Healthy Skin, Healthy Healing

Allen Fiske would rather run his sailboat charter company than deal with another skin flap surgery.

Allen Fiske would rather run his sailboat charter company than deal with another skin flap surgery. He carefully watches his diet, and especially makes sure he takes in enough protein and vitamins.

According to journal articles, up to 80 percent of people with spinal cord injuries will have at least one pressure sore during their lifetime, and 30 percent will have two or more. In rehab we are taught the basics about keeping skin healthy — having a therapist fit you for the proper cushion or seating system, doing weight shifts every 15-20 minutes and using a mirror to check daily for “hot spots” on buttocks, thighs, and other hard-to-see areas. But many of us overlook the importance of being active and developing good eating habits, which also help reduce the incidence of skin breakdown.

Stay Active
According to several clinical practice guidelines, being active and having a positive outlook reduces your risk for pressure sores. This includes social activities, hobbies, work, attending school or volunteering. Staying involved with family, friends and your community not only improves your overall health and state of mind, it also means you are more likely to pay attention to your skin care and nutrition.

Being active also increases your circle of friends and provides an emotional support network in the event you do get a pressure ulcer. If you are able, physical activity burns calories, helps manage weight and increases circulation. Exercise increases craving for healthier foods like fruits and vegetables, and inactivity seems to cause a craving for junk food. You are a lot less likely to fill up on empty calories when you are out and about than when you are parked in front of the television.

Proper Nutrition
Healthy skin needs to be fed. Proper nutrition not only helps skin resist pressure ulcers but also aids in healing. An often overlooked benefit is it helps fight the onset of type 2 diabetes — a disease that interferes with skin integrity, wound healing and occurs at a rate three times higher in people with SCI compared to the general population.

The building blocks required for strong, healthy skin are a proper balance of vitamins, minerals, and nutrients, as well as sufficient hydration. But which vitamins and nutrients are best for resilient skin, and how often should we take them? Wound care specialists and dieticians agree: Every vitamin and nutrient is vital for resilient skin, and the best way to get them is with a balanced diet.

Kerrie Powers, dietician at Craig Hospital in Denver, says most people she sees with pressure ulcers could use more protein and nutrients in their diet. She says the ideal diet for keeping skin healthy is low in fat and includes lots of fruits, vegetables, whole grains and protein sources — including beans, green leafy vegetables, lean meats, fish, chicken, cheeses, yogurt, or meat substitutes like tofu and other soy products. Although protein is a vital part of a healthy diet, it is important to get the right amount. Too much can be hard on the kidneys [see "Eat Your Protein" below for daily protein requirements].

A healthy diet helps speed things up for people with slow-moving bowels. However, sometimes you can get too much of a good thing. Andrea Curran — a registered dietician from Kaiser Permanente Hospital in Oakland, Calif., agrees with Powers’ recipe for healthy skin, but adds a tip for wheelers worried about too much high fiber causing loose stool or bowel accidents. “Bananas are a good source of soluble fiber and they help firm up stool. Another option to bulk up stool is to add a supplement like Benefiber,” says Curran.

Both Curran and Powers say good hydration is another key for healthy skin. A rule of thumb is to drink enough fluid to keep your urine in the clear to straw-colored category. Water is best. Fruit juice is fine but is high in calories and may put on unwanted pounds. Limit caffeinated drinks because they act as a diuretic and flush fluid out of your system.

Foods to avoid (or at least limit) include sodas, fast food, fried food and high fructose corn syrup sweets — they are high in calories but have no nutritional value.

As far as vitamin supplements go, Cherisse Tebben, family nurse practitioner and certified wound and ostomy continence nurse at Craig Hospital, says, “We do recommend zinc, vitamin C and a multivitamin. As far as dosages, recommended daily allowance amounts are a good place to start. She also cautions that many foods are enriched with vitamin C and zinc, and too much zinc can become toxic. Ask your doctor before taking more.

