Skin problems in individuals with lower-limb loss: literature review and proposed classification system.
Article Type: Clinical report
Subject: Amputees (Health aspects)
Skin diseases (Diagnosis)
Skin diseases (Care and treatment)
Rehabilitation (Research)
Authors: Bui, Kelly M.
Raugi, Gregory J.
Nguyen, Viet Q.
Reiber, Gayle E.
Pub Date: 12/31/2009
Publication: Name: Journal of Rehabilitation Research & Development Publisher: Department of Veterans Affairs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 Department of Veterans Affairs ISSN: 0748-7711
Issue: Date: Dec 31, 2009 Source Volume: 46 Source Issue: 9
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 227281560
Full Text: INTRODUCTION

Problems with skin integrity can disrupt the daily use of a prosthetic limb and interfere with the independence and lifestyle of individuals with lower-limb loss. Biomechanical factors involved in the interaction between a prosthetic limb and skin interface, including distribution of weight, shear force, moisture, and temperature, can lead to skin problems [1-3].

Skin problems associated with prosthetic limb use are common. While a range of skin diagnoses, such as allergic contact dermatitis, epidermal hyperplasia, malignancies, and ulcerations, have been described [4], we found no consistency in the literature regarding how these problems are reported. Accordingly, we do not know the epidemiology of the residual-limb dermatologic issues faced by individuals with lower-limb loss. A recent literature review [5] cited only one study [6] with sufficient rigor to ascertain a prevalence of 16 percent for skin problems on the residual limb. However, the skin problems reported in that study were limited to abscesses and ulcers, a narrow subset of the whole spectrum of dermatologic issues that could affect prosthetic limb use and user satisfaction.

As a first step toward filling this gap in knowledge, we undertook a systematic review of the literature to better define the prevalence and types of skin problems on the residual limb related to prosthetic use. We use this information to propose a classification system that may be of use in future clinical studies.

METHODS

We searched the literature published through 2008 using four databases: MEDLINE, EMBASE, CINAHL, and RECAL. MEDLINE is a biomedical database containing publications since the 1950s. EMBASE is a biomedical and pharmacological database containing publications since 1988. CINAHL is a nursing and allied health database containing publications since 1982. RECAL is an orthotics and prosthetics database containing publications from 1900 to 2007. Table 1 shows medical subject headings (MeSH) and free text words that we used to search MEDLINE, CINAHL, and EMBASE. MeSH are standardized terms defined by the National Library of Medicine and arranged in a hierarchical structure that allows searching at various levels of specificity. In RECAL, we used the free text words "skin" and "amputation" (MeSH not available). We restricted our search to the English language and humans in MEDLINE and EMBASE and to the English language in CINAHL (option to limit to human research not available).

We reviewed the title and abstract of all publications identified in our literature search. We selected articles if they discussed skin problems in adults (>18 years old) with lower-limb loss (transtibial, transfemoral, or knee disarticulation, but not foot, ankle, or hip disarticulation) who were fitted with a prosthesis. We excluded articles that discussed wound healing immediately postamputation. We removed duplicate articles obtained from different databases.

Our second selection process involved reviewing study research methodology. We selected articles if they included a description of the inclusion and exclusion criteria and the study population, identified the reason for amputation, identified the level of amputation, and reported both the prevalence and types of skin problems on a residual limb associated with prosthetic limb use. We excluded all case studies, case series, reviews, expert opinions, and letters to editors. We also excluded articles published before 1990 or with a sample size of fewer than 40 subjects.

Lastly, we reviewed the reference lists of these articles for publications related to skin problems in individuals with lower-limb loss (transtibial, transfemoral, or knee disarticulation). Relevant articles published after 1990 underwent the second selection process we mentioned previously.

RESULTS

Our initial search using MeSH and free text words yielded 777 articles: 313 from MEDLINE, 233 from EMBASE, 31 from CINAHL, and 200 from RECAL (Table 2). Our first selection process yielded 71 publications: 50 from MEDLINE, 5 from EMBASE, 3 from CINAHL, and 13 from RECAL (Table 2). We found an additional 19 related articles published after 1990 in the reference lists. We then reviewed the study methodology of the resulting 90 articles and retained 2 publications from MEDLINE and 2 from the reference lists (Table 2).

