From the Research
Topical treatments alone are not sufficient for stage four pressure ulcers. These advanced ulcers require a comprehensive approach including surgical debridement, systemic antibiotics if infected, nutritional support, pressure offloading, and advanced wound care. For wound care, after thorough debridement, appropriate dressings such as calcium alginates, hydrocolloids, or negative pressure wound therapy (wound VAC) should be used based on wound characteristics. Topical antimicrobials like silver sulfadiazine or cadexomer iodine may be used for colonized wounds, but not as standalone treatments. Moist wound healing principles should be maintained with dressing changes typically every 1-3 days depending on exudate levels. Stage four ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, making them too severe for topical treatments alone to be effective. These deep wounds require addressing underlying causes, managing tissue damage, preventing infection, and supporting the body's healing mechanisms through multiple interventions simultaneously. Recovery typically takes months and may require plastic surgery consultation for skin grafts or flaps in severe cases. According to a study published in 1, the evidence for topical treatments in pressure ulcers is of low or very low certainty, and it is unclear whether particular dressings or topical agents improve the probability of healing of pressure ulcers. Another study published in 2 found that silicone dressings may reduce pressure ulcer incidence, but the evidence is of low certainty. A comprehensive treatment protocol, as described in 3, is essential for the successful treatment of pressure ulcers, and includes recognizing the risk of pressure ulcers, daily assessment of the skin, objective measurement of every wound, and immediate initiation of a treatment protocol.
Some key points to consider when treating stage four pressure ulcers include:
- Surgical debridement to remove non-viable tissue
- Systemic antibiotics if the ulcer is infected
- Nutritional support to promote wound healing
- Pressure offloading to reduce further pressure on the ulcer
- Advanced wound care, including the use of appropriate dressings and topical antimicrobials
- Moist wound healing principles to promote a conducive environment for wound healing
- Regular dressing changes to maintain a clean and moist wound environment
- Consideration of plastic surgery consultation for skin grafts or flaps in severe cases.
It is essential to note that the treatment of stage four pressure ulcers requires a multidisciplinary approach, and the patient's overall health and well-being should be taken into consideration when developing a treatment plan. As stated in 1, the network meta-analysis is uninformative regarding which interventions might best be included in a large trial, and it may be that research is directed towards prevention, leaving clinicians to decide which treatment to use on the basis of wound symptoms, clinical experience, patient preference, and cost.