Keeping Weight Off
Avoiding excess weight also helps reduce the incidence of pressure sores. Tebben stresses the concept of ideal weight: “If you are too thin, there is nothing but skin and bone contacting the cushion and the wheelchair, plus any bump during a bad transfer is really a setup for a pressure ulcer. And if you are overweight, you are more likely to have problems with sheer forces (sliding and rubbing) during transfer.” Curran adds that the average ideal weight for paras and quads is difficult to base on height and weight alone because some people have a lot of muscle atrophy and others have lots of muscle. A rule of thumb is to subtract 10 percent from ideal weight charts if you’re a para. Quads should subtract 15 percent. Visual assessment should also figure in.

Even with proper nutrition, equipment and precaution, pressure ulcers still happen, and many physicians lack the training to spot and treat them. Tebben says if you get a pressure ulcer, it is better to seek the help of a wound care specialist earlier rather than later. “There are different products and different ways to stimulate healing at each stage of a pressure ulcer. Most general physicians aren’t current on these. A wound care specialist is.”

Staying Vigilant
Allen Fiske, 64, a sailboat charter captain from Braden, Fla., learned his lesson the hard way. Fiske, in his 28th year as a T11-12 para, says, “I have always done skin checks with a mirror every morning, and I went 26 years without any pressure sores. And now I’ve had two skin flap surgeries in two years.”

Last spring Fiske noticed a small red area the size of a pencil eraser with a pinhole on his right ischium, where he had his first flap surgery. “I went to my primary care doc and he said, ‘It’s just superficial and will probably be gone in a week.’” Three days later the hole was larger and Fiske’s mom inserted a Q-tip into it. To their surprise, it went in several inches. Fiske went to a wound care center, where a CT scan showed a larger, deep pressure-ulcer cavity.

The wound care center put Fiske through a series of IV antibiotics and a bone biopsy to make sure there was no osteomyelitis (bone infection). Another skin flap surgery was scheduled, but first Fiske had to be cleared for surgery with a pre-albumin blood test. Pre-albumin and albumin blood tests determine if your body has enough protein and calories stored. If you don’t have enough, there is much less potential for the body to heal a wound.

With proper nutrition, Fiske’s pre-albumin levels came back to normal. He had his second skin flap surgery in early September 2010. “Every morning during my recovery I was given a Pro-Stat drink — a high protein drink with arginine, vitamin C and zinc. They also gave me extra vitamin C and zinc and encouraged me to eat a lot.” By November his flap healed well enough to continue his recovery at his mom’s house.

Fighting through two skin flaps in two years is more than some people can handle. But Fisk has a charter business he loves. He is planning on getting all of his seating surfaces pressure-mapped to avoid another sore, and he’s looking forward to becoming completely healed so he can return to taking people on sailing charters.

Diabetes
People with SCI have a higher incidence of type 2 diabetes than nondisabled people, partly because they tend to carry excess fat in the abdominal area. Obesity — especially abdominal fat — reduces the effects of insulin and allows too much sugar in the blood. Diabetes can start to develop as soon as age 40, and the older you get, the greater your chances of developing it.

Type 2 diabetes damages blood vessels and decreases circulation, resulting in less blood flow, which makes skin more prone to damage, says Tebben. Aging also decreases blood flow, and high amounts of sugar in the blood increase bacteria, making wound healing much more difficult and infection more likely. “We are able to heal wounds when a person with SCI has diabetes, but it is very difficult and takes a lot longer. It’s very important to keep sweets to a minimum, control your weight and exercise if you are able — to avoid type 2 diabetes.”

Shorty Powers, 59, from Terrell, Texas, is a legendary fisherman, outdoorsman and founder and president of Turning Point Nation. Powers, in his 40th year as a T12 para, has always been extremely active. He has also carried a fair amount of weight in his gut. Five years ago he developed type 2 diabetes. “I manage it with insulin, but I was lazy and didn’t do as good of a job at managing it as I should have. I would only do the blood sugar draw at night. I didn’t change my diet or anything.”