The 86 articles we excluded included 41 case reports or case series; 16 reviews or expert opinions; 4 letters to editors; 2 duplicated articles; and 7 articles about topics not of interest, including novel treatments for skin problems, quality of life, shear force, or no reported skin problems. We also excluded an additional two articles: one article (with the exception of its abstract) was written in Korean and the other, although referenced in another study, was unpublished. The remaining 14 articles we excluded were clinical studies discussing skin problems in individuals with limb loss. Four studies discussed both upper- and lower-limb amputations [7-10], one of which was published before 1990 [7]. Ten cross-sectional and cohort studies about lower-limb loss did not meet our selection criteria because of insufficient sample size [1112], the presence of nonadult participants [13-17], missing selection criteria [14], failure to report the prevalence of skin problems [14,18], or lack of skin problem specification [12,17,19-20].

Table 3 identifies the four publications that met our selection criteria, representing research performed in the Netherlands, Canada, the United States, and Singapore from 1990 to 2008 [6,21-23]. All the studies were cross-sectional and obtained data through either a chart review or a questionnaire delivered by mail or telephone. A physician assessed skin problems in three out of the four studies; the last study was by patient self-report [23]. The most common reasons for amputation were vascular disease, diabetes, and trauma. The most common amputation level was transtibial.

The overall prevalence of skin problems ranged from 15 to 41 percent, with increasing prevalence in the more recent studies. The most commonly reported skin problems ([greater than or equal to] 20%) were wounds (including ulcers), abscesses, and blisters. The articles did not specify the method of skin problem assessment (i.e., physical examination, laboratory data, or biopsy).

DISCUSSION

We found one systematic literature review about skin problems in individuals with lower-limb loss that reviewed the literature published through 2002 [5]. We used similar methodological assessment criteria, including an assessment of the inclusion and exclusion criteria, a description of the study population, and the prevalence rate of skin problems. We added several criteria, including the level of amputation, the reason for amputation, and a description of types of skin problems. These additions allowed us to narrow our focus to lower-limb amputations, better characterize the study populations, and describe the types of skin problems commonly reported in the literature.

The limited number of cohort studies (n = 4), none of which met our inclusion criteria, identifies an area for future research. Because of the inherent limitations of a cross-sectional study, including the inability to obtain an incidence of skin problems and to infer causality of factors that may lead to skin problems, we recommend that future studies answer these questions by using more rigorous study designs.

None of the clinical studies included a definition or standardized method of assessment for skin problems, thus making it difficult for us to describe and categorize the common types of skin problems in individuals with lower-limb loss. In the literature, some studies consider perspiration and hygiene problems as factors leading to skin problems [2], whereas others categorize these precursor conditions as skin problems themselves [11,14,18]. Some studies reported using patch testing and swab testing to clarify the underlying etiology of skin problems [13], whereas others did not report how the skin problems were assessed and subsequently diagnosed [15,22]. Description of skin problems varied across studies and depended on the person reporting the skin problems (patient vs physician), with more detailed descriptions provided by physicians. The lack of standardization made it difficult for us to accurately compare the prevalence rates of skin problems across studies and to describe the most commonly occurring skin problems. Differing skin problem prevalence rates may also be attributed to the etiology of the amputation or the country of study.

Our study is limited to reviewing the existing literature (1990-2008) about individuals with lower-limb loss. We did not include unpublished studies, those with a sample size of fewer than 40 subjects, or those written in languages other than English. To the best of our knowledge, this study comprehensively reviews the literature that exists on skin problems in individuals with lower-limb loss. In addition to completing a search inquiry in four databases, we also reviewed reference lists to ensure that we did not miss relevant studies.

We recommend that future classification of lower-limb problems on the residual limb be categorized according to either morphology or etiology rather than with generalizations (e.g., "rash" or "wound"). Hygiene problems, odor, and sweating should be considered precursors to skin problems. We propose a classification schema as shown in Tables 4 and 5, in which the same skin conditions are included regardless of classification strategy. Standardized definitions of skin problems will allow clinicians and researchers to report the prevalence and types of skin problems on residual limbs with improved external validity and reliability.

