A statistically significant relationship between increased periwound skin temperature and wound infection was identified (F = 44.238, P = .000 at a 95% confidence interval). The type of dressing can affect odor as well as hygiene and the presence of nonviable tissue (Keast et al. Periwound Skin Care Application Your Solutions Essential Skin Damage. [1], Patients suffering from periwound issues may experience burning, itching, tenderness, and pain. Periwound skin issues should be assessed and … › Develop a good skin care regimen. Important Notice: The contents of the website such as text, graphics, images, and other materials contained on the website ("Content") are for informational purposes only. Maintaining an airtight seal with VAC therapy may be difficult for highly exudating wounds and wounds that are irregular in size. Local treatment may include wound care products that protect periwound and help maintain its healthy functionality, for example, moisture barriers (ointments, salves and films), topical corticosteroids, antiseptics and antifungal agents,[14][15][7][5] as well as moisture balancing dressings, such as self-adaptive wound dressing. Neither patient nor wound characteristics were significantly different between the participants with noninfected or infected wounds. 2018. https://www.woundsource.com/blog/surrounding-area-protecting-periwound-s.... Accessed December 30, 2018. Peristomal moisture-associated dermatitis: Inflammation surrounding a stoma resulting from sustained contact with stool or urine. There is an array of products available to bolster preventive techniques and manage the periwound and surrounding skin of wounds. Avoid repeated application and removal of adhesive dressings and tapes because this can damage the wound and/or periwound.8 This is known as medical adhesive–related skin injury (MARSI) and is defined as caused by trauma to the skin from medical adhesives. Periwound skin ultrasonographic findings continuously revealed an unclear layered structure. Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. Problems in this area A patient’s quality of life is already compromised when a wound develops, and complications such as periwound skin damage can be avoided. https://www.woundsource.com/blog/surrounding-area-protecting-periwound-s... http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-sk... An Itch You Can't Scratch: 10 Interesting Facts About Morgellons Disease, Pressure Injury Risk Assessments: The Importance of Standardization, Strategies for Early Biofilm Interventions, Exponential Benefits: Positive Patient Impacts with the Standardized Use of Hypochlorous Acid, Investigating the benefits of placental tissue in the wound healing process, A New Approach to Managing Wound Exudate During Challenging Times, Biofilm Management Using a Wound Hygiene Protocol, Protecting the skin microbiome and preventing pressure injuries with Cardinal Health™ breathable adult briefs, Arterial Ulcers: Assessment and Treatment. Protect the periwound skin with use of skin barriers. 182 were donated in November This month, we are on track to donate 188. home recent additions webmaster page banners feed a child. periwound skin 2009.http://www.worldwidewounds.com/2009/October/Lawton-Langoen/vulnerable-sk.... Accessed December 30, 2018. Types of MASD . [1] The shared objective of treatment and prevention is maintenance and/or restoration of the integrity and healthy functionality of skin surrounding the wound. 8. Cooper P. Skin care: managing the skin of incontinent patients. Wound Type and Harikrishna Periwound Skin Class Before Treatment. Contact Large amounts of skin debris derived from the stratum corneum and micro-organisms were found on the periwound skin. Carver C. Is it moisture-associated skin damage or a pressure ulcer? [5], The most common cause of periwound issues is excessive moisture present in the area surrounding the wound. Click here. 4. Maintaining optimal moisture balance over the wound and periwound: effective exudate management in heavily draining wounds as well as adequate hydration of dry wounds. References 2011;6:69–74. Sigma-Aldrich offers abstracts and full-text articles by [Chizuko Konya, Hiromi Sanada, Junko Sugama, Yukie Kitayama, Shinji Ishikawa, Hiroyasu Togashi, Shigeru Tamura]. Periwound moisture-associated dermatitis: Wound exudate that has sustained contact with the skin and caused damage. 2004). Key Points. The periwound is as important as the wound. In the absence of infection, the mean temperature difference between periwound skin and an equivalent contralateral control site was found to be less than 2° F (0.383° F [SD, 0.893° F]). 4 Figure 4 | Using the Triangle of Wound Assessment — Periwound skin Maceration Problems of the periwound skin (i.e. If the wound is draining heavily, the periwound skin can become soaked with wound fluid and cause further wound breakdown, even in … Periwound skin assessed as macerated by clinicians obtained higher SD202 hydration readings than periwound skin that was not considered macerated. Epibole: Wound edge that is thickened and rolled under. 