bring your skin condition under control and are available as a cream, lotion, foam, gel, and shampoo.

Your Health Care Professional/GP/Consultant will advise which topical steroid is appropriate.

How do I apply my topical steroid?

• You may be given more than one topical steroid to treat different areas of the body.

• Make sure that you understand which topical steroid to use and where on your body to use it.

• If you are unsure, discuss with your pharmacist, consultant or nurse.

• Follow the application instructions carefully and use for the required length of time.

• Wash your hands before and after applying your topical steroid.

• Leave a gap of 30 minutes between applying your topical steroid and your moisturiser. This is to avoid diluting the topical steroid with the moisturiser and potentially spreading it to areas that it is not needed.

• Apply the steroid using the Fingertip Unit (FTU). FTU is the amount of topical steroid that just covers the end of an adult finger from the tip to the crease of the first joint.

• One FTU is enough to cover an area the size of two adult hands with the fingers together.

The instructions can vary between patients depending on age and where on the body requires treatment, so please ask if you are unsure.

Are topical steroids safe to use?

Topical steroids are safe and effective when used as directed and in combination with good skincare management. Side effects can occur and are normally related to the potency of the topical steroid, where it is being used, the condition of the skin on which it is being used and the age of the person using the topical steroid.

Side effects can be reduced if you follow the application instructions carefully. Fear of side effects can cause your skin condition to be under-treated. Stopping treatment too soon or not using the topical steroid at all will be detrimental to the overall management of your skin condition.

Pregnant women should consult their doctor regarding the continued use of their usual topical steroid.

Allergy to the topical steroid can occur but is rare. Please inform your doctor if your skin condition gets worse whilst using the topical steroid.

Referrals

Referral criteria

Tissue viability referral form

Pressure ulcer care

Pressure ulcer identification, prevention and care – guide for professionals

Leg ulcer care

Leg ulcer referral form

Prescribing for leg ulcers

Compression Therapy for leg ulcers

Lower limb pathway

Wound care

Wound management guidelines and formulary

Skin tears

Skin tear pathway

National Wound Care Strategy Programme leaflet on ‘Looking after a skin tear’

Wounds

Wound care pathway

Wound debridement pathway

National Wound Care Strategy Programme leaflet on ‘Looking after your wound’

Self-care for wounds patient diary

Wound Care Education for Health and Care

Moisture damage

Prevention and management of moisture associated skin damage pathway