CONCLUSIONS

We conclude that the prevalence of skin problems in individuals with lower-limb loss from 1990 to 2008 was 15 to 41 percent; the most commonly reported skin problems were wounds, abscesses, and blisters. The prevalence and types of skin problems reported varied by study and their respective method of assessment and definition of skin problems. We recommend that future studies use the standard dermatology definitions for skin-problem classification as described in Tables 4 and 5. We also recommend a standardized assessment of an individual's residual limb at regular intervals so that comparisons may be made across studies and the causality of skin problems may be better inferred. Through such studies, we will better understand skin problems in individuals with lower-limb loss and effectively devise prevention and intervention for this significant problem.

ACKNOWLEDGMENTS

Author Contributions:

Study concept and design: K. M. Bui, G. J. Raugi, G. E. Reiber.

Acquisition, analysis, and interpretation of data: K. M. Bui.

Drafting of manuscript: K. M. Bui, G. J. Raugi.

Critical revision of manuscript for important intellectual content: K. M. Bui, G. J. Raugi, V. Q. Nguyen, G. E. Reiber.

Statistical analysis: K. M. Bui.

Obtained funding: G. E. Reiber.

Administrative, technical, or material support: G. E. Reiber.

Study supervision: G. J. Raugi, G. E. Reiber.

Financial Disclosures: The authors have declared that no competing interests exist.

Funding/Support: This material was based on work supported by the Department of Veterans Affairs Health Services Research and Development Service (grant HR 05-244) and a Career Scientist Award (grant RCS 98-353) to Dr. Reiber.

Additional Contributions: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. Dr. Bui is now with the Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, and Dr. Nguyen is now with the Department of Dermatology, Henry Ford Hospital, Detroit, Michigan.

Submitted for publication April 20, 2009. Accepted in revised form August 11, 2009.

REFERENCES

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[13.] Koc E, Tunca M, Akar A, Erbil AH, Demiralp B, Arca E. Skin problems in amputees: A descriptive study. Int J Dermatol. 2008;47(5):463-66. [PMID: 18412862] DOI:10.1111/j.1365-4632.2008.03604.x

[14.] Lake C, Supan TJ. The incidence of dermatological problems in the silicone suspension sleeve user. J Prosthet Orthot. 1997;9(3):97-106. DOI:10.1097/00008526-199700930-00003

[15.] Pierce RO Jr, Kernek CB, Ambrose TA 2nd. The plight of the traumatic amputee. Orthopedics 1993;16(7):793-97. [PMID: 8361918]

[16.] Pohjolainen T. A clinical evaluation of stumps in lower limb amputees. Prosthet Orthot Int. 1991;15(3):178-84. [PMID: 1780222]

[17.] Walker CR, Ingram RR, Hullin MG, McCreath SW. Lower limb amputation following injury: A survey of long-term functional outcome. Injury. 1994;25(6):387-92. [PMID: 8045644] DOI:10.1016/0020-1383(94)90132-5

[18.] Hachisuka K, Nakamura T, Ohmine S, Shitama H, Shinkoda K. Hygiene problems of residual limb and silicone liners in transtibial amputees wearing the total surface bearing socket. Arch Phys Med Rehabil. 2001;82(9):1286-90. [PMID: 11552206] DOI: 10.1053/apmr.2001.25154

[19.] Datta D, Vaidya SK, Howitt J, Gopalan L. Outcome of fitting an ICEROSS prosthesis: Views of trans-tibial amputees. Prosthet Orthot Int. 1996;20(2):111-15. [PMID: 8876004]

[20.] Kauzlari N, Kauzlari KS, Kolundzi R. Prosthetic rehabilitation of persons with lower limb amputations due to tumour. Eur J Cancer Care. 2007;16(3):238-43. [PMID: 17508943] DOI:10.1111/j.1365-2354.2006.00727.x

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[23.] Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil. 2000;81(3):292-300. [PMID: 10724073] DOI:10.1016/S0003-9993(00)90074-1

DOI: 10.1682/JRRD.2009.04.0052

Abbreviation: MeSH = medical subject headings.