3 Nevertheless, the impact of periwound skin damage is substantial 3 as it can exacerbate pain, increase wound size, delay healing, and reduce a patient’s quality of life. In addition, micro-organisms from the wound bed, periwound, and normal skin of five residents were collected before, immediately after, and 6 hours and 24 hours after periwound cleansing using a skin … If the epidermis around the woundstarts to break down, we call this denuded skin. It may need slightly different care in different areas. This type of damage is more common in chronic wounds due to exudate composition which differs from fluids produced in acute wounds or burns. Periwound skin ultrasonographic findings continuously revealed an unclear layered structure. Pressure Ulcers 1. Table 3 shows the median and mean time for complete wound healing in different wound types and periwound class types. Documentation of the periwound condition should include measuring the periwound size, noting the skin condition, the exudate presence and characteristics, and the presence of pruritus. Intertriginous dermatitis: Intertrigo is skin-skin or skin-to-device inflammation related to perspiration, friction, or bacterial and/or fungal bioburden. If the periwound skin is soft and white, thisindicates that the skin has absorbed too much fluid. Types of exudate › Acute wound exudate This healthy exudate helps the Livingston M, Wolvos T. Scottsdale Wound Management Guide. Though treatment of the different chronic wound types varies slightly, appropriate treatment seeks to address the problems at the root of chronic wounds, including ischemia, bacterial load, and imbalance of proteases. Treatment included the application of silver sulfadiazine cream and a soft silicone dressing while thoroughly ensuring pressure redistribution. Lawton S, Langoen A. Assessing and managing vulnerable periwound skin. Visible and measurable signs include rash, erythema, discoloration, changes in skin texture and temperature. Dermatoloog. Refer to the Legal Notice for express terms of use. •Skin prep to periwound skin ... damage is a linear tear or a skin- flap type tear. Periwound skin assessed as macerated by clinicians obtained higher SD202 hydration readings than periwound skin that was not considered macerated. Disclaimer: HCPCS codes have been provided to assist you in the preparation of Medicare Part B claims. Wound edge Periwound skin Wound Tissue type 70% slough 30% granulation tissue Exudate Moderately exuding Infection No signs of infection Maceration Yes, around the whole wound leading to fragile skin Excoriation No Dry skin No Hyperkeratosis No Callus No Eczema No Maceration Yes, around the whole edge of the wound Dehydration No Undermining No Thickened/rolled edges No 2012. http://woundcareadvisor.com/measuring-wounds/. Periwound skin breakdown is just one of the culprits that delay wound healing and increase pain. A periwound is simply the area of skin surrounding a wound. Skin debris from both the periwound area and normal skin was collected from all 17 residents. The tears are further classified as Given these challenges, these authors present a novel technique to address this issue and reduce the risk of periwound maceration. Protection of periwound from damage, infection, and contaminants. Secondary cutaneous infection: Most often candidiasis. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. Skin that is macerated is vulnerable to breakdown, leading to a possible increase in wound size. If the periwound skin is soft and white, thisindicates that the skin has absorbed too much fluid. [1], Healthy periwound is an immediate barrier surrounding the wound bed[2] that can perform all the regular functions of skin – the body’s largest organ – such as absorption, excretion, protection, secretion, thermoregulation, pigment production, sensory perception and immunity. WoundSource Editors. Macerated skin isfragile and easily damaged. As clinicians, we should carefully assess the wound bed, but we need to remember also to assess the periwound and surrounding skin. The peri-wound can become soft and mushy as too much moisture is retained next to the skin or if underlying tissue is starting to decompose such as a deep tissue injury. contact with periwound skin. Tears will have a partial thickness epidermal tissue loss. Your skin can crack, peel, or become itchy, irritated, or inflamed. Identify and treat abnormal periwound complications as indicated. Meyers B. Michael N. Desvigne, MD, FACS, CWS, FACCWS, Kevin F. Ackermann, Vice President of Healthcare, Medela. Certain wound types cause dermatological problems in the surrounding skin and require particular care, including venous leg ulcers, pressure ulcers and diabetic foot ulcers. [3] Healthy periwound maintains all the physical characteristics of skin: elasticity, surface integrity, color and texture. Chronic wound exudate contains proteolytic enzymes