What is the recommended management for a Stage 3 pressure‑related ulcer?

Stage 3 Pressure Ulcer Treatment

For Stage 3 pressure ulcers, use hydrocolloid or foam dressings after debridement, initiate protein or amino acid supplementation immediately, and ensure proper pressure redistribution with specialized support surfaces. 1, 2

Primary Wound Management

Debridement

• Debridement is essential for Stage 3 ulcers before applying dressings, as these wounds involve full-thickness tissue loss. 3
• Debridement can be performed autolytically, mechanically, enzymatically, or sharply depending on wound characteristics and urgency. 3
• Prompt sharp debridement is mandatory if infection is present. 3

Dressing Selection

• Apply hydrocolloid or foam dressings as first-line treatment after debridement. 1, 2, 4
• Hydrocolloid dressings are superior to gauze for reducing wound size and should be changed every 1-7 days based on exudate levels (typically every 1.5-3 days for moderate drainage). 1, 4
• Foam dressings are equivalent to hydrocolloid for complete wound healing outcomes. 1, 2
• Avoid dextranomer paste, as it is inferior to other dressings for reducing wound size. 1
• Keep the wound bed continuously moist while keeping surrounding intact skin dry. 3

Infection Management

• Apply topical antimicrobials (iodine preparations, medical-grade honey, or silver-containing dressings) when infection is documented. 4
• Common adverse effects of local wound applications include skin irritation, inflammation, tissue damage, and maceration. 1, 2

Nutritional Support

• Initiate protein or amino acid supplementation immediately to improve wound healing rate. 1, 2, 4
• This recommendation is based on evidence showing reduced wound size with protein supplementation, though optimal dose and form remain undefined. 1
• Do not use vitamin C supplementation alone, as it has shown no benefit compared to placebo. 2, 5
• Nutritional status is predictive of wound healing outcomes. 6

Pressure Redistribution

• Use air-fluidized beds if available, as these are superior to other support surfaces for reducing pressure ulcer size. 4
• Alternative foam mattresses reduce pressure ulcer incidence by 69% compared to standard hospital mattresses. 4, 5
• Ensure proper repositioning and mobility optimization, as better mobility correlates with improved healing. 7

Adjunctive Therapies

Electrical Stimulation

• Consider electrical stimulation as adjunctive therapy to accelerate wound healing (moderate-quality evidence for Stage 2-4 ulcers). 1, 2
• Exercise caution in frail elderly patients, who are more susceptible to adverse events including skin irritation. 1, 2, 5
• Note that while electrical stimulation accelerates healing rate, evidence is insufficient to prove superiority for complete wound healing. 1

Biological Agents

• Platelet-derived growth factor can be considered for more severe Stage 3 ulcers. 1, 2
• Evidence is insufficient for other biological agents. 1, 2

Surgical Considerations

• Refer for surgical consultation if the ulcer fails conservative management after 4-6 weeks, has extensive tunneling, or shows bone involvement. 4
• Surgery is considered an option for advanced-stage pressure ulcers, though evidence is insufficient to determine superiority of one surgical technique over another. 1
• Be aware that dehiscence rates range from 12-24% after surgical repair, with higher rates when bone is removed or for ischial ulcers. 1, 2, 4
• Sacral ulcers have lower recurrence rates after surgery compared to ischial ulcers. 2, 5

Critical Pitfalls to Avoid

• Do not use gauze dressings as primary treatment, as they are inferior to hydrocolloid dressings for reducing wound size. 1, 2
• Do not neglect Stage 1 and 2 ulcers at other sites when focusing on Stage 3 treatment, as multisite ulcers are common in elderly patients. 8
• The relationship between reduction in wound size and eventual complete healing has not been well-defined, so monitor for complete healing rather than assuming size reduction equals cure. 1, 2, 5