Wound Maceration: The Ins and Outs for Clinicians

In the past, medical professionals touted that a dry wound environment was the most effective environment for wound healing. Today, though, we recognize just how beneficial and important moisture is to the healing process. However, even with that insight, it’s important to find balance between wet and dry, as too much of a good thing can hinder a wound’s ability to heal correctly.  

Wound maceration is something that wound care specialists should aim to avoid, but doing so means being informed about it. Therefore, we will explore what wound maceration is, its impact on the healing process, how to prevent it, and more. 

What Is Macerated Skin? 

According to the National Institutes of Health, in medicine, the term maceration refers to the “softening and breaking down of skin resulting from prolonged exposure to moisture.” It causes the stratum corneum, which is the outermost layer of the epidermis and the skin’s protective barrier, to swell from excessive moisture exposure. The epidermal layer experiences decreased tensile strength as a result, making one’s skin more susceptible to tearing. 

Admittedly, skin maceration is a fairly common condition, but it’s essential to understand that not all maceration is the same. The sources of the moisture, the patient’s health, and other factors all impact whether and what type of treatment is necessary. 

Skin Maceration: From Mild Cases to Concerning Occurrences 

Macerated skin often has a whitish, almost soggy appearance, but might show up as more grayish-white in patients with darker skin tones. Despite its unique features, like the wrinkled skin and spongy texture, it usually does not require medical treatment.  

In fact, everyone has experienced skin maceration to some extent, as it can occur from activities like taking a bath, showering, swimming, or wearing wet clothing for an extended period. Yet, as you’ve probably experienced in those situations, it’s very rare for anyone to need medical intervention for skin maceration. Usually, once the skin has had a chance to dry thoroughly, the issue resolves itself. However, this straightforward outcome isn’t the case for every skin maceration case you come across.  

Wound maceration, as opposed to a skin maceration, is a cause for alarm, as it indicates that the skin surrounding or within the wound has sustained damage from prolonged exposure to moisture. Treatment is vital in this scenario, as forgoing it could completely halt the healing process, lead to infection, and cause pain. Because of the risk to the healing process, intervention is necessary, as this occurrence could have a negative impact on a patient’s overall health and quality of life.

Maceration vs. Moisture-Associated Skin Damage 

Often, when wound care specialists discuss macerated skin, the term, moisture-associated skin damage (MASD) also comes up. MASD is an umbrella term that describes the visible skin damage caused by prolonged or continuous exposure to different sources of moisture and their contents. It’s distinguished from skin maceration by skin inflammation that occurs with or without erosion or secondary cutaneous infection. 

At first glance, one might think that maceration and MASD are the same, but there are differences. Maceration is a key symptom and component of MASD, but the two conditions are not the same. Think of maceration as the initial stage of skin damage caused by overhydration. The excess moisture can soften and weaken the skin, making it more susceptible to irritants and friction. At this stage, if it’s able to dry out properly, the patient would likely heal just fine. 

However, if the skin is repeatedly exposed to moisture and is also in the presence of mechanical, chemical, and/or biological agents, the situation could progress to moisture-associated skin damage. 

The Different Types of MASD

There are numerous moisture sources that can contribute to MASD, including respiratory or digestive secretions, saliva, mucus, or exudate. Depending on the source, it’ll be classified under one of the four main types of skin damage, which are: 

• Intertriginous dermatitis
• Incontinence-associated dermatitis
• Periwound moisture-associated dermatitis
• Peristomal moisture-associated dermatitis

Prevention protocols and treatment methods vary for each type of skin damage. 

How to Properly Identify Wound Maceration

As a practitioner, it’s crucial that you can distinguish between well-hydrated skin and overhydrated skin that’s experiencing maceration. 

