What are the implications and management options for a yellowing epidermis graft site in an adult patient who has undergone skin grafting for a condition such as burns, trauma, or surgical excision of a lesion?

Yellowing Epidermis Graft Site: Infection Until Proven Otherwise

A yellowing epidermis graft site indicates probable infection or necrotic tissue and requires immediate assessment with wound swabs and consideration for debridement with topical antimicrobial therapy. 1

Immediate Assessment and Action

Obtain bacterial and fungal cultures immediately from the yellowing areas, as yellow discoloration typically represents either purulent exudate from infection or sloughy necrotic tissue. 1

• Take swabs from the yellowing/sloughy areas for bacterial and candidal culture 1
• Assess for clinical signs of infection including extension of graft loss, wound conversion, delayed healing, or systemic signs 1
• Document the percentage of graft affected and whether there is subepidermal pus formation 1

Management Algorithm

If Infection is Confirmed or Highly Suspected:

Apply topical antimicrobial agents to the yellowing/sloughy areas only, with choice guided by local microbiological advice and culture results. 1

• Consider silver-containing products or dressings as first-line topical antimicrobials 1
• Administer systemic antibiotics only if there are clinical signs of systemic infection - do not use prophylactically 1
• Regularly cleanse the graft site by irrigating gently with warmed sterile water, saline, or chlorhexidine (1:5000) 1

If Necrotic/Loose Infected Tissue is Present:

Remove necrotic or loose infected epidermis and clean wounds using topical antimicrobial agents (such as betadine or chlorhexidine), potentially under anesthesia if extensive. 1

• Consider debridement with specialized equipment for larger areas 1
• After debridement, apply greasy emollient (such as 50% white soft paraffin with 50% liquid paraffin) over the whole area including denuded sections 1

Dressing Management

Apply nonadherent dressings to any exposed dermis following debridement or graft loss. 1

• Use atraumatic, nonadherent dressings such as Mepitel™ or Telfa™ as primary layer 1
• Apply secondary foam or absorptive burn dressing to collect exudate 1
• Change dressings based on exudate levels and wound assessment 1

Critical Pitfalls to Avoid

Do not leave infected or necrotic tissue in place - while detached epidermis can sometimes act as a biological dressing in acute settings, yellowing indicates this tissue is no longer viable and is likely harboring infection. 1

Do not initiate systemic antibiotics without clear clinical signs of infection - this promotes resistance and does not improve outcomes in the absence of systemic involvement. 1

When to Escalate Care

Consider transfer to a specialized burn center if there is evidence of: 1

• Clinical deterioration with extension of graft loss
• Local sepsis not responding to initial management
• Wound conversion (deepening) or significantly delayed healing beyond expected timeframes 1

Environmental Considerations

Maintain strict barrier nursing to reduce nosocomial infections, with the ambient temperature raised to 25-28°C if extensive graft areas are involved. 1