Therapy should be individualized for each patient and involves more than simple wound management. Pressure ulcers are frequently a clinical sign of underlying medical conditions which should be treated to facilitate healing. Treatment takes great coordination by inpatient facilities such as nursing homes, where caretakers often use the NPUAP-designed PUSH (Pressure Ulcer Scale for Healing) tool or the Bates–Jensen Wound Assessment Tool (BWAT) to document wound healing.23,24 Photography can also be an important means of documenting improvement and should include dimensions, date, and wound location.25 Few controlled trials have evaluated specific treatment modalities for pressure ulcers, but reasonable interventions include use of basic support surfaces, repositioning the patient, optimizing nutritional status, and moisturizing sacral skin with expectations of some improvement within 2 weeks.26 The general principles of therapy for pressure ulcers are as follows.
Relief of Pressure, Shear, and Frictional Forces
Positioning techniques are critical in the management of tissue loads.
While in bed, patients should be positioned to avoid pressure over existing ulcers or over bony prominences, especially the trochanter. Pillows or foam wedges can be used to raise a pressure ulcer off its support surface or to prevent direct contact between bony prominences, such as knees or ankles. It is important to limit the amount of time the head of the bed is elevated and to maintain the head of the bed at the lowest possible level of elevation tolerable to reduce shearing forces at sacral tissues. Immobilized patients are usually placed in a 30° oblique position to the left or right, which should be alternated every 2 hours at a minimum. International best practices have validated this approach though controlled studies are still needed.
The patient and caregivers must learn appropriate transfer or mobilization techniques to avoid friction. The patient should be lifted rather than dragged across the bedsheets, using lifting devices such as a trapeze or bed linen.27 Repositioning should be done as frequently as warranted by the patient's condition.
Moisture from urinary or fecal incontinence, perspiration, or wound drainage should be minimized, and the skin should be kept clean. Absorbing underpads or briefs, diapers, and occasionally urinary catheters or rectal tubes may be required to help manage incontinence. Skin barrier creams can help protect the skin from maceration.
Patients, who are sitting, may select a pressure-relieving cushion based on specific needs. Donut-type devices should be avoided because they result in venous congestion and may worsen ulcers. Patients should be encouraged to reposition themselves frequently.
Support surfaces can be used on top of or instead of standard mattresses. They distribute pressure over a large surface area, and the type of support surface used will depend on the patient's needs and abilities. Support surfaces are typically divided into static and dynamic, the latter powered by electricity (eTable 100-3.1).
eTable 100-3.1 Special Support Surfaces for Patients with Pressure Ulcers ||Download (.pdf)
eTable 100-3.1 Special Support Surfaces for Patients with Pressure Ulcers
Thick foam mattress
Thick foam mattress overlay
Difficult to clean, not reusable for other patients
Prevention or treatment of solitary ulcers
Inflatable, waffle-shaped plastic or nylon mattress overlay
Inexpensive, very portable, usable on transport carts, easy to store, reusable
Prevention or treatment of solitary ulcers
Water-filled mattress overlay
Difficult to maintain
Prevention or treatment of solitary ulcers
A box containing glass beads and covered with a polyester sheet; the beads are fluidized by a flow of warm, pressurized air, which floats the polyester cover
Feces and body fluids flow through the sheet, frequent turning of patient unnecessary
Very expensive and heavy, generates heat, causes insensible water loss, reduces access to patient, noisy
Treatment of ulcers in functionally dependent patients with large, deep, or multiple ulcers; preferred for patients with incontinence or nonhealing wounds, or patients who are not surgical candidates
Multiple inflated fabric pillows attached to a modified hospital bed frame
Lightweight, similar to a hospital bed
Treatment of ulcers in functionally dependent patients with large, deep, or multiple ulcers; prevention of ulcers in patients in intensive care unit
Static support surfaces are recommended for patients who can assume several positions without bearing weight on an ulcer. These include specialized foam mattresses and mattresses with various fillings. They may also be overlays used atop of a base mattress.
