What are the recommended treatments for pressure ulcers?

Pressure Ulcer Treatment

Use hydrocolloid or foam dressings combined with protein supplementation and air-fluidized beds for optimal pressure ulcer healing, as these interventions have the strongest evidence for reducing wound size and promoting complete healing. 1

Wound Dressing Selection

Apply hydrocolloid dressings as first-line therapy, as they are superior to gauze dressings for reducing wound size and equivalent to foam dressings for complete wound healing. 1, 2 This recommendation is based on moderate-quality evidence showing clear benefit over traditional gauze while being more cost-effective than advanced biological dressings. 1

• Select either hydrocolloid or foam dressings based on exudate control, patient comfort, and cost considerations rather than antimicrobial properties. 1
• Avoid dextranomer paste, as it is inferior to other dressings for reducing wound size. 2
• Do not rely on antimicrobial dressings as the sole intervention to accelerate healing. 1

Common pitfall: The most commonly reported harms for dressings include skin irritation, inflammation, tissue damage, and maceration—monitor closely for these complications. 2

Pressure Redistribution Surfaces

Use air-fluidized beds for patients with existing pressure ulcers, as they are superior to standard hospital beds for reducing pressure ulcer size. 2, 1, 3 This is supported by moderate-quality evidence demonstrating clear superiority over conventional surfaces. 3

• Alternative foam mattresses provide a 69% relative risk reduction in pressure ulcer incidence compared to standard hospital mattresses. 1, 3
• Avoid expensive alternating-air and low-air-loss beds, as they do not substantially differ from other surfaces in reducing wound size and add unnecessary costs without proven superiority. 1, 3

Nutritional Support

Provide protein or amino acid supplementation to all patients with pressure ulcers, as this improves the rate of wound healing when used with standard therapies. 2, 1, 3 This is particularly important in patients with nutritional deficiencies. 1

• Ensure adequate caloric intake and correct nitrogen balance. 1
• Do not use vitamin C supplementation alone, as it has not shown benefit compared to placebo. 1, 3

Debridement

Perform sharp debridement to remove all necrotic tissue, surrounding callus, and biofilm from the wound bed, as this allows accurate assessment of ulcer depth and eliminates physical impediments to healing. 1

• Debride frequently with a scalpel to maintain a clean wound bed. 1
• Critical caveat: Exercise extreme caution in ischemic ulcers without signs of infection, as aggressive debridement can worsen tissue damage. 1

Adjunctive Therapies

Use electrical stimulation as adjunctive therapy for stage 2 to 4 ulcers, as moderate-quality evidence shows it accelerates healing rate when added to standard treatment. 1, 3 This produces similar results across hospital and rehabilitation settings. 2

• Important warning: Frail elderly patients have more adverse events (primarily skin irritation) with electrical stimulation than younger patients—use with caution in this population. 2, 1
• Light therapy and laser therapy have not shown substantial adverse effects and may reduce ulcer size. 2

Infection Management

Evaluate for infection requiring antibiotic therapy if the ulcer shows signs of deep tissue involvement, cellulitis, or drainage. 1

• Direct antibiotic therapy against Gram-positive and Gram-negative organisms as well as anaerobes when infection is present. 1

Surgical Considerations

Consider surgical repair for advanced-stage pressure ulcers, though recognize that reoperation due to recurrence or flap failure ranges from 12% to 24%. 2, 3

• Choose rotation flaps when possible, as they have the lowest complication rates (12%) compared to tensor fascia lata flaps (49%). 2, 1
• Be aware that dehiscence is more common when bone is removed during surgery and in patients with ischial ulcers compared to sacral or trochanteric ulcers. 2, 1
• Patients with sacral pressure ulcers have lower recurrence rates after surgery than those with ischial ulcers. 3

Treatment Algorithm by Stage

For stage I-II ulcers:

• Apply hydrocolloid or foam dressings 1
• Initiate protein/amino acid supplementation 1
• Use alternative foam mattresses for pressure redistribution 1

For stage III-IV ulcers:

• Perform sharp debridement first 1
• Apply hydrocolloid or foam dressings 1
• Consider platelet-derived growth factor for severe ulcers 2
• Use air-fluidized beds for optimal pressure redistribution 1, 3
• Add electrical stimulation as adjunctive therapy 1

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). 1

Do not neglect vascular assessment when pedal pulses are absent or ulcers fail to improve—ankle-brachial index <0.6, toe pressure <50 mmHg, or TcPO2 <30 mmHg indicate need for revascularization. 1

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. 1