What is the recommended management and ointment for a sacral ulcer grade II?

Management of Grade II Sacral Pressure Ulcer

For a grade II sacral pressure ulcer, use hydrocolloid or foam dressings as your primary wound dressing, combined with sharp debridement of any callus or slough, protein supplementation (1.2-1.5 g/kg/day), and complete pressure offloading using specialized support surfaces. 1, 2

Wound Care Dressing Selection

Primary Dressing Recommendation

• Apply hydrocolloid or foam dressings to maintain a moist wound environment and control exudate 1
• Hydrocolloid dressings are superior to gauze dressings for reducing ulcer size and have better absorption capacity, require fewer dressing changes, and cause less pain during changes 1, 3
• Foam dressings may be slightly more effective than hydrocolloid dressings, with one study showing 90.7% healing at 8 weeks versus 77.1% for hydrocolloid (p=0.039), and shorter average healing time (3 weeks vs. 4 weeks) 4
• Triangle-shaped hydrocolloid border dressings applied point-down show longer wear time and greater reduction in ulcer width compared to oval-shaped dressings 5

Dressing Change Frequency

• Change dressings every 1-3 days based on exudate levels 2
• Incontinence will reduce the interval between dressing changes and should be anticipated 5
• Select dressings principally based on exudate control, comfort, and cost 1

What NOT to Use

• Do not use gauze dressings as they are inferior to hydrocolloid dressings for reducing ulcer size 1
• Do not use antimicrobial dressings (silver, iodine) solely to accelerate healing in non-infected wounds 1
• Dextranomer paste is inferior to other wound dressings and should be avoided 1

Debridement Protocol

• Perform sharp debridement to remove all necrotic tissue, slough, and surrounding callus 1, 2
• This is the preferred method over enzymatic, autolytic, or mechanical debridement 1
• Relative contraindications include severe pain or severe ischemia 1
• If sharp debridement is contraindicated, consider enzymatic debridement agents 2

Wound Cleansing

• Clean the wound with normal saline or clean water at each dressing change 1, 2
• Use aseptic technique and strict hand hygiene 2
• Do not use antimicrobial solutions routinely unless infection is suspected 1

Pressure Relief (Critical Component)

• Implement complete offloading of the sacral area using an air-fluidized bed or specialized pressure-redistribution surface 2
• Air-fluidized beds reduce pressure ulcer size more effectively than other support surfaces (moderate-quality evidence) 1
• Maintain a strict turning schedule every 2-4 hours 2
• The majority of patients (70%) should utilize a pressure-reducing mattress or bed 5

Nutritional Support

• Provide protein or amino acid supplementation at 1.2-1.5 g/kg/day to reduce wound size 1, 2
• This recommendation is based on moderate-quality evidence showing protein-containing supplements improve wound healing 1
• Consider vitamin and mineral supplementation only if documented deficiencies are present 2
• Vitamin C supplementation alone does not improve healing (low-quality evidence) 1

Adjunctive Therapies to Consider

Electrical Stimulation

• Consider electrical stimulation as adjunctive therapy to accelerate wound healing (moderate-quality evidence) 1, 2
• This is the only adjunctive therapy with moderate-quality evidence supporting its use 1
• It produces similar results in hospital and rehabilitation settings 1

Other Adjunctive Options

• For non-healing wounds after 2-4 weeks of standard care, consider negative pressure wound therapy for post-operative wounds 2
• Consider collagen matrix dressings to reduce protease activity 2
• Do not use growth factors, platelet-derived growth factor, autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide, electromagnetic therapy, therapeutic ultrasound, light therapy, or laser therapy as they lack sufficient evidence 1

Monitoring and Reassessment

• Evaluate for lack of symptomatic response within 4-8 weeks to determine need to modify therapy 1
• Document wound measurements (length, width, depth), exudate characteristics, and surrounding skin condition weekly 2
• Reassess treatment plan if no improvement is seen within 2-4 weeks 2
• Monitor for signs of infection using clinical assessment (increased pain, erythema, warmth, purulent drainage) 2

Infection Management (If Present)

• Obtain wound cultures only when infection is suspected, using the Levine technique for swab collection 2
• If infection is present, apply antimicrobial dressings containing silver, iodine, or medical-grade honey 2
• Systemic antibiotics are indicated only for spreading cellulitis or systemic signs of infection 1
• Sacral pressure ulcer infections are typically polymicrobial, including both aerobes (S. aureus, Enterococcus, Proteus, E. coli, Pseudomonas) and anaerobes (Peptococcus, Bacteroides fragilis, Clostridium perfringens) 1

Common Pitfalls to Avoid

• Do not rely solely on intermediate outcomes like reduction in wound size without tracking complete healing 1
• Avoid switching between different oral formulations of the same dressing type without evidence of benefit 5
• Do not use advanced therapies without first optimizing basic wound care (pressure relief, debridement, appropriate dressings, nutrition) 2
• Incontinence management is critical as it significantly reduces dressing wear time 5

Prognosis

• Sacral pressure ulcers have a lower recurrence rate after surgical repair compared to ischial pressure ulcers (low-quality evidence) 1, 6
• With appropriate treatment, grade II sacral ulcers can heal in 3-4 weeks on average 4
• Healing rates of 77-91% at 8 weeks are achievable with appropriate dressing selection 4