How is the stage of a pressure ulcer determined and what are the appropriate treatment options?

Pressure Ulcer Staging and Treatment

Staging Classification

Pressure ulcers are staged I through IV based on tissue depth and involvement, with stage I representing non-blanchable erythema of intact skin and stage IV indicating full-thickness tissue loss with exposed bone, tendon, or muscle. 1

Stage Definitions

• Stage I: Non-blanchable redness of intact skin, typically over a bony prominence 1
• Stage II: Partial-thickness skin loss involving epidermis and/or dermis; presents as a shallow open ulcer or intact/ruptured blister 1
• Stage III: Full-thickness tissue loss with visible subcutaneous fat, but bone, tendon, or muscle are not exposed 1
• Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; may include slough, eschar, undermining, or tunneling 1

Essential Assessment Parameters

When staging, document the following characteristics for each ulcer 2:

• Size measurements: Length, width, and depth in centimeters 2
• Tissue characteristics: Presence of eschar, granulation tissue, slough, and epithelialization 2
• Wound features: Exudate amount and character, odor, sinus tracts, undermining, and tunneling 2
• Periulcer tissue: Assess surrounding skin for erythema, warmth, induration, swelling, and signs of infection 2
• Pain assessment: Evaluate pain prior to wound examination 2

Treatment Algorithm by Stage

Stage I and II Ulcers

For superficial pressure ulcers (stages I-II), use hydrocolloid or foam dressings combined with pressure redistribution as first-line treatment. 3, 4

• Apply hydrocolloid or foam dressings to reduce wound size (weak recommendation, low-quality evidence) 3
• Hydrocolloid dressings are superior to gauze dressings for reducing wound size 3, 4
• Use alternative foam mattresses rather than standard hospital mattresses (69% relative risk reduction in ulcer incidence) 4
• Provide protein or amino acid supplementation to reduce wound size (weak recommendation, low-quality evidence) 3
• Stage II ulcers are typically caused by friction and/or moisture, not pressure alone 5

Stage III and IV Ulcers

Deep pressure ulcers (stages III-IV) require aggressive debridement of necrotic tissue and often necessitate surgical intervention, particularly in spinal cord injury patients. 6

• Perform urgent sharp debridement if advancing cellulitis or sepsis is present 1
• Rule out osteomyelitis in all full-thickness pressure ulcers before proceeding with treatment 5, 7
• Stage III-IV ulcers result from pressure and/or shearing forces 5
• Consider surgical closure for ulcers that fail to improve or are too large to heal in reasonable time 5, 7

Adjunctive Therapies

Use electrical stimulation as adjunctive therapy to accelerate wound healing in stage II-IV ulcers (weak recommendation, moderate-quality evidence). 3

• Electrical stimulation accelerates healing rate but lacks evidence for improving complete wound healing 3
• Exercise caution in frail elderly patients who are more susceptible to adverse events from electrical stimulation 3, 4
• Air-fluidized beds reduce pressure ulcer size compared with other surfaces (moderate-quality evidence) 3

Infection Management

Topical antibiotics should be considered only if there is no improvement in healing after 14 days of appropriate wound care. 1

• Manage bacterial load initially with wound cleansing using normal saline 1
• Reserve systemic antibiotics for advancing cellulitis, osteomyelitis, or systemic infection 1, 7
• Cultures and antibiotic therapy are indicated only with evidence of infection: erythema, edema, cellulitis, leukocytosis, bandemia, or fever 5, 7

When to Consult a Wound Specialist

Consult a wound specialist immediately for stage III-IV ulcers requiring surgical debridement, undrained abscess, unidentified necrotic tissue/bone, or signs of advancing infection. 8

Immediate Consultation Triggers

• Undrained abscess or unidentified necrotic soft tissue/bone 8
• Stage III-IV ulcers potentially requiring surgical debridement or reconstruction 8
• Recalcitrant or atypical wounds requiring biopsy to rule out malignancy (melanoma, Kaposi sarcoma) 8
• Wounds requiring extensive debridement beyond bedside capabilities 8

Consultation After Failed Standard Management

Initiate specialist consultation if the ulcer fails to heal after 6 weeks of optimal standard care. 8

Before referral, verify the following have been addressed 8:

• Adequate pressure offloading is maintained 8
• Complete debridement of all nonviable tissue has been performed 8
• Appropriate wound dressings (hydrocolloid or foam) are being used 8
• Protein/amino acid supplementation is provided 8
• Limb perfusion is adequate without unidentified ischemia 8
• Infection is adequately treated with appropriate antimicrobials 8

Critical Pitfalls to Avoid

• Do not use vitamin C supplementation alone, as it has not shown benefit compared to placebo 3, 4
• Avoid delaying specialist consultation beyond 6 weeks of ineffective standard treatment 8
• Do not overlook underlying osteomyelitis as a cause of treatment failure in full-thickness ulcers 8, 5
• Do not use ultrasonic debridement as it lacks evidence of benefit over standard care 9
• Avoid topical antibiotics as first-line treatment; use wound cleansing first 1
• Patients with ischial ulcers have higher dehiscence rates and may require earlier specialist consultation 8