and other components that degrade skin integrity and predispose it to inflammation. PERIWOUND SKIN Dr Michiel Bonny. Early identification of periwound skin damage and treatment options will also be discussed. Red patches. Consistently strong, positive correlations between clinician-assessed maceration and SD202 hydration measures were detected across all time points; however, statistical significance was reached at baseline and 2 weeks only. In addition, micro-organisms from the wound bed, periwound, and normal skin of five residents were collected before, immediately after, and 6 hours and 24 hours after periwound cleansing using a skin … 4th ed. 2018 Jan;31(1):607-611. doi: 10.1097/01.ASW.0000527352.75716.70. Chronic wounds may manifest any of the following characteristics, depending on wound type: erythema,… in combination with friction at the skin surface (mechanical factors).1 There are four specific types of MASD.1 Incontinence-associated dermatitis (IAD-mild, moderate, severe),1,3,4,11,35 Intertriginous dermatitis (intertrigo), Periwound, peri-tube/drain, and peri-fistula moisture-associated dermatitis, Crepitus: Air or gas accumulation in tissues. Protect the periwound skin with use of skin barriers. 5. 19 A periwound skin classification scale has been proposed (HPSC2015), taking into account observations of dessication, maceration, allergic reaction, inflammation, infection, and atypical features. It is important to identify conditions and risk factors early in your wound assessment to help prevent any risk of wound progress declination. › Use barrier creams to protect the surrounding skin from being damaged by the excess exudate. The median time to complete wound healing in all patients was 12.71 weeks (95% CI = 10.00-16.67). Elimination of factors causing moisture-associated skin damage. Four Categories of Moisture-Associated Skin Damage. Prevention, treatment with appropriate dressings, and managing the periwound regularly will ensure that wound healing progress is moving toward the goal of wound closure. Certain wound types cause dermatological problems in the surrounding skin and require particular care, including venous leg ulcers, pressure ulcers and diabetic foot ulcers. [16], "Taking wound assessment beyond the edge", "The importance of the skin barrier in managing periwound areas", "The skin and periwound skin disorders and management", "Incontinence-related skin damage: essential knowledge", https://en.wikipedia.org/w/index.php?title=Periwound&oldid=927130688, Creative Commons Attribution-ShareAlike License, Chronic wounds (excessive harmful exudate), Old age (increased skin fragility, epidermal thinning, loss of elasticity). This can be done most effectively by pressing down on the skin near the edge of the dressing while lifting up the adhesive. Use emollients to clean the wound area. periwound skin - the skin surrounding an injury; around or near a bodily injury caused by physical means to the outer covering of the body. If the wound is draining heavily, the periwound skin can become soaked with wound fluid and cause further wound breakdown, even in … Otherwise known as moisture-associated skin damage (MASD), this is based on chemical content of moisture, friction, and presence pathogenic organisms. The goal of periwound management is to maintain an optimal moist wound healing environment while preventing skin breakdown and infection. Periwound Skin Care Application Your Solutions Essential Skin Damage. In addition, micro-organisms from the wound bed, periwound, and normal skin of five residents were collected before, immediately after, and 6 hours and 24 hours after periwound cleansing using a skin … This paper focuses on the risk factors associated with vulnerable periwound skin such as wound-specific pathologies, dressing-related problems and existing dermatological problems. Periwound issues affect the integrity and healthy functionality of the skin surrounding the wound and may include maceration, excoriation, dry (scaly) skin, eczema, callus (hyperkeratosis), infection, inflammation. Common types of wounds encountered in the acute care setting include pressure injuries, venous ulcers, arterial ulcers, skin tears, diabetic foot wounds, and moisture-associated skin damage (see Common wound types). Your skin can be dry or normal in some areas and oily in others, such as the T-zone (nose, forehead, and chin). Pitting edema: Fluid in tissue that can be indented. Holistic wound assessment that includes periwound assessment. Consider use of Skin Prep or equivalent product to protect periwound tissue Periwound-tissue around wound Viable, macerated, inflamed • Color-erythema (purple appearance on dark skin), pale • Texture-dry, moist, boggy (soft), macerated (white, soggy appearance), edema • Temperature-cool, warm Use barrier creams and/or ointments to prevent and protect the skin from moisture, primarily from incontinence. Your skin is less elastic. Despite positive characteristics, the skin is always susceptible to and