An occasional mistake that clinicians make with wounds is assuming that the newly formed epithelial tissue present over granulation tissue is macerated skin. The new tissue usually has a thin texture and either a light pink or pearly white appearance. This is very similar to macerated skin, which may also have a whitish color. It’s vital that practitioners carefully examine the patient and confirm what kind of tissue it is before beginning treatment, as you don’t want to remove what’s considered a healthy wound response. 

In cases where a patient has a macerated chronic wound, such as a pressure injury, you may find a substantial amount of exudate at  the affected area. There are certain visual characteristics commonly associated with maceration, such as the skin appearing white, rough-looking, swollen, and/or wrinkly like a prune. It might also be accompanied by necrotic tissue and/or erythema. 

Sometimes, the location of macerated skin leads clinicians to believe it could be something else. When it’s at the periwound area, it’s not always apparent because the skin’s color may change, from pale to red. 

Common Causes of Macerated Skin 

Now that we understand what skin maceration is, it’s time to explore its potential causes. 

Fecal and Urinary Incontinence 

If a patient suffers from involuntary leakage of urine or feces, it’s highly likely that they may develop maceration. The presence of either substance can increase one’s pH levels and boost the skin’s permeability, thus weakening the skin’s natural protective barrier. Research shows that approximately 13 million people in the United States suffer from urinary incontinence alone, and nearly 1 in 10 adults are affected by fecal incontinence. Both are more common in women, older adults, and those who are bedridden. 

The areas most affected by incontinence are the hips, genitals, and buttocks, as well as the skin between the pelvis and rectum. Clinicians should be cautious if a patient has a wound at one of these locations. 

Certain Health Conditions

Conditions, such as hyperhidrosis, also known as excessive sweating, can lead to skin maceration. It affects nearly 5% of Americans and increases one’s risk of other skin ailments, such as athlete’s foot or pitted keratolysis. Research finds that individuals with hyperhidrosis have a 30% greater risk of skin infections than those without. 

Obesity can also cause macerated skin due to mechanical friction, When this happens, it’s referred to as intertrigo. Patients with obesity have a greater surface area of body folds, thus creating more opportunities for friction to occur. In addition, they’re more likely to sweat heavily into these folds because increased subcutaneous fat has an insulating effect. It’s easy for the skin folds to retain moisture, so without proper care, it can become red and macerated from weeping. Plus, individuals with a body mass index (BMI) greater than 25 are predisposed to a Candida species fungal superinfection. 

Some Wound Management Interventions

Interventions like occlusive therapy use wound exudate to create a moist wound environment that encourages autolytic debridement and promotes wound healing. However, if the films are left on too long, the excess moisture could lead to skin maceration. As important as it is to clean the skin, especially around a wound, doing so too frequently or with too much force can cause maceration as well. 

Excessive Exudate Production

Exudate is a vital part of wound healing, aiding with the delivery of nutrients, the diffusion of growth factors, and more. In acute wounds, exudate provides the wound bed with a moist environment suitable for progressing through the different stages of healing. However, the composition of exudate differs in chronic wounds. 

Complex, non-healing wounds tend to be highly exudative, and the excess moisture they produce can lead to maceration of the wound bed and surrounding tissues. There’s even evidence showing that wounds, like venous ulcers, generate significant exudate and are associated with periwound skin discoloration. 

How Does Skin Maceration Affect Wound Healing? 

Discovering macerated skin surrounding a wound is concerning, but how exactly does it impact the healing process? To answer this question, it helps to have an understanding of what the skin endures when it’s healthy. 

The Life Cycle of Healthy Skin Cells 

The epidermis is comprised of several layers of keratinocytes, which are cells that help with the secretion of collagen, protein formation, and improving the skin’s overall structural integrity. They’re initially produced in the deepest layer of the epidermis, known as the stratum basale, but they do travel upwards towards the skin’s surface. Along the journey, they create desmosomes, which can be thought of as adhesive tools. Their role is to help the adjacent cells attach, and once they’re connected, they fill with keratin, a type of protein that makes the skin relatively waterproof. 

