Treatment of Pressure Ulcers (Bedsores)
Use hydrocolloid or foam dressings as your primary wound treatment, supplement with protein or amino acids if the patient has nutritional deficiencies, and consider electrical stimulation as adjunctive therapy to accelerate healing. 1
Core Treatment Algorithm
1. Wound Dressing Selection
- First-line choice: Hydrocolloid or foam dressings reduce wound size better than gauze dressings 1
- Hydrocolloid and foam dressings perform equivalently for complete wound healing
- Avoid: Gauze dressings are inferior for wound size reduction
- Do not use expensive alternatives: Advanced dressings like platelet-derived growth factor (PDGF) cost more without sufficient evidence of superiority over hydrocolloid/foam options 1
2. Nutritional Support
- Add protein or amino acid supplementation specifically for patients with nutritional deficiencies 1
- This intervention reduces wound size when combined with standard dressings
- Important caveat: Evidence comes from studies of nutritionally deficient patients—do not assume all pressure ulcer patients need supplementation
- Vitamin C supplementation shows no benefit compared to placebo 1
3. Adjunctive Electrical Stimulation
- Consider adding electrical stimulation for stage 2-4 ulcers to accelerate healing rate 1
- This has moderate-quality evidence supporting faster wound healing
- Watch for: Skin irritation (most common adverse effect)
- Caution in: Frail elderly patients are more susceptible to adverse events 1
4. Pressure Relief
- Address the underlying cause by ensuring proper pressure redistribution
- Air-fluidized beds show superiority over standard hospital beds for reducing ulcer size 1
- Do not routinely use: Alternating-air or low-air-loss beds lack sufficient evidence and add unnecessary costs 1
What NOT to Do
Avoid these interventions with insufficient or negative evidence:
- Alternating-air or low-air-loss mattresses (expensive without proven benefit) 1
- Hyperbaric oxygen therapy (insufficient evidence despite common use) 1
- Zinc or L-carnosine supplementation (insufficient evidence) 1
- Topical phenytoin, maggot therapy (insufficient evidence) 1
- Most antiseptics and antibiotics show no clear healing benefit and may actually reduce healing rates (povidone iodine performed worse than non-antimicrobial alternatives) 2
Evidence Quality and Clinical Reality
Critical limitation: All three main recommendations from the American College of Physicians carry weak recommendation grades with low-to-moderate quality evidence 1. The relationship between wound size reduction and complete healing remains poorly defined 1.
The evidence base is sparse: Most studies are small, short-duration, and at high risk of bias 3. A 2017 Cochrane network meta-analysis of 39 studies concluded they were "unable to determine which dressings or topical agents are most likely to heal pressure ulcers" 3.
Practical Implementation
Given the weak evidence, focus on:
- Hydrocolloid or foam dressings (cost-effective, some evidence of benefit)
- Protein supplementation if nutritional assessment reveals deficiency
- Electrical stimulation if resources permit and patient tolerates it
- Aggressive pressure relief through repositioning and appropriate support surfaces
When Ulcers Become Chronic
For stage 3-4 ulcers that fail to heal despite optimal management:
- Shift goals from healing to symptom control (odor, pain, infection prevention) 4
- Consider palliative wound care approaches 5
- Surgery may be considered for advanced-stage ulcers, though evidence comparing surgical techniques is insufficient 1
- Common surgical complication: Dehiscence occurs in 12-24% of cases, more frequently when bone is removed or with ischial ulcers 1
Multidisciplinary Approach Required
Pressure ulcer treatment requires coordination between nurses (wound assessment, dressing changes), physicians (medical management), dietitians (nutritional optimization), and physical/occupational therapists (mobility, positioning) 1.