What is the most appropriate initial dressing for a pressure ulcer with slough?

Dressing Selection for Pressure Ulcers with Slough

For a pressure ulcer with slough, select hydrocolloid or foam dressings based primarily on exudate control, comfort, and cost—these are equally effective and superior to gauze dressings. 1

Initial Management Approach

Before selecting a dressing, sharp debridement of the slough should be performed when possible (unless contraindications like severe ischemia or pain exist), as removing devitalized tissue is fundamental to wound healing. 1

After debridement, the wound should be cleaned with clean water or saline and dressed with a sterile dressing that maintains a warm, moist environment. 1

Primary Dressing Recommendations

First-Line Options

Hydrocolloid dressings are recommended by the American College of Physicians as they:

• Reduce wound size more effectively than gauze dressings 1
• Are equivalent to foam dressings for complete wound healing 1
• Are cost-effective compared to advanced biological dressings 1, 2

Foam dressings are an equally appropriate alternative:

• Show similar healing rates to hydrocolloid dressings 1
• May be selected based on exudate level, patient comfort, and cost 1, 2

Selection Criteria

Choose between hydrocolloid and foam based on: 1

• Exudate level: Foam dressings handle heavier exudate better
• Patient comfort: Consider ease of application and wear time
• Cost: Both are cost-effective; select the less expensive option in your setting

What NOT to Use

Avoid antimicrobial dressings (silver, iodine, honey) as they do not accelerate healing or prevent infection when used solely for wound healing purposes. 1

Do not use dextranomer paste, as it is inferior to other dressings for reducing wound size. 1, 3

Avoid platelet-derived growth factor (PDGF) dressings for routine use—while they may improve healing in ulcers >7 cm, hydrocolloid and foam dressings are equally effective and far less expensive. 1, 3

Alternative Considerations for Slough Management

If slough persists despite sharp debridement:

Hydrogel dressings can facilitate autolytic debridement by donating moisture to soften and remove slough, though evidence for superior healing compared to hydrocolloid is insufficient. 4, 5, 6

Hydrocolloid/alginate combinations may help manage exudate while promoting autolytic debridement in heavily exudating wounds with slough. 7

Critical Clinical Pitfalls

• Do not rely on dressings alone: Pressure offloading remains the foundation of treatment; no dressing compensates for continued pressure. 3
• Do not use advanced support surfaces routinely: Evidence is insufficient to justify the expense of alternating-air or low-air-loss beds over standard pressure redistribution. 1
• Avoid frequent dressing changes: Select dressings that can remain in place for several days to avoid wound bed disruption and reduce cost. 7
• Do not prescribe antibiotics prophylactically: Reserve systemic antibiotics only for clear signs of infection (increasing pain, erythema, warmth, purulent drainage). 3

Adjunctive Measures

Add protein or amino acid supplementation to reduce wound size, particularly in nutritionally deficient patients. 1, 3

Consider electrical stimulation as an adjunct to accelerate healing rate in stage 2-4 ulcers, though evidence for complete healing is limited. 1