Bob VogelQ. I’m in my second year as a T9 complete paraplegic and I do my best to keep my skin healthy, including routine weight shifts and nightly mirror checks for potential trouble spots. Although I’m careful, I’m currently tending quarter-sized burns on each knee, which I now realize happened when I was warming myself near a wood stove after a day of cross-country skiing.

When I shared this cautionary tale at my local SCI support group, others chimed in with their winter-related skin injuries. I thought I had a handle on skin protection, but this is a whole new area that I don’t recall from rehab. Are there any online resources that list potential winter skin dangers?

— Todd

A. Todd, your question brings up the importance of developing year-round awareness of potential weather-related skin dangers like heat, cold and sun exposure for areas that no longer have sensation. I was unable to find a website that details wintertime SCI skin protection, so I turned to several SCI experts, starting with Diana Elledge, a registered nurse who works on the Craig Hospital Nurse Advice Line.

She explains the primary winter threats to your skin are cold, heat and dryness that can lead to cracking. In cold weather, frostbite is arguably the most obvious skin danger, more so when sensation and blood flow in extremities are compromised by SCI. “The best way to stay warm and avoid frostbite is to put on lots of layers while your extremities are still warm,” says Elledge. “Also, don’t forget a warm hat and scarf, as we can lose a great deal of heat from our head and neck.”

To protect your hands, mittens are warmer than gloves, and silk liners inside mittens are even warmer. For your feet, in addition to wearing insulated boots, thermal socks designed to trap heat work well. In very cold weather, be sure to take frequent indoor breaks to inspect areas with no sensation for skin that looks different than usual, or has a pallor, as this can be an early sign of frostbite.

Burns are another, perhaps less obvious, cold weather danger to skin. Kathleen Dunn, a retired clinical nurse specialist and rehab case manager, laid out some of the main things to watch for to prevent burns:

Car heating — Heated car seats have been known to malfunction and cause severe burns in people with reduced sensation. Either do not use them or be extremely careful. Also, do not let your feet rest against the floor heater, and be sure heater vents on the floor of the car’s front seat do not blow directly on your feet.

Hot water — Always use an area of skin that has sensation to check the temperature of shower or bath water. Although plumbing codes state maximum water temperature from a sink, shower or bathtub fixture should be 120 degrees Fahrenheit, this can cause burns. For perspective, the human pain threshold is around 106-108 F, and 120 F water can cause a burn in 19 seconds. Use insulated mugs to avoid the danger of hot beverages spilling into the lap.

Heating devices — Do not use any type of heating pad, electric blanket, electric socks or foot warmers; hand warmers designed to be shaken and put into gloves or pockets; heated rice bags or blue ice pad on areas with no sensation. They all have the potential to cause burns. “Also, be careful using these on areas where you do have sensation. I’ve had clients that were burned when they fell asleep and had a heating pad shift to an area where they had no sensation,” says Dunn.

Proximity to heat — Stay a safe distance from fire places, space heaters, wall heaters, radiators, wood stoves and camp fires. Keep in mind that when you are in your wheelchair, your feet, shins and legs are at least two feet closer to the heat source than your face and arms, so you may not know you are too close. In addition, be aware that wheelchair parts can absorb enough extra radiant heat to cause a burn.

Vents — Don’t park your wheelchair over floor heating vents to warm up; it can cause burns on the backs of calves.

Sunburn — Be sure to put on sunscreen and wear sunglasses if you plan to be out and about on a sunny, snowy day. Snow reflects 80 percent of the sun’s rays back at us.

Since many of the potential burn dangers involve trying to get warm, it raises the question — how do you warm up safely? I find that when my legs become cold to the touch, the best way to warm them is in a warm shower or bath. Dunn suggests using a towel warmer to warm a towel or blanket for your legs, or to pre-warm your bed. Other “warm hacks” for sleeping include using flannel sheets and a down comforter, and wearing pajamas or long underwear and socks.

Keeping your skin hydrated is another challenge in cold weather. As air temperature drops, so does the moisture content. When cold air is heated, it becomes even drier, pulling moisture from the skin. “The most important thing you can do to combat dry skin is drink water, water and more water,” says Elledge. Skin is 64 percent water — dry skin is an early sign of dehydration and can lead to cracking and skin breakdown. Craig’s module on Hydration with SCI suggests drinking 12 eight-ounce glasses of water a day — that’s almost 3 liters, or three-fourths of a gallon. If you can’t do that, at least drink enough water to keep your urine in the clear to straw-colored range. As always, be sure to empty your bladder frequently enough to keep volumes below 450 cc (about two cups).

Elledge also reminds that while showering or bathing in hot water can help warm you up, it also zaps moisture from the skin. Keeping your bathing water temp lukewarm will help keep your skin soft.

Even with proper hydration, arid air can still cause dry, flaky skin. Dunn recommends a good moisturizing cream that is high in urea to help treat this. Avoid products that contain alcohol or perfumes because they can irritate the skin. Dunn has seen good success with moisturizers such as Bag Balm, as well as U-Lactin cream or lotion.

Last but not least are the dreaded, painful cracks around fingernails and fingers from pushing a manual chair in slush and snow. Dunn says the best way to prevent them is to wear waterproof gloves anytime you venture out in winter weather.

When fingers do crack, try soaking them in tepid water for five minutes and then apply a thick cream like Cetaphil hand cream. For fast healing of cracked fingers, fill the fingers of disposable vinyl or nitrile gloves with Cetaphil, and wear them overnight. This usually heals cracks within one or two applications.

Resources
• Craig Nurse Advice Line, 800/247-0257
• “Hotel Hot Water and Rental Car Burn Dangers,” newmobility.com/2012/03/hotel-hot-water-and-rental-car-burn-dangers
• “Hydration with A Spinal Cord Injury,” craighospital.org/resources/h2o-to-go-hydration