What is the recommended treatment for a stage 2 pressure ulcer?

Treatment of Stage 2 Pressure Ulcers

Use hydrocolloid or foam dressings as your primary wound treatment for stage 2 pressure ulcers, combined with pressure redistribution using alternative foam mattresses rather than standard hospital mattresses. 1, 2

Primary Wound Management

Dressing Selection

• Apply hydrocolloid or foam dressings to reduce wound size and promote healing. 1, 2
• Hydrocolloid dressings are superior to gauze dressings for reducing wound size, and achieve similar complete wound healing rates compared to foam dressings (hydrocellular or polyurethane). 1, 2
• Select dressings based on exudate control, comfort, and cost rather than antimicrobial properties. 3
• Avoid antimicrobial dressings as the sole intervention to accelerate healing. 3

Wound Debridement

• Perform sharp debridement to remove all necrotic tissue and surrounding callus, which allows accurate assessment of ulcer depth and extent. 3
• Debride frequently with a scalpel to maintain a clean wound bed. 3
• Sharp debridement can usually be performed without general anesthesia in neuropathic ulcers. 3

Pressure Redistribution and Offloading

Support Surfaces

• Use alternative foam mattresses rather than standard hospital mattresses, which provides a 69% relative risk reduction in pressure ulcer incidence. 2
• Avoid expensive advanced support surfaces like alternating-air and low-air-loss beds, as evidence for these is limited and they add unnecessary costs to healthcare systems. 1, 2
• Pressure-redistribution surfaces significantly improve healing rates (HR = 2.317). 4

Positioning and Offloading

• Implement total contact casting or other casting techniques for plantar ulcers. 3
• Consider temporary footwear, individually molded insoles, or non-weight bearing with crutches to eliminate ongoing mechanical stress. 3
• Ensure proper positioning and avoid constrictive dressings. 3

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size, particularly in patients with nutritional deficiencies. 1, 2
• Multivitamin supplementation facilitates healing (HR = 1.431). 4
• Vitamin C supplementation alone has not shown benefit compared to placebo. 1, 2
• Ensure adequate caloric intake and correct nitrogen balance. 3

Adjunctive Therapies

Electrical Stimulation

• Consider electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2 to 4 ulcers. 1, 5, 2
• This has moderate-quality evidence showing acceleration of healing rate. 1, 2
• Exercise caution in frail elderly patients, who are more susceptible to adverse events including skin irritation. 1, 2

Advanced Therapy Considerations

• Consider advanced wound therapy if the ulcer fails to show a reduction of 50% or more after 4 weeks of appropriate wound management. 5
• Topical growth factors, acellular matrix tissues, and bioengineered cellular therapies may be considered for chronic, more superficial ulcerations. 5

Monitoring and Prognostic Factors

Expected Healing Time

• Stage 2 pressure ulcers heal on average in 22.9 days (median 18 days). 6
• Ulcers smaller than 3.1 cm² heal significantly faster (19.2 days) compared to those 3.1 cm² or greater (31.0 days). 4, 6

Factors Associated with Better Healing

• Small ulcer size (≤3.0 cm²) significantly improves healing (HR = 1.670). 4
• Higher mean arterial pressure within the range of 52-112 mm Hg facilitates healing (HR = 1.016). 4
• Serum albumin ≥2.5 g/dL is associated with better healing outcomes. 4

Common Pitfalls to Avoid

• Do not continue standard therapy beyond 4 weeks without considering advanced wound therapy if the ulcer shows inadequate improvement. 5
• Avoid performing aggressive debridement in ischemic ulcers without signs of infection, which can worsen tissue damage. 3
• Do not neglect vascular assessment when pedal pulses are absent or ulcers fail to improve, as ankle-brachial index <0.6, toe pressure <50 mmHg, or TcPO2 <30 mmHg indicate need for revascularization. 3
• Assess footwear meticulously if the ulcer is on the foot, as ill-fitting shoes are the most frequent cause of ulceration. 3
• Do not overlook signs of infection requiring antibiotic therapy if the ulcer shows signs of deep tissue involvement. 3