What is the best topical prevention for pressure ulcers?

Best Topical Prevention of Pressure Ulcers

Skin barrier creams containing fatty acids are the best topical prevention for pressure ulcers, as they decrease the risk of pressure ulcers compared to standard care (RR 0.42,95% CI 0.22 to 0.80). 1

Risk Assessment and Patient Selection

• Use validated tools like Braden, Norton, or Waterlow scales to identify patients at risk of developing pressure ulcers 2, 1
• Risk factors to consider:
  • Limited mobility
  • Older age
  • Black race or Hispanic ethnicity
  • Lower body weight
  • Cognitive impairment
  • Physical impairments
  • Comorbidities affecting tissue integrity (incontinence, diabetes, edema, poor circulation)
  • Hypoalbuminemia and malnutrition 2

Topical Prevention Strategies

Primary Recommendation: Barrier Creams

• Apply skin barrier creams containing fatty acids in a thin, even layer to intact skin
• Reapply after each cleansing or as directed by product instructions 1
• Use a skin cleanser rather than soap for cleansing, as soap can be drying and alter skin pH 1

Dimethicone-Based Skin Protectants

• Apply after cleaning skin gently with mild cleanser
• For perineal areas, apply after each incontinent episode or diaper change 3
• Provides long-lasting protection against moisture-related skin damage

Silicone Foam Dressings

• Recent evidence shows silicone foam dressings reduce the incidence of pressure ulcers when used prophylactically (RR 0.50,95% CI 0.33 to 0.77) 4
• Particularly effective for sacral pressure ulcers (RR 0.59,95% CI 0.35-0.98) 5
• Works by:
  • Decreasing frictional forces transmitted to the skin
  • Absorbing and redistributing shear forces
  • Reducing pressure on tissues through cushioning
  • Managing moisture at the skin-surface interface 6

Comprehensive Prevention Approach

Support Surfaces

• The American College of Physicians strongly recommends advanced static mattresses or advanced static overlays for patients at increased risk (strong recommendation, moderate-quality evidence) 2
• Recommends against using alternating-air mattresses or alternating-air overlays (weak recommendation, moderate-quality evidence) 2
• Avoid doughnut cushions as they can increase pressure injury risk by concentrating pressure on surrounding tissue 1

Repositioning

• Reposition patients every 2-4 hours based on individual risk assessment 1
• Maintain the head of the bed at the lowest safe elevation to prevent shear 7

Skin Care Protocol

1. Assess skin regularly for early signs of pressure damage
2. Clean with mild skin cleanser (not soap)
3. Apply barrier cream containing fatty acids to intact skin
4. Consider prophylactic silicone foam dressings for high-risk areas (sacrum, heels)
5. Manage moisture from incontinence, perspiration, or wound drainage

Common Pitfalls to Avoid

• Relying solely on topical agents without addressing support surfaces and repositioning
• Using doughnut cushions which can worsen pressure injuries
• Failing to manage moisture, which increases friction and maceration
• Neglecting nutritional status, which is critical for skin integrity
• Inconsistent risk assessment and prevention protocols

By implementing this comprehensive approach with appropriate topical agents, support surfaces, and repositioning schedules, pressure ulcer incidence can be significantly reduced, improving patient outcomes and quality of life.