Kelly M. Bui, MD; (1) Gregory J. Raugi, MD, PhD; (2-3) Viet Q. Nguyen, MD; (1) Gayle E. Reiber, MPH, PhD (2,4) *

(1) School of Medicine, University of Washington, Seattle, WA; (2) Health Services Research and Development Service, Department of Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA; (3) Primary and Specialty Medical Services, Division of Dermatology, VA Puget Sound Health Care System, Seattle, WA; (4) School of Public Health, University of Washington, Seattle, WA

* Address all correspondence to Gayle E. Reiber, MPH, PhD; VA Puget Sound Health Care System, Health Services Research and Development Service, MS 152, 1660 S. Columbian Way, Seattle, WA 98108; 206-764-2089; fax: 206-764-2935. Email: greiber@u.washington.edu
Table 1.

Medical subject headings, free text words, and combinations used in
MEDLINE, CINAHL, and EMBASE literature searches.

No.   MEDLINE

1     amputation/ or disarticulation/
2     residual limb.mp
3     amputation stumps/
4     (amputation or stump or disarticulation).mp
5     amputees/ or amputee.mp
6     1 or 2 or 3 or 4 or 5
7     lower extremity/ or leg/ or knee/ or thigh/
8     (lower extremity or lower limb or tibia
        or femur or trans-tibial or trans-femoral
        or leg * or knee * or thigh *).mp
9     (metatarsal or foot or ankle or hip).mp
10    (7 or 8) not 9
11    prosthetic limb.mp
12    artificial limbs/ or artificial limb.mp
13    10 or 11 or 12
14    exp * skin diseases/ or exp * skin/
15    prosthesis fitting/adverse effect
16    14 or 15
17    6 and 13 and 16
18    Limit to English and humans

No.   CINAHL

1     amputation/ or amputation, traumatic/
2     above-knee amputation/ or below-knee
        amputation
3     residual limb.mp or amputation stumps/
4     (amputation or stump or disarticulation).mp
5     amputees/ or amputee.mp
6     1 or 2 or 3 or 4 or 5
7     lower extremity/ or knee/ or leg/ or thigh/
8     (lower extremity or lower limb or tibia
        or femur or trans-tibial or trans-femoral
        or leg * or knee * or thigh *).mp
9     (metatarsal or foot or ankle or hip).mp
10    (7 or 8) not 9
11    (prosthetic limb or leg prosthesis).mp
12    artificial limb.mp or limb prosthesis/
13    10 or 11 or 12
14    exp * skin diseases/ or exp * skin/
15    prosthesis fitting/adverse effect
16    14 or 15
17    6 and 13 and 16
18    Limit to English

No.   EMBASE

1     amputation/ or traumatic amputation/
2     limb amputation/ or leg amputation/ or
        knee amputation
3     above-knee amputation/ or below-knee
        amputation
4     residual limb.mp/ or amputation stump/
5     (disarticulation or amputation or stump
        or amputee).mp
6     1 or 2 or 3 or 4 or 5
7     limb/ or leg/ or knee/ or lower leg/ or thigh/
8     femur/ or tibia/ (lower extremity or transtibial
        or trans-femoral or femur * or tibia *
        or leg * or knee * or thigh *).mp
9     (metatarsal or foot or ankle or hip).mp
10    (7 or 8) not 9
11    (artificial limb or prosthetic limb or leg
        prosthesis).mp
12    leg prosthesis/ or limb prosthesis/ or limb
        prosthesis.mp
13    10 or 11 or 12
14    exp * skin diseases/ or exp * skin/
15    13 and 14
16    Limit to English and humans
17    --
18    --

Table 2.

Source and number of publications we identified, included, and
excluded.

                                 Included
                  Publications   After First
Source            Identified     Selection *

MEDLINE               313            50
EMBASE                233             5
CINAHL                 31             3
RECAL                 200            13
Reference Lists        --            --
Total                 777            71

                                     Included
                  Identified in      After Second
                  Reference          Selection
Source            Lists ([dagger])   ([double dagger])

MEDLINE                  --               2
EMBASE                   --               0
CINAHL                   --               0
RECAL                    --               0
Reference Lists          19               2
Total                    19               4

* Title and abstracts were reviewed. Publications were included if
discussed skin problems in adults (>18 years old) with lower-limb loss
(not foot, ankle, or hip) and in English.

** Titles and abstracts (if available) were reviewed for all articles
published after 1990. Articles were included if discussed skin problems
in adults (>18 years old) with lower-limb loss (not foot, ankle, or
hip).

Table 3. Qualified studies of reported skin problems.