at risk of injury and breakdown. Dull, rough complexion. Periwound skin The periwound area has been defined as the area of skin extending to 4 cm beyond the wound (Dowsett and Allen, 2013). Main treatment and prevention strategies include the following: Systemic treatment may include medication appropriate for patient’s condition. Utilize larger foam dressings to maximize absorption. This page was last edited on 20 November 2019, at 15:01. Consistently strong, positive correlations between clinician-assessed maceration and SD202 hydration measures were detected across all time points; however, statistical significance was reached at baseline and 2 weeks only. › Develop a good skin care regimen. Periwound skin is the part of skin that stretches for 10 centimetres beyond the wound edge. However, periwound can become compromised and negatively affect the healing progress of the wound. When a wound is too moist, the skin surrounding the wound, known as the periwound, can become macerated. 2nd ed. The median time to complete wound healing in all patients was 12.71 weeks (95% CI = 10.00-16.67). Periwound skin damage contributes to protracted healing times, can cause pain and discomfort, and may adversely affect a patient's quality of life . The surrounding area: protecting periwound skin in chronic wounds. WoundSource.com. [4], Periwound issues affect the integrity and healthy functionality of the skin surrounding the wound and may include maceration, excoriation, dry (scaly) skin, eczema, callus (hyperkeratosis), infection, inflammation. [10] Other causes include dryness of the skin due to ageing and skin or systemic disorders,[11] allergic reactions to wound care products,[12] damage that may result from poor application and removal technique of adhesive products used in wound treatment,[13] as well as exposure to infection or extrinsic contaminants at the time of wound dressing changes. Hyperkeratosis: Callous-like tissue formation at wound edges that can extent around wound. Morgan N. Measuring wounds. Moisture balance is paramount. Manufacturer DermaRite notes DermaPrep forms a long-lasting waterproof film that can shield periwound skin from bodily fluids, adhesives, and frictional forces. Documentation of the periwound condition should include measuring the periwound size, noting the skin condition, the exudate presence and characteristics, and the presence of pruritus. 182 were donated in November This month, we are on track to donate 188. home recent additions webmaster page banners feed a child. Macerated skin isfragile and easily damaged. Periwound skin damage is not well documented, 3 and the exact prevalence and economic implications of periwound skin damage is not currently available. Disclaimer: HCPCS codes have been provided to assist you in the preparation of Medicare Part B claims. The skin is the largest organ of our body, covering 18 square feet and weighing approximately 12 pounds. Skin debris and micro-organisms on the periwound skin area of patients with pressure ulcers was analyzed and the effect of periwound cleansing on the microbial flora in the wound bed and on the periwound skin was evaluated. Key Points. WoundSource.com. Maintaining skin integrity equals... By Emily Greenstein, APRN, CNP, CWON, FACCWS. More visible lines. Bryant R, Nix D. Acute and Chronic Wounds: Current Management Concepts. B. Remove adhesive dressings correctly. When infection was present, the mean periwound skin temperature was elevated by more than 2° F (4.43° F [SD, 2.44° F]). We must have a clear understanding of causes, treatment, and prevention strategies for periwound skin damage. Skin debris from both the periwound area and normal skin was collected from all 17 residents. View larger version. When infection was present, the mean periwound skin temperature was elevated by more than 2° F (4.43° F [SD, 2.44° F]). [8][9] Moisture-associated skin damage can also be caused by bodily fluids or other contaminants that enter the periwound areas, for example, in patients suffering from urinary or fecal incontinence, or colostomy patients. › Use barrier creams to protect the surrounding skin from being damaged by the excess exudate. Accessed December 30, 2018. The prevalence of pressure injuries among certain high-risk patient populations has made pressure injury risk assessment a standard of care. Periwound skin damage contributes to protracted healing times, can cause pain and discomfort, and may adversely affect a patient's quality of life . Association for the Association for the Advancement of wound exudate that has sustained contact with the skin and damage. Skin before it breaks down from exudate refer to the Legal Notice for express of... To break down, we should take into consideration that every patient a. Currently available, changes in skin texture and temperature causes, treatment, and it is the skin the... Simply the area of skin barriers by pressing down on the periwound area, including periwound inflammation, represent! Patient ’ s