“Low-tech” foam mattresses are the most commonly used material for pressure reduction, given their ease of use, affordability, and evidence base. A Cochrane Systematic Review examined five trials comparing foam alternatives with standard hospital mattresses, demonstrating a relative risk reduction of 60% in pressure ulcer incidence with the use of foam mattresses.28 Foam slabs should be 3–4 inches thick to effectively reduce pressure. A trial with 70 intensive care unit patients in France showed 85% risk reduction in heel ulcers in patients using a total foam body support system compared to control groups receiving standard pressure ulcer protocol including a water mattress.29
Other “low-tech” pressure supports include static supports filled with air, water, gel, silicone, polyvinyl, heel elevators, and sheepskins. Most of them permit a high degree of immersion, allowing the body to sink into the surface as it conforms to the bony prominences. This increases the surface pressure distribution area and lowers the interface pressure by transferring the pressure to adjacent areas. Unfortunately, many of the water-filled and bead-filled mattresses that demonstrated success in clinical trials are no longer available. A Cochrane Systematic Review of two trials examining the effects of sheepskins showed relative risk of 0.42 for pressure ulcer development compared to standard low-tech support surfaces.28
Patients who cannot tolerate frequent turning, immobile patients, those with large or multiple ulcers, and patients with unresponsive ulcers may require dynamic support surfaces, which are electrically powered. These provide cyclical, alternating pressure relief, and include air-fluidized, low-air-loss, and/or alternating-air beds.
Air-fluidized beds contain microspheric silicon-coated beads encased in an air-permeable fabric (polyester or Gore-Tex). The beads are suspended by pressurized streams of warmed air, which allows patients to “float” and decreases pressure through the principle of immersion while simultaneously reducing shear. Feces and body fluids flow freely through the sheet; thus, the skin is kept dry.
Low-air-loss systems use a series of connected, air-filled cushions that are inflated to specific pressures. Some have alternating and pulsating pressure features. A prospective, randomized trial demonstrated that the use of low-air-loss beds resulted in threefold faster wound healing than use of a foam mattress.30 Unlike with air-fluidized beds, urine and feces do not pass through the fabric of low-air-loss beds.
Alternating-pressure systems distribute pressure by shifting the body weight to different surface contact areas. The air is pumped into the chambers at periodic intervals to inflate and deflate them in opposite phases, which thereby changes the location of contact pressure. Though alternating-pressure systems have not been proven more efficacious than low-tech supports, a cost effectiveness analysis by the UK National Health Service associated them with 80% probability of being cost saving due to shorter hospital stays and delay in ulceration.28,31
Other pressure supports that may be of modest benefit include kinetic turning beds, operating table overlays, and seat cushions. Kinetic turning beds are primary used in ICU settings for pulmonary concerns. Operating table overlays may decrease postoperative pressure ulcer incidence and should be employed with high-risk patients undergoing long procedures.
Cleansing should be performed gently to minimize mechanical and chemical trauma to healing tissues. Normal saline is preferred because it is most physiologic in relation to the wound. Safe and effective irrigation pressures for ulcers range from 4 to 15 psi; higher pressures than this may cause trauma and drive bacteria into the wound tissue. Certain skin cleansers and antiseptics such as povidone iodine, sodium hypochlorite solution, hydrogen peroxide, acetic acid, and liquid detergents should be avoided, because these agents are cytotoxic and may retard epithelialization.
Ulcers with devitalized, necrotic tissue should be débrided, because necrotic tissue supports the growth of pathogenic organisms. Mechanical débridement techniques include application of moistened saline or wet-to-moist dressings, hydrotherapy (whirlpool), wound irrigation, and application of dextranomers. Wet-to-dry dressings changed every 4 to 6 hours are painful and are nonselective for necrotic tissue. Whirlpool devices can be considered for pressure ulcers with thick exudate, slough, or necrotic tissue. For wound irrigation, a large 35-mL syringe and 19-gauge angiocatheter can be used to provide adequate pressure.1
Sharp débridement involves the use of a scalpel, scissors, or other sharp instrument to remove devitalized tissue and is generally indicated in cases in which there is eschar. For smaller ulcers, local anesthesia can be used, whereas larger stage III or IV ulcers may require extensive surgical débridement under general anesthesia. Enzymatic débridement can be used in patients who cannot tolerate surgery. Topical agents such as sutilains, collagenase, fibrinolysin, and deoxyribonuclease can be used. Papain was removed from the market due to hypersensitivity reactions.32 Dressings should be changed once to several times daily. Contact dermatitis can sometimes occur, and these agents should not be used if tendon is exposed.2
Autolytic débridement involves the use of synthetic dressings to cover the wound, which allows digestion of necrotic tissue by enzymes normally present in wound fluids.