                 Country                             Study
Study            of Study          Type of Study     Population

Baars et al.,    The Netherlands   Cross-sectional   Subjects (60)
2008 [1]                           chart review

Dudek et al.,    Canada            Cross-sectional   Subjects (745)
2005 [2]                           chart review      Residual limbs
                                                     (828)

Pezzin et al.,   United States     Cross-sectional   Subjects (78)
2000 [3]                           telephone
                                   interview

Chan and Tan,    Singapore         Cross-sectional   Subjects (47)
1990 [4]                           questionnaire     (1989-1990)

                Study             Reason for
Study           Population        Amputation
                                  (%)

Baars et al.,    Rehabilitation   Vascular (63.0)
2008 [1]         hospital         Trauma (10.0)
                 (1998-2006)      Infection (8.0)
                                  DM (8.0)
                                  Other(11.0)

Dudek et al.,    Amputee clinic   PVD/DM (50.0)
2005 [2]         (1997-2003)      Trauma (33.0)
                                  Other (17.0)

Pezzin et al.,   University-      Trauma (100.0)
2000 [3]         affiliated
                 trauma
                 center
                 (1984-1994)

Chan and Tan,    Amputee clinic   DM (85.1)
1990 [4]                          Malignancy (8.5)
                                  Vascular (6.4)

                 Amputation
                 Level                  Assessment of
Study            (%)                    Skin Problems

Baars et al.,    Transtibial (83.0)     Exam by
2008 [1]         Knee disarticulation   physiatrist
                 (17.0)

Dudek et al.,    Transtibial (66.4)     Exam by
2005 [2]         Transfemoral           physiatrist
                 (19.2)
                 Other (14.4)

Pezzin et al.,   Transtibial (51.0)     Patient self-
2000 [3]         Transfemoral           report
                 (20.0)
                 Knee disarticulation
                 (17.0)
                 Other (12.0)

Chan and Tan,    Transtibial (93.6)     Exam by
1990 [4]         Symes (4.3)            physiatrist
                 Transfemoral
                 (2.1)

                 Overall
                 Prevalence   Types of Skin
Study            (%)          Problems (%)

Baars et al.,    38           Superficial
2008 [1]                      wound (69)
                              Blister (22)
                              Folliculitis (6)
                              Rash (3)

Dudek et al.,    41           Ulcer (27)
2005 [2]                      Irritation (17)
                              Inclusion cyst
                              (15)
                              Callus (11)
                              Verrucous
                              hyperplasia
                              (9)
                              Blister (7)
                              Fungal infection
                              (5)
                              Cellulitis (2)
                              Other(7)

Pezzin et al.,   24           Wound or sore
2000 [3]                      (100)

Chan and Tan,    15           Ulcer (57)
1990 [4]                      Abscess (43)

* All clinical studies that described inclusion and exclusion criteria,
study population, reason for amputation, level of amputation, skin
problems on residual limb related to prosthesis use, and prevalence and
types of skin problems.

Table 4. Classification of dermatologic problems on residual limbs by
morphology.

Problem                           Morphology

Hyperplastic or                   Squamous cell carcinoma
  Neoplastic Conditions           Inclusion cyst/epidermoid cyst
                                  Foreign body reaction
                                  Callus
                                  Verrucous hyperplasia

Disruption of Skin Integrity      Wound dehiscence
                                  Irritation/abrasion
                                  Blister/erosion/ulcer

Follicular and Pseudofollicular   Folliculitis
  Inflammation                    Miliaria rubra

Interfollicular Inflammation      Eczema craquele
                                  Dermatophytosis
                                  Allergic contact dermatitis
                                  Irritant dermatitis
Infection                         Cellulitis

Table 5. Classification of dermatologic problems on residual limbs by
etiology.

Problem                         Etiology

Surgical Complications          Wound dehiscence
                                Foreign body reaction
                                Inclusion cyst/epidermoid cyst

Reaction to Repetitive Injury   Callus
                                Irritation/abrasion
                                Blister/erosion/ulcer
                                Squamous cell carcinoma

Reaction to Occlusion:          Folliculitis
  Noninfectious                 Miliaria rubra
                                Eczema craquele
                                Irritant dermatitis
                                Verrucous hyperplasia
                                Allergic contact dermatitis

Reaction to Occlusion:          Cellulitis
  Infectious                    Dermatophytosis
                                Folliculitis
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