What are the treatment options for skin ulcers?

Treatment Options for Skin Ulcers

The most effective treatment approach for skin ulcers involves multiple strategies including proper wound care, appropriate dressings, nutritional support, and addressing underlying causes. 1, 2

Core Treatment Strategies

Wound Care and Debridement

• Clean the wound regularly with water or saline to remove debris and create an optimal healing environment 2
• Perform regular debridement with a scalpel to remove necrotic tissue, which is necessary for proper wound healing 2
• Surgical debridement is particularly important for infected pressure ulcers to remove all necrotic tissue 2

Dressings

• Use hydrocolloid or foam dressings as they are superior to gauze dressings for reducing wound size 1, 2
• Hydrocolloid dressings are equivalent to foam dressings for complete wound healing (moderate-quality evidence) 1
• Avoid dextranomer paste as it is inferior to other wound dressings for reducing ulcer area 1
• Be aware that common adverse effects of dressings include skin irritation, inflammation, tissue damage and maceration 1

Pressure Offloading

• Implement complete pressure offloading from the affected area to minimize trauma to the ulcer site 2
• Air-fluidized beds are superior to standard hospital beds for reducing pressure ulcer size 1
• Alternating-air beds and low-air-loss mattresses do not differ substantially from other surfaces for reducing wound size 1, 2

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size, especially in nutritionally deficient patients 1, 2
• Protein supplementation has been shown to improve the rate of wound healing 1
• Vitamin C supplementation alone has not shown benefits compared to placebo 1

Adjunctive Therapies

Electrical Stimulation

• Use electrical stimulation as an adjunctive therapy to accelerate wound healing for stage 2 to 4 pressure ulcers (moderate-quality evidence) 1, 2
• Be cautious when using electrical stimulation in frail elderly patients, as they are more susceptible to adverse events 1
• The most common adverse effect reported with electrical stimulation is skin irritation (low-quality evidence) 1

Biological Agents

• Platelet-derived growth factor (PDGF) has shown improvement in ulcer healing compared with placebo for more severe ulcers 1
• Evidence is insufficient to determine the effect of other biological agents 1

Other Adjunctive Therapies

• Light therapy may reduce ulcer size compared with control and is not associated with substantial adverse events 1
• Consider hyperbaric oxygen therapy for diabetic foot ulcers that have not responded to standard care 1
• Evidence is insufficient or shows no benefit for electromagnetic therapy, therapeutic ultrasound, negative-pressure wound therapy, and laser therapy 1

Special Considerations Based on Ulcer Type

Pressure Ulcers

• Surgical repair is an option for advanced-stage pressure ulcers 1
• Be aware that dehiscence is a common complication following surgical repair, especially when bone is removed or with ischial ulcers 1
• Patients with sacral pressure ulcers have a lower recurrence rate after surgery than those with ischial pressure ulcers 1
• Patients with spinal cord injury have a higher rate of recurrent pressure ulcers after surgical flap closure 1

Diabetic Foot Ulcers

• For diabetic foot ulcers, consider the following specific approaches:
  • Debride all necrotic tissue and surrounding callus 1
  • Assess for peripheral arterial disease; if present, consider revascularization 1
  • For infected ulcers, start appropriate antibiotic therapy 1
  • Consider negative pressure therapy to help heal post-operative wounds 1
  • Consider systemic hyperbaric oxygen treatment for poorly healing wounds 1

Monitoring and Follow-up

• Regularly assess the wound for signs of healing or deterioration 2
• If the ulcer is not showing signs of healing within 6 weeks despite optimal management, reevaluate treatment approach and consider specialist referral 1, 2
• Develop a prevention plan once the ulcer is healed to avoid recurrence 2

Treatment Algorithm

1. Identify and address underlying cause (vascular insufficiency, pressure, diabetes) 3, 4
2. Clean wound and perform appropriate debridement 2
3. Apply appropriate dressing (hydrocolloid or foam) 1, 2
4. Implement pressure offloading measures 2
5. Provide protein supplementation 1
6. Consider adjunctive therapies for non-healing ulcers 1, 2
7. Evaluate for surgical intervention if conservative measures fail 1