Recognition of Maceration

Maceration is a common clinical complication that poses challenges in chronic wound treatment.¹ Excessive moisture can be trapped on the wound surface, especially when occlusive dressings are overused or when nonbreathable cover dressings are applied for extended periods. Maceration as part of the broader umbrella of moisture-associated skin damage (MASD) occurs as a cascade of events that stem from an impaired microclimate and increased humidity on the wound’s surface.

The increased moisture level causes overhydration and the stratum corneum to swell, resulting in decreased tensile strength of this epidermal layer.¹ In chronic wounds, corrosive exudates can be overproduced by these aging wounds that are stuck in the inflammatory phase. When dressings fail to promote efficient exudate management, seepage of these harmful substances into the periwound is a precipitating factor that may lead to maceration and wound worsening.² In addition, macerated wounds may further prolong the inflammatory phase, thus slowing down wound healing while also increasing the chance for wound enlargement and progression.²

The typical clinical presentation of maceration is a circumferential “halo,” or wrinkling of the skin or periwound that manifests as a lighter tone than healthy skin.^1,2 Maceration may also manifest as an area of denudement within the wound edges that extends to the periwound. The surface may also appear boggy.¹ Left untreated, this damaged and denuded skin can easily be broken down by light friction, corrosion, or adhesive use.¹ Furthermore, breakdown of macerated skin can cause an increase in wound size while also serving as a potential portal of entry for opportunistic skin infections.^1,2

Prevention and Management of Maceration

Preventing maceration while maintaining an undisturbed, moist wound healing environment can be a challenge for most clinicians. Although proper dressing selection using smart absorbent, nonadherent, and breathable dressings may assist in preventing maceration, the frequency of dressing changes is key to achieving optimum outcomes.^1,2

Less frequent but timely dressing changes are essential to avoid saturation while also allowing for an undisturbed wound healing environment.² Frequent dressing changes that focus on dressing oversaturation prevention, which also allows for undisturbed wound healing, may be critical to achieving optimal management.^1,2 To avoid further maceration, the use of protective skin barriers such as liquid cyanoacrylate sprays or wipes on the periwound may aid in moisture management and the prevention of medical adhesive–related skin injury (MARSI).^1,2 In addition, applying a thin layer of moisture barrier cream, ointment, or lotion to intact periwound skin may help prevent the onset of maceration.¹

Conclusion

Maceration is a common complication that is especially prevalent among chronic wounds. Therefore, early recognition, prevention, and management are essential to successful wound care outcomes and may include the appropriate use of superabsorbent and nonadherent dressings, skin protectants, and moisture barrier creams that will prevent overhydration of both the wound and the periwound.

References

1. Thayer D, Rozenboom BJ, LeBlanc K. Prevention and management of moisture-associated skin damage (MASD), medical adhesive-related skin injury (MARSI), and skin tears. In: McNichol LL, Ratliff CR, Yates SS, eds. Wound, Ostomy and Continence Nurses Society Core Curriculum: Wound Management. 2nd ed. Wolters Kluwer; 2022:323-353.
2. Brown A. Managing exudate and maceration in venous leg ulceration within the acute health setting. Br J Nurs. 2017;26(suppl 20):S18-S24. doi:10.12968/bjon.2017.26.Sup20.S18

About the Author

Alex M. Aningalan, MSN, RN, CWON, WCC, is a board-certified wound and ostomy nurse clinician and specialist. He has varied experiences in both acute and long-term care. In addition to wound healing, he is passionate about nursing education, nursing mentorship, and nursing scholarship. He loves to share the value of the wound and ostomy care specialty, especially among new-to-practice nurses, while encouraging and promoting it to fellow and emerging clinicians who share his passion for wound and ostomy care. In addition, he values the importance of leadership, evidence-based practice, and interprofessional collaboration among clinicians and patient populations.