Immediate Steps for Treating Abrasions
Rodney S. W. Basler, MD; Michael A. Garcia; Kara S. Gooding, PA
William O. Roberts, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 4 - APRIL 2021
In any athletic setting, the skin represents the interface between the participant and the sports environment (1). Unfortunately, this interface is often disrupted when the athlete comes into a very intimate relationship with this environment, resulting in an abrasion.
In older medical texts, the skin is often classed anatomically into two segments: the epidermis and the dermis, the latter of which is referred to by the antiquated term, "true skin." Nowhere is this descriptive distinction more obvious than when a traumatic event separates the epidermis, often along with the upper part of the dermis, from the more substantive reticular dermis.
Traumatic abrasions are defined as a superficial removal of granular and keratinized cells from the underlying dermis and are produced by acute contact of exposed skin with the immediate environment (2). This results in an irregularly denuded epidermis and an exposed upper dermis with punctate bleeding and tissue exudate. Such injuries are referred to by descriptive terms such as "raspberry" (figure 1), "strawberry," "mat burn," and "road rash" (3). Artificial turf can have a low coefficient of friction, especially when wet, allowing an athlete's exposed skin to slide across it for a greater distance than on grass, producing an injury more like a burn than an abrasion (figure 2). The diagnosis of abrasions is not difficult in the athletic setting.
Immediate sideline treatment consists of very gentle cleansing with a mild detergent soap or cleansing agent (menthylated shaving gel works well, partly because it provides a cooling sensation, which can give the patient some relief), bacitracin ointment, and a dry dressing. With minor injuries, the risk of bacterial infection, which is the primary immediate concern, is small. A large abrasion, however, can be covered with bacitracin, the surrounding skin prepped with an adhesive such as benzoin, the dressing applied to the wound, and the area covered with athletic tape. The entire dressing is then wrapped with an elastic, self-adhesive bandage like Coban (3M Company, St Paul) to hold it in place.
In situations that require hemostasis for return to play, Monsel's (ferric subsulfate) solution can be used on the sideline for quick control of bleeding. Unfortunately, this addition to the procedure will prolong the healing process and can be quite painful.
Conventional treatment has consisted of cleansing the affected area with a mild soap and water or a mild antiseptic wash, such as hydrogen peroxide. This would then be followed with the application of antibiotic ointment along with a dry dressing. The problem with this approach lies in the fact that mechanical cleansing by scrubbing the wounds can produce increased trauma and a renewal of the inflammatory response. It has also been seen that the application of antiseptics, such as hydrogen peroxide or povidone-iodine, can actually cause harm to the tissue and interfere with function, which can further increase the injury and lengthen the healing process (4). Topical antimicrobials have been shown to be detrimental to fibroblasts and other cells needed for wound restoration (4).
In light of these findings, newer, improved methods for treating abrasions are recommended. The most advisable treatment for cleansing the wound is to flush it using a "pistol" syringe or bulb syringe containing a nontoxic surfactant, such as Shur-Clens (ConvaTec, Skillman, New Jersey) or a 0.9% sodium chloride solution, followed by the application of a hydrocolloid or semiocclusive hydrogel dressing.
A moist healing environment is provided by the dressing, which will promote cell migration, remove excess exudate, allow for gaseous exchange, and provide an impermeable barrier to bacteria and other contaminants. The moist environment provided by the proper dressing is important for optimal cell migration by preventing crust formation and allowing the wound to heal from the bottom as well as from the edges. Two basic options fulfill this requirement. One option is semipermeable film dressings, such as Bioclusive (Johnson & Johnson, New Brunswick, New Jersey) and Tegaderm (3M Company, St Paul), in combination with semiocclusive hydrogels such as Spenco 2nd Skin (Spenco Medical Corp, Waco, Texas). These dressings are impermeable to water and bacteria but allow the exudate to evaporate.
Another option is the use of hydrocolloid dressings. These also offer a hospitable healing environment but differ from the semiocclusive hydrogels by absorbing the exudate rather than allowing for evaporation. In addition, the hydrocolloid dressing can remain in place for up to 7 days after being applied as can be done with the semipermiable films. Examples of hydrocolloidal dressings are Duoderm (ConvaTec, Skillman, New Jersey) and Cutinova hydro (Beiersdorf, Inc, Norwalk, Connecticut).
Coverage and Prevention
After abrasions are irrigated with a pistol syringe or bulb syringe and covered with a hydrocolloid or semiocclusive hydrogel dressing, the dressing may need to be covered with tape and/or padding for practice or competition. Prevention of abrasions is generally aimed at protecting areas of potential trauma. Wearing protective equipment such as sliding pads, long-sleeved shirts, and protective socks may help prevent skin trauma.
Dr Basler is a dermatologist in Lincoln, Nebraska, and team physician for the University of Nebraska-Lincoln. Mr Garcia is a technical assistant and Ms Gooding is a physician assistant at South Lincoln Dermatology Clinic in Lincoln.