Skin Integrity
The physiologic changes that take place after an SCI are varied and have the potential to impact almost every body system. In their “Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury,” Houghton and Campbell (2013) outlined a number of such changes with a direct impact on the skin. These include, but are not limited to, impaired autonomic regulation of subcutaneous blood flow and skin moisture levels, reduced skin temperature reactivity, reduced immune response, and changes in connective tissue composition (including changes in extracellular matrix formation and collagen fiber type proportion). Long-term impacts of SCI may also include alterations in metabolic function, muscle mass, and body weight, all of which can directly or indirectly affect skin integrity.
Information about skin complications in SCI is derived largely from work in adults. The scope of skin challenges in pediatric SCI and effective treatment strategies to address them are less well defined. The term “pressure injury” is used to encompass the spectrum of potential damage to the skin and soft tissues as a result of the application of pressure (ranging from subclinical changes prior to ulceration to deep tissue injuries). Although this is the most common skin complication of SCI, there are other potential skin-related comorbidities that can arise in the context of pediatric SCD, including self-inflicted wounds and latex allergy. Younger age at the time of injury and duration of injury are both documented risk factors for skin complications in adults with SCI (Gélis et al. 2009), and therefore, the risk of pressure injuries, in particular, may increase as children age with their condition.
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Author, Year Country Study Design Sample Size |
Study Characteristics |
Results |
| Pressure Injuries | ||
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(McCaskey et al., 2011) USA Case Report & General Review |
Population: 5 yr female with C3-C4 complete SCI. Problem: Pressure Ulcers |
1. Article reviews this case report and then provides an excellent general review on pressure ulcers risk factors in pediatrics with considerations for care. |
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(Vogel et al., 2002b) Part I USA Observational N=216 |
Population: Age at injury: 14.1±4.0 yr; Age at interview: 28.6±3.4 yr; Time since injury: 14.2±4.6 yr; Gender: males=150, females=66; Level of injury: tetraplegia=123, paraplegia=93. Severity of injury: C1-4 ABC=41, C5-8 ABC=67, T1-S5 ABC=82, tetra/para D=26. Intervention: None. Survey. Outcome Measures: Prevalence of pressure ulcerations (PU). |
2. PU within the previous 3 yr were experienced by 44% (n=94), of which the mean number of ulcers per subject was 2.5, with 53% reporting 1 ulcer, 17% experiencing 2 ulcers, and 30% reporting > 2 ulcers. 3. Among men, 48% reported PU, in contrast to 33% of the women (p=0.045). 4. PU occurred more commonly in non-white than in white subjects (p=0.04). 5. Individuals who had sports-related SCI were significantly less likely to sustain PU compared with participants with non-sports-related SCI (p=0.033). 6. Those with violence-related SCI were not at greater risk of developing PU compared with those with nonviolent SCI. 7. PU were significantly associated with more severe neurologic impairment as measured either by ASIA Motor scores or by injury severity groupings. 8. Mean ASIA Motor score was significantly lower in subjects with PU compared with those without ulcers (p=0.006); however, PU were not more common in those with tetraplegia compared with those with paraplegia. 9. Individuals with PU demonstrated significantly more functional limitation as measured by the FIM. Both the total (p=0.002) and the motor FIM scores (p=0.002) were significantly lower in subjects with PU. 10. PU were not significantly associated with either bladder or bowel incontinence. 11. There was no difference in PU between those with and without bowel incontinence. 12. Subjects who smoked cigarettes or marijuana regularly demonstrated a significantly higher prevalence of PU p=0.01). 13. PU less commonly affected those who drank alcohol at least monthly compared with those who denied drinking alcohol (p=0.031). 14. Development of PU was significantly associated with spasticity (p=0.009). 15. PU were not statistically associated with heterotopic ossification, hip subluxation, hip contractures, or scoliosis. |
| Traumatic Skin Lesions | ||
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(Almeida et al., 2009) Brazil Case Report N=1
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Population: Age: 19 mo; Gender: 1 male; Injury etiology: Transverse Myelitis with atrophy C3-T1. Problem: Self-injury (biting) to the mouth and bruxism. Intervention: Triamcinolone and 3mm thick silicone mouth guard in the maxillary arch. |
1. One year post intervention, the patient’s lips had completely healed and there was no tooth mobility. |
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(Colville & Mok, 2003) United Kingdom Case Reports N=2 |
Case Report 1: Population: Age: 6 yr; Injury etiology: traumatic, high-level SCI from shrapnel. Problem: Self-injury (biting) to the tongue and lips. Intervention: Psychologist involvement, psychosocial meetings, play therapy, reassurance, discharge planning.
Case Report 2: Population: Age: 12 yr; Injury etiology: SCI requiring spinal fusion and halo traction. Problem: Self-injury (biting) to the lips, spitting at nurses, anger, fear of death. Intervention: Psychologist and interpreter involvement. |
Case Report 1: 1. Behaviour completely abated.
Case Report 2: 2. Lip-biting behaviour diminished but child continued to be difficult to manage and did not develop any attachments with ward staff prior to discharge.
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(Vogel & Anderson, 2002) USA Case Reports N=4 |
Case Report 1: Population: Age: 6 yr; Gender: Male; Injury etiology: SCI; Level of injury: complete left C7, right T1.Problem: Picking/scratching nipples. Pt. described them as being “irritated.” Intervention: Carbamazepine (10mg/mg/day).
Case Report 2: Population: Age: 11 mo; Gender: Male; Injury etiology: SCI at birth; Level of injury: C5. Problem: Biting of the dorsum of both hands and thumb nails. Intervention: Gloves (ages 3-5 yr), 10-15 mg/kg/day Carbamazepine (ages 5-8 yr), 15 mg/kg/day Gabapentin (age 9yr).
Case Report 3: Population: Age: 13 yr; Gender: Female; Injury etiology: Transverse Myelitis; Level of injury: left C8, right T1. Problem: Biting to arms and fingers. Pt. attributed this to anxiety and “tingling” to the area. Intervention: Counseling initiated followed by carbamazepine at age 14 yr (100 mg, three times daily), and then gabapentin (300 mg, three times daily).
Case Report 4: Population: Age: 17 yr; Gender: Male; Injury etiology: SCI; Level of injury: C5. Problem: Bilateral hand and terminal digit biting. Pt. reported the biting helped to move his hands. Intervention: Education, occupational therapy, gloves. |
Case Report 1: 1. Significant improvement in in self-injurious behaviour, relapsing only when the medication was stopped/ started (between age 6 and 14 yr).
Case Report 2: 2. Resolution of symptoms with behaviour only returning when medication was stopped/restarted.
Case Report 3: 3. Resolution of symptoms with behaviour only returning when medication was stopped/restarted.
Case Report 4: 4. Resolution of symptoms within one year without reoccurring. |
| Latex Allergy | ||
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(Vogel et al., 2002b) Part I USA Observational N=216 |
Population: Age at injury: 14.1±4.0 yr; Age at interview: 28.6±3.4 yr; Time since injury: 14.2±4.6 yr; Gender: males=150, females=66; Level of injury: tetraplegia=123, paraplegia=93. Severity of injury: C1-4 ABC=41, C5-8 ABC=67, T1-S5 ABC=82, tetra/para D=26. Intervention: None. Survey. Outcome Measures: Prevalence of PU (PU), hospitalizations, latex allergy, medical conditions, health insurance |
1. Eighteen individuals reported allergy to latex. 2. Latex allergy was significantly more common in women (16%) than in men (6%) (p=0.017). 3. Latex allergy was reported by 33% of those with SCI related to medical or surgical conditions, in contrast to a 6% prevalence in the other etiology groupings (p<0.001). 4. Latex allergy was also significantly associated with higher ASIA Motor scores (p=0.003). 5. Latex allergy was more common in those with normal bladder control than those on intermittent catheterization programs or those with indwelling catheters (p=0.005). |
Discussion
Pressure injuries are the most common skin-related complication of SCI. In adults, skin conditions are a leading cause of unplanned hospitalization among those with SCI, and the associated costs to the health care system are substantial (DeVivo & Vogel 2004). In a retrospective survey of 216 individuals with SCI sustained in childhood, 43% of respondents reported having experienced at least one pressure ulcer within the last three years (Vogel et al. 2002b), with almost half of those (47%) indicating that they had experienced two or more pressure ulcers within that time. Factors that were associated with increased rates of ulceration included: male gender, non-white race, non-sports-related injury, more severe motor impairment (based on American Spinal Injury Association Impairment Scale motor scores), lower total and motor subscale Functional Independence Measure scores, smoking, and presence of spasticity. Many of these findings are in keeping with the adult literature (Eslami et al. 2012; Gélis et al. 2009). The impact of race on pressure injury risk in adults with SCI has been postulated to relate to health care disparities (Saunders et al. 2015), which were not specifically studied in the survey by Vogel et al. (2002b). In the study by Vogel et al. (2002b), bowel/bladder incontinence, heterotopic ossification, presence of hip contractures or scoliosis, and tetra versus paraplegic status did not significantly relate to the rate of pressure ulcers. The absence of a link between incontinence and pressure injury is particularly notable as it is frequently cited as a risk factor for pressure injury in adults with SCI (Wilczweski et al. 2012). Given the limitations of this single, survey-based retrospective study of pressure injuries in pediatric SCI, it’s unclear if these factors confer less risk in a pediatric population or if the risk associated with these conditions simply hasn’t yet been adequately captured by the available literature. It is important to note as well that previous pressure injury has been found to be one of the most consistent risk factors for pressure injury in the adult population (Gélis et al. 2009; Verschueren et al. 2011). That risk has been suggested for people with pediatric SCI by the high frequency of recurrent ulcerations reported in the last 3 years (Vogel et al. 2002b).
Traumatic self-inflicted skin lesions have been reported rarely in both children and adults with SCI (Almeida et al. 2009; Colville & Mok 2003; Frost et al. 2008; Vogel & Anderson 2002). In the few pediatric cases presented above, lesions were generally confined to fingers and lips. Cases were described as being linked to one of several factors including dysesthesia, pain, or psychological triggers. Accordingly, interventions included the use of physical barriers (mouth guards or gloves), psychological support, or anti-epileptic medications (specifically carbamazepine or gabapentin). Responses to interventions varied, but patients largely improved over time, with relapses occurring in some instances when the medications were stopped.
Latex allergy affects approximately 4.3% of the general population (Wu et al. 2016). It occurs more frequently in children with spinal dysraphism and has been attributed to repeated exposures to natural rubber latex. Whether or not this allergy is more common in people with SCI is undetermined, but there may be an association with long-term catheter use (Monasterio et al. 2000). In the retrospective survey by Vogel et al. in 2002, information about latex allergy in individuals with pediatric-onset SCI was collected. Approximately 8% of the respondents reported a latex allergy. It was more commonly reported by females but did not appear to be associated with catheter use.
Overall, the literature regarding skin complications in people with pediatric-onset SCI is fairly limited. As a result, though some associations can be identified, it’s difficult to draw specific conclusions. Pressure injuries are the most common and most concerning skin-related complications of pediatric SCI and ongoing efforts to understand contributing factors and reduce rates of pressure injury recurrence are warranted.