After four weeks, the keratinocytes shed from the stratum corneum and are replaced by the cells from the layers below it. This allows the protective barrier to have new, healthy cells.  

How Maceration Impacts the Skin Cell Process

Unfortunately, when maceration occurs, it greatly disrupts the skin cell journey. The excess moisture, whether from exudate, sweat, or some other source, causes the cells to swell. When this happens, they lose their protective properties. 

From there, the desmosomes, which are meant to hold the keratinocytes together, end up disengaging due to the breakdown of a family of enzymes referred to as the matrix metalloproteinases (MMPs). At this point, the cells lack a defined structure, making them vulnerable to bacterial infection and other external forces. In turn, they begin shedding prematurely from the skin’s surface. 

Maceration Is a Big Problem for Wounds 

As we discussed above, maceration can be destructive even when it occurs on otherwise healthy skin. Therefore, if a wound is present, and the skin is already in a fragile state, there is even greater concern. 

In a study examining the relationship between wound healing and maceration, researchers found that healing was significantly delayed in wounds with macerated edges. As a practitioner, this is likely not surprising, as the body already undergoes significant changes when attempting to restore the integrity of damaged tissue. 

Maceration only adds to the complexities by: 

• Diminishing the bond between keratinocytes, which are responsible for producing new epithelium to cover the wound, during healing. 
• Decreasing the skin’s protective barrier, thus making it easier for bacteria to enter. 
• Increasing the level of pain and discomfort patients experience.
• Softening the skin, making it more susceptible to external trauma, from pressure, friction, dressing changes/removal, cleaning, etc.  

If not treated, the periwound area could experience significant breakdown and cause the wound to expand. Chronic wounds may even become stuck in the inflammatory phase due to excessive exudate. 

Preventing Wound Maceration

Given their ability to interrupt the wound healing process, it’s ideal to avoid maceration from happening in the first place. Yet, this is easier said than done for several reasons. A patient’s overall health, their environment, the location of the wound, and other factors all contribute to whether maceration occurs. On top of that, maceration is more prevalent in chronic wounds, which are a common and costly public health problem. 

Nonetheless, there are strategies that can help practitioners avoid maceration and improve patient outcomes.

• With mild cases, the skin may heal from just being exposed to air
• Dressing changes should not be performed too often, as frequent friction and rubbing can cause injury to softened skin
• The skin should be kept dry to ensure the source of moisture doesn’t saturate the area
• Protective skin creams or barriers can help moderate hydration
• Proper hygiene maintenance is especially important if a patient is experiencing incontinence
• Fragrance-free moisturizers can prevent dermatitis
• If a wound produces high-flow exudate, the underlying problem (e.g., medication) should be the focus of treatment

How to Treat Wound Maceration

If a patient develops severe skin maceration, the treatment goal is to try to keep the skin as clean and dry as possible. To maintain cleanliness, use a gentle formulation and carefully dab around the affected area. 

Maceration can make it challenging to continue other wound therapies; however, skin protectants, such as liquid cyanoacrylate sprays, can help. They make it easier for adhesive products to stick without further damaging the skin. Paper adhesives are preferred. For chronic wounds with heavy exudate, try utilizing absorbent dressings, such as hydrofiber, alginates, and hydrocolloids. 

Monitor for signs of infection as well. If there is an infection and no dermatitis, a topical antimicrobial may be beneficial. In cases where dermatitis is present without infection, the condition may be better managed with the use of corticosteroids. 

Wound Maceration: A Complex Dilemma 

As established, maceration can negatively affect proper healing. It alters the wound area and predisposes it to infection, all of which can be detrimental for wound healing. And even if a patient doesn’t yet have a wound, the softening of the skin could eventually lead to a wound that’s contaminated by microorganisms. 

Overall, while moisture is crucial to skin health and wound healing, clinicians want to avoid an excess amount of it. By following these suggestions, healthcare professionals can better prevent and manage macerated skin wounds.