What is the treatment for a pressure ulcer?

Treatment of Sacral Pressure Ulcers

For sacral pressure ulcers, apply hydrocolloid or foam dressings, provide protein supplementation, use air-fluidized beds or alternative foam mattresses for pressure redistribution, and consider electrical stimulation as adjunctive therapy to accelerate healing. 1, 2

Algorithmic Approach to Treatment

Step 1: Wound Care and Dressings

• Use hydrocolloid or foam dressings as first-line local wound care, as these are superior to gauze dressings for reducing wound size and are cost-effective compared to advanced biological dressings 1, 2
• Hydrocolloid dressings are equivalent to foam dressings for complete wound healing, so choose based on exudate control, comfort, and cost 1, 2
• 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 2
• Debride frequently with a scalpel to maintain a clean wound bed 2

Common pitfall: Avoid dextranomer paste, as it is inferior to other dressings for reducing wound size 1

Step 2: Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size and improve the rate of wound healing, particularly in patients with nutritional deficiencies 1, 2
• Ensure adequate caloric intake and correct nitrogen balance 2
• Do not rely on vitamin C supplementation alone, as it has not shown benefit compared to placebo 1, 2

Step 3: Pressure Redistribution

• Use air-fluidized beds as the superior option for reducing pressure ulcer size compared to standard hospital beds 1, 2
• Alternative foam mattresses provide a 69% relative risk reduction in pressure ulcer incidence compared to standard hospital mattresses and are a cost-effective option 1, 2
• Alternating-air beds and low-air-loss mattresses do not substantially differ from other surfaces in reducing wound size, so avoid these expensive options without proven superiority 1, 2

Important consideration: Sacral pressure ulcers have a lower recurrence rate after surgery compared to ischial or trochanteric ulcers, which is relevant for prognosis 3, 1

Step 4: Adjunctive Therapies

• Consider electrical stimulation for stage 2 to 4 ulcers to accelerate wound healing when added to standard treatment 1, 2
• The most common adverse effect is skin irritation 3, 1

Critical caveat: Frail elderly patients have more adverse events associated with electrical stimulation than younger patients, so use with caution in this population 3, 1, 2

Step 5: Infection Management

• Evaluate for infection requiring antibiotic therapy if the ulcer shows signs of deep tissue involvement, cellulitis, or drainage 2
• Direct antibiotic therapy against Gram-positive and Gram-negative organisms as well as anaerobes when infection is present 2

Step 6: Surgical Considerations for Advanced Ulcers

• Consider surgical repair for advanced-stage (stage III and IV) pressure ulcers 1, 2, 4
• Rotation flaps are associated with the lowest complication rates (12%) compared to other surgical flap procedures like tensor fascia lata flaps (49%) 3, 2
• Be aware that dehiscence is the most commonly reported harm from surgery, with reoperation rates ranging from 12% to 24% 3
• Dehiscence is more common when bone is removed during surgery 3, 1, 2

Important prognostic factor: Patients with sacral pressure ulcers have lower recurrence rates after surgery than those with ischial pressure ulcers 1, 2

Critical 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
• Do not perform aggressive debridement in ischemic ulcers without signs of infection, as this can worsen tissue damage 2
• Do not use antimicrobial dressings as the sole intervention to accelerate healing, as they are not recommended for this purpose 2

Evidence Quality Considerations

The American College of Physicians guidelines 3 provide the framework for this treatment approach, with moderate-quality evidence supporting hydrocolloid dressings and electrical stimulation, and low-quality evidence supporting protein supplementation and specific support surfaces. While many interventions showed similar results to controls, air-fluidized beds demonstrated clear superiority for reducing ulcer size, and nutritional supplementation with protein or amino acids showed improved healing rates 3