What is the recommended topical treatment for sacral excoriation/erythema?

Topical Treatment for Sacral Excoriation/Erythema

The recommended first-line topical treatment for sacral excoriation/erythema is a barrier cream containing dimethicone applied after gentle cleansing, with the addition of a low to medium potency topical corticosteroid for inflammatory components. 1, 2

Assessment and Classification

Before initiating treatment, assess the sacral area for:

• Severity of erythema (blanching vs. non-blanching)
• Presence of excoriation or skin breakdown
• Signs of infection
• Contributing factors (moisture, incontinence, pressure)

Treatment Algorithm

Step 1: Cleansing

• Clean affected area gently with a mild, non-irritating cleanser
• Pat dry or allow to air dry (avoid rubbing)
• Remove any adhesive residue completely 1

Step 2: Topical Treatment Selection

For Mild Erythema without Excoriation:

• Apply dimethicone-based barrier cream after each cleansing 2
• Apply emollients/moisturizers to maintain skin barrier
• Consider hydrocolloid dressing for protection, particularly triangle-shaped dressings which show better outcomes for sacral areas 3

For Moderate Erythema with Excoriation:

• Apply low to medium potency topical corticosteroid (1-2.5% hydrocortisone) once or twice daily 1
• Follow with dimethicone-based barrier cream
• Consider soft silicone multi-layered foam dressings for protection 4

For Severe Erythema or Signs of Infection:

• Apply medium potency topical corticosteroid (e.g., mometasone furoate 0.1%) 1
• Consider topical antibiotics if infection is suspected
• Consult dermatology or wound care specialist

Frequency of Application

• Apply barrier creams after each cleansing and especially after incontinent episodes 2
• Apply corticosteroids once or twice daily to affected areas 1
• Change dressings as needed based on soiling or loosening

Special Considerations

Monitoring

• Regularly assess for improvement or deterioration
• Consider objective measurement methods like reflectance spectrophotometry to differentiate between blanching and non-blanching erythema 5
• Monitor for sub-epidermal moisture which can predict early skin damage 6

Cautions

• Avoid alcohol-based products as they can further dry and irritate the skin 1
• Limit prolonged use of topical corticosteroids to avoid skin atrophy
• Do not use high-potency corticosteroids on sacral area unless directed by specialist

For Bile Acid-Related Excoriation

• In cases where bile acids may be contributing to excoriation (e.g., patients on promotility agents), consider cholestyramine ointment compound 7

When to Refer to Specialist

Refer to dermatology or wound care specialist if:

• No improvement after 2-4 weeks of appropriate treatment
• Signs of spreading infection
• Progression to deeper tissue involvement
• Uncertainty about diagnosis

Prevention Strategies

• Regular repositioning to reduce pressure
• Use of pressure-reducing mattresses or cushions 3
• Prompt management of incontinence
• Regular application of moisturizers to maintain skin barrier
• Proper nutrition and hydration

By following this treatment approach, most cases of sacral excoriation and erythema can be effectively managed, preventing progression to more serious pressure injuries and improving patient comfort.