For years Powers had been successfully battling pressure sores on the outside of his hips — caused by a combination of limited blood flow to his legs and sleeping on his side. But the combination of diabetes and age caught up with him. In February 2009 he developed a pressure ulcer on his right hip that went into the bone. The surgeon had to remove the top of Powers’ femur, which left the leg free floating.

The following February Powers developed a pressure ulcer on his left hip and had the same type of surgery to cut out the hip. The surgeon saw a pressure ulcer on his ankle about the size of a dime. Over the next few months Powers underwent three skin graft surgeries on his ankle and one on his hip. But healing wasn’t happening, and the surgeon said it was time to start thinking about amputating the leg. “He said we can take off one leg or both legs. I had blood circulation problems for years in both legs, and I’ve had cellulitus in each leg three or four times,” says Powers.

In June 2010 the surgeon removed both of Powers’ legs at the hip. “The amputations healed up fast and there weren’t any problems,” he says. “If I had to do it over again, I would have tried to save one leg for transfers, balance, and to keep my pants up.”

Powers is now trying to heal a pressure ulcer on his tailbone — the result of a botched transfer. He has managed to close the wound halfway. It has been a difficult struggle, but Powers never backs down. He is now diligent about keeping his blood sugar under control, checking it before every meal — mainly so he can return to his favorite fishing spots.

Tebben advises people with diabetes to control their blood sugar, stick with the proper foods and avoid sweets and soft drinks. Evidence suggests that, even with SCI, diabetes can be controlled or reversed through diet, weight loss and exercise.

The message is clear. For healthy skin, steer away from drive-through fast food and make an attempt to keep your shopping cart on the outer aisles of the grocery store. That’s where most of the desirable food groups — fruits, vegetables, whole grains, meat, poultry and fish — can usually be found.


Protein, Calories and Amino Acids

“If someone is lacking in protein and calorie stores, we have them drink products like Nestlé Arginaid, which supplies arginine — an amino acid involved in protein formation and the synthesis of collagen — and Nestlé Boost, a drink that is high in calories, protein, vitamins and minerals,” says Cherisse Tebben, wound care nurse at Craig Hospital. “These drinks are expensive — around $2 per serving. The next best thing is Carnation Instant Breakfast, which is high in protein and vitamins and much lower in cost.”

Dietician Kerrie Powers agrees that arginine and glutamine — the most abundant amino acid building block in the body — are helpful supplements in wound healing. She cautions they should be taken on the advice of a dietician. Arginine affects the way your body handles waste and can have adverse effects on people with liver and kidney problems. It can also cause problems with potassium balance and extra bleeding in people who use blood thinners.

“The body needs extra nutrition to heal a pressure sore,” about 20-50 percent more protein per day than the average person, Powers says. “With inpatients I prescribe a multivitamin, vitamin C and zinc. Since the body also requires extra calories to heal, we have patients consume either whey-based or beef collagen-based supplements, like Ensure, or any high-calorie, high-protein supplement.


Eat Your Protein
“If someone is lacking in protein and calorie stores, we have them drink products like Nestlé Arginaid, which supplies arginine — an amino acid involved in protein formation and the synthesis of collagen — and Nestlé Boost, a drink that is high in calories, protein, vitamins and minerals,” says Cherisse Tebben, wound care nurse at Craig Hospital. “These drinks are expensive — around $2 per serving. The next best thing is Carnation Instant Breakfast, which is high in protein and vitamins and much lower in cost.”

Dietician Kerrie Powers agrees that arginine and glutamine — the most abundant amino acid building block in the body — are helpful supplements in wound healing. She cautions they should be taken on the advice of a dietician. Arginine affects the way your body handles waste and can have adverse effects on people with liver and kidney problems. It can also cause problems with potassium balance and extra bleeding in people who use blood thinners.

“The body needs extra nutrition to heal a pressure sore,” about 20-50 percent more protein per day than the average person, Powers says. “With inpatients I prescribe a multivitamin, vitamin C and zinc. Since the body also requires extra calories to heal, we have patients consume either whey-based or beef collagen-based supplements, like Ensure, or any high-calorie, high-protein supplement.

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