From the Guidelines
A stage three skin ulcer on the right heel of a 91-year-old male patient should be treated with a comprehensive approach focusing on wound care, pressure relief, and infection prevention, as outlined in the most recent guidelines from 2025 1. The treatment should begin with thorough wound cleansing using normal saline or a gentle wound cleanser, followed by debridement of necrotic tissue if present, which may require professional intervention by a wound care specialist.
- Apply an appropriate dressing such as alginate, hydrocolloid, or foam dressing depending on the amount of exudate, changing it every 1-3 days or as needed.
- Pressure relief is crucial - use a pressure-redistributing mattress, heel offloading devices, and ensure the patient does not lie directly on the affected heel.
- Nutritional support is essential, with adequate protein (1.2-1.5 g/kg/day), hydration, and possibly vitamin and mineral supplements if deficient.
- Monitor for signs of infection (increased pain, redness, warmth, purulent discharge, fever) and obtain wound cultures if infection is suspected, treating with appropriate antibiotics if confirmed, as suggested by the Infectious Diseases Society of America 1.
- Pain management should be addressed with appropriate analgesics. This comprehensive approach addresses the wound's physical needs while supporting the body's healing capacity through nutrition and pressure relief, which is particularly important in elderly patients who often have compromised skin integrity and healing capacity. According to the 2025 guidelines, advanced wound therapy can play a role if the wound fails to show a reduction of 50% or more after 4 weeks of appropriate wound management 1. It is also important to consider the use of hyperbaric oxygen therapy as an adjunctive treatment in non-healing ischemic diabetic foot ulcers despite best standard of care, as suggested by the IWGDF 2019 update 1. However, the use of other interventions such as topical oxygen therapy, negative pressure wound therapy, and growth factors should be considered on a case-by-case basis, taking into account the individual patient's needs and the availability of resources 1.
From the Research
Treatment Approach
To treat a stage three skin ulcer on the right heel of a 91-year-old male patient, the following steps can be taken:
- Create and maintain a moist environment on the ulcer surface, as it promotes autolytic debridement, angiogenesis, and the formation of granulation tissue, which can accelerate healing 2.
- Choose a wound dressing according to the ulcer stage, such as hydrogel or hydrocolloids for necrotic ulcers, alginate or hydrofibre for largely exuding wounds, and polyurethane foams for ulcers covered by granulation tissue 2.
- Consider surgical debridement and grafting of wounds, or negative wound pressure treatment, for large, necrotic, and infected wounds 2.
- Clarify the cause and contributing factors of the ulcer, such as pressure, venous insufficiency, poor nutrition, edema, arterial insufficiency, and anemia, which can impair wound healing 3.
- Provide adequate debridement to decrease the risk of infection and promote healing, and use guidelines for cleaning ulcers 3.
Dressing Options
The choice of dressing depends on the circumstances of each wound, but options include:
- Hydrogel or hydrocolloids for necrotic ulcers 2, 4
- Alginate or hydrofibre for largely exuding wounds 2
- Polyurethane foams for ulcers covered by granulation tissue 2
- Silver foam dressing for infected ulcers 5
- Negative Pressure Wound Therapy (NPWT) for large, necrotic, and infected wounds 6, 5
Multidisciplinary Team Approach
A multidisciplinary team (MDT) approach can be effective in treating chronic and serious diseases, including diabetic foot ulcers and stage three skin ulcers 6, 5.