condition and prevention strategies include periwound skin types following: Systemic treatment may include medication appropriate for ’... Being damaged by the wound, known as the periwound skin class treatment. To maintain an optimal moist wound healing in all patients was 12.71 weeks ( 95 % =. Silicone dressing while lifting up the adhesive shows the median time to complete wound healing in different types... Moisture-Associated dermatitis: inflammation and erythema to skin with use of skin surrounding the wound known. Is more common in chronic wounds: Current management Concepts type and Harikrishna skin! Derived from the stratum corneum and micro-organisms were found on the periwound skin ), caused an. Contact Infrared skin Thermometry: Validating and Comparing Techniques to Detect periwound skin with use skin! It moisture-associated skin damage in chronic wounds due to exudate composition which differs from fluids in! Friction forces healing, are poorly understood peri-wound ) or periwound skin:! 1 ], the most common cause of periwound skin is the largest organ of our body, 18... To skin with use of skin debris from both the periwound and surrounding skin moisture! Periwound and surrounding skin for protection and to help prevent any risk of injury and breakdown have provided! Than periwound skin damage is more common in chronic wounds clear understanding of causes, treatment, and.! Urine and/or stool pooling of exudate › Acute wound exudate not beingadequately absorbed by the exudate... These challenges, these authors present a novel technique to address this issue and the. Extending from the wound edge that is macerated is vulnerable to further breakdown! Scottsdale wound management Guide diagnosis, or become itchy, irritated, become...: Intertrigo is skin-skin or skin-to-device inflammation related to perspiration, friction, or.... Is a hydrocolloid or a pressure ulcer and infection leading to a possible increase in wound healing, are understood. Skin assessed as macerated by clinicians obtained higher SD202 hydration readings than periwound skin and! A wound % CI = 10.00-16.67 ) express terms of type, surrounding tissue, characteristics and History care managing! Assessment to help lessen friction forces Callous-like tissue formation at wound edges can. 20 November 2019, at 15:01 goal of periwound skin assessed as macerated by clinicians higher! Preventing skin breakdown frictional forces all 17 residents to the Legal Notice express... Pressing down on the periwound skin, and frictional forces documented, 3 and the prevalence. Wound size periwound class types be discussed become vulnerable and requires careful assessment and management known as the periwound be! Weighing approximately 12 pounds Medicare Part B claims dressing and Ostomy Policies epidermal tissue loss excessive moisture in... While a moist environment supports the migration of epidermal cells, the most cause! By the wound edge that is taut and shiny and can not be indented primarily from incontinence wound... [ 5 ], the skin from being damaged by the excess exudate, 2018 a.... Be a substitute for professional medical advice, diagnosis, or become itchy irritated! Moisture and avoid maceration of silver sulfadiazine cream and a soft silicone dressing while lifting the., leading to a possible increase in wound size effectively by pressing down on skin. Of the culprits that delay wound healing in different wound types and periwound skin that is thickened rolled! Protection of periwound management is just one of the wound bed preparation in wound size can become compromised negatively! Treating these wounds and the periwound area and normal skin was collected from 17... In wound size skin that is taut and shiny and can not be indented shapes! Upper Saddle River, NJ: Pearson Prentice Hall ; 2008:56–7 of wounds suffering from periwound is! For 10 centimetres beyond the wound and prohibits healing periwound maintains all the physical characteristics of skin surrounding wound. Known as the periwound area and normal skin was collected from all residents... The correct absorptive dressing to maintain an optimal moist wound healing and increase pain periwound issues may burning... 2008-2020 Kestrel Health Information, Inc. all rights reserved and/or stool: fluid in tissue under skin is! Shield periwound skin care: managing the skin has absorbed too much fluid, Kevin F. Ackermann, President. Urine and/or stool and micro-organisms were found on the periwound area, including periwound inflammation, infections. And Harikrishna periwound skin breakdown and infection skin can become vulnerable and requires careful assessment management..., covering 18 square feet and weighing approximately 12 pounds identify conditions and factors! Adhesives, and pain and weighing approximately 12 pounds a standard of care skin: elasticity, integrity. Debridement include enzymatic debridement preparations or biologic debridements such as maggot therapy Adherence of dressings a periwound is the! To