What are the treatment options for pressure ulcers?

Treatment of Pressure Ulcers

Use hydrocolloid or foam dressings as first-line wound management, provide protein or amino acid supplementation to patients with nutritional deficiencies, and add electrical stimulation as adjunctive therapy to accelerate healing. 1, 2

Wound Dressing Selection

• Apply hydrocolloid or foam dressings to reduce wound size and promote healing, as these are superior to gauze dressings and cost-effective compared to advanced biological dressings like platelet-derived growth factor. 1, 2

• Select dressings based on exudate control, comfort, and cost rather than antimicrobial properties, as antimicrobial dressings are not recommended as the sole intervention to accelerate healing. 2, 3

• Maintain a continuously moist wound bed while keeping surrounding intact skin dry, which optimizes the healing environment. 4

Debridement

• Perform sharp debridement to remove all necrotic tissue, surrounding callus, and biofilm from the wound bed, which allows accurate assessment of ulcer depth and eliminates physical impediments to healing. 3, 5

• Debride frequently with a scalpel to maintain a clean wound bed, though exercise caution in ischemic ulcers without signs of infection as aggressive debridement can worsen tissue damage. 3, 6

• Alternative debridement methods include autolytic, enzymatic, biologic, and mechanical approaches, though evidence is insufficient to determine their comparative effectiveness versus dressings. 1, 5

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size, particularly in patients with nutritional deficiencies, as this improves the rate of wound healing when used in conjunction with standard therapies. 1, 2

• Ensure adequate caloric intake and correct nitrogen balance, as vitamin C supplementation alone has not shown benefit compared to placebo. 1, 2

Pressure Redistribution

• 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 the quality of evidence for these is limited, harms are poorly reported, and they add unnecessary costs without proven superiority. 1, 2

• Air-fluidized beds are superior to standard hospital beds for reducing pressure ulcer size, though evidence on complete wound healing remains limited. 1

• Implement total contact casting or other casting techniques for plantar ulcers to eliminate ongoing mechanical stress. 3

Adjunctive Therapies

• Use electrical stimulation as adjunctive therapy to accelerate wound healing for stage 2 to 4 ulcers, as moderate-quality evidence shows it accelerates healing rate when added to standard treatment. 1, 2

• Be aware that frail elderly patients have more adverse events associated with electrical stimulation (primarily skin irritation) than younger patients. 1

• Consider advanced wound therapy if the ulcer fails to show a 50% or more reduction after 4 weeks of appropriate basic wound management. 6

• Evidence is insufficient to support the routine use of negative-pressure wound therapy, hyperbaric oxygen therapy, electromagnetic therapy, therapeutic ultrasound, or laser therapy for pressure ulcers. 1, 5

Infection Management

• Evaluate for infection requiring antibiotic therapy if the ulcer shows signs of deep tissue involvement, cellulitis, or drainage. 3, 6, 7

• Direct antibiotic therapy against Gram-positive and Gram-negative organisms as well as anaerobes when infection is present. 6

Surgical Considerations

• Consider surgical repair for advanced-stage pressure ulcers, though evidence is insufficient to determine the superiority of one surgical technique over another. 1

• Recognize that dehiscence is more common when bone is removed during surgery and in patients with ischial ulcers compared to sacral or trochanteric ulcers. 1

• Rotation flaps are associated with the lowest complication rates (12%) compared to other surgical flap procedures like tensor fascia lata flaps (49%). 1

Common Pitfalls to Avoid

• Do not continue standard therapy beyond 4 weeks without considering advanced wound therapy if the ulcer shows inadequate improvement (less than 50% reduction in size). 2, 6

• Do not perform aggressive debridement in ischemic ulcers without signs of infection, as this can worsen tissue damage. 2, 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 even in patients with other underlying pathology. 2, 3

• Do not overlook underlying osteomyelitis or deformities in diabetic foot ulcers that may require surgical offloading procedures. 6