In addition to traditional débridement methods, the use of sterile fly larvae (maggots) to clean necrotic tissue is gaining popularity and appears to be safe and effective.
Dressings can help protect the wound from the environment, reduce or prevent wound infection, stimulate autolytic débridement, reduce wound pain, and stimulate the development of granulation tissue. It has been demonstrated experimentally that wounds maintained in a moist environment heal 40% faster than air-exposed wounds. Control of moisture and drainage from the wound helps provide an optimum wound environment for healing. There are several types of dressings, each one of which has specific properties, advantages, and disadvantages (eTable 100-3.2). Higher stage ulcers usually require more absorptive dressings to maintain a moist environment. A variety of specialized dressings may be helpful for pressure ulcer management, including a bilayer matrix wound dressing, pig-derived acellular small intestine submucosa, and natural latex biomembrane. Both the NPUAP and the EPUAP (European Pressure Ulcer Advisory Panel) state in their international pressure ulcer guidelines that gauze dressings should be avoided in clean, open pressure ulcers since they may stick to wounds, causing pain with dressing changes.24 In fact, a systematic review of 29 studies demonstrated hydrocolloid dressings to be superior to gauze in terms of pressure ulcer healing, pain associated with dressing change, absorption capacity, side effects, and cost.33
eTable 100-3.2 Summary of Wound Care Products Available for the Treatment of Pressure Ulcers ||Download (.pdf)
eTable 100-3.2 Summary of Wound Care Products Available for the Treatment of Pressure Ulcers
Woven, loose mesh cotton gauze dampened with sterile water or saline
Inexpensive, versatile (can cover even largest wounds)
Frequent dressing changes required, may dehydrate and adhere to wound, cover wrap or dressing necessary
Wounds covered by eschar; very large, irregularly shaped or multiple wounds; infected wounds
Transparent, gas-permeable polyurethane films that mimics the function of the skin
Transparent, waterproof, single dressing may remain 5–7 days
Provide no cushioning of wound
Stage I ulcers
Polyurethane semipermeable foams
Transparent, waterproof, cushion wound surface, maintain moist wound environment, absorb excess wound exudate
Cover wrap or dressing necessary
Noninfected stage II or III ulcers that are not completely covered by eschar
Self-adhesive, semipermeable or occlusive dressings composed of a hydrocolloid material that interacts with wound fluid and forms a gel that sits on the wound surface
Self-adhesive; create moist wound environment; promote autolysis, angiogenesis, and granulation; single dressing may remain in place 5–7 days; little nurse care required
May fall off highly exudative wounds, can melt and stick to clothing or bedding
Noninfected stage II or III wounds with light to moderate exudate; ideal for smaller, solitary ulcers
Amorphous, water- or glycerin-based gels composed of a three-dimensional hydrophilic polymer
Highly absorbent, transparent, conform to wound surface, can be used for stage IV ulcers
Dehydrate easily, require additional cover wrap or dressing
Stage II to IV ulcers with moderate drainage
Highly absorbent material derived from seaweed
Highly absorbent, conform to wound shape
Cause desiccation of the wound, require additional wrap or dressing
Stage III to IV ulcers with copious drainage
Composed of sodium carboxymethylcellulose; antibacterial substances such as silver can be incorporated into the dressings
Highly absorbent (more than alginates), packed into cavity, single dressing may remain in place up to 7 days if no active infection
Cause desiccation of the wound, require additional wrap or dressing
Heavily exuding, infected deep wounds, cavities, and fistulas
Contain nanocrystalline silver, some may contain charcoal (absorbs odor)
Have antimicrobial activity, provide prophylaxis of recurrent infection
Cannot be used concomitantly with papain-containing dressings or in those with silver allergy, require frequent change, require additional wrap or dressing
Wounds with active infection or colonized by large bacterial load
Contain cadexomer iodine
Have antimicrobial activity, absorb drainage
Cannot be used in those with iodine sensitivity or thyroid diseases, not effective in dry wounds, require additional wrap or dressing
Exuding, infected wounds
Intact skin surrounding the ulcer should always be assessed for signs of inflammation and infection. Irritation of surrounding skin may result from epidermal skin stripping during dressing changes or maceration secondary to contact with feces, urine, or wound drainage. Periwound skin must be adequately moisturized but neither macerated nor eroded.28 A randomized clinical trial of 331 patients over a 30-day period demonstrated pressure ulcer incidence was 7.32% in a group of patients treated twice daily over high-risk sites with Mepentol, a hyperoxygenated fatty acid preparation, compared with 17.37% in the placebo group treated with a generic greasy product. In addition, Mepentol, comprised of such compounds as oleic acid, linoleic acid, arachidonic acid, and eicosenoic acid was found to be cost effective.34 Creams or gels containing metronidazole, balsam of Peru, trypsin, and recombinant human platelet-derived growth factor are also available.
