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Skin complications of paraplegia and tetraplegia

Author: Katherine Hartley, Medical Student, University of Nottingham, Nottingham, UK. Copy edited by Gus Mitchell. November 2020.


Skin complications of paraplegia and tetraplegia — codes and concepts
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What is paraplegia and tetraplegia?

Paraplegia and tetraplegia are a loss of neurological function usually resulting from a spinal cord injury. In paraplegia only the lower body and limbs are affected following a spinal cord injury in the thoracic, lumbar, or sacral region. Tetraplegia also involves the upper limbs and upper body due to interruption in the cervical spine. Loss of function can be complete or incomplete, congenital or acquired, reduced or complete loss of sensation, paralysis or weakness.

Multiple body systems can be affected including the musculoskeletal, gastrointestinal, and genitourinary systems. It is important to consider the effects on mental health especially following an acute event.

What are the skin complications of paraplegia and tetraplegia?

Temperature regulation and sweating

Spinal cord injuries in the cervical and upper thoracic spine can result in an inability to maintain a constant core temperature.

Changes in sweat secretion are common after spinal cord injuries. Reduced or absent sweating may occur below the level of the injury, with a compensatory hyperhidrosis above it. Less often there may be reflex sweating below a cervical or high thoracic injury.

Pressure ulcer

Pressure ulcers are a common complication of spinal cord injury, and the most common long-term complication. A pressure ulcer is defined as a soft tissue injury resulting from unrelieved pressure over a bony prominence resulting in ischaemia, cell death, and tissue necrosis. Pressure, moisture, shear forces, and friction are extrinsic factors contributing to the development of skin ischaemia and necrosis. Pressure ulcers usually develop below the level of spinal cord injury, with the most common sites being over the ischial tuberosity (from prolonged sitting), sacrum, trochanter, and heel.

Paraplegia and tetraplegia are particularly associated with pressure ulcer development due to reduced mobility, reduced skin sensation, and faecal/urinary incontinence.

Pressure ulcer

Other factors contributing to increased risk include:

  • Increasing age
  • Malnutrition
  • Cognitive impairment
  • Smoking
  • Anaemia
  • Obesity
  • Peripheral vascular disease.

The European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP) classification system is used to categorise pressure ulcers.

Careful daily examination of the skin is required to identify early signs of pressure at an easily reversible stage. Skin care should include:

  • Early detection of pressure areas
  • Minimise persistent pressure by frequent repositioning or wheelchair pushups
  • Avoid pressure on areas of skin erythema
  • Use of pressure relieving mattresses and cushions
  • Reduce risk factors by correcting malnutrition, encouraging smoking cessation, and maintaining glycaemic control in patient with diabetes
  • Manage bladder and bowel incontinence to minimise skin contact time with urine or faeces
  • Barrier creams to protect the skin from moisture and irritants.

Once skin ulceration has developed, treatment options may include:

  • Take skin swabs and treat infection promptly
  • Apply dressings to broken skin to reduce the risk of infection
  • Negative pressure wound therapy
  • Removal of necrotic tissue with debridement.

Cutaneous infections

Alterations to immune function following spinal cord injury are thought to increase the risk of skin infections.

Tinea is the most commonly reported infection associated with paraplegia and tetraplegia, almost always developing below the level of the spinal cord injury. Predisposing factors may include hyperhidrosis, humid environment (limited airing of the skin), occlusive clothing, maintaining adequate skin hygiene, and comorbidities. The most common presentations associated with paraplegia and tetraplegia are tinea cruris, tinea pedis, and onychomycosis.

Management is as usual for tinea: skin scapings or nail clippings for fungal microscopy and culture, topical or oral antifungal medications prescribed, and treatment of predisposing factors to reduce the risk of recurrence.

Post-operative wound infections are three times more common than in patients without a spinal cord injury. Secondary bacterial infection of surgical wounds, pressure ulcers, and eczema should be confirmed on swabs and treated appropriately, in addition to treatment of the underlying condition.

Inflammatory dermatoses

Asteatotic eczema develops in very dry skin, particularly on the lower limbs below the level of injury. It is reported to develop in the first 12 months after the spinal cord injury. Dry skin is commonly associated with paraplegia and tetraplegia and may be due to a number of factors including reduced skin blood flow, reduced sweating, and nutritional deficiencies. Treatment is with regular emollient use and topical corticosteroids when required.

Seborrhoeic dermatitis is often reported in patients following spinal cord injury. Studies on the effect of a spinal cord injury on sebaceous gland function have shown contradictory results. Seborrhoeic dermatitis affects the skin above the level of injury, and some authors suggest it results from inadequate hair and face washing in the initial acute period following injury.

Other cutaneous complications

  • Impaired wound healing
  • Ingrown toenail (in tetraplegia).

What are the complications of skin problems associated with paraplegia and tetraplegia?

Pressure ulcers can be complicated by secondary infection, which may not manifest as pain due to reduced or absent skin sensation.

Tinea pedis increases the risk of lower leg cellulitis by providing an entry point for bacteria through the skin between the toes.

Asteatotic eczema can generalise if severe, resulting in widespread, secondary disseminated eczema.

How can skin complications of paraplegia and tetraplegia be prevented?

Skin complications of paraplegia and tetraplegia can be prevented in the following ways:

  • Daily examination of the skin to detect conditions early and prevent complications
  • Minimise injury to the skin
  • Prompt care of wounds to prevent infections
  • Adjust body position regularly to avoid pressure ulcers
  • Avoid excessive heat or cold exposure
  • Keep the skin clean and dry.

See smartphone apps to check your skin.
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Bibliography

  • Hagen EM. Acute complications of spinal cord injuries. World J Orthop. 2015;6(1):17–23. doi:10.5312/wjo.v6.i1.17. PubMed Central
  • Han ZA, Choi JY, Ko YJ. Dermatological problems following spinal cord injury in Korean patients. J Spinal Cord Med. 2015;38(1):63–7. doi:10.1179/2045772313Y.0000000154. PubMed Central
  • Kruger EA, Pires M, Ngann Y, Sterling M, Rubayi S. Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends. J Spinal Cord Med. 2013;36(6):572–85. doi:10.1179/2045772313Y.0000000093. PubMed Central
  • Rubin-Asher D, Zeilig G, Klieger M, Adunsky A, Weingarden H. Dermatological findings following acute traumatic spinal cord injury. Spinal Cord. 2005;43(3):175–8. doi:10.1038/sj.sc.3101697. PubMed

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