What are the recommended topical treatments for decubitus (pressure) ulcers?

Topical Treatments for Decubitus Ulcers

Primary Dressing Recommendation

Apply hydrocolloid or foam dressings as first-line topical treatment for pressure ulcers, as these dressings are superior to gauze for reducing wound size and promoting healing while remaining cost-effective. 1, 2, 3

Algorithmic Approach to Topical Treatment Selection

Step 1: Initial Wound Assessment and Preparation

• Perform sharp debridement first to remove necrotic tissue, planktonic bacteria, and biofilm—this is the critical first step before applying any dressing 2, 3
• Assess for infection using NERDS/STONES criteria (Nonhealing, Exudate, Red friable tissue, Debris, Smell / Size increasing, Temperature elevation, probes to bone, New breakdown, Erythema/Edema, Exudate, Smell) 2
• Stage the ulcer (Stage II-IV) to determine depth and tissue involvement 2

Step 2: Select Primary Dressing Based on Clinical Context

For most pressure ulcers (Stage 2-4):

• Use hydrocolloid or foam dressings as your primary choice—these reduce wound size more effectively than gauze and cost significantly less than advanced biological dressings like platelet-derived growth factor 1, 2, 3
• Change dressings based on clinical need rather than fixed schedules: every 1-3 days for moderate to heavy exudate, extending to 3-7 days once exudate decreases 2

When infection is present:

• Apply topical antimicrobials including iodine preparations, medical-grade honey, or silver-containing dressings after debridement 2
• However, recognize that evidence shows povidone iodine may actually impair healing compared to non-antimicrobial dressings—fewer ulcers heal with povidone iodine versus protease-modulating dressings or hydrogel 2, 4
• Use antimicrobials judiciously and not as sole intervention for healing 3

For wounds with excessive protease activity:

• Consider collagen matrix dressings to reduce protease activity and excessive inflammation while promoting dermal fibroblast proliferation 2
• Protease-modulating dressings may increase healing probability compared to saline gauze, though evidence is moderate quality 5

Step 3: Avoid These Common Pitfalls

• Do not use povidone iodine routinely—it may impair healing compared to non-antimicrobial alternatives 2, 4
• Do not use dextranomer paste—it is inferior to other dressing options 2
• Do not use expensive platelet-derived growth factor (PDGF) dressings as first-line treatment—while low-quality evidence suggests they may promote healing, hydrocolloid and foam dressings are equally effective and far more cost-effective 1
• Do not continue the same dressing beyond 4 weeks without reassessing if wound size has not reduced by at least 50% 3, 6

Essential Adjunctive Measures

Nutritional Support

• Provide protein or amino acid supplementation to reduce wound size, particularly when nutritional deficiency exists 1, 2, 3, 6
• Do not routinely supplement with vitamin C or other vitamins unless documented deficiency exists—no benefit has been demonstrated 2, 3, 6

Electrical Stimulation

• Add electrical stimulation to standard treatment for Stage 2-4 ulcers to accelerate healing rate—this has moderate-quality evidence supporting its use 1, 2, 3, 6
• Be aware that frail elderly patients experience more adverse events (primarily skin irritation) with electrical stimulation 3

Pressure Offloading

• Use alternative foam mattresses rather than standard hospital mattresses—this provides 69% relative risk reduction in pressure ulcer incidence 3, 6
• Avoid expensive advanced support surfaces like alternating-air and low-air-loss beds, as evidence is limited and they add unnecessary costs without proven superiority 1, 3, 6

Evidence Quality Context

The evidence base for topical treatments is notably weak. A comprehensive network meta-analysis of 39 studies found the evidence to be sparse, with low or very low certainty for most comparisons due to small sample sizes, high risk of bias, and imprecision 5. The Cochrane reviews on hydrogel dressings and antimicrobials similarly found insufficient evidence to determine superiority of specific treatments 4, 7. Despite this uncertainty, the American College of Physicians guidelines consistently recommend hydrocolloid and foam dressings as the most practical, evidence-supported, and cost-effective first-line approach 1, 2, 3.

When to Escalate Treatment

• Obtain wound cultures only when infection is clinically suspected using quantitative tissue biopsy or semiquantitative swab with Levine technique 2
• Probe to bone if osteomyelitis is suspected, and obtain imaging (MRI, CT, or ultrasound) if probe-to-bone test is positive 2
• Consider surgical repair for advanced-stage ulcers, recognizing that rotation flaps have the lowest complication rates (12%) compared to other surgical techniques 3