What is the recommended management for a decubitus (pressure) ulcer?

Management of Decubitus (Pressure) Ulcers

The cornerstone of pressure ulcer management is pressure redistribution using advanced static foam mattresses combined with hydrocolloid or foam dressings, sharp debridement of necrotic tissue, and protein supplementation for nutritional deficiencies. 1, 2

Immediate Pressure Redistribution

• Use advanced static foam mattresses or overlays as the primary support surface, which provides a 69% relative risk reduction in pressure ulcer progression compared to standard hospital mattresses 2
• Avoid expensive alternating-air or low-air-loss beds for routine management, as they offer no proven superiority over advanced static surfaces and add unnecessary costs 1, 2
• Reserve air-fluidized beds specifically for large ulcers (>7 cm), as they are superior to standard hospital beds for reducing wound size in severe cases 1, 2
• Reposition patients every 2-4 hours using a 30° tilt position to reduce pressure on bony prominences 3

Wound Dressing Selection

• Apply hydrocolloid or foam dressings as first-line therapy, as these are superior to gauze dressings for reducing wound size and promoting complete healing 1, 2
• Select dressings based on exudate control, comfort, and cost rather than antimicrobial properties alone 2
• Avoid dextranomer paste, which is inferior to other dressings for wound size reduction 1
• Be aware that skin irritation, inflammation, and tissue maceration are the most common adverse effects of local wound applications 1, 2

Debridement Protocol

• Perform sharp debridement with a scalpel to remove all necrotic tissue, surrounding callus, and biofilm from the wound bed, which allows accurate depth assessment and eliminates physical barriers to healing 2
• Debride frequently to maintain a clean wound bed 2
• Exercise extreme caution in ischemic ulcers without signs of infection, as aggressive debridement can worsen tissue damage in poorly perfused wounds 2

Nutritional Support

• Provide protein or amino acid supplementation to patients with nutritional deficiencies, as this improves wound healing rates when combined with standard therapies 1, 2
• Ensure adequate caloric intake and correct nitrogen balance 2
• Do not rely on vitamin C supplementation alone, as it shows no benefit compared to placebo 1, 2

Infection Management

• Evaluate for deep tissue infection, cellulitis, or purulent drainage requiring antibiotic therapy 2
• Direct antibiotic coverage against Gram-positive and Gram-negative organisms as well as anaerobes when infection is documented 2

Adjunctive Therapies for Non-Healing Ulcers

• Use electrical stimulation as adjunctive therapy for stage 2-4 ulcers that fail to improve with standard care, as moderate-quality evidence shows it accelerates healing rates 1, 2
• Be aware that frail elderly patients experience more adverse events (primarily skin irritation) with electrical stimulation than younger patients 1, 2
• Consider platelet-derived growth factor for severe ulcers, as it improves healing compared to placebo in advanced-stage wounds 1, 2

Surgical Considerations

• Consider surgical repair for advanced-stage pressure ulcers that fail conservative management, though evidence is insufficient to determine superiority of specific surgical techniques 1, 2
• Recognize that rotation flaps have the lowest complication rates (12%) compared to tensor fascia lata flaps (49%) 1, 2
• Understand that dehiscence is more common when bone is removed during surgery and in patients with ischial ulcers versus sacral or trochanteric locations 1, 2
• Reoperation rates due to recurrence or flap failure range from 12% to 24% 1

Critical Decision Points and Pitfalls

• Do not continue standard therapy beyond 4 weeks without considering advanced wound therapy if the ulcer shows less than 50% reduction in size 2
• Do not perform aggressive debridement in ischemic ulcers without infection, as this worsens tissue damage 2
• Assess vascular status 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 2
• For foot ulcers, meticulously assess footwear, as ill-fitting shoes are the most frequent cause of ulceration even with other underlying pathology 2
• Do not overlook underlying osteomyelitis or deformities in diabetic foot ulcers that may require surgical offloading 2

Staging-Based Treatment Algorithm

For Stage I-II ulcers:

• Apply hydrocolloid or foam dressings 2
• Initiate protein supplementation if nutritional deficiency present 2
• Use advanced static foam mattress 2
• Reposition every 2-4 hours 3

For Stage III-IV ulcers:

• Perform sharp debridement of all necrotic tissue 2
• Apply hydrocolloid or foam dressings after debridement 2
• Consider platelet-derived growth factor for severe ulcers 1, 2
• Add electrical stimulation if inadequate improvement after 4 weeks 2
• Evaluate for surgical repair if conservative measures fail 2