First-Line Management for Wheelchair-Bound Patients with Dermatitis
The first-line management for wheelchair-bound patients with dermatitis consists of appropriate skin cleansing, barrier protection, and topical corticosteroids of appropriate potency for the affected areas. 1, 2
Assessment and Prevention
Pressure Points and Moisture Management
- Evaluate common pressure points: sacrum, ischial tuberosities, greater trochanters
- Assess for moisture accumulation in skin folds and areas of prolonged contact with wheelchair surfaces
- Implement regular position changes (every 1-2 hours if possible) to relieve pressure
Cleansing Protocol
- Use gentle soap-free cleansers rather than standard soaps 2
- Clean affected areas promptly after exposure to moisture, particularly after incontinence episodes
- Avoid hot water which can further irritate skin and cause dryness
Treatment Algorithm
Step 1: Barrier Protection
- Apply emollients/moisturizers liberally to all at-risk areas at least twice daily
- Use specialized barrier products for areas prone to moisture exposure 3
- Consider zinc-based preparations for areas with persistent moisture exposure
Step 2: Topical Anti-inflammatory Treatment
- Apply appropriate potency topical corticosteroids to affected areas:
- Mild potency (e.g., 1% hydrocortisone) for face and skin folds
- Moderate potency for trunk and extremities
- Potent preparations only for limited periods on thickened/lichenified areas 1
- Apply no more than twice daily; newer preparations may require only once-daily application 1
Step 3: Infection Management
- For signs of secondary bacterial infection (increased redness, exudate, odor):
- Flucloxacillin is first-line for Staphylococcus aureus (most common pathogen)
- Erythromycin for penicillin-allergic patients
- Phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
- For suspected fungal infections in skin folds, use appropriate antifungal preparations
Special Considerations for Wheelchair Users
Seating Surface Management
- Ensure appropriate wheelchair cushioning to reduce pressure and friction
- Use breathable materials for seating surfaces to reduce moisture accumulation
- Consider specialized pressure-relieving cushions for high-risk patients
Environmental Factors
- Maintain optimal humidity levels (40-60%) in living environment
- Avoid excessive heat which can exacerbate sweating and dermatitis
- Consider clothing made of natural, breathable fabrics
Adjunctive Treatments
For Severe Pruritus
- Sedating antihistamines may be used short-term for severe itching, particularly at night
- Non-sedating antihistamines have limited value for dermatitis-related pruritus 1, 4
For Persistent Cases
- Consider ichthammol 1% in zinc ointment or paste bandages for lichenified areas 1
- For resistant cases, topical calcineurin inhibitors (tacrolimus, pimecrolimus) may be used, especially on sensitive areas like the face 2, 4
When to Refer to Specialist
- Diagnostic uncertainty
- Failure to respond to appropriate first-line treatment
- Signs of extensive secondary infection
- Need for systemic therapy 1
Common Pitfalls to Avoid
- Using potent topical steroids for prolonged periods, especially on thin skin areas
- Neglecting to address underlying causes (pressure, moisture, friction)
- Failing to recognize and treat secondary infections promptly
- Overlooking the importance of regular position changes and proper wheelchair cushioning
Remember that wheelchair-bound patients are particularly vulnerable to moisture-associated skin damage due to limited mobility and potential for prolonged skin contact with moist surfaces. Preventive measures are as important as treatment in this population.