What is the initial treatment approach for a stage 2 decubitus (pressure) sacral ulcer?

Treatment for Stage 2 Sacral Decubitus Ulcers

For a stage 2 sacral pressure ulcer, immediately implement complete pressure offloading with repositioning every 2-4 hours, apply hydrocolloid or foam dressings to maintain a moist wound environment, and provide protein supplementation at 1.2-1.5 g/kg/day. 1, 2

Immediate Pressure Relief (Most Critical)

• Reposition the patient every 2-4 hours with visual and tactile checks of all at-risk areas at least once daily 1
• Use high-level prevention support surfaces such as air-loss mattress or dynamic mattress to redistribute pressure away from the sacrum 1
• Implement early mobilization as soon as medically stable, as the sacrum is the most common location (39% of pressure ulcers) 1
• Use discharge tools including cushions, foam, and pillows to avoid interosseous contact 1

Critical pitfall: Do not rely solely on support surfaces to eliminate all pressure—active repositioning remains essential even with advanced mattresses 3

Wound Care Protocol

Cleansing and Assessment

• Clean the wound with normal saline or water at each dressing change 2
• Document wound size, depth, exudate amount, and surrounding skin condition at baseline and weekly 2
• Assess for signs of infection using clinical examination (increased pain, erythema, warmth, purulent drainage) 2

Dressing Selection

• Apply hydrocolloid or foam dressings as the primary dressing—these are superior to gauze dressings for reducing ulcer size 1, 2, 4
• Hydrocolloid and foam dressings are equivalent in effectiveness (moderate-quality evidence), so choose based on exudate level 1, 4
• For moderate to heavy exudate, consider alginate or hydrofiber dressings 2
• Change dressings every 1-3 days based on exudate levels 2

Critical pitfall: Avoid gauze dressings—they are inferior to hydrocolloid dressings for wound healing 1, 4

Nutritional Support

• Provide protein supplementation at 1.2-1.5 g/kg/day to support wound healing 2, 4
• Assess for and correct vitamin and mineral deficiencies if present 2
• Protein or amino acid supplementation improves healing rates (low-quality evidence but recommended) 4

Note: Vitamin C supplementation alone has not shown benefit compared to placebo 4

Adjunctive Therapies to Consider

• Electrical stimulation accelerates wound healing as adjunctive therapy (moderate-quality evidence) 1, 2, 4
• The most common adverse effect is skin irritation, which is generally mild 1, 4
• Electrical stimulation is similarly effective across different healthcare settings (hospital vs rehabilitation center) 1

Caution: Frail elderly patients have more adverse events with electrical stimulation—use with closer monitoring in this population 1, 4

Monitoring and Reassessment

• Document wound measurements and characteristics weekly 2
• Reassess the treatment plan if no improvement occurs within 2-4 weeks 2
• Monitor for complications including infection, increased wound size, or deterioration to stage 3 2

Special Considerations for Sacral Location

• Sacral pressure ulcers have lower recurrence rates after surgery compared to ischial ulcers (if surgical intervention becomes necessary for progression) 1, 5, 4
• The sacral location requires particular attention to fecal and urinary incontinence management, as moisture increases maceration risk 5
• Implement strict hand hygiene and aseptic technique during dressing changes 2

What NOT to Do

• Do not use dextranomer paste—it is inferior to other wound dressings 1, 4
• Do not mistake wound exudate, debris, or slough for biofilm in stage 2 ulcers 2
• Do not obtain wound cultures unless infection is clinically suspected 2
• Avoid relying on intermediate outcomes like wound size reduction alone without tracking toward complete healing 2