Bacterial Colonization and Infection Management
Ulcer cleansing and débridement are important to control microbial burden in pressure sores. Systemic antibiotic therapy is not recommended for contamination or minor localized infections but is indicated when bacteremia, cellulitis, or osteomyelitis is present.
Topical antibiotics are used to prevent or treat wound infection, reduce bacterial load, or reduce odor and signs of inflammation. Topical antibiotics such as neomycin and bacitracin are common allergens and can cause contact dermatitis and, rarely, anaphylaxis. Topical formulations of antibiotics that are used systemically (e.g., gentamicin) should be avoided because bacterial resistance may develop. However, the Agency for Healthcare Research and Quality guideline recommends a short 2-week course of topical antibiotics for a clean ulcer that is not healing or that is producing a moderate amount of exudate despite appropriate care.35 The use of topical metronidazole 1% solution or 0.75% or 0.80% gel has gained popularity in reduction of wound odor, though randomized controlled trials are still needed to prove efficacy.36
Pain management requires a combination of conservative measures, medications, and appropriate wound care. Muscle relaxants and physical and occupational therapy may be helpful to decrease muscle spasm in the area of ulceration. Transcutaneous electrical nerve stimulation may help relieve acute and chronic pain. The use of topical anesthetics such as lidocaine-prilocaine cream on wounds 30 minutes before débridement significantly reduces pain associated with wound care procedures. An opiate diamorphine gel was also shown to significantly reduce pain with dressing changes in a small randomized controlled trial of patients with stage II and III ulcers.37
Nonopioid analgesics (aspirin, other nonsteroidal anti-inflammatory drugs) are first-line systemic therapy, followed by stronger medications such as opioids. Adjuvant medications such as tricyclic antidepressants can be used to enhance analgesia.37 They can also improve depression in some chronic pain states and have sedative, sleep-enhancing qualities.
Screening for nutritional deficiencies is an important part of assessment and management of pressure ulcers. Adequate patient dietary intake of protein is important in healing pressure ulcers.38
A reasonable protein amount is between 1.2 and 1.5 g/kg/day, and caloric intake should be between 30 and 35 kcal/kg/day. Vitamin C or zinc deficiency can have negative effects on wound healing, but supplementation is useful only when deficiency is confirmed or suspected. If dietary intake continues to be inadequate, oral or parenteral nutritional supplementation may be required. A study of 672 critically ill patients showed that oral supplementation of 400 kcal/day resulted in 17% risk reduction for the development of pressure ulcers.39
Markers of nutritional deficiency include a serum albumin
level of less than 3.5 mg/dL and unintentional weight loss of more than 15% of baseline. Patients should be kept adequately hydrated.
The long-term efficacy of surgical repair of pressure ulcers, especially in older patients, has been questioned because of high recurrence rates and mortality. The decision to undertake surgical repair should be made with full knowledge of the risks and benefits, surgical and nonsurgical alternatives, and complications associated with each procedure. Surgical techniques include skin grafting; creation of cutaneous, muscle, and fasciocutaneous flaps or pedicled flaps; microvascular free tissue transfer reconstruction; and simple direct suture, depending on the site, number, and grade of lesions, and the patient's clinical condition. In general, surgery is often required for stage IV ulcers, whereas more superficial ulcers may heal with conservative therapy.
Adjunctive therapies have been used in case studies, but more data are needed to determine the effectiveness of these therapies, which include ultrasound, electromagnetic therapy, electrical stimulation, negative pressure (vacuum-assisted closure), monochromatic phototherapy, and honey.40
Whenever possible, others factors that impair healing such as smoking; hypovolemia; cold; chronic diseases including diabetes mellitus, systemic arterial hypertension, anemia, and vascular alterations; and the use of medications such as corticosteroids should be limited or controlled.