What ointment is recommended for an adult patient with limited mobility and a pressure ulcer, considering potential underlying conditions like diabetes or vascular disease?

Topical Treatment for Pressure Ulcers (Bed Sores)

For pressure ulcers (bed sores), dressings should be selected primarily based on exudate control, comfort, and cost—not on the expectation that any specific ointment or topical agent will accelerate healing. 1

Primary Wound Care Approach

Debridement Takes Priority Over Topical Agents

• Remove all necrotic tissue, slough, and surrounding callus using sharp debridement as the first-line intervention, as this is more important than any topical agent selection 1
• Repeat debridement as needed to maintain a clean wound bed 1
• Urgent surgical debridement is required if advancing cellulitis, gas-forming infection, abscess, necrotizing fasciitis, or sepsis develops 1, 2

Dressing Selection Guidelines

• Choose basic contact dressings (low-adherence dressings like paraffin gauze or simple absorbent dressings) or advanced dressings (alginate, hydrogel, films, hydrocolloid, foam) based on the amount of wound exudate 1
• Maintain a moist wound-healing environment after debridement 1, 3
• Inspect and change dressings frequently based on exudate levels 1

What NOT to Use

Antimicrobial Ointments and Dressings

• Do not use dressings or ointments containing antimicrobial agents (silver, iodine, honey, polyhexamethylene) with the sole aim of accelerating healing 1
• These antimicrobial-containing products have not been proven beneficial for routine wound management in non-infected pressure ulcers 1
• Topical antibiotics should only be considered if there is no improvement in healing after 14 days of optimal care, suggesting possible bacterial burden 2

Avoid Footbaths

• Do not use footbaths or soaking, as they induce skin maceration and worsen outcomes 1

Special Considerations for Specific Ointments

Sucrose-Octasulfate Dressing

• Consider sucrose-octasulfate–impregnated dressing as adjunctive treatment for noninfected, neuro-ischemic ulcers that are difficult to heal (this applies more to diabetic foot ulcers than typical pressure ulcers) 1

Enzymatic Debridement Ointments

• Clostridial collagenase ointment has mixed evidence and significant methodological limitations; it is not recommended as a primary treatment 1
• Enzymatic debridement is a non-urgent alternative when sharp debridement is contraindicated 2

Infection Management

When to Use Topical Antibiotics

• For superficial skin infection (mild): cleanse, debride, and start empiric oral antibiotics targeting S. aureus and streptococci rather than relying on topical agents 1
• For deep infection (moderate to severe): urgent surgical debridement and parenteral broad-spectrum antibiotics are required, not topical ointments 1
• Systemic antibiotics are indicated for advancing cellulitis, osteomyelitis, or systemic infection—topical agents are insufficient 2

Essential Concurrent Interventions (More Important Than Ointment Choice)

Pressure Relief

• Implement systematic repositioning every 2-4 hours using the 30-degree tilt position 4
• Use advanced static air mattresses or dynamic mattresses immediately for all patients with existing pressure ulcers 4
• Non-weight bearing and limitation of standing/walking are critical for healing 1

Vascular Assessment

• If ankle pressure <50 mmHg or ankle-brachial index <0.5, consider urgent vascular imaging and revascularization before expecting any topical agent to work 1
• Healing will be severely impaired with toe pressures <50 mmHg or transcutaneous oxygen pressure <30 mmHg 1

Nutritional Support

• Provide protein supplementation for malnourished patients, as malnutrition significantly impairs wound healing regardless of topical treatment 4, 3

Clinical Pitfalls to Avoid

• Do not delay debridement while searching for the "perfect" ointment—mechanical removal of necrotic tissue is far more important than topical agent selection 1, 3
• Do not use expensive antimicrobial dressings routinely; they add cost without proven benefit in non-infected wounds 1
• Do not apply topical treatments to ischemic ulcers without first addressing vascular insufficiency 1
• Recognize that optimal wound care cannot compensate for continuing pressure trauma or untreated ischemia 1