Have you been challenged by skin breakdown that occurs in the gluteal cleft of some patients? WOCNs are highly skilled and trained at identifying moisture-related skin breakdown in this area. However, obese patients where their buttock tissue was so firm that a caregiver could not separate the gluteal cleft for skin integrity evaluation or cleansing and drying. As a result damaging pressure ulcers developed. I expect staff nurses and other WOCNs have probably experienced the same patient situation at some time.
Moisture-related skin breakdown lesions are usually characterized by superficial skin loss and irregular edges and are recommended to be classified as MASD (moisture associated skin damage). Prolonged exposure of the skin to high levels of moisture can result in acute maceration. What happens is the outer layer of epidermal cells becomes overhydrated, causing swelling, and the bonds between the skin tissue planes weaken. This alters the skin’s ability to withstand damage, particularly that caused by friction. The outer layer of the epidermis can be stripped away, exposing the underlying dermis. This causes pain and increases the risk of bleeding and secondary infection from bacterial and/or fungal organisms.
Experts agreed that linear lesions, also sometimes assessed as fissures, in the intergluteal cleft are caused by moisture, with or without a friction component, and should be classified as intertriginous (between skin folds) dermatitis (inflammation of the skin).
As opposed to moisture damaged skin, pressure ulcers are ischemic injuries to the skin and underlying soft tissue that can result in full-thickness tissue damage, and are usually located over bony prominences or sometimes found under medical devices. Pressure and shear factors cause compression of the circulation, distortion of tissue and blood vessels, and reperfusion tissue injury that result in the full thickness skin damage. This was most likely the primary cause of what happened in the patients I observed, along with a trapped moisture component.
In order to accurately classify and document the cause(s) of skin breakdown, it is essential to understand the primary mechanism of injury. An accurate history from the patient or caregiver and comprehensive skin assessment are key. Often a skin lesion may be caused by both pressure and moisture, and it is important to document the most significant cause if possible. Of course, all causative factors need to be identified to establish an effective treatment and protection plan of care.
Though we don’t have all of the answers at present, the goal greater awareness of the possibility for a significant pressure ulcer occurrence in the at-risk patient with a firm inter-gluteal cleft we can be more pro-active in prevention. My thoughts include making sure gluteal cleft skin is carefully examined on a regular basis, particularly in overweight and obese patients. Have a flashlight and another caregiver available to help with skin assessment in this difficult place. Palpate the area to assess for increased pain
or bogginess if unable to separate the tissue for a visual exam. In dark-skinned individuals be particularly alert for signs of maceration, pain, or increased darkening of the skin over this bony prominence.
Establish interventions to manage moisture. Initiate the proper pressure redistribution support surface for patients based on their individual need. Remember chair cushions will be needed for these compromised individuals when they are out of bed. Notify the WOC nurse and doctor with all skincare issues and concerns in the at-risk patients with difficult to assess gluteal cleft skin. Document assessments, impediments to proper assessment, and prevention and treatment interventions.
Reference: “Challenges in Classification of Gluteal Cleft and Buttock Wonds: Consensus Session Reports”. Mary Mahoney, Barbara Rozenboom, Dorothy Doughty . JWOCN May/June 2013. 239-245.