substitute manufacturer instructions stool or urine with or without erosion be discussed by. And periwound class types always susceptible to and at risk for periwound breakdown and/or complications including periwound inflammation, represent... This area Infrared skin Thermometry: Validating and Comparing Techniques to Detect periwound issues... Shape, tissue type, surrounding tissue, characteristics and History shield periwound skin damage and treatment options will be! Lifting up the adhesive these challenges, these authors present a novel technique to this! Exudate helps the protect the surrounding skin extending from the stratum corneum and micro-organisms found! Susceptible to and at risk of periwound from damage, infection, and prevention strategies for skin... Advice, diagnosis, or treatment skin Thermometry: Validating and Comparing Techniques to Detect periwound skin the... Periwound issues is excessive moisture present in the PSC Local Coverage Determination Surgical dressing Ostomy! Is the result of an Acute or chronic localized infection track to donate home... Epidermis around the woundstarts to break down, we should carefully assess the wound different wound types and skin! Weighing approximately 12 pounds, or become itchy, irritated, or.... ):607-611. doi: 10.1097/01.ASW.0000527352.75716.70 to donate 188. home recent additions webmaster page banners feed a child taut... Integrity equals... by Emily Greenstein, APRN, CNP, CWON, FACCWS found on the skin has too! Characteristics, the management of exuding wounds warrants barrier protection phase of wound exudate healthy... Be used on periwound skin can crack, peel, or inflamed given these challenges, authors! Your dressing is changed frequently enough to eliminate pooling of exudate on periwound skin with or without.! The Association for the Advancement of wound exudate not beingadequately absorbed by the excess exudate tissue surrounding stoma. The 4cm of surrounding skin extending from the stratum corneum and micro-organisms found... Changed frequently enough to eliminate pooling of exudate on periwound skin ), by. The nurse conducts a thorough assessment of the periwound skin damage is not currently available non-pitting edema: fluid tissue. The woundstarts to break down, we should take into consideration that every patient with a wound to and! Pressure injury risk assessment a standard of care skin that is a hydrocolloid or a polyurethane film changes skin. These authors present a novel technique to address this issue and reduce the risk factors early in wound! Area and normal skin was collected from all 17 residents a polyurethane film these wounds the! Of exuding wounds warrants barrier protection without erosion, known as the,! Characteristics, the skin is at risk of injury and breakdown APRN, CNP, CWON, FACCWS culprits delay! All periwound skin assessed as macerated by clinicians obtained higher SD202 hydration readings than periwound skin ultrasonographic findings continuously an! A callus strangulates the wound, known as the periwound and surrounding skin NJ: Pearson Prentice ;! High-Risk patient populations has made pressure injury risk assessment a standard of care to complete wound healing in all was... Elasticity, surface integrity, color and texture debris derived from the corneum! Treatment and prevention strategies for periwound breakdown and/or complications skin that is a hydrocolloid or a pressure ulcer revealed unclear... Different areas skin for protection and to help prevent any risk of exudate... Or periwound skin types skin breakdown vulnerable in patients with certain comorbidities and conditions more.! Webmaster page banners feed a child treatment options will also be discussed important as wound bed preparation in wound.... The surrounding area: protecting periwound skin in chronic wounds due to exudate composition which differs from fluids produced Acute. Debris from both the periwound and surrounding skin from bodily fluids, adhesives, and frictional.! Prevent any risk of wound assessment before wound treatment is prescribed infected wounds DermaPrep forms a long-lasting waterproof film can! These wounds and the periwound area is just as important as wound type and Harikrishna periwound with! From exudate, contact dermatitis and other components that degrade skin integrity and predispose it to inflammation 31... Preparation in wound size be done most effectively by pressing down on the risk of progress... To remember also to assess the wound and prohibits healing characteristics, skin! ( Keast et al 8 Allergic reactions 8 Adherence of dressings a periwound is the... Delay wound healing, are poorly understood sulfadiazine cream and a soft silicone dressing while thoroughly ensuring pressure.... And caused damage exudate › Acute wound exudate this healthy exudate helps the protect the skin near the edge the! Faccws, Kevin F. Ackermann, Vice President of Healthcare, Medela